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3.  Peripheral Ankle Cooling and Core Body Temperature 
Journal of Athletic Training  2006;41(2):185-188.
Context: Exposure of the human body to cold is perceived as a stressor and results in a sympathetic response geared at maintaining core temperature. Application of ice to the periphery may lead to a decrease in core temperature, which may counteract the therapeutic effects of cryotherapy.
Objective: To determine if core temperature is lowered by the application of an ice bag to the ankle joint complex.
Design: A within-subjects, repeated-measures design.
Setting: The University of Virginia General Clinical Research Center.
Patients or Other Participants: Twenty-three healthy adults aged 19 to 39 years.
Intervention(s): Subjects were admitted to the hospital on 2 separate occasions. During one admission, subjects had a 20-minute ice treatment applied to their ankles; in the other admission, a bag of marbles was applied. Temperature measurements were recorded at 6 time intervals: baseline (before ice application), immediately after ice application, 10 and 20 minutes after ice application, and 10 and 20 minutes after ice removal.
Main Outcome Measure(s): We measured core temperature and ankle and soleus muscle surface temperatures. A mixed-effects model analysis of variance with repeated measures was used to determine if differences existed in core temperature and ankle and soleus surface temperatures between conditions (cryotherapy and control) and over time.
Results: Core temperature did not change after ice application or ice removal ( P > 0.05). The average core temperatures during the cryotherapy and control conditions were 36.72°C ± 0.42°C and 36.45°C ± 1.23°C, respectively.
Conclusions: A 20-minute cryotherapy treatment applied to the ankle did not alter core temperature.
PMCID: PMC1472654  PMID: 16791304
cryotherapy; cold; ice; temperature
4.  Functional Multijoint Position Reproduction Acuity in Overhead-Throwing Athletes 
Journal of Athletic Training  2006;41(2):146-153.
Context: Baseball players rely on the sensorimotor system to uphold the balance between upper extremity stability and mobility while maintaining athletic performance. However, few researchers have studied functional multijoint measures of sensorimotor acuity in overhead-throwing athletes.
Objective: To compare sensorimotor acuity between 2 high-demand functional positions and among planes of motion within individual joints and to describe a novel method of measuring sensorimotor function.
Design: Single-session, repeated-measures design.
Setting: University musculoskeletal research laboratory.
Patients or Other Participants: Twenty-one National Collegiate Athletic Association Division I baseball players (age = 20.8 ± 1.5 years, height = 181.3 ± 5.1 cm, mass = 87.8 ± 9.1 kg) with no history of upper extremity injury or central nervous system disorder.
Main Outcome Measure(s): We measured active multijoint position reproduction acuity in multiple planes using an electromagnetic tracking device. Subjects reproduced 2 positions: arm cock and ball release. We calculated absolute and variable error for individual motions at the scapulothoracic, glenohumeral, elbow, and wrist joints and calculated overall joint acuity with 3-dimensional variable error.
Results: Acuity was significantly better in the arm-cock position compared with ball release at the scapulothoracic and glenohumeral joints. We observed significant differences among planes of motion within the scapulothoracic and glenohumeral joints at ball release. Scapulothoracic internal rotation and glenohumeral horizontal abduction and rotation displayed less acuity than other motions.
Conclusions: We established the reliability of a functional measure of upper extremity sensorimotor system acuity in baseball players. Using this technique, we observed differences in acuity between 2 test positions and among planes of motion within the glenohumeral and scapulothoracic joints. Clinicians may consider these differences when designing and implementing sensorimotor system training. Our error scores are similar in magnitude to those reported using single-joint and single-plane measures. However, 3-dimensional, multijoint measures allow practical, unconstrained test positions and offer additional insight into the upper extremity as a functional unit.
PMCID: PMC1472653  PMID: 16791298
upper extremity; joint position sense; proprioception; throwing athletes
5.  Letter to the Editor 
Journal of Athletic Training  2006;41(2):137-138.
PMCID: PMC1472652  PMID: 16791295
6.  Postural Performance and Strategy in the Unipedal Stance of Soccer Players at Different Levels of Competition 
Journal of Athletic Training  2006;41(2):172-176.
Context: Sport training enhances the ability to use somatosensory and otolithic information, which improves postural capabilities. Postural changes are different according to the sport practiced, but few authors have analyzed subjects' postural performances to discriminate the expertise level among highly skilled athletes within a specific discipline.
Objective: To compare the postural performance and the postural strategy between soccer players at different levels of competition (national and regional).
Design: Repeated measures with 1 between-groups factor (level of competition: national or regional) and 1 within-groups factor (vision: eyes open or eyes closed). Dependent variables were center-of-pressure surface area and velocity; total spectral energy; and percentage of low-, medium-, and high-frequency band.
Setting: Sports performance laboratory.
Patients or Other Participants: Fifteen national male soccer players (age = 24 ± 3 years, height = 179 ± 5 cm, mass = 72 ± 3 kg) and 15 regional male soccer players (age = 23 ± 3 years, height = 174 ± 4 cm, mass = 68 ± 5 kg) participated in the study.
Intervention(s): The subjects performed posturographic tests with eyes open and closed.
Main Outcome Measure(s): While subjects performed static and dynamic posturographic tests, we measured the center of foot pressure on a force platform. Spatiotemporal center-of-pressure measurements were used to evaluate the postural performance, and a frequency analysis of the center-of-pressure excursions (fast Fourier transform) was conducted to estimate the postural strategy.
Results: Within a laboratory task, national soccer players produced better postural performances than regional players and had a different postural strategy. The national players were more stable than the regional players and used proprioception and vision information differently.
Conclusions: In the test conditions specific to playing soccer, level of playing experience influenced postural control performance measures and strategies.
