Evidence-Based Practice

Evidence-based practice is described as using a combination of clinician expertise, best evidence available, and patient values to provide optimal patient care. All three aspects are vital as neither clinician experience nor research is perfect; as one area lacks, the other two become even more important in the health care process. Using evidence-based practice will help athletic trainers in a variety of areas such as deciding which orthopedic special tests to emphasize, which modalities to use to better achieve specific goals, and which exercises to prescribe for specific pathologies.

Cervical Spine Motion During Football Equipment Removal

The authors of this study examined cervical spine motion during four different football equipment-removal protocols. The fours protocols included removing the helmet only (H), removing the helmet and shoulder pads (HS), removing the helmet and performing the pack and fill technique (HP) and removing the helmet and shoulder pads and performing the pack and fill technique (HSP). The pack and fill technique involves filling the space under the head and neck with rolled towels in an attempt to maintain neutral cervical spine alignment. Four certified athletic trainers performed the techniques on eight male, collegiate football players. Changes in cervical spine position from initiation to release as well as angular and linear excursions from initiation to release were assessed during the four protocols.

The HP protocol resulted in the least amount of change in cervical spine position as well as the least amount of angular and linear excursions when compared to all other protocols. This indicates that the HP technique creates less cervical spine motion than the HS technique that the National Athletic Trainers' Association recommends as a part of their all-or-nothing equipment removal recommendation. It is important to note that the NATA position statement on acute management of cervical spine injuries still supports the all-or-nothing approach and therefore should be utilized by athletic trainers until a change in recommendations is made. However, the pack and fill technique examined in this article may be a viable option in a situation where removal of shoulder pads from an injured athlete is not possible.

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NATA Position Statement on PPEs and Disqualifying Conditions

The National Athletic Trainers' Association position statement provides evidence-based recommendations for pre-participation physical examinations, including identification of disqualifying conditions. The position statement addresses medical and family history as well as general health, cardiovascular, neurologic, and orthopaedic screening. Other topics addressed include medication use, nutritional considerations, and heat-illness risk factors.

The recommendations were given grades based on the quality of the evidence that the authors obtained. The Strength of Recommendation Taxonomy (SORT) was used as the grading method and includes grades of A, B or C. Recommendations with a grade of A were determined from consistent, high quality patient-oriented evidence while recommendations with a grade of C were determined from disease-oriented evidence, case series, quasi-experimental research, consensus, usual practice and opinion. Underscoring the need for recommendations based on high quality evidence is that 22 of the 29 recommendations received a SORT grade of C.

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Clinical Guidelines Regarding Lumbar Disc Herniations with Radiculopathies

The guidelines developed by the North American Spine Society's Clinical Guidelines Committee give evidence-based recommendations for diagnosing and treating lumbar disc herniations that produce radicular symptoms. In addition to diagnosis and treatment, the guidelines address cost-effectiveness of surgical treatment options.

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The Effectiveness of Prophylactic Ankle Braces in Reducing the Incidence of Acute Ankle Injuries in Adolescent Athletes: A Critically Appraised Topic

Once a month, a new article will be posted below providing you with the most current information regarding best practices. It isn't always easy accessing and interpreting research so hopefully this will help all of us improve patient care and the future of the athletic training profession.

The authors of this critically appraised topic examined previous research studies to determine if the use of prophylactic ankle bracing is effective at reducing ankle injuries in adolescent athletes. The authors identified three studies performed since 2010 that met their inclusion criteria. Participants in the three studies were high school football, men's and women's basketball, and men's and women's volleyball players. All three studies were reported to have a high level of evidence. 

Two of the three studies showed a reduction in number of ankle injuries when wearing braces. The studies that showed a reduction in injury were performed on football and basketball players. These same studies also showed no differences in reduction rates regardless of gender or previous history of ankle injury. This indicates that regardless of gender or history of previous ankle injuries, prophylactic ankle bracing can be effective. Although a reduction in number of injuries occurred, there was no effect on injury severity. This indicates that although prophylactic ankle bracing may prevent ankle injuries from occurring, they won't affect the degree of injury once it occurs. Based on these results the authors indicate that there is moderate evidence suggesting the use of prophylactic ankle bracing but that it may be most useful in football and basketball as opposed to volleyball. These results may be of added value to some high school athletic trainers who find implementing a preventative rehabilitation program, and ensuring athlete adherence, to be difficult.

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The Effect of Preoperative Quadriceps Strength on Strength and Function After Anterior Cruciate Ligament Reconstruction

The authors of this critically appraised topic examined previous research studies to determine if preoperative quadriceps strength is related to greater strength and better function after an anterior cruciate ligament (ACL) reconstruction. The authors identified 3 studies performed since 2004 that met their inclusion criteria. All three studies were reported to have a high level of evidence.

All three studies showed a positive relationship between preoperative quadriceps strength and postoperative knee strength and function. Abnormal or poor preoperative knee strength was related to lower postoperative knee strength and worse lower extremity function. Normal or good preoperative strength was related to greater postoperative knee strength and better function. This indicates that greater preoperative quadriceps strength may result in greater knee strength and better lower extremity function after an ACL reconstruction. This critically appraised topic provides strong support for establishing normal levels of quadriceps strength prior to ACL reconstruction surgery.

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Evidence Based Research Article Review: Hip Strengthening

The authors examined the effects of hip and quadriceps strengthening on female participants with patellofemoral pain syndrome. 58 participants were split into either a hip strengthening group or a quadriceps strengthening group for the first 4 weeks. The groups were then combined into a functional exercise group for the following 4 weeks. All participants were assessed on pain, function and strength at baseline, 4 weeks and 8 weeks.

There were no differences between groups regarding strength or function over the 8 week period. There was a difference in pain between groups. Although both groups reported the same level of pain at baseline and 8 weeks, the hip strengthening group reported significantly lower pain at the 4 week period. This indicates that although hip and quadriceps strengthening may eventually create the same improvements in strength, pain, and function, emphasizing hip strengthening may reduce pain quicker and provide comfort for the patient earlier in the rehabilitation process.

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Evidence Based Research Article Review: Canadian C-Spine Rules (CCR)

The authors examined the efficacy of the Canadian C-Spine Rules (CCR) in determining when to request or avoid radiography. The CCR involves assessing a set of criteria to determine if radiographs are necessary. It was designed to assess stable, alert patients who experienced an acute trauma. Clinicians examine if any high-risk factors such as dangerous mechanisms or paresthesia in the extremities are present. They also examine if there are any low-risk factors that allow safe assessment of cervical spine range of motion. If range of motion assessment is safe then the patients are asked to rotate their neck to the left and right. If there are no high-risk factors, patients are able to safely perform range of motion assessments, and can rotate at least 45 degrees from midline, radiography is not warranted. This clinical prediction rule was compared to the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC). 

Two percent of patients had cervical spine injuries that were deemed clinically important. The CCR and NLC were valuable in identifying when a clinically important cervical spine injury was absent, and therefore avoided radiography, although the CCR was more valuable in this process. These tools were not as valuable in identifying when a clinically important c-spine injury was present, although the CCR was more valuable in this process as well. This indicates that the Canadian C-Spine Rules can help determine if a patient needs referral for an x-ray following acute trauma.

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