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ACUTE EFFECTS AND RECOVERY TIME FOLLOWING CONCUSSION IN COLLEGIATE FOOTBALL PLAYERS

Background:
 There is a lack of empirical data on the recovery time following sport related concussion and this makes clinical decision about return to play difficult.

Research question/s:
 What are the immediate effects and what is the natural recovery course (symptoms, cognitive functioning, and postural stability) following sport related concussion?

Methodology:Subjects: 1631 football players from 15 colleges in the USA.

Experimental procedure: All players underwent preseason baseline testing on concussion assessment measures in 1999, 2000, and 2001. 94 players with concussion (CONC group; based on American Academy of Neurology criteria) and 56 non-injured controls (CON group) underwent assessment of symptoms, cognitive functioning, and postural stability at 3 hours, and 1, 2, 3, 5, 7, and 90 days post injury (84% compliance).

Measures of outcome: Scores on the Graded Symptom Checklist (GSC), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and a neuropsychological test battery.

Main finding/s:
 The CONC group exhibited more severe symptoms (GSC score 20.93 [95% CI 15.65 to 26.21] points higher than CON), cognitive impairment (SAC score 2.94 [95% CI 1.50 to 4.38] points lower than CON), and balance problems (BESS score 5.81 [95% CI -0.67 to 12.30] points higher than CON) immediately after concussion. Symptoms gradually resolved by day 7 (GSC mean difference 0.33; 95% CI -1.41 to 2.06), cognitive functioning improved to baseline levels within 5–7 days (day 7 SAC mean difference -0.03; 95% CI -1.33 to 1.26), and balance deficits dissipated within 3–5 days after injury (day 5 BESS mean difference -0.31; 95% CI -3.02 to 2.40).


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Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7.

There were no significant differences in symptoms or functional impairments in the CONC and CON groups 90 days after concussion.

Conclusion/s:
 Collegiate football players with concussion require several days (up to 7 days) for recovery of symptoms, cognitive dysfunction, and postural instability.

Evidence based rating: 7.5/10

Clinical interest rating: 8.5/10

Type of study: Prospective cohort study

Methodological considerations: Well-conducted study, only mild-moderate concussions studied, selection bias, confounding variables

Keywords: football, concussion, head, injury, symptoms, neuropsychology

SEPTIC ARTHRITIS OF THE PUBIC SYMPHYSIS

Background:
 Chronic groin pain is a common clinical problem in athletes, and the diagnosis is not often clear.

Research question/s:
 Does septic septic arthritis of the symphysis pubis due to Streptococcus pneumoniae cause groin pain in athletes?

Methodology:Subjects: Case report and a review of 99 cases.

Experimental procedure: A single case of bacterial pubic symphysitis is described and 100 cases are reviewed for predisposing factors, clinical signs, investigations, treatment, and prognosis.

Main finding/s:
 Specific sports: Soccer (9/19), runners (3/19), football players (2/19), tennis players (2/19), and 1/19 each for handball, rugby, and ballet.


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Clinical features: Clinical features of pubic symphysis infection included fever (74%), pubic pain (68%), painful or waddling gait (59%), pain with hip motion (45%), and groin pain (41%).

Staphylococcus aureus was the major cause among athletes, Pseudomonas aeruginosa among intravenous drug users, and infections among patients with pelvic malignancies were usually polymicrobial, involving faecal flora. Patients with recent urinary incontinence surgery usually had monomicrobial infection, with no predominant pathogen.

Treatment suggested: antibiotics for 6 weeks, surgical debridement (55% subjects).

Conclusion/s:
 In a case series of 100 patients with septic pubic symphysitis, 19% occurred in athletes, commonly presenting in soccer players (or sports involving hip adduction) with fever (74%) pubic pain (68%) and painful gait (59%).

Evidence based rating: 4/10

Clinical interest rating: 8/10

Type of study: Case series

Methodological considerations: Case series mainly of clinical interest

Keywords: pubic symphysitis, groin pain, athletes, infection

PHYSICAL ACTIVITY AND WEIGHT LOSS: DOES PRESCRIBING HIGHER PHYSICAL ACTIVITY GOALS IMPROVE OUTCOME?

