Stephen W Marshall

University of North Carolina at Chapel Hill, North Carolina, United States

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Publications (253)1013.76 Total impact

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    ABSTRACT: Objective: The study described initial pharmacological treatment of children in the United Kingdom diagnosed as having ADHD and assessed predictors of medication persistence. Methods: U.K. children ages 3-16 diagnosed as having ADHD between 1994 and 2006 were identified from primary care practice data. Child characteristics, prescription patterns, and initial medication prescribed were described over the study period. The associations of child and clinical factors with medication persistence (defined as initial treatment length greater than six months) were estimated by using binomial regression. Results: Of 2,878 children with an ADHD diagnosis, 46% (N=1,314) received at least one prescription for ADHD medication within two years of diagnosis. The mean initial treatment length was 10.7±.5 months. Only 35% (N=464) of pharmacologically treated children had a treatment length greater than six months after initial medication prescription when the analysis used a 30-day grace period; 57% were persistent in treatment when a less stringent 60-day grace period was used. Children who were initially prescribed long-acting methylphenidate were more likely to persist in treatment than those prescribed standard methylphenidate (risk ratio=1.2, 95% confidence interval=1.1-1.4). Conclusions: A large proportion of children who received medication for ADHD in primary care did not continue in initial treatment for more than six months. Few child or clinical factors were associated with treatment persistence. Epidemiological research about the effects of long-term ADHD medication use should account for the observed limited persistence in medication treatment.
    Psychiatric services (Washington, D.C.) 03/2015; DOI:10.1176/appi.ps.201300148 · 1.99 Impact Factor
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    ABSTRACT: Over the past decade, there has been significant debate regarding the effect of cumulative subconcussive head impacts on short and long-term neurological impairment. This debate remains unresolved because valid epidemiological estimates of athletes' total contact exposure are lacking. We present a measure to estimate the total hours of contact exposure in football over the majority of an athlete's lifespan. Through a structured oral interview, former football players provided information related to primary position played and participation in games and practice contacts during the pre-season, regular season, and post-season of each year of their high school, college, and professional football careers. Spring football for college was also included. We calculated contact exposure estimates for n=64 former football players (n=32 college football only, n=32 professional and college football). The Head Impact Exposure Estimate (HIEE) discriminated between individuals who stopped after college football, and individuals who played professional football (P<0.001). The HIEE measure was independent of concussion history (P=0.82). Estimating total hours of contact exposure may allow for the detection of differences between individuals with variation in subconcussive impacts, regardless of concussion history. This measure is valuable for the surveillance of subconcussive impacts and their associated potential negative effects.
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    ABSTRACT: Athlete-recalled and clinically documented concussion histories have been used in research on former athletes, but both have limitations. Comparisons of these 2 types of concussion histories are needed to improve the accuracy of estimates of concussion history for future research and clinical care. To estimate the agreement between athlete-recalled and clinically documented concussion histories during college and to explore reasons for differences. Cohort study (diagnosis); Level of evidence, 3. Athlete-recalled concussion histories were provided by a convenience sample of 130 former collegiate athletes using an online questionnaire, and they were individually linked to previously collected clinical data that tracked medically diagnosed concussions at the host institution from 1996 to 2012. The intraclass correlation coefficient (ICC2,1) was used to assess agreement between athlete-recalled and clinically documented concussion histories. Descriptive analyses were performed to assess reasons for disagreement. Agreement between athlete-recalled and clinically documented concussion histories was low (ICC2,1 = 0.21; 95% confidence interval, 0.05-0.37), but it was higher for women (ICC2,1 = 0.65; 95% confidence interval, 0.44-0.79) and for athletes playing more recently (2005-2012; ICC2,1 = 0.39; 95% confidence interval, 0.01-0.67). Of the 53 athletes who self-reported college sports-related concussions, 40% believed that they sustained impacts that should have been diagnosed as concussions but were undetected, and 21% admitted nondisclosure of suspected concussions. Common reasons for nondisclosure included the following: did not think injury was serious enough (91%), did not know it was a concussion (73%), and did not want to leave the game/practice (73%). Given the low agreement between athlete-recalled and clinically documented concussion histories, methodologic research is needed to improve the quality of tools used to assess concussion histories in former athletes. © 2015 The Author(s).
