Sports Chiropractic Research

A Clinical Primer to Sport-Related Concussion Management: A Case-Based Approach

Dr. David Oh, DC, FRCCSS(C)
Dr. Andrew Parks, DC, FRCCSS(C)

Disclosures: The authors used AI technologies (ChatGPT) was used to proofread and suggest improvements in wording and grammar for this manuscript. All sections were initially written by the human authors and revised by them after artificial intelligence assistance.

Introduction

Sports-related concussion (SRC) has historically been misunderstood. From antiquated management recommendations, outdated ideas related to pathophysiology, and a hesitation to implement updated evidence, sports clinicians, coaches, parents, and sports teams often report a lack of clarity regarding the management of SRCs.

The Amsterdam 2022 International Consensus Statement¹ highlighted clear and practical guidelines to frame how we should approach the management of SRC. The guidelines reinforce that recovery is not merely about waiting for symptoms to fade but requires a proactive strategy that addresses an athlete’s unique neurophysiological, autonomic, and biomechanical impairments that can arise following SRC.

To illustrate these principles in practice, we’ll follow the case of Jack, a 16-year-old high school hockey player who sustains a concussion during a game. Using Jack’s case as an example, we’ll explore how the latest research, clinical tools, and the integration of sports chiropractic care can optimize SRC management.

 The Paradigm Shift: Beyond Rest and Waiting for Symptom Resolution

Jack takes an elbow to the head during a high-intensity play. Thereafter, he experiences dizziness, mild nausea, and difficulty concentrating. Under the Berlin 2016 guidelines², he would have been prescribed strict rest for at least 24-48 hours, with no physical exertion, limited screen time, and avoidance of cognitive stressors. His return-to-play process would have been dictated by symptom resolution, with physical activity introduced only when he was asymptomatic.

However, the updated 2022 guidelines¹ take a fundamentally different approach. Strict rest is no longer the gold standard. Instead, we recognize that prolonged inactivity may delay recovery by contributing to persisting autonomic dysregulation, vestibular dysfunction, and cardiovascular instability. In fact, recent randomized control trials and prospective cohort studies have demonstrated that earlier symptom-limited aerobic exercise following SRC has a markedly positive relationship with faster recovery.

In our case, Jack’s care team initiated early symptom limited exercise within 48 hours, prescribed light aerobic activities such as walking or stationary cycling at intensities that did not exacerbate symptoms. This strategy is backed by robust evidence suggesting that controlled movement and exercise enhances oxygen and nutrient delivery, neuroplasticity, cerebral autoregulation, autonomic function and cardiovascular control, and reduces the likelihood of persistent post-concussion symptoms (PPCS).

Why Sports Chiropractors Play a Key Role in SRC Management

Sports chiropractors, specifically those with additional training and understanding of neuroanatomy, neurophysiology and concussion management, are well equipped to be leaders of a concussion healthcare team. Beyond monitoring symptoms, they assess and treat cervicogenic contributions to concussion symptoms^1,3,4—an often-overlooked contributor to symptoms in certain patients. Additionally, the cervical spine provides robust inputs that integrate within the central vestibular system in the brainstem along with other vestibular and visual inputs. This complex but often underappreciated integration is the foundation to what allows us to move and navigate in a dynamic and ever-changing physical environment when we are healthy. Aberrant inputs from one or more of these systems may result in a sensory mismatch which can drive feelings of dissociation, unsteadiness, visual disturbances, nausea, persistent neck pain or emotional dysregulation. Additionally, this central vestibular integration is tightly intertwined with autonomic nervous system reflexes through vestibulo-sympathetic pathways. These reflexes mediate blood distribution to the cerebrum based on sensory feedback of where the body and head is in space. Dysregulation of these reflexes may lead to hypoperfusion of the cerebrum resulting in symptoms including but not limited to lightheadedness, visual changes, dizziness, headaches and exercise intolerance. Therefore, assessment and rehabilitation should aim at identifying and actively treating these sensory and integrative errors through rehabilitation.  A case series by Germann et al. (2020)³ highlights the effectiveness of multi-modal interventions, including:

• Manual therapy for the cervical spine to address somatosensory dysfunction and concomitant musculoskeletal pain
• Vestibulo-ocular rehabilitation to optimize head and eye coordination and oculomotor control
• Graduated aerobic exercise exposure to stabilize autonomic control of blood pressure and heart rate while facilitating oxygen and nutrient delivery
• Deep neck flexor exercises to improve cervical stability, cervical proprioceptive function and reduce headache intensity

It is essential to note that the mechanisms of such dysregulation may be different between injuries and also in different age cohorts. Thus, objective biometric assessment of autonomic nervous system function via HR, HRV, pupillometry, and exercise measurements are valuable to monitor recovery trajectories but also to aid in rehabilitation prescription. A recent systematic review by Parks et al. (2023)⁵ synthesizes the existing literature of autonomic nervous system dysfunction in pediatric SRC. There is also emerging evidence to suggest value in implementing objective oculomotor testing via Video-Oculography (VOG) or other eye-tracking devices to detect subtle disturbances in the smooth pursuit, saccade, optokinetic and visual systems.

Early Concussion Care: The Data on Timing Matters

A 2025 study by Oh et al. (BMJ Open Sport & Exercise Medicine)⁶ underscores a crucial finding: timing of care is critical. Athletes who sought care within seven days of injury recovered an average of four days faster than those who delayed treatment (18 vs. 22 days median recovery time).

