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issn:1938-162
1.  Masthead 
Journal of Athletic Training  2015;50(12):1215-1216.
doi:10.4085/1062-6050-50.12.1215
PMCID: PMC4741243
2.  Table of Contents 
Journal of Athletic Training  2015;50(12):1217-1218.
doi:10.4085/1062-6050-50.12.1217
PMCID: PMC4741244
3.  Early Results of a Helmetless-Tackling Intervention to Decrease Head Impacts in Football Players 
Journal of Athletic Training  2015;50(12):1219-1222.
Objective
To test a helmetless-tackling behavioral intervention for reducing head impacts in National Collegiate Athletic Association Division I football players.
Design
Randomized controlled clinical trial.
Setting
Football field.
Patients or Other Participants
Fifty collegiate football players (intervention = 25, control = 25).
Intervention(s)
The intervention group participated in a 5-minute tackling drill without their helmets and shoulder pads twice per week in the preseason and once per week through the season. During this time, the control group performed noncontact football skills.
Main Outcome Measure(s)
Frequency of head impacts was recorded by an impact sensor for each athlete-exposure (AE). Data were tested with a 2 × 3 (group and time) repeated-measures analysis of variance. Significant interactions and main effects (P < .05) were followed with t tests.
Results
Head impacts/AE decreased for the intervention group compared with the control group by the end of the season (9.99 ± 6.10 versus 13.84 ± 7.27, respectively). The intervention group had 30% fewer impacts/AE than the control group by season's end (9.99 ± 6.10 versus 14.32 ± 8.45, respectively).
Conclusion
A helmetless-tackling training intervention reduced head impacts in collegiate football players within 1 season.
doi:10.4085/1062-6050-51.1.06
PMCID: PMC4741245  PMID: 26651278
injury prevention; athletic injuries; head and neck injuries
4.  Statistical Primer for Athletic Trainers: The Difference Between Statistical and Clinical Meaningfulness 
Journal of Athletic Training  2015;50(12):1223-1225.
Objective
To explain statistical significance and clinical meaningfulness and to provide guidance in evaluating the clinical meaningfulness of a study.
Background
Understanding the results and statistics reported in original research remains a large challenge for many certified athletic trainers, which in turn, may be among the biggest barriers to integrating research into athletic training practice.
Description
Statistical significance reflects the influence of chance on the outcome, whereas clinical meaningfulness reflects the degree to which the differences and relationships reported in a study are relevant to athletic training practice. As consumers of original research, athletic trainers must understand the core factors, most notably sample size, that influence statistical significance.
Recommendations
To assist clinicians in evaluating the clinical meaningfulness of a research study, authors should provide the core elements necessary for interpreting statistical significance and discuss the clinical meaningfulness of statistically significant findings.
doi:10.4085/1062-6050-51.1.04
PMCID: PMC4741246  PMID: 26771255
statistics; P values; research design
5.  Ankle-Dorsiflexion Range of Motion After Ankle Self-Stretching Using a Strap 
Journal of Athletic Training  2015;50(12):1226-1232.
Context
 A variety of ankle self-stretching exercises have been recommended to improve ankle-dorsiflexion range of motion (DFROM) in individuals with limited ankle dorsiflexion. A strap can be applied to stabilize the talus and facilitate anterior glide of the distal tibia at the talocrural joint during ankle self-stretching exercises. Novel ankle self-stretching using a strap (SSS) may be a useful method of improving ankle DFROM.
Objective
 To compare the effects of 2 ankle-stretching techniques (static stretching versus SSS) on ankle DFROM.
Design
 Randomized controlled clinical trial.
Setting
 University research laboratory.
Patients or Other Participants
 Thirty-two participants with limited active dorsiflexion (<20°) while sitting (14 women and 18 men) were recruited.
Main Outcome Measure(s)
 The participants performed 2 ankle self-stretching techniques (static stretching and SSS) for 3 weeks. Active DFROM (ADFROM), passive DFROM (PDFROM), and the lunge angle were measured. An independent t test was used to compare the improvements in these values before and after the 2 stretching interventions. The level of statistical significance was set at α = .05.
Results
 Active DFROM and PDFROM were greater in both stretching groups after the 3-week interventions. However, ADFROM, PDFROM, and the lunge angle were greater in the SSS group than in the static-stretching group (P < .05).
Conclusions
 Ankle SSS is recommended to improve ADFROM, PDFROM, and the lunge angle in individuals with limited DFROM.
doi:10.4085/1062-6050-51.1.01
PMCID: PMC4741247  PMID: 26633750
limited ankle dorsiflexion; rehabilitation; injury prevention
6.  Whole-Body Vibration While Squatting and Delayed-Onset Muscle Soreness in Women 
Journal of Athletic Training  2015;50(12):1233-1239.
Context
 Research into alleviating muscle pain and symptoms in individuals after delayed-onset muscle soreness (DOMS) has been inconsistent and unsuccessful in demonstrating a useful recovery modality.
Objective
 To investigate the effects of short-term whole-body vibration (WBV) on DOMS over a 72-hour period after a high-intensity exercise protocol.
Design
 Randomized controlled clinical trial.
Setting
 University laboratory.
Patients or Other Participants
 Thirty women volunteered to participate in 4 testing sessions and were assigned randomly to a WBV group (n = 16; age = 21.0 ± 1.9 years, height = 164.86 ± 6.73 cm, mass = 58.58 ± 9.32 kg) or a control group (n = 14; age = 22.00 ± 1.97 years, height = 166.65 ± 8.04 cm, mass = 58.69 ± 12.92 kg).