    The American Journal of Sports Medicine 01/2015; DOI:10.1177/0363546514562180 · 4.70 Impact Factor
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    ABSTRACT: Background: Activity-related patient-reported outcome measures are an important component of assessment after knee ligament injury in young and physically active patients; however, normative data for most activity scales are limited. Objective: To present reference values by sex for the Marx Activity Rating Scale (MARS) within a young and physically active population while accounting for knee ligament injury history and sex. Study Design: Cross-sectional study. Level of Evidence: Level 2. Methods: All incoming freshman entering a US Service Academy in June of 2011 were recruited to participate in this study. MARS was administered to 1169 incoming freshmen (203 women) who consented to participate within the first week of matriculation. All subjects were deemed healthy and medically fit for military service on admission. Subjects also completed a baseline questionnaire that asked for basic demographic information and injury history. We calculated means with standard deviations, medians with interquartile ranges, and percentiles for ordinal and continuous variables, and frequencies and proportions for dichotomous variables. We also compared median scores by sex and history of knee ligament injury using the Kruskal-Wallis test. MARS was the primary outcome of interest. Results: The median MARS score was significantly higher for men when compared with women (χ2 = 13.22, df = 1, P < 0.001) with no prior history of knee ligament injury. In contrast, there was no significant difference in median MARS scores between men and women (χ2 = 0.47, df = 1, P = 0.493) who reported a history of injury. Overall, median MARS scores were significantly higher among those who reported a history of knee ligament injury when compared with those who did not (χ2 = 9.06, df = 1, P = 0.003). Conclusion: Assessing activity as a patient-reported outcome after knee ligament injury is important, and reference values for these instruments need to account for the influence of prior injury and sex.
    Sports Health A Multidisciplinary Approach 01/2015; DOI:10.1177/1941738115576121
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    ABSTRACT: Both high and low indoor relative humidity (RH) directly impact indoor air quality (IAQ), an important school health concern. Prior school studies reported a high prevalence of mold, roaches, and water damage; however, few examined associations between modifiable classroom factors and RH, a quantitative indicator of dampness. We recorded RH longitudinally in 134 North Carolina classrooms (n= 9066 classroom-days) to quantify the relationships between modifiable classroom factors and average daily RH below, within, or above levels recommended to improve school IAQ (30-50% or 30-60% RH). The odds of having high RH (>60%) were 5.8 (95% Confidence Interval (CI): 2.9, 11.3) times higher in classrooms with annual compared to quarterly heating, ventilating, and air conditioning (HVAC) system maintenance, and 2.5 (95% CI: 1.5, 4.2) times higher in classrooms with HVAC economizers compared to those without economizers. Classrooms with direct expansion split systems compared to chilled water systems had 2.7 (95% CI: 1.7, 4.4) times higher odds of low RH (60%) of those without setbacks. This research suggests actionable decision points for school design and maintenance to prevent high or low classroom RH. This article is protected by copyright. All rights reserved.
    Indoor Air 12/2014; DOI:10.1111/ina.12176 · 4.20 Impact Factor
  • Zachary Kerr, Stephen W. Marshall, Johna Register-Mihalik
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    ABSTRACT: Background: Recurrent concussion may result in neuro-dementia. However, athletes may not disclose sport-related concussion symptoms to others. Research is needed on factors influencing nondisclosure of concussion symptoms by athletes. Methods: Former collegiate athletes who played between 1987-2012 (n=797) completed an online self-administered questionnaire about impacts sustained during sport participation that should have been diagnosed by team medical staff as concussions, but were not. We asked why concussions went undiagnosed and what sources of information influenced respondents’ knowledge of concussions. Results: Of the 214 respondents self-reporting sport-related concussions (26.9% of sample), 44.9% stated that they had sustained impacts that should have been diagnosed by medical staff as concussions, but were not. Common reported factors associated with non-diagnosis were not telling team medical staff (33.2%) and no team medical staff being present (19.2%). Among those with non-disclosed concussions, common self-reported reasons for non-disclosure included: not wanting to leave the game/practice (78.9%); not wanting to let team down (71.8%); and not knowing it was a concussion (70.4%). Sources of knowledge that helped respondents realize impacts may have been undiagnosed concussions were continuing education (20.8%); friends (14.6%); and the media (71.9%), particularly ESPN (32.3%). Conclusion: Among those former collegiate athletes self-reporting sport-related concussions, nearly half of former collegiate athletes reported sustaining undiagnosed sport-related concussions. External influences such as perceived peer expectations and media coverage were influential in former athletes’ concussion reporting. This information may assist in refining public health campaigns that seek to improve disclosure of symptoms (e.g. CDC’s Heads-Up program).
