The two articles in the area of cardiovascular physiology and disease in youth were chosen for commentary because of their exploration of new approaches to the diagnosis and management of cardiovascular derangements in young persons. The first, by Hinds et al., describes the potential clinical importance of detection of cardiovascular changes during exercise testing in adolescent athletes following concussions. This approach might prove useful in establishing safe return-to-play guidelines. The second, a review article by Van De Schoor et al, evaluates the frequency of myocardial scarring in athletes, some of adolescent age, which is a recognized risk factor for sudden cardiac death. These findings support other evidence indicating that sports participation per se might rarely increase the risk of such tragedies. Clearly more research is indicated by the information raised in both of these articles, but their importance to clinical medicine is obvious.
Lara Mitchinson, Amity Campbell, Damian Oldmeadow, Will Gibson and Diana Hopper
Volleyball players are at high risk of overuse shoulder injuries, with spike biomechanics a perceived risk factor. This study compared spike kinematics between elite male volleyball players with and without a history of shoulder injuries. Height, mass, maximum jump height, passive shoulder rotation range of motion (ROM), and active trunk ROM were collected on elite players with (13) and without (11) shoulder injury history and were compared using independent samples t tests (P < .05). The average of spike kinematics at impact and range 0.1 s before and after impact during down-the-line and cross-court spike types were compared using linear mixed models in SPSS (P < .01). No differences were detected between the injured and uninjured groups. Thoracic rotation and shoulder abduction at impact and range of shoulder rotation velocity differed between spike types. The ability to tolerate the differing demands of the spike types could be used as return-to-play criteria for injured athletes.
Andrea Cripps and Scott C. Livingston
Sport-related concussions are a significant health issue due to the high incidence of concussions sustained each sports season. Current approaches to the evaluation of acutely concussed athletes include the use of balance assessments to identify and monitor underlying postural instability arising from concussion. Balance assessment has been recommended as a primary measurement tool for monitoring recovery and for making return-to-play decisions. Balance impairments have been shown to occur in the initial postconcussion period (ie, 1–10 d). Numerous clinical and laboratory measures have been used in the assessment of balance immediately after concussion, and clinicians are faced with deciding which measures to use.
Focused Clinical Question:
How do clinical or field-based balance-assessment tools compare to laboratory-based balance measures in identifying deficits in postural stability among acutely concussed athletes?
Lynda M. Mainwaring, Sean M. Bisschop, Robin E.A. Green, Mark Antoniazzi, Paul Comper, Vicki Kristman, Christine Provvidenza and Doug W. Richards
Despite suggestions that emotions influence recovery from injury, there is little research into the emotional sequelae of mild traumatic brain injury (MTBI), or “concussion,” in sport. This examination compares emotional functioning of college athletes with MTBI to that of uninjured teammates and undergraduates. A short version of the Profile of Mood States (POMS; Grove & Prapavessis, 1992) assessed baseline emotions in all groups, and serial emotional functioning in the MTBI and undergraduate groups. Whereas preinjury profiles were similar across groups, the MTBI group showed a significant postinjury spike in depression, confusion, and total mood disturbance that was not seen for the other groups. The elevated mood disturbances subsided within 3 weeks postinjury. Given that concussed athletes were highly motivated to return to play, these data could be used as a benchmark of normal emotional recovery from MTBI. Findings are discussed in relation to current literature on emotional reaction to injury and directions for future research.
Eric Emmanuel Coris, Stephen Walz, Jeff Konin and Michele Pescasio
Heat illness is the third leading cause of death in athletics and a leading cause of morbidity and mortality in exercising athletes. Once faced with a case of heat related illness, severe or mild, the health care professional is often faced with the question of when to reactivate the athlete for competitive sport. Resuming activity without modifying risk factors could lead to recurrence of heat related illness of similar or greater severity. Also, having had heat illness in and of itself may be a risk factor for future heat related illness. The decision to return the athlete and the process of risk reduction is complex and requires input from all of the components of the team. Involving the entire sports medicine team often allows for the safest, most successful return to play strategy. Care must be taken once the athlete does begin to return to activity to allow for re-acclimatization to exercise in the heat prior to resumption particularly following a long convalescent period after more severe heat related illness.
