Return to play and physical performance tests: evidence-based, rough guess or charade?

Measurement properties of upper extremity physical performance tests in athletes: a systematic review

BACKGROUND

Upper extremity Physical Performance Tests (PPTs) have been used in sports contexts to provide functional status of the athletes. However, whether these tests present appropriate measurement properties to be considered a valuable measurement is not clear.

OBJECTIVE

To systematically review the measurement properties of upper extremity PPTs in athletes.

METHODS

Databases (e.g., Medline, EMBASE, CINAHL, SPORTDiscus, CENTRAL) were searched in March 2021. Two reviewers independently rated the methodological quality using the 4-point Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Quality of evidence was graded by measurement property for each test, considering the adequacy, the sample size, and the methodological quality of the studies.

RESULTS

Fifteen studies were included with a pooled sample of 684 athletes. The PPTs analyzed were Arm-Jump Board Test, Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), Finger Hang Test, Medicine Ball Explosive Power Test, One-Arm Hop Test, Posterior Shoulder Endurance Test, Pull-Up Shoulder Endurance Test, Repetition to Failure Assessment, Seated Medicine Ball Throw Test (SMBT), Seated Single-Arm Shot-Put Test (SSPT), Shoulder Endurance Test, Two-Arm Bent Hang Test, Unilateral Seated Shot-Put Test, and Upper Limb Rotation Test. Evidence synthesis provided moderate and high-quality evidence for sufficient inter-session and intra-session reliability of the CKCUEST, respectively. There was moderate evidence for sufficient inter-session reliability of the SSPT and for insufficient validity of the SMBT.

CONCLUSION

The CKCUEST and the SSPT are sufficiently reliable in athletes. More studies are needed to investigate other psychometric properties for these tests and other upper extremity PPTs.

Missing The Forest For The Trees: A Lack Of Upper Extremity Physical Performance Testing In Sports Physical Therapy

Background

Despite shoulder and elbow injuries being common in athletics, return to sport and reinjury rates are less than ideal. These outcomes may be driven by the absence of evidence-informed testing to determine an athlete's readiness for sport.

Purpose

The purpose of this study was to explore the reported frequency of physical performance testing for return to sport readiness by physical therapists treating athletes with upper extremity injuries and to identify potential barriers that may limit use of these tests. A secondary aim was to compare practice patterns of clinicians with sports physical therapy specialty certification to clinicians without.

Study Design

International, cross-sectional survey using purposive sampling.

Methods

A survey instrument was created to assess the frequency of use of physical performance tests by physical therapists treating athletes with upper extremity injuries, as well as the barriers limiting the use of these tests. The 19-question online survey was distributed via email and Twitter among sports physical therapists. Independent t-tests and Chi Square analyses were conducted to determine differences in practice patterns between physical therapists with and without specialization and the frequency of potential barriers that may limit the use of these tests.

Results

Four hundred ninety-eight participants met study eligibility and completed the survey. Fewer than half of participants reported using any physical performance test in making return to sport decisions for athletes with upper extremity injuries. The greatest barriers to the use of physical performance tests were a lack of equipment followed by lack of understanding of the literature, lack of time, and lack of supporting literature. Sports specialist clinicians were significantly more likely (p<0.001) to use physical performance tests than non-specialist clinicians (71.6% versus 36.3%).

Conclusion

In this survey of physical therapists (n=498), the majority admit to not using physical performance tests when making return to sport decisions for athletes with upper extremity injuries regardless of specialization.Physical therapists have an opportunity to improve the utilization physical performance testing in the upper extremity athlete in hopes of reducing injury recurrence and enhance return to sport rates.

Level of Evidence

Level 3b.

A Novel Approach to Assessment of Perceptual-Motor Efficiency and Training-Induced Improvement in the Performance Capabilities of Elite Athletes

