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  • Fewer Than a Third of HS Students Receive Recommended Amount of Phys Ed

    When it comes to the number of US high school students participating in physical education in school, the good news is that rates haven't declined much since 1995. The bad news is, rates haven't gone up, either—and remain well below national recommendations.

    Recently, the National Physical Activity Plan Alliance (NPAPA) released an analysis of 22 years' worth of data on US high-schooler participation in physical education classes. They found that after a notable drop between 1991 and 1995, rates have remained fairly consistent, with only 29.4% of students meeting national recommendations for daily classes. Former APTA Board of Directors member Dianne V. Jewell, PT, DPT, PhD, represents APTA on the NPAPA. APTA is an organizational partner of the NPAPA.

    Using data obtained from the CDC's National Youth Risk Behavior Survey, researchers found that the rate for daily participation was the highest in 1991, with 41.6% of students attending physical education classes 5 days a week. By 1995, that rate had dropped to 25.4%, and remained fairly consistent for each study period thereafter.

    Among other findings in the report:

    • Overall, the average number of days per week of physical education attendance reported in 2013 was 4.15—lower than the 4.64 average reported in 1991, but better than 1995, when that average dipped to 3.6.
    • The percentage of students reporting 0 days of physical education each week in 2013 was close to 1991 levels, at 52%.
    • The percentage of students who reported participating in phys ed only 1 day per week increased between 1991 and 2013, from .9% to 1.8%.
    • Participation in phys ed for 1 day a week or more declined as students advanced through high school, with 64.3% of freshmen reporting any physical education, followed by sophomores (50.5%), juniors (39.6%) and seniors (35.2%). The same general pattern held when it came to reports of daily phys ed classes (from 42.2% of freshmen to 20.2% of seniors).
    • Across the entire study period, more boys than girls—57% versus 49%—reported attending physical education classes.

    The study's authors speculate that the drop in participation between 1991 and 1995 may be linked to the widespread adoption of block scheduling in high schools during that time, a scheduling system less likely to offer daily classes in any subject.

    Regardless of the reasons, they write, the fact is that the rates of participation weren't high enough even in 1991 and remain problematic today. Authors call for schools to prioritize the "adoption of policies and programs aimed at increasing participation in physical education," writing that the NPAPA has developed "evidence-based strategies and tactics" that could help to make a difference.

    APTA has long supported the promotion of physical activity and the value of physical fitness. In addition to representation on the NPAPA and other organizations, the association offers several resources on obesity, including a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    ED Visit Rates for Youth Soccer-Related Injuries Climb by More Than 100% in 25 Years

    The popularity of youth soccer has grown tremendously since 1990—and with it, the rate of emergency department (ED) visits related to the sport, say researchers, who cite a 111% jump in injury rates for players aged 7-17 over a 25-year period. Those rates also include a nearly 1,600% increase in soccer-related ED visits for concussions, a dramatic change that may be linked to wider awareness of the seriousness of mild traumatic brain injury, according to the study's authors.

    For the study, researchers analyzed ED data reported to the National Electronic Injury Surveillance System 1990-2014, focusing on data linking an ED visit to a pediatric soccer-related injury and tracking demographics of the injured player as well as type and cause of injury received. These data were matched up with soccer participation rates obtained from the National Sporting Goods Association to estimate injury rates over time. The study was published in the journal Pediatrics.

