Stakeholder-Engaged Development of a Theory-Driven, Feasible, and Acceptable Approach to Concussion Education

Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

Injury prevention strategies at the 2019 FIFA Women's World Cup display a multifactorial approach and highlight subjective wellness measurements

OBJECTIVE

To report the injury prevention programs utilised by top-level female footballers competing internationally.

METHODS

An online survey was administered to physicians of the 24 competing national teams at the 2019 Federation Internationale de Football Association (FIFA) Women's World Cup. The survey included 4 sections regarding perceptions and practices concerning non-contact injuries: (1) risk factors, (2) screening tests and monitoring tools, (3) preventative strategies, and (4) reflection on their World Cup experience.

RESULTS

Following responses from 54% of teams, the most common injuries encountered included muscle strains, ankle sprains, and anterior cruciate ligament ruptures. The study also revealed the most important injury risk factors during the FIFA 2019 World Cup. Intrinsic risk factors include accumulated fatigue, previous injury, and strength endurance. Extrinsic risk factors include reduced recovery time between matches, congested match schedule, and the number of club team matches played. The 5 most used tests for risk factors were flexibility, joint mobility, fitness, balance, and strength. Monitoring tools commonly used were subjective wellness, heart rate, minutes/matches played, and daily medical screening. Specific strategies to limit the risk of an anterior cruciate ligament injury included the FIFA 11+ program and proprioception training.

CONCLUSION

The present study revealed multifactorial approaches to injury prevention strategies for women's national football teams at the FIFA 2019 World Cup. Challenges to injury prevention program implementation reflect time limitations, schedule uncertainties, and varying club team recommendations.

LEVEL OF EVIDENCE

IV.

Does Running Increase the Risk of Hip and Knee Arthritis? A Survey of 3804 Marathon Runners

BACKGROUND

Long-distance running is a popular form of cardiovascular exercise with many well-described health benefits, from improving heart health to the management of obesity, diabetes, and mental illness. The impact of long-distance running on joint health in recreational runners, however, remains inconclusive.

HYPOTHESIS

The prevalence of osteoarthritis in runners is not associated with an athlete's running-related history, including the number of marathons completed, cumulative years of running, average weekly mileage, and average running pace.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A survey was distributed to all participants registered for the 2019 or 2021 Chicago marathon (n = 37,917). Surveys collected runner demographics and assessed for hip/knee pain, osteoarthritis, family history, surgical history, and running-related history. Running history included the number of marathons run, number of years running, average running pace, and average weekly mileage. The overall prevalence of osteoarthritis was identified, and a multivariable logistic regression model was used to identify variables associated with the presence of hip and/or knee osteoarthritis.

RESULTS

Surveys were completed by 3804 participants (response rate of 10.0%). The mean age was 43.9 years (range, 18-83 years) and participants had completed on average 9.5 marathons (median, 5 marathons; range, 1-664 marathons). The prevalence of hip and/or knee arthritis was 7.3%. A history of hip/knee injuries or surgery, advancing age, family history, and body mass index (BMI) were risk factors for arthritis. Cumulative number of years running, number of marathons completed, weekly mileage, and mean running pace were not significant predictors for arthritis. The majority (94.2%) of runners planned to run another marathon, despite 24.2% of all participants being told by a physician to do otherwise.

CONCLUSION

From this largest surveyed group of marathon runners, the most significant risk factors for developing hip or knee arthritis were age, BMI, previous injury or surgery, and family history. There was no identified association between cumulative running history and the risk for arthritis.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial

OBJECTIVES

Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.

METHODS

A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season.

RESULTS

Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35).

CONCLUSIONS AND RELEVANCE

Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting.

TRIAL REGISTRATION NUMBER

NCT04099329.

Review of Injury Patterns of the 2018 Bank of America Chicago Marathon to Optimize Medical Planning

ABSTRACT

Medical planning for a marathon requires an understanding of the volumes and types of injuries experienced by runners during a race. This chart review of medical records from the 2018 Bank of America Chicago Marathon (N = 1016) measured volume and types of injuries at the race aid stations to determine the impact that race distance has on medical resource utilization. The type and volume of each injured runner diagnosis was compared between quartiles of the race using a chisquare analysis. The most common presenting complaints were musculoskeletal (MSK), followed by medical/other, and then wound care. The proportion of MSK complaints increased over the course of the race, whereas the percentage of medical and wound care complaints was highest at the finish line tents. Understanding the expected volume and type of injuries along the course of a race optimizes medical planning and leads to better utilization of resources and staff.