Standard clinical assessments of mild traumatic brain injury are inadequate to detect subtle abnormalities that can be revealed by sophisticated diagnostic technology. An association has been observed between sport-related concussion (SRC) and subsequent musculoskeletal injury, but the underlying neurophysiological mechanism is not currently understood. A cohort of 16 elite athletes (10 male, 6 female), which included nine individuals who reported a history of SRC (5 male, 4 female) that occurred between 4 months and 8 years earlier, volunteered to participate in a 12-session program for assessment and training of perceptual-motor efficiency. Performance metrics derived from single- and dual-task whole-body lateral and diagonal reactive movements to virtual reality targets in left and right directions were analyzed separately and combined in various ways to create composite representations of global function. Intra-individual variability across performance domains demonstrated very good SRC history classification accuracy for the earliest 3-session phase of the program (Reaction Time Dispersion AUC = 0.841; Deceleration Dispersion AUC = 0.810; Reaction Time Discrepancy AUC = 0.825, Deceleration Discrepancy AUC = 0.794). Good earliest phase discrimination was also found for Composite Asymmetry between left and right movement directions (AUC = 0.778) and Excursion Average distance beyond the minimal body displacement necessary for virtual target deactivation (AUC = 0.730). Sensitivity derived from Youden's Index for the 6 global factors ranged from 67 to 89% and an identical specificity value of 86% for all of them. Median values demonstrated substantial improvement from the first 3-session phase to the last 3-session phase for Composite Asymmetry and Excursion Average. The results suggest that a Composite Asymmetry value ≥ 0.15 and an Excursion Average value ≥ 7 m, provide reasonable qualitative approximations for clinical identification of suboptimal perceptual-motor performance. Despite acknowledged study limitations, the findings support a hypothesized relationship between whole-body reactive agility performance and functional connectivity among brain networks subserving sensory perception, cognitive decision-making, and motor execution. A complex systems approach appears to perform better than traditional data analysis methods for detection of subtle perceptual-motor impairment, which has the potential to advance both clinical management of SRC and training for performance enhancement.

The shoulder endurance test (SET): A reliability and validity and comparison study on healthy overhead athletes and sedentary adults

OBJECTIVES

The primary purpose was to examine the reliability of a new shoulder physical performance test -the Shoulder Endurance Test (SET)- in young healthy overhead athletes and sedentary adults and to provide preliminary reference values. The secondary objective was to determine whether there are differences on SET scores based on groups, sides and days. The third objective was to evaluate the relationship between the SET and shoulder rotational isometric strength in both groups.

DESIGN

Reliability and validity study.

SETTING

Laboratory setting.

PARTICIPANTS

A total sample of 92 participants volunteered to participate in this study (30 healthy overhead athletes - 62 sedentary adults).

MAIN OUTCOME MEASURES

We used a two-session measurement design separated by seven days to evaluate the reliability. We calculated intraclass correlation coefficients to determine relative reliability and used standard error of measurement and minimal detectable change to quantify absolute reliability. Systematic differences in SET scores between groups, days and sides were analysed with a two-way analysis of variance (ANOVA) for repeated measures. To check for systematic differences within groups between day 1 and day 2, a Wilcoxon Signed Rank Test was performed. Relationship between shoulder rotational isometric strength and the SET was determined using the Spearman Rank test (r_s).

RESULTS

Relative reliability was high to very high in both groups (intraclass correlation coefficient [2,1] range = 0.78-0.93) and absolute reliability was clinically acceptable. The standard error of measurement varied from 10.7 s to 16.45 s. The minimal detectable change ranged from 29.6 s to 45.6 s. Weak correlations were found between the SET and isometric shoulder rotational strength (r_s range = 0.309-0.431).

RESULTS

of the ANOVA for repeated measures showed a significant two-way interaction effect for day x groups (p = 0.020) and a significant main effect for side (p= < 0.001). Results of the Wilcoxon Signed Rank Test showed no systematic differences in group 1 between day 1 and day 2 for both sides (p = 0.79 dominant side; p = 0.66 non-dominant side).

CONCLUSIONS

The SET is a reliable clinically applicable shoulder physical performance test in young adult overhead athletes and sedentary adult.

Pre-season screening of the upper body and trunk in Australian football players: A prospective study

OBJECTIVE

To determine whether screening tests of upper body, trunk region, and of whole-body function could prospectively identify community AFL players who sustain in-season shoulder/head/neck injuries. Additionally, to present screening test reference values.

DESIGN

Prospective cohort; SETTING: Community sport; PARTICIPANTS: 142 male community AFL players (range 15-37 years).

MAIN OUTCOME MEASURES

(i) isometric shoulder external and internal rotation (ER/IR) strength; (ii) upper body combined elevation functional ROM; (iii/iv) whole-body functional jump ROM; (v) static thoracic spine angle; (vi) cervical joint proprioception, and (vii) trunk muscle size and function. Results were compared among players with (n = 21) and without (n = 121) an in-season shoulder, head, or neck injury. ROC analysis and odds ratios were used to determine the predictive values.

RESULTS

Two screening tests predicted an in-season shoulder, head, or neck injury; dominant and non-dominant isometric ER strength (AUC 0.629, 95%CI 0.51-0.74; optimal cut point 182 N and AUC 0.619, 95%CI 0.50-0.74; optimal cut point 184 N, respectively). The adjusted odds ratio for the strongest predictor: dominant ER muscle strength was 6.02 (95%CI 1.8-19.9).

