Analysis of a Division I Sports Medicine Program's COVID-19 Protocol: Identifying Factors that Predict Testing Demands and Positive Rates During a Pandemic

OBJECTIVE

To determine factors indicating testing frequency and positive test results in a Division I sports department intrapandemic.

DESIGN

Retrospective analysis.

SETTING

A single Division I collegiate sports department.

PATIENTS

All student-athlete (n = 437), student staff (n = 89), and adult staff (n = 202) members of the sports department. Total cohort (n = 728).

INTERVENTIONS

The authors analyzed the independent variables of local positive rates, sport characteristics, and campus events for impact on the volume of the departmental testing and positive rates.

MAIN OUTCOME MEASURES

Measured dependent variables of the volume of departmental testing and positive rates were analyzed.

RESULTS

Positive predictive rates (PPRs) largely differed from local, off-campus rates in timing and duration (59.52%: P < 0.05). Overall, 20633 tests were administered with 201 positive results (0.97% PPR). Student-athlete numbers were highest in all categories, followed by adult then student staff. Greater proportions of contact sports became positive (53.03%: P < 0.001) and all-male sports (47.69%: P < 0.001). No comparative difference was seen for teams using fomites (19.15%: P = 0.403). Spring sports teams had the lowest percentage of the team positive (22.22%: P < 0.001). Winter sports had the highest PPR (1.15%), all occurring during team-controlled activities. Playing sports indoors did not increase inside team-controlled activity positive rates ( P = 0.066).

CONCLUSIONS

Longitudinal changes in local, off-campus infection rates partially affected sports departmental positive results while testing rates were more influenced by sport and university schedule. Testing resources should be directed toward high-risk sports, which included contact sports (football, basketball, and soccer), all-male teams, both Winter and indoor sports inside team-controlled activities, and sports with long periods of time outside team-controlled activities.

Name, Image, and Likeness and the Health of the Young Athlete: A Call to Action for Sports Medicine Providers and the Athletic Healthcare Network

CONTEXT

In June 2021, the National Collegiate Athletic Association (NCAA) adopted a new policy allowing NCAA athletes the opportunity to benefit and profit from their name, image, and likeness (NIL). Several state high-school associations have established policies to guide their members and students through the new era of NIL. While the potential benefits cannot be ignored, NIL presents novel responsibilities and stressors to athletes. This paper will review the paucity of literature on the effect of NIL on youth athletes and bring attention to mental health, well-being, or academic performance impacted by NIL.

EVIDENCE ACQUISITION

Articles were identified through Google and PubMed search starting from NIL policy approval (June 30, 2021). Search terms included "name, image and likeness" and "NIL."

STUDY DESIGN

Clinical commentary.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Although 1 article was identified through PubMed search and numerous articles were identified through Google search, no articles directly evaluated the effects of NIL on the mental health, well-being, or academic performance of youth athletes.

CONCLUSION

It is critical for sports medicine providers and other members of the athletic healthcare network to familiarize themselves with these emerging topics to best serve their patients and communities. The athletic healthcare network must be prepared to address possible NIL-related health ramifications for our patients and their families and help them navigate a confusing and predatory landscape. We must provide resources to youth athletes to minimize the risks associated with NIL involvement and related activities, and to ensure that athletes with NIL contracts are able to balance their academic and athletic responsibilities. Fostering strong relationships between stakeholders and sports medicine staff is paramount to creating an environment that permits honest discussions about NIL and the health of athletes from youth to adulthood.

STRENGTH-OF-RECOMMENDATION TAXONOMY

N/A.

Assessments Used by Athletic Trainers to Decide Return-to-Activity Readiness in Patients With an Ankle Sprain

CONTEXT

Athletic trainers (ATs) often care for patients with ankle sprains. Expert consensus has been established for rehabilitation-oriented assessments (ROASTs) that should be included in ankle-sprain evaluations. However, the methods ATs use to determine return-to-activity readiness after an ankle sprain are unknown.

OBJECTIVES

To identify ATs' methods for determining patients' return-to-activity readiness after an ankle sprain and demographic characteristics of the ATs and their methods.

SETTING

Online survey.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

We recruited 10 000 clinically practicing ATs. A total of 676 accessed the survey, 574 submitted responses (85% completion rate), and 541 respondents met the inclusion criteria.

MAIN OUTCOME MEASURE(S)

We distributed an online survey to ATs that asked about their assessment of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes in deciding return to activity. Descriptive statistics were used to characterize participant demographics and frequencies of the assessment measures used by ATs. Chi-square analysis was conducted to identify relationships between the demographics and assessment selection.

RESULTS

Pain, swelling, range of motion, strength, balance, gait, and functional capacity were assessed by 76.2% to 96.7% of ATs. Arthrokinematics, physical activity level, and patient-reported outcomes were assessed by 25.3% to 35.1% of participants. When selecting specific assessment methods, ATs often did not use recommended ROASTs. Athletic trainers with higher degrees, completion of more advanced educational programs, employment in nontraditional settings, more clinical experience, and familiarity with expert consensus recommendations were more likely to use ROASTs.

CONCLUSIONS

Before approving return to activity for patients with ankle sprains, ATs did not use some recommended outcomes and assessment methods. Practice in nontraditional settings, more advanced degrees, more clinical experience, and familiarity with expert consensus guidelines appeared to facilitate the use of ROASTs.

How can outdoor sports protect themselves against climate change-related health risks? - A prevention model based on an expert Delphi study

OBJECTIVES

To systematically develop an adaptation model to reduce climate change-related health risks for outdoor athletes.

DESIGN

Delphi Method study.

