Clinical Guidelines in Sports Medicine: Am I Reading a Guideline or a Consensus Statement: What’s the Difference? Does it Matter?

Introduction: The integration of research evidence into clinical practice is one of the most challenging aspects of sports medicine. The time required to search library databases and read multiple systematic reviews represents a significant barrier to many clinicians. Clinical guidelines and consensus statements provide a summary of best practice for clinical conditions, and provide clinical recommendations. In sports medicine, the terms clinical guideline and consensus statement are often used interchangeably; however, important differences exist between these resources. The aims of this review were to identify the clinical guidelines published in key international sports medicine journals over the last five years, and assess their methodological quality. Methods: In March 2014, the top ten international sports medicine journals (identified on current impact factors) were searched using the single keyword ‘guideline’. Peer-reviewed papers providing clinical recommendations that were described by the authors as a guideline were included. The International Centre for Allied Health Evidence (iCAHE) guideline checklist, which consists of fourteen ‘yes’ and ‘no’ responses, graded 1 or 0 respectively, was used to assess the methodological quality of each clinical guideline. Results: Ten publications were retained from a pool of 34 potentially-relevant publications. The iCAHE guideline checklist scores ranged from 3 to 11 out of a possible 14. Within the ten included publications, the most frequently identified methodological problems were a failure to describe the strategy used to search for evidence, failure to critically appraise the quality of underlying evidence and failure to clearly link the hierarchy and quality of underlying evidence to each recommendation. Discussion: The ten sports medicine journals included in this review published few clinical guidelines, and these were of poor to moderate quality. These clinical guidelines should be interpreted with caution because of methodological problems identified by this review. Consensus statements are useful resources for busy sports medicine clinicians; however, these resources should be subjected to the same rigorous appraisal as clinical guidelines, in order to identify areas where bias may potentially limit the usefulness of the recommendations

Alterations in medial-lateral postural control after anterior cruciate ligament reconstruction during stair use

Background: Dynamic postural control during everyday tasks is poorly understood in people following anterior cruciate ligament reconstruction (ACLR). Understanding dynamic postural control can provide insight into potentially modifiable impairments in people following ACLR who are at increased risk for second ACL injury and/or knee osteoarthritis. Research question: Determine whether measures indicative of dynamic postural control differ between individuals with and without ACLR during stair ascent and descent. Methods: Seventeen individuals with ACLR (\u3e1 yr post-surgery) and 16 age and sex-matched healthy controls participated. Centre of pressure (COP) measures included: i) COP excursion, ii) COP velocity, and iii) dynamic time-toboundary (TTB). Mixed linear models were used to compare COP measures for the ACLR leg, non-ACLR leg, and healthy controls during stair ascent and stair descent. Results: There were no statistically significant differences observed during stair ascent (all p \u3e 0.05). Several statistical differences were found during stair descent for individual with ACLR, but not between those with ACLR and healthy controls. The ACLR leg had higher medial-lateral COP excursion (mean difference 1.06 cm, [95 %CI 0.08–2.06 cm], p = 0.036; effect size = 0.38) compared to the non-ACLR leg during stair descent. In addition, the ACLR leg had a lower medial-lateral TTB (mean difference −13 ms [95 %CI −38 to 2 ms], p = 0.005; effect size = 0.49) and medial-lateral TTB normalized to stance time (mean difference −5.8 % [95 %CI −10.3 to 1.3 %], p = 0.012; effect size = 0.80) compared to the non-ACLR leg during stair descent. No statistical differences were observed for anterior-posterior measures during stair descent (all p \u3e 0.05). Significance: Taken together, findings indicate that there are small to large differences in medial-lateral postural control in the ACLR leg compared to the non-ACLR leg during stair descent. Further work is required to understand clinical implication of these novel observations

Neuromuscular control and knee function after anterior cruciate ligament reconstruction

© 2014 Dr. Luke PerratonKnee functional outcomes after anterior cruciate ligament reconstruction (ACLR) are variable, particularly amongst recreational athletes. Functional performance tests and self-reported measures of knee function are used clinically to quantify knee function after ACLR. Although these tests provide some indication of gross-motor function, they do not accurately quantify neuromuscular control. Sub-optimal neuromuscular control may be associated with poor knee function and, in turn, to altered knee joint loading and knee osteoarthritis. Despite years of ACLR research, knowledge of the relationship between neuromuscular control and knee function is limited mostly to bivariate analyses. These analyses do not account for participant characteristics such as age, sex, body mass index, the presence of chondral and meniscal injuries, greater anterior knee joint laxity or the participation limitations experienced by individuals. Knowledge of these associations is necessary to help explain the variability in knee functional outcomes following ACLR. Therefore, the aim of the research reported in this thesis was to investigate the cross-sectional associations between clinical tests of knee joint function and i) sports participation, ii) participant characteristics and iii) neuromuscular control following ACLR. To address this broad aim, four studies were conducted using a cross-sectional, observational study design. Sixty-six participants (23 women, median age 28.4, range 19-39) at an average of 18 months (SD 3 months) following ACLR with an ipsilateral hamstring graft, and 41 matched control participants (16 women, median age 25.8, range 18-39) were recruited. The inter-session reliability and standard error of measurement of variables were determined with 26 control participants (8 women, median age 24.7, range 19-37). In Study 1, the knee function of ACLR and control participants was assessed using a battery of self-reported and functional performance (hop) tests. Compared to control participants, ACLR participants demonstrated significant limitations in self-reported knee function and functional performance and significantly more ACLR participants failed the battery of functional tests. In a multivariate logistic regression model, older age, higher BMI and greater anterior knee joint laxity were significant predictors of failing the battery of knee functional tests. In Study 2, the quadriceps force control and thigh muscle activation strategies of ACLR and control participants were assessed using a novel, sub-maximal intensity, open kinetic chain force-matching task. Participants used quadriceps force to match a moving target torque that was displayed on a screen. ACLR participants demonstrated significantly greater target matching error, indicative of less-accurate quadriceps force production and higher levels of quadriceps activation and hamstring coactivation. In a multivariate linear regression model, less-accurate quadriceps force production was associated with greater vastus lateralis activation, lower lateral hamstring coactivation, female sex, older age at the time of testing, greater anterior knee joint laxity and meniscal surgery at the time of ACLR. Together these variables explained 42% of the variance in quadriceps force control in the ACLR group. In Study 3, the trunk and lower limb biomechanics of ACLR and control participants were compared in the landing phase of a novel forward hopping task which involved a dynamic take-off. Hop distance and take-off velocity were standardised to minimise variability in task performance between individuals. Significantly smaller knee flexion excursion, peak knee extensor moments and peak trunk flexion angles were observed in the ACLR group. In a multivariate linear regression model, greater anterior knee joint laxity, higher vastus medialis activation, lower medial hamstring coactivation and lower quadriceps strength relative to body mass accounted for 54% of the variance in knee flexion excursion in the ACLR group. Study 4 addressed the main aim of the thesis by investigating the multivariate associations between knee joint function, participant characteristics and neuromuscular control. Less-accurate quadriceps force production, greater lateral hamstring coactivation during the force matching task and female sex were significant predictors of failing the functional test battery. In the closed kinetic chain, smaller knee flexion excursion, smaller peak knee extensor moment and greater anterior knee joint laxity were significant predictors of failing the test battery. Prospective studies are now needed to determine whether the biomechanical and neuromuscular variables identified by this research are predictive of long-term knee function and knee osteoarthritis