Jack’s parents, initially unsure whether immediate care was necessary, decide to bring him to a sports chiropractor within 48 hours of injury. Here’s why that decision matters:

• Timely autonomic assessment allows for targeted interventions and graded exercise therapy, specifically catered to Jack’s findings
• Faster integration of cervical and vestibular rehabilitation prevents compounding dysfunctions via aberrant sensory inputs from respective systems

Jack reported neck pain and dizziness, which may suggest a cervical, vestibular, autonomic and/or visual components to his symptoms. His sports chiropractor integrated modalities to assess and target each of these neurological domains where appropriate. Some strategies included sub-symptoms exercise, manual therapy and joint repositioning training of the cervical spine, deep neck flexor training, and oculomotor rehabilitation into his treatment plan.

A very important point is that the implementation of oculomotor and vestibular rehabilitation is highly specific to the individual and their specific findings. There are many intricate and overlapping systems that connect the cerebellum, cortex, and brainstem that drive the control of eye movement. This includes eye movement latency, velocity and accuracy during smooth pursuits, saccades and combined head-eye movement. Using a generalist approach and applying the same exercises for each patient is not recommended as it may make an individual more symptomatic, and is non-specific to their individual injury or neurology.

 Tools for Better Precision: SCOAT6 Use in Concussion Care

Sideline assessments like the SCAT6 are excellent for acute concussion screening, but for in-office evaluations, chiropractors benefit from a more structured tool: the Sport Concussion Office Assessment Tool 6 (SCOAT6)¹, a tool that is designed for ongoing monitoring and is ideally used in an office setting.

When Jack arrived at his chiropractor’s office, his SCOAT6 assessment included:

• Symptom burden tracking to monitor changes over time
• Vestibular-ocular testing to identify visual motion sensitivity or dysfunction
• Cervical spine examination to assess range of motion and segmental dysfunction
• Autonomic function assessment, including HRV and orthostatic intolerance screening

It’s important to note that the SCOAT6 is an incredibly accessible tool that is easy to implement for most practitioners. It does not rely on any advanced diagnostic technology and is easily applied at the bedside with minimal equipment. That said, the use of the SCOAT6 does not discount the potential for more advanced testing if indicated and required in certain cases. There may be large inter-examiner variability with the techniques and subjective interpretation of a bedside evaluation of oculomotor control and vestibular function. More objective and reproducible measures such as Vestibulo-Oculography (VOG) and Posturography may provide more accurate data and allow for more valid visit-to-visit comparison throughout recovery. The use of such equipment is largely reserved to practitioners who solely treat traumatic brain injury and other neurological disorders.

In this case that we present, Jack’s chiropractor gained data from the SCOAT6 to refine his rehab plan. The tool ensures that Jack’s treatment evolves dynamically, adapting to his progress rather than relying on outdated stepwise and algorithmic recovery models. No advanced diagnostic equipment was used in the evaluation of this case.

Conclusion: Where We Go from Here

The Amsterdam 2022 guidelines¹, alongside the SCOAT6, help provide clarity and individualized context in the management of athletes with SRC. Sports chiropractors have an important role to play as neuromusculoskeletal experts to promote earlier assessment, diagnosis and individualized rehabilitation/treatment to help our athletes return safely to sport.

However, with each new concussion case we attend to we must pause, reflect and ask ourselves the following question with humility: can we treat something to the best of our ability if we do not measure it and deeply understand the breadth and depth of it?

SRC is a complex injury, and it is important to recognize when it is appropriate to refer to a colleague or medical specialist for advanced objective biometric testing or co-management.

 References

1. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British journal of sports medicine. 2023 Jun 1;57(11):695-711.
2. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine. 2017 Jun 1;51(11):838-47.
3. Germann D, Marshall C, Kazemi M. Multi-modal management of sport and non-sport related concussion by chiropractic sports specialists: a case series. The Journal of the Canadian Chiropractic Association. 2020 Dec;64(3):214.
4. Cancelliere C, Howitt S, Halowski T, Jacobs C, Da Roza M, Wright D, Connell G, Yu H. Expanding concussion care in Canada: the role of chiropractors and policy implications. The Journal of the Canadian Chiropractic Association. 2024 Aug;68(2):86.
5. Parks A, Hogg-Johnson S. Autonomic nervous system dysfunction in pediatric sport-related concussion: a systematic review. The Journal of the Canadian Chiropractic Association. 2023 Dec;67(3):246.
6. Oh DY, Germann D, Cancelliere C, Kazemi M, Marshall C, Hogg-Johnson S. Association of early versus late care seeking for sport-related concussion in adolescent athletes in Canada: a historical cohort study. BMJ Open Sport & Exercise Medicine. 2025 Feb 8;11(1).

This is a great review by Alex Lee, BSc, DC, FRCCSS (C)

Article: Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review (please note this is an open access publication https://pubmed.ncbi.nlm.nih.gov/32060141/ 

I encourage everyone to read this open-access publication. The key clinical implications of this work (see Table 5 in the article) are: 1) psychological, social, and contextual factors should be acknowledged and must be considered when caring holistically for athletes, 2) these factors are dynamic and change across the recovery process, 3) it is important to address these factors early in the recovery process and build a strong provider-athlete relationship, and 4) make sure to focus on the individual athlete to provide athlete-centred care.

