Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2–3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations.
Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs. A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review. The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved. These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.Introduction
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The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown. To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school. Descriptive epidemiology study. National Collegiate Athletic Association (NCAA) men's ice hockey teams. Collegiate men's ice hockey athletes. The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers. Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non–time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non–time-loss injury rates were lower. In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey.Context
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The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown. To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department). Cross-sectional study. Collegiate sports medicine programs. Representatives of 325 universities. A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined. Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers. In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.Context
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Structural features of health care environments are associated with patient health outcomes, but these relationships are not well understood in sports medicine. To evaluate the association between athlete injury outcomes and structural measures of health care at universities: (1) clinicians per athlete, (2) financial model of the sports medicine department, and (3) administrative reporting structure of the sports medicine department. Descriptive epidemiology study. Collegiate sports medicine programs. Colleges that contribute data to the National Collegiate Athletic Association (NCAA) Injury Surveillance Program. We combined injury data from the NCAA Injury Surveillance Program, sports medicine staffing data from NCAA Research, athletic department characteristics from the United States Department of Education, and financial and administrative oversight model data from a previous survey. Rates of injury, reinjury, concussion, and time loss (days) in NCAA athletes. Compared with schools that had an average number of clinicians per athlete, schools 1 standard deviation above average had a 9.5% lower injury incidence (103.6 versus 93.7 per 10000 athlete-exposures [AEs]; incidence rate ratio [IRR] = 0.905, P < .001), 2.7% lower incidence of reinjury (10.6 versus 10.3 per 10000 AEs; IRR = 0.973, P = .004), and 6.7% lower incidence of concussion (6.1 versus 5.7 per 10000 AEs; IRR = 0.933, P < .001). Compared with the average, schools that had 1 standard deviation more clinicians per athlete had 16% greater injury time loss (5.0 days versus 4.2 days; IRR = 1.16, P < .001). At schools with sports medicine departments financed by or reporting to the athletics department (or both), athletes had higher injury incidences (31% and 9%, respectively). The financial and reporting structures of collegiate sports medicine departments as well as the number of clinicians per athlete were associated with injury risk. Increasing the number of sports medicine clinicians on staff and structuring sports medicine departments such that they are financed by and report to a medical institution may reduce athlete injury incidence.Context
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Detection of subtle changes in brain sensorimotor processes may enable clinicians to identify athletes who would derive the greatest benefit from interventions designed to reduce the risk for future injury and progressive neurologic or musculoskeletal dysfunction. To develop a generalizable statistical model for identifying athletes who possess subtle alterations in sensorimotor processes that may be due to previous concussion. Cross-sectional study. Residential Olympic Training Center sports medicine clinic. A primary cohort of 35 elite athletes and a secondary cohort of 40 elite athletes who performed identical tests the preceding year. Two upper extremity tests of visual-motor reaction time and 2 tests of whole-body reactive agility were administered. The whole-body tests required lateral or diagonal responses to virtual-reality targets, which provided measures of reaction time, speed, acceleration, and deceleration. Sport-related concussion history, which was reported