Identification of Cardiometabolic Risk Among Collegiate Football Players

Context:

Excessive fat mass clearly has adverse effects on metabolic processes that can ultimately lead to the development of chronic disease. Early identification of high-risk status may facilitate referral for definitive diagnostic tests and implementation of interventions to reduce cardiometabolic risk.

Objective:

To document the prevalence of metabolic syndrome among collegiate football players and to develop a clinical prediction rule that does not require blood analysis to identify players who may possess a high level of cardiometabolic risk.

Design:

Cross-sectional cohort study.

Setting:

University athletic training research laboratory.

Patients or Other Participants:

Sixty-two National Collegiate Athletic Association Division I Football Championship Subdivision football players (age  =  19.9 ± 1.2 years, height  =  182.6 ± 6.1 cm, mass  =  97.4 ± 18.3 kg).

Main Outcome Measure(s):

Anthropometric characteristics associated with body fat, isokinetic quadriceps strength, and biometric indicators associated with metabolic syndrome were measured. Participants were classified as high risk or low risk for future development of type 2 diabetes and cardiovascular disease.

Results:

The prevalence of metabolic syndrome in the cohort was 19% (12 of 62), and 79% (49 of 62) of the players exceeded the threshold for 1 or more of its 5 components. A 4-factor clinical prediction rule that classified individuals on the basis of waist circumference, blood pressure, quadriceps strength, and ethnic category had 92% sensitivity (95% confidence interval  =  65%, 99%) and 76% specificity (95% confidence interval  =  63%, 86%) for discrimination of high-risk or low-risk status.

Conclusions:

The risk for developing type 2 diabetes and cardiovascular disease appears to be exceptionally high among collegiate football players. A lack of race-specific criteria for the diagnosis of metabolic syndrome almost certainly contributes to an underestimation of the true level of cardiometabolic risk for African American collegiate football players.     

Soccer-Specific Warm-Up and Lower Extremity Injury Rates in Collegiate Male Soccer Players

Context:

A number of comprehensive injury-prevention programs have demonstrated injury risk-reduction effects but have had limited adoption across athletic settings. This may be due to program noncompliance, minimal exercise supervision, lack of exercise progression, and sport specificity. A soccer-specific program described as the F-MARC 11+ was developed by an expert group in association with the Federation Internationale de Football Association (FIFA) Medical Assessment and Research Centre (F-MARC) to require minimal equipment and implementation as part of regular soccer training. The F-MARC 11+ has been shown to reduce injury risk in youth female soccer players but has not been evaluated in an American male collegiate population.

Objective:

To investigate the effects of a soccer-specific warm-up program (F-MARC 11+) on lower extremity injury incidence in male collegiate soccer players.

Design:

Cohort study.

Setting:

One American collegiate soccer team followed for 2 seasons.

Patients or Other Participants:

Forty-one male collegiate athletes aged 18–25 years.

Intervention(s):

The F-MARC 11+ program is a comprehensive warm-up program targeting muscular strength, body kinesthetic awareness, and neuromuscular control during static and dynamic movements. Training sessions and program progression were monitored by a certified athletic trainer.

Main Outcome Measure(s):

Lower extremity injury risk and time lost to lower extremity injury.

Results:

The injury rate in the referent season was 8.1 injuries per 1000 exposures with 291 days lost and 2.2 injuries per 1000 exposures and 52 days lost in the intervention season. The intervention season had reductions in the relative risk (RR) of lower extremity injury of 72% (RR = 0.28, 95% confidence interval = 0.09, 0.85) and time lost to lower extremity injury (P < .01).

Conclusions:

This F-MARC 11+ program reduced overall risk and severity of lower extremity injury compared with controls in collegiate-aged male soccer athletes.Key Words: injury prevention, sport injuries, athletic trainers

Key Points

• The F-MARC 11+ reduced the risk of lower extremity injuries in youth female soccer players, but limited evidence for its effectiveness exists in males and at the collegiate level.
• A traditional warm-up did not prevent injury as effectively as the F-MARC 11+ program, despite taking the same amount of time.
• When supervised by an athletic trainer, the F-MARC 11+ prevented injuries in collegiate male soccer players.
• An athletic trainer administered intervention, reduced injury risk, and improved program compliance, progression, and execution.