    Among the findings:

    • Between 1990 and 2014, the annual soccer-related injury rate for children aged 7-17 rose by 111%, from 1.53 per 10,000 participants to 15.68. Reported concussion rates increased by 1,595% during the same time period, from .53 per 10,000 to 3.92 per 10,000.
    • The numbers of injuries for boys did not increase significantly between 1990 and 2008, but girls' injuries increased by 101.9% during that time. From 2008 to 2014, those numbers leveled off for girls, but increased for boys by 44.6%.
    • Children of all ages reported increasing numbers of injuries during the 25-year study period, but children 7 to 11 years old reported a more dramatic (61%) increase from 2008 to 2014.
    • When a cause of injury was cited, it was most often "struck by" (38.5%), followed by "fell" (28.7%) and "twisted" (12.8%). “Collision” accounted for 5.6% of injuries.
    • Younger players (ages 7 to 11) were more likely to sustain an injury from a fall or ball, while players 8 to 17 years old were more likely to be injured through twisting or a collision. Female players were more likely than male players to receive an injury from twisting.
    • Sprain or strain made up 34.6% of injuries, followed by fracture (23.2%), soft tissue injury (21.9%), and concussion (7.3%). Among boys, the proportion of concussion was higher in the 7-11 age group; among girls, the concussion number was higher at the 8-17 age range.
    • The most commonly injured body regions were upper extremity (20.7%), ankle (17.8%), head or neck (17.7%), and knee (11.2%).
    • Most—98.3%—players treated at the ED were released. Of players admitted to the hospital 70% were boys. Fractures were the most common reason for admission (60.6%).

    Authors write that while dramatic, the increase in concussion rate, particularly during the past 10-15 years, may not mean that youth soccer players have in fact experienced a 1,600% increase in concussions. While acknowledging that the rate may be increasing, researchers also cite growing awareness among players, coaches, parents, and the general public around the seriousness of concussion as a factor that has itself increased ED visits. Additionally, they write, concussion-related laws, more frequent diagnosis of concussion, and "lower thresholds" for parents to decide to bring a child to the ED could well be pushing up the rate. They note that similar patterns have been revealed in other sports.

    Still, they write, there's no denying that injury rates across the board have increased dramatically. As for what can be done to counter those climbing rates, citing 1 study that linked 12% of all soccer-related injuries to illegal activities, authors call for stepped-up injury prevention efforts that include more emphasis on (and enforcement of) the rules of the sport. They also recommend concussion prevention strategies including preseason neck muscle-strengthening exercises, writing that studies have shown an association between weak neck muscles and concussion risk among high school athletes.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Want more information on managing youth athletes and making return-to-play decisions? Check out these e-learning courses available at the APTA Learning Center:

    Study: 'Safe Landing Strategies' to Reduce Falls Injury Show Promise

    National Falls Prevention Awareness Day, coming up on September 22, helps to focus attention on the importance of reducing the risk of falls and fall-related injuries. How can physical therapists (PTs) and physical therapist assistants (PTAs) help patients develop ways to react if and when those falls occur? One study suggests the use of "safe landing strategies" including elbow flexion, squatting, and a "martial arts roll" may significantly reduce body impact, though more testing needs to be done.

    In a study e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free), authors reviewed results of 13 studies involving 219 participants who were instructed to react to a fall by employing 1 of 7 landing strategies: squatting during a backwards fall, slightly flexing the elbow during a forward fall, and reacting to a side fall by either rotating forward, stepping sideways, relaxing the muscles, rolling away from the impact point (martial arts roll), and "martial arts slapping," which involves slapping the falling side arm on the ground after a martial arts roll. Researchers then measured fall velocity and impact force in various body areas such as the hips and compared these with forces recorded in falls that did not employ these strategies.

    Here's what authors of the current article found when they gathered the results of the studies:

    • Squatting during a backwards fall reduced impact velocity of the wrist by 11% and the hip by 18%, and lowered the impact energy of the hip by 44%.
    • Elbow flexion during a forward fall reduced impact force of the elbow by 40%, the shoulder by 26%, the wrist by 26%, and the hand by 14%. Impact velocity of the neck was not affected.
    • Among the side fall strategies, martial arts rolling was the only strategy that significantly decreased hip impact force, with a 25% reduction. Both martial arts rolling and relaxed muscle reactions reduced the impact angle of the trunk by 60%. Martial arts slapping did not have an effect on any of the impacts measured.