Resumption of Sport at the United States Olympic and Paralympic Training Facilities During the COVID-19 Pandemic

In this brief report, we describe the safety of reopening US Olympic and Paralympic Training facilities (USOPTFs) during the coronavirus disease 2019 (COVID-19) pandemic from July 2020 through October 2020. We evaluated the prevalence of COVID-19 infection at the time of reentry and cardiopulmonary sequelae of COVID-19 in elite athletes. All athletes returning to a USOPTF were required to go through a reentry protocol consisting of an electronic health history, a 6-day quarantine including twice-daily symptom surveys, COVID-19 polymerase chain reaction and antibody testing, physical examination, 12-lead electrocardiogram, high-sensitivity cardiac troponin I, and pulmonary function testing. Athletes with current or prior COVID-19 infection also underwent an echocardiogram, cardiology consultation, and additional testing as indicated. All athletes followed rigorous infection prevention measures and minimized contact with the outside community following reentry. At the time of this report, 301 athletes completed the reentry protocol among which 14 (4.7%) tested positive for active (positive polymerase chain reaction test, n = 3) or prior (positive antibody test, n = 11) COVID-19 infection. During the study period, this cohort accrued 14,916 days living and training at USOPTFs. Only one (0.3%) athlete was subsequently diagnosed with a new COVID-19 infection. No cardiopulmonary pathology attributable to COVID-19 was detected. Our findings suggest that residential elite athlete training facilities can successfully resume activity during the COVID-19 pandemic when strict reentry and infection prevention measures are followed. Dissemination of our reentry quarantine and screening protocols with COVID-19 mitigation measures may assist the global sports and medical community develop best practices for reopening of similar training centers.

Cardiac Structure and Function in Elite Female and Male Soccer Players

Importance

Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players.

Objective

To describe ECG and echocardiographic findings in healthy elite US soccer players.

Design, Setting, and Participants

This cross-sectional study analyzed Fédération Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included.

Main Outcomes and Measures

Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges.

Results

A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes.

Conclusions and Relevance

These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.

Medical Tent Usage From Bank of America Chicago Marathon 2015-2017

BACKGROUND

As mass participation events continue to increase in popularity, the need for medical care continues to increase. Our objective was to evaluate the course medical tent usage throughout the Bank of America Chicago Marathon course. Our second objective was to evaluate emergency medical services (EMS) utilization during the event.

HYPOTHESIS

We hypothesize that as the race progresses, medical tents will see more participants and EMS will have an increase in utilization.

LEVEL OF EVIDENCE

Level 4.

METHODS

This study was a retrospective analysis of data collected by the medical staff from 2015 to 2017. Documented patient encounters were analyzed from each course medical tent. Twenty medical tents were spaced roughly 1.2 miles apart depending on location and ease of EMS access to the medical tent location.

RESULTS

From 2015 to 2017, the course medical tents saw 2973 patients, with a 96.3% discharge rate. The data showed a linear increase of 5.69 patients seen per mile until mile 20 (linear regression P < 0.01). After mile 20, the number of patients seen per mile was about the same. The data also showed an increase in EMS utilization every 5 miles as the race progressed (P = 0.04) and an increase in ratio of patients transported to the hospital compared with patients transferred to the main medical tents up to mile 20 (P = 0.02).

CONCLUSION

Course medical tents saw a statistically significant linear increase in patients per mile until mile 20. Total EMS utilization showed a statistically significant increase in usage as the race progressed and a statistically significant increase in ratio of transports to transfers as the race progressed until mile 20.

CLINICAL RELEVANCE

This study has the potential to influence medical tent and EMS placement for endurance events with increasing patient encounters and hospital transports as the mileage of the endurance event increases.

Practical Hydration Solutions for Sports

Personalized hydration strategies play a key role in optimizing the performance and safety of athletes during sporting activities. Clinicians should be aware of the many physiological, behavioral, logistical and psychological issues that determine both the athlete’s fluid needs during sport and his/her opportunity to address them; these are often specific to the environment, the event and the individual athlete. In this paper we address the major considerations for assessing hydration status in athletes and practical solutions to overcome obstacles of a given sport. Based on these solutions, practitioners can better advise athletes to develop practices that optimize hydration for their sports.

Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York

There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women’s Soccer League jointly hosted a conference entitled, ‘Head Injury in Soccer: From Science to the Field’, on 21–22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.

Epidemiological Findings of Soccer Injuries During the 2017 Gold Cup

Background:

Surveillance programs are vital to analyze the cause and nature of lesions and ultimately establish protocols of action to lower injury rates.

Purpose:

To evaluate the adherence of team doctors to an electronic surveillance system and determine the incidence and characteristics of injuries among soccer players participating in the 2017 Gold Cup.

Study Design:

Descriptive epidemiological study.

Methods:

All data were collected from the electronic medical reports submitted during each match of the 2017 Gold Cup. Twelve teams participated in the tournament (each with 23 players), for a total of 276 players. A 19-question online survey was filled out by the team physician after each injury. Each report contained the player’s number, the exact time of injury (minute of play), the location and diagnosis of injury as indicated by a previously defined code, and its severity in terms of the number of days of absence from training and match play.

Results:

The electronic reporting system had a response rate of 100.0%, with 97.2% of questions answered completely. The mean age of injured players was 27 years (range, 21-35 years) and was not statistically significantly different from the overall mean player age (P > .05). There were no significant differences in the frequency of injuries when analyzed by player position (P = .743). The overall rate of injuries was 1.04 per match, with the most common injuries being contusions (42.3%), sprains (7.7%), strains (7.7%), and fractures (7.7%). These injuries were more commonly the result of contact (75.0%) than noncontact (25.0%) mechanisms (P < .001). Injuries most commonly occurred between the 60th and 75th minute of play when comparing all 15-minute time intervals (P = .004).

Conclusion:

This study supports the use of electronic injury reporting, which demonstrated a high level of adherence among an international cohort of team physicians and has significant potential for improving injury surveillance and tracking responses to prevention programs. Injury rates in the Gold Cup were similar to those in previous studies and demonstrated the highest rates late in the second half of the game, specifically between the 60th and 75th minute of play.

Assessment of knowledge and attitudes regarding automated external defibrillators and cardiopulmonary resuscitation among American University students

AIM

We sought to quantify knowledge and attitudes regarding automated external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR) among university students. We also aimed to determine awareness of the location of an actual AED on campus.

METHODS

We performed an online survey of undergraduate and graduate students at a mid-sized, private university that has 37 AEDs located throughout its two campuses.

RESULTS

267 students responded to the survey. Almost all respondents could identify CPR (98.5%) and an AED (88.4%) from images, but only 46.1% and 18.4%, respectively, could indicate the basic mechanism of CPR and AEDs. About a quarter (28.1%) of respondents were comfortable using an AED without assistance, compared with 65.5% when offered assistance. Of those who did not feel comfortable, 87.7% indicated that they were 'afraid of doing something wrong.' One out of 6 (17.6%) respondents knew that a student centre had an AED, and only 2% could recall its precise location within the building. Most (66.3%) respondents indicated they would look for an AED near fire extinguishers, followed by the entrance of a building (19.6%).

CONCLUSIONS

This study found that most students at an American university can identify CPR and AEDs, but do not understand their basic mechanisms of action or are willing to perform CPR or use AEDs unassisted. Recent CPR/AED training and 9-1-1 assistance increases comfort. The most common fear reported was incorrect CPR or AED use. Almost all students could not recall where an AED was located in a student centre.

Lack of awareness of fluid needs among participants at a midwest marathon

BACKGROUND

Marathon running has become popular, particularly among inexperienced runners.

HYPOTHESIS

Many marathoners are inexperienced and lack concern for potential complications of marathon running.

STUDY DESIGN

Cross-sectional survey.

METHODS

In sum, 419 runners completed a survey on a variety of topics regarding training for a marathon and hydration strategies.

