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issn:1938-162
1.  Correction 
doi:10.4085/1062-6050-49.2.27
PMCID: PMC3975784
2.  Correction 
doi:10.4085/1062-6050-49.2.26
PMCID: PMC3975785
3.  Correction 
doi:10.4085/1062-6050-49.1.10
PMCID: PMC3917290
4.  Cervical Spine Motion During Football Equipment-Removal Protocols: A Challenge to the All-or-Nothing Endeavor 
Journal of Athletic Training  2014;49(1):42-48.
Context
The National Athletic Trainers' Association position statement on acute management of the cervical spine-injured athlete recommended the all-or-nothing endeavor, which involves removing or not removing both helmet and shoulder pads, from equipment-laden American football and ice hockey athletes. However, in supporting research, investigators have not considered alternative protocols.
Objective
To measure cervical spine movement (head relative to sternum) produced when certified athletic trainers (ATs) use the all-or-nothing endeavor and to compare these findings with the movement produced using an alternative pack-and-fill protocol, which involves packing the area under and around the cervical neck and head with rolled towels.
Design
Crossover study.
Setting
Movement analysis laboratory.
Patients or Other Participants
Eight male collegiate football players (age = 21.4 ± 1.4 years; height = 1.87 ± 0.02 m; mass = 103.6 ± 12.5 kg).
Intervention(s)
Four ATs removed equipment under 4 conditions: removal of helmet only followed by placing the head on the ground (H), removal of the helmet only followed by pack-and-fill (HP), removal of the helmet and shoulder pads followed by placing the head on the ground (HS), and removal of the helmet and shoulder pads followed by pack-and-fill (HSP). Motion capture was used to track the movement of the head with respect to the sternum during equipment removal.
Main Outcome Measure(s)
We measured head movement relative to sternum movement (translations and rotations). We used 4 × 4 analyses of variance with repeated measures to compare discrete motion variables (changes in position and total excursions) among protocols and ATs.
Results
Protocol HP resulted in a 0.1 ± 0.6 cm rise in head position compared with a 1.4 ± 0.3 cm drop with protocol HS (P < .001). Protocol HP produced 4.9° less total angular excursion (P < .001) and 2.1 cm less total vertical excursion (P < .001) than protocol HS.
Conclusions
The pack-and-fill protocol was more effective than shoulder pad removal in minimizing cervical spine movement throughout the equipment-removal process. This study provides evidence for including the pack-and-fill protocol in future treatment recommendations when helmet removal is necessary for on-field care.
doi:10.4085/1062-6050-48.6.11
PMCID: PMC3917294  PMID: 24377964
National Athletic Trainers' Association position statement; pack and fill; motion analysis; helmet removal
5.  National Athletic Trainers' Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions 
Journal of Athletic Training  2014;49(1):102-120.
Objective
To present athletic trainers with recommendations for the content and administration of the preparticipation physical examination (PPE) as well as considerations for determining safe participation in sports and identifying disqualifying conditions.
Background
Preparticipation physical examinations have been used routinely for nearly 40 years. However, considerable debate exists as to their efficacy due to the lack of standardization in the process and the lack of conformity in the information that is gathered. With the continuing rise in sports participation at all levels and the growing number of reported cases of sudden death in organized athletics, the sports medicine community should consider adopting a standardized process for conducting the PPE to protect all parties.
Recommendations
Recommendations are provided to equip the sports medicine community with the tools necessary to conduct the PPE as effectively and efficiently as possible using available scientific evidence and best practices. In addition, the recommendations will help clinicians identify those conditions that may threaten the health and safety of participants in organized sports, may require further evaluation and intervention, or may result in potential disqualification.
doi:10.4085/1062-6050-48.6.05
PMCID: PMC3917287  PMID: 24499039
medical history; family history; sudden cardiac death; concussion; sickle cell trait; diabetes; heat illness; hydration
6.  Selection Criteria for Patients With Chronic Ankle Instability in Controlled Research: A Position Statement of the International Ankle Consortium 
Journal of Athletic Training  2014;49(1):121-127.
ABSTRACT
While research on chronic ankle instability (CAI) and awareness of its impact on society and health care systems has grown substantially in the last 2 decades, the inconsistency in participant or patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient or participant selection criteria in research focused on CAI with justifications using the best available evidence. The International Ankle Consortium provides this position paper to present and discuss an endorsed set of selection criteria for patients with CAI based on the best available evidence to be used in future research and study designs. These recommendations will enhance the validity of research conducted in this clinical population with the end goal of bringing the research evidence to the clinician and patient.
doi:10.4085/1062-6050-49.1.14
PMCID: PMC3917288  PMID: 24377963
8.  Postural-Stability Tests That Identify Individuals With Chronic Ankle Instability 
Journal of Athletic Training  2014;49(1):15-23.
Context:
Chronic ankle instability (CAI) is characterized by repeated ankle sprains, which have been linked to postural instability. Therefore, it is important for clinicians to identify individuals with CAI who can benefit from rehabilitation.
Objective:
To assess the likelihood that CAI participants will exhibit impaired postural stability and that healthy control participants will exhibit better test performance values.
Design:
Case-control study.
Setting:
Laboratory.
Patients or Other Participants:
People with CAI (n = 17, age = 23 ± 4 years, height = 168 ± 9 cm, weight = 68 ± 12 kg) who reported ankle “giving-way” sensations and healthy volunteers (n = 17, age = 23 ± 3 years, height = 168 ± 8 cm, weight = 66 ± 12 kg).