    While encouraging, the results are somewhat limited not only by participant size, but by the nature of the studies themselves: average participant age was under 30 in 12 of the studies, and 8 of the 13 studies were based on self-initiated falls, either from a kneeling (6 studies) or standing position (2 studies). In the remaining studies, participants were released from a tether while standing, with 1 study telling participants in advance when the tether would be released.

    Authors point out that proper execution of these strategies "depends on muscle strength and early initiation of the techniques"—2 factors that may be problematic for an elderly individual who experiences a sudden fall. "It is debatable whether these fall techniques would be both effective and suitable for older adults," they write. "It is important to note that some protective responses have associated risks that might lead to adverse consequence when performed inappropriately."

    Still, authors believe the impact differences noted in the studies do warrant further research into whether the effectiveness of the strategies is generalizable to the most at-risk population, and how these strategies affect fracture risk. However, they add, getting at those results will require studies that use "innovative methods to simulate real-life falls."

    APTA offers a wide variety of resources on falls prevention, including a clinical summary on falls risk in community-dwelling older adults, a practice guideline on the assessment and prevention of falls, tests and measures related to falls, a Physical Therapy-published clinical guidance statement from the Academy of Geriatric Physical Therapy, an online community for PTs and physical therapist assistants interested in falls prevention, and a balance and falls webpage.

    Spearheaded by the National Council on Aging (NCOA), Falls Prevention Awareness Day was created to highlight what NCOA describes as the leading cause of injuries among older Americans. An estimated 2.5 million falls-related injuries are treated annually, including 734,000 hospitalizations. Nearly 22,000 Americans die from injuries related to falls.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Concussed Athletes More Likely to Experience Later Lower Extremity Injuries After Return to Play

    Authors of a new study of college athletes say that concussion creates a "window of susceptibility" in players that more than triples the risk of a later lower extremity musculoskeletal injury over nonconcussed athletes. This finding, they write, "implies that return-to-play guidelines may not be sufficient … to protect athletes" from other, later injuries.

    Researchers tracked injury patterns among 73 concussed athletes (52 male, 21 female) in the University of Florida's football, lacrosse, soccer, and basketball programs, pairing each athlete with 2 nonconcussed athletes who played the same sport and position. The concussed athletes in the study—referred to by authors as the "exposed" athletes—were all returned to play with at least 30 days left in the season. Monitoring of in-season injury incidence continued for the rest of the season, or as much as 90 days after return to play, whichever came first. Athletes with a history of concussion within the past 6 months were excluded, as were those whose concussions occurred outside the competitive season.

    Authors were on the lookout for time-loss due to a lower extremity musculoskeletal injury, defined as a sprain, strain, dislocation, or rupture that resulted in the player being withheld from competition for at least 1 day (overuse injuries, fractures, and contusions were not included). The results were published in the August 20 edition of Sports Medicine (abstract only available for free).

    Researchers found that 50% of the 90 exposed athletes sustained a time-loss lower extremity injury during the study period, compared with 20% of the 148 nonexposed players studied. Though median time lost after the injury did not differ much between the 2 groups, the exposed group was estimated to have a risk of lower extremity musculoskeletal injury 3.39 times higher than the nonexposed group.

    Among other findings presented in the study:

    • Exposed male athletes had a later-injury risk that was 3.72 times higher than their nonexposed counterparts, while exposed female athletes had a 2.75 times higher risk than their nonexposed cohort. Authors suspect that the differences between odds ratios in men and women may have more to do with the sports played than their sex.
    • Among "starters," those with previous concussions were 2.84 times more likely to suffer a later injury than the nonexposed starters. Among reserve players, that risk rate was 3.9 times higher for exposed players than for the nonexposed athletes.
    • In both the exposed and nonexposed groups, ankle sprain was the most prevalent injury, but rates were significantly higher for the exposed athletes. Those athletes also suffered disproportionately higher incidences of midfoot sprains and hip adducter strains.