Soccer is among the most popular sports in the world, boasting more than 265 million¹ youth and amateur players and more than 37 000 American collegiate players.² Soccer participation has continued to increase over the past decade worldwide and especially in the United States National Collegiate Athletic Association (NCAA).² Lower extremity injury rates for male NCAA soccer athletes have remained relativity stable over the past decade (practice versus game: 8 versus 12.18 per 1000 exposures).² Junge and Dvorak,³ in a systematic review of soccer injuries in international male players, reported 10 to 35 injuries per 1000 hours of match play and 2 to 7 per 1000 hours of training in international male soccer players. In cohorts of international, elite-level soccer athletes, the injury rate was high (1.3 injuries per player per season); most injuries affected the lower extremity (87%) and resulted from noncontact mechanisms (58%).⁴ The most common injury in male collegiate soccer players was ankle sprains (3.19 per 1000 exposures), followed by thigh muscle strains and knee sprains at 2.28 and 2.07 per 1000 exposures, respectively.² These findings are consistent with reports of international-level soccer athletes.⁴ These lower extremity injuries have substantial short-term consequences, such as loss of participation, and the potential for long-term consequences, such as decreased physical activity⁵ and increased risk of osteoarthritis.^5–10 Nearly 20% of all soccer injuries were severe, requiring greater than 10 days of time lost from activity.² Knee ligament ruptures and leg fractures accounted for 35% of these injuries, many of which required surgical intervention and prolonged rehabilitative care; these patients also had a greatly increased risk of a secondary injury when they returned to soccer competition.^2,11The high injury rate in soccer players has persisted despite scientific advances in injury etiology,^12–17 screening techniques, and the identification of athletes who may be at greater risk.^18–25 Although injury-prevention programs have successfully decreased lower extremity injuries such as ankle sprains,^24,26–29 anterior cruciate ligament (ACL) injuries,^18,30,31 and hamstrings strains,^{20,24,29,32–34} they have not yet been widely adopted,³⁵ limiting their potential effects in soccer athletes.³⁶Although numerous training programs have been designed to prevent injury,^{3,24,26,29,31,32,37–55} few incorporate sport-specific components.^{37,38,41,42,56,57} Many of these programs have shown promising results in decreasing the risk of injury.^{18,37,38,41,58} However, extensive time, expert personnel, and special equipment are needed for these programs to be effective. To make injury-prevention programs as widely accessible as possible, the F-MARC 11+ program was developed by the Federation International de Football Association (FIFA) Medical Assessment and Research Center (F-MARC).⁵⁹ This program can be completed in a short time frame, takes minimal training to implement, and requires only a soccer ball, making it an attractive alternative for sport coaches, strength and conditioning professionals, and rehabilitation specialists already working with limited time and budgets. Thus far, 4 studies^37,38,41,60 have reported on the use of a version of the F-MARC 11+ program in adolescent males and females, with injury reductions ranging from 21% to 71%. In Norwegian handball players, similar training programs have produced a 49% reduction in injury risk⁴⁰ and 94% reduction in ACL injury risk.³⁹To our knowledge, the F-MARC 11+ has yet to be investigated for effectiveness in injury risk reduction in an American male collegiate soccer population. Therefore, our aim was to examine the effect of a sport-specific program implemented with athletic trainer supervision to track compliance, injury occurrence, and program performance quality. We hypothesized that the comprehensive, exercise-based soccer warm-up program (the F-MARC 11+) would be more effective than the traditional dynamic warm-up in preventing lower extremity injuries in male NCAA Division III collegiate soccer athletes.     

Patient-Reported Outcomes in Male and Female Collegiate Soccer Players During an Athletic Season

Context

 Clinicians are urged to document patient-based outcomes during rehabilitation to measure health-related quality of life (HRQOL) from the patient''s perspective. It is unclear how scores on patient-reported outcome instruments (PROs) vary over the course of an athletic season because of normal athletic participation.

Objective

 Our primary purpose was to evaluate the effect of administration time point on HRQOL during an athletic season. Secondary purposes were to determine test-retest reliability and minimal detectable change scores of 3 PROs commonly used in clinical practice and if a relationship exists between generic and region-specific outcome instruments.

Design

 Cross-sectional study.

Setting

 Athletic facility.

Patients or Other Participants

 Twenty-three collegiate soccer athletes (11 men, 12 women).

Main Outcome Measure(s)

 At 5 time points over a spring season, we administered the Disablement in the Physically Active Scale (DPA), Foot and Ankle Ability Measure-Sport, and Knee Injury and Osteoarthritis Outcome Score (KOOS).

Results

 Time effects were observed for the DPA (P = .011) and KOOS Quality of Life subscale (P = .027). However, the differences between individual time points did not surpass the minimal detectable change for the DPA, and no post hoc analyses were significant for the KOOS-Quality of Life subscale. Test-retest reliability was moderate for the KOOS-Pain subscale (intraclass correlation coefficient = 0.71) and good for the remaining KOOS subscales, DPA, and Foot and Ankle Ability Measure-Sport (intraclass correlation coefficients > 0.79). The DPA and KOOS-Sport subscale demonstrated a significant moderate relationship (P = .018).

Conclusions

 Athletic participation during a nontraditional, spring soccer season did not affect HRQOL. All 3 PROs were reliable and could be used clinically to monitor changes in health status throughout an athletic season. Our results demonstrate that significant deviations in scores were related to factors other than participation, such as injury. Finally, both generic and region-specific instruments should be used in clinical practice.Key Words: health-related quality of life, patient-centered outcomes, injury history, evidence-based practice

Key Points

• The Disablement in the Physically Active Scale, Foot and Ankle Ability Measure-Sport, and Knee Injury and Osteoarthritis Outcome Score scales are reliable instruments that have been used clinically to assess activity limitations and participation restrictions in collegiate athletes.
• Significant changes in health-related quality of life are likely to be associated with an injury that restricts athletic participation or another factor rather than participation itself.
• To capture all dimensions of health-related quality of life, clinicians should use both a generic and a region-specific instrument.