Reviewer: Alex Lee, BSc, DC, FRCCSS(C)

Reference: Truong LK, Mosewich AD, Holt CJ, Le CY, Miciak M, Whittaker JL. Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review. Br J Sports Med. 2020;54:1149-1156.

Background/aim: Injuries have a substantial impact on athletes. In addition to physical outcomes, non-physical factors – such as psychological, social, and contextual factors – can influence recovery. To provide athlete-centred care, these factors must be investigated and appropriately addressed when caring for athletes recovering from an injury.

Objective: To explore the role of psychological, social, and contextual factors across the recovery stages following a traumatic time-loss sport-related knee injury.

Methods: This study conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews. These authors searched six databases – MEDLINE, PyscINFO, CINAHL, SportDiscus, SCOPUS, and ProQuest from inception to May 2018. The search strategy involved combining search terms to identify articles about athletes recovering from a traumatic time-loss knee injury that described a psychological, social or contextual factor during recovery. Operational definitions were: psychological factor – cognitive, behavioural or affective responses associated with an individual’s experience of injury, rehabilitation, surgery and return to sport; social factor – social networks and social exchanges that shape an individual’s experience of injury, rehabilitation, surgery, and return to sport; contextual factor – structural and institutional systems in which an individual is embedded that influence their experience of injury, rehabilitation, surgery, and return to sport. Article screening was conducted by two raters, and data extraction was completed by the lead author. Methodological quality of the included studies was assessed by two raters using the Mixed Methods Appraisal Tool. The authors utilized an inductive thematic analysis to identify patterns, summarise consistent findings across studies, and generate common themes.

Results: Of 7289 records, 77 studies representing 5540 participants were included. Psychological factors were investigated across all studies, while social and contextual factors were assessed in 39% and 21% of included studies, respectively. The data synthesis identified four themes within the psychological domain: barriers to progress, active coping, independence, and recovery expectations. Two themes were identified in the social domain: social support and engagement in care. Two themes were identified within the contextual domain: environmental influences and sport culture. The psychological, social, and contextual themes varied across the recovery stages (acute, rehabilitation, and return to sport stages) with the concept of individualization to the athlete that was present across all themes and recovery stages (see Figure 2 in the open-access article for a visual representation of the themes across the recovery stages).

Conclusions: This scoping review identified a diverse set of psychological, social, and contextual factors present across the stages of recovery in athletes recovering from a sport-related knee injury. Understanding these factors and their implications on recovery can inform management to optimize care.

Commentary/Critique: An injury can have a drastic effect on an athlete. As healthcare providers, we need to take a holistic approach to address the impact of an injury on the athlete – considering not just the physical impact of the injury to the athlete, but also the psychological and social impact. Additionally, the contextual factors of sport – its environment and culture – influences how athletes recover. While many healthcare practitioners may intuitively consider these factors when caring for athletes, we must study these factors objectively to ensure we don’t miss key areas that athletes require us to focus on, to truly provide holistic athlete-centred care. This scoping review by Truong et al reviewed the literature to identify the psychological, social, and contextual factors across recovery stages following a sport-related knee injury.

Overall, this scoping review was well executed and followed the standardized reporting for this study type outlined by the PRISMA Extension for Scoping Reviews. The search strategy was clear and comprehensive. Two raters screened articles for inclusion and rated the articles using a quality rating tool. Readers should be aware that only one author conducted data extraction, so we are not sure how much we can trust that the data extracted would have been the same if another individual also extracted the data independently.

The results of the thematic analysis were informative to healthcare providers working with athletes. The review outlines and discusses the various psychological factors that impact athletes during an injury such as fear and anxiety. It also discusses the benefit of providing strategies to athletes for active coping and building independence during the recovery process. Recovery expectations of athletes are highlighted, with interactions with athletes’ healthcare providers as important to shape these expectations. The review discusses the role of social support to the athlete’s recovery journey, with the athlete’s social networks with family, friends, and teammates important more early in the rehabilitation process, with a shifting importance of social networks with coaches and healthcare staff in the latter phases of the recovery process. The results also point to the importance of actively engaging athletes in their care to build self-efficacy. The authors also provide discussion about the contextual influence of sport where the culture of sport can lead to pressure on athletes to endure pain, downplay injuries, and return to sport prematurely. The authors also discuss the cross-cutting concept of individualisation where psychological, social, and contextual factors can manifest differently across athletes, highlighting the importance of considering the athlete individually when providing care.

Reviewer: Alex Lee, BSc, DC, FRCCSS(C)

Reference:

• Finch CF, Talpey S, Bradshaw A, Soligard T, Engebretsen L. Research priorities of international sporting federations and the IOC research centres. BMJ Open Sport Exerc Med [Internet]. 2016;2:1–8. Available from: http://dx.doi.org/10.1136/bmjsem-2016-000168
• Finch CF. Whose research agenda is it? Reconciling the views of researchers and sports stakeholders. Vol. 15, Br J Sports Med. BMJ Publishing Group; 2017. p. 3–4.

Article: Research priorities of international sporting federations and the IOC research centres,

Background/aim: The prevention of injury in sport and promotion of athlete’s health needs to be both targeted and underpinned by scientific evidence.