Ian W. Ford and Sandy Gordon
A two-part study was used to survey sport trainers and athletic therapists on both the frequency and significance of emotions and behaviors displayed by athletes during treatment and the importance of psychological techniques in injury management. A questionnaire, developed from a preliminary study with experienced sport trainers (Part 1), was mailed to sport trainers in Australia and New Zealand and athletic therapists in Canada(Part 2). Responses from Australian (n = 53), New Zealand (n = 11), and Canadian (n = 32) participants suggested that (a) wanting to return to play too soon, anxiety and frustration, noncompliance, and denial were experienced frequently by injured athletes during rehabilitation and significantly hindered effective recovery; (b) psychological skills training and learning to deal with psychological responses to injury would facilitate more effective treatment; and (c) athletes' self-presentation styles influence the support and attention received from trainers/therapists. Findings suggest that the applied sport psychology content of professional training programs for sport trainers and athletic therapists should be extended.
Bradford Strand, Shannon David, Katie J. Lyman and Jay M. Albrecht
The purpose of this original research was to survey high school coaches in four states in the Midwest region of the United States regarding their knowledge of first aid, cardiopulmonary resuscitation (CPR), and use of an Automated External Defibrillator (AED) as well as confidence in managing/treating emergency situations. Responses to general knowledge inquiries revealed that coaches were able to accurately answer questions related to return to play, level of consciousness, external bleeding, and cardiac arrest. However, coaches were unable to correctly answer questions specific to rest, ice, compression, and elevation (RICE) and also misidentified information related to pediatric AED use. Because sudden cardiac death is the leading cause of death and has been linked to lack of bystander intervention, the results of this project should be considered by coaches and administrators to implement certification and continuing education for high school coaches. Finally, coaches who were certified in first aid, CPR, and AED were more confident in treating an individual who required care compared with coaches not certified. Therefore, individuals who coach at all levels of sport and recreational activities should consider formal training and certification.
Tamara C. Valovich McLeod and Johna K. Register-Mihalik
An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life.
Clinical Outcomes Assessment:
Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms.
Clinical Decision Making:
The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete’s symptoms.
Clinical Bottom Line:
Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.
Jessica R. Edler, Kenneth E. Games, Lindsey E. Eberman and Leamor Kahanov
The tibial plateau is a critical load-bearing surface in humans. Although tibial plateau fractures represent only 1% of all fractures, proper management by all members of the health care team, including athletic trainers, physicians, and physical therapists, is required for successful patient outcomes. A 14-year-old national-level competitive female diver injured her right knee during the precompetition warm-up period. Upon evaluation by an athletic trainer, the patient was referred for imaging and examination by a physician. She was seen by an orthopedic surgeon for consultation. The patient elected for a surgical repair of the tibial plateau fracture. Following surgery she underwent an 11-week comprehensive therapeutic exercise program with athletic trainers and physical therapists. The patient’s return-to-play progression included dry land activities, platform diving, 1-m springboard diving, and 3-m springboard diving. The patient has successfully returned to competitive diving. Proper identification of tibial fractures can be difficult considering their low occurrence in youth and their similar clinical presentation to more common youth injuries such as anterior cruciate ligament ruptures. Clinicians providing immediate on-site medical care should be thorough in their clinical exam including palpation and axial loading of the joint.
Michelle Cleary, Daniel Ruiz, Lindsey Eberman, Israel Mitchell and Helen Binkley
We present a case of severe dehydration, muscle cramping, and rhabdomyolysis in a high school football player followed by a suggested program for gradual return to play.
A 16-year-old male football player (body mass = 69.1 kg, height = 175.3 cm) reported to the ATC after the morning session on the second day of two-a-days complaining of severe muscle cramping.
The initial assessment included severe dehydration and exercise-induced muscle cramps. The differential diagnosis was severe dehydration, exertional rhabdomyolysis, or myositis. CK testing revealed elevated levels indicating mild rhabdomyolysis.
The emergency department administered 8 L of intravenous (IV) fluid within the 48-hr hospitalization period, followed by gradual return to activity.
To our knowledge, no reports of exertional rhabdomyolysis in an adolescent football player exist. In this case, a high school quarterback with a previous history of heat-related cramping succumbed to severe dehydration and exertional rhabdomyolysis during noncontact preseason practice. We provide suggestions for return to activity following exertional rhabdomyolysis.