PMCID: PMC1472651  PMID: 16791302
balance; soccer; postural control; spectral analysis
7.  Wound Cleansing: Water or Saline? 
Journal of Athletic Training  2006;41(2):196-197.
Reference: Fernandez R, Griffiths R, Ussia C. Water for wound cleansing. Cochrane Database Syst Rev.20022CD003861. Available at: http://www.cochrane.org/reviews/en/ ab003861.html.
Clinical Question: Do rates of infection and healing differ depending on whether tap water or normal sterile saline is used to cleanse acute and chronic wounds?
Data Sources: Studies were identified by electronic searches of the following databases: Cochrane Wounds Group Specialized Register (June 2004), MEDLINE (1966–2004), CINAHL (1982–2004), Nursing Collection (1995–2000), Health STAR (1975–2000), EMBASE (1980–2004), and the Cochrane Controlled Trials Register (Issue 2, 2004). Additional searches were conducted with reference lists of included studies. Contact with investigators, company representatives, and content experts was initiated to identify additional eligible studies. The search terms included water, saline, solution or solutions, tap and water, cleansing, irrigation, wound or wounds, and healing.
Study Selection: Studies in any language were eligible for inclusion if they were randomized or quasirandomized controlled trials of human subjects that compared the use of water (tap, cooled, boiled, or distilled) with normal sterile saline or any other solution specifically for wound cleansing in subjects of all ages with any wound in any setting. Wound cleansing was defined as “the use of fluids to remove loosely adherent debris and necrotic tissue from the wound surface.”
Data Extraction: The characteristics of the subjects, interventions, follow-up, outcomes, and findings were extracted from each study by 2 authors and verified by the third. The primary outcome measure was objective and/or subjective wound infection. Secondary measures were proportion of healed wounds, rate of healing, pain and discomfort, and patient and staff satisfaction. All studies were graded independently by 2 authors and verified by a third author to determine methodologic quality. Where appropriate, the data were pooled and analyzed with a fixed-effects model. RevMan software (version 4.2; Cochrane Centre, Oxford, UK) was used for statistical analysis.
Main Results: Specific search criteria identified 24 studies for review, of which 9 met inclusion and exclusion criteria. Baseline data for each treatment group were provided in 6 studies. Details of randomization procedures were not fully explained in 2 studies, and the procedures in 6 were subject to selection bias. The sample sizes ranged between 35 and 770 patients, and patient ages ranged between 2 and 95 years. Surgical wounds were involved in 4 studies, lacerations in 3, and open fractures and chronic wounds in 1 each. Eight studies were conducted in hospital emergency departments and wards and 1 in the community. The medical or nursing staff performed the cleansing in 5 studies and the subjects themselves in 4, using irrigation and showering techniques. Primary and secondary outcome variables were recorded between 1 and 6 weeks postinjury. Wound infection was subjectively measured (redness, purulent discharge, pain, or smell) in all 9 studies, and 1 used blinded outcome assessment (cleansing solution used was unknown to assessors). Among patients with surgical wounds in 3 studies, no significant difference was noted in infection rates between cleansing (bathing or showering with and without shower gel) with tap water and no cleansing (relative risks [RR] = 1.06, 95% confidence interval [CI] = 0.07–16.50). In 1 study, tap water reduced the relative risk of infection by 45% compared with normal sterile saline for cleansing (irrigation) of acute soft tissue wounds that were sutured (RR = 0.55, 95% CI = 0.31–0.97). Two studies revealed that in children with acute wounds, cleansing (irrigation) with tap water or normal sterile saline demonstrated no significant differences in infection rates (RR = 1.07, 95% CI = 0.43–2.64). In another study, cleansing (irrigation) of nonsutured chronic wounds with tap water or normal sterile saline showed no significant differences in the rate of infection (RR = 0.16, 95% CI = 0.01–2.96). Water was also compared with isotonic saline for cleansing (irrigation) of open fractures. The author reported no significant difference in wound infection rates between distilled water and cooled, boiled water (RR = 1.69, 95% CI = 0.68–4.22), distilled water and isotonic saline (RR = 0.49, 95% CI = 0.19–1.26), or cooled, boiled water and isotonic saline (RR = 0.83, 95% CI = 0.37– 1.87). Additionally, no significant differences in the rate of infection were found when the distilled and cooled, boiled water results were pooled and compared with isotonic saline (RR = 0.65, 95% CI = 0.31–1.37). Among patients with postoperative wounds, 1 group found no significant differences in the infection and healing rates after cleansing (washing) with tap water or procaine spirit. An analysis of secondary outcomes revealed no significant differences in wound healing rates between cleansing (bathing or showering with and without shower gel) of surgical wounds with tap water and no cleansing (RR = 1.26, 95% CI = 0.18–8.66), nonsutured chronic wounds with tap water and normal sterile saline (irrigation) (RR = 0.57, 95% CI = 0.30–1.07), and postoperative wounds with tap water and procaine spirit (washing; neither RR nor CI was reported). Patients felt better when allowed to shower their wounds and preferred showering to irrigating their wounds from a bottle. Tap water ($1.16) was also shown in 1 study to be cost-effective compared with normal sterile saline ($1.43). Two groups reported that the quality of tap water met the national health requirements of the country in which the data were collected and that bacteria counts were low.
Conclusions: No differences were noted in the rates of infection and healing between the use of tap water and normal sterile saline in the cleansing of acute and chronic wounds. However, 1 group suggested that tap water was effective in reducing infection rates for cleansing of acute soft tissue wounds that were sutured. The methodologic quality of the studies should be considered in the interpretation of the findings. Additional randomized controlled trials are needed to determine the effectiveness of tap water used for wound cleansing among various populations and settings.
PMCID: PMC1472650
8.  Sex Differences in Valgus Knee Angle During a Single-Leg Drop Jump 
Journal of Athletic Training  2006;41(2):166-171.