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: Background: Young athletes suffering from a concussion should be assessed by a trained health care provider. However, many concussions are never diagnosed because children and their parents do not seek care. We examined whether parents’ knowledge and attitudes towards concussion were associated with post-concussion care-seeking for their children. Methods: A cohort of 214 youth sport parents [(63% female; parent age: 44.1(±6.5 yrs); child age: 11.6±(1.9 yrs)] completed a pre-validated concussion knowledge (max possible score=28), attitudes (max possible score=63) and care-seeking survey. Higher knowledge and attitude scores represented more favorable scores. Parents reported number of: diagnosed concussions, times their child displayed signs/symptoms of concussion following a head impact, and care-seeking behaviors following these events. The main outcome was care-seeking for all potential concussions (all-care group) vs. not (lower-care group). Results: Twenty-six percent (n=55) of parents reported that their child had ≥ 1 potential concussion. The majority of these parents (72%, n=40) did not follow-up with a medical provider after each event. Mean attitude score was 51.5(±1.6) in the all-care group and 48.1(±4.2) in the lower-care group. Mean knowledge score was 23.6(±2.5) in the all-care group and 23.6±(2.9) in the lower-care group. More favorable parental attitudes towards concussion were positively associated with care-seeking (OR: 1.7; 95% CI: 1.1, 2.8). Parents’ knowledge was not associated with better care-seeking (OR: 0.9; 95% CI: 0.7, 1.3). Conclusions: While concussion knowledge is undoubtedly important, parental attitudes were more important in predicting care-seeking. Future parental interventions should stress the importance of prompt care for all potential concussions.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: Objective: To compare the odds of sustaining moderate and severe head impacts, rather than mild, between high school football players with high and low visual performance. Design: Prospective quasi-experimental. Setting: Clinical Research Center/On-field. Participants: Thirty-seven high school varsity football players. Interventions: Athletes completed the Nike SPARQ Sensory Station visual assessment before the season. Head impact biomechanics were captured at all practices and games using the Head Impact Telemetry System. Main Outcome Measures: Each player was classified as either a high or low performer using a median split for each of the following visual performance measures: visual clarity, contrast sensitivity, depth perception, near-far quickness, target capture, perception span, eye-hand coordination, go/no go, and reaction time. We computed the odds of sustaining moderate and severe head impacts against the reference odds of sustaining mild head impacts across groups of high and low performers for each of the visual performance measures. Results: Players with better near-far quickness had increased odds of sustaining moderate [odds ratios (ORs), 1.27; 95% confidence intervals (CIs), 1.04-1.56] and severe head impacts (OR, 1.45; 95% CI, 1.05-2.01) as measured by Head Impact Technology severity profile. High and low performers were at equal odds on all other measures. Conclusions: Better visual performance did not reduce the odds of sustaining higher magnitude head impacts. Visual performance may play less of a role than expected for protecting against higher magnitude head impacts among high school football players. Further research is needed to determine whether visual performance influences concussion risk. Clinical Relevance: Based on our results, we do not recommend using visual training programs at the high school level for the purpose of reducing the odds of sustaining higher magnitude head impacts. Copyright
    Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 11/2014; DOI:10.1097/JSM.0000000000000143 · 2.01 Impact Factor
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    ABSTRACT: Musculoskeletal injuries during military and sport-related training are common, costly, and potentially debilitating. There is a need to develop and implement evidence-based injury prevention strategies to reduce the burden of musculoskeletal injury. The lack of attention to implementation issues is a major factor limiting the ability to successfully reduce musculoskeletal injury rates using evidence-based injury prevention programs. This article proposes 7 steps that can be used to facilitate successful design and implementation of evidence-based injury prevention programs within the logical constraints of a real-world setting by identifying implementation barriers and associated solutions.