METHODS

A classic asynchronous Delphi study was conducted with a total of three survey rounds. 24 experts from the eight largest outdoor sport associations by membership in the German Olympic Sports Confederation were included as well as 24 medical experts with expertise in sport medicine, internal medicine, allergology, dermatology, infectiology, or toxicology. Based on open-ended questions, panelists were asked to consider prevention measures for sport organizations and clubs. Free text responses were analyzed by qualitative content analysis according to Mayring.

RESULTS

Experts recommended establishing the following eight fields of prevention measures: technical and structural measures; organizational measures; personalized measures; basic, advanced, and continuing education; concepts of action, warning concepts, and financial concepts; cooperation and coordination; campaigns; and evaluation measures.

CONCLUSIONS

The pyramid model presented in this study systematizes possible sport-specific adaptation measures on climate change by empirical aggregation of knowledge from scientists, sport organizations, clubs, trainers, and professional athletes. To assess the effectiveness of these prevention measures, sport organizations may incorporate them not only into broader operations but also everyday training routines.

Acupuncture in Sports Medicine

Acupuncture is gaining popularity and wider acceptance as a treatment modality within the field of sports medicine. Our objective was to provide a comprehensive review of the existing literature pertaining to acupuncture in sports medicine to shed light on approaches utilized in acupuncture while revealing its personalized nature and its impact on athletes' preparation, performance, and recovery. We evaluated acupuncture research in the context of medicine and sports-related injury treatment, assessing its impact on athletic performance across demographics of athletes. Athletes participating in most sports have shown positive outcomes from acupuncture interventions. Acupuncture improves peak oxygen levels, maximum heart rate, delayed-onset muscle soreness, pain, swelling, explosive force production, and joint mobility. Furthermore, the efficacy of acupuncture appears to be similar regardless of age and sex. Lastly, the acceptance of acupuncture is influenced by cultural factors, with Western and traditional East Asian cultures exhibiting distinct perspectives on its rationale and mechanisms of action. Traditional East Asian acupuncturists typically employ qi and meridian theories in their acupuncture practices, with the recent incorporation of Western concepts. Acupuncture shows promise as an effective treatment for musculoskeletal pain and neuropathies in athletes across different age groups and for addressing injuries in various sports. Our comprehensive review will enhance our understanding of acupuncture's potential as a complementary or distinct therapeutic approach compared to conventional therapies. Additionally, our review explores its specific applications within different sports and delves into the cultural dimensions involved in integrating this practice into modern sports medicine.

Are we levelling the playing field? A qualitative case study of the awareness, uptake and relevance of the IOC consensus statements in two countries

OBJECTIVES

Research evidence is commonly compiled into expert-informed consensus guidelines intended to consolidate and distribute sports medicine knowledge. Between 2003 and 2018, 27 International Olympic Committee (IOC) consensus statements were produced. This study explored the policy and practice impact of the IOC Statements on athlete health and medical team management in two economically and contextually diverse countries.

METHODS

A qualitative case study design was adopted. Fourteen face-to-face interviews were conducted with purposively selected interviewees, seven participants from Australia (higher economic equality) and seven from South Africa (lower economic equality), representing their national medical commissions (doctors and physiotherapists of Olympic, Paralympic and Youth teams). A framework method was used to analyse interview transcripts and identify key themes.

RESULTS

Differences across resource settings were found, particularly in the perceived usefulness of the IOC Statements and their accessibility. Both settings were unsure about the purpose of the IOC Statements and their intended audience. However, both valued the existence of evidence-informed guidelines. In the Australian setting, there was less reliance on the resources developed by the IOC, preferring to use locally contextualised documents that are readily available.

CONCLUSION

The IOC Statements are valuable evidence-informed resources that support translation of knowledge into clinical sports medicine practice. However, to be fully effective, they must be perceived as useful and relevant and should reach their target audiences with ready access. This study showed different contexts require different resources, levels of support and dissemination approaches. Future development and dissemination of IOC Statements should consider the perspectives and the diversity of contexts they are intended for.

Challenges and Opportunities for the Use of Patient-Reported Outcome Measures in Orthopaedic Pediatric and Sports Medicine Surgery

Patient-reported outcome measures (PROMs) are essential tools in assessing treatment response, informing clinical decision making, driving healthcare policy, and providing important prognostic data regarding patient health status change. These tools become essential in orthopaedic disciplines, such as pediatrics and sports medicine, given the diversity of patient populations and procedures. However, the creation and routine administration of standard PROMs alone do not suffice to appropriately facilitate the aforementioned functions. Indeed, both the interpretation and optimal application of PROMs are essential to provide to achieve greatest clinical benefit. Contemporary developments and technologies surrounding PROMs may help augment this benefit, including the application of artificial intelligence, novel PROM structure with improved interpretability and validity, and PROM delivery methods that provide increased access to patients resulting in greater compliance and data acquisition yields. Despite these exciting innovations, several challenges remain in this realm that must be addressed to continue to advance the clinical usefulness and subsequent benefit of PROMs. This review will highlight the opportunities and challenges surrounding contemporary PROM use in the orthopaedic subspecialties of pediatrics and sports medicine.

The Trade Secret Taboo: Open Science Methods are Required to Improve Prediction Models in Sports Medicine and Performance

Clinical prediction models in sports medicine that utilize regression or machine learning techniques have become more widely published, used, and disseminated. However, these models are typically characterized by poor methodology and incomplete reporting, and an inadequate evaluation of performance, leading to unreliable predictions and weak clinical utility within their intended sport population. Before implementation in practice, models require a thorough evaluation. Strong replicable methods and transparency reporting allow practitioners and researchers to make independent judgments as to the model's validity, performance, clinical usefulness, and confidence it will do no harm. However, this is not reflected in the sports medicine literature. As shown in a recent systematic review of models for predicting sports injury models, most were typically characterized by poor methodology, incomplete reporting, and inadequate performance evaluation. Because of constraints imposed by data from individual teams, the development of accurate, reliable, and useful models is highly reliant on external validation. However, a barrier to collaboration is a desire to maintain a competitive advantage; a team's proprietary information is often perceived as high value, and so these 'trade secrets' are frequently guarded. These 'trade secrets' also apply to commercially available models, as developers are unwilling to share proprietary (and potentially profitable) development and validation information. In this Current Opinion, we: (1) argue that open science is essential for improving sport prediction models and (2) critically examine sport prediction models for open science practices.

Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies.

"Knowing the Noise That Surrounds the Athlete": A Qualitative Study Exploring the Health-Seeking Behaviors of Athletes With Limb Deficiency Drawing on the Experiences and Perceptions of the Medical Staff and Athletes

OBJECTIVE

The aim of the study is to explore the health-seeking behaviors of athletes with limb deficiency, drawing on the experiences and perception of the sports medicine team and athletes.

DESIGN

The study used an interpretive hermeneutic phenomenological methodology with a subtle realist paradigmatic view to investigate commonality in unique experiences within reality. Data collection was completed with two focus groups in December 2019 and March 2020. Thirteen participants took part including athletes and sports medicine team members (physiotherapists, doctors, and strength and conditioning coaches) working in parasports. Focus group manuscripts were transcribed verbatim from audio recordings. An inductive, iterative process was used to identify themes and subthemes, with processes in place to establish rigor.

RESULTS

Two themes and five subthemes emerged in relation to the "internalization and adjustment to social identity" and "the importance and impact of factors, which impact the athlete social identity."

CONCLUSIONS

Health-seeking behaviors of athletes with limb deficiency were influenced by a unique blend of personal and environmental factors that contribute toward social identity. The sports medicine team require specific awareness of factors that may diminish health-seeking behaviors to deliver a personalized approach and negate consequences.

Assessing Performing Artists in Medical and Health Practice - The Dancers, Instrumentalists, Vocalists, and Actors Screening Protocol

ABSTRACT

Training in the performing arts exposes individuals to often extreme physical and psychological demands, which are linked to high occupational injury rates. The intense demands of performing artists have been likened to those of sport athletes. However, distinct differences in these demands necessitate specialized approaches to the health care of performing artists. Through the Athletes and the Arts collaboration, the American College of Sports Medicine and Performing Arts Medicine Association identified that the creation of a specialized preparticipation screening tool for performing artists would likely enhance health care for performing artists significantly. Based on a thorough review of established assessments and an extensive consultation process with domain experts, a consensus best-practice screening tool was developed: the Dancer, Instrumentalist, Vocalist, Actor (DIVA) Preparticipation Screening. This screening tool is modeled on the athletic preparticipation examination (PPE) in its structure and 30-min target duration. However, DIVA diverges considerably from the PPE in its content to address the specific risks and needs of performing artists. In particular, screening questions and physical examination procedures focus strongly on musculoskeletal injuries and mental health conditions, in response to the preponderance and interactions of these conditions appearing in performing artists. The DIVA tool presented is intended as a "living tool," which can be modified in the future to include new effective assessment techniques as appropriate. Training in the DIVA preparticipation physical examination is included as a core component of the essentials of performing arts medicine continuing education course described in detail in a companion manuscript in this issue.

'It's All Downhill from Here': A Scoping Review of Sports-Related Concussion (SRC) Protocols in Downhill Mountain Biking (DHI), with Recommendations for SRC Policy in Professional DMB

INTRODUCTION

Downhill mountain biking (DHI) is a form of cycling and does not currently have a specific sports-related concussion (SRC) assessment.

OBJECTIVE

To review the extent, range and nature of research investigating SRC in DMB, provide a summary of key literature findings relating to its identification and management, and then develop a SRC protocol specific to DMB.

DESIGN

Scoping review as per recognised methods.

SETTING

Literature-based. The following databases were searched: MEDLINE, EMBASE, Scopus and Web of Science, with no restrictions on date. Results were limited to the English language.

PARTICIPANTS

Six articles were included in the review from 64 identified articles. The article had to specifically include an analysis of adult downhill riders for inclusion.

OUTCOME MEASURES

Study type, study group (amateur/professional), concussion incidence, concussion assessment and recommendations.

MAIN RESULTS

Concussion incidence was identified as between 5-23%. No study outlined a trackside assessment of cyclists or a protocol for return to play where SRC was identified. Several authors identified that riders often continued to participate despite the presence of a concussion. No sport-specific SRC assessment was determined for DHI, and a SRC assessment was therefore developed.

CONCLUSIONS

This review illustrates the lack of studies and formal protocol in SRC assessment for DHI. In light of this, we propose a three-stage framework specific to the sport to best identify a concussion and act where appropriate while minimising disruption to competition. This framework involves assessing the cyclist on the 'sideline', a second assessment post-event in the medical room and a third assessment the following day. A SRC consensus meeting specific for DHI is suggested with an identified need for updated guidance from UCI, requiring possible rule changes for the sport.

Accuracy of the "International Criteria" for ECG screening in athletes in comparison with previous published criteria: rationale and design of a diagnostic meta-analysis

INTRODUCTION

The impact of the International Criteria for ECG interpretation in athletes has further improved the diagnostic accuracy of the 12-lead ECG use for preparticipation screening (PPS); moreover, these criteria have been evaluated in different populations of athletes and settings proving good results.

EVIDENCE ACQUISITION

We aimed to perform a comprehensive review of the use of the International Criteria for ECG interpretation in athletes, stemming from a systematic review to diagnostic meta-analysis, limiting our inclusion only to observational studies to determine the diagnostic accuracy of ECG for detecting cardiac anomalies related to sudden cardiac death in athletes.

EVIDENCE SYNTHESIS

This meta-analysis is expected to include several important studies related to PPS on different populations of athletes comparing different ECG criteria and detail important data on the diagnostic accuracy of ECG in PPS. Furthermore, we intend to highlight the advantage of using ECG in PPS.