Intervention(s)
 Participants performed 4 sets to failure of single-legged split squats with 40% of their body weight to induce muscle soreness in the quadriceps. The WBV or control treatment was administered each day after DOMS.
Main Outcome Measure(s)
 Unilateral pressure-pain threshold (PPT), range of motion (ROM), thigh circumference, and muscle-pain ratings of the quadriceps were collected before and for 3 days after high-intensity exercise. Each day, we collected 3 sets of measures, consisting of 1 measure before the WBV or control treatment protocol (pretreatment) and 2 sets of posttreatment measures.
Results
 We observed no interactions for PPT, thigh circumference, and muscle pain (P > .05). An interaction was found for active ROM (P = .01), with the baseline pretreatment measure greater than the measures at baseline posttreatment 1 through 48 hours posttreatment 2 in the WBV group. For PPT, a main effect for time was revealed (P < .05), with the measure at baseline pretreatment greater than at 24 hours pretreatment and all other time points for the vastus medialis, greater than 24 hours pretreatment through 48 hours posttreatment 2 for the vastus lateralis, and greater than 24 hours pretreatment and 48 hours pretreatment for the rectus femoris. For dynamic muscle pain, we observed a main effect for time (P < .001), with the baseline pretreatment measure less than the measures at all other time points. No main effect for time was noted for thigh circumference (P = .24). No main effect for group was found for any variable (P > .05).
Conclusions
 The WBV treatment approach studied did not aid in alleviating DOMS after high-intensity exercise. Further research is needed in various populations.
doi:10.4085/1062-6050-51.1.02
PMCID: PMC4741248  PMID: 26599957
range of motion; edema; pressure-pain threshold
7.  Necessity of Removing American Football Uniforms From Humans With Hyperthermia Before Cold-Water Immersion 
Journal of Athletic Training  2015;50(12):1240-1246.
Context
 The National Athletic Trainers' Association and the American College of Sports Medicine have recommended removing American football uniforms from athletes with exertional heat stroke before cold-water immersion (CWI) based on the assumption that the uniform impedes rectal temperature (Trec) cooling. Few experimental data exist to verify or disprove this assumption and the recommendations.
Objectives
 To compare CWI durations, Trec cooling rates, thermal sensation, intensity of environmental symptoms, and onset of shivering when hyperthermic participants wore football uniforms during CWI or removed the uniforms immediately before CWI.
Design
 Crossover study.
Setting
 Laboratory.
Patients or Other Participants
 Eighteen hydrated, physically active men (age = 22 ± 2 years, height = 182.5 ± 6.1 cm, mass = 85.4 ± 13.4 kg, body fat = 11% ± 5%, body surface area = 2.1 ± 0.2 m2) volunteered.
Intervention(s)
 On 2 days, participants exercised in the heat (approximately 40°C, approximately 40% relative humidity) while wearing a full American football uniform (shoes; crew socks; undergarments; shorts; game pants; undershirt; shoulder pads; jersey; helmet; and padding over the thighs, knees, hips, and tailbone [PADS]) until Trec reached 39.5°C. Next, participants immersed themselves in water that was approximately 10°C while wearing either undergarments, shorts, and crew socks (NOpads) or PADS without shoes until Trec reached 38°C.
Main Outcome Measure(s)
 The CWI duration (minutes) and Trec cooling rates (°C/min).
Results
 Participants had similar exercise times (NOpads = 40.8 ± 4.9 minutes, PADS = 43.2 ± 4.1 minutes; t17 = 2.0, P = .10), hypohydration levels (NOpads = 1.5% ± 0.3%, PADS = 1.6% ± 0.4%; t17 = 1.3, P = .22), and thermal-sensation ratings (NOpads = 7.2 ± 0.3, PADS = 7.1 ± 0.5; P > .05) before CWI. The CWI duration (median [interquartile range]; NOpads = 6.0 [5.4] minutes, PADS = 7.3 [9.8] minutes; z = 2.3, P = .01) and Trec cooling rates (NOpads = 0.28°C/min ± 0.14°C/min, PADS = 0.21°C/min ± 0.11°C/min; t17 = 2.2, P = .02) differed between uniform conditions.
Conclusions
 Whereas participants cooled faster in NOpads, we still considered the PADS cooling rate to be acceptable (ie, >0.16°C/min). Therefore, if clinicians experience difficulty removing PADS or CWI treatment is delayed, they may immerse fully equipped hyperthermic football players in CWI and maintain acceptable Trec cooling rates. Otherwise, PADS should be removed preimmersion to ensure faster body core temperature cooling.
doi:10.4085/1062-6050-51.1.05
PMCID: PMC4741249  PMID: 26678288
clothing; equipment; exertional heat stroke; rectal temperature
8.  The Role of Personality in Job Satisfaction Among Collegiate Athletic Trainers 
Journal of Athletic Training  2015;50(12):1247-1255.
Context
 The degree to which an individual likes his or her job is known as job satisfaction. A person with higher job satisfaction is less likely to depart from a profession than a person with lower job satisfaction. Researchers studying job satisfaction among other allied health professionals suggest a personality component could explain why the reasons for departure can be so individual.
Setting
 Collegiate institutions.