Objective: To identify the research priorities of International Sporting Federation (ISFs) compared to the current research focus of the International Olympic Committee Research Centres (IOC-RCs).

Methods: Online survey of ISF Medical Chairpersons (n=22, 69% response) and IOC-RC Directors (n=7, 78% response). Open-ended responses relating to injury/illness priorities and specific athlete targets were thematically coded. Ratings were given of the need for different research types according to the Translating Research into Injury Prevention Practice (TRIPP) Framework stages.

Results: Both ISFs and IOC-RFs prioritised research into concussion (27%, 72%, respectively), competitive overuse (23%, 43%) and youth (41%, 43%). The ISFs also ranked catastrophic injuries (14%), environmental factors (18%), elite athletes (18%) and Paralympic athletes (14%) as important. The IOC-RCs gave higher priority to preventing respiratory illness (43%), longterm health consequences of injury (43%) and recreational athletes (43%). There was a trend towards ISFs valuing TRIPP stage 5/6 research more highly and for the IOC-RCs to value TRIPP stage 1/2 research.

Conclusions: There are opportunities to better link the priorities and actions of the ISFs and IOC-RCs, to ensure more effective practice-policy-research partnerships for the benefit of all athletes. Setting a mutually-agreed research agenda will require further active engagement between researchers and broader ISF representatives.

Keywords: injury prevention, research agenda, sports research

Commentary/Critique: With the 2022 Winter Olympics underway, we can reflect on our roles as sports chiropractors working with athletes. We should not only care for them at the polyclinics, but also aim to prevent injury and illness to improve their health. To do so, we need to understand the injury prevention research effort.

This cross-sectional online survey1 compared the research priorities of ISFs to the IOC-RC to identify similarities and differences. These authors found the research priorities aligned well for concussion, anterior cruciate ligament injuries and chronic overuse injuries, with particular emphasis on youth. The IOC-RCs were more engaged with research into long-term negative health outcomes and recreational participants, while the ISFs are more interested in conducting implementation research and studies that evaluate intervention effectiveness.

Why is this work important? Presently, efforts are underway to develop research agendas for the sports chiropractic field in various jurisdictions. While identifying the opinions on research priorities from sports chiropractors is necessary to establish a research agenda, the field should also engage with their stakeholders (athletes and sports federations) to understand their viewpoints on research priorities. In Finch’s follow up editorial to this present study – “Whose research agenda is it? Reconciling the views of researchers and sports stakeholders”2 – she discuses the importance of engaging with sports stakeholders when developing an injury prevention research agenda and recommends researchers partner with sports stakeholders early in the process of establishing a research agenda. She writes that by engaging with stakeholders, researchers can incorporate the sports-specific context into their research, which can increase the likelihood of adoption by the sports community. This work by Finch et al,1,2 should resonate with sports chiropractors as we should aim to be partners in the sports arena, not just on the field and polyclinic, but also in research laboratories and interdisciplinary investigative teams.

This great public policy looks at adults with acute or chronic pain, including cancer patients, without progressive or terminal disease, treated in an outpatient setting, excluding hospice and end-of-life care.

Objectives. Provide a framework for comprehensive pain evaluation and individualized multimodal treatment. Improve quality of life and function in patients experiencing pain, while reducing the morbidity and mortality associated with pain treatments, particularly opioid analgesics.

https://michmed-public.policystat.com/policy/7109483/latest/

Reviewer Name: Claudio Merkier

Title: Effect of Drop-Piece High-Velocity, Low-Amplitude Manipulation to the Midfoot of Asymptomatic Adult Sprinters on Performance During a Unilateral Horizontal Drop-Jump Test: A Feasibility Investigation

Reference: Bell, S. and Howarth, S. J. (2021) Effect of drop-piece high-velocity, low-amplitude manipulation to the midfoot of asymptomatic adult sprinters on performance during a unilateral horizontal drop-jump test: A feasibility investigation, Journal of Manipulative and Physiological Therapeutics, 44 (7), pp. 527-534. https://doi.org/10.1016/j.jmpt.2021.12.006

Introduction: Sprinters and athletic coaches frequently describe anecdotal improvements to sprinting performance following instrument-assisted high-velocity low-amplitude (IA-HVLA) manipulation applied to the athlete’s feet; however, there is minimal published data investigating these claims. Based on recent neurophysiological research demonstrating acute improvements in force production and fatigue resistance following spinal manipulation, a positive impact on sprint performance is plausible, although this remains unexplored in trained sprinters.

 Objectives: The purpose of this study was to investigate the feasibility of measuring the immediate effects of drop piece high-velocity, low-amplitude manipulation (DP-HVLAM) to the midfoot region on jump distance in competitive adult sprinters during a standardized unilateral horizontal drop-jump (U-HDJ) test.

Methods: Seven asymptomatic competitive adult sprinters (4 women) were recruited for this study. Testing was conducted on the dominant leg. Participants completed a 10-minute self-selected warm-up, followed by a 6-jump familiarization period with the U-HDJ test. All participants completed 3 U-HDJ trials before and after receiving DP-HVLAM to the joints of the midfoot assessed as being hypomobile by a licensed sports chiropractor. The primary outcome of the U-HDJ test was horizontal displacement, measured using an optoelectronic motion-capture system. Mean, SD, and 95% confidence intervals were determined for the post-treatment change in jump distance. A single-sample t-test with a = 0.05 assessed the post-treatment change in jumping distance.