    Authors believe that the increased risk of injury is related to "persistent subclinical effects of concussion" that aren't always evaluated when making return-to-play decisions. Among possible contributors: reduced excitability of the motor cortex and "persistent alterations in neurocognition" that "inhibit [the athlete's] ability to create appropriate neuromuscular responses to perform an athletic maneuver in a safe manner, successfully dodge an opponent, or brace for a collision." To further complicate the picture, authors note, the rate of postconcussion injury remained relatively constant over the 90-day study period, suggesting that the increased risk may extend past the window studied.

    The bottom line, according to authors, is that return-to-play guidelines may not be sufficient to take this "window of susceptibility" into account.

    "Current clinical tools may also be insensitive in detecting meaningful post-concussion deficits, or may provide insufficient coverage of possible domains of effect," authors write. They suggest that more sensitive tests be developed that incorporate "measures of neuromuscular control," and that postconcussion rehabilitation include the "neuromuscular-based injury prevention strategies that have been used with evidence of success in reducing the risk of injuries such as ankle sprains and [anterior cruciate ligament] ruptures."

    Authors of the study include Ashley Harrison, PT, DPT, Susan Tillman, PT, and Terese Chmielewski, PT, PhD.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    APTA offers numerous resources relating to concussion, including these courses in the APTA Learning Center: Concussion and Postconcussive Syndrome: When to Rest, Exercise, or Return to Sport and Safe Return to Sports and Prevention of Re-injury for Young Athletes (E-Learning). Find more resources on these APTA webpages:

    From PTJ: For the Very Elderly, Poststroke IRF Stays May Not Be Long Enough

    For patients who are very elderly, receiving postacute stroke care in inpatient rehabilitation facilities (IRFs) often results in increased functional ability, with 54% of patients achieving discharge to the community. But, say researchers who studied IRF data from 2002 to 2007, there are "worrisome trends" that point to the notion that the average length of stay (LOS) wasn't enough to produce a clinically significant increase in function.

    The study, e-published ahead of print in Physical Therapy(PTJ), APTA's scientific journal, examined functional outcomes and length of stay in inpatient rehabilitation facilities for patients with stroke at age 85 or older. Most studies haven’t broken out the data for this age group, which is “most at risk for disability,” authors note.

    Authors focused on IRFs because stroke outcomes have been “consistently associated with more functional improvements and more discharges to home” for patients in IRFs than for those in skilled nursing facilities. IRFs are required to provide at least 3 hours of therapy per day.

    Analyzing data from the Centers for Medicare and Medicaid Services over a 5-year period, researchers looked at Functional Independence Measure (FIM) scores at discharge, and whether patients were discharged to the community or an institution.

    Almost 54% of patients were discharged to the community after an average stay of 16 days. Patients experienced an average functional gain of approximately 21 points on the FIM. However, that change in score did not reach the minimal clinically important difference, leading experts to assert that a longer length of stay might lead to better outcomes.

    Researchers found that the length of stay actually decreased throughout the 5 years of the study, as did the mean FIM scores at discharge, which steadily dropped from 76.8 to 73.2 between 2002 and 2007. There was a similar trend for rate of discharge to the community.

    Researchers found that postacute IRF stroke rehabilitation “meets or exceeds recommended guidelines” for stroke care, but recommend that plans of care should achieve 78–126 points on the FIM to increase the odds of a patient being discharged to the community.

    Authors write that while more studies are needed to determine the optimal LOS for this patient population, "There may be a benefit to patients and the health care system to extend the LOS for very elderly patients to better approximate a level of function that may allow a community discharge."

    The study was funded in part by a 2010 APTA Health Policy and Administration Section Research Award and a 2010 American Heart Association Predoctoral Fellowship.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Want to know more about the effects of aging on rehabilitation? Check out "Neuromuscular Changes with Aging," an online course offered though the APTA Learning Center.

    Systematic Review: Commercial Video Games Likely a Good Option for Rehab

    While researchers and designers continue to work on advanced video games and hardware intended specifically for rehabilitation, a new systematic review says that there's sufficient research to support the idea that off-the-shelf games available on commercial gaming systems are useful as an adjunct to more traditional rehab approaches.

    Researchers writing in the International Journal of Rehabilitation Research (abstract only available for free) described findings from their analysis of 126 research articles published between 2008 and 2015, all of which focused on the use of commercially available gaming systems (VGs)—Nintendo Wii, Sony PlayStation, and Microsoft Xbox—as a component of rehabilitation. A total of 4,240 patients were included in the studies, which looked at VG use in connection with stroke recovery, cerebral palsy (CP), Parkinson disease (PD), balance training, problems associated with aging, and weight control.

    The most frequent use of VG in rehabilitation was for aging-related issues (28%), followed by weight control (25%), balance (22%), stroke (13%), CP (8%), and PD (4%). Patients participated in an average of 22 VG sessions, although variability was significant, ranging from an average of 16 sessions for stroke, to 94 sessions for weight control. With weight control excluded, the average dropped to 19 sessions, with a mean rate of 3 to 4 sessions per week. Studies of the Nintendo Wii system predominated at 79%, with 13% using PlayStation, and the remaining 8% focused on Xbox (and Kinect).

    Authors of the review then analyzed the studies according to each pathology. Here's what they found:

    Stroke. A total of 26 studies looked at VG and stroke. Authors write that because stroke rehabilitation requires significant amounts of repetition of movement, "VG is an interesting tool that enables patients to perform repetitive task-training," and "being immersed in games allows more motion repetitions without a decrease in motivation." Six studies found positive results for upper extremity gross motor function, 1 study found improvements in fine motor function, 3 studies cited improvements in balance, and 1 study each reported improvements in upper limb strength and grip strength.

    Cerebral palsy. Authors found that most research in the 16 studies addressing the use of VG for individuals with CP pointed to VG as a way to improve motivation and cooperation. Improvements in global gross motor function were noted in 4 studies; fine motor function was reported to improve in 2 studies; and 3 studies found positive effects associated with balance. No studies focused on strength.

    Parkinson disease. PD and VG was the subject of 10 studies, most of which focused on gait. Authors write that "significant" improvements gross motor performance—particularly gait parameters including freezing—were reported in 4 studies, with additional marked improvements in fine motor function noted in 3 studies. Five studies cited balance improvements, and 4 studies "indirectly" indicated improvements in strength.

    Aging. In the 37 studies on the use of VG for aging-related issues, the most prevalent issue reported was a higher reluctance among individuals 60 and older to use VGs, and a preference for traditional therapy exercises. Studies tended to find no significant differences between VG and control groups in improvements in gross and fine motor function, but several cited improvement in balance through VG that exceeded controls. Three studies reported improvements in strength in the VG group.

    Balance training. Results of the 25 studies related to balance control were mixed, with no clear advantage or disadvantage associated with VGs.

    Weight control. The 10 studies included in the review focused more on research related to level of physical activity associated with VGs (mostly moderate) and patient preference (balance games were preferred over aerobic games). Two studies focused on the type of game and device as it related to motivation, with patients demonstrating higher motivation (and expending more energy) while playing "cooperative" games, and lower motivation when playing "competitive" games.

    Authors of the study acknowledge that the research shows particular benefits for neurological rehabilitation, but add that "overall, results show that rehabilitation that includes VGs is at least as efficient as conventional therapy."

    "Because most patients, except some elderly patients, like VGs and prefer them to traditional exercises, VGs should be integrated into treatment for various pathologies," authors write. "The results of this review showed that integration of VGs in [physical rehabilitation] programs is efficient, despite the fact that none of these games were designed for clinical purposes."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Researchers Say Brain-Controlled Exoskeleton Training Sparked Neurological Improvement in Individuals With Paraplegia

    While pursuing a brain-controlled exoskeleton technology for individuals with paraplegia, researchers at Duke University uncovered something unexpected: in what they call "unprecedented neurological recovery," researchers found that patients actually experienced neurological improvements in sensation and voluntary muscle control during the brain-machine interface (BMI) training period. A few patients were even upgraded from complete to incomplete paraplegia classification after 12 months of work with the BMI.

    The findings, presented in the journal Scientific Reports, were uncovered after researchers monitored progress in 8 patients with spinal cord injury (SCI) as they participated in the Walk Again program. The program employs noninvasive electrode monitoring that allows the patient to control movements—first in a virtual reality setting, but, ultimately, by way of a brain-controlled exoskeleton capable of providing tactile information delivered to the patients' forearms. The exoskeleton was featured at the 2014 World Cup soccer tournament, when 29-year-old Juliano Pinto, who has complete paralysis of his lower trunk, completed the ceremonial kickoff at the event.

    As researchers moved patients through the training program, they found that after 7 months, several patients were experiencing improvements in tactile, proprioceptive, vibration, and nociceptive perception (though none of the patients appeared to improve in temperature sensation). By the 10th month of training, all patients experienced what authors of the report describe as a "significant improvement" in sensation. Additionally, the patients experienced improvements in gastrointestinal function, with 2 patients improving in frequency of bowel function. Levels of independence also increased, with 2 patients becoming more independent in the bathroom, and 2 improving their level of independence in transfers—1 from the wheelchair to the toilet, and another from the wheelchair to the car.

    Researchers aren't sure exactly what happened to create the improvements, but they say that since the patients in the study had suffered their SCIs a year or more before the study, the idea of spontaneous recovery—something that can happen in more recent injury—"can basically be ruled out."

    Instead, they write, "we propose that our long-term BMI-based training triggered a significant process of functional plasticity," and that "such functional cortical plasticity may have accounted for the reemergence of lower limb representations in these cortical areas." They assert that "such functional cortical plasticity likely led to the reactivation of upper motor cortical neurons that normally project to the spinal cord, via the corticospinal tract."

    In an interview with the Miami Herald, lead researcher Miguel Nicolelis, PhD, described the findings as "something that nobody expected and that was a tremendous shock." He told the Herald, “I think what we did was to turn these guys on again. We just got [the nerves and brain] transmitting information again."

    According to researchers, the findings could help to recast the ways BMI technologies are regarded.

    "Overall, the results obtained in our study suggest that BMI applications should be upgraded from merely a new type of assistive technology … to a potentially new neurorehabilitation therapy, capable of inducing partial recovery of key neurological functions," they write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Bike Riding Most Common Sports-Related Reason for ED Visits and Inpatient Admissions

    A recent analysis of sports-related emergency department (ED) and hospital inpatient stays is giving new credence to the phrase "as easy as falling off a bike." Apparently it's pretty easy, with bicycling-related injuries leading the way in hospital use.

    The analysis, produced by the Healthcare Cost and Utilization Project (H-CUP), tracked 2013 data on 2.8 million ED visits and 105,490 inpatient admissions for injuries related to a long list of sports activities that included everything from the usual suspects to bungee jumping-related injuries, to injuries experienced at "school recess and summer camp." Researchers sliced and diced the data in a variety of ways to come up with a picture of who's getting hurt doing what, and in which ways.

    Here are a few of the findings:

    Bicycling finishes first. Injuries related to bicycle riding topped the list for ED visits, with 383,790 ED visits in 2013, or nearly 14% of all reported sports-related injuries. It was the top injury category for males 18-44 and 45-64, and the second most-frequent category for females of all ages. Bicycling was also the most-cited reason for inpatient stays overall.

    "Walking, marching, and hiking" wasn't far behind. Second only to bicycling, injuries sustained while on foot (but not while running), were reported at 340,290, or just over 12% of all sports-related injuries. The prevalence of this type of injury rose with age, taking the top position for both men and women 65 and older, and the first and second positions for women and men 45-64, respectively.