CONCLUSIONS

The present diagnostic meta-analysis results will aid sports medicine physicians and cardiologist in adhering to the most accurate criteria for ECG evaluation in athletes and it may help to solve controversies aroused regarding the excess cost of ECG in PPS related to the amount of false positive cases.

Two Symptoms to Triage Acute Concussions: Using Decision Tree Modeling to Predict Prolonged Recovery After a Concussion

OBJECTIVE

The objective was to examine the 22 variables from the Sport Concussion Assessment Tool's 5th Edition Symptom Evaluation using a decision tree analysis to identify those most likely to predict prolonged recovery after a sport-related concussion.

DESIGN

A cross-sectional design was used in this study. A total of 273 patients (52% men; mean age, 21 ± 7.6 yrs) initially assessed by either an emergency medicine or sport medicine physician within 14 days of concussion (mean, 6 ± 4 days) were included. The 22 symptoms from the Sport Concussion Assessment Tool's 5th Edition were included in a decision tree analysis performed using RStudio and the R package rpart. The decision tree was generated using a complexity parameter of 0.045, post hoc pruning was conducted with rpart, and the package carat was used to assess the final decision tree's accuracy, sensitivity and specificity.

RESULTS

Of the 22 variables, only 2 contributed toward the predictive splits: Feeling like "in a fog" and Sadness. The confusion matrix yielded a statistically significant accuracy of 0.7636 (P [accuracy > no information rate] = 0.00009678), sensitivity of 0.6429, specificity of 0.8889, positive predictive value of 0.8571, and negative predictive value of 0.7059.

CONCLUSIONS

Decision tree analysis yielded a statistically significant decision tree model that can be used clinically to identify patients at initial presentation who are at a higher risk of having prolonged symptoms lasting 28 days or more postconcussion.

Contact and SARS-CoV-2 Infections Among College Football Athletes in the Southeastern Conference During the COVID-19 Pandemic

This cohort study of college football players in a single athletic conference examines the association of close contact events among players on opposing teams and subsequent positive SARS-CoV-2 tests.

Adaptations to Protect Sideline Providers as They Respond to Sudden Cardiac Arrest During Sars-CoV-2

ABSTRACT

The 2019 severe acute respiratory syndrome coronavirus 2 has dramatically changed the sports landscape, compelling sports medical providers to adapt to evolving scientific discoveries and adopt ever-changing guidelines that protect our athletes, ourselves, and our staff. To best serve our athletes, providers need to be proactive and anticipate potential complications in providing care for athletes as athletic events resume.

Implementation of an efficient SARS-CoV-2 specimen pooling strategy for high throughput diagnostic testing

The rapid identification and isolation of infected individuals remains a key strategy for controlling the spread of SARS-CoV-2. Frequent testing of populations to detect infection early in asymptomatic or presymptomatic individuals can be a powerful tool for intercepting transmission, especially when the viral prevalence is low. However, RT-PCR testing-the gold standard of SARS-CoV-2 diagnosis-is expensive, making regular testing of every individual unfeasible. Sample pooling is one approach to lowering costs. By combining samples and testing them in groups the number of tests required is reduced, substantially lowering costs. Here we report on the implementation of pooling strategies using 3-d and 4-d hypercubes to test a professional sports team in South Africa. We have shown that infected samples can be reliably detected in groups of 27 and 81, with minimal loss of assay sensitivity for samples with individual Ct values of up to 32. We report on the automation of sample pooling, using a liquid-handling robot and an automated web interface to identify positive samples. We conclude that hypercube pooling allows for the reliable RT-PCR detection of SARS-CoV-2 infection, at significantly lower costs than lateral flow antigen (LFA) tests.

Interim Guidance on the Preparticipation Physical Examination for Athletes During the SARS-CoV-2 Pandemic

The American Medical Society for Sports Medicine (AMSSM) convened a writing group to address the current evidence and knowledge gaps regarding preparticipation evaluation of athletes during the SARS-CoV2 pandemic. The writing group held a series of meetings beginning in April 2020. The task force reviewed the available literature and used an iterative process and expert consensus to finalize this guidance statement that is intended to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic. The statement is not intended to address treatment, infection control principles, or public health issues related to SARS-CoV2. The AMSSM task force acknowledges the clinical uncertainty, evolving public health objectives, and the limited data currently available to create this guidance statement.

A Systematic Review of Methods and Criteria Standard Proposal for the Use of Principal Component Analysis in Team's Sports Science

The availability of critical information about training and competition is fundamental on performance. Principal components analysis (PCA) is widely used in sports as a multivariate technique to manage big data from different technological assessments. This systematic review aimed to explore the methods reported and statistical criteria used in team's sports science and to propose a criteria standard to report PCA in further applications. A systematic electronic search was developed through four electronic databases and a total of 45 studies were included in the review for final analysis. Inclusion criteria: (i) of the studies we looked at, 22.22% performed factorability processes with different retention criteria (r > 0.4-0.7); (ii) 21 studies confirmed sample adequacy using Kaiser-Meyer-Olkim (KMO > 5-8) and 22 reported Bartlett's sphericity; (iii) factor retention was considered if eigenvalues >1-1.5 (n = 29); (iv) 23 studies reported loading retention (>0.4-0.7); and (v) used VariMax as the rotation method (48.9%). A lack of consistency and serious voids in reporting of essential methodological information was found. Twenty-one items were selected to provide a standard quality criterion to report methods sections when using PCA. These evidence-based criteria will lead to a better understanding and applicability of the results and future study replications.

Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males

Energy availability (EA) is defined as the amount of dietary energy available to sustain physiological function after subtracting the energetic cost of exercise. Insufficient EA due to increased exercise, reduced energy intake, or a combination of both, is a potent disruptor of the endocrine milieu. As such, EA is conceived as a key etiological factor underlying a plethora of physiological dysregulations described in the female athlete triad, its male counterpart and the Relative Energy Deficiency in Sport models. Originally developed upon female-specific physiological responses, this concept has recently been extended to males, where experimental evidence is limited. The majority of data for all these models are from cross-sectional or observational studies where hypothesized chronic low energy availability (LEA) is linked to physiological maladaptation. However, the body of evidence determining causal effects of LEA on endocrine, and physiological function through prospective studies manipulating EA is comparatively small, with interventions typically lasting ≤ 5 days. Extending laboratory-based findings to the field requires recognition of the strengths and limitations of current knowledge. To aid this, this review will: (1) provide a brief historical overview of the origin of the concept in mammalian ecology through its evolution of algebraic calculations used in humans today, (2) Outline key differences from the ‘energy balance’ concept, (3) summarise and critically evaluate the effects of LEA on tissues/systems for which we now have evidence, namely: hormonal milieu, reproductive system endocrinology, bone metabolism and skeletal muscle; and finally (4) provide perspectives and suggestions for research upon identified knowledge gaps.

Psychologists' Role in Concussion Assessments for Children and Adolescents in Pediatric Practice

An estimated 1.1 to 1.9 million children and adolescents in the United States are treated for a sports- or recreationally-related concussion each year. The importance of formalized assessment and measurement of concussion symptoms has been widely recognized as a component of best-practice treatment. The present paper reviews a sample of the most commonly used measures of concussion symptomology and explores psychologists' role in their application in a pediatric practice. In addition, other issues such as accessibility and the appropriateness of application with child and adolescent patients are discussed. Literature is reviewed from journals pertaining to pediatric and adolescent medicine, sports medicine, neuropsychology, and testing and measurement.

Complementary and Alternative Medicine Prescribing Practices Among Sports Medicine Providers

CONTEXT

The drive for a quick return to sport after injury can be great. Athletes look to their sports medicine provider for guidance on a speedy and effective recovery. The sports medicine physician has a number of different treatment options to consider when they turn to their medical armamentarium. One of those treatment choices is complementary and alternative medicine (CAM). Unfortunately, there is limited evidence for many of the CAM modalities. Furthermore, CAM prescribing practices among sports medicine physicians is unknown. The aim of this study is to determine the prescribing practices of CAM among physicians for common sports medicine pathologies.

METHODS

An online survey of the prescribing practices of CAM by physician members of the American Medical Society for Sports Medicine.

RESULTS

A total of 257 physicians answered the question on prescribing CAM for a response rate of 11%. Of those who responded, 88% prescribed at least one type of CAM in the last one year. The responders identified 23 different CAM modalities they prescribed. Of those modalities prescribed, chiropractic/osteopathic manipulation was the most common followed by acupuncture/electroacupuncture and yoga. Less commonly prescribed CAM included omega-3 fatty acids, riboflavin, and meditation. Providers utilized CAM for common sports medicine pathologies including ligamentous, tendinous and muscle injury, concussion, and low back pain among others. The survey participants believed many of these CAM modalities to be effective.

CONCLUSIONS

Among responders, the prescribing prevalence of at least one CAM therapy was high. Sports medicine physicians utilized a number of different CAM modalities to treat common sports medicine pathologies.

Understanding the dimensions of sport-injury related growth: A DELPHI method approach

Despite the multitude of adverse physical and psychosocial consequences of sports injury, evidence also highlights the potential for positive benefits in the injury aftermath. The purpose of this study is to address this gap by exploring the dimensions of personal growth following a severe sports injury. A 3-rounds e-Delphi method was utilized to develop a consensual understanding of the dimensions of sport-injury related growth. A panel of 24 psychology of sport injury experts participated in the process. The final list of items obtained was subjected to conventional content analysis to identify general themes. The process led to the development of a 5-dimension model capable of describing athletes' experiences of personal growth following a severe sports-related injury: personal strength, improved social life, health benefits, sport benefits, and social support and recognition. The domains of sport-injury related growth identified here are consistent with growth-domains identified in previous personal growth literature. However, they also highlight the importance of contextualizing the experience of growth. We have captured key elements of sport-injury related growth, domains that can be used as the basis for further psychometric testing and for further interventions to increase adjustment and well-being during the rehabilitation process.

Medical-Grade ECG Sensor for Long-Term Monitoring

The recent trend in electrocardiogram (ECG) device development is towards wireless body sensors applied for patient monitoring. The ultimate goal is to develop a multi-functional body sensor that will provide synchronized vital bio-signs of the monitored user. In this paper, we present an ECG sensor for long-term monitoring, which measures the surface potential difference between proximal electrodes near the heart, called differential ECG lead or differential lead, in short. The sensor has been certified as a class IIa medical device and is available on the market under the trademark Savvy ECG. An improvement from the user’s perspective—immediate access to the measured data—is also implemented into the design. With appropriate placement of the device on the chest, a very clear distinction of all electrocardiographic waves can be achieved, allowing for ECG recording of high quality, sufficient for medical analysis. Experimental results that elucidate the measurements from a differential lead regarding sensors’ position, the impact of artifacts, and potential diagnostic value, are shown. We demonstrate the sensors’ potential by presenting results from its various areas of application: medicine, sports, veterinary, and some new fields of investigation, like hearth rate variability biofeedback assessment and biometric authentication.

Clinical Results of Ultrasound-Guided Carpal Tunnel Release Performed by a Primary Care Sports Medicine Physician

OBJECTIVES

The purpose of this study was to determine the safety and efficacy of ultrasound-guided carpal tunnel release (USCTR) in a consecutive group of patients treated by a single primary care sports medicine physician.

