Prevention of spinal cord injuries that occur in swimming pools

Long-term assessment of the functional independence measure in sports-related spinal cord injury

CONTEXT

Patients with spinal cord injury (SCI) secondary to traumatic sports-related etiology potentially face loss of independence. The Functional Independence Measure (FIM) assesses the amount of assistance patients require and has shown sensitivity to changes in patient functional status post injury.

OBJECTIVES

We aimed to (1) examine long-term outcomes following sports-related SCI (SRSCI) using FIM scoring at the time of injury, one year, and five years post-injury, and (2) determine predictors of independence at one and five-year follow-up considering surgical and non-surgical management. Few studies have investigated the cohort analyzed in this study.

METHODS

The 1973-2016 National Spinal Cord Injury Model Systems (SCIMS) Database was used to develop a SRSCI cohort. The primary outcome of interest captured functional independence using a multivariate logistic regression, defined by FIM individual scores greater than or equal to six, evaluated at one and five years.

RESULTS

A total of 491 patients were analyzed, 60 (12%) were female, 452 (92%) underwent surgery. The cohort demographics were stratified by patients with and without spine surgery and evaluated for functional independence in FIM subcategories. Increased time spent in inpatient rehabilitation and FIM score at post-operative discharge were associated with greater likelihood of functional ability at both one and five-year follow-up.

CONCLUSION

Our study demonstrated that SRSCI patients are a unique subset of SCI patients for whom factors repeatedly associated with independence at one year follow-up were dissimilar to those associated with independence at five-year follow-up. Larger prospective studies should be conducted to establish guidelines for this unique subcategory of SCI patients.

Demographics and functional outcome of shallow water diving spinal injuries in northern Germany - A retrospective analysis of 160 consecutive cases

AIM

To describe demographic findings, typical injuries and functional neurological outcomes in patients with cervical trauma and tetraplegia sustained after diving into shallow water.

PATIENTS AND METHODS

A retrospective study was performed including all patients treated in BG Klinikum Hamburg suffering from tetraplegia after jumping into shallow water between 1st June 1980 and 31st July 2018.

RESULTS

One hundred and sixty patients with cervical spinal injuries and tetraplegia following a dive into shallow water were evaluated. Of these, 156 patients (97.5%) were male. The mean age was 24.3 years ± 8.1 and the accidents occurred most often in inland waters (56.2%) and mostly between May and August (90.6%). In all cases there was one vertebra fractured, whereas in 48.1% of cases, two vertebrae were severed. In the majority of cases (n = 146), a surgical procedure was performed. Overall, the mean hospital stay was 202 days (±72, range: 31-403) and one patient died. On admission, 106 patients (66.2%) showed a complete lesion according to AIS A, with incomplete lesions in the remaining 54 patients (AIS B: n = 25 [15.6%], AIS C: n = 26 [16.3%], AIS D: n = 3 [1.9%]). In two thirds of the patients, the level of paralysis on admission was at the level of segments C4 (31.9%) or C5 (33.7%). Seventeen patients (10.6%) needed prehospital resuscitation. In 55 patients (34.4%), the neurological findings improved during the course of inpatient treatment and rehabilitation. Sixty-eight patients (42.5%) developed pneumonia, of which 52 patients (76.5%) were ventilated. In addition, 56.5% of patients with paralysis levels C0-C3 required ventilation, whereas only 6.3% of patients with paralysis levels C6-C7 were affected. Three patients (1.9%) were discharged from hospital with continuous ventilation. Overall, 27.4% of all AIS A patients, 56% of all AIS B patients and 46.2% of all AIS C patients improved neurologically, with 17% of all patients being able to walk.

CONCLUSIONS

The consequences of a cervical spine injury after diving into shallow water are severe and lifelong. Functionally, patients may benefit from care in a specialised centre, both in the acute phase and during rehabilitation. The more incomplete the primary paralysis, the greater the possibility of neurological recovery.

The trends in sports-related spinal cord injury in China

STUDY DESIGN

Retrospective epidemiological study.

OBJECTIVES

To determine the characteristics of sports-related spinal cord injury (SCI) in China and assess changes in the trend of these injuries that may impact policy making.

SETTING

China Rehabilitation Research Center (CRRC), Beijing.

METHODS

Of the 2448 SCI cases reviewed, 6.7% (n = 164) were caused by sport- and recreation-related accidents. They were admitted to the CRRC between January 1, 2013 and December 31, 2019. We collected data on age, sex, etiology, the neurological level of injury, the American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores on admission, and the neurological recovery results at discharge.

RESULTS

Dancing (58.6%), followed by water sports (14.7%) and taekwondo (4.2%) were the leading etiologies. Of the SCIs caused by dancing, 27.1% of the individuals had incomplete injury, and of these, 57.7% showed improved neurological function. However, 72.9% had complete injury, and these individuals did not show any improvement in neurological function. Individuals with dance-related SCIs graded as A and D according to the AIS, showed no significant improvement in their motor function scores at the time of discharge. While the scores of those graded B and C increased significantly, there were no significant differences in the light touch and pin touch scores.