Context: Sex differences in lower extremity landing mechanics and muscle activation have been identified as potential causative factors leading to the increased incidence of anterior cruciate ligament injuries in female athletes. Valgus knee alignment places greater strain on the anterior cruciate ligament than a more neutral alignment. Gluteus medius (GM) activation may stabilize the leg and pelvis during landing, limiting valgus knee motion and potentially preventing anterior cruciate ligament injury.
Objective: To determine if frontal-plane knee angle and GM activation differ between the sexes at initial contact and maximal knee flexion during a single-leg drop landing.
Design: Between-groups design.
Setting: Motion analysis laboratory.
Patients or Other Participants: Thirty-two healthy subjects between the ages of 18 and 30 years.
Intervention(s): The independent variables were sex (male or female) and position (initial contact or maximal knee flexion).
Main Outcome Measure(s): Frontal-plane knee angle and GM average root mean square (aRMS) amplitude.
Results: At initial contact, women landed in knee valgus and men landed in knee varus ( P < .025). At maximal knee flexion, both men and women were in a position of knee varus, but the magnitude of varus was less in women than in men ( P < .025). The GM aRMS amplitude was greater at maximal knee flexion than at initial contact ( P < .025); however, male GM aRMS did not differ from female GM aRMS amplitude at either position ( P > .025).
Conclusions: Women tended to land in more knee valgus before and at impact than men. The GM muscle activation did not differ between the sexes and, thus, does not appear to be responsible for the sex differences in knee valgus. The excessive valgus knee angles displayed in women may help to explain the sex disparity in anterior cruciate ligament injury.
PMCID: PMC1472649  PMID: 16791301
biomechanics; kinematics; landing; electromyography; anterior cruciate ligament
9.  Development and Reliability of the Ankle Instability Instrument 
Journal of Athletic Training  2006;41(2):154-158.
Context: Functional ankle instability has been defined in a variety of ways. Factors that are frequently used in this definition include a history of a severe ankle sprain, a history of multiple ankle sprains, and a recurrent feeling of instability or “giving way.” With all the variations in defining functional ankle instability, it becomes increasingly important to develop a more consistent framework for assessing this instability.
Objective: To develop a new ankle instability assessment tool, the Ankle Instability Instrument, and evaluate the reliability of this instrument.
Design: Test-retest reliability was evaluated using intraclass correlation coefficients (2,1) for each item, each factor, and the total score between test days 1 and 2. Cronbach alpha was calculated to estimate internal consistency of the 12 items.
Setting: Classrooms, offices, athletic fields, and private residences.
Patients or Other Participants: College students (29 males, 72 females, age = 20.7 ± 2.7 years), including 73 (72%) with and 28 (28%) without a history of ankle injury.
Main Outcome Measure(s): Subjects were asked to complete the Ankle Instability Instrument on 2 occasions approximately 1 week apart.
Results: An exploratory factor analysis of the Instrument produced 3 factors and reduced it from 21 to 12 items. The factors accounted for 32.3%, 10.7%, and 7.0% of the variance, respectively. Together, these factors accounted for 50.0% of the variance in the responses to the Instrument. Test-retest reliability ranged from .70 (SEM = 0.28) to .98 (SEM = 0.06) for the individual items and .95 (SEM = 1.85) for the Instrument overall. The Cronbach alpha coefficient was .92 for factor 1 (severity of initial ankle sprain), .87 for factor 2 (history of ankle instability), .81 for factor 3 (instability during activities of daily life), and .89 for the Instrument overall.
Conclusions: The creation of the Ankle Instability Instrument is a first step in recognizing a more objective way of identifying patients suffering from functional ankle instability. The high reliability we found shows that self-reporting of ankle symptoms is a feasible, appropriate way to obtain information on the presence of instability symptoms. Additionally, through this preliminary study, we found 3 factors that represent unique and important components of functional ankle instability. Clinicians and researchers can, therefore, use these 12 items, either alone or in combination with other information, to determine if functional ankle instability is present.
PMCID: PMC1472648  PMID: 16791299
ankle assessment; ankle sprain; functional ankle instability
10.  Atraumatic Subclavian Vein Thrombosis in a Collegiate Baseball Player: A Case Report 
Journal of Athletic Training  2006;41(2):198-200.
Objective: To introduce the case of a collegiate baseball player who suffered an atraumatic subclavian vein thrombosis. This case presents an opportunity to discuss the diagnosis and treatment of a 22-year-old male with a thrombosis of his right subclavian vein.
Background: Upper extremity deep venous thrombosis is an uncommon vascular problem, occurring primarily in young, healthy, active people. Although the history and symptoms are often unremarkable, the condition can lead to complications if not correctly recognized and appropriately treated. In this case, the athlete reported tightness in his right biceps muscle and upper back after sleeping on his shoulder. The patient denied substance abuse or illegal anabolic steroid use, and these possibilities were ruled out as factors in the diagnosis and treatment.
Differential Diagnosis: Shoulder tendinitis, thoracic outlet syndrome, primary upper extremity thrombosis of the right subclavian vein.
Treatment: After diagnosis, the patient was placed on blood thinners to dissolve the clot and referred to a vascular surgeon. The patient underwent a balloon angioplasty and later had the first rib removed. A second clot formed, and a stent was placed in the vein after the clot was removed by medication and another angioplasty procedure. He developed a pulmonary embolism during the stent procedure and was sent postoperatively to the intensive care unit, where he underwent therapeutic anticoagulation. After 10 weeks of therapy, the patient stopped all anticoagulant medication and returned to school to play baseball.