    Tackle football leads among children. For the under-18 group, tackle football represented 167,350 ED visits, and the boys' leading reason for injury. For girls, "school recess and summer camp" led the way, but with a much lower incidence of 66,230 visits. Even in this age group, bicycle riding was in the top 5 for both boys and girls, representing 11.8% and 9.8% of all sports-related ED visits, respectively.

    More men than women went to the ED or were admitted as inpatients, with 2 exceptions. Men led women—sometimes by wide margins—in ED and inpatient numbers in every age category except the oldest, where women 65 and above were the largest group for both ED visits and inpatient stays.

    Nearly 1 in 4 sports-related ED visits were for a sprain. Sprains led the way for injury type in the ED, followed by fractures at 21% and superficial injury at 18%. For inpatient stays, fracture, at 59%, was the most prevalent reason for admission, followed by "other diagnoses" (14%), intracranial injury (11%), other injury (10%), and crushing injury (6%, and most commonly associated with equestrian sports).

    Prevalence of injury type depended on the sport. Basketball was the sport most often associated with a sprain, representing 40% of the ED visits related to that sport. Soccer (31%) was second, followed by running (28%) in the sprain category. For fractures associated with ED visits, school recess and summer camp reported a 42% rate, followed by roller skating and skateboarding (33%), and bicycle riding (22%).

    Head injuries were most commonly associated with bicycle riding, baseball, and "unspecified" activities. A total of 26% of ED visits related to bicycle riding involved an intracranial injury—the largest injury category for that sport. Baseball wasn't far behind at 24%, followed by activities that weren't able to be determined based on the ICD-9 codes used in the analysis (21%).

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Survey Reveals High Rates of Disagreement Among Spine Surgeons on LBP Treatment

    Ask 2 spine surgeons for a recommendation on what kind of spine surgery to have for low back pain (LBP)—or whether to have surgery at all—and you're likely to get 2 different answers, according to results of a new survey that found high rates of disagreement, with some significant regional variability.

    In an article published recently in Spine (abstract only available for free), researchers shared results of a study in which 445 spine surgeons across the US (75% orthopedic surgeons, 25% neurological surgeons) were asked to respond to 2 case scenarios and related imaging. Scenario 1 described a 44-year-old man with mechanical LBP refractory to conservative management, no leg pain, and discogram at L4-5 causing concordant pain; L3-4 and L5-S1 were negative controls. Scenario 2 presented the same patient, but with discogram at L4-5 and L5-S1 causing concordant pain, and L3-4 a negative control. The surgeons were instructed to provide their recommendation by choosing 1 of 4 fusion surgeries, or no surgery at all.

    Authors analyzed the results by geographic region, practice setting, years of experience, and other factors. Here's what they found:

    Overall disagreement on how to proceed was 75%-76%, with significant geographic variation. Even in the regions and scenarios with the highest rate of agreement—scenario 1 in the Midwest, and scenario 2 in the Southeast—more than 2 out 3 surgeons (69%) provided differing recommendations. The highest rates of disagreement occurred in the Southwest for both scenarios, with disagreement rates of 82% for scenario 1 and 85% for scenario 2.

    The rates at which "no surgery" was recommended also varied by region. Overall, no surgery was recommended 41.4% of the time, ranging from a low of 29% in the Southwest for both scenarios to 52% in the Midwest for scenario 1, and 50% in the Northeast for scenario 2.

    Practice setting played a big role in whether a surgeon recommended no surgery. Researchers found that surgeons in academic practice were nearly 4 times more likely to choose no surgery than surgeons in hybrid and private practice settings. Similarly, surgeons with fellowship training were twice as likely to select no surgery as a first option than surgeons without that training.

    Practice setting also seemed to be related to disagreement rates. Surgeons in academic settings had a 56% disagreement rate, compared with 78%-79% disagreement rates among surgeons in hybrid or private practice settings.