Objective
 To determine the relationship between job satisfaction and personality among collegiate athletic trainers (ATs).
Patients or Other Participants
 A total of 202 ATs (68 [33.7%] men and 134 [66.3%] women), were recruited using the National Athletic Trainers' Association e-mail database. We excluded any AT from this study who worked outside of the collegiate setting. The response rate was 20.2%.
Intervention(s)
 Data were collected using a Web-based survey instrument consisting of 3 sections: (1) demographics, (2) job satisfaction survey, and (3) Big Five Personality Inventory.
Main Outcome Measure(s)
 Independent t tests were run to determine sex differences, and correlations were run to evaluate relationships between demographics and job satisfaction and between job satisfaction and personality.
Results
 Women reported higher levels of neuroticism than men. Extroversion and conscientiousness showed a weak positive relationship with job satisfaction. A moderate positive relationship was found between agreeableness and job satisfaction. A moderate negative relationship was noted between neuroticism and job satisfaction.
Conclusions
 Based on our findings, head ATs or other organizational leaders may consider using personality assessments during interview processes, or athletic training program directors may be able to better guide students interested in athletic training based on knowledge of their personalities.
doi:10.4085/1062-6050-50.11.08
PMCID: PMC4741250  PMID: 26599958
workplace influences; retention; sex differences
9.  Perceptions of Support Networks During the Graduate-Assistant Athletic Trainer Experience 
Journal of Athletic Training  2015;50(12):1256-1266.
Context
 The graduate-assistant position can be a highly influential experience because it is often the first time novice athletic trainers (ATs) are practicing autonomously.
Objective
 To gain an understanding of how graduate-assistant ATs (GAATs) perceive professional socialization and mentorship during their assistantships.
Design
 Semistructured phone interviews.
Setting
 Graduate-assistant ATs in various clinical settings.
Patients or Other Participants
 Twenty-five GAATs (20 women, 5 men) studying in 1 of 3 academic tracks (postprofessional athletic training = 8, athletic training-based curriculum = 11, non–athletic training-based curriculum = 6). Median age was 24 years.
Data Collection and Analysis
 Phone interviews were digitally recorded and transcribed verbatim. Data analysis used principles of the general inductive approach. Credibility was maintained using peer review, field notes, and intercoder reliability.
Results
 Participants identified peer support throughout their experiences, in both academic and clinical settings. The GAATs frequently relied on other GAATs for support due to shared experiences and understanding of workloads. Participants described difficulty receiving supervisor support from full-time staff ATs due to the supervisors' workload and time constraints, limiting their availability for mentoring. Guidance from academic support personnel occurred only in athletic training-centered academic programs. Communication emerged as helpful for incoming GAATs; the previous GAATs provided formal mentorship via job descriptions highlighting role responsibilities and expectations. Differences between assistantship types were noted only in terms of receiving balanced mentorship between the academic and clinical staffs, such that students studying in postprofessional athletic training programs perceived more balanced support.
Conclusions
 Our results confirm the literature regarding the GAAT's pursuit of continued formal mentoring. The GAATs perceived less support from full-time AT staff members due to limited availability. Therefore, GAATs leaned on their peers for support during the graduate experience.
doi:10.4085/1062-6050-50.11.09
PMCID: PMC4741251  PMID: 26565423
mentorship; peer support; support networks
10.  Athletic Trainers' Skills in Identifying and Managing Athletes Experiencing Psychological Distress 
Journal of Athletic Training  2015;50(12):1267-1276.
Context
Athletic trainers (ATs) commonly use psychological skills during sport rehabilitation. However, little is known about their ability to accurately implement these skills.
Objective
To assess ATs' skills in identifying psychological symptoms, selecting appropriate strategies, and making referral decisions for athletes experiencing various degrees of psychological distress.
Design
Cross-sectional study.
Setting
Participants were recruited using the National Athletic Trainers' Association professional member database.
Patients or Other Participants
Of the 2998 ATs who were selected randomly, 494 (16.5%) partially completed the questionnaire and 326 (10.9%) completed the entire survey (mean age = 34.7 ± 10.8 years, mean years of experience = 11.3 ± 9.9).
Main Outcome Measure(s)
Using the Web-based questionnaire created for this study, we collected ATs' demographic information and assessed their perceptions about responsibilities as ATs, psychosocial competencies, training in sport psychology, and referral behaviors. Additionally, respondents were asked to identify symptoms, match psychological strategies (eg, goal setting, imagery, progressive muscle relaxation), and make referral decisions for athletes in 3 case vignettes.
Results
The ATs demonstrated high accuracy in identifying symptoms and making referral decisions but struggled in selecting appropriate psychosocial strategies for athletes. Stepwise regression analyses revealed that ATs who had had specific coursework in sport psychology were able to more accurately identify symptoms (t = 3.01, P < .01), and those ATs with more experience reported lower accuracy scores for their intended course of action (t  =  −2.25, P < .05).
Conclusions
Our analogue research design provided new insights into ATs' knowledge and use of sport psychology in practice. The results highlighted the importance of coursework focusing on applied areas of sport psychology in the training of ATs.
doi:10.4085/1062-6050-50.12.02
PMCID: PMC4741252  PMID: 26599960
injury psychology; psychosocial strategies; assessment
11.  Staffing Levels at National Collegiate Athletic Association Football Bowl Subdivision-Level Institutions 
Journal of Athletic Training  2015;50(12):1277-1285.