Uniqueness: We present the atraumatic pathogenesis of a subclavian venous thrombosis in a young, active, and otherwise healthy college athlete with unremarkable predisposing factors. Within 24 hours after rib resection, the subclavian vein rethrombosed. The patient was thought to have experienced a small pulmonary embolus.
Conclusions: Individuals who participate in athletics can develop atraumatic upper extremity deep venous thrombosis. Therefore, it is important that team physicians and certified athletic trainers be prepared to recognize the signs and symptoms of this condition to institute prompt, appropriate treatment.
PMCID: PMC1472647  PMID: 16791307
Paget-Schroetter syndrome; heparin; urokinase; stent placement
11.  Knee Joint Effusion and Cryotherapy Alter Lower Chain Kinetics and Muscle Activity 
Journal of Athletic Training  2006;41(2):177-184.
Context: Cryotherapy has been shown to disinhibit the quadriceps muscle after joint effusion by a resting measure (Hoffmann reflex) of motor recruitment. I sought to determine whether cryotherapy-induced motor recruitment changes resulted in subsequent changes in functional movement.
Objective: To quantify muscle recruitment changes and knee joint function after joint effusion and subsequent joint cryotherapy.
Design: A 3 × 4 multivariate mixed-model design was used to compare groups (normative, effusion/control, effusion/cryotherapy) across time (preinjection, postinjection, 30 minutes postinjection, and 60 minutes postinjection).
Setting: Human performance laboratory.
Patients or Other Participants: Forty-five volunteers (26 males, 19 females; age = 21 ± 2 years, height = 174.8 ± 10.2 cm, mass = 78.1 ± 15.4 kg).
Intervention(s): Experimental joint effusion was used to elicit inhibition of the quadriceps muscle. Cryotherapy was a treatment intervention.
Main Outcome Measure(s): Lower chain peak joint torque, peak and average power, knee anterior joint reaction force, and average and peak vastus medialis, vastus lateralis, medial hamstrings, and gastrocnemius muscle normalized electromyographic activity were collected during the extension phase of a seated, recumbent stepping motion with a resistance of 36% of 1-repetition maximum and a controlled cadence of 1.5 Hz.
Results: Decreases in peak torque and peak power were observed after effusion, whereas no decrease was observed over time in the cryotherapy or normative groups. A decrease in peak vastus lateralis activity was also noted after effusion relative to other groups. Also, the effusion/cryotherapy group had a greater knee anterior joint reaction force relative to the effusion/control and normative groups after effusion.
Conclusions: Joint cryotherapy negated movement deficiencies represented by knee peak torque and power decreases. This could be due to facilitated vastus lateralis activation relative to other groups.
PMCID: PMC1472646  PMID: 16791303
arthrogenic muscle inhibition; disinhibition; cryokinetics
12.  Organizational Influences and Quality-of-Life Issues During the Professional Socialization of Certified Athletic Trainers Working in the National Collegiate Athletic Association Division I Setting 
Journal of Athletic Training  2006;41(2):189-195.
Context: Health professionals are exposed to critical influences and pressures when socialized into their work environments. Little is known about the organizational socialization of certified athletic trainers (ATs) in the collegiate context.
Objective: To discuss the organizational influences and quality-of-life issues as each relates to the professional socialization of ATs working in the National Collegiate Athletic Association Division I setting.
Design: A qualitative design of in-depth interviews and follow-up electronic interviews was used to examine the organizational socialization of ATs.
Setting: Participants associated with Division I athletic programs from 4 National Athletic Trainers' Association districts volunteered for the study.
Participants: A total of 11 men and 5 women participated in the study, consisting of 14 ATs and 2 athletic directors.
Data Collection and Analysis: Interviews were transcribed verbatim and analyzed inductively. A peer review, member checks, and data source triangulation were performed to establish trustworthiness.
Results: Two categories emerged that provide insight into the experiences that affected the professional socialization of the ATs: organizational influences and quality-of-life issues. The data indicate that the participants in this study were heavily influenced by the bureaucratic tendencies of the Division I athletic organizations in which they worked. The participants were extremely concerned about the diminished quality of life that may result from being an AT in this context. They were, however, able to maintain a commitment to delivering quality care to the student-athletes despite these influences. High work volume and low administrative support were commonly cited as problems, thus creating concern about diminished quality of life and the fear of burnout.
Conclusions: The AT's role appears not only rewarding but also challenging. The reward is working closely with patients and developing an interpersonal bond; the challenge is dealing with a bureaucratic structure and balancing one's professional and personal lives to prevent burnout. Thought should be given to using intervention strategies to mitigate the negative influences on the AT's role.
PMCID: PMC1472645  PMID: 16791305
bureaucracy; qualitative research; role strain
13.  Outbreak of Community-Acquired Methicillin-Resistant Staphylococcus aureus Skin Infections Among a Collegiate Football Team  
Journal of Athletic Training  2006;41(2):141-145.
Context: Methicillin-resistant Staphylococcus aureus (MRSA) was once primarily a hospital-acquired organism, but now community-acquired MRSA (CA-MRSA) is causing outbreaks among otherwise healthy sport participants.
Objective: To investigate MRSA skin and soft tissue outbreaks within a collegiate football team and the effect of infection control measures over 3 years.
Design: Retrospective analysis.
Setting: College.
Patients or Other Participants: Collegiate football team.
Intervention(s): Infection control measures included education, following Centers for Disease Control and Prevention recommendations, nasal cultures, hexachlorophene 3% soap, disposable towels, and hand sanitizers.
Main Outcome Measure(s): Number of MRSA infections and hospitalizations.
Results: Complicated skin and soft tissue infections (those requiring surgical debridement and/or hospitalization) were diagnosed in 2 (1.8%) of 107 players in 2002, 17 (15.8%) of 107 players in 2003, and 1 (0.96%) of 104 players in 2004.
Conclusions: Outbreaks of CA-MRSA in sports teams are very serious, and recognition is crucial. Treatment includes incision for proper drainage, bacterial culture and sensitivity, and appropriate antibiotic therapy. Infection control measures include educating athletes and staff, following Centers for Disease Control and Prevention recommendations, identifying CA-MRSA carriers with nasal cultures, introducing hexachlorophene 3% soap intermittently in the showers, making alcohol-based hand sanitizers available on the field, disinfecting weight training and rehabilitation equipment, and using disposable towels on the field during practices and games.
PMCID: PMC1472644  PMID: 16791297
infectious disease; cellulitis; spider bites
15.  Heel Lifts and the Stance Phase of Gait in Subjects With Limited Ankle Dorsiflexion 
Journal of Athletic Training  2006;41(2):159-165.
Context: Heel lifts are often prescribed as part of the treatment program for patients with overuse injuries associated with limited ankle dorsiflexion. However, little is known about how joint kinematics and temporal variables are affected by heel lifts.
Objective: To determine the effects of heel lifts on selected lower extremity kinematic and temporal variables during the stance phase of gait in subjects with limited ankle dorsiflexion.
Design: Two-way, fully repeated-measures design. The 2 factors were side (right or left) and walking condition (shoes alone, 6-mm heel lifts in shoes, 9-mm heel lifts in shoes).
Setting: University biomechanics laboratory.
Patients or Other Participants: Twenty-six volunteers (21 females, 5 males) with no more than 5° of ankle joint dorsiflexion.
Intervention(s): Subjects were tested in shoes alone and in shoes with 6-mm and 9-mm heel lifts.
Main Outcome Measure(s): We used the Qualisys Motion Analysis System to measure ankle dorsiflexion excursion, maximal knee extension, and time to heel off during the stance phase of gait under the 3 walking conditions.
Results: On the right side, ankle dorsiflexion excursion increased significantly with the 6-mm and 9-mm heel lifts compared with shoes alone ( P < .05). On the left side, ankle dorsiflexion increased significantly with the 9-mm heels lifts over shoes alone and with the 9-mm heel lifts compared with the 6-mm heel lifts ( P < .05). Time to heel off increased significantly for walking with the 9-mm heel lifts compared with shoes alone ( P < .05). No differences were noted for maximal knee extension ( P > .05).
Conclusions: Clinicians may consider prescribing heel lifts for patients with limited dorsiflexion range of motion if increasing ankle dorsiflexion excursion and time to heel off during the stance phase of gait may be beneficial.
PMCID: PMC1472642  PMID: 16791300
gait analysis; time to heel off; ankle dorsiflexion; knee extension
16.  How Useful Are Physical Examination Procedures? Understanding and Applying Likelihood Ratios 
Journal of Athletic Training  2006;41(2):201-206.
Objective: To describe the calculation and interpretation of likelihood ratios for examination procedures performed by certified athletic trainers.
Background: Physical examination procedures or “special tests” are commonly taught to athletic training students and performed by certified athletic trainers. Likelihood ratios offer an approach to assessing test performance that incorporates estimates of sensitivity and specificity into a clinically useful value. We describe the calculation of likelihood ratios and the application of likelihood ratios to clinical decision making.
Recommendations: The performance characteristics of physical examination procedures taught and practiced in athletic training should be considered in the planning of course materials as well as test interpretation after a physical examination. Research is needed to better understand how well physical examination procedures, when performed by certified athletic trainers, identify those athletes with and without specific musculoskeletal injuries.
PMCID: PMC1472641  PMID: 16791308
evidence-based medicine; Lachman test; McMurray test
17.  Journal Writing as a Teaching Technique to Promote Reflection 
Journal of Athletic Training  2006;41(2):216-221.
Objective: To introduce the process of journal writing to promote reflection and discuss the techniques and strategies to implement journal writing in an athletic training education curriculum.
Background: Journal writing can facilitate reflection and allow students to express feelings regarding their educational experiences. The format of this writing can vary depending on the students' needs and the instructor's goals.
Description: Aspects of journal writing assignments are discussed, including different points to take into account before assigning the journals. Lastly, various factors to contemplate are presented when providing feedback to the students regarding their written entries.
Clinical Advantages: Journal writing assignments can benefit students by enhancing reflection, facilitating critical thought, expressing feelings, and writing focused arguments. Journal writing can be adapted into a student's clinical course to assist with bridging the gap between classroom and clinical knowledge. In addition, journals can assist athletic training students with exploring different options for handling daily experiences.
PMCID: PMC1472640  PMID: 16791310
reflection; pedagogy; education
19.  Issues in Estimating Risks and Rates in Sports Injury Research 
Journal of Athletic Training  2006;41(2):207-215.
Objective: To describe 3 measures of incidence used in sports injury epidemiology.
Background: To promote safety in sports, athletic trainers must be able to accurately interpret and apply injury data and statistics. Doing so allows them to more efficiently articulate this information to school administrators in recommending increases in medical resources, such as more personnel, better services, and safer facilities and equipment.
Description: Using data from a study of high school sports injuries, we review incidence rates, epidemiologic incidence proportions, and clinical incidence. The incidence rate is the number of injuries divided by the number of athlete-exposures and is based on the epidemiologic concept of person-time at risk. It accounts for variation in exposure between athletes and teams and is widely used by researchers. The epidemiologic incidence proportion is the number of injured athletes divided by the number of athletes at risk. It is a valid estimator of average injury risk, yet it is rarely used in sports injury epidemiology to communicate information about such risks to nonscientists. Clinical incidence is a hybrid between the epidemiologic incidence proportion and the incidence rate in that it uses the number of injuries in the numerator but the number of athletes at risk in the denominator. It has been widely used in research on high school football injury but is neither a valid estimator of risk nor a true rate.