by 54% (n = 19) of the athletes in the primary cohort and 45% (n = 18) of the athletes in the secondary cohort. Univariable analyses identified 12 strong predictors of sport-related concussion history, which we combined to create a composite metric with maximum predictive value. Composite lateral asymmetry for whole-body reactive movements and persisting effects of previous musculoskeletal injury yielded a logistic regression model with exceptionally good discrimination (area under the curve = 0.845) and calibration (predicted-observed probabilities within 7 subgroups: r = 0.959, P = .001). Application of the derived model to compatible data acquired from another cohort of elite athletes demonstrated very good discrimination (area under the curve = 0.772) and calibration (within 8 subgroups: r = 0.849, P = .008). Asymmetry in whole-body reactive movement capabilities may be a manifestation of a subtle abnormality in the functional connectivity of brain networks that might be relevant to previously reported associations between sport-related concussion history and musculoskeletal injury occurrence.Context
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In the absence of baseline testing, normative data may be used to interpret postconcussion scores on the clinical reaction-time test (RTclin). However, to provide normative data, we must understand the performance factors associated with baseline testing. To explore performance factors associated with baseline RTclin from among candidate variables representing demographics, medical and concussion history, self-reported symptoms, sleep, and sport-related features. Cross-sectional study. Clinical setting (eg, athletic training room). A total of 2584 National Collegiate Athletic Association student-athletes (n = 1206 females [47%], 1377 males [53%], and 1 unreported (<0.1%); mass = 76.7 ± 18.7 kg; height = 176.7 ± 11.3 cm; age = 19.0 ± 1.3 years) from 3 institutions participated in this study as part of the Concussion Assessment, Research and Education Consortium. Potential performance factors were sex; race; ethnicity; dominant hand; sport type; number of prior concussions; presence of anxiety, learning disability, attention-deficit disorder or attention-deficit/hyperactivity disorder, depression, or migraine headache; self-reported sleep the night before the test; mass; height; age; total number of symptoms; and total symptom burden at baseline. The primary study outcome measure was mean baseline RTclin. The overall RTclin was 202.0 ± 25.0 milliseconds. Female sex (parameter estimate [B] = 8.6 milliseconds, P < .001, Cohen d = 0.54 relative to male sex), black or African American race (B = 5.3 milliseconds, P = .001, Cohen d = 0.08 relative to white race), and limited-contact (B = 4.2 milliseconds, P < .001, Cohen d = 0.30 relative to contact) or noncontact (B = 5.9 milliseconds, P < .001, Cohen d = 0.38 relative to contact) sport participation were associated with slower RTclin. Being taller was associated with a faster RTclin, although this association was weak (B = −0.7 milliseconds, P < .001). No other predictors were significant. When adjustments are made for sex and sport type, the following normative data may be considered (mean ± standard deviation): female, noncontact (211.5 ± 25.8 milliseconds), limited contact (212.1 ± 24.3 milliseconds), contact (203.7 ± 21.5 milliseconds); male, noncontact (199.4 ± 26.7 milliseconds), limited contact (196.3 ± 23.9 milliseconds), contact (195.0 ± 23.8 milliseconds). Potentially clinically relevant differences existed in RTclin for sex and sport type. These results provide normative data adjusting for these performance factors.Context
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After knee-joint injury, pain, effusion, and mechanoreceptor damage alter afferent signaling, which can result in quadriceps inhibition and subsequent weakness. The individual contributions of each factor to inhibition remain unclear due to confounding knee-joint injuries and indirect experimental models. To characterize the influence of naturally occurring knee damage and pain on quadriceps neuromuscular function in individuals with patellar tendinopathy. Cross-sectional study. Research laboratory. Twenty participants who self-reported patellar tendinopathy (PT) and 10 healthy control individuals underwent ultrasonic tendon assessment. Injured participants were dichotomized by an orthopaedic surgeon into groups with (1) pain and structural tendon abnormality and (2) regional pain alone. Quadriceps inhibition was assessed with the Hoffman reflex and the central activation ratio via the superimposed-burst technique. Normally distributed measures were analyzed using a 1-way analysis of variance and post hoc independent t tests. Kruskal-Wallis tests with post hoc Mann-Whitney U tests were used to analyze nonnormally distributed data. An a priori α level of P ≤ .05 was set. Control participants presented with more spinal-reflex excitability (0.37 ± 0.23) than the PT (0.10 ± 0.06; P = .03) and regional-pain (0.18 ± 0.05; P = .02) groups. Knee-extension strength was greater in the control (3.37 ± 0.59 Nm/kg) than in the PT (2.41 ± 0.67 Nm/kg; P = .01) group but not the regional-pain group (3.05 ± 0.66 Nm/kg; P = .24). Control individuals presented with more quadriceps activation (97.93% ± 3.12) than the PT (84.44% ± 16.98; P < .01) and regional-pain (91.17% ± 10.56; P = .01) groups. No differences were present for any measures between the PT and regional-pain groups (P values > .05). Deficits in spinal-reflex excitability, quadriceps activation, and strength were present in both the PT and regional-pain groups. A combination of pain and structural damage appeared to have the greatest negative effect on quadriceps function, as only the PT group presented with neuromuscular outcomes that failed to meet clinical thresholds.Context
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Patellofemoral pain (PFP) is one of the most prevalent knee conditions observed in women. Current research suggests that individuals with PFP have altered muscle activity, kinematics, and kinetics during functional tasks. However, few authors have examined differences in lower extremity biomechanics in this population during the drop-vertical jump (DVJ). To determine how lower extremity electromyography, kinematics, and kinetics during a DVJ and lower extremity isometric strength differed between women with and those without PFP. Cross-sectional study. Laboratory. Fifteen healthy women (age = 20.23 ± 1.39 years, height = 169.32 ± 5.38 cm, mass = 67.73 ± 9.57 kg) and 15 women with PFP (age = 22.33 ± 3.49 years, height = 166.42 ± 6.01 cm, mass = 65.67 ± 13.75 kg). Three trials of a DVJ. Surface electromyography, kinematics, and kinetics were collected simultaneously during a DVJ. Lower extremity strength was measured isometrically. Independent-samples t tests were performed to assess group differences. Normalized muscle activity in the vastus medialis (healthy group = 120.84 ± 80.73, PFP group = 235.84 ± 152.29), gluteus maximus (healthy group = 43.81 ± 65.63, PFP group = 13.37 ± 13.55), and biceps femoris (healthy group = 36.68 ± 62.71, PFP group = 11.04 ± 8.9) during the landing phase of the DVJ differed between groups. Compared with healthy women, those with PFP completed the DVJ with greater hip internal-rotation moment (0.04 ± 0.28 N/kg versus 0.06 ± 0.14 N/kg, respectively) and had decreased knee-flexion excursion (76.76° ± 7.50° versus PFP = 74.14° ± 19.85°, respectively); they took less time to reach peak trunk flexion (0.19 ± 0.01 seconds versus 0.19 ± 0.02 seconds, respectively) and lateral trunk flexion (0.12 ± 0.07 seconds versus 0.11 ± 0.04 seconds, respectively). During the DVJ, women with PFP had increased hip internal-rotation moment and decreased knee-flexion excursion with less time to peak trunk flexion and lateral flexion. Muscle activation was increased in the vastus medialis but decreased in the gluteus maximus and biceps femoris. This suggests that altered motor-unit recruitment in the hip and thigh may result in changes in biomechanics during a DVJ that are often associated with an increased risk of injury.Context
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The quadriceps tendon (QT) has become increasingly used by orthopaedic surgeons as an alternative autograft choice in anterior cruciate ligament reconstruction. As its use increases, athletic trainers and other rehabilitation clinicians will treat a greater number of patients with this autograft type. The recently developed, minimally invasive technique for harvest of the all-soft tissue autograft has many benefits, including versatility, decreased donor-site morbidity, and enhanced cosmesis. Early clinical trials revealed that the QT autograft resulted in decreased anterior knee pain and similar strength and functional outcomes to those of more common autograft types. From a rehabilitation perspective, many characteristics should be considered, such as the importance of early knee extension and quadriceps activation. Therefore, the purpose of this technical note is to expose athletic trainers to the QT autograft so that they may provide the best care for patients after anterior cruciate ligament reconstruction.