Intervention(s):
Participants performed 7 balance tests: Balance Error Scoring System (BESS), time in balance, foot lift, single-legged stance on a force plate, Star Excursion Balance Test, side hop, and figure-of-8 hop.
Main Outcome Measure(s):
Balance was quantified with errors (score) for the BESS, length of time balancing (seconds) for time-in-balance test, frequency of foot lifts (score) for foot-lift test, velocity (cm/s) for all center-of-pressure velocity measures, excursion (cm) for center-of-pressure excursion measures, area (cm2) for 95% confidence ellipse center-of-pressure area and center-of-pressure rectangular area, time (seconds) for anterior-posterior and medial-lateral time-to-boundary (TTB) measures, distance reached (cm) for Star Excursion Balance Test, and time (seconds) to complete side-hop and figure-of-8 hop tests. We calculated area-under-the-curve values and cutoff scores and used the odds ratio to determine if those with and without CAI could be distinguished using cutoff scores.
Results:
We found significant area-under-the-curve values for 4 static noninstrumented measures, 3 force-plate measures, and 3 functional measures. Significant cutoff scores were noted for the time-in-balance test (≤25.89 seconds), foot-lift test (≥5), single-legged stance on the firm surface (≥3 errors) and total (≥14 errors) on the BESS, center-of-pressure resultant velocity (≥1.56 cm/s), standard deviations for medial-lateral (≤1.56 seconds) time-to-boundary and anterior-posterior (≤3.78 seconds) time-to-boundary test, posteromedial direction on the Star Excursion Balance Test (≤0.91), side-hop test (≥12.88 seconds), and figure-of-8 hop test (≥17.36 seconds).
Conclusions:
Clinicians can use any of the 10 significant measures with their associated cutoff scores to identify those who could benefit from rehabilitation that reestablishes postural stability.
doi:10.4085/1062-6050-48.6.09
PMCID: PMC3917291  PMID: 24377958
lower extremity; ankle sprains; Balance Error Scoring System; Star Excursion Balance Test
9.  The Persistent Influence of Concussive Injuries on Cognitive Control and Neuroelectric Function 
Journal of Athletic Training  2014;49(1):24-35.
Context:
Increasing attention is being paid to the deleterious effects of sport-related concussion on cognitive and brain health.
Objective:
To evaluate the influence of concussion incurred during early life on the cognitive control and neuroelectric function of young adults.
Design:
Cross-sectional study.
Setting:
Research laboratory.
Patients or Other Participants:
Forty young adults were separated into groups according to concussive history (0 or 1+). Participants incurred all injuries during sport and recreation before the age of 18 years and were an average of 7.1 ± 4.0 years from injury at the time of the study.
Intervention(s):
All participants completed a 3-stimulus oddball task, a numeric switch task, and a modified flanker task during which event-related potentials and behavioral measures were collected.
Main Outcome Measure(s):
Reaction time, response accuracy, and electroencephalographic activity.
Results:
Compared with control participants, the concussion group exhibited decreased P3 amplitude during target detection within the oddball task and during the heterogeneous condition of the switch task. The concussion group also displayed increased N2 amplitude during the heterogeneous version of the switch task. Concussion history was associated with response accuracy during the flanker task.
Conclusions:
People with a history of concussion may demonstrate persistent decrements in neurocognitive function, as evidenced by decreased response accuracy, deficits in the allocation of attentional resources, and increased stimulus-response conflict during tasks requiring variable amounts of cognitive control. Neuroelectric measures of cognitive control may be uniquely sensitive to the persistent and selective decrements of concussion.
doi:10.4085/1062-6050-49.1.01
PMCID: PMC3917292  PMID: 24377962
concussions; inhibition; mental flexibility; attention; P3; N2
10.  Sport-Related Concussion and Sensory Function in Young Adults 
Journal of Athletic Training  2014;49(1):36-41.
Context:
The long-term implications of concussive injuries for brain and cognitive health represent a growing concern in the public consciousness. As such, identifying measures sensitive to the subtle yet persistent effects of concussive injuries is warranted.
Objective:
To investigate how concussion sustained early in life influences visual processing in young adults. We predicted that young adults with a history of concussion would show decreased sensory processing, as noted by a reduction in P1 event-related potential component amplitude.
Design:
Cross-sectional study.
Setting:
Research laboratory.
Patients or Other Participants:
Thirty-six adults (18 with a history of concussion, 18 controls) between the ages of 20 and 28 years completed a pattern-reversal visual evoked potential task while event-related potentials were recorded.
Main Outcome Measure(s):
The groups did not differ in any demographic variables (all P values > .05), yet those with a concussive history exhibited reduced P1 amplitude compared with the control participants (P = .05).
Conclusions:
These results suggest that concussion history has a negative effect on visual processing in young adults. Further, upper-level neurocognitive deficits associated with concussion may, in part, result from less efficient downstream sensory capture.
doi:10.4085/1062-6050-49.1.02
PMCID: PMC3917293  PMID: 24377961
mild traumatic brain injuries; visual processing; event-related potentials; pattern-reversal visual evoked potentials
11.  Feedback in Clinical Education, Part I: Characteristics of Feedback Provided by Approved Clinical Instructors 
Journal of Athletic Training  2014;49(1):49-57.
Context
Providing students with feedback is an important component of athletic training clinical education; however, little information is known about the feedback that Approved Clinical Instructors (ACIs; now known as preceptors) currently provide to athletic training students (ATSs).
Objective
To characterize the feedback provided by ACIs to ATSs during clinical education experiences.
Design
Qualitative study.