As evidence-based practice grows in the field of athletic training, clinicians are encouraged to document clinical outcomes to demonstrate the effectiveness of treatments or interventions to improve patient care.¹ Patient-reported outcome instruments (PROs) are patient-centered outcomes used in clinical practice to capture the patient''s perspective regarding physical impairment, functional limitations, and overall health-related quality of life (HRQOL).¹ The HRQOL is a measure of a person''s function in everyday life and an evaluation of his or her physical, psychological, and social aspects of health derived from personal beliefs, preferences, experiences, and expectations.^2,3 Most often, HRQOL is measured using PROs, and numerous PROs have been created. These instruments are commonly classified into 3 categories: generic, region specific, and dimension specific.¹ Generic PROs measure the patient''s perception of his or her overall health and can capture a range of health-related problems.¹ Examples of generic PROs are the Short-Form 12⁴ and the Disablement in the Physically Active Scale (DPA).^5,6 Region-specific PROs assess the patient''s perception of function for a certain region of the body, such as the ankle or knee.¹ Examples of region-specific PROs that are used in athletes are the Foot and Ankle Ability Measure-Sport (FAAM-S)⁷ and the Knee Injury and Osteoarthritis Outcome Score (KOOS).⁸Health-related quality of life has not been studied thoroughly in athletes and is a topic of interest to athletic training researchers and clinicians.^9–13 Throughout a traditional or nontraditional athletic season, athletes participate in different team activities that may contribute to an increase or decrease in HRQOL, regardless of the athlete''s injury status. Given that athletes are involved in practices, games, agility training, conditioning, and weight training, we must consider the effect of continuous athletic participation on HRQOL. If participation in these activities can change HRQOL, use of these instruments after injury may be confounded by this phenomenon and influence how PRO scores are interpreted. Furthermore, when using PROs in clinical practice, it is important to know their test-retest reliability. The ability of an instrument to measure a change in health status depends on the instrument''s ability to measure consistently over time. Assessing the test-retest reliability of these instruments will allow us to calculate the minimal detectable change (MDC). At this time, neither the test-retest reliability nor the MDC have been calculated for the DPA in healthy, physically active persons participating in intercollegiate athletics. In addition, multiple PROs can be used to assess different dimensions of HRQOL. Currently, we do not know if a relationship exists between generic and region-specific instruments. If a relationship does exist, athletic trainers may be able to use fewer PROs to assess HRQOL in their patients.Our study had 3 purposes. The first purpose was to determine the test-retest reliability and calculate the MDC value of the DPA, FAAM-S, and KOOS subscales in collegiate soccer athletes with a history of lower extremity injury. We hypothesized that these instruments would demonstrate good test-retest reliability in this population. The second purpose was to determine the effect of administration time point on HRQOL scores in collegiate soccer players during an athletic season. We hypothesized that the administration time point would not affect HRQOL. Finally, we aimed to determine if a relationship exists between the DPA and the 2 region-specific instruments. We hypothesized that a strong positive relationship would exist between the generic and 2 region-specific instruments in an athletic population.     

Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion

Context

 Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care.

Objective

 To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution''s sports medicine department, the clinician''s sex, and other factors.

Design

 Cross-sectional study.

Setting

 Web-based survey of National College Athletic Association member institutions.

Patients or Other Participants

 A total of 789 athletic trainers and 111 team physicians from 530 institutions.

Main Outcome Measure(s)

 We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions'' sports medicine departments, and the division of competition in which their institutions participate.

Results

 We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did.

Conclusions

 Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.Key Words: conflict of interest, organizational structure, sex, college

Key Points

• More than half of sports medicine clinicians had experienced pressure from coaches and athletes to return athletes to participation prematurely after a concussion.
• Clinicians experienced greater pressure from coaches at schools where the sports medicine department reported to the athletic department than at schools where the sports medicine department reported to an independent medical institution.
• Female clinicians experienced greater pressure from coaches than male clinicians experienced.
• More research is needed to determine how pressure affects clinical practice and whether pressure on clinicians affects return-to-participation decisions.