METHODS

The study group consisted of 35 USCTRs performed on 22 consecutive patients for whom clinical outcomes were available before USCTR and at 1 to 2 weeks, 1 month, and 3 months after USCTR. All procedures were performed by the same operator using a single USCTR technique. Outcomes included complications, Quick Disabilities of the Arm, Shoulder, and Hand scores, Boston Carpal Tunnel Questionnaire symptom severity and functional status scores, and a 5-point global satisfaction score.

RESULTS

The 22 patients included 13 female and 9 male patients (ages 31-82 years). Eleven patients (22 wrists) had bilateral simultaneous USCTRs; 2 patients (4 wrists) had staged bilateral USCTRs; and 9 patients had unilateral USCTRs. No complications occurred in any patient. Statistically and clinically significant reductions in Quick Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire symptom severity and functional status scores occurred by 1 to 2 weeks after USCTR (mean 1- to 2-week changes, -29.23, -1.74, and -1.18, respectively), and further improvements occurred during the 3-month follow-up period (mean 3-month changes, -51.11, -2.29, and -1.91; P < .0001 for all values versus before USCTR). Mean global satisfaction scores at 1 to 2 weeks and 3 months were 4.63 and 4.66.

CONCLUSIONS

Ultrasound-guided CTR is a safe and effective procedure that can be performed by an experienced primary care sports medicine physician and typically results in significant improvements within the first 2 weeks after the procedure. Furthermore, bilateral simultaneous USCTRs are feasible and may provide significant advantages for patients who are candidates for bilateral CTRs.

Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management

The Wilderness Medical Society convened an expert panel in 2018 to develop a set of evidence-based guidelines for the treatment of type 1 and 2 diabetes, as well as the recognition, prevention, and treatment of complications of diabetes in wilderness athletes. We present a review of the classifications, pathophysiology, and evidence-based guidelines for planning and preventive measures, as well as best practice recommendations for both routine and urgent therapeutic management of diabetes and glycemic complications. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each recommendation.

Promotion of Pre- and Post-Transplant Physical Exercise in the Emilia-Romagna Region: The Network of the Program "Transplantation, Physical Activity, and Sport"

BACKGROUND

Following the positive experience of the national project "A transplant...and now it's time for sport," the Transplant Reference Center of the Emilia-Romagna Region has pursued the promotion of pre- and post-transplant physical exercise by developing a network.

METHODS

The path involved the transplant centers and operative units (UU.OO) who wanted to target transplant and waiting list patients, who are clinically stable, to perform personalized exercise through a program (supervised or not) prescribed by a specialist in sports medicine. With the collaboration of the Collective Prevention and Public Health Service, the network was established, consisting of the sports medicine centers and the gyms that promote health for adapted physical activity (PS-AMA). To implement the network, training courses for all the professionals involved (doctors, nurses, exercise specialists) and operational meetings in the transplant centers-nephrology units with patients' associations have been organized.

RESULTS

To date, there are 14 transplant centers and UU.OO, 9 sports medicine centers, and 45 PS-AMA involved in this network. Seven training courses were organized with the participation of 193 health professionals. Since January 2016, there have been 65 transplanted patients and 5 patients on the waiting list who practice the prescribed exercise. Of these, 45 carry out supervised exercise in PS-AMA; 25 perform autonomous exercise. Each patient is monitored every 6 months. No problems related to the exercise performance were recorded.

CONCLUSIONS

The development of a network of professionals and associations is the key element to raise awareness of physical activity among transplanted and waiting-for-transplant patients, reducing the pathologies associated with a sedentary lifestyle.

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial

INTRODUCTION

Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA.

METHODS AND ANALYSIS

We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year.

ETHICS AND DISSEMINATION

The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NTR7261.

Arthroscopy, Sports Medicine, and Rehabilitation (ASMAR): A New, Open Access, Electronic Journal

Arthroscopy, Sports Medicine, and Rehabilitation (ASMAR) is our new, open-access, electronic, companion journal to Arthroscopy and Arthroscopy Techniques. While there is already "so much to read, so little time," bearing in mind the context that some submissions are not accepted for publication in Arthroscopy despite admirable quality, the necessity of ASMAR becomes clear.

Current Concepts in Concussion: Initial Evaluation and Management

Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Concussion management in combat sports: consensus statement from the Association of Ringside Physicians

Various organisations and experts have published numerous statements and recommendations regarding different aspects of sports-related concussion including definition, presentation, treatment, management and return to play guidelines. 1-7 To date, there have been no written consensus statements specific for combat sports regarding management of combatants who have suffered a concussion or for return to competition after a concussion. In combat sports, head contact is an objective of the sport itself. Accordingly, management and treatment of concussion in combat sports should, and must, be more stringent than for non-combat sports counterparts.The Association of Ringside Physicians (an international, non-profit organisation dedicated to the health and safety of the combat sports athlete) sets forth this consensus statement to establish management guidelines that ringside physicians, fighters, referees, trainers, promoters, sanctioning bodies and other healthcare professionals can use in the ringside setting. We also provide guidelines for the return of a combat sports athlete to competition after sustaining a concussion. This consensus statement does not address the management of moderate to severe forms of traumatic brain injury, such as intracranial bleeds, nor does it address the return to competition for combat sports athletes who have suffered such an injury. These more severe forms of brain injuries are beyond the scope of this statement. This consensus statement does not address neuroimaging guidelines in combat sports.

The Use of Patient-Reported Outcome Measures: Secondary School Athletic Trainers' Perceptions, Practices, and Barriers

CONTEXT

Incorporating patient-reported outcomes (PROs) into daily routine is essential for patient-centered clinical practice. Secondary school athletic trainers (ATs) may encounter unique barriers that limit their willingness to use PROs.

OBJECTIVE

To explore how secondary school ATs who were using PROs perceived their application, benefits, and problems compared with those who did not.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 2984 secondary school ATs received an e-mail invitation, and 322 completed the survey (response rate = 10.8%). Respondents were 43 ± 10 years old, with most indicating at least 11 years as a Board of Certification-certified AT (n = 276, 85.7%).