CONCLUSION

Greater ER strength was associated with in-season shoulder/head/neck injuries in community AFL players; however, further research is required to determine the clinical significance of this finding.

Assessment of Flexion Strength Following Single- Versus Double-Hamstring Tendon Harvest for Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare isometric hamstring strength deficits, knee laxity, functional outcomes, and patient-reported outcomes between patients who underwent anterior cruciate ligament (ACL) reconstruction with doubled semitendinosus and gracilis tendon autograft (ST/G) versus quadrupled semitendinosus autograft (ST), at a minimum follow-up of 1-year postoperatively.

METHODS

Patients who underwent ACL reconstruction with ST/G or ST hamstring autografts were retrospectively identified. Isometric hamstring strength was tested with a hand-held dynamometer at 30, 60, and 90° of knee flexion. Anterior knee laxity was assessed using a KT-1000 arthrometer. Functional outcomes were collected using the single-leg hop test and single-leg squat test. Side-to-side differences were determined and compared between the ST/G and ST groups. Patient-reported outcomes were collected on all patients.

RESULTS

Eighty-four patients who underwent ST/G (n = 34) or ST (n = 50) autograft ACL reconstruction were recruited to participate in this study. There was no difference in knee laxity between the groups. Side-to-side hamstring strength deficits increased with increased flexion angles. At 90° of flexion, the ST/G group had a significantly greater flexion strength deficit compared with the ST group (37.8 ± 15.1% vs 24.7 ± 12.5%, P < .001). Aside from a significant difference in the KOOS pain Score (P .045), no other significant differences in functional or patient reported outcomes between the groups were identified.

CONCLUSIONS

Patients who underwent ACL reconstruction with ST/G compared with ST autograft have a significantly greater isometric flexion strength deficit at 90° of flexion. Future investigations are required to determine the clinical relevance of this difference and whether specialized therapy protocols can mitigate this deficit.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The Self-Assessment Corner for Shoulder Strength: Reliability, Validity, and Correlations With Upper Extremity Physical Performance Tests

CONTEXT

Rotator cuff weakness and rotation ratio imbalances are possible risk factors for shoulder injury among overhead athletes. In consensus statements, organizations have highlighted the importance of a screening examination to identify athletes at risk of injury. The screening should be portable and designed to be feasible in many different environments and contexts.

OBJECTIVE

To evaluate the reliability and validity of the Self-Assessment Corner (SAC) for self-assessing shoulder isometric rotational strength and examining whether performance on 2 physical performance tests was correlated with isometric shoulder rotational strength using the SAC in handball players.

DESIGN

Cross-sectional study.

SETTING

Sport setting.

PATIENTS OR OTHER PARTICIPANTS

A first sample of 42 participants (18 men, 24 women) was recruited to determine the reliability and validity of the SAC. In a second sample of 34 handball players (18 men, 16 women), we examined correlations between physical performance tests and the SAC.

MAIN OUTCOME MEASURE(S)

The SAC was used to measure isometric rotational strength with the upper extremity at 90° of abduction in the frontal plane and 90° of external rotation and the elbow flexed to 90° with neutral rotation of the forearm. The SAC findings were compared with those from manual testing. Results from the seated medicine ball throw (SMBT) and closed kinetic chain upper extremity stability test (CKCUEST) were used to establish relationships with the SAC. We calculated intraclass correlation coefficients to determine relative reliability and used standard error of measurement and minimal detectable change to quantify absolute reliability. Relationships among the different strength-testing procedures and with the physical performance tests were determined using the Pearson product moment correlation coefficient (r) or Spearman rank correlation coefficient (r_s).

RESULTS

We observed good to excellent reliability (intraclass correlation coefficient [2,k] range = 0.89 to 0.92). The standard error of measurement varied from 3.45 to 3.48 N. The minimal detectable change with 95% confidence intervals ranged from 8.06 to 8.13 N. Strong correlations were present among strength procedures (r = 0.824, r_s range = 0.754-0.816). We observed moderate to strong correlations between the CKCUEST findings and rotational strength (r range = 0.570-0.767). Moderate correlations were found between rotational strength and SMBT (r range = 0.573-0.626).

CONCLUSIONS

The SAC is a clinically applicable and standardized protocol for self-assessing rotational strength in young healthy adults without pathologic conditions. Performance on the SMBT and CKCUEST may be valuable as a screening tool to further assess shoulder strength.