Addressing the health burden of mild traumatic brain injury from sport is increasingly considered a public health priority.¹ More than 450 000 college students participate in organized interscholastic sports each year.^2,3 Among collegiate athletes in contact and collision sports, Daneshvar et al⁴ estimated that 43 concussions are sustained per 100 000 athlete-exposures to a game or practice, which is nearly twice the rate of diagnosed concussions sustained by high school athletes competing in the same sports. This estimate likely understates the true incidence of concussions because many are undiagnosed.^5–8 Recent evidence^9–14 has suggested that repeated concussive and subconcussive brain trauma can lead to neurologic problems later in life, including changes in cognition and behavior.Conflict of interest in the care of concussed athletes is a topic of growing ethical discourse.^15–19 Writing for the Chronicle of Higher Education about US collegiate sport, Wolverton²⁰ painted a picture of colleges fraught with pressure on physicians and athletic trainers (ATs) from coaches and athletic administrators. A total of 101 clinicians who provide patient care for football teams in the National Collegiate Athletic Association (NCAA) Division I Football Bowl Subdivision participated in the non–peer-reviewed study, and more than half reported that they had “felt pressure from football coaches to return concussed players to action before they were medically ready.”²⁰ Some of this pressure was attributed to conflicts of interest inherent in the organizational structure and incentives of sports medicine departments. In some instances, ATs reported directly to head football coaches.²⁰ Even in substantially lower-stakes youth sports, Bramley et al²¹ reported that a sample of hockey coaches indicated they would be more likely to allow an athlete who had sustained a concussion to continue participating if the game was considered important, such as for a championship. Consequently, clinicians in collegiate sports medicine departments may find themselves in a challenging situation: having ethical responsibilities to provide appropriate medical care to their patients while facing perceived or real pressure from their employers to return athletes to participation.^15–19,22 In a survey of sports medicine physicians in New Zealand, Anderson and Gerrard²³ observed that whereas all respondents expressed a sense of responsibility to their athlete patients, 72% also believed they had a responsibility to the team coach, and 55% believed they had a responsibility to team management.The National Athletic Trainers'' Association recently released a consensus statement detailing best practices for sports medicine management in secondary schools and colleges, including the advantages and disadvantages of different models of supervisory relationships in sports medicine.²⁴ Supervisory models in which ATs or team physicians are employed by athletic departments are described as having the potential for conflict of interest in the medical care provided to athletes. Pecci and Laursen²⁵ and Laursen²⁶ have advocated for sports medicine departments to be nested within medical units, such as university health centers, rather than athletic departments. They suggested that this organizational structure would reduce real and perceived conflicts of interest in the care of athletes and would have additional benefits, such as easier access to other health care providers and more centralized oversight of medical care.^25,26 Whereas these arguments are intuitive, no researchers have conducted an empirical evaluation of whether supervisory structure is systematically associated with different types of pressure on clinicians regarding the care of collegiate athletes who have sustained concussions.Another potentially important variable that could modify the pressure that clinicians experience is their sex. Approximately half of all ATs are women, but women represent only about one-quarter of full-time staff ATs and only 1 in 8 head ATs in collegiate sports medicine departments.^27–30 Some investigators³¹ have suggested that male and female ATs may have different experiences interacting with coaches and other ATs in the collegiate athletic environment. Mazerolle et al³¹ conducted qualitative interviews with 14 female NCAA Division I ATs and described how they “often encountered gender discrimination when working with a team sport coached by a man.” They described a perception that coaches view female ATs as “more sympathetic and less pragmatic” than male ATs and that this judgment undermines the coaches'' confidence in the care they provide athletes. This differential perception is reinforced by 2 surveys^32,33 in which male collegiate athletes reported being more comfortable receiving care from male ATs. Stereotypical judgments about women in the workplace tend to be strongest when women are an underrepresented minority, as is the case with female ATs in collegiate sports environments, and can inform the control strategies of individuals in positions of power.³⁴ Quantifying the extent to which pressure is experienced in the care of concussed athletes and whether it is modified by clinician characteristics such as sex are important steps in understanding whether institution-level intervention is needed.Therefore, the purpose of our study was to obtain empirical evidence about whether clinicians who provide care to US collegiate sports teams experienced pressure to prematurely clear athletes for participation after a concussion. We hypothesized that clinicians in sports medicine departments reporting to the athletic department would experience greater pressure from coaches and athletes than clinicians in departments reporting to medical institutions and that female clinicians would experience greater pressure from coaches and athletes than male clinicians would experience.     

A Refined Prediction Model for Core and Lower Extremity Sprains and Strains Among Collegiate Football Players

Context

Researchers have identified high exposure to game conditions, low back dysfunction, and poor endurance of the core musculature as strong predictors for the occurrence of sprains and strains among collegiate football players.

Objective

To refine a previously developed injury-prediction model through analysis of 3 consecutive seasons of data.

Design

Cohort study.

Setting

National Collegiate Athletic Association Division I Football Championship Subdivision football program.

Patients or Other Participants

For 3 consecutive years, all 152 team members (age = 19.7 ± 1.5 years, height = 1.84 ± 0.08 m, mass = 101.08 ± 19.28 kg) presented for a mandatory physical examination on the day before initiation of preseason practice sessions.

Main Outcome Measure(s)

Associations between preseason measurements and the subsequent occurrence of a core or lower extremity sprain or strain were established for 256 player-seasons of data. We used receiver operating characteristic analysis to identify optimal cut points for dichotomous categorizations of cases as high risk or low risk. Both logistic regression and Cox regression analyses were used to identify a multivariable injury-prediction model with optimal discriminatory power.

Results

Exceptionally good discrimination between injured and uninjured cases was found for a 3-factor prediction model that included equal to or greater than 1 game as a starter, Oswestry Disability Index score equal to or greater than 4, and poor wall-sit–hold performance. The existence of at least 2 of the 3 risk factors demonstrated 56% sensitivity, 80% specificity, an odds ratio of 5.28 (90% confidence interval = 3.31, 8.44), and a hazard ratio of 2.97 (90% confidence interval = 2.14, 4.12).

Conclusions

High exposure to game conditions was the dominant injury risk factor for collegiate football players, but a surprisingly mild degree of low back dysfunction and poor core-muscle endurance appeared to be important modifiable risk factors that should be identified and addressed before participation.Key Words: clinical decision making, primary injury prevention, low back pain

Key Points

• A 3-factor prediction model that includes 2 modifiable injury risk factors can be used to identify collegiate football players who might benefit from targeted risk-reduction interventions.
• A mild degree of low back dysfunction and a suboptimal level of core-muscle endurance appeared to be important injury risk factors that should be identified and addressed.
• High exposure to game conditions was a dominant injury risk factor.
• The combination of high exposure to game conditions with a potentially modifiable risk factor was associated with a substantially increased risk of core or lower extremity sprain or strain.