    Clinics in Sports Medicine 10/2014; 33(4):615-632. DOI:10.1016/j.csm.2014.06.012 · 2.58 Impact Factor
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    ABSTRACT: BACKGROUND: Little research has examined concussion outcomes in terms of impact location (ie, the area on the head in which the impact occurred). This study describes the epidemiology of concussions resulting from player-to-player collision in high school football by impact location. METHODS: National High School Sports-Related Injury Surveillance Study data (2008/2009-2012/2013) were analyzed to calculate rates and describe circumstances of football concussion (eg, symptomology, symptom resolution time, return to play) resulting from player-to-player collisions by impact location (ie, front-, back-, side-, and top-of-the-head). RESULTS: Most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7%) and side-of-the-head (22.3%) impacts. Number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. However, a larger proportion of football players sustaining concussions from top-of-the-head impacts experienced loss of consciousness (8.0%) than those sustaining concussions from impacts to other areas of the head (3.5%) (injury proportion ratio 2.3; 95% confidence interval 1.2-4.2; P = .008). Players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the-head impacts (86.4%) than concussions from impacts to other areas of the head (24.0%) (injury proportion ratio 3.6; 95% confidence interval 3.2-4.0; P < .001). CONCLUSIONS: Among high school football players who sustained concussions due to player-to-player collisions, concussion outcomes were generally independent of impact location. Recommended strategies for reducing the proportion of top-of-the-head impacts include improved education regarding tackling with proper "head-up" technique.
    Pediatrics 08/2014; 134(3). DOI:10.1542/peds.2014-0770 · 5.30 Impact Factor
  • Z. Y. Kerr, J. D. DeFreese, S. W. Marshall
    08/2014; 2(8). DOI:10.1177/2325967114544107
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    AOSSM Annual Meeting, Seattle, WA; 07/2014
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    ABSTRACT: An athlete is thought to reduce head acceleration after impact by contracting the cervical musculature, which increases the effective mass of the head.
    The American Journal of Sports Medicine 06/2014; 42(9). DOI:10.1177/0363546514536685 · 4.70 Impact Factor
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    ABSTRACT: A headform is needed to validate and compare helmet- and mouthguard-based sensors that measure the severity and direction of football head impacts. Our goal was to quantify the dynamic response of a mandibular load-sensing headform (MLSH) and to compare its performance and repeatability to an unmodified Hybrid III headform. Linear impactors in two independent laboratories were used to strike each headform at six locations at 5.5 m/s and at two locations at 3.6 and 7.4 m/s. Impact severity was quantified using peak linear acceleration (PLA) and peak angular acceleration (PAA), and direction was quantified using the azimuth and elevation of the PLA. Repeatability was quantified using coefficients of variation (COV) and standard deviations (SD). Across all impacts, PLA was 1.6 ± 1.8 g higher in the MLSH than in the Hybrid III (p = 0.002), but there were no differences in PAA (p = 0.25), azimuth (p = 0.43) and elevation (p = 0.11). Both headforms exhibited excellent or acceptable repeatability for PLA (HIII:COV = 2.1 ± 0.8%, MLSH:COV = 2.0 ± 1.2%, p = 0.98), but site-specific repeatability ranging from excellent to poor for PAA (HIII:COV = 7.2 ± 4.0%, MLSH:COV = 8.3 ± 5.8%, p = 0.58). Direction SD were generally <1° and did not vary between headforms. Overall, both headforms are similarly suitable for validating PLA in sensors that measure head impact severity in football players, however their utility for validating sensor PAA values varies with impact location.
    Annals of Biomedical Engineering 06/2014; 42(9). DOI:10.1007/s10439-014-1052-2 · 3.23 Impact Factor
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    ABSTRACT: Background : Since 1982, the National Collegiate Athletic Association has used the Injury Surveillance System (ISS) to collect injury and athlete-exposure data from a representative sample of collegiate institutions and sports. At the start of the 2004-2005 academic year, a Web-based ISS replaced the paper-based platform previously used for reporting injuries and exposures. Objective : To describe the methods of the Web-based National Collegiate Athletic Association ISS for data collection as implemented from the 2004-2005 to 2013-2014 academic years. Description : The Web-based ISS monitored National Collegiate Athletic Association-sanctioned practices and competitions, the number of participating student-athletes, and time-loss injuries during the preseason, regular season, and postseason in 25 collegiate sports. Starting in the 2009-2010 academic year, non-time-loss injuries were also tracked. Efforts were made to better integrate ISS data collection into the workflow of collegiate athletic trainers. Data for the 2004-2005 to 2013-2014 academic years are available to researchers through a standardized application process available at the Datalys Center Web site. Conclusions : As of February 2014, more than 1 dozen data sets have been provided to researchers. The Datalys Center encourages applications for access to the data.