    Generally, the less-experienced surgeons recommended no surgery more often—and also agreed with each other at higher rates. Surgeons with fewer than 5 years' practice duration recommended no surgery at a 56% rate in scenario 1 and a 60% rate in scenario 2, with rates of disagreement at 65% and 61%, respectively. Surgeons with more than 20 years in practice disagreed at 77% and 80% rates for the 2 scenarios, and chose no surgery 41% of the time for scenario 1 and 36% of the time for scenario 2.

    "The lack of definitive evidence supporting one surgical approach versus another, and the lack of definitive evidence identifying the indications for surgery among this patient population, is a major contributor to this variability," authors write. "This heterogeneity … is concerning as it implies patients can present with the same pathology to different surgeons and receive entirely different surgeries, or no surgery."

    Authors recommend that surgeons do something about the wide variability, particularly in light of health care's march toward value-based care rooted in identifiable outcomes. "It is imperative that spine surgeons be proactive in defining what works best for their patients, or it is quite possible that such will be dictated to them by other stakeholders (i.e., payers)," they add.

    Authors hope that acknowledging this variability "will spur additional studies aimed at identifying the indications as well as the most cost-effective treatments for LBP." In the meantime, they recommend that "patients should be involved in the decision-making process to identify the optimal treatment based on their values."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    European Guidelines Strongly Recommend Physical Therapy With Exercise for Fibromyalgia

    Experts from 12 European countries now unanimously recommend supervised exercise as a primary intervention for individuals with fibromyalgia. According to an updated clinical practice guideline (CPG) by the European League Against Rheumatism (EULAR) published in BMJ, physical therapy with graded exercise is the only intervention that received the group's strongest recommendation.

    The previous EULAR guideline found very few studies on pharmacologic or nonpharmacologic treatments for fibromyalgia, but that has changed. The current CPG is based on an analysis of 275 published articles and 107 systematic reviews. Authors looked at how well interventions addresseed, pain, fatigue, sleep, and daily functioning, and assigned levels of support for each intervention: "strong against," "weak against," "weak for," and "strong for."

    Highlights include:

    Aerobic exercise and resistance training significantly reduce pain and improve physical function.
    The evidence seems to suggest that land- and water-based exercise are equally effective, though more research is needed in that regard. The recommendation was “strong for.”

    Acupuncture may decrease pain and fatigue.
    Some studies showed improvements in pain and fatigue after acupuncture, but the “evidence supporting the use of real versus sham acupuncture was less consistent.” The EULAR recommendation was “weak for.”

    Chiropractic treatment is not proven to be effective at relieving pain.
    Due to a lack of high-quality studies, authors recommended “strong against.”

    Hydrotherapy/balneotherapy show promise to relieve pain.
    While both showed “significant improvement in pain,” the studies did not evaluate “intention to treat.” The recommendation was “weak for.”

    Massage does not significantly reduce pain.
    Authors recommended “weak against” massage, because the data that did show some positive effect was from low-quality studies.

    Mindfulness/mind-body therapy may decrease pain.
    While the studies showed improvement in pain, there was risk of bias. Authors recommended “weak for.”

    Based on this evidence, authors recommend that, after being diagnosed with fibromyalgia and receiving patient education materials, the next option should be physical therapy “with graded physical exercise” that could be combined with other nonpharmacologic treatments like acupuncture.

    For patients not helped by physical therapy or other nondrug therapies, authors suggest a few medications to address severe pain or sleep problems and psychological therapies for depression, anxiety, catastrophizing, and “overly coping.”

    Experts also recommend research into what type of exercise is most effective, and whether combining drug therapy and nondrug therapy might be more effective than a single therapy alone.

    The EULAR revised recommendations for the management of fibromyalgia are available through APTA's PTNow website, which offers a wide range of synthesized research and evidence-based practice information.