Setting
One National Collegiate Athletic Association Division I athletic training facility and 1 outpatient rehabilitation clinic that were clinical sites for 1 entry-level master's degree program accredited by the Commission on Accreditation of Athletic Training Education.
Patients or Other Participants
A total of 4 ACIs with various experience levels and 4 second-year ATSs.
Data Collection and Analysis
Extensive field observations were audio recorded, transcribed, and integrated with field notes for analysis. The constant comparative approach of open, axial, and selective coding was used to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study.
Results
The ACIs gave 88 feedback statements in 45 hours and 10 minutes of observation. Characteristics of feedback categories included purpose, timing, specificity, content, form, and privacy.
Conclusions
Feedback that ACIs provided included several components that made each feedback exchange unique. The ACIs in our study provided feedback that is supported by the literature, suggesting that ACIs are using current recommendations for providing feedback. Feedback needs to be investigated across multiple athletic training education programs to gain more understanding of certain areas of feedback, including frequency, privacy, and form.
doi:10.4085/1062-6050-48.6.14
PMCID: PMC3917295  PMID: 24143902
assessment; evaluation; pedagogy; preceptors
13.  Feedback in Clinical Education, Part II: Approved Clinical Instructor and Student Perceptions of and Influences on Feedback 
Journal of Athletic Training  2014;49(1):58-67.
Context:
Approved Clinical Instructors (ACIs; now known as preceptors) are expected to provide feedback to athletic training students (ATSs) during clinical education experiences. Researchers in other fields have found that clinical instructors and students often have different perceptions of actual and ideal feedback and that several factors may influence the feedback exchanges between instructors and students. However, understanding of these issues in athletic training education is minimal.
Objective:
To investigate the current characteristics and perceptions of and the influences on feedback exchanges between ATSs and ACIs.
Design:
Qualitative study.
Setting:
One entry-level master's degree program accredited by the Commission on Accreditation of Athletic Training Education.
Patients or Other Participants:
Four ACIs and 4 second-year ATSs.
Data Collection and Analysis:
Individual, semistructured interviews were conducted with participants and integrated with field notes and observations for analysis. We used the constant comparative approach to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study.
Results:
Participants described that feedback plays an important role in clinical education and has several purposes related to improving performance. The ACIs and ATSs also discussed several preferred characteristics of feedback. Participants identified 4 main influences on their feedback exchanges, including the ACI, the ATS, personalities, and the learning environment.
Conclusions:
The ACIs and ATSs had similar perceptions of ideal feedback in addition to the actual feedback that was provided during their clinical education experiences. Most of the preferences for feedback were aligned with recommendations in the literature, suggesting that existing research findings are applicable to athletic training clinical education. Several factors influenced the feedback exchanges between ACIs and ATSs, which clinical education coordinators should consider when selecting clinical sites and training ACIs.
doi:10.4085/1062-6050-48.6.15
PMCID: PMC3917297  PMID: 24151809
assessment; evaluation; pedagogy; preceptors
14.  Perceived Levels of Frustration During Clinical Situations in Athletic Training Students 
Journal of Athletic Training  2014;49(1):68-74.
Context:
Athletic training students (ATSs) are involved in various situations during the clinical experience that may cause them to express levels of frustration. Understanding levels of frustration in ATSs is important because frustration can affect student learning, and the clinical experience is critical to their development as professionals.
Objective:
 To explore perceived levels of frustration in ATSs during clinical situations and to determine if those perceptions differ based on sex.
Design:
 Cross-sectional study with a survey instrument.
Setting:
 A total of 14 of 19 professional, undergraduate athletic training programs accredited by the Commission on Accreditation of Athletic Training Education in Pennsylvania.
Patients or Other Participants:
 Of a possible 438 athletic training students, 318 (72.6%) completed the survey.
Main Outcomes Measure(s):
 The Athletic Training Student Frustration Inventory was developed and administered. The survey gathered demographic information and included 24 Likert-scale items centering on situations associated with the clinical experience. Descriptive statistics were computed on all items. The Mann-Whitney U was used to evaluate differences between male and female students.
Results:
 A higher level of frustration was perceived during the following clinical situations: lack of respect by student-athletes and coaching staffs, the demands of the clinical experience, inability of ATSs to perform or remember skills, and ATSs not having the opportunity to apply their skills daily. Higher levels of frustration were perceived in female than male ATSs in several areas.
Conclusions:
 Understanding student frustration during clinical situations is important to better appreciate the clinical education experience. Low levels of this emotion are expected; however, when higher levels exist, learning can be affected. Whereas we cannot eliminate student frustrations, athletic training programs and preceptors need to be aware of this emotion in order to create an environment that is more conducive to learning.
doi:10.4085/1062-6050-48.6.12
PMCID: PMC3917298  PMID: 24143904
scaffolding; professional socialization; athletic training education
15.  Validity of Musculoskeletal Ultrasound for Identification of Humeroradial Joint Chondral Lesions: A Preliminary Investigation 
Journal of Athletic Training  2014;49(1):7-14.
Context:
Epicondylalgia is a common condition involving pain-generating structures such as tendon, neural, and chondral tissue. The current noninvasive reference standard for identifying chondral lesions is magnetic resonance imaging. Musculoskeletal ultrasound (MUS) may be an inexpensive and effective alternative.
Objective:
To determine the intrarater reliability and validity of MUS for identifying humeroradial joint (HRJ) chondral lesions.
Design:
Cross-sectional study.
Setting:
Clinical anatomy research laboratory.
Patients or Other Participants:
Twenty-eight embalmed cadavers (14 women, 14 men; mean age = 79.5 ± 8.5 years).
Main Outcome Measure(s):
An athletic trainer performed MUS evaluation of each anterior and distal-posterior capitellum and radial head to identify chondral lesions. The reference standard was identification of chondral lesions by gross macroscopic examination. Intrarater reliability for reproducing an image was calculated using the intraclass correlation coefficient (3,k) for measurements of the articular surface using 2 images. Intrarater reliability to evaluate a single image was calculated using the Cohen κ for agreement as to the presence of chondral lesions. Validity was calculated using the agreement of MUS images and gross macroscopic examination.
Results:
Intrarater reliability was 0.88 (95% confidence interval = 0.77, 0.94) for reproducing an image and 0.93 (95% confidence interval = 0.80, 1.06) for evaluating a single image. Identifying chondral lesions on all HRJ surfaces with MUS demonstrated sensitivity = 0.93, specificity = 0.28, positive predictive value = 0.58, negative predictive value = 0.77, positive likelihood ratio = 1.28, and negative likelihood ratio = 0.27.
Conclusions:
Musculoskeletal ultrasound is a reliable and sensitive tool for a clinician with relatively little experience and training to rule out HRJ chondral lesions. These results may assist with clinical assessment and decision making in patients with lateral epicondylalgia to rule out HRJ chondral lesions.
doi:10.4085/1062-6050-49.1.03
PMCID: PMC3917299  PMID: 24377960
elbow joint; articular cartilage; reliability; assessment
16.  The Professional Socialization of the Athletic Trainer Serving as a Preceptor 
Journal of Athletic Training  2014;49(1):75-82.
Context:
The role of the preceptor requires the athletic trainer to be versed in effective instructional techniques, supervisory skills, and communication skills beyond his or her competence as an athletic trainer, but many have not received formal training in educational techniques.
Objective:
To gain a better understanding about the professional socialization process for the athletic trainer assuming the role of the preceptor.
Design:
Qualitative study.
Setting:
Athletic training education programs.
Patients or Other Participants:
Twenty-four preceptors (11 men, 13 women; age = 32 ± 7 years, clinical experience = 9 ± 6 years, preceptor experience = 5 ± 3 years) employed in the collegiate (n = 12) or secondary school (n = 12) setting.
Data Collection and Analysis:
We gathered data using asynchronous, in-depth interviewing via QuestionPro. We analyzed data using a general inductive approach to uncover the dominant themes. Credibility was secured by using consistency and stakeholder checks and a peer review.
Results:
We identified 2 main themes by which preceptors develop in their roles as clinical instructors: formal processes and informal processes. The participants used observations, previous experiences or interactions with role models, and self-reflection and evaluation as informal socialization processes. Formal socialization processes included preceptor training/workshops, professional development, and formal teacher certification.
Conclusions:
Athletic trainers who serve as preceptors learned their roles by a combination of informal and formal processes. Preceptor training sessions appeared to be effective in initially helping preceptors learn their responsibilities, whereby more informal processes seemed to help them refine their skills. Furthermore, one socialization strategy did not appear to dominate role learning; rather, a combination of several processes fostered an understanding.
doi:10.4085/1062-6050-48.6.16
PMCID: PMC3917300  PMID: 24377957
instructional techniques; mentoring; learning
17.  Experiences and Attitudes of Collegiate Athletic Trainers Regarding Alcohol-Related Unintentional Injury in Athletes 
Journal of Athletic Training  2014;49(1):83-88.
Context:
Alcohol-related unintentional injury (ARUI) has been an unexamined consequence of alcohol consumption by collegiate athletes. It has a potentially devastating effect on their athletic performances and careers. Awareness of this problem in athletes could have a huge effect on what athletic trainers (ATs) do to recognize, treat, and prevent it in a collegiate athlete population.
Objective:
To examine the experiences and attitudes among collegiate and university ATs about ARUI in the athletes in their care.
Design:
Cross-sectional study.
Setting:
Web-based survey.
Patients or Other Participants:
A total of 1767 e-mail addresses for collegiate and university ATs within National Athletic Trainers' Association Districts 1, 2, 3, and 9.
Main Outcome Measure(s):
We calculated frequencies, percentages, and attitudes of ATs regarding ARUI in collegiate athletes during the 2010–2011 academic year.
Results:
The resulting sample size for the analysis was 459 (26.0%) participants of the initial total sample. More than 56% (n = 260) of the ATs reported that they had evaluated, treated, or referred if needed at least 1 ARUI in a collegiate athlete. On average, these ATs had evaluated, treated, or referred if needed 3 alcohol-related unintentional injuries within the 2010–2011academic year. About 73% (n = 331) of ATs agreed that ARUI is a serious problem. Nearly 80% (n = 358) indicated they believe ATs should receive more training to identify student–athletes with alcohol-related problems.
Conclusions:
Alcohol-related unintentional injury is a common and serious consequence of alcohol use among collegiate athletes. Many ATs also view it as a serious problem yet would like more training in how to address it. Alcohol-related unintentional injury may have important negative effects on the careers and athletic performances of athletes. Researchers need to determine how prevalent ARUI is in the collegiate athlete population and what ATs can do to address it.
doi:10.4085/1062-6050-48.6.02
PMCID: PMC3917301  PMID: 24377956
alcohol use; alcohol-related consequences; collegiate athletes
18.  Incidence of Injury Among Male Brazilian Jiujitsu Fighters at the World Jiu-Jitsu No-Gi Championship 2009 
Journal of Athletic Training  2014;49(1):89-94.
Context:
Brazilian jiujitsu is a modern combat martial art that uses joint locks to submit an opponent and achieve victory. This form of martial art is a relatively young but rapidly growing combat sport worldwide.
Objective:
To determine the cumulative injury incidence and risk of injury by belt rank and body region at an international-level Brazilian jiujitsu tournament.
Design:
Descriptive epidemiology study.
Setting:
World Jiu-Jitsu No-Gi Championship 2009 in Long Beach, California.
Patients or Other Participants:
We monitored 951 athletes (age range, 18–50 years) enrolled to compete in the World Jiu-Jitsu No-Gi Championship 2009.
Intervention(s):
Fighters were categorized by belt level for group comparisons (belt experience). Incidence rates per 1000 athlete-exposures (AEs) and incidence rate ratios were compared by belt rank.
Main Outcome Measure(s):
Incidence rates and incidence rate ratios.
Results:
During the tournament, 1606 AEs and 62 total injuries were reported. Of these injuries, 40 affected the joints, for an overall incidence rate of 24.9 per 1000 AEs. The joint incidence rate by belt rank was 21.5 per 1000 AEs for blue, 21.3 per 1000 AEs for purple, 25.2 per 1000 AEs for brown, and 35.1 per 1000 AEs for black. We found no differences for incidence rate ratios of joint injury among individual belt groups (P > .05). More experienced (brown belt and black belt) competitors had a higher injury risk than the less experienced (blue belt and purple belt) competitors; however, the difference was not significant (incidence rate ratio = 1.65, 95% confidence interval = 0.9, 2.9; P = .06). The incidence of joint injury was highest at the knee (7.5 per 1000 AEs) and elbow (7.5 per 1000 AEs).
Conclusions:
The data from this international Brazilian jiujitsu tournament indicated that the risk of joint injury was similar among belt ranks or experience during this Brazilian jiujitsu competition. The knee and elbow were the joints most susceptible to injury. Future investigation of injury mechanism is warranted to develop strategies to reduce potential risk factors attributed to injury.
doi:10.4085/1062-6050-49.1.11
PMCID: PMC3917302  PMID: 24377959
mixed martial arts; combat sports; collegiate wrestling
19.  Should Athletes Return to Activity After Cryotherapy? 
Journal of Athletic Training  2014;49(1):95-96.
Reference/Citation
Bleakley CM, Costello JT, Glasgow PD. Should athletes return to sport after applying ice? A systematic review of the effect of local cooling on functional performance. Sports Med. 2012; 42(1):69–87.
Clinical Question
Does local tissue cooling affect immediate functional performance outcomes in a sport situation?
Data Sources
Studies were identified by searching MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE, each from the earliest available record through April 2011. Combinations of 18 medical subheadings or key words were used to complete the search.
Study Selection
This systematic review included only randomized controlled trials and crossover studies published in English that examined human participants who were treated with a local cooling intervention. At least 1 functional performance outcome that was measured before and after a cooling intervention had to be reported. Excluded were studies using whole-body cryotherapy or cold-water immersion above the waist and studies that measured strength or force production during evoked muscle contraction.
Data Extraction
Data were extracted by 2 authors using a customized form to evaluate relevant data on study design, eligibility criteria, detailed characteristics of cooling protocols, comparisons, and outcome measures. Disagreement was resolved by consensus or third-party adjudication. To perform an intent-to-treat analysis when possible, data were extracted according to the original allocation groups, and losses to follow-up were noted. The review authors were not blinded to the study author, institution, or journal. For each study, mean differences or standardized mean differences and 95% confidence intervals were calculated for continuous outcomes using RevMan (version 5.1; The Nordic Cochrane Centre, Copenhagen, Denmark). Treatment effects were based on between-groups comparisons (cryotherapy versus control) using postintervention outcomes or within-group comparisons (precryotherapy versus postcryotherapy). If continuous data were missing standard deviations, other statistics including confidence intervals, standard error, t values, P values, or F values were used to calculate the standard deviation. The Cochrane risk-of-bias tool was used to assess the methodologic quality of included studies. Each study was evaluated for sequence generation, allocation concealment, assessor blinding, and incomplete outcome data. Studies were graded as low or high based on the criteria met, but the risk of bias across the studies was consistently high, so meaningful subgroup classifications were not possible. Differences in study quality and intervention details, including duration of cryotherapy interventions and time periods after intervention before follow-up, were potential sources of bias and considered for a subgroup analysis.
Main Results
Using the search criteria, the authors originally identified 1449 studies. Of these, after title and abstract review, 99 studies were deemed potentially relevant and kept for further analysis (1350 studies were excluded). Of the 99 potentially relevant studies, 35 were included in the final review (64 studies were excluded), with relevant outcomes of strength, power, vertical jump, endurance, agility, speed, performance accuracy, and dexterity reported. The 64 excluded studies were rejected due to intervention relevancy, outcome relevancy, and non-English language. In the 35 studies meeting the inclusion criteria, 665 healthy participants were assessed. Muscle strength (using an isokinetic dynamometer, cable tensiometer, strain-gauge device, or load cell) was assessed in 25 studies, whole-body exercise (vertical jump height, power, timed hop test, sprint time, and time taken to complete running-based agility tests, including carioca runs, shuttle sprints, T-shuttle, and cocontraction tests) was assessed in 6, performance accuracy (throwing or shooting) was assessed in 2, and hand dexterity was assessed in 2. Outcomes before and immediately after cryotherapy intervention were reported in all studies; additional outcome assessments at times ranging from 5 to 180 minutes postintervention were recorded in 11 studies. The review authors reported a high risk of bias: selection bias (poor randomization and concealment of group allocation), performance and detection bias (poor blinding of assessors), and attrition bias (incomplete data). Because of the diversity of studies, particularly with respect to cryotherapy protocols and the potential for rewarming before the posttest, the effects of cryotherapy on functional performance were mixed. From the included studies, the authors concluded that cryotherapy treatment reduced upper and lower extremity muscle strength immediately after cryotherapy. However, increases in force output after cryotherapy were reported in 5 studies. Regardless of the effect of cryotherapy on strength, the clinical meaningfulness of most of the data may not be important due to variability and small effects. Studies reporting outcomes of muscle endurance resulted in conflicting evidence: endurance increased immediately after cryotherapy in 6, whereas muscle endurance decreased in 3 . These conflicting results limit the ability to draw clinically relevant conclusions about the effect of cryotherapy on muscle endurance. The majority of studies evaluating whole-body exercise demonstrated decreases in performance after cryotherapy; these outcomes included vertical jump, sprint, and agility, even when cryotherapy was applied only to a body part. Additionally, cryotherapy appeared to decrease hand dexterity and throwing accuracy immediately after intervention, although an increase in shooting performance postintervention was reported in 1 study .
Conclusions
The authors suggested that the available evidence indicates that athletic performance may be adversely affected when athletes return to play immediately after cryotherapy treatments. Many of the included studies used variable cooling protocols, reflecting differences in time, temperature, and mode of cryotherapy. The majority of the included studies used cryotherapy for at least 20 minutes. However, when considering an immediate return to activity, this cooling duration may not be clinically relevant because cryotherapy applications during practice and competitions usually last less than 20 minutes. When immediate return to activity occurs after cryotherapy, short-duration cold applications or progressive warm-ups should be implemented to prevent a deleterious effect on functional performance.
doi:10.4085/1062-6050-48.3.13
PMCID: PMC3917303  PMID: 23724775
cold modalities; functional performance; strength; endurance
20.  Frostbite in an Adolescent Football Player: A Case Report 
Journal of Athletic Training  2014;49(1):97-101.
Objective:
To present the case of vascular compromise of a finger from a confluent circumferential blister due to an inappropriately applied commercial cold pack in a high school athlete and to describe the mechanism of iatrogenic injury, acute surgical management, rehabilitation, and pathophysiology of frostbite and constriction injuries.
Background:
A 17-year-old male football player presented with a frostbite and constriction injury to the index finger secondary to prolonged use of a cooling pack after a mild traumatic injury to the digit. He developed a prolonged sensory deficit from thermal injury, as well as acute vascular compromise requiring urgent operative intervention.
Differential Diagnosis:
Frostbite and constriction injury to the index finger.
Treatment:
Emergency surgical decompression and occupational therapy.
Uniqueness:
Frostbite injuries can occur iatrogenically because of inappropriate use of cooling devices or gel packs. Fingers are commonly injured extremities that are particularly susceptible to frostbite and compression injuries. To our knowledge, no case of vascular compromise from the blister constriction of digits has been reported.
Conclusions:
Patients and their caregivers must be educated about how to properly use cooling devices. Clinicians need to fully evaluate patients with iatrogenic frostbite injuries, giving particular attention to neurovascular status, and must recognize the need for surgical release of constriction syndrome to prevent substantial morbidity.
doi:10.4085/1062-6050-48.6.19
PMCID: PMC3917304  PMID: 24143903
constriction syndrome; freezing; cryotherapy; vascular compromise; hand injuries; ice packs
21.  Thermoregulation and Stress Hormone Recovery After Exercise Dehydration: Comparison of Rehydration Methods 
Journal of Athletic Training  2013;48(6):725-733.
Context:
Athletic trainers recommend and use a multitude of rehydration (REHY) methods with their patients. The REHY modality that most effectively facilitates recovery is unknown.
Objective:
To compare 5 common REHY methods for thermoregulatory and stress hormone recovery after exercise dehydration (EXDE) in trained participants.
Design:
Randomized, cross-over, controlled study.
Patients or Other Participants:
Twelve physically active, non–heat-acclimatized men (age = 23 ± 4 years, height = 180 ± 6 cm, mass = 81.3 ± 3.7 kg, V̇o2max = 56.9 ± 4.4 mL·min−1·kg−1, body fat = 7.9% ± 3%) participated.
Intervention(s):
Participants completed 20-hour fluid restriction and 2-hour EXDE; they then received no fluid (NF) or REHY (half-normal saline) via ad libitum (AL), oral (OR), intravenous (IV), or combination IV and OR (IV + OR) routes for 30 minutes; and then were observed for another 30 minutes.
Main Outcome Measure(s):
Body mass, rectal temperature, 4-site mean weighted skin temperature, plasma stress hormone concentrations, and environmental symptoms questionnaire (ESQ) score.
Results:
Participants were hypohydrated (body mass −4.23% ± 0.22%) post-EXDE. Rectal temperature for the NF group was significantly greater than for the IV group (P = .023) at 30 minutes after beginning REHY (REHY30) and greater than OR, IV, and IV + OR (P ≤ .009) but not AL (P = .068) at REHY60. Mean weighted skin temperature during AL was less than during IV + OR at REHY5 (P = .019). The AL participants demonstrated increased plasma cortisol concentrations compared with IV + OR, independent of time (P = .015). No differences existed between catecholamine concentrations across treatments (P > .05). The ESQ score was increased at REHY60 for NF, AL, OR, and IV (P < .05) but not for IV + OR (P = .217). The NF ESQ score was greater than that of IV + OR at REHY60 (P = .012).