Context
The “Appropriate Medical Coverage for Intercollegiate Athletics” (AMCIA) document was created to support assessment and calculation of athletic training personnel requirements. However, little is known regarding disparities between current and recommended staffing practices.
Objective
To identify the staffing and employment characteristics of athletic health care services at Football Bowl Subdivision-level institutions.
Design
Cross-sectional study.
Setting
Web-based survey.
Patients or Other Participants
Head athletic trainers and athletic training staff members who were knowledgeable about budget and staff.
Main Outcome Measure(s)
The survey, Assessment of Staffing Levels at National Collegiate Athletic Association Football Bowl Subdivision-Level Institutions, was used to evaluate personal, university, and staff demographics; staffing and employment topics; and AMCIA variables and use.
Results
The survey was accessed and partially completed by 104 individuals (response rate = 84.6%). A total of 79 athletic trainers (response rate = 76%) completed the entire survey. One-third of the respondents (34.2%, n = 26) met the recommended number of full-time equivalents (FTEs) for football, two-thirds of the respondents (65.7%, n = 50) failed to meet the recommendation, and 26.2% (n = 27) were missing data needed for FTE calculation. Among those who did not meet the recommended FTEs (n = 50), 38.0% (n = 19) were within 1 FTE of being compliant, 26.0% (n = 13) were within 2 FTEs, and 24.0% (n = 12) were within 3 FTEs. About one-third of respondents (35.9%, n = 37) reported not using the AMCIA, citing lack of funding (29.7%, n = 11), lack of administrative support (21.6%, n = 8), and other reasons (37.8%, n = 14).
Conclusions
The majority of institutions that used the AMCIA were able to provide justification for staffing. For most of the institutions that failed to meet their recommendation, adding 1–3 FTE athletic trainers for football would change their compliance status. A uniform definition of the term FTE within collegiate athletics is needed to allow for structured assessment and allocation of staffing and workloads.
doi:10.4085/1062-6050-50.12.04
PMCID: PMC4741253  PMID: 26599959
burnout; work-life balance; staffing; full-time equivalent; medical coverage
12.  High School Athletes' Parents' Perceptions and Knowledge of the Skills and Job Requirements of the Certified Athletic Trainer 
Journal of Athletic Training  2015;50(12):1286-1291.
Context
Parents play a crucial role in determining medical services for their children, and it is important they understand the scope of practice and skills of the athletic trainer (AT).
Objective
To understand parents' perceptions and knowledge of the skills and job requirements of the secondary school AT.
Design
Cross-sectional study.
Setting
Sport meetings and banquets at 5 high schools in southwest Michigan during the fall, winter, and spring seasons.
Patients or Other Participants
A total of 539 parents whose children competed in at least 1 high school sport participated.
Data Collection and Analysis
A Parents' Perceptions and Knowledge of Certified Athletic Trainers Survey consisting of 32 questions, divided into 3 sections (demographics, perceptions, and knowledge), was developed and given to parents of high school athletes. One-way analyses of variance were used to determine significance among 3 categories of experience and perception and knowledge of ATs.
Results
Of the 539 parents who responded, 28% responded yes, and 72% responded no to having experience with an AT for their own injuries. When asked if they had experience with an AT due to their child's injuries, 60% responded yes. We found a difference among the 3 categories of experience for perception scores (P = .002) and knowledge scores (P < .001).
Conclusions
In the absence of past experience with an AT, parents' perceptions and knowledge of the skills and job requirements of the secondary school AT are limited. Athletic trainers should educate parents on their professional roles, which may enhance their ability to provide better health care.
doi:10.4085/1062-6050-51.1.11
PMCID: PMC4741254  PMID: 26678289
secondary schools; awareness; guardians
13.  A Preliminary Formula to Predict Timing of Symptom Resolution for Collegiate Athletes Diagnosed With Sport Concussion 
Journal of Athletic Training  2015;50(12):1292-1298.
Context
Symptom presentation and recovery after sport concussion (SC) are variable. Empirically based models documenting typical symptom duration would assist health care providers in managing return to play after SC.
Objective
To develop a prediction model for SC symptom duration.
Design
Cross-sectional study.
Setting
Two National Collegiate Athletic Association Division I university laboratories.
Patients or Other Participants
Seventy-six (51 male and 25 female) concussed athletes with an average age of 19.5 ± 1.65 years who were evaluated within 24 hours of diagnosis.
Intervention(s)
Participants completed the Revised Head Injury Scale (HIS-r), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), and Sensory Organization Test within 24 hours of SC diagnosis.
Main Outcome Measure(s)
A stepwise multivariate regression incorporating ImPACT and Sensory Organization Test composites and HIS-r symptom severity-duration was used to predict the number of days athletes reported symptoms after SC. The resulting regression formula was cross-validated using the Stine cross-validation coefficient.
Results
The final formula consisted of the HIS-r's self-reported neck pain, drowsiness, tingling, and nervousness duration and ImPACT total symptom severity (R = 0.62, R2 = 39%, R2adj = 34.2%, P < .001). Approximately 29% (R2cv = 29%) of the variance associated with total days symptomatic after SC was explained by our preliminary formula when cross-validated. The current formula correctly identified 76% of participants who recovered within 10 days of injury.
Conclusions
Our results suggest that self-reported duration of 4 symptoms during the initial 24 hours after injury along with total symptom severity as measured by ImPACT accounted for a considerable amount of variance associated with days symptomatic after SC in collegiate athletes. Until the formula is cross-validated in a college-aged sample, caution is warranted in using it clinically.
doi:10.4085/1062-6050-50.12.03
PMCID: PMC4741255  PMID: 26565424
traumatic brain injuries; prediction; prolonged recovery; symptom severity; symptom duration
14.  Asymptomatic Elite Adolescent Tennis Players' Signs of Tendinosis in Their Dominant Shoulder Compared With Their Nondominant Shoulder 
Journal of Athletic Training  2015;50(12):1299-1305.
Context
Tennis is an asymmetric overhead sport with specific muscle-activation patterns, especially eccentrically in the rotator cuff. Magnetic resonance imaging (MRI) findings in asymptomatic adolescent elite tennis players have not previously been reported.
Objective
The first aim of the study was to describe MRI findings regarding adaptations or abnormalities, as well as muscle cross-sectional area (CSA), of the rotator cuff. The second aim of the study was to investigate the rotator cuff based on the interpretation of the MRI scans as normal versus abnormal, with the subdivision based on the grade of tendinosis, and its association with eccentric rotator cuff strength in the dominant arm (DA) of the asymptomatic elite adolescent tennis player.
Setting
Testing environment at the radiology department of Medicinsk Röntgen AB.
Patients or Other Participants
Thirty-five asymptomatic elite tennis players (age = 17.4 ± 2.7 years) were selected based on ranking and exposure time.
Intervention(s)
We assessed MRI scans and measured the CSA of the rotator cuff muscle. The non-DA (NDA) was used as a control. In addition, eccentric testing of the external rotators of the DA was performed with a handheld dynamometer.
Results
The DA and NDA displayed different frequencies of infraspinatus tendinosis (grade 1 changes) (P < .05). Rotator cuff measurements revealed larger infraspinatus and teres minor CSA (P < .05) in the DA than in the NDA. Mean eccentric external-rotation strength in the DA stratified by normal tendon and tendinosis was not different between groups (P = .723).
Conclusions
Asymptomatic adolescent elite tennis players demonstrated infraspinatus tendinosis more frequently in the DA than in the NDA. Clinicians must recognize these tendon changes in order to modify conditioning and performance programs appropriately.
doi:10.4085/1062-6050-51.1.07
PMCID: PMC4741256  PMID: 26651279
magnetic resonance imaging; adolescents; overhead athletes; tennis
15.  Accuracy of Urine Color to Detect Equal to or Greater Than 2% Body Mass Loss in Men 
Journal of Athletic Training  2015;50(12):1306-1309.
Context
 Clinicians and athletes can benefit from field-expedient measurement tools, such as urine color, to assess hydration state; however, the diagnostic efficacy of this tool has not been established.
Objective
 To determine the diagnostic accuracy of urine color assessment to distinguish a hypohydrated state (≥2% body mass loss [BML]) from a euhydrated state (<2% BML) after exercise in a hot environment.
Design
 Controlled laboratory study.
Setting
 Environmental chamber in a laboratory.
Patients or Other Participants
 Twenty-two healthy men (age = 22 ± 3 years, height = 180.4 ± 8.7 cm, mass = 77.9 ± 12.8 kg, body fat = 10.6% ± 4.6%).
Intervention(s)
 Participants cycled at 68% ± 6% of their maximal heart rates in a hot environment (36°C ± 1°C) for 5 hours or until 5% BML was achieved. At the point of each 1% BML, we assessed urine color.
Main Outcome Measure(s)
 Diagnostic efficacy of urine color was assessed using receiver operating characteristic curve analysis, sensitivity, specificity, and likelihood ratios.
Results
 Urine color was useful as a diagnostic tool to identify hypohydration after exercise in the heat (area under the curve = 0.951, standard error = 0.022; P < .001). A urine color of 5 or greater identified BML ≥2% with 88.9% sensitivity and 84.8% specificity (positive likelihood ratio = 5.87, negative likelihood ratio = 0.13).
Conclusions
 Under the conditions of acute dehydration due to exercise in a hot environment, urine color assessment can be a valid, practical, inexpensive tool for assessing hydration status. Researchers should examine the utility of urine color to identify a hypohydrated state under different BML conditions.
doi:10.4085/1062-6050-51.1.03
PMCID: PMC4741257  PMID: 26642041
diagnostic accuracy; hydration; field measurement; sensitivity; specificity
16.  Methods and Descriptive Epidemiology of Services Provided by Athletic Trainers in High Schools: The National Athletic Treatment, Injury and Outcomes Network Study 
Journal of Athletic Training  2015;50(12):1310-1318.
Context
Research is limited on the extent and nature of the care provided by athletic trainers (ATs) to student-athletes in the high school setting.
Objective
To describe the methods of the National Athletic Treatment, Injury and Outcomes Network (NATION) project and provide the descriptive epidemiology of AT services for injury care in 27 high school sports.
Design
Descriptive epidemiology study.
Setting
Athletic training room (ATR) visits and AT services data collected in 147 high schools from 26 states.
Patients or Other Participants
High school student-athletes participating in 13 boys' sports and 14 girls' sports during the 2011−2012 through 2013−2014 academic years.
Main Outcome Measure(s)
The number of ATR visits and individual AT services, as well as the mean number of ATR visits (per injury) and AT services (per injury and ATR visit) were calculated by sport and for time-loss (TL) and non–time-loss (NTL) injuries.