CONCLUSIONS

The etiology of sports-related SCI in China has changed dramatically, with dancing replacing water sports as the primary cause of SCIs. Individuals with dance-related SCIs have a poor prognosis. In China, prevention of dance-related SCIs has become a priority.

Spinal Cord Injury With Tetraplegia in Young Persons After Diving Into Shallow Water: What Has Changed in the Past 10 to 15 Years?

STUDY DESIGN

Retrospective, monocentric, observational study in a tertiary health care center.

OBJECTIVES

To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water.

METHODS

Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences.

RESULTS

A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge (P ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients (P ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications.

CONCLUSIONS

People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.

An Overview of Spinal Injuries due to Dive or Fall into Shallow Water: Our Long-Term, Double-Center Experience from the Aegean Coast

Purpose

We aimed to evaluate the demographic and clinical features of patients with cervical spinal injuries secondary to shallow-water diving and share our therapeutic outcomes.

Methods

A retrospective study was carried out using data extracted from the medical files of 39 patients (3 females and 36 males) who were treated surgically (n = 29) or conservatively (n = 10). Demographics, clinical features, operative data, American Spine Injury Association (ASIA) impairment scales, and Karnofsky Performance Status (KPS) results were noted.

Results

The average age of our series (n = 39) was 31.59 ± 14.80 (range, 14 to 92) years. The vast majority of patients (n = 34, 87.2%) presented with isolated cervical trauma. At initial admission, neurological deficits were diagnosed in 22 (56.4%) patients. A single-level cervical involvement was noted in 18 (46.2%) patients, while 21 cases (53.8%) displayed injury involving multiple levels. The levels of cervical injury were C5 (n = 16, 41%), C6 (n = 11, 28.2%), C7 (n = 6, 15.4%), C1 (n = 5, 12.8%), and C4 (n = 1, 2.6%). A total of 22 patients had neurological deficits at admission. Surgery was performed using anterior (n = 21, 72.4%), posterior (n = 7, 24.1%), and combined anterior and posterior (n = 1, 3.4%) routes. Nine patients (23.1%) exhibited improvement in their neurological deficits. There were significant improvements in both the ASIA impairment scale and KPS results after treatment.

Conclusion

Our data indicated that dive- or fall-related cervical spinal injuries are associated with profound morbidity. Reinforcement of primary prevention, identification of target population, and increased awareness on this topic are the key steps to minimize the frequency and severity of complications and to optimize therapeutic outcomes.

Blood Alcohol Concentration Is Associated With Improved AIS Motor Score After Spinal Cord Injury

Objective

To investigate the relationship between blood alcohol concentration (BAC) and neurologic recovery after traumatic spinal cord injury (TSCI) using standardized outcome measures from the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) examination.

Method

This is a retrospective review of merged, prospectively collected, multicenter data from the Spinal Cord Injury Model Systems Database and institutional trauma databases from five academic medical centers across the United States. Patients with SCI and a documented BAC were analyzed for American Spinal Injury Association Impairment Scale (AIS) motor score, FIM, sensory light touch score, and sensory proprioception score upon admission and discharge from rehabilitation. Linear regression was used for the analysis.

Results

The study identified 210 patients. Mean age at injury was 47 ± 20.5 years, 73% were male, 31% had an AIS grade A injury, 56% had ≥1 comorbidity, mean BAC was 0.42 ± 0.9 g/dL, and the mean Glasgow Coma Score upon arrival was 13.27 ± 4.0. ISNCSCI motor score gain positively correlated with higher BAC (4.80; confidence interval [CI], 2.39-7.22; p < .0001). FIM motor gain showed a trend toward correlation with higher BAC, although it did not reach statistical significance (3.27; CI, -0.07 to 6.61; p = .055). ISNCSCI sensory light touch score gain and sensory proprioception score gain showed no correlation with BAC (p = .44, p = .09, respectively).

Conclusion

The study showed a positive association between higher BAC and neurologic recovery in patients with SCI as measured by ISNCSCI motor score gain during rehabilitation. This finding has not been previously reported in the literature and warrants further study to better understand possible protective physiological mechanisms underlying the relationship between BAC and SCI.

Wet and wounded: Pediatric facial trauma from swimming and diving

OBJECTIVES

Swimming has been reported as the most common recreational activity among American youths, while diving remains a popular youth activity as well. We characterize the most common facial injuries occurring during these activities and evaluate facial fracture mechanisms and demographic trends, as this information may be helpful in preventative counseling as well as diagnosis.

METHODS

The National Electronic Injury Surveillance System was assessed for swimming- and diving-related facial injuries in children from 2007 to 2016. Estimates of national injury incidence were recorded, and patient diagnoses, demographics, and injury mechanisms were evaluated.

RESULTS

In the 10-year period assessed, 789 NEISS entries extrapolated to an estimated 27,709 patients nationwide were analyzed. The yearly incidence fluctuated but steadily rose from 2013 to 2016. Males comprised a majority of injuries (58%), and laceration was the most common diagnosis (65%), followed by abrasion/contusion (22%) and fracture (9%). Facial fractures were most likely to involve the nasal bones (87%). Swimming injuries were more numerous overall (74%), but a greater proportion of diving injuries resulted in fracture (12% vs. 7%). Teenagers were also more likely to suffer fractures than were younger children involved in the same activities.

CONCLUSION

Most analyses of swimming and diving injuries have focused on spinal and orthopedic trauma. Nevertheless, the nature of headfirst diving and swim strokes suggest facial trauma is an underappreciated concern for clinicians. These findings reinforce the need for safer swimming and diving practices and serve as a useful resource for physicians managing pediatric facial injuries.

Alcohol use, aquatic injury, and unintentional drowning: A systematic literature review

ISSUES

Drowning is a global public health issue, and there is a strong association between alcohol and risk of drowning. No previous systematic review known to date has identified factors associated with alcohol use and engagement in aquatic activities resulting in injury or drowning (fatal and non-fatal).

APPROACH

Literature published from inception until 31 January 2017 was reviewed. Included articles were divided into three categories: (i) prevalence and/or risk factors for alcohol-related fatal and non-fatal drowning and aquatic injury, (ii) understanding alcohol use and aquatic activities, and (iii) prevention strategies. Methodological quality of studies was assessed using National Health and Medical Research Council (NHMRC) Level of Evidence and risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scales.

KEY FINDINGS

In total, 74 studies were included (57 on prevalence and/or risk factors, 15 on understanding alcohol use, and two on prevention strategies). Prevalence rates for alcohol involvement in fatal and non-fatal drowning varied greatly. Males, boating, not wearing lifejackets, and swimming alone (at night, and at locations without lifeguards) were risk factors for alcohol-related drowning. No specific age groups were consistently identified as being at risk. Study quality was consistently low, and risk of bias was consistently high across studies. Only two studies evaluated prevention strategies.

IMPLICATIONS

There is a need for higher quality studies and behavioural basic and applied research to better understand and change this risky behaviour.

CONCLUSION

On average, 49.46% and 34.87% of fatal and non-fatal drownings, respectively, involved alcohol, with large variations among studies observed.

Emergency department visits coded for swimming pool diving injuries

Despite legislative efforts to enhance safety in public swimming pools, diving injuries are still common. This study investigated the characteristics of emergency departments (EDs) visits for diving accidents. This study utilized 2006-2014 data from the Nationwide Emergency Department Sample and examined visits for accidents due to diving or jumping into water (swimming pool). Data were stratified by age categories. Over 83,000 ED visits were found and the majority of visits were by males. Significantly more patients were in the 15-24 age category. The majority of patients were discharged and were covered by private insurance. Total charges for the six-year period approached $620 million. Spinal cord injuries were more common in those over age 25, whereas intracranial injuries occurred more frequently in younger patients. This study provides a profile of patients presenting to US EDs for diving-related injuries.

Prevention of diving-induced spinal cord injuries-preliminary results of the first Romanian mass media prophylactic educational intervention

STUDY DESIGN

The study was an observational study of the seasonal incidence of diving accidents, according to the summer weather pattern and the influence of an educative prophylactic intervention.

OBJECTIVES

The study analyzed the preliminary results of a national project, disseminated on social networking (Facebook) and broadcasted on main national and international Romanian TV channels.

SETTING

The study was conducted at the Neurorehabilitation, Teaching Emergency Hospital 'Bagdasar-Arseni.'

METHODS

The study had a dichotomous design (a retrospective review and a prospective component), and it analyzed the evolution trends of diving accidents, before and after the prophylactic intervention. The retrospective review analyzed 41 diving accidents, registered during 2011-2015. The prospective component focused on cases registered in 2016. Spearman's Rho non-parametric test was used to evaluate the association between two variables (the air temperature and the number of diving accidents).

RESULTS

The study involved 46 males and 1 female, with a mean age (at the time of injury) 26.4±7.02 (median 25, mode 23), admitted to rehabilitation in an early post-acute status after surgical intervention. Male youths and young adults <35 years old represented 83% of all cases. During 2011-2015, a monotonic association between the summer climate and the incidence of diving-induced tetraplegia (R=0.97468; P=0.00482) was noticed. Analyzing the evolutionary trends of similar cases registered in 2016, variables did not increase in value together (R=0.73561; P=0.09561). In 2016, the number of diving-induced quadriplegics was reduced on average by 26.8%.