Results: Authors were able to measure immediate effects. The preliminary findings showed an increase in jump distance after DP-HVLAM to the midfoot region (mean = 0.06 m, SD = 0.05 m; P = .014; 95% confidence interval, 0.02-0.11; effect size = 1.30).

Conclusion: This study demonstrates that it was feasible to measure immediate improvement in performance after DP-HVLAM in a clinical assessment with correlation to sprinting performance in a population of elite sprinters. As this was a feasibility study, the small sample size, overlapping confidence intervals, and specific population limit the extrapolation of these findings.

Keywords: Sports Medicine; Chiropractic; Biomechanical Phenomena; Foot; Running; Athletic Performance

Critique: This feasibility study has addressed a clearly focused research question in terms of a specific population (adult competing sprinter athletes), intervention (mid-foot DP- HVLAM as clinically assessed by a licensed sports chiropractor). However, this study consisted of a single arm without control group comparison. The study methodology was clearly detailed with the purpose to assess the effects of an intervention (DP-HVLAM) on specific outcome measure (U-HDJ distance).

 A limitation for this study is the small sample size n=7 elite sprinters. A strength of this study is the inclusion of elite competition athletes.

The authors reported the study was performed very close to competition time with minimal risk to safety and minimal adverse risk to performance and no adverse reaction effects of treatment. However, they acknowledged performance bias as contributary factors for the effects of DP-HVLAM, as no blinding of participants was possible due to the nature of the intervention.

 In summary, a well-designed laboratory feasibility study that assessed how a single session of DP-HVLAM of hypomobile lateral midfoot-joints increased temporarily      U-HDJ distance in competing asymptomatic adult sprinter athletes.

Reviewer Name: Freya Moran

Title: Musculoskeletal Considerations for Exercise and Sport.

Reference: L. Borowski, E. Barchi, J. Han, D. Friedman, C. Carter. Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy. American Academy of Orthopaedic Surgeons. August 15, 2021, Vol. 29, No 16. DOI: 101.5435/JAAOS-D-21-00044. 

Background: Despite the 75 million women of childbearing age (living in the United States), there is very little scientific literature regarding the risks and benefits of athletic activity, and the musculoskeletal conditions surrounding pregnancy. This has resulted in a protectionist attitude toward these individuals because consequences of these activities are largely unknown. Because the chances of a musculoskeletal health practitioner encountering one of these women as a patient is high, and resources for these professionals is scarce, treatments are often based on opinion rather than scientific data.

Objectives: To describe the musculoskeletal health considerations surrounding pregnancy and athletic individuals.

Methods: this review article summarized the current understanding of musculoskeletal conditions from 49 published articles on topics including joint stability, disordered eating habits, transient osteoporosis, pelvic floor muscle dysfunction and training, pubic diastasis, and back pain.

Results:

Health considerations that the musculoskeletal provider should be aware of include:

• Preconception and the presence of eating disorder, particularly in cross-country, gymnastics, and other endurance or aesthetic sport. Common risk factors for eating disorders that professionals should be aware of include early sport-specific training, overuse and overtraining syndromes, positive injury history, pressure to lose weight, and negative sport culture/coaching behaviors. Additionally, history should include menstrual status to screen for amenorrhea, and the presence or history of osteoporosis. The effects of eating disorders may not be reversible, and even relative energy deficit in sport carries the risk of impaired function and diminished peak performance, as well as a disruption of the neuroendocrine axis and interference with fertility. Other complications include bone stress injury, decreased immunity, infertility, or unexpected pregnancy.
• Joint instability beginning in the 10^th week of pregnancy that can last to between 4 and 12 weeks after delivery. Relaxin reaches peak levels between weeks 10-12 of gestation, decreasing the tensile strength of ligaments in preparation for birth. However, women who already have hypermobility syndromes such as Ehlers-Danlos do not seem to suffer from an increased risk of negative outcomes. It was also noted that there has been no study investigating pregnancy-related ligament laxity and risk of manifesting patellofemoral or shoulder subluxation/dislocation.
• Back pain appeared most often in athletes performing gymnastics, diving, weightlifting, and racquet sports. During pregnancy it appears most frequently at 22 weeks of gestation, and is associated with reduced hip extensor strength, lower endurance in the back extensors and hip abductors, and decreased activity of the paraspinal musculature at L4/5. Degenerative spondylolisthesis at L4/5 has a higher incidence in women who have had children. It was observed that athletic women experience pelvic girdle pain at the same rates as nonathletic women.
  • Red Flags include saddle anesthesia, new incontinence or retention, and progressive sensorimotor deficit.
  • Imaging: for women who show “red flags” for back pain, the appropriate imaging modality includes MRI or ultrasonography.
  • Treatment of LBP in pregnant populations has traditionally included exercise, but there is actually little scientific evidence to support this. Of the literature that does exist, water training and stability training of the hip abductors, adductors, gluteus maximus, transverse and oblique abdominis, erector spinae, lumbar multifidus QL, and latissimus dorsi are the most likely to improve outcomes.
• Pelvic Girdle Pain is considered self-limiting and typically appears at 18 weeks, peaks between weeks 24 and 36, and resolves within 3 months postpartum. Stability exercise programs have been shown most effective. No differences were observed for individuals who used a postural realignment device, and it was observed that athletic women experience pelvic girdle pain at the same rates as nonathletic women.
• Transient Osteoporosis: typically presents in the last trimester or immediately postpartum and most often affects the spine and hips. Osteoporosis associated with pregnancy is often more severe than premenopausal or idiopathic osteoporosis and often results in multiple pathologic fractures, most often of the vertebra (one study found that the average patient suffered 5.4 vertebral fractures by the time they were diagnosed). No data exists comparing athletic to nonathletic populations, however it is generally thought that patients with a history of disordered eating and history of multiple stress fractures may be more vulnerable to this condition, and should be treated with a multidisciplinary approach including supplementation of calcium and Vitamin D, and weight-bearing activity.
• Pubic Symphesis Diastasis is considered pathological when more than 10mm. Most often occurring post-partum, risk factors for this condition include multiparity, fetal macrosomia, precipitous or prolonged labor, shoulder dystocia, forceps delivery, maternal connective tissue disorder, and previous pelvic pathology/trauma. Patients presenting with urinary dysfunction and pelvic instability or pain with ambulation should be closely monitored. CT scan may be indicated to observe injury to the posterior pelvic ring, but in most cases the condition is non-operative when less than 40mm unless instability or other progressive symptoms occur.
• Carpal Tunnel Syndrome remains the most common neuropathy with prevalence as high as 62%, with most women reporting symptoms after 32 weeks. EMG testing is safe during pregnancy, but often not necessary as the clinical diagnosis of CTS is sufficient and the same as in non-pregnant individuals. The condition usually resolves after birth in 5 of 6 women, but can last up to a year. Treatment includes wrist splinting at night, corticosteroid injections, and lastly, surgical decompression.
• De Quervain Tenosynovitis is under-researched in the athletic population in terms of whether athletes who use their hands or play racquet sports are more at risk. Postpartum is a typical time for presentation of symptoms as it relates to increased fluid retention, and treatment includes bracing, NSAID’s or CSI (corticosteroid injection), and rehabilitative exercises, however first dorsal compartment surgical release reports a 91% cure rate.
• Diastasis Rectus Abdominis is found in more than half of pregnant women, however it is not yet known if the rate of occurrence is lower in athletes as compared to non-athletes. Abdominal strengthening protocols are sufficient treatment and surgery is performed mainly only for cosmetic reasons.
• Pelvic Floor Dysfunction including symptoms of urinary or fecal incontinence, organ prolapse, and myofascial pain. Stress-related urinary incontinence is reported in up to 80% of female athletes even before pregnancy, but age, weight, and number of pregnancies are all risk factors for this condition. However, reported rates in athletes are similar to the non-athletic demographic. It was noted that cesarean delivery does not eliminate the risk of developing these symptoms. Pelvic floor physical therapy (PFPT) is an effective treatment option and recommended with level 1, Grade A evidence.

Conclusion:

The field of pregnancy-related musculoskeletal conditions in the athletic populations remains under-investigated and an area ripe for research. What literature that does exist suggests that activity during pregnancy has a positive effect, and therefore, a musculoskeletal practitioner is very likely to encounter an athlete who is, or wants to become pregnant. It is therefore critical that the individual understands the common conditions and their pathologies before engaging in treatment or designing a treatment plan that is most effective and evidence-informed.

Key words: pregnancy, musculoskeletal conditions, exercise, sport, review;

Critique:

Overall, the attitude of the article suggested that women should be encouraged to engage in physical activity before, during, and after pregnancy due to its multiple health benefits and risks being relatively low, so long as the individual does not suffer from other comorbidities or risk factors. The article strives to remind practitioners that pain during and after pregnancy is a common occurrence in both athletic and non-athletic populations, but that surgical treatment is rarely indicated, which favors the use of conservative care as a means of pain control. This review article stressed how under-researched this area is, and despite the lacking evidence created a well-rounded summary of common conditions all practitioners should be aware of, including a basic overview their treatment in the multidisciplinary setting and imaging modalities.

Title: Does This Patient Have Hip Osteoarthritis? 

Link: Does This Patient Have Hip Osteoarthritis?: The Rational Clinical Examination Systematic Review.

Reviewer: Dr Henry Pollard BSc, Grad DC, Grad Dip AppSc, MSportSc, PhD, ICSC, FAICE (2019)

Reference: Metcalfe D, Perry DC, Claireaux HA, Simel DL, Zogg CK, Costa ML.JAMA. 2019 Dec 17;322(23):2323-2333. doi: 10.1001/jama.2019.19413.

Objective: To identify the clinical findings that are most strongly associated with hip OA.

Data Sources: Systematic search of MEDLINE, PubMed, EMBASE, and CINAHL from inception until November 2019.

Study Selection: Included studies (1) quantified the accuracy of clinical findings (history, physical examination, or simple tests) and (2) used plain radiographs as the reference standard for diagnosing hip OA.

Data Extraction and Synthesis: Studies were assigned levels of evidence using the Rational Clinical Examination scale and assessed for risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool. Data were extracted using individual hips as the unit of analysis and only pooled when findings were reported in 3 or more studies.

Main outcomes and measures: Sensitivity, specificity, and likelihood ratios (LRs).

Results: Six studies were included, with data from 1110 patients and 1324 hips, of which 509 (38%) showed radiographic evidence of OA. Among patients presenting to primary care physicians with hip or groin pain, the affected hip showed radiographic evidence of OA in 34% of cases. A family history of OA, personal history of knee OA, or pain on climbing stairs or walking up slopes all had LRs of 2.1 (sensitivity range, 33%-68%; specificity range, 68%-84%; broadest LR range: 95% CI, 1.1-3.8). To identify patients most likely to have OA, the most useful findings were squat causing posterior pain (sensitivity, 24%; specificity, 96%; LR, 6.1 [95% CI, 1.3-29]), groin pain on passive abduction or adduction (sensitivity, 33%; specificity, 94%; LR, 5.7 [95% CI, 1.6-20]), abductor weakness (sensitivity, 44%; specificity, 90%; LR, 4.5 [95% CI, 2.4-8.4]), and decreased passive hip adduction (sensitivity, 80%; specificity, 81%; LR, 4.2 [95% CI, 3.0-6.0]) or internal rotation (sensitivity, 66%; specificity, 79%; LR, 3.2 [95% CI, 1.7-6.0]) as measured by a goniometer or compared with the contralateral leg. The presence of normal passive hip adduction was most useful for suggesting the absence of OA (negative LR, 0.25 [95% CI, 0.11-0.54]).

Conclusions and relevances: Simple tests of hip motion and observing for pain during that motion were helpful in distinguishing patients most likely to have OA on plain radiography from those who will not. A combination of findings efficiently detects those most likely to have severe hip OA.

Critique: Hip osteoarthritis (OA) is a common cause of pain and disability. It is often present in adults/masters athletes. Additionally, through a mechanism of regional interdependence be associated with lumbar and knee complaints. This review presents key examination and history taking factors to consider during a consultation and examination.

Reviewer: Lizandi Schoeman

Title: RTS guidelines – acute lateral ankle sprain injuries.

Reference: Smith MD, Vicenzino B, Bahr R, et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. British Journal of Sports Medicine Published Online First: 22 June 2021. doi: 10.1136/bjsports-2021-104087.

Abstract

Background: Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap.

Methods: We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses.

Results: Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement—PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session).

Conclusion: Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury.

Key words: PAASS framework

Critique: This paper provides important guideline criteria for return to play that can be used by medical professionals when treating athletes with lateral ankle sprains. These injuries occur frequently in different sport codes and thus it is important that all medical professionals cover these main aspects when treating their athletes to prevent recurrent ankle sprain injuries.

Reviewer: Alex Lee, BSc, DC, FRCCSS(C)

Title: Lifestyles and mindsets of Olympic, Paralympic and world champions: is an integrated approach the key to elite performance?

Reference: Burns L, Weissensteiner JR, Cohen M. Lifestyles and mindsets of Olympic, Paralympic and world champions: is an integrated approach the key to elite performance? Br J Sports Med. 2019;53:818-824.

Abstract: https://bjsm.bmj.com/content/53/13/818

Background: Being a world-class athlete is more than the outcome of an event; it is a way of life that encompasses all aspects of the athlete’s lifestyle and becomes an integral part of their identity. International sporting bodies advocate a holistic approach to athlete development, yet key lifestyle, relational, training and performance practices are commonly overlooked. Unlocking the secrets to performance involves understanding the attributes, skills, strategies, support, environment and lifestyles of elite athletes.

Objective: To explore the contribution, interplay, and impact of lifestyle and psychological factors among a sample of world-class, champion athletes.

Methods:  Open-ended, semi-structured interviews were conducted with 10 World, Olympic and Paralympic Champion athletes that covered their sporting development and athletic profile including their mindset, training and competition practices, along with lifestyle and other key factors to which they attributed their success. A thematic approach guided by grounded theory principles was employed to source and analyze their perspectives and experiences and determine common themes.

Results: Four dominant and overlapping themes emerged (see Box 1): psychological attributes, interpersonal relationships, performance strategies and lifestyle practices. All athletes attributed their success to psychological rather than physical factors, and the vast majority relied on mental rehearsal skills and recovery practices. Championship performance requires a particular way of life that integrates mindset, performance, lifestyle and relationship factors.

Box 1: Emergent themes and subthemes

Psychological attributes

• Superior self-regulation
• Intrinsic motivation
• Effective visualization and imagery strategies
• Reliance on faith, routines or rituals
• Strong work ethics
• Self-confidence and dominance
• Effective coping strategies and positive mindset

Performance strategies

• Maximizing training and performance opportunities
• Effective utilization of sports science
• Physical therapies and recovery

Interpersonal relationships

• Having the right support team
• The athlete-coach partnership

Lifestyle practices

• Nutrition and hydration
• Utilization of complementary therapies
• Importance of time out

Conclusion: The athletic profile and support required to reach and sustain podium-level performance is multidimensional, integrated and psychological factors are paramount. Championship performance is likely to occur at the intersection of a strong psychological profile, interpersonal support, effective performance strategies and lifestyle.

Keywords:athlete, sport, performance, qualitative

Critique: As sports healthcare providers we aim to provide the best care possible to support our athletes to optimize their performance. We must recognize that performance is multi-factorial, and while we may approach improving performance from a clinician’s perspective, it is important to understand the athlete’s perspective and the contextual factors of being an athlete. This qualitative study helps fill this gap by studying the lived experience of World, Olympic and Paralympic champion athletes to understand their perspective of the factors that contribute to becoming a champion. The authors identified four major themes with subthemes and present a conceptual model that represents the complementary and dynamic nature of the contributors to world-class performance: psychology, performance, relationships and lifestyle. While psychological attributes were emphasized by the athletes, their reliance on the use of physical therapies for recovery and complementary therapies (such as chiropractic) as a part of their lifestyle practices was also identified. As sports healthcare providers, we can help our athletes attain performance success by contributing to the identified factors in Box 1 (above). Healthcare providers can support their athlete’s psychological strategies, utilize sports science and their clinical skills to optimize performance/recovery, be a part of an athlete’s interpersonal support team, and facilitate beneficial lifestyle practices.

A strength of this study is that the investigators interviewed elite athletes who attained Olympic, Paralympic and/or world championship medals. This sample of athletes have proven success, and their experience provides valuable insight into the factors that contribute to performance success. A weakness of this study is the small sample size (N=10). The authors do not state why they only interviewed 10 athletes. In qualitative research, authors typically report the point at which further interviews do not substantially change the qualitative codes identified from the analysis, referred to as data saturation. We do not know if further interviews would have substantially changed the analysis in this paper.

Overall, this paper provides valuable insight into the athlete’s perspective of what contributes to achieving performance success. As sports healthcare providers, we must do our best to understand the athlete’s perspective, so we can best tailor our care to help our athletes achieve their performance goals.

Reviewer: Claudio Merkier

Title: The effects of a single session of spinal manipulation on strength and cortical drive-in athletes

Reference:  Christiansen, T. L., Niazi, I. K., Holt, K., Nedergaard, R. W., Duehr, J., Allen, K., Marshall, P. P., Türker, K. S., Hartvigsen, J. and Haavik, H. (2018) The effects of a single session of spinal manipulation on strength and cortical drive-in athletes, European Journal of Applied Physiology, 118 (4), pp. 737. DOI: 10.1007/s00421-018-3799-x.

Introduction:

Athletic performance is affected by a complex range of physiological factors, such as neuromuscular coordination, muscle strength and endurance. Neuromuscular fatigue, diminished muscle strength and power are all detrimental to sports performance with the likelihood to increase the risk of injuries. These factors can be assessed by measuring maximum voluntary contraction (MVC) and spinal reflex responses. Improvement of these physiological factors may contribute to optimize motor and athletic performance.

Objectives:

The primary aim of this study was to examine whether a single session of spinal manipulative therapy (SMT) increases strength and cortical drive in the soleus musculature of elite taekwondo athletes.

Methods:

Soleus-evoked V-waves, H-reflex and MVC of the plantar flexors were documented from 11 elite taekwondo athletes using a randomised controlled crossover design. Interventions were either SMT or passive movement control. Outcomes were assessed at pre-intervention and at three post-intervention time periods (immediate post, post 30 min and post 60 min). A multifactorial repeated measures ANOVA was conducted to assess within and between group differences. Time and session were used as factors. An after-test analysis was conducted when relevant significant effect was present and was set at p ≤ 0.05.

Results:

SMT increased MVC force [F (3,30) = 5.95, p < 0.01], and V-waves [F (3,30) = 4.25, p = 0.01] over time compared to the passive movement control. Between group differences were significant for all time periods (p < 0.05),  but not for the post60 force measurements (p = 0.07).

Conclusion:

A single session of SMT increased muscle strength and corticospinal excitability to ankle plantar flexor muscles in elite Taekwondo athletes. The increased MVC force lasted for 30 min and the corticospinal excitability increase persisted for at least 60 min.

Keywords:

Spinal manipulation, Athletic performance, Taekwondo, V-wave, H-reflex, Maximum voluntary contraction force, MVC, Fatigue.

Critique:

This randomised cross-over study has addressed a clearly focused research question in terms of a specific population (elite taekwondo athletes), intervention (SMT as clinically assessed by a chiropractor), and control comparison (passive movement of the head and spine prior to reaching the end feel of a joint).  The study was clearly designed to assess the effects of an intervention (SMT) on specific outcome measures (MVC and spinal reflexes such Hoffman’s reflex).

The assignment of participants to interventions or control was randomised by computer-generated random number table. However, the chiropractors and athletes were not blinded to group allocation due to the nature of the intervention. Outcome-assessors and bioengineering data-analysts remained blinded to group allocation throughout the study period and file names were coded before sent them to an independent data analyst.

A limitation for this study is the small sample size as the authors aimed to enrol 15 participants, but only 12 athletes were able to be recruited, and one of them were excluded, because he did not finish both sessions due to lack of interest.

A strength of this study is that each athlete acts as their own control which reduced the carry-over effects. Also, the order of receiving SMT was randomised, therefore levelling any potential benefits from the earlier evaluation.

The authors acknowledged performance bias and placebo effects as contributary factors for the effects of SMT, as no blinding of participants was possible due to the nature of the intervention. Their main recommendations for future athletic performance research are to mimic real setting studies by testing exercise outcomes related to the given sports and taken in consideration gender and age.

In summary, a well-designed laboratory study that assessed how a single session of SMT of dysfunctional joints increased temporarily plantar flexor muscle strength and cortical drive in elite taekwondo athletes.