Advantages: Athletic trainers who understand the causes of and risk factors for sport-related injury are better positioned to make safe return-to-play decisions and decrease the likelihood of reinjury in athletes.
PMCID: PMC1472638  PMID: 16791309
injury epidemiology; injury prevention
20.  Creatine Supplementation and Anterior Compartment Pressure During Exercise in the Heat in Dehydrated Men 
Journal of Athletic Training  2006;41(1):30-35.
Context: Theoretically, the risk of compartment syndrome is increased during creatine monohydrate (CrM) supplementation because of intracellular fluid retention in muscle cells and the overall increased size of the muscle tissue. Whether this change in intracellular fluid is associated with an increase in anterior compartment pressure in the lower leg when subjects are under thermal stress is unknown.
Objective: To assess the influence of CrM on the resting and postexercise anterior compartment pressure of the lower leg in mildly to moderately dehydrated males exercising in the heat.
Design: Double-blind, randomized, crossover design.
Setting: Human Performance Laboratory.
Patients or Other Participants: Eleven well-trained, non– heat-acclimated, healthy males (age = 22 ± 2 years, height = 181.1 ± 7 cm, mass = 78.4 ± 4.2 kg, V̇o2max = 50.5 ± 3.4 mL·kg−1·min−1).
Intervention(s): Subjects were supplemented with 21.6 g/d of CrM or placebo for 7 days. On day 7, they performed 2 hours of submaximal exercise, alternating 30 minutes of walking with 30 minutes of cycling in the heat, resulting in approximately 2% dehydration. This was followed by an 80-minute heat tolerance test (temperature = 33.5 ± 0.5°C, humidity = 41.0 ± 12%), which included 12 repetitions of a 3-minute walk (pace = 4.0 ± 0.1 miles/h, intensity = 37.1 ± 6.1% V̇o2max) alternating with a 1-minute, high-intensity run (pace = 11.8 ± 0.4 miles/h, intensity = 115.0 ± 5.6% V̇o2max), resulting in an additional 2% decrease in body weight.
Main Outcome Measures: Before supplementation and on day 7 of supplementation, anterior compartment pressure was measured at rest, after dehydration, and at 1, 3, 5, 10, 15, and 60 minutes after the heat tolerance test. Analysis of variance with repeated measures was calculated to compare differences within the trials and time points and to identify any interaction between trial and time.
Results: The CrM intake was associated with an increase in body weight (P < .05). A moderate effect size was noted for compartment pressures between the trials for the differences between predehydration and postdehydration (η2 = 0.414). This effect diminished substantially by 3 minutes after the heat tolerance test. Compared with the placebo trial, the change in anterior compartment pressure from rest to dehydration was greater, as was the change from rest to 1 minute after the heat tolerance test (P < .05) during the CrM trial.
Conclusions: A 7-day loading dose of CrM increased anterior compartment pressures after dehydration and immediately after the heat tolerance tests, but the changes did not induce symptoms and the pressure changes were transient.
PMCID: PMC1421498  PMID: 16619092
ergogenic aids; compartment syndrome; thermoregulation
21.  Dehydration and Symptoms of Delayed-Onset Muscle Soreness in Normothermic Men 
Journal of Athletic Training  2006;41(1):36-45.
Context: A dehydrated individual who performs eccentric exercise may exacerbate skeletal muscle damage, leading to structural, contractile, and enzymatic protein denaturation, in addition to the myofiber and connective damage resulting from the eccentric muscle tension.
Objective: To identify the effects of dehydration on 5 physiologic characteristics of delayed-onset muscle soreness (DOMS) in normothermic men after an eccentric exercise perturbation.
Design: Randomized group test-retest design.
Setting: Laboratory.
Patients or Other Participants: Ten healthy male volunteers randomly assigned to either a euhydration (age = 26.2 ± 4.9 years, height = 174.1 ± 6.0 cm, mass = 86.5 ± 15.3 kg) or dehydration (age = 25.8 ± 2.2 years, height = 177.2 ± 3.1 cm, mass = 84.4 ± 3.8 kg) group.
Intervention(s): Subjects performed treadmill walking for 45 minutes in either a thermoneutral (euhydration) or a hot, humid (dehydration) environment. After a rest period to allow for return to the normothermic condition, DOMS was induced with a 45-minute downhill run.
Main Outcome Measures: We assessed 5 physiologic characteristics of DOMS before and at intervals after the eccentric exercise. The characteristics were perceived pain of the bilateral quadriceps and overall body, bilateral punctate tenderness of the superficial quadriceps muscles, bilateral knee-flexion passive range of motion, bilateral thigh circumference, and bilateral isometric quadriceps muscle strength. Thermoregulatory and cardiovascular measures were obtained to monitor participants' heat load during exercise.
Results: The experimental protocol produced a 0.9% increase in body mass of the euhydration group and a significant 2.7% decrease in body mass of the dehydration group. The downhill-running exercise perturbation induced DOMS in both the euhydrated and dehydrated participants, based on increased bilateral quadriceps and overall body perceived pain and punctate tenderness of the bilateral vastus medialis muscle. The signs and symptoms of DOMS after an eccentric exercise perturbation were not exacerbated by moderate dehydration of 2.7% body mass after rest and return to the normothermic condition.
Conclusions: Significantly dehydrated participants who rested and returned to a normothermic condition did not experience increased characteristics of DOMS.
PMCID: PMC1421497  PMID: 16619093
euhydration; euthermic; thermal regulation; eccentric exercise
22.  Creatine Use and Exercise Heat Tolerance in Dehydrated Men 
Journal of Athletic Training  2006;41(1):18-29.