Association of pre-season musculoskeletal screening and functional testing with sports injuries in elite female basketball players

Basketball is one of the most popular sports in Lithuania, and participation in women’s basketball is on the rise. Pre-participation examinations, including musculoskeletal screening and functional performance testing, is an essential part of a multidisciplinary approach to prevent future injuries. Because the lower extremities are the most commonly-injured body area in basketball players. Assessing fundamental movement qualities is of utmost importance. The aim of our study was to determine if functional tests can predict sports injuries in elite female basketball players. A total of 351 records for professional female basketball players were screened during 2013–2016 season. We analysed functional characteristics before the season and used functional performance tests for injury risk assessment: the Functional Movement Screen (FMS), the lower quarter Y Balance test (YBT-LQ) and the Landing Error Scoring System (LESS). Data from 169 players’ records were analysed: 77 of them made it to the end of season without injury, making up the non-injured group, while 92 of them suffered lower limb sport injuries during the sport season (injury group). Student’s t-test and the Mann-Whitney U-test were used to determine differences between groups. The most commonly encountered sports injuries in our population were those of knee 40.2% and ankle 38%. The injury group had a lower total FMS score (p = 0.0001) and higher total LESS score (p = 0.028) than non-injury group. The dynamic balance of lower limbs was similar in both groups. Imperfect functional movement patterns and poor jump-landing biomechanics during pre-season screening were associated with lower extremity injuries in elite female basketball players. Impairments of dynamic stability in the lower extremities were not associated with injury rates in our population. A combination of functional tests can be used for injury risk evaluation in female basketball players.

Use of functional performance tests in sports: Evaluation proposal for football players in the rehabilitation phase

Objectives

Based on the criteria of a group of experts, this study aims to select a set of functional performance tests which can be applied to evaluate the functional status of a football player in the recovery process and make a decision in relation to their return to practice.

Materials and methods

A total of 16 experts were selected by the coordinator group to judge an initial list of functional performance tests and, thus, reach a consensus about the tests which are best suited to the needs of the injured player. Each of the experts had to evaluate each one of the tests in a scale from 1 to 5 in relation to their suitability. Delphi method was used to reach consensus in the expert group.

Results

From the initial list of 25, the tests which obtained the best evaluation were: Counter movement jump (4.3±0.9), Single hop test (4.1±0.8), Triple hop test (4.1±0.9), Crossover hop test (4.1±0.7), Yo-Yo intermittent recovery (4.2±0.6), Barrow test (4.1±0.6), Shuttle run 8¥5 m (4.1±0.8). Star excursion balance test (4±0.7) and Y balance test (4.1±0.7).

Conclusion

In the opinion of the experts selected here, these tests are the ones which best respond to the needs involved in a complex decision such as RTP.

Clinician-Friendly Physical Performance Tests for the Knee

Reference:  Hegedus EJ, McDonough S, Bleakley C, Cook CE, Baxter GD. Clinician-friendly lower extremity physical performance measures in athletes: a systematic review of measurement properties and correlation with injury. Part 1: the tests for knee function including the hop tests. Br J Sports Med. 2015;49(10):642-648.

CLINICAL QUESTION

  Do individual physical performance tests (PPTs) used as measures for lower extremity function have any relationship to injuries in athletes aged 12 years or older?

DATA SOURCES

  Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to locate articles. The authors searched PubMed, EMBASE, and SPORTDiscus, in addition to searching by hand. The search strategy combined the terms athlete, lower extremity, and synonyms of performance test with the names of performance tests.

STUDY SELECTION

  Studies were included if they involved a test that met the operational definition for a PPT. The included studies assessed components of sport function (eg, speed, agility, and power), determined readiness for return to sport, or predicted injury to the lower extremity. All PPT measures could be performed on the field, courtside, or in a gym with affordable, portable, and readily available equipment. Studies were excluded if they made use of 3-dimensional motion capture, force platforms, timing gates, treadmills, stationary bikes, metabolic charts, or another nonportable, costly testing device. Athletes were categorized on the Tegner Scale at a minimum of level 5, which is the lowest level that still encompasses competitive athletes. Studies were included if 50% or more of the participants were rated above 5 on the Tegner Scale. Studies were excluded if the sole purpose was to judge movement quality or range of motion. Studies were selected if they identified the knee or a knee injury as a focal point of the paper.

DATA EXTRACTION

  The Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) was used to critique the methodologic quality of each paper with a 4-point Likert scale. The title and methods of each paper were extracted. Extracted data were summarized using ratings of unknown, conflicting, limited, moderate, and strong.