MAIN OUTCOME MEASURE(S)

The ATs were invited to complete a Web-based survey regarding the uses and benefits of and problems with PROs. Those using PROs in clinical practice were asked their criteria for selecting the measures, whereas those not using PROs were asked their reasons for not using them. Dependent variables were endorsements of uses and benefits of and problems with PROs.

RESULTS

The most commonly cited uses of PROs were determining treatment effectiveness (193/264, 73%) and demonstrating effectiveness to administration (174/264, 66%). Improving communication with the patient (267/296, 90%) and helping to direct the plan of care (256/297, 86%) were the most frequently endorsed benefits of PROs. Time to score and analyze (152/284, 53%) and time for patients to complete (134/284, 47%) PROs were the problems encountered most often. For ATs not using PROs (223/262, 85%), the most frequent reason was the lack of a support structure (102/219, 46%). For ATs using PROs (39/262, 15%), quick completion times (32/39, 82%) was the most common criterion used to select individual measures.

CONCLUSIONS

A majority of secondary school ATs recognized the benefits of PROs and yet did not use them in clinical practice due to setting-specific barriers.

Blood Biomarkers in Sports Medicine and Performance and the Future of Metabolomics

The field of sports medicine and performance has undergone an important transformation in the past years where the scientific approach is becoming increasingly more important for teams and athletes. Physical and physiological fitness, nutrition, fatigue and recovery, as well as injury prevention are key elements of the scientific monitoring of athletes nowadays. Many different methods are used nowadays as part of the scientific monitoring and testing of the competitive athlete. Among them, physiological and metabolic testing, biomechanical and movement assessments, GPS-based tracking systems, heart rate monitors, power meters, and training software are an integrative part of the scientific monitor program of many teams and athletes.Blood biomarkers through traditional blood analysis have been used for over three decades (mainly in Europe) to monitor athletic performance. In the same manner that different cells in the body respond to the stress of an infection or a disease, cells in athletes respond to the stress of competition and training. Nowadays, the area of blood biomarkers is an emerging field in the US offering important level of possibilities to monitor athletes. The field of metabolomics can offer a significantly higher level of blood biomarkers for sports medicine and performance monitoring.

The use of ultrasound in athletes

Ultrasound is being used by sports physicians in their daily practice to problem solve, but there is still a reluctance for some radiologists to embrace this technique. It has become the "stethoscope" of the sports physician as it is freely available to have in the office setting (Tok, et al. [1]). This has been made possible by advances in technology making it cheaper and more affordable. In the United Kingdom, ultrasound has been performed by sports physicians, rheumatologists, surgeons, physiotherapists, podiatrists, anaesthetists, neurologists and emergency care physicians. It has become a core area of the curriculum in some of these specialties. In athletes it not only provides confirmation of the diagnosis but leads to a better treatment algorithm and can be used to direct intervention. Radiologists need to be aware of its strengths and weaknesses even if they are not able to perform such examinations.

Orthobiologics A Comprehensive Review of the Current Evidence and Use in Orthopedic Subspecialties

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

Elite athletes and anticoagulant therapy: an intermittent dosing strategy

Traditionally, the athlete who requires long-term anticoagulation has been told to forgo participation in contact and collision sports. However, a strategy of short-term interruption of anticoagulant therapy may be designed for some athletes, allowing them return to full athletic activity. A personalized pharmacokinetic/pharmacodynamic study of a direct oral anticoagulant (DOAC) may allow athletic participation when plasma drug concentration is minimal and resumption of treatment after the risk of bleeding sufficiently normalizes. Scientific data and uncertainties regarding this approach, as well as practical challenges in the implementation, will be discussed.

Cost Effectiveness of a Platelet-rich Plasma Preparation Technique for Clinical Use

INTRODUCTION

Despite limited clinical evidence, platelet-rich plasma (PRP) is currently used for the treatment of various soft tissue injuries, but optimal use of PRP has yet to be determined. In many instances, PRP is prepared using commercial devices that lack standardized preparation techniques and consistent quality of the PRP produced.

OBJECTIVE

The aim of this study is to explore a simple, easy, economical method of PRP preparation that is practical for clinical use.

MATERIALS AND METHODS

This cross-sectional study was conducted at the Sports Medicine Clinic at the University of Malaya Medical Centre, Malaysia. Participants were healthy postgraduate students and staff at the Sports Medicine Department. The PRP was prepared using a single centrifugation technique. Leukocyte and platelet levels were compared with that of a whole blood baseline and a commercial preparation kit.

RESULTS

The PRP produced using this technique contained significantly higher mean platelet (1725.0 vs. 273.9 x 109/L) and leukocyte (33.6 vs. 7.7 x 109/L) levels compared with whole blood. There was no significant difference in the mean platelet and leukocyte levels between the PRP produced in this study and by a commercial PRP system.

CONCLUSIONS

A single-centrifugation protocol using readily available materials in a typical clinical setting could produce PRP of comparable quality to those of a commercial PRP production system.

Exercise Testing in Sports Medicine

BACKGROUND

Bicycle and treadmill exercise tests are used in sports medicine and occupational medicine to detect latent disease, to monitor treatment, and to measure patients' physical performance ability and reserve. In this review, we describe the indications, contraindications, and manner of performance of these tests, along with the variables tested, criteria for evaluation, (sub)maximal stress, and the factors that affect these tests, including age, sex, and medications.

METHODS

This review is based on pertinent articles retrieved by a selective literature search and on the ergometry guidelines of four medical specialty societies.