RESULTS

Overall, 211 females (38.3 ± 9.1 years old) and 208 males (41.6 ± 11.0 years old) participated. They trained for 6.8 ± 4.3 months and had run for 9.8 ± 9.1 years; 33.5% had no marathon experience and 16.9% had run 1 marathon. Of the injuries reported, 77.6% and 72.9% were minor musculoskeletal injuries during the current and previous running seasons, respectively. Of the 278 runners who had run a marathon, 54 (19.0%) had been treated in the medical tent, 31.5% of whom for dehydration. Furthermore, 54.9% and 64.3% of the survey participants were "not at all" concerned with musculoskeletal injury and hyponatremia, respectively. Also, 88.7% did not know their sweat rate; 67.8% did not weigh themselves; and 81.3% had no other method of hydration assessment. No significant correlations were found between concern for hyponatremia and age, sex, or experience.

CONCLUSIONS

Most participants were inexperienced, lacked concern for injury or hyponatremia, and were not using methods of hydration assessment.

Cardiac arrest during long-distance running races

BACKGROUND

Approximately 2 million people participate in long-distance running races in the United States annually. Reports of race-related cardiac arrests have generated concern about the safety of this activity.

METHODS

We assessed the incidence and outcomes of cardiac arrest associated with marathon and half-marathon races in the United States from January 1, 2000, to May 31, 2010. We determined the clinical characteristics of the arrests by interviewing survivors and the next of kin of nonsurvivors, reviewing medical records, and analyzing postmortem data.

RESULTS

Of 10.9 million runners, 59 (mean [±SD] age, 42-13 years; 51 men) had cardiac arrest (incidence rate, 0.54 per 100,000 participants; 95% confidence interval [CI], 0.41 to 0.70). Cardiovascular disease accounted for the majority of cardiac arrests. The incidence rate was significantly higher during marathons (1.01 per 100,000; 95% CI, 0.72 to 1.38) than during half-marathons (0.27; 95% CI, 0.17 to 0.43) and among men (0.90 per 100,000; 95% CI, 0.67 to 1.18) than among women (0.16; 95% CI, 0.07 to 0.31). Male marathon runners, the highest-risk group, had an increased incidence of cardiac arrest during the latter half of the study decade (2000-2004, 0.71 per 100,000 [95% CI, 0.31 to 1.40]; 2005-2010, 2.03 per 100,000 [95% CI, 1.33 to 2.98]; P=0.01). Of the 59 cases of cardiac arrest, 42 (71%) were fatal (incidence, 0.39 per 100,000; 95% CI, 0.28 to 0.52). Among the 31 cases with complete clinical data, initiation of bystander-administered cardiopulmonary resuscitation and an underlying diagnosis other than hypertrophic cardiomyopathy were the strongest predictors of survival.

CONCLUSIONS

Marathons and half-marathons are associated with a low overall risk of cardiac arrest and sudden death. Cardiac arrest, most commonly attributable to hypertrophic cardiomyopathy or atherosclerotic coronary disease, occurs primarily among male marathon participants; the incidence rate in this group increased during the past decade.

Emergent evaluation of injuries to the shoulder, clavicle, and humerus

This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulder's physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.

Ultrasound-guided three-in-one nerve block for femur fractures

Femur fractures typically affect elderly patients with multiple co-morbidities. Pain control can be difficult, requiring intensive nursing and physician care as elderly patients may manifest cardiovascular and respiratory complications from opiate administration. Ultrasound (US)-guided three-in-one (3-in-1) femoral nerve block (FNB) is an option for pain management in patients with femur fractures, as it provides regional anesthesia to the femoral, obturator and lateral cutaneous nerves. Our goal is to provide medical education regarding the use of US-guided 3-in-1FNB as a rapid and easy procedure that may provide optimal patient care in patients with femur fractures.

Preparing for the surge: perspectives on marathon medical preparedness

In preparing for medical coverage of a mass participation event such as a marathon, race directors and their medical staff members need to account for the unexpected. Extremes in weather as well as the potential for outside threats need to be given consideration before race day in order to adequately prepare. Through the recruitment of local expertise from various agencies in one's community during both the planning stages, and on race day, the added stressors of such extremes will be minimized, if not eliminated. This article will provide concrete examples of how the Chicago Marathon has used its own experiences with such extremes. Readers will be given useful tools to implement in their own marathons or other mass participation events-planning to equip them better for the unexpected surge.