    Journal of athletic training 05/2014; 49(4). DOI:10.4085/1062-6050-49.3.58 · 1.51 Impact Factor
  • 05/2014; 6(3):105-110. DOI:10.3928/19425864-20140501-03
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    ABSTRACT: Abstract Primary objective: To summarize the factors associated with athletes' disclosure-and non-disclosure-of sports-related concussion and concussion symptoms within the context of the socio-ecological framework and to identify research gaps in the current literature. Methods: Searches using electronic databases identified studies written in English, published through October 2013 and addressing some aspect of disclosure of concussion and concussion symptoms. The literature search aimed to be comprehensive and inclusive of all previous contributions. Main outcomes and results: Of the 30 identified studies, most originated from the US (n = 19) and sampled athletes (n = 21) and coaches (n = 10) from high school (n = 11) and college levels (n = 9). The identified reasons for non-disclosure were organized into four levels using the socio-ecological framework: intra-personal (e.g. lack of knowledge; internal pressure; sex; concussion history; n = 20 studies); inter-personal (e.g. others' knowledge/attitudes; external pressure; external support; n = 15 studies); environment (e.g. access to concussion prevention materials; sports culture; n = 4 studies); and policy (e.g. concussion-related legislation; n = 3 studies). No study examined all four levels. Conclusions: Research gaps exist concerning factors influencing athletes' disclosure of sports-related concussions and concussion symptoms. Notably, researchers have focused on intra-personal and inter-personal levels, placing less emphasis on the environment and policy levels.
    Brain Injury 04/2014; DOI:10.3109/02699052.2014.904049 · 1.86 Impact Factor
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    ABSTRACT: There is limited evidence describing methods and challenges for implementing anterior cruciate ligament (ACL) injury prevention programs (IPP) in a "real-world" context. Evaluate the effects of a ACL IPP workshop on elite-division youth soccer coaches' behavioral determinants to implement a ACL IPP, and describe coaches' subsequent ACL IPP implementation compliance. Descriptive study. Elite-division youth soccer club. A convenient sample of 34 soccer coaches (age=34.6±9.1 yrs) of elite-division youth soccer club teams. We administered a workshop aimed at increasing coaches' behavioral determinants to implement a ACL IPP. Coaches were provided with instructional materials following the workshop. Coaches' behavioral determinants regarding ACL IPP using pre/post-workshop surveys and coaches' subsequent rate and fidelity of implementation of the ACL IPP during the following soccer season. Wilcoxon signed-rank tests indicated the workshop increased coach attitude toward; conducting a ACL IPP (P=.020), substituting a ACL IPP for a warm-up (P=.007), and improving player cutting and landing technique by implementing a ACL IPP (P=.001). The workshop increased coaches' perceived behavioral control; coaches felt more comfortable in their ability to teach their team a ACL IPP (P=.002) and more confident leading a ACL IPP if given instructions (P=.025). The workshop increased coaches' intent to implement a ACL IPP the next season (P<.001); for 15 minutes (P=.008) and 20 minutes (P=.011) prior to the start of a training session. Only 53% of the club's teams implemented the ACL IPP, with implementers demonstrating high variability in program fidelity. ACL IPP workshops can effectively increase coach attitudes, perceived behavioral control, and intent to implement a ACL IPP. However, amplification of behavioral determinants does not appear to directly translate to high-level implementation compliance. Future research should investigate supplementary strategies to facilitate optimal ACL IPP implementation to improve compliance.