RESULTS

The proper performance of ergometric stress tests calls for preparation and monitoring by qualified staff as well as standardized testing conditions. Ergometric studies are indispensable as a clinical diagnostic method for the early recognition of disease, for follow-up over time, and for individual counseling. The patient's maximal achievable performance is a predictor of morbidity and mortality. Among the variables that can be measured in the submaximal performance range, the respiratory rate, heart rate, and lactate performance curves are more accurate prognostic predictors than the so-called threshold values (physical working capacity, anaerobic-aerobic threshold). Ergometric stress tests can be used to detect (among other conditions) latent hypertension, pulmonary diseases (e.g., exertional asthma), pabnormal ECG changes, and cardiovascular disorders (e.g., ischemia, arrhythmia, congestive heart failure). The ergometric findings are influenced by the choice of stress-inducing protocol. They provide important information for the planning and monitoring of exercise training and for the treatment of persons suffering from diverse physical conditions, as well as for leisure-time athletes. They are less suit- able for use in the design of training programs for high-performance athletes.

CONCLUSION

Ergometric stress tests provide important data in clinical and preventive medicine. The findings are often difficult to interpret because of the wide range of normal findings, the use of different stress-inducing protocols, and the lack of gen- erally accepted reference values. The establishment of a nationwide fitness and health registry for ergometric data would be very helpful for the individualized inter- pretation of test findings and for the monitoring of exercise training and therapy.

Sports Cardiology - Example Illustrative Cases

The following four cases are typical of the dilemmas faced by sports cardiologists on a regular basis. These are real-life cases and, for each, in addition to a focussed evaluation, the authors openly discuss the clinical predicament and give their personal viewpoints. The cases are designed to be engaging and informative, demonstrating the benefits of expertise in sports cardiology when confronted with athletes with cardiological conundrums.

Pilot single-centre cross-sectional study to determine emergency physicians' knowledge and management of sports concussion: an experience from Singapore

INTRODUCTION

Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore.

METHODS

An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition.

RESULTS

Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion.

CONCLUSION

Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.

A Growing Consensus for Change in Interpretation of Clinical Research Evidence

CONTEXT

  The paradigm of evidence-based practice (EBP) is well established among the health care professions, but perspectives on the best methods for acquiring, analyzing, appraising, and using research evidence are evolving.

BACKGROUND

  The EBP paradigm has shifted away from a hierarchy of research-evidence quality to recognize that multiple research methods can yield evidence to guide clinicians and patients through a decision-making process. Whereas the "frequentist" approach to data interpretation through hypothesis testing has been the dominant analytical method used by and taught to athletic training students and scholars, this approach is not optimal for integrating evidence into routine clinical practice. Moreover, the dichotomy of rejecting, or failing to reject, a null hypothesis is inconsistent with the Bayesian-like clinical decision-making process that skilled health care providers intuitively use. We propose that data derived from multiple research methods can be best interpreted by reporting a credible lower limit that represents the smallest treatment effect at a specified level of certainty, which should be judged in relation to the smallest effect considered to be clinically meaningful. Such an approach can provide a quantifiable estimate of certainty that an individual patient needs follow-up attention to prevent an adverse outcome or that a meaningful level of therapeutic benefit will be derived from a given intervention.

CONCLUSIONS

  The practice of athletic training will be influenced by the evolution of the EBP paradigm. Contemporary practice will require clinicians to expand their critical-appraisal skills to effectively integrate the results derived from clinical research into the care of individual patients. Proper interpretation of a credible lower limit value for a magnitude ratio has the potential to increase the likelihood of favorable patient outcomes, thereby advancing the practice of evidence-based athletic training.

Sport science internships for learning: a critical view

Sport science has gained vast popularity with students who have an interest in both physiology and the underpinning mechanisms of exercise concerning performance and health. The high numbers of graduates each year, coupled with the low number of graduate positions working in sports, has led to a high level of competition between students. To stand out from the crowd, sport science students may undertake an internship placement as part of their course, designed to enhance theoretical, practical, and soft skills in an applied setting. In the present article, we highlight some of the positives and negatives of sport science internships and ways in which they can be implemented and facilitated. Suggestions have also been provided to make students more aware of the reality of working in professional sports, which includes awareness of the potential for long and unsociable hours of work.

Cost Implications of Using Different ECG Criteria for Screening Young Athletes in the United Kingdom

BACKGROUND

High false-positive rates and cost of additional investigations are an obstacle to electrocardiographic (ECG) screening of young athletes for cardiac disease. However, ECG screening costs have never been systematically assessed in a large cohort of athletes.

OBJECTIVE

This study investigated the costs of ECG screening in athletes according to the 2010 European Society of Cardiology (ESC) recommendations and the Seattle and refined interpretation criteria.

METHODS

Between 2011 and 2014, 4,925 previously unscreened athletes aged 14 to 35 years were prospectively evaluated with history, physical examination, and ECG (interpreted with the 2010 ESC recommendations). Athletes with abnormal results underwent secondary investigations, the costs of which were based on U.K. National Health Service Tariffs. The impact on cost after applying the Seattle and refined criteria was evaluated retrospectively.

RESULTS

Overall, 1,072 (21.8%) athletes had an abnormal ECG on the basis of 2010 ESC recommendations; 11.2% required echocardiography, 1.7% exercise stress test, 1.2% Holter, 1.2% cardiac magnetic resonance imaging, and 0.4% other tests. The Seattle and refined criteria reduced the number of positive ECGs to 6.0% and 4.3%, respectively. Fifteen (0.3%) athletes were diagnosed with potentially serious cardiac disease using all 3 criteria. The overall cost of de novo screening using 2010 ESC recommendations was $539,888 ($110 per athlete and $35,993 per serious diagnosis). The Seattle and refined criteria reduced the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis, respectively.

CONCLUSIONS

Contemporary ECG interpretation criteria decrease costs for de novo screening of athletes, which may be cost permissive for some sporting organizations.