Injury prevention is mentioned in virtually every definition of sports medicine, but very little research evidence is available to support specific procedures for reduction of injury risk. A 4-step model to guide sports injury-prevention research and practice was introduced more than 20 years ago by van Mechelen et al.¹ The model subsequently was modified to incorporate additional concepts,^2,3 but very little progress has been made beyond the initial step of documenting injury incidences for various populations.^4,5 Risk factors for some specific types of injury have been identified, but little information in the literature has supported specific screening procedures to identify individual athletes who possess elevated injury risk.^6–8 The relative lack of evidence for the effectiveness of specific interventions for reducing injury incidence may be explained by the highly injury-specific and sport-specific nature of many risk factors⁹ and the cumulative effects, and possibly interactive effects, of multiple risk factors in creating injury susceptibility.^3,10–13Injury prevention is typically categorized as a clinical-practice domain that is distinct from injury rehabilitation, but some overlap exists. A previously sustained injury is a well-established risk factor for subsequent injury, which often may be attributable to suboptimal clinical management.^14,15 Furthermore, intrinsic injury risk factors may affect the rate at which an athlete''s functional capabilities are restored after an injury. An individual''s capacity to tolerate the external loads imposed by sport-related activities largely depends on tissue stiffness,¹¹ which is potentially modifiable through training-induced adaptations in neuromuscular function. Furthermore, injury-induced neural inhibition of muscle function can produce subtle and persistent performance deficiencies among highly active elite athletes.¹⁶ Most injuries do not completely remove athletes from participation,¹⁵ which may result in an unrecognized, persistent increase in injury susceptibility.A clinical prediction model can provide a quantitative estimate of the likelihood that an individual who possesses a particular combination of factors will ultimately develop a particular condition or experience an adverse event at some time.¹⁷ The combination of simple core-muscle–endurance test results, survey responses, anthropometric measurements, and recorded exposures to game conditions has been shown to differentiate the preseason profiles of collegiate football players who subsequently sustained core or lower extremity sprains or strains from players who did not, which was represented quantitatively by an odds ratio (OR).⁸ The maximum time that static body positions can be maintained against gravity has been reported to provide highly reliable measurements of core-muscle endurance.¹⁸ Wilkerson et al⁸ administered 4 tests in the same sequence: (1) back-extension hold, (2) 60° trunk-flexion hold, (3) side-bridge hold, and (4) bilateral wall-sit hold. Surveys that were originally designed to quantify joint function to document treatment outcome can be modified for use as discriminative instruments before injury occurrence.¹⁹ Researchers⁸ have suggested that well-validated outcome survey instruments can undergo minor modifications to obtain preparticipation joint function scores that have value for injury prediction. Self-perception of the preparticipation functional status of the lower back, knees, and ankles and feet has been quantified by 3 surveys with well-established psychometric properties: (1) the Oswestry Disability Index (ODI),^20,21 (2) the International Knee Documentation Committee Subjective Knee Form,²² and (3) the sports component of the Foot and Ankle Ability Measure.²³Wilkerson et al⁸ observed that the odds for occurrence of a core or lower extremity sprain or strain over 1 football season were 16 times greater for players who had at least 3 of the following characteristics: (1) trunk-flexion hold time equal to or less than 161 seconds, (2) bilateral wall-sit–hold time equal to or less than 88 seconds, (3) ODI score equal to or greater than 6, and (4) starting in 3 or more games or playing in all 11 games. With game exposure removed from the analysis, the odds for injury incidence among players with at least 2 of the 3 potentially modifiable risk factors was 4 times greater than the risk level for players with 0 or 1 factor. In subsequent years, the core-muscle–endurance tests were modified to increase their difficulty and thereby shorten the time required for their administration. Every modification of testing procedures resulted in improved efficiency of administration without loss of predictive power. Two subsequent single-season analyses confirmed the validity of the original multifactor model, but the results also demonstrated that the model could be simplified without substantial loss of predictive power (G.B.W., unpublished data, 2011, 2012). Therefore, the purpose of our study was to analyze 3 consecutive seasons of combined data for preseason status, game exposures, and injury occurrences to derive a refined model for prediction of core or lower extremity sprain or strain during participation in collegiate football.     

Distal Medial Collateral Ligament Grade III Injuries in Collegiate Football Players: Operative Management,Rehabilitation, and Return to Play

ContextManagement of isolated grade III medial collateral ligament injuries is controversial, as both nonoperative and operative management can result in return to play. However, operative management is recommended in elite athletes who have a grade III injury with distal avulsion.ObjectiveWe present a standardized rehabilitation protocol in a case series of 7 National Collegiate Athletic Association Division I American football athletes who sustained grade III distal medial collateral ligament tears that were repaired operatively, with emphasis on return to play.ResultsMedian time to surgery was 4 days (range = 2–67 days). Median time from surgery to noncontact drills was 120.5 days (range = 104–168 days), and median time from surgery to full-contact sport was 181 days (range = 139–204 days). All athletes returned to play at their preinjury level of competition.ConclusionsOur study highlighted how operative management with a standardized rehabilitation protocol can be applied to Division I football players and result in safe return to play.     