Development and implementation of an online hybrid model for teaching evidence-based practice to health professions: processes and outcomes from an Australian experience

Saravana Kumar, Luke Perraton, Zuzana Machotka.International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, Adelaide, South Australia.Abstract: Evidence-based practice is now considered to be a vital element of health care service delivery. The call to use evidence to inform other areas, such as teaching and learning, is growing. This paper reports on the processes used to integrate best evidence into teaching practices within an undergraduate health science program. An existing course within this program at an Australian tertiary institution was remodeled by a newly appointed course coordinator in response to critical feedback from student cohorts. A systematic, iterative, five-step approach was used in the development of the new course. The process of development was influenced by current research evidence, an audit of the existing course, and critical feedback from ­students. The new course was evaluated using quantitative and qualitative research methods for five study periods. In 2005, prior to implementing the changes, the overall student satisfaction rating for the course was zero (representing the lowest possible score). In 2006, the overall student satisfaction rating was 62.07, in 2007 it was 65.8, and in 2008 it was 55.7. Qualitative ­findings also supported these quantitative findings, indicating improvements in the structure and process of the new course. The outcomes from the evaluation of the remodeled course provide evidence of a consistent quality learning experience for students, and support the concept of using research evidence to guide the development of teaching and learning practices in the training of health professionals.Keywords: evidence-based teaching, learning, health care, qualitative, quantitative

Whole-body vibration to treat low back pain: fact or fad?

Purpose: The purpose of this systematic review was to evaluate the current evidence base for whole-body vibration as a treatment for low back pain (LBP). Summary of key points: Whole-body vibration through occupational exposure has previously been recognized as an aetiological factor in LBP. Previous studies have identified whole-body vibration (WBV) as a cause of LBP in various sitting-based occupations that involve machinery and repetitive vibration. In the last decade, however, WBV has been advocated as a safe and effective treatment for LBP. Despite the growing popularity of WBV in clinical practice, this systematic review of the literature identified only two studies that investigated the effectiveness of WBV as a treatment option for LBP, and an assessment of the quality of these studies demonstrated several methodological problems that may have biased their findings. While there is emerging evidence for the effectiveness of WBV in treating some medical conditions, the evidence for WBV as a treatment for LBP remains equivocal. Recommendations: Based on the current body of evidence, routine use of WBV to treat LBP should be undertaken with caution. Further rigorous research designed to investigate the effectiveness of WBV as a safe and high-quality treatment for LBP is required.

Day Therapy Programs for Adolescents with Mental Health Problems: A Systematic Review

Day therapy programs are one of many interventions available for adolescents with mental health issues. Day therapy programs utilise a multi-disciplinary community-based approach to the treatment of mental health issues and allow adolescents to remain under the care of their family. To date, no review has specifically investigated the effectiveness of day therapy programs for adolescents. This review aims to investigate both the effectiveness of day therapy programs for adolescents with mental health problems and highlight the key components underpinning these programs. A systematic review of peer- reviewed literature was undertaken, using recognised processes. Eight studies were included in this review, including both interventional and descriptive study designs. All eight studies found positive effects of varying degrees for day therapy programs for adolescents with mental health problems. Most used a multi-modal, multi-disciplinary group-based approach and utilised one or more co-interventions. A frequency of once per week was most commonly used; however, the optimal frequency and duration of day therapy programs remains unclear. Most studies used more than one type of health professional to deliver their intervention. Unsurprisingly, psychologists or psychiatrists were involved in delivering interventions in all but one study. Current research evidence suggests that day therapy programs may be an effective intervention for adolescents with mental health issues. A multimodal and multidisciplinary group-based treatment approach may be most effective, and participants could benefit from the involvement of at least one health professional from a psychology or psychiatric background. However, a range of health professionals may contribute to a day therapy program and a range of locations and settings may be appropriate. Further high-level, high-quality research using standardised outcome measures is required to support these findings and determine key parameters, such as an optimal frequency and duration for day therapy programs