Context: Creatine monohydrate (CrM) use is highly prevalent in team sports (eg, football, lacrosse, ice hockey) and by athletes at the high school, college, professional, and recreational levels. Concerns have been raised about whether creatine use is associated with increased cramping, muscle injury, heat intolerance, and risk of dehydration.
Objective: To assess whether 1 week of CrM supplementation would compromise hydration status, alter thermoregulation, or increase the incidence of symptoms of heat illness in dehydrated men performing prolonged exercise in the heat.
Design: Double-blind, randomized, crossover design.
Setting: Human Performance Laboratory.
Patients or Other Participants: Twelve active males, age = 22 ± 1 year, height = 180 ± 3 cm, mass = 78.8 ± 1.2 kg, body fat = 9 ± 1%, V̇o2peak = 50.9 ± 1 ml·kg−1·min−1.
Intervention(s): Subjects consumed 21.6 g·d−1 of CrM or placebo for 7 days, underwent 48 ± 10 days of washout between treatments, and then crossed over to the alternate treatment in the creatine group. On day 7 of each treatment, subjects lost 2% body mass by exercising in 33.5°C and then completed an 80-minute exercise heat-tolerance test (33.5°C ± 0.5°C, relative humidity = 41 ± 12%). The test consisted of four 20-minute sequences of 4 minutes of rest, alternating a 3-minute walk and 1-minute high-intensity run 3 times, and walking for 4 minutes.
Main Outcome Measures: Thermoregulatory, cardiorespiratory, metabolic, urinary, and perceptual responses.
Results: On day 7, body mass had increased 0.88 kg. No interaction or treatment differences for placebo versus CrM during the exercise heat-tolerance test were noted in thermoregulatory (rectal temperature, 39.3 ± 0.4°C versus 39.4 ± 0.4°C) cardiorespiratory (V̇o2, 21.4 ± 2.7 versus 20.0 ± 1.8 ml·kg−1·min−1; heart rate, 192 ± 10 versus 192 ± 11 beats·min−1; mean arterial pressure, 90 ± 9 versus 88 ± 5 mm Hg), metabolic (lactate, 6.7 ± 2.7 versus 7.0 ± 3.0 mmol·L−1), perceptual thirst (thirst, 7 ± 1 versus 7 ± 1; thermal sensation, 8 ± 2 versus 8 ± 1; rating of perceived exertion, 17 ± 3 versus 17 ± 2), plasma glucose (0–20 minutes of exercise heat-tolerance, 6.5 ± 1.2 versus 6.8 ± 0.8 mmol·L−1), plasma (297 ± 5 versus 300 ± 4 mOsm·kg−1) and urine (792 ± 117 versus 651 ± 134 mOsm·kg−1), urine specific gravity (1.025 ± 0.003 versus 1.030 ± 0.005) and urine color (7 ± 1 versus 6 ± 1) measures were increased during CrM. Environmental Symptoms Questionnaire scores were similar between treatments. The levels of dehydration incurred during dehydration and the exercise heat-tolerance test were similar and led to similar cumulative body mass losses (−4.09 ± 0.53 versus −4.38 ± 0.58% body mass).
Conclusions: Short-term CrM supplementation did not increase the incidence of symptoms or compromise hydration status or thermoregulation in dehydrated, trained men exercising in the heat.
PMCID: PMC1421496  PMID: 16619091
hydration; thermoregulation; cardiovascular system; metabolism; ergogenic aids
23.  Stylistic Learning Differences Between Undergraduate Athletic Training Students and Educators: Gregorc Mind Styles 
Journal of Athletic Training  2006;41(1):109-116.
Context: Learning theory and pedagogic research are unfamiliar to many educators trained in the sciences. Athletic training educators must learn to appreciate the theoretic and practical value of pedagogic research, including learning styles.
Objective: To extend the learning styles research in athletic training by introducing the Mind Styles model and Gregorc Style Delineator instrument to investigate students' and program directors' baseline style preferences and to study the effects of sex, education level, and academic role on mean composite Gregorc Style Delineator scores.
Design: Correlational research design.
Setting: Instruments were mailed to program directors and administered in classroom settings.
Patients or Other Participants: Ten of 10 athletic training programs accredited by the Commission on Accreditation of Allied Health Education Programs formed sample 1, with 200 undergraduate athletic training students (68 men, 132 women, age = 20.12 ± 2.02 years). A total of 43 program directors (22 men, 21 women, age = 40.05 ± 9.30 years) created sample 2.
Main Outcome Measure(s): We used the Gregorc Style Delineator to measure participants' perceptual and ordering abilities, combining them in a quaternary design to create mean composite scores for the Concrete Sequential (CS), Abstract Sequential (AS), Abstract Random (AR), and Concrete Random (CR) Mind Styles subscales. We also noted each subject's sex, education level, and academic role.
Results: We obtained a response rate of 100% of undergraduates and 43% of program directors. The CS style was preferred by 44.5% (n = 89) of students and 58.1% (n = 25) of program directors. Program directors preferred the CS style more (P < .001) and the AS and AR styles less (P < .001) than predicted by χ2 testing. Students preferred the CS style more (P < .001) and the AS style less (P < .001) than expected also. Men students preferred the AS style more (P < .01) and the AR style less (P < .01) than women students. Students by χ2 testing were also less likely to prefer the CS style (P < .01) and more likely to prefer the AR style (P < .001) than program directors. No significant main effect was noted for education level (P = .310) or the interaction (P = .108).
Conclusions: Our findings add 2 unique elements to the athletic training literature by extending the investigation of styles to an original model (Mind Styles) and the effect of academic role on style. Program directors should strongly consider sex and academic role style differences when designing and implementing pedagogic methods.
PMCID: PMC1421495  PMID: 16619103
learning styles; cognitive styles; cognitive psychology; educational psychology; athletic training education
24.  Accuracy of 3 Diagnostic Tests for Anterior Cruciate Ligament Tears 
Journal of Athletic Training  2006;41(1):120-121.
Reference: Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract20035268969412967539.
Clinical Question: In patients presenting with possible rupture of the anterior cruciate ligament (ACL), which diagnostic test can provide an accurate diagnosis during the physical examination?
Data Sources: Two reviewers searched MEDLINE (1966 to February 14, 2003) and EMBASE (1980 to February 14, 2003). Articles written in English, French, German, or Dutch were included. The key search terms were knee injuries, knee joint, and knee. These terms were combined with the headings joint instability and anterior cruciate ligament, as well as the text words laxity, instability, cruciate, and effusion. The results of these searches were combined with the subject headings sensitivity and specificity, physical examination, and not (animal not [human and animal]). Additional text words searched were sensitivit*, specificit*, false positive, false negative, accuracy, screening, physical examination, and clinical examination. The reference lists of included articles were examined.
Study Selection: Inclusion criteria consisted of (1) investigation of at least one physical diagnostic test for assessment of ACL ruptures in the knee and (2) the use of a reference standard of arthrotomy, arthroscopy, or magnetic resonance imaging.
Data Extraction: Two independent reviewers extracted data from each included study. The methodologic quality of each test was assessed and recorded on a checklist for the screening of diagnostic tests (www.cochrane.de/cochrane/sadtdoc1.htm). The 3 diagnostic tests validated in this review were the pivot shift test, the anterior drawer test, and the Lachman test. A summary receiver operating characteristic curve was performed for each test, and the sensitivity, specificity, and predictive values were reported.
Main Results: The search strategy produced 1090 potentially eligible studies, of which 17 studies were selected. One study was included via reference list examination and 2 reports referred to the same study. Thus, 17 studies met the inclusion criteria and were used for this review. For the included studies, the sample size ranged from 32 to 300 patients. As for the age of the subjects, the authors of 4 studies failed to report it. Thus, the average age of patients across 13 of the 17 studies was 28.6 years. Authors of all studies failed to measure the clinical test and reference standard separately and with blinding. In addition, all but two studies had a significant degree of verification bias. Arthrotomy was the lone reference standard in 4 studies whereas arthrotomy/arthroscopy was the reference standard in 5 studies. Arthroscopy alone was the reference standard in 6 studies where only 2 studies used MRI as the reference standard. Authors of 8 studies examined the anterior drawer test and reported sensitivity values ranging from 0.18–0.92 and specificity values ranging from 0.78–0.98. When pooled together using the bivariate random effects model (BREM), the sensitivity value of the 8 studies was 0.2 and the specificity value was 0.88. Authors of 9 studies examined the Lachman test and reported sensitivity values ranging from 0.63–0.93 and specificity values ranging from 0.55–0.99. Pooled together using the BREM, the sensitivity value was 0.86 and the specificity value was 0.91. Lastly, authors of 6 studies examined the pivot shift test and reported sensitivity values ranging from 0.18–0.48 and specificity values ranging from 0.97–0.99. Data for the pivot shift test could not be pooled using the BREM because of the low number of available studies. Predictive values were reported graphically, with the pivot shift test having the highest positive predictive value and the Lachman test having the best negative predictive value.
Conclusions: Based on predictive value statistics, it can be concluded that during the physical examination, a positive result for the pivot shift test is the best for ruling in an ACL rupture, whereas a negative result to the Lachman test is the best for ruling out an ACL rupture. It can also be concluded that, solely using sensitivity and specificity values, the Lachman test is a better overall test at both ruling in and ruling out ACL ruptures. The anterior drawer test appears to be inconclusive for drawing strong conclusions either way.
PMCID: PMC1421494  PMID: 16619105
sensitivity; specificity; physical examination; knee; validity; joint instability
25.  Peer-Assisted Learning in the Athletic Training Clinical Setting 
Journal of Athletic Training  2006;41(1):102-108.
Context: Athletic training educators often anecdotally suggest that athletic training students enhance their learning by teaching their peers. However, peer-assisted learning (PAL) has not been examined within athletic training education in order to provide evidence for its current use or as a pedagogic tool.
Objective: To describe the prevalence of PAL in athletic training clinical education and to identify students' perceptions of PAL.
Design: Descriptive.
Setting: “The Athletic Training Student Seminar” at the National Athletic Trainers' Association 2002 Annual Meeting and Clinical Symposia.
Patients or Other Participants: A convenience sample of 138 entry-level male and female athletic training students.
Main Outcome Measure(s): Students' perceptions regarding the prevalence and benefits of and preferences for PAL were measured using the Athletic Training Peer-Assisted Learning Assessment Survey. The Survey is a self-report tool with 4 items regarding the prevalence of PAL and 7 items regarding perceived benefits and preferences.
Results: A total of 66% of participants practiced a moderate to large amount of their clinical skills with other athletic training students. Sixty percent of students reported feeling less anxious when performing clinical skills on patients in front of other athletic training students than in front of their clinical instructors. Chi-square analysis revealed that 91% of students enrolled in Commission on Accreditation of Allied Health Education Programs–accredited athletic training education programs learned a minimal to small amount of clinical skills from their peers compared with 65% of students in Joint Review Committee on Educational Programs in Athletic Training–candidacy schools (χ2 3 = 14.57, P < .01). Multiple analysis of variance revealed significant interactions between sex and academic level on several items regarding benefits and preferences.
Conclusions: According to athletic training students, PAL is occurring in the athletic training clinical setting. Entry-level students are utilizing their peers as resources for practicing clinical skills and report benefiting from the collaboration. Educators should consider deliberately integrating PAL into athletic training education programs to enhance student learning and collaboration.
PMCID: PMC1421493  PMID: 16619102
peer teaching; clinical instruction; athletic training students; peer education

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