Conclusions:
Combination IV + OR REHY reduced body temperature to a greater degree than OR and AL REHY when compared with NF. Future studies addressing clinical implications are needed.
doi:10.4085/1062-6050-48.6.01
PMCID: PMC3867082  PMID: 24143900
heat stress; heat illness; hypohydration
22.  Ad Libitum Fluid Intake and Plasma Responses After Pickle Juice, Hypertonic Saline, or Deionized Water Ingestion 
Journal of Athletic Training  2013;48(6):734-740.
Context:
Adding sodium (Na+) to drinks improves rehydration and ad libitum fluid consumption. Clinicians (∼25%) use pickle juice (PJ) to treat cramping. Scientists warn against PJ ingestion, fearing it will cause rapid plasma volume restoration and thereby decrease thirst and delay rehydration. Advice about drinking PJ has been developed but never tested.
Objective:
To determine if drinking small volumes of PJ, hypertonic saline (HS), or deionized water (DIW) affects ad libitum DIW ingestion, plasma variables, or perceptual indicators.
Design:
Crossover study.
Setting:
Laboratory.
Patients or Other Participants:
Fifteen, euhydrated (urine specific gravity ≤ 1.01) men (age = 22 ± 2 years, height = 178 ± 6 cm, mass = 82.9 ± 8.4 kg).
Intervention(s):
Participants completed 3 testing days (≥72 hours between days). After a 30-minute rest, a blood sample was collected. Participants completed 60 minutes of hard exercise (temperature = 36 ± 2°C, relative humidity = 16 ± 1%). Postexercise, they rested for 30 minutes; had a blood sample collected; rated thirst, fullness, and nausea; and ingested 83 ± 8 mL of PJ, HS, or DIW. They rated drink palatability (100-mm visual analog scale) and were allowed to drink DIW ad libitum for 60 minutes. Blood samples and thirst, fullness, and nausea ratings (100-mm visual analog scales) were collected at 15, 30, 45, and 60 minutes posttreatment drink ingestion.
Main Outcome Measure(s):
Ad libitum DIW volume, percentage change in plasma volume, plasma osmolality (OSMp,) plasma sodium concentration ([Na+]p), and thirst, fullness, nausea, and palatability ratings.
Results:
Participants consumed more DIW ad libitum after HS (708.03 ± 371.03 mL) than after DIW (532.99 ± 337.14 mL, P < .05). Ad libitum DIW ingested after PJ (700.35 ± 366.15 mL) was similar to that after HS and DIW (P > .05). Plasma sodium concentration, OSMp, percentage change in plasma volume, thirst, fullness, and nausea did not differ among treatment drinks over time (P > .05). Deionized water (73 ± 14 mm) was more palatable than HS (17 ± 13 mm) or PJ (26 ± 16 mm, P < .05).
Conclusions:
The rationale behind advice about drinking PJ is questionable. Participants drank more, not less, after PJ ingestion, and plasma variables and perceptual indicators were similar after PJ and DIW ingestion. Pickle juice did not inhibit short-term rehydration.
doi:10.4085/1062-6050-48.5.04
PMCID: PMC3867083  PMID: 23952039
acetic acid; electrolytes; rehydration; sodium; vinegar
23.  Mild Dehydration and Cycling Performance During 5-Kilometer Hill Climbing 
Journal of Athletic Training  2013;48(6):741-747.
Context:
Hydration has been shown to be an important factor in performance; however, the effects of mild dehydration during intense cycling are not clear.
Objective:
To determine the influence of mild dehydration on cycling performance during an outdoor climbing trial in the heat (ambient temperature = 29.0°C ± 2.2°C).
Design:
Crossover study.
Setting:
Outdoor.
Patients or Other Participants:
Ten well-trained, male endurance cyclists (age = 28 ± 5 years, height = 182 ± 0.4 cm, mass = 73 ± 4 kg, maximal oxygen uptake = 56 ± 9 mL·min−1·kg−1, body fat = 23% ± 2%, maximal power = 354 ± 48 W).
Intervention(s):
Participants completed 1 hour of steady-state cycling with or without drinking to achieve the desired pre-exercise hydration level before 5-km hill-climbing cycling. Participants started the 5-km ride either euhydrated (EUH) or dehydrated by −1% of body mass (DEH).
Main Outcome Measure(s):
Performance time, core temperature, sweat rate, sweat sensitivity, and rating of perceived exertion (RPE).
Results:
Participants completed the 5-km ride 5.8% faster in the EUH (16.6 ± 2.3 minutes) than DEH (17.6 ± 2.9 minutes) trial (t1 = 10.221, P = .001). Postexercise body mass was −1.4% ± 0.3% for the EUH trial and −2.2% ± 0.2% for the DEH trial (t1 = 191.384, P < .001). Core temperature after the climb was greater during the DEH (39.2°C ± 0.3°C) than EUH (38.8°C ± 0.2°C) trial (t1 = 8.04, P = .005). Sweat rate was lower during the DEH (0.44 ± 0.16 mg·m−2·s−1) than EUH (0.51 ± 0.16 mg·m−2·s−1) trial (t8 = 2.703, P = .03). Sweat sensitivity was lower during the DEH (72.6 ± 32 g·°C−1·min−1) than EUH (102.6 ± 54.2 g·°C−1·min−1) trial (t8 = 3.072, P = .02). Lastly, RPE after the exercise performance test was higher for the DEH (19.0 ± 1.0) than EUH (17.0 ± 1.0) participants (t9 = −3.36, P = .008).