MAIN RESULTS

  An initial search revealed 3379 original articles for consideration. After initial review, 169 full-text articles were evaluated and 29 articles were included in the systematic review. Six tests were examined for the best evidence of methodologic quality: (1) 1-legged single hop for distance, (2) 1-legged triple hop for distance, (3) 6-m timed hop, (4) crossover hop for distance, (5) triple jump, and (6) 1-legged vertical jump. A summary of the methodologic properties of the 6 tests showed fair/poor reliability, fair/poor hypothesis testing, good criterion validity, and good/poor responsiveness. No tests predicted knee injury in athletes.

CONCLUSIONS

  Although numerous authors have evaluated PPTs at the knee, evidence for the measurement quality of these functional tests is limited and conflicting. Ample opportunity exists for researchers to further examine PPTs for the knee. Until more knowledge is gained about these PPTs, clinicians should exercise caution when making clinical decisions based on the results of these tests.

The functional movement test 9+ is a poor screening test for lower extremity injuries in professional male football players: a 2-year prospective cohort study

Background

The 9+ screening battery test consists of 11 tests to assess limitations in functional movement.

Aim

To examine the association of the 9+ with lower extremity injuries and to identify a cut-off point to predict injury risk.

Methods

Professional male football players in Qatar from 14 teams completed the 9+ at the beginning of the 2013/2014 and 2014/2015 seasons. Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff during these seasons. Univariate and multivariate Cox regression analyses were used to calculate HR and 95% CI. Receiver operating characteristic (ROC) curves were calculated to determine sensitivity and specificity and identify the optimal cut-off point for risk assessment.

Results

362 players completed the 9+ and had injury and exposure registration. There were 526 injuries among 203 players (56.1%) during the two seasons; injuries to the thigh were the most frequent. There was no association between 9+ total score and the risk of lower extremity injuries (HR 1.02, 95% CI 0.99 to 1.05, p=0.13), even after adjusting for other risk factors in a multivariate analysis (HR 1.01, 95% CI 0.98 to 1.04, p=0.37). ROC curve analysis revealed an area under the curve of 0.48, and there was no cut-off point that distinguished injured from non-injured players.

Conclusion

The 9+ was not associated with lower extremity injury, and it was no better than chance for distinguishing between injured and uninjured players. Therefore, the 9+ test cannot be recommended as an injury prediction tool in this population.

Functional Assessment and Injury Risk in a Professional Soccer Team

At the last World Conference on Sport and Physical Therapy celebrated in Bern (Switzerland, 2015), it was confirmed that the functional skills of an athlete are a very important variable to be considered in the recovery of an injury. On the other hand, its use as a predictive risk tool still lacks solid evidence. The purpose of this study was to determine whether a battery of functional tests (FPT) could be used as a preliminary measure for the season in order to identify the injury risk in a professional soccer team in the Spanish Second Division B League. Fifty-two soccer players (ages of 25.3 ± 4.6 years, 10.33% ± 0.9% fat) were functionally assessed during two seasons (2012–2013 and 2013–2014) and analyzed from an injury perspective. A total of 125 injuries were recorded. The sample was grouped based on the number of injuries and the required absence days. Except for the bipodal vertical jump (CMJ), none of the functional tests revealed differences among the groups. The correlation study between the functional condition and the suffered injuries did not show any significant results.

Interseason variability of a functional movement test, the 9+ screening battery, in professional male football players

BACKGROUND

The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.

AIM

To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.

METHODS

Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.

RESULTS

A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.

CONCLUSIONS

The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons.

Clinician-friendly physical performance tests in athletes part 3: a systematic review of measurement properties and correlations to injury for tests in the upper extremity

OBJECTIVE

In parts 1 and 2 of this systematic review, the methodological quality as well as the quality of the measurement properties of physical performance tests (PPTs) of the lower extremity in athletes was assessed. In this study, part 3, PPTs of the upper extremity in athletes are examined.

METHODS

Database and hand searches were conducted to identify primary literature addressing the use of upper extremity PPTs in athletes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to critique the methodological quality of each paper. The Terwee Scale was used to analyse the quality of the measurement properties of each test.

RESULTS

11 articles that examined 6 PPTs were identified. The 6 PPTs were: closed kinetic chain upper extremity stability test (CKCUEST), seated shot put (2 hands), unilateral seated shot put, medicine ball throw, modified push-up test and 1-arm hop test. Best evidence synthesis provided moderate positive evidence for the CKCUEST and unilateral seated shot put. Limited positive evidence was available for the medicine ball throw and 1-arm hop test.

CONCLUSIONS

There are a limited number of upper extremity PPTs used as part of musculoskeletal screening examinations, or as outcome measures in athletic populations. The CKCUEST and unilateral seated shot put are 2 promising PPTs based on moderate evidence. However, the utility of the PPTs in injured populations is unsubstantiated in literature and warrants further investigation.