Background:
 It is generally recommended that physical activity facilitates long term weight loss, but the optimal level of physical activity to recommend is unknown.

Research question/s:
 Is a higher level of physical activity (weekly energy expenditure) more effective for long term weight loss than that normally used in behavioural treatments?

Methodology:Subjects: 202 overweight men and women.

Experimental procedure: Subjects were randomly assigned to either a standard behaviour therapy (SBT) for obesity, incorporating an energy expenditure (EE) goal of 1000 kcal/week, or to a high physical activity (HPA) treatment, in which the goal was an EE of 2500 kcal/week. Subjects in the HPA treatment group participants were encouraged to recruit one to three exercise partners into the study, and received personal counselling from an exercise coach, and small monetary incentives.

Measures of outcome: Physical activity level (kcal/week), weight loss (kg).

Main finding/s:Physical activity level: There was a higher mean (± SD) physical activity level in the HPA than in the SBT group at 6 months (HPA 2399 ± 157 kcal/week, SBT 1837 ± 1431 kcal/week), 12 months (HPA 2249 ± 1751 kcal/week, SBT 1565 ± 1309 kcal/week), and 18 months (HPA 2317 ± 1854 kcal/week, SBT 1629 ± 1483 kcal/week) (all p<0.01) weight loss.


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Conclusion/s:
 Higher levels of physical activity (energy expenditure >2500 kcal/week) promote long term weight loss better than conventional recommendations (1000 kcal/week energy expenditure).

Evidence based rating: 7.5/10

Clinical interest rating: 7/10

Type of study: Randomised controlled clinical trial

Methodological considerations: Well conducted study

Keywords: obesity, weight loss, physical activity, exercise goals, social support, treatment

INFLUENCE OF PARTICIPATION IN HIGH IMPACT SPORTS DURING ADOLESCENCE AND ADULTHOOD ON BONE MINERAL DENSITY IN MIDDLE AGED MEN: A 27 YEAR FOLLOW-UP STUDY

Background:
 The influence of physical activity during childhood and adolescence on adult bone mass is not well understood.

Research question/s:
 Does participation in high impact sports during adolescence (at 13 years) and adulthood improve bone health in males aged 40 years?

Methodology:Subjects: 154 Belgian men aged 13 years at study onset (1969) and aged 40 years (27 year follow-up).

Experimental procedure: Subjects were divided into three groups according to their sports participation history: participation during adolescence and adulthood in high impact sports (HH; n  =  18), participation during adolescence in high impact sports and during adulthood in non-impact sports or no sports (HN; n  =  15), and participation during adolescence and adulthood in non-impact sports or no sports (NN; n  =  14).

Measures of outcome: Bone mineral density (BMD) of total body and lumbar spine.

Main finding/s:
 Total body BMD: Body mass and impact loading during adulthood was a significant predictor of total body BMD. Total body BMD was higher in the HH group at age 40 years, but not significantly (F  =  3.17, p  =  0.0515).


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Lumbar spine BMD: Body mass and impact loading during adulthood was a significant predictor of lumbar spine BMD.

Conclusion/s:
 Participation in impact sports during adolescence, and then continuing the participation in impact sports improves BMD in males aged 40 years.

Evidence based rating: 7/10

Clinical interest rating: 7.5/10

Type of study: Prospective cohort study

Methodological considerations: BMD measurements were not longitudinal (selection bias)

Keywords: adolescence, bone density, densitometry, x-ray, exercise, men, sports, impact sports

INTRA-ARTICULAR HYALURONIC ACID IN TREATMENT OF KNEE OSTEOARTHRITIS

Background:
 The intra-articular injection (two to three injections) of hyaluronic acid is an approved treatment for knee osteoarthritis (OA), but its efficacy remains controversial.

Research question/s:
 Is intra-articular hyaluronic acid effective (reducing pain) in the treatment of knee osteoarthritis?

Methodology:Literature search: 1) Human clinical trials in MEDLINE and Cochrane Trials Register, using the search terms (osteoarthritis, osteoarthrosis, or degenerative arthritis) and (hyaluronic acid, Hyalgan, Synvisc, Artzal, Suplasyn, BioHy, or Orthovisc); 2) Hand searched manuscript bibliographies that met inclusion criteria. Included publications: 1) published or unpublished, 2) English and non-English, 3) single- or double-blinded, randomised controlled trials comparing intra-articular hyaluronic acid with intra-articular placebo injection for the treatment of knee OA, 4) extractable data on pain reported by one of the outcome measures.

Data synthesis: 1) Calculated effect size (small effect sizes, 0.2–0.5; large effect sizes, 1.0–1.8, equivalent to a total knee replacement), 2) random-effects model was used to pool study results, 3) the Cochrane Q test was used to evaluate heterogeneity, and 4) a funnel plot and the Egger test was used to evaluate publication bias.

Main finding/s:Effect size: Pooled effect size for hyaluronic acid was 0.32 (95% CI 0.17 to 0.47). Two trials using highest molecular weight hyaluronic acid (6000 kDa) had effect sizes >1.5 (similar to total knee replacement), but a third trial of the same compound showed a nearly null effect. When the trials using 6000 kDa were removed, pooled effect size for intra-articular hyaluronic acid decreased to 0.19 (95% CI 0.10 to 0.27).


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Publication bias: Evidence of publication bias (two unpublished trials pooled effect size = 0.07 (95% CI -0.15 to 0.28).

Conclusion/s:
 Intra-articular hyaluronic acid for the treatment of knee osteoarthritis has a small beneficial effect when compared with placebo; the highest molecular weight hyaluronic acid (6000 kDa) may be more efficacious but the presence of publication bias suggests that even this effect may be overestimated.

Evidence based rating: 9/10

Clinical interest rating: 7.5/10

Type of study: Meta analysis

Methodological considerations: Well conducted study

Keywords: knee, osteoarthritis, intra-articular, hyaluronic acid, meta-analysis

IDENTIFICATION OF INDIVIDUALS WITH PATELLOFEMORAL PAIN WHOSE SYMPTOMS IMPROVED AFTER A COMBINED PROGRAMME OF FOOT ORTHOSIS USE AND MODIFIED ACTIVITY: A PRELIMINARY INVESTIGATION

Background:
 It is not known which examination findings or factors in a patient’s history could be used to predict which patients with patellofemoral pain syndrome (PFPS) will respond to a specific intervention.

Research question/s:
 Which aspects of the examination could be used to identify those patients with PFPS that are most likely to respond to off-the-shelf foot orthoses and instruction in activity modification?

Methodology:Subjects: 45 subjects (male  =  34, female  =  11) with clinically diagnosed PFPS.

Experimental procedure: All subjects underwent a clinical assessment at the initial visit (including rearfoot alignment, forefoot alignment, navicular drop, Q angle, patellar orientation, axis of the first MTP joint, Thomas test, leg length). Subjects were then given foot orthoses and instructed in activity modification for 3 weeks.

Measures of outcome: Pain: VAS (with a 50% reduction in pain considered as success), and likelihood ratios (LRs) to determine which examination findings were most predictive of success.

Main finding/s:
 Predictors of improvement were forefoot valgus alignment of ⩾ 2 degrees (+LR 4.0; 95% CI 0.7 to 21.9), great toe extension of ⩽78 (+LR 4.0; 95% CI 0.7 to 21.9), and navicular drop of ⩽3 mm (+LR 2.4; 95% CI 1.3 to 4.3).


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Conclusion/s:
 Patients with patellofemoral pain syndrome (PFPS) who have forefoot valgus alignment of ⩾ 2, passive great toe extension of ⩽ 78, or navicular drop of ⩽ 3 mm are most likely to respond favourably to initial intervention with an off-the-shelf foot orthosis and instruction in activity modification.

Evidence based rating: 6.5/10

Clinical interest rating: 7.5/10

Type of study: Case control study

Methodological considerations: Reliability of measurements, most subjects had bilateral knee pain

Keywords: knee pain, orthotics, patellofemoral, physical examination, rehabilitation

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