Results
Over the 3-year period, 210 773 ATR visits and 557 381 AT services were reported for 50 604 injuries. Most ATR visits (70%) were for NTL injuries. Common AT services were therapeutic activities or exercise (45.4%), modalities (18.6%), and AT evaluation and reevaluation (15.9%), with an average of 4.17 ± 6.52 ATR visits and 11.01 ± 22.86 AT services per injury. Compared with NTL injuries, patients with TL injuries accrued more ATR visits (7.76 versus 3.47; P < .001) and AT services (18.60 versus 9.56; P < .001) per injury. An average of 2.24 ± 1.33 AT services were reported per ATR visit. Compared with TL injuries, NTL injuries had a larger average number of AT services per ATR visit (2.28 versus 2.05; P < .001).
Conclusions
These findings highlight the broad spectrum of care provided by ATs to high school student-athletes and demonstrate that patients with NTL injuries require substantial amounts of AT services.
doi:10.4085/1062-6050-51.1.08
PMCID: PMC4741258  PMID: 26678290
medical coverage; sports; injury surveillance; NATION
17.  False-Positive Rates of Reliable Change Indices for Concussion Test Batteries: A Monte Carlo Simulation 
Journal of Athletic Training  2015;50(12):1319-1322.
Background
 Neurocognitive testing is widely performed for the assessment of concussion. Athletic trainers can use preseason baselines with reliable change indices (RCIs) to ascertain whether concussed athletes' cognitive abilities are below preinjury levels. Although the percentage of healthy individuals who show decline on any individual test is determined by its RCI's confidence level (eg, 10% false-positive rate using an RCI with an 80% confidence interval), the expected rate of 1 or more significant RCIs across multiple indices is unclear.
Objective
 To use a Monte Carlo simulation procedure to estimate the normal rate (ie, base rate) of significant decline on 1 or more RCIs in multitest batteries.
Results & Conclusion
 For batteries producing 7 or more uncorrelated RCIs (80% confidence intervals), the majority of normal individuals would show significant declines on at least 1 RCI. Expected rates are lower for tests with fewer indices, higher inter-RCI correlations, and more stringent impairment criteria. These reference points can help testers interpret RCI output for multitest batteries.
doi:10.4085/1062-6050-51.1.09
PMCID: PMC4741259  PMID: 26678291
neurocognitive assessment; base rates; impairment
18.  Masthead 
Journal of Athletic Training  2015;50(11):1113-1114.
doi:10.4085/1062-6050-50.11.1113
PMCID: PMC4732388
19.  Table of Contents 
Journal of Athletic Training  2015;50(11):1115-1116.
doi:10.4085/1062-6050-50.11.1115
PMCID: PMC4732389
20.  Shoulder Coordination During Full-Can and Empty-Can Rehabilitation Exercises 
Journal of Athletic Training  2015;50(11):1117-1125.
Context
Supraspinatus tear is a common rotator cuff injury. During rehabilitation, debate persists regarding the most appropriate exercises. Whereas shoulder coordination is part of normal arm function, it has been infrequently considered in the context of exercise selection.
Objective
To assess shoulder-motion coordination during 2 common supraspinatus rehabilitation exercises and to characterize load and motion-direction influences on shoulder coordination.
Design
Descriptive laboratory study.
Setting
Motion-analysis laboratory.
Patient or Other Participants
Fifteen asymptomatic right-hand–dominant men (age = 26 ± 4 years, height = 1.77 ± 0.06 m, mass = 74.3 ± 7.7 kg).
Intervention(s)
Full-can and empty-can exercises with and without a 2.27-kg load.
Main Outcome Measure(s)
We recorded motion with an optoelectronic system. Scapulohumeral rhythm and complete shoulder joint kinematics were calculated to quantify shoulder coordination. The effects of exercise type, load, motion direction, and humerothoracic-elevation angle on the scapulohumeral rhythm and shoulder-joint angles were assessed.
Results
We observed multivariate interactions between exercise type and humerothoracic elevation and between load and humerothoracic elevation. Scapulohumeral rhythm increased by a mean ratio of 0.44 ± 0.22 during the full-can exercise, whereas the addition of load increased mean glenohumeral elevation by 4° ± 1°.
Conclusions
The full-can exercise increased the glenohumeral contribution, as hypothesized, and showed normal shoulder coordination. During the empty-can exercise, the increased scapulothoracic contribution was associated with a compensatory pattern that limits the glenohumeral contribution. Using loads during shoulder rehabilitation seems justified because the scapulohumeral rhythm is similar to that of unloaded arm elevation. Finally, motion direction showed a limited effect during the exercises in healthy individuals.
doi:10.4085/1062-6050-50.9.06
PMCID: PMC4732390  PMID: 26451620
kinematics; shoulder joint; scapulohumeral rhythm; supraspinatus muscle
21.  Selective Activation of Shoulder, Trunk, and Arm Muscles: A Comparative Analysis of Different Push-Up Variants 
Journal of Athletic Training  2015;50(11):1126-1132.
Context
The push-up is a widely used exercise for upper limb strengthening that can be performed with many variants. A comprehensive analysis of muscle activation during the ascendant phase (AP) and descendant phase (DP) in different variants could be useful for trainers and rehabilitators.