    British journal of sports medicine 04/2014; 48(7):595. DOI:10.1136/bjsports-2014-093494.96 · 4.17 Impact Factor
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    ABSTRACT: Context : Of the individuals able to return to sport participation after an anterior cruciate ligament(ACL) injury, up to 25% will experience a second ACL injury. This population may be more sensitive to hormonal fluctuations, which may explain this high rate of second injury. Objective : To examine changes in 3-dimensional hip and knee kinematics and kinetics during a jump landing and to examine knee laxity across the menstrual cycle in women with histories of unilateral noncontact ACL injury. Design : Controlled laboratory study. Setting : Laboratory. Patients or Other Participants : A total of 20 women (age = 19.6 ± 1.3 years, height = 168.6 ± 5.3 cm, mass = 66.2 ± 9.1 kg) with unilateral, noncontact ACL injuries. Intervention(s) : Participants completed a jump-landing task and knee-laxity assessment 3 to 5 days after the onset of menses and within 3 days of a positive ovulation test. Main Outcome Measure(s) : Kinematics in the uninjured limb at initial contact with the ground during a jump landing, peak kinematics and kinetics during the loading phase of landing, anterior knee laxity via the KT-1000, peak vertical ground reaction force, and blood hormone concentrations (estradiol-β-17, progesterone, free testosterone). Results : At ovulation, estradiol-β-17 (t = -2.9, P = .009), progesterone (t = -3.4, P = .003), and anterior knee laxity (t = -2.3, P = .03) increased, and participants presented with greater knee valgus moment (Z = -2.6, P = .01) and femoral internal rotation (t = -2.1, P = .047). However, during the menses test session, participants landed harder (greater peak vertical ground reaction force; t = 2.2, P = .04), with the tibia internally rotated at initial contact (t = 2.8, P = .01) and greater hip internal-rotation moment (Z = -2.4, P = .02). No other changes were observed across the menstrual cycle. Conclusions : Knee and hip mechanics in both phases of the menstrual cycle represented a greater potential risk of ACL loading. Observed changes in landing mechanics may explain why the risk of second ACL injury is elevated in this population.
    Journal of athletic training 02/2014; 49(2). DOI:10.4085/1062-6050-49.2.01 · 1.51 Impact Factor
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    ABSTRACT: Information as to how anterior cruciate ligament (ACL) injury and reconstructive surgery (ACLR) alter lower extremity biomechanics may improve rehabilitation and return to play guidelines, reducing the risk for repeat ACL injury. To compare lower extremity biomechanics before ACL injury and after subsequent ACLR for the injured and uninjured leg. Baseline unilateral lower extremity biomechanics were collected on the dominant leg of participants without ACL injury when they entered the Joint Undertaking to Monitor and Prevent ACL (JUMP-ACL) study. Thirty-one participants with subsequent ACL injury, reconstructive surgery and full return to physical activity completed repeat, follow-up biomechanical testing, as did 39 uninjured, matched controls. Not all injured participants suffered injury to the dominant leg, requiring separation of those with ACL injury into two groups: ACLR-injured leg group (n=12) and ACLR-uninjured leg group (n=19). We compared the landing biomechanics of these three groups (ACLR-injured leg, ACLR-uninjured leg, control) before ACL injury (baseline) with biomechanics after ACL injury, surgery and return to physical activity (follow-up). ACL injury and ACLR altered lower extremity biomechanics, as both ACLR groups demonstrated increases in frontal plane movement (increased hip adduction and knee valgus). The ACLR-injured leg group also exhibited decreased sagittal plane loading (decreased anterior tibial shear force, knee extension moment and hip flexion moment). No high-risk biomechanical changes were observed in control group participants. ACL injury and ACLR caused movement pattern alterations of the injured and uninjured leg that have previously shown to increase the risk for future non-contact ACL injury.
    British journal of sports medicine 02/2014; 49(3). DOI:10.1136/bjsports-2013-092982 · 4.17 Impact Factor

Publication Stats

8k Citations
1,013.76 Total Impact Points

Institutions

  • 1996–2014
    • University of North Carolina at Chapel Hill
      • • Department of Epidemiology
      • • Department of Orthopaedics
      • • Department of Exercise and Sport Science
      • • Injury Prevention Research Center
      North Carolina, United States
  • 2013
    • WakeMed Health & Hospitals
      Raleigh, North Carolina, United States
  • 2012
    • United States Military Academy
      • Department of Mathematical Sciences
      West Point, New York, United States
  • 2011
    • University of Georgia
      • Department of Kinesiology
      Athens, GA, United States
  • 2010
    • Palo Alto Medical Foundation
      Palo Alto, California, United States
  • 2008–2010
    • Duke University Medical Center
      • Department of Community and Family Medicine
      Durham, NC, United States
    • Iowa State University
      • Department of Industrial and Manufacturing Systems Engineering
      Ames, Iowa, United States
  • 2009
    • University of Nevada, Reno
      Reno, Nevada, United States
    • Neuroscience & Tms Treatment Center
      Nashville, Tennessee, United States
  • 2003
    • Boston University
      Boston, Massachusetts, United States
  • 1992–1997
    • University of Otago
      • • Injury Prevention Research Unit
      • • Department of Preventive & Social Medicine
      Dunedin, Otago, New Zealand
  • 1994
    • Population Services International
      Washington, Washington, D.C., United States