The effect of ultrasound frequency on phonophoresis drug delivery in humans is unknown. To determine if a low (45-kHz) or high (1-MHz) frequency delivered a higher dexamethasone (Dex) concentration through the skin. Controlled laboratory study. Laboratory. A total of 40 healthy men between the ages of 18 and 45 years (age = 23.1 ± 2.6 years, height = 176.1 ± 7.2 cm, mass = 88.5 ± 19.4 kg, posterior calf subcutaneous thickness measured using musculoskeletal ultrasound imaging = 0.6 ± 0.2 cm). Participants were randomly assigned to 1 of 4 groups (ultrasound frequency at microdialysis probe depth): (1) 45-kHz frequency at 1 mm, (2) 45-kHz frequency at 4 mm, (3) 1-MHz frequency at 1 mm, or (4) 1-MHz frequency at 4 mm (n = 10 in each group). Three linear microdialysis probes were inserted at the desired tissue depth. We rubbed dexamethasone sodium phosphate (Dex-P) into the skin and then applied a 15-minute phonophoresis treatment. Dialysate was collected during the treatment and 60 minutes posttreatment and analyzed for Dex-P, Dex, and the metabolite form of Dex. The sum of the 3 analytes was calculated as total dexamethasone (Dex-total), and differences between the 45-kHz and 1-MHz treatment groups were determined by a repeated-measures analysis of variance. At 1 mm, 3 (30%) participants in the 45-kHz and 4 (40%) participants in the 1-MHz group had measurable levels of Dex-P. Total dexamethasone increased after the treatment ceased, independent of ultrasound frequency (P < .001), with a trend of the 45-kHz treatment to produce a greater increase in drug concentration (P = .006). At 4 mm, 5 (50%) participants in the 45-kHz and 1 (10%) participant in the 1-MHz group had measurable levels of Dex-P. We observed no difference in Dex-total concentration between treatment groups at 4 mm (P = .72). Phonophoresis provided a mechanism for Dex-total delivery at the 1- and 4-mm tissue depths. However, the effectiveness of the ultrasound frequencies varied between the 2 measured tissue depths.Context
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Limited information exists about health patterns among female rowers at the collegiate level. Furthermore, the element of weight class (lightweights classified as <130 lb [59 kg]) as a factor in the physical and mental health of female collegiate athletes has not been investigated, despite weight requirements in sport being a risk factor for the female athlete triad. To test the hypotheses that (1) components of the female athlete triad were more prevalent in lightweight than in openweight rowers; (2) perceived stress levels were greater in lightweight than in openweight rowers; and (3) rowers who were unable to row due to injury had greater perceived stress levels than uninjured athletes. Cross-sectional study. Twelve collegiate women's rowing programs consisting of 6 National Collegiate Athletic Association Division I openweight and 6 Intercollegiate Rowing Association–level lightweight teams. A total of 158 female collegiate rowers (78 lightweight, 80 openweight). An electronic survey addressing injury history, diet and eating habits and body image (according to the triad screening questionnaire), stress levels (Perceived Stress Scale), and athlete identity (Athlete Identity Measurement Scale) was administered. Lightweight rowers reported limiting or carefully controlling foods more frequently than openweight rowers (41.9% to 29.9%, P = .013). A history of an eating disorder was more prevalent among lightweight than openweight rowers (25.7% to 13.0%, P = .048). Prevalences of stress fractures and menstrual irregularities did not differ between weight classes. Lightweight and openweight rowers' scores on the Perceived Stress Scale (16.0 ± 9.9 and 17.3 ± 6.4, respectively) were not different. Injured rowers scored higher on the Perceived Stress Scale (19.4 ± 7.2) than did uninjured rowers (16.6 ± 5.72). Weight class did not contribute to differences in the prevalence of female athlete triad components or perceived stress, although lightweight rowers were more likely to have a history of eating disorder. Injury may be a risk factor for increased stress in this population.Context
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Reliability and Validity of the Functional Assessment of Neurocognition in Sport (FANS): A Paradigm Shift in Post-Concussion Return-to-Sport Decision-Making
Driving After Concussion: Clinical Measures Associated with Post-concussion
The role of shoulder posture in pitching mechanics and injury risk in high school baseball pitchers
Corticospinal Excitability during Standing and Its Association with Postural Control Following Acute Lateral Ankle Sprain.
The socio-economic cost of anterior cruciate ligament injuries and lateral ankle sprains in amateur football and basketball.
JAT eISSN: 1938-162X
JAT ISSN: 1062-6050
ATEJ ISSN: 1947-380X