Objective
To obtain information on the effect of different push-up variants on the electromyography (EMG) of a large sample of upper limb muscles and to investigate the role of the trunk and abdomen muscles during the AP and DP.
Design
Cross-sectional study.
Setting
University laboratory.
Patients or Other Participants
Eight healthy, young volunteers without a history of upper extremity or spine injury.
Intervention(s)
Participants performed a set of 10 repetitions for each push-up variant: standard, wide, narrow, forward (FP), and backward (BP). Surface EMG of 12 selected muscles and kinematics data were synchronously recorded to describe the AP and DP.
Main Outcome Measure(s)
Mean EMG activity of the following muscles was analyzed: serratus anterior, deltoideus anterior, erector spinae, latissimus dorsi, rectus abdominis, triceps brachii caput longus, triceps brachii caput lateralis, obliquus externus abdominis, pectoralis major sternal head, pectoralis major clavicular head, trapezius transversalis, and biceps brachii.
Results
The triceps brachii and pectoralis major exhibited greater activation during the narrow-base variant. The highest activation of abdomen and back muscles was recorded for the FP and BP variants. The DP demonstrated the least electrical activity across all muscles, with less marked differences for the abdominal and erector spinae muscles because of their role as stabilizers.
Conclusions
Based on these findings, we suggest the narrow-base variant to emphasize triceps and pectoralis activity and the BP variant for total upper body strength conditioning. The FP and BP variants should be implemented carefully in participants with low back pain because of the greater activation of abdominal and back muscles.
doi:10.4085/1062-6050-50.9.09
PMCID: PMC4732391  PMID: 26488636
fitness; training; kinesiology; rehabilitation
22.  Forward Shoulder Posture in Collegiate Swimmers: A Comparative Analysis of Muscle-Energy Techniques 
Journal of Athletic Training  2015;50(11):1133-1139.
Context
Empirical data for treating forward shoulder posture supports stretching the anterior shoulder musculature. Although muscle-energy techniques (METs) have been hypothesized to lengthen muscle, no data have described the usefulness of this technique among swimmers.
Objective
To determine if an MET provides improvements in resting pectoralis minor length (PML), forward scapular position, and scapular upward rotation in female collegiate swimmers.
Design
Controlled laboratory study.
Setting
Athletic training room.
Patients or Other Participants
Thirty-nine asymptomatic National Collegiate Athletic Association Division I women's swimmers (19 experimental, 20 control).
Intervention(s)
The experimental group received 2 treatment sessions per week for 6 weeks. The control group received no intervention during this 6-week period.
Main Outcome Measure(s)
We administered pretest and posttest measurements for PML, forward scapular position, and scapular upward rotation in positions of rest and 60°, 90°, and 120° of humeral elevation. The MET consisted of a 3-second stretch in the direction of the pectoralis minor fibers, followed by a 5-second isometric horizontal adduction contraction at 25% of maximum force. Immediately after this contraction, the entire sequence was repeated with the muscle being stretched to the new endpoint. A total of 4 cycles of MET were continuously applied per treatment session twice per week for 6 weeks. We conducted 1-way analyses of covariance to determine any between-groups postintervention test differences.
Results
The MET group had a greater increase in PML postintervention (P = .001, effect size = 1.6) and a greater decrease in forward scapular position postintervention (P = .001, effect size = 1.07) compared with the control group. No differences were found for scapular upward rotation (P > .10).
Conclusions
Our results indicate that 6 weeks of MET treatments applied to the pectoralis minor of asymptomatic female swimmers provided improvements in PML and forward scapular position compared with a control group.
doi:10.4085/1062-6050-50.11.07
PMCID: PMC4732392  PMID: 26509682
manual therapy; scapular kinematics; injury prevention
23.  Assessment of Muscle Pain Induced by Elbow-Flexor Eccentric Exercise 
Journal of Athletic Training  2015;50(11):1140-1148.
Context:
Delayed-onset muscle soreness (DOMS) is a common muscle pain that many people experience and is often used as a model of acute muscle pain. Researchers have reported the effects of various interventions on DOMS, but different DOMS assessment protocols used in these studies make it difficult to compare the effects.
Objective:
To investigate DOMS characteristics after elbow-flexor eccentric exercise to establish a standardized DOMS assessment protocol.
Design:
Descriptive laboratory study.
Setting:
Research laboratory.
Patients or Other Participants:
Ten healthy, untrained men (21–39 years).
Intervention(s):
Participants performed 10 sets of 6 maximal isokinetic eccentric contractions of the elbow flexors.
Main Outcome Measure(s):
Indirect muscle-damage markers were maximal voluntary isometric contraction torque, range of motion, and serum creatine kinase activity. Muscle pain was assessed before exercise, immediately postexercise, and 1 to 5 days postexercise using (1) a visual analog scale (VAS), (2) a category ratio-10 scale (CR-10) when applying static pressure and palpation at different sites (3, 9, and 15 cm above the elbow crease), and (3) pressure-pain thresholds (PPTs) at 50 sites (pain mapping).
Results:
Maximal voluntary isometric contraction and range of motion decreased and creatine kinase activity increased postexercise, indicating muscle damage. Palpation induced greater pain than static pressure, and longitudinal and transverse palpations induced greater pain than circular palpation (P < .05). The PPT was lower in the medial region before exercise, but the pain-sensitive regions shifted to the central and distal regions of the biceps brachii at 1 to 3 days postexercise (P < .05). The VAS was correlated with the CR-10 scale (r = 0.91, P < .05) but not with the PPT (r = −0.28, P = .45).