CONCLUSIONS

One year is not enough for a successful, durable educative intervention. It is compulsory to continue, extend and intensively promote this program.

[Spinal cord injuries resulting from diving accidents in the Canary Islands]

OBJECTIVE

Diving accidents is one of the leading causes of spinal cord injury after falls and car accidents. The objective of this study was to determine the epidemiological and clinical characteristics of these patients in our setting to better prevent these injuries.

MATERIAL AND METHODS

We performed a retrospective, descriptive study of patients who have suffered from a traumatic spinal cord injury after a diving accident in the Canary Islands, Spain from 2000 to 2014. These patients were admitted to the Spinal Cord Unit of Hospital Universitario Insular de Gran Canaria.

RESULTS

Of the 264 patients admitted to our unit for acute traumatic spinal cord injury, 23 (8.7%) cases were due to diving. Grouping the patients into 5years periods, 56% of the injuries occurred in 2000-2005, 17% in 2006-2010 and 26% in 2011-2014. All patients were male, with a mean age of 29years. Approximately 65% were under 30years. A total of 22/23 patients had a fracture and injury most commonly occurred to the C5 vertebra. Burst fractures were the most common. A total of 86% of cases underwent surgery. All the spinal cord injuries were cervical, with C6 being the neurological level most often affected. A total of 65% of spinal cord injuries were complete injuries.

CONCLUSIONS

Spinal cord injury secondary to diving accidents is the third leading cause of traumatic spinal cord injury in our setting. It affects young males and the most common clinical presentation is a complete cervical spinal cord injury. Given the irreversible nature of the injury, prevention, aimed mainly at young people, is of great importance.

Fatal Cervical Spine Injury From Diving Accident

Spinal cord injuries result after diving into shallow water, often after incautious jumps head first into water of unknown depth during recreational or sport activities. Mortality is generally due to upper cervical trauma. The authors present a case of a diving-related death in a young woman who underwent medicolegal investigations. The measured water depth at the supposed dive site was 1.40 m. Postmortem radiology and autopsy revealed fractures of the body and the posterior arch of the fifth cervical vertebra, a fracture of the right transverse process of the sixth cervical vertebra and hemorrhages involving the cervical paraspinal muscles. Neuropathology showed a posterior epidural hematoma involving the whole cervical region and a symmetric laceration of the spinal cord located at the fourth and fifth cervical vertebra level, surrounded by multiple petechial hemorrhages. Toxicology revealed the presence of ethanol in both blood and urine samples. The death was attributed to cervical spine fracture (C5-C6), spinal cord contusion, and subsequent drowning. This case highlights the usefulness of postmortem radiology, examination of the deep structures of the neck, toxicology, neuropathology, and a detailed research of signs of drowning to formulate appropriate hypotheses pertaining to the cause and mechanism of death.

Epidemiology of sport-related spinal cord injuries: A systematic review

CONTEXT

Despite the recognition of sports as a significant contributor in the etiology of spinal cord injury (SCI), no studies have systematically explored the epidemiology of SCI caused by sports.

OBJECTIVE

This paper aims to give a systematic overview of the epidemiology of sport-related spinal cord injury around the world.

METHODS

A systematic review was conducted to identify published literature reporting the epidemiology of SCI caused by sports. The literature search was conducted in MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO and Sportdiscus with date limits 1980 through to July 2015. Data from 54 studies covering 25 countries was extracted and collated.

RESULTS

Important findings include identification of 6 countries in which sports accounts for over 13% of SCI (highest to lowest: Russia, Fiji, New Zealand, Iceland, France and Canada); individual sports with high risk for SCI (diving, skiing, rugby, and horseback riding); and the most common level of injury for various sports (almost entirely cervical for hockey, skiing, diving and American football, while over half of horseback riding and snowboarding injuries are thoracic or lumbosacral).

CONCLUSION

This paper identifies countries and sports with higher rates of sport-related SCIs where implementation of prevention programs and reporting systems to track SCI epidemiology may be helpful, and highlights gaps in our current knowledge for further investigation. The comparison of SCI occurrence for each sport across countries, as well as examination of the specific characteristics of SCI incurred for individual sports will assist in directing efforts for prevention.

Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972-2014

OBJECTIVE

To document trends in the demographic and injury profile of new spinal cord injury (SCI) over time.

DESIGN

Cross-sectional analysis of longitudinal data by injury years (1972-1979, 1980-1989, 1990-1999, 2000-2009, 2010-2014).

SETTING

Twenty-eight Spinal Cord Injury Model Systems centers throughout the United States.

PARTICIPANTS

Persons with traumatic SCI (N=30,881) enrolled in the National Spinal Cord Injury Database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Age, sex, race, education level, employment, marital status, etiology, and severity of injury.

RESULTS

Age at injury has increased from 28.7 years in the 1970s to 42.2 years during 2010 to 2014. This aging phenomenon was noted for both sexes, all races, and all etiologies except acts of violence. The percentage of racial minorities expanded continuously over the last 5 decades. Virtually among all age groups, the average education levels and percentage of single/never married status have increased, which is similar to the trends noted in the general population. Although vehicular crashes continue to be the leading cause of SCI overall, the percentage has declined from 47.0% in the 1970s to 38.1% during 2010 to 2014. Injuries caused by falls have increased over time, particularly among those aged ≥46 years. Progressive increases in the percentages of high cervical and motor incomplete injuries were noted for various age, sex, race, and etiology groups.

CONCLUSIONS

Study findings call for geriatrics expertise and intercultural competency of the clinical team in the acute and rehabilitation care for SCI. This study also highlights the need for a multidimensional risk assessment and multifactorial intervention, especially to reduce falls and SCI in older adults.

Cervical spine injuries from diving accident: a 10-year retrospective descriptive study on 64 patients

INTRODUCTION

Ninety percent of the lesions resulting from diving injuries affect the cervical spine and are potentially associated with spinal cord injuries. The objective is to determine the most frequent lesion mechanisms. Evaluate the therapeutic alternatives and the biomechanical evolution (kyphotic deformation) of diving-induced cervical spine injuries. Define epidemiological characteristics of diving injuries.

MATERIALS AND METHODS

A retrospective analysis over a period of 10 years was undertaken for patients admitted to the Department of Neurosurgery of Montpellier, France, with cervical spinal injuries due to a diving accident. Patients were re-evaluated and clinical and radiological evaluation follow-ups were done.

RESULTS

This study included 64 patients. Cervical spine injuries resulting from diving predominantly affect young male subjects. They represent 9.5% of all the cervical spine injuries. In 22% of cases, patients presented severe neurological troubles (ASIA A, B, C) at the time of admission. A surgical treatment was done in 85% of cases, mostly using an anterior cervical approach.

DISCUSSION

This is a retrospective study (type IV) with some limitations. The incidence of diving injuries in our region is one of the highest as compared to reports in the literature. Despite an increase of our surgical indications, 55% of these cases end up with a residual kyphotic deformation but there is no relationship between the severity of late vertebral deformity and high Neck Pain and Disability Scale (NPDS) scores.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Evidence-based practice in primary prevention of spinal cord injury

A spinal cord injury (SCI) not only causes paralysis, but also has long-term impact on physical and mental health. There are between 236,000 to 327,000 individuals living with the consequences of SCI in the United States, and the economic burden on the individuals sustaining the injury, their support network, and society as a whole is significant. The consequences of SCI require that health care professionals begin thinking about primary prevention. Efforts are often focused on care and cure, but evidence-based prevention should have a greater role. Primary prevention efforts can offer significant cost benefits, and efforts to change behavior and improve safety can and should be emphasized. Primary prevention can be applied to various etiologies of injury, including motor vehicle crashes, sports injuries, and firearm misuse, with a clear goal of eliminating unnecessary injury and its life-changing impact.

Cervical spine injuries resulting from diving accidents in swimming pools: outcome of 34 patients

Cervical spine injuries after diving into private swimming pools can lead to dramatic consequences. We reviewed 34 patients hospitalized in our center between 1996 and 2006. Data was collected from their initial admission and from follow-up appointments. The injuries were sustained by young men in 97% (mean age 27) and the majority happened during the summer (88%). Fractures were at C5-C7 in 70%. American Spinal Injury Association class (ASIA) on admission was A for 8 patients, B for 4, C for 4, D for 1, and E for 17. There were 23 surgical spine stabilizations. Final ASIA class was A for 6 patients, B for 1, C for 3, D for 5, and E for 18. The mean duration of hospitalization was 21.3 days in our neurosurgical center (mean overall cost: 36,000 Euros/patient) plus 10.6 months in rehabilitation center for the 15 patients admitted who had an ASIA class A to C. Mean overall direct cost for a patient with class A is almost 300,000 Euros, compared to around 10,000 Euros for patients with class D and E. In addition, a profound impact on personal and professional life was seen in many cases including 11 divorces and 7 job losses. Dangerous diving into swimming pools can result in spinal injuries with drastic consequences, including permanent physical disability and a profound impact on socio-professional status. Moreover, there are significant financial costs to society. Better prevention strategies should be implemented to reduce the impact of this public health problem.

Diving-related injuries in children <20 years old treated in emergency departments in the United States: 1990-2006

OBJECTIVE

The purpose of this work was to comprehensively examine diving-related injuries in the United States among children and adolescents <20 years of age.

METHODS

We conducted a retrospective analysis of diving-related injury data from the National Electronic Injury Surveillance System, including patients aged <20 years old who were seen in an emergency department for a diving-related injury from 1990 through 2006.

RESULTS

An estimated 111341 patients aged <or=19 years were treated in emergency departments for diving-related injuries over the 17-year period of the study. The average annual injury rate was 8.4 injuries per 100000 US residents <20 years old. Patients aged 10 to 14 years composed the largest group (36.3%) of injured divers. Injuries to the head and/or neck (38.2%) and face (21.7%) were the most common, with the most frequent diagnoses being lacerations (33.9%) and soft tissue injuries (24.3%). Collision with a diving board and/or platform was the leading cause of injuries (43.9%). Children <10 years old had increased odds of sustaining a laceration, children <5 years old had increased odds of injury to the face, and 10- to 19-year-olds had increased odds of sustaining a fracture or an injury to the extremities. The odds of injury caused by contact with the diving board dramatically increased if the child was performing a flip and/or handstand or a backward dive.

CONCLUSIONS

To our knowledge, this is the first study to examine recreational and competitive diving-related injuries among children and adolescents using a nationally representative sample. These results can help inform pediatricians, parents, coaches, and trainers regarding injuries seen during recreational and competitive diving and can help guide future prevention efforts.

Risk factors and prevention for spinal cord injury from diving in swimming pools and natural sites in Quebec, Canada: a 44-year study

BACKGROUND

Diving is the most frequent cause of spinal cord injury (SCI) from recreation and sport in Canada. This study was done to identify risk factors for SCI from diving in the province of Quebec.

METHODS

An interview survey was done for a target population of 203 subjects with a SCI from diving treated in the two specialized rehabilitation centers in Quebec during 1961-2004. Telephone interviews of consenting individuals were used to collect pertinent personal, equipment, and environmental factors for each incident.

RESULTS

Response was 44% (89/203); 92% were male and 85% <35 years old. Only 37% were aware prior to injury of the risk of SCI from diving, and only 33% had received water safety training. Swimming pools were the site of 51% (n=45) and natural bodies of water for 49% (n=44). 87% (n=39) of pools were single-unit home pools and 57% (n=26) above-ground. Depth indicators were absent for 100% of above-ground and 74% of in-ground pools. For SCI in in-ground pools, 63% resulted from striking the up-slope between deep and shallow ends. For dives at natural sites, a dock or wharf was the most frequent location, 36% (n=16). In 52% of pools and 79% of natural sites, depth was <1.4m (4.6ft). Signs prohibiting diving were absent in 96% of above-ground and 89% of in-ground pools. Alcohol was reported in 47% of SCIs.

INTERPRETATION

The target for prevention of diving SCI is male youths and young adults. Above-ground pools are too shallow and small for diving. Deep ends of many in-ground pools are excessively shallow and short since many SCIs resulted from striking the up-slope. Prevention of SCI from diving needs to focus on education of potential victims, pool vendors and manufacturers, and regulations for safety norms in private pools. Water safety should highlight diving as a high-risk activity, and emphasize that most home pools and natural sites are unsafe. Safer evidence-based pool designs and more effective warnings need to be implemented.

Central nervous system injuries in sport and recreation: a systematic review

Many sports have been associated with a variety of neurological injuries affecting the central nervous system (CNS), with some injuries specific to that sport. A systematic review of sport-specific CNS injuries has not been attempted previously, and could assist in the understanding of morbidity and mortality associated with particular sporting activities, either professional or amateur. A systematic review of the literature was performed using PubMed (1965-2003) examining all known sports and a range of possible CNS injuries attributable to that sport. Numerous sporting activities (45) have associated CNS injuries as reported within the literature. The sports most commonly associated with CNS injuries are: football, boxing, hockey, use of a trampoline, and various winter activities. A number of sporting activities are associated with unique CNS injuries or injury-related diseases such as heat stroke in auto racing, vertebral artery dissection in the martial arts, and dementia pugilistica in boxing. Neurological injuries of the CNS due to sport comprise a wide collection of maladies that are important for the neurologist, neurosurgeon, orthopaedic surgeon, physiatrist, sports medicine doctor, athletic trainer and general physician to recognise.

Spinal cord injuries due to diving accidents

STUDY DESIGN

Retrospective study and data analysis.

OBJECTIVE

To investigate and analyse the main features of spinal cord injuries due to diving accidents accepted in our Centre from June 1978 to December 2002.

SETTING

Regional Spinal Unit of Florence, Italy.

INTRODUCTION

Diving accidents mostly occur in a young and healthy population and most of the patients develop tetraplegia with a severe lifelong disability. From 1978 to 2002, 65 patients with spinal injuries due to diving accidents were admitted to the Regional Spinal Unit of Florence.

MATERIAL AND METHODS

A retrospective study was conducted by analysing data stored in our local computerized database. We considered the vertebral injury, ASIA-ISCOS neurological classification on admission and discharge, gender, age at the time of injury, month of injury, treatment of vertebral lesion, length of stay in the Spinal Unit, neurological outcome, and complications. Data were analysed statistically by using the Fisher's exact test and logistic regression.

RESULTS

In all, 62/65 patients were males (95%). Mean age at injury time: 22 years. On admission, 35/65 were neurologically complete ASIA A (54%), while 16 were classified ASIA B, 7 ASIA C and 7 ASIA D, according to the ASIA-ISCOS neurological standard of classification. C6 was the most common neurological motor level (40%) and C5 the most common vertebral injury level. In all, 36/65 (55%) patients underwent surgical treatment. Mean hospitalization time was 5 months. No neurological deterioration was recorded. In all, 20/65 (31%) patients improved neurologically and 16/20 (80%) of those had received surgical treatment. In all, 15/65 (23%) patients had complications and one patient died during the hospitalization period.

CONCLUSIONS AND DISCUSSION

Patients whose vertebral lesions were surgically treated had a better neurological outcome than conservatively treated ones. Teardrop fractures showed worse neurological outcome as compared with burst fractures. Neurological improvement was more present in initially incomplete lesions. Treatment with high dose methylprednisolone during the first 8 h after trauma seemed to influence the neurological outcome positively. Age was also an important factor in influencing the neurological outcome.

A demographic profile of new traumatic spinal cord injuries: Change and stability over 30 years

OBJECTIVE

To evaluate epidemiologic trends in new spinal cord injuries (SCIs) in the United States over 3 decades.

DESIGN

Consecutive case series.

SETTING

Model Spinal Cord Injury Systems (MSCIS) facilities.

PARTICIPANTS

Persons (N=30,532) admitted to MSCIS facilities within 365 days of injury between 1973 and 2003, and enrolled in the National Spinal Cord Injury Database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Data were collected at MSCIS admission and rehabilitation discharge. Variables included age, gender, race and ethnic group, year of injury, and level and extent of injury. Specific etiologies were grouped as motor vehicle collisions (MVCs), violence, falls, sports, and other. Demographic and injury severity trends were analyzed by year of injury groupings according to decades (1973-1979, 1980-1989, 1990-1999, 2000-2003.) Chi-square tests assessed statistical significance. One-way analysis of variance compared mean ages.

RESULTS

The male/female ratio remained fairly stable at 4:1, but the percentage of women increased slightly over time, especially from MVC etiologies ( P <.001). Over time, the mean age at injury increased significantly ( P <.001); it was 37.7+/-17.5 years in 2000-2003. The majority of cases were white (66.1%). Tetraplegia (54.1%) and complete injuries (55.6%) occurred more than paraplegia and incomplete injuries, respectively. MVCs (45.6%) remained the most common etiology; falls (19.6%) held the second position over violence (17.8%), except for the 1990-1999 period when the positions were reversed. Significantly increasing percentages of new injuries were seen for SCI due to automobile, motorcycle, bicycle, and all-terrain vehicle crashes, blunt object attacks, snow skiing, and medical and surgical mishaps.

CONCLUSIONS

Many previously seen SCI demographic trends continued into the 2000 decade.

Epidemiology of non-submersion injuries in aquatic sporting and recreational activities

Although the issues of drowning and near-drowning in aquatic sporting and recreational activities receive considerable attention in the epidemiological literature, there is not a recognised literature on non-submersion injuries occurring in these activities. This review draws together the epidemiological literature on non-submersion injuries and describes the incidence, nature and causes of these injuries, common risk factors, and strategies for prevention. Activities covered by the review include swimming, diving, boating, surf sports, fishing, water polo and water sliding. For most activities there is a dearth of good quality descriptive studies, with most involving cases-series designs and few providing estimates of incidence. Inconsistencies in inclusion criteria and the reporting of incidence rates makes comparisons within and between activities difficult. Incidence rates were identified for most activities and in general the incidence of injury was low, especially for more serious injury. However, some activities were associated with severely disabling injury, such as spinal cord injury (diving) and amputation (from propeller strikes in water skiing and swimming). Only three studies reporting the significance of postulated risk factors were identified. Lack of knowledge about the water being entered and alcohol consumption are significant risk factors in recreational diving; increased blood alcohol concentrations were reported to increase the risk of death in boating; and obesity and tandem riding were reported to increase the risk of injury on public water slides. Few evaluations of preventive measures were identified. Two studies reported reductions in the incidence of water slide injuries following the introduction of design changes and supervision, but neither had a non-intervention comparison group. Improvements in swimming and diving skills were reported in three studies, but these were not designed to measure changes in the risk of injury.This review demonstrates that there is a need for well-designed epidemiological research on non-submersion injury in aquatic sporting and recreational activities. The first priority should be for studies designed to describe accurately the incidence, nature, severity and circumstances of these injuries, followed by research on the significance of postulated risk factors. Once this research has been undertaken, interventions targeted at reducing the incidence of injury in aquatic sporting and recreational activities can be designed and evaluated.

Incidence and patterns of spinal cord injury in Australia

The objective of this paper is to report on the epidemiology of spinal cord injury (SCI) based on the Australian SCI register and to discuss the implications for prevention. All adult cases of SCI are reported to the registry. The case reports for 1998/1999 were aggregated and described. The age adjusted rate of persisting SCI was 14.5 per million of population. Rates were highest in young adults and in males. The vast majority of cases (93%) were due to unintentional injury. Forty-three percent were due to motor vehicle crashes, principally from motor vehicle rollover. Cases of SCI from falls, aquatic activities, and working for income are also described. Incomplete cervical cord injuries were most common (38%), particularly as a result of motor vehicle crashes and low falls. The study indicates that the surveillance of SCI needs to be improved internationally so that comparative studies can be undertaken. It is recommended that the Centers for Disease Control case definition be adopted. Australia is one of the few countries that have a register based on that case definition, and the only one that has a register covering a full national adult population. The results presented on the basis of this data source provide some hitherto unavailable information on the incidence rates and patterns of SCI. National population based surveillance is fundamental to an understanding of the epidemiology, and hence the prevention, of this severe and costly health and welfare problem.

Risk reduction in diving spinal cord injury: teaching safe diving skills

Thirty-four recreational swimmers underwent an intervention program to improve diving skills. Participants with low diving skills completed seven 10-minute sessions which emphasised locking thumbs and holding arms extended beyond the head, and steering and gliding skills. Various dive entries were video-recorded and maximum depth reached was used as the criterion measure. A one-way repeated measures analysis of variance was conducted for each dive condition. Maximum depth decreased for all dives. Velocity at maximum depth was greater for the Treadwater, Deck and Block conditions. Improved streamlining and increased 'spring' were evident in more confident participants. Hands separated in 71% of pre-intervention dives but only in 3% of post-intervention dives. Preintervention, arms were pulled backward before. or at, maximum depth in 30% of participants but none did this post-intervention. Diving skills were improved following participation in the intervention program.

Alcohol usage in sport and exercise

In this review we consider some of the acute and chronic effects of alcohol on human exercise and sport performance. The 1982 position stand of the American College of Sport Medicine on the use of alcohol in sport emphasized that there was little benefit for an athlete. Subsequent literature continues to demonstrate that there are adverse effects on performance. However, the literature is often confusing and disparate. We will attempt to explain the effects and speculate on the possible mechanisms. We divide the review into acute and chronic metabolic and physiological effects of alcohol on exercise performance, primarily in humans. We also review the epidemiological evidence of the associations between alcohol use and problem alcohol behaviors in various athletic groups. Finally, we review the limited data on the effectiveness of exercise therapy in the treatment of alcohol dependent patients. In spite of scientific evidence that alcohol use is, in general, detrimental (or of no benefit) to sport (exercise) performance, alcohol continues to be used by athletes both on a chronic basis and even immediately prior to sports participation. There is some encouraging but limited evidence that student-athlete alcohol use is decreasing and exercise can be effective as part of alcohol rehabilitation.

Sports-related spinal cord injuries

Although a relatively small number of all injuries sustained while participating in sports occur to the spinal cord, the impact that these injuries make on the U.S. health care system is enormous. Critical care nurses, who work in the field of trauma, should be aware of the epidemiology and etiology of these injuries while providing therapeutic interventions. Additionally, an understanding of the classification of these injuries will be beneficial when providing education to the patient and family.

Substance abuse, violence, and outcome after traumatic spinal cord injury

Alcohol and drug use have been shown to contribute to the onset of traumatic spinal cord injury and to be a marker for later onset substance abuse issues. Admission toxicology (drug and alcohol) screens were collected from 87 consecutive rehabilitation medicine patients with a diagnosis of acute traumatic spinal cord injury. Forty-six patients (53%) presented with positive screens (44% alcohol only, 30% drug only, 26% both). Seventy-five percent of those with positive alcohol screens met state criteria for alcohol intoxication (blood alcohol level, > or =0.08 mg/dl). Compared with individuals with negative screens, those with positive screens were significantly (P < 0.05) younger and unmarried. Compared with nonviolence-related spinal cord injury, patients with violence-related spinal cord injury (gunshot wound and assault) were significantly (P < 0.01) more likely to have positive admission toxicology screens (76% v 41%), drug screens (62% v 14%), and intoxication screens (72% v 34%). Rehabilitation outcome comparisons between those with positive and negative screens revealed similar length of stay, admission and discharge Functional Independence Measure (FIM) scores, FIM change scores, and FIM efficiency scores. This study has important implications with regard to substance abuse issues and their impact on traumatic spinal cord injury outcome, which may assist in better targeting prevention.