Conclusions:
We found mild dehydration decreased cycling performance during a 5-km outdoor hill course, probably due to greater heat strain and greater perceived intensity.
doi:10.4085/1062-6050-48.5.01
PMCID: PMC3867084  PMID: 23952038
hypohydration; heat stress; hyperthermia; hydration status; exercise
24.  Lower Extremity Energy Absorption and Biomechanics During Landing, Part I: Sagittal-Plane Energy Absorption Analyses 
Journal of Athletic Training  2013;48(6):748-756.
Context:
Eccentric muscle actions of the lower extremity absorb kinetic energy during landing. Greater total sagittal-plane energy absorption (EA) during the initial impact phase (INI) of landing has been associated with landing biomechanics considered high risk for anterior cruciate ligament (ACL) injury. We do not know whether groups with different INI EA magnitudes exhibit meaningful differences in ACL-related landing biomechanics and whether INI EA might be useful to identify ACL injury-risk potential.
Objective:
To compare biomechanical factors associated with noncontact ACL injury among sagittal-plane INI EA groups and to determine whether an association exists between sex and sagittal-plane INI EA group assignment to evaluate the face validity of using sagittal-plane INI EA to identify ACL injury risk.
Design:
Descriptive laboratory study.
Setting:
Research laboratory.
Patients or Other Participants:
A total of 82 (41 men, 41 women; age = 21.0 ± 2.4 years, height = 1.74 ± 0.10 m, mass = 70.3 ± 16.1 kg) healthy, physically active individuals volunteered.
Intervention(s):
We assessed landing biomechanics using an electromagnetic motion-capture system and force plate during a double-legged jump-landing task.
Main Outcome Measure(s):
Total INI EA was used to group participants into high, moderate, and low tertiles. Sagittal- and frontal-plane knee kinematics; peak vertical and posterior ground reaction forces (GRFs); anterior tibial shear force; and internal hip extension, knee extension, and knee varus moments were identified and compared across groups using 1-way analyses of variance. We used a χ2 analysis to compare male and female representation in the high and low groups.
Results:
The high group exhibited greater knee-extension moment and posterior GRFs than both the moderate (P < .05) and low (P < .05) groups and greater anterior tibial shear force than the low group (P < .05). No other group differences were noted. Women were not represented more than men in the high group (χ2 = 1.20, P = .27).
Conclusions:
Greater sagittal-plane INI EA likely indicates greater ACL loading, but it does not appear to influence frontal-plane biomechanics related to ACL injury. Women were not more likely than men to demonstrate greater INI EA, suggesting that quantification of sagittal-plane INI EA alone is not sufficient to infer ACL injury-risk potential.
doi:10.4085/1062-6050-48.4.09
PMCID: PMC3867085  PMID: 23944382
anterior cruciate ligament; landing biomechanics; kinetics; kinematics
25.  Lower Extremity Energy Absorption and Biomechanics During Landing, Part II: Frontal-Plane Energy Analyses and Interplanar Relationships 
Journal of Athletic Training  2013;48(6):757-763.
Context:
Greater sagittal-plane energy absorption (EA) during the initial impact phase (INI) of landing is consistent with sagittal-plane biomechanics that likely increase anterior cruciate ligament (ACL) loading, but it does not appear to influence frontal-plane biomechanics. We do not know whether frontal-plane INI EA is related to high-risk frontal-plane biomechanics.
Objective:
To compare biomechanics among INI EA groups, determine if women are represented more in the high group, and evaluate interplanar INI EA relationships.
Design:
Descriptive laboratory study.
Setting:
Research laboratory.
Patients or Other Participants:
Participants included 82 (41 men, 41 women; age = 21.0 ± 2.4 years, height = 1.74 ± 0.10 m, mass = 70.3 ± 16.1 kg) healthy, physically active volunteers.
Intervention(s):
We assessed landing biomechanics with an electromagnetic motion-capture system and force plate.
Main Outcome Measure(s):
We calculated frontal- and sagittal-plane total, hip, knee, and ankle INI EA. Total frontal-plane INI EA was used to create high, moderate, and low tertiles. Frontal-plane knee and hip kinematics, peak vertical and posterior ground reaction forces, and peak internal knee-varus moment (pKVM) were identified and compared across groups using 1-way analyses of variance. We used a χ2 analysis to evaluate male and female allocation to INI EA groups. We used simple, bivariate Pearson product moment correlations to assess interplanar INI EA relationships.
Results:
The high–INI EA group exhibited greater knee valgus at ground contact, hip adduction at pKVM, and peak hip adduction than the low–INI EA group (P < .05) and greater peak knee valgus, pKVM, and knee valgus at pKVM than the moderate– (P < .05) and low– (P < .05) INI EA groups. Women were more likely than men to be in the high–INI EA group (χ2 = 4.909, P = .03). Sagittal-plane knee and frontal-plane hip INI EA (r = 0.301, P = .006) and sagittal-plane and frontal-plane ankle INI EA were associated (r = 0.224, P = .04). No other interplanar INI EA relationships were found (P > .05).
Conclusions:
Greater frontal-plane INI EA was associated with less favorable frontal-plane biomechanics that likely result in greater ACL loading. Women were more likely than men to use greater frontal-plane INI EA. The magnitudes of sagittal- and frontal-plane INI EA were largely independent.
doi:10.4085/1062-6050-48.4.10
PMCID: PMC3867086  PMID: 23944381
anterior cruciate ligament; kinetics; kinematics

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