Conclusions:
The way in which muscles are assessed affects the pain level score. This finding suggests that pain level and pain threshold cannot be used interchangeably and that the central and distal regions of the biceps brachii should be included in DOMS assessment using the VAS, CR-10 scale, and PPT after elbow-flexor eccentric exercise.
doi:10.4085/1062-6050-50.11.05
PMCID: PMC4732393  PMID: 26523661
muscle damage; delayed-onset muscle soreness; pressure-pain threshold; palpation; visual analog scale
24.  Landing Technique and Performance in Youth Athletes After a Single Injury-Prevention Program Session 
Journal of Athletic Training  2015;50(11):1149-1157.
Context
Injury-prevention programs (IPPs) performed as season-long warm-ups improve injury rates, performance outcomes, and jump-landing technique. However, concerns regarding program adoption exist. Identifying the acute benefits of using an IPP compared with other warm-ups may encourage IPP adoption.
Objective
To examine the immediate effects of 3 warm-up protocols (IPP, static warm-up [SWU], or dynamic warm-up [DWU]) on jump-landing technique and performance measures in youth athletes.
Design
Randomized controlled clinical trial.
Setting
Gymnasiums.
Patients or Other Participants
Sixty male and 29 female athletes (age = 13 ± 2 years, height = 162.8 ± 12.6 cm, mass = 37.1 ± 13.5 kg) volunteered to participate in a single session.
Intervention(s)
Participants were stratified by age, sex, and sport and then were randomized into 1 protocol: IPP, SWU, or DWU. The IPP consisted of dynamic flexibility, strengthening, plyometric, and balance exercises and emphasized proper technique. The SWU consisted of jogging and lower extremity static stretching. The DWU consisted of dynamic lower extremity flexibility exercises. Participants were assessed for landing technique and performance measures immediately before (PRE) and after (POST) completing their warm-ups.
Main Outcome Measure(s)
One rater graded each jump-landing trial using the Landing Error Scoring System. Participants performed a vertical jump, long jump, shuttle run, and jump-landing task in randomized order. The averages of all jump-landing trials and performance variables were used to calculate 1 composite score for each variable at PRE and POST. Change scores were calculated (POST − PRE) for all measures. Separate 1-way (group) analyses of variance were conducted for each dependent variable (α < .05).
Results
No differences were observed among groups for any performance measures (P > .05). The Landing Error Scoring System scores improved after the IPP (change = −0.40 ± 1.24 errors) compared with the DWU (0.27 ± 1.09 errors) and SWU (0.43 ± 1.35 errors; P = .04).
Conclusions
An IPP did not impair sport performance and may have reduced injury risk, which supports the use of these programs before sport activity.
doi:10.4085/1062-6050-50.11.01
PMCID: PMC4732394  PMID: 26523663
injury risk; knee; anterior cruciate ligament
25.  Intramuscular Heating Characteristics of Multihour Low-Intensity Therapeutic Ultrasound 
Journal of Athletic Training  2015;50(11):1158-1164.
Context
The heating characteristics of a stationary device delivering sustained acoustic medicine with low-intensity therapeutic ultrasound (LITUS) are unknown.
Objective
To measure intramuscular (IM) heating produced by a LITUS device developed for long-duration treatment of musculoskeletal injuries.
Design
Controlled laboratory study.
Setting
University research laboratory.
Patients or Other Participants
A total of 26 healthy volunteers (16 men, 10 women; age = 23.0 ± 2.1 years, height = 1.74 ± 0.09 m, mass = 73.48 ± 14.65 kg).
Intervention(s)
Participants were assigned randomly to receive active (n = 20) or placebo (n = 6) LITUS at a frequency of 3 MHz and an energy intensity of 0.132 W/cm2 continuously for 3 hours with a single transducer or dual transducers on the triceps surae muscle. We measured IM temperature using thermocouples inserted at 1.5- and 3-cm depths into muscle. Temperatures were recorded throughout treatment and 30 minutes posttreatment.
Main Outcome Measure(s)
We used 2-sample t tests to determine the heating curve of the LITUS treatment and differences in final temperatures between depth and number of transducers.
Results
A mild IM temperature increase of 1°C was reached 10 ± 5 minutes into the treatment, and a more vigorous temperature increase of 4°C was reached 80 ± 10 minutes into the treatment. The maximal steady-state IM temperatures produced during the final 60 minutes of treatment at the 1.5-cm depth were 4.42°C ± 0.08°C and 3.92°C ± 0.06°C using 1 and 2 transducers, respectively. At the 3.0-cm depth, the maximal steady-state IM temperatures during the final 60 minutes of treatment were 3.05°C ± 0.09°C and 3.17°C ± 0.05°C using 1 and 2 transducers, respectively. We observed a difference between the temperatures measured at each depth (t78 = −2.45, P = .02), but the number of transducers used to generate heating was not different (t78 = 1.79, P = .08).
Conclusions
The LITUS device elicited tissue heating equivalent to traditional ultrasound but could be sustained for multiple hours. It is a safe and effective alternative tool for delivering therapeutic ultrasound and exploring dosimetry for desired physiologic responses.
doi:10.4085/1062-6050-50.11.03
PMCID: PMC4732395  PMID: 26509683
therapeutic modalities; tissue temperature; rehabilitation

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