Pancreatic Laceration in a Female Collegiate Soccer Athlete: A Case Report

Objective:

To characterize the diagnosis of pancreatic trauma in an athletic population and to raise awareness among health care providers of the possibility of this life- and organ-threatening injury.

Background:

An 18-year-old, previously healthy female collegiate soccer athlete sustained a direct blow from an opponent''s knee between the left and right upper abdominal quadrants while attempting to head the ball. She initially presented with only minimal nausea and discomfort, but this progressed to abdominal pain, tenderness, spasm, and vomiting. She was referred to the emergency department, where she was diagnosed with a pancreatic laceration.

Differential Diagnosis:

Duodenal, hepatic, or splenic contusion or laceration; hemorrhagic ovarian cyst.

Treatment:

The patient underwent a distal pancreatectomy and total splenectomy.

Uniqueness:

Pancreatic injuries, particularly those severe enough to warrant surgical intervention, are extremely rare in athletes.

Conclusions:

Recognition of a pancreatic injury can be very challenging outside the hospital setting. This is problematic, because a delay in diagnosis is a significant source of preventable morbidity and mortality after this rare injury. Thus, early identification depends on a high index of suspicion, a thorough examination, and close observation. It is imperative that athletic trainers and other health care professionals be able to identify this condition so that referral and management can occur without delay.Key Words: abdomen, blunt trauma, cholangiopancreatography, pancreatectomy, splenectomyInjuries to the pancreas from blunt trauma are relatively uncommon and rarely occur during athletic training and competition.^1–3 However, these injuries are associated with high morbidity and mortality because they are difficult to detect and diagnosis is often delayed.⁴ Identification of a serious intra-abdominal condition is often challenging, as many injuries may not be apparent during the initial assessment.^1,5 Furthermore, the mechanisms of injury often result in associated damage that may divert an athletic trainer''s attention from a potentially life- or organ-threatening intra-abdominal condition. We present this case of a pancreatic laceration in a collegiate female soccer athlete to inform health care professionals in the sports setting about this uncommon but life-threatening condition. This case is unique in that this injury rarely occurs in athletes, but it was severe enough to warrant removal of the spleen and a a large section of the pancreas.     

Recovery After High-Intensity Intermittent Exercise in Elite Soccer Players Using VEINOPLUS Sport Technology for Blood-Flow Stimulation

Context

Electric muscle stimulation has been suggested to enhance recovery after exhaustive exercise by inducing an increase in blood flow to the stimulated area. Previous studies have failed to support this hypothesis. We hypothesized that the lack of effect shown in previous studies could be attributed to the technique or device used.

Objective

To investigate the effectiveness of a recovery intervention using an electric blood-flow stimulator on anaerobic performance and muscle damage in professional soccer players after intermittent, exhaustive exercise.

Design

Randomized controlled clinical trial.

Setting

National Institute of Sport, Expertise, and Performance (INSEP).

Patients or Other Participants

Twenty-six healthy professional male soccer players.

Intervention(s)

The athletes performed an intermittent fatiguing exercise followed by a 1-hour recovery period, either passive or using an electric blood-flow stimulator (VEINOPLUS). Participants were randomly assigned to a group before the experiment started.

Main Outcome Measures(s)

Performances during a 30-second all-out exercise test, maximal vertical countermovement jump, and maximal voluntary contraction of the knee extensor muscles were measured at rest, immediately after the exercise, and 1 hour and 24 hours later. Muscle enzymes indicating muscle damage (creatine kinase, lactate dehydrogenase) and hematologic profiles were analyzed before and 1 hour and 24 hours after the intermittent fatigue exercise.

Results

The electric-stimulation group had better 30-second all-out performances at 1 hour after exercise (P = .03) in comparison with the passive-recovery group. However, no differences were observed in muscle damage markers, maximal vertical countermovement jump, or maximal voluntary contraction between groups (P > .05).

Conclusions

Compared with passive recovery, electric stimulation using this blood-flow stimulator improved anaerobic performance at 1 hour postintervention. No changes in muscle damage markers or maximal voluntary contraction were detected. These responses may be considered beneficial for athletes engaged in sports with successive rounds interspersed with short, passive recovery periods.Key Words: calf muscle, fatigue, athletes

Key Points

• After intermittent fatiguing exercise, these elite male soccer players showed better restoration of anaerobic performance with blood-flow stimulation than with passive recovery at 1 hour.
• Neither modality improved clearance of muscle damage markers or maximal voluntary contraction.

Rapid recovery of performance is important for elite athletes engaged in intermittent exercise that involves periods of intense exercise interspersed with short recovery periods (eg, martial arts, ice hockey, field sports). Optimizing training recovery may also be beneficial for performing successive bouts of training or competition over a season without associated fatigue or overtraining effects.The inability to repeat the same level of performance in short-duration exercise is frequently attributed to peripheral fatigue involving metabolite accumulation and muscle damage^1,2 resulting from mechanical stress, imbalances in muscle cell homeostasis, or local inflammation from exercise.³ Indeed, the response of different muscle enzymes (mainly creatine kinase [CK] and lactate dehydrogenase [LDH]) has received researchers'' attention because strenuous exercise induces muscle cell structural damage, which results in increased plasma concentrations of muscle enzymes such as CK and LDH.⁴ The efflux of CK and LDH proteins from muscle may be attributed to increased permeability of the plasma membrane or intramuscular vasculature (or both).⁵ Thus, a reduction in these markers has been proposed as an indicator of recovery after strenuous exercise that induces muscle damage.⁶ To optimize recovery, various techniques have been suggested to accelerate the clearance of muscular damage or metabolite accumulations. Usually, these techniques focus on local fatigue. Their main goal is to treat fatigue by directly applying the recovery method to the working muscles (eg, electromyostimulation, local cryotherapy, or cold-water immersion). This approach showed positive results after muscle damage by reducing local inflammation, especially when cold modalities were used.⁷ However, results on peripheral fatigue from metabolite accumulation are inconclusive, probably because the metabolic byproducts are released into the blood. From these findings, a change in the recovery approach from a local treatment to a systemic view was necessary. One possible way to achieve this goal is to improve the peripheral circulation and the venous return by stimulating total blood flow. In athletes, several techniques have been proposed to achieve this result. Of these, active recovery,^8,9 contrast water therapy,¹⁰ compression garments,¹¹ low-level laser therapy,¹² and low-frequency electromyostimulation¹³ have been investigated and compared with passive recovery (PAS).^6,14 The results of these studies provide no definitive consensus on the ability to improve explosive strength and anaerobic capacity performance or clear muscle damage markers after exercise.^15–17 Lattier et al¹⁸ showed no difference in neuromuscular function and maximal test performance after a recovery intervention using blood-flow stimulation from electromyostimulation compared with PAS or active recovery. Based on these observations, several authors concluded that the effects of these techniques are minimal, especially on performance. However, researchers^13,19 have hypothesized that this lack of effect could also be associated with the technique, the device used, or the localization of the electric stimulation (eg, systemic treatment [calf] versus local treatment [quadriceps]), suggesting that the blood flow and, more particularly, the venous return may not be effectively increased. Accordingly, Martin et al¹³ recommended optimizing the electric stimulation to better approximate the physiologic contraction of the muscle; a new way of using an electric muscle stimulator on the calf muscles could provide interesting results. This systemic approach is based on results showing that total blood flow can be efficiently stimulated by intensifying the pumping action associated with calf muscle contractions from techniques such as electromyostimulation, cuff inflation, or walking.²⁰ Indeed, these muscles, which have been termed the “peripheral venous heart,” “calf muscle pump,” and “musculovenous pump,” were responsible for 80% of the venous return^21–23 and considered a second heart. A low-intensity, repetitive mechanical contraction-relaxation muscle cycle may increase local and total blood flow, translocation, and removal of metabolites and reduce intracellular fluid volume.²⁴ However, using electric muscle stimulation to increase blood flow for exercise recovery has been ineffective despite the emergence of new devices that significantly improved total blood flow and venous return.^25–29 Therefore, we hypothesized that such a device applied to the calf muscles could result in faster restoration in performance and reduce the amount of muscle damage markers after fatiguing exercise.The purpose of our study was to investigate the effectiveness of muscle stimulation using the VEINOPLUS unit (Ad Rem Technology, Paris, France) on explosive strength and 30-second all-out performance and CK and LDH recovery profiles in professional soccer players after exhaustive intermittent exercise. We proposed that use of the VEINOPLUS would result in better restoration of anaerobic performance than passive recovery.     

Return to Preinjury Levels of Participation After Superior Labral Repair in Overhead Athletes: A Systematic Review

Context

Athletes often preoperatively weigh the risks and benefits of electing to undergo an orthopaedic procedure to repair damaged tissue. A common concern for athletes is being able to return to their maximum levels of competition after shoulder surgery, whereas clinicians struggle with the ability to provide a consistent prognosis of successful return to participation after surgery. The variation in study details and rates of return in the existing literature have not supplied clinicians with enough evidence to give overhead athletes adequate information regarding successful return to participation when deciding to undergo shoulder surgery.

Objective

To investigate the odds of overhead athletes returning to preinjury levels of participation after arthroscopic superior labral repair.

Data Sources

The CINAHL, MEDLINE, and SPORTDiscus databases from 1972 to 2013.

Study Selection

The criteria for article selection were (1) The study was written in English. (2) The study reported surgical repair of an isolated superior labral injury or a superior labral injury with soft tissue debridement. (3) The study involved overhead athletes equal to or less than 40 years of age. (4) The study assessed return to the preinjury level of participation.

Data Extraction

We critically reviewed articles for quality and bias and calculated and compared odds ratios for return to full participation for dichotomous populations or surgical procedures.

Data Synthesis

Of 215 identified articles, 11 were retained: 5 articles about isolated superior labral repair and 6 articles about labral repair with soft tissue debridement. The quality range was 11 to 17 (42% to 70%) of a possible 24 points. Odds ratios could be generated for 8 of 11 studies. Nonbaseball, nonoverhead, and nonthrowing athletes had a 2.3 to 5.8 times greater chance of full return to participation than overhead/throwing athletes after isolated superior labral repair. Similarly, nonoverhead athletes had 1.5 to 3.5 times greater odds for full return than overhead athletes after labral repair with soft tissue debridement. In 1 study, researchers compared surgical procedures and found that overhead athletes who underwent isolated superior labral repair were 28 times more likely to return to full participation than those who underwent concurrent labral repair and soft tissue debridement (P < .05).

Conclusions

The rate of return to participation after shoulder surgery within the literature is inconsistent. Odds of returning to preinjury levels of participation after arthroscopic superior labral repair with or without soft tissue debridement are consistently lower in overhead/throwing athletes than in nonoverhead/nonthrowing athletes. The variable rates of return within each group could be due to multiple confounding variables not consistently accounted for in the articles.Key Words: return to play, odds of return, shoulder injuries

Key Points

• Odds ratios of full return to participation were greater for nonoverhead athletes after superior labral repair.
• Evidence supporting return to participation after superior labral repair was low to moderate.

Shoulder injury, which can affect either the static or dynamic anatomical structures, can result in poor upper extremity function and suboptimal athletic performance. In the overhead athlete, anatomic tissue derangement frequently manifests as superior labral injury, which may occur alone or with concurrent rotator cuff injury (internal impingement).¹ In either condition, symptoms can present as pain on external rotation and cocking, weakness in clinical or functional upper extremity strength, symptoms of internal derangement (clicking, catching, sliding), and functional problems with velocity or control during overhead tasks.² In many patients, the symptoms of tissue derangement can be addressed nonoperatively with rehabilitation; however, if nonoperative efforts do not resolve symptoms or restore performance, operative management may be warranted to restore the compromised anatomy.Patients often preoperatively weigh the risks and benefits of electing to undergo an orthopaedic procedure to repair damaged tissue. A common concern for patients is being able to return to their maximum levels of competition after shoulder surgery, whereas clinicians are concerned with providing a consistent prognosis of successful return to participation after surgery. In a systematic review, Gorantla et al³ examined postoperative subjective outcomes after the repair of type II superior labral lesions. The researchers identified multiple differences among the reviewed studies, including variations in patient populations (eg, athletes, workers, general population), diagnosis, surgical technique, and size of the patient populations. Of the studies with populations comprising overhead athletes (5 of 11), return-to-participation rates varied from 22% to 92%.³ The variations in study details and rates of return have not supplied clinicians with enough evidence to provide overhead athletes with adequate information about successful return to participation when considering shoulder surgery. Therefore, the purpose of our systemic review was to investigate the odds of return to preinjury levels of participation of overhead athletes after arthroscopic superior labral repair. Two primary objectives were addressed in this systematic review using the patient, intervention, and outcome format: (1) In patients undergoing isolated superior labral repair (intervention), were the odds of returning to preinjury level of participation (outcome) equal between overhead and nonoverhead athletes (patient)? (2) In patients undergoing labral repair with soft tissue debridement (intervention), were the odds of returning to preinjury level of participation (outcome) equal between overhead and nonoverhead athletes (patient)?     

Traumatic Hemarthrosis of the Knee Secondary to Hemophilia A in a Collegiate Soccer Player: A Case Report

OBJECTIVE: To present the case of a collegiate soccer player who suffered from a traumatic knee hemarthrosis secondary to hemophilia A. This case presents an opportunity to discuss the participation status of athletes with hemophilia. BACKGROUND: Hemophilia is a hereditary blood disease characterized by impaired coagulability of the blood. Hemophilia A is the most common of the severe, inherited bleeding disorders. This type, also called classic hemophilia, is due to a deficiency of clotting factor VIII. The athlete with hemophilia A reported pain and loss of function of his knee during a soccer game despite the absence of injury. DIFFERENTIAL DIAGNOSIS: Anterior cruciate ligament tear, intra-articular fracture, meniscus tear, capsular tear, hemarthrosis. TREATMENT: After the injury, the athlete was admitted to the hospital, where his knee joint was aspirated and he was infused with factor VIII. Later, he participated in traditional knee rehabilitation and was returned to play at the discretion of the orthopaedist and the hematologist. UNIQUENESS: In past participation guidelines, individuals with bleeding disorders were disqualified from athletic participation; however, with advances in medical care, these individuals may be permitted to participate in accordance with the law. CONCLUSIONS: Individuals with hemophilia participate in athletics; therefore, team physicians and athletic trainers must be prepared to care for these individuals.     

Return to Work After Myocardial Infarction in a Lower Socioeconomic Population

A retrospective study of the work status of 45 consecutive male patients who were at least 12 months post myocardial infarction was carried out. The vast majority of patients were in the lower socioeconomic classes. Only 31 percent of those previously working returned to employment. No differences were found in mean age, physical disability, or anxiety; however, those not working were significantly more depressed (P < .05). A major factor related to failure to return to work may be that the majority of this lower socioeconomic group of patients worked as laborers and did not have the education or training to find alternative jobs.     

Trunk-Rotation Flexibility in Collegiate Softball Players With or Without a History of Shoulder or Elbow Injury

Context:

Throwing is a whole-body motion that requires the transfer of momentum from the lower extremity to the upper extremity via the trunk. No research to date examines the association between a history of shoulder or elbow injury and trunk flexibility in overhead athletes.

Objective:

To determine if injury history and trunk-rotation flexibility are associated and to compare trunk-rotation flexibility measured using 3 clinical tests: half-kneeling rotation test with the bar in the back, half-kneeling rotation test with the bar in the front, and seated rotation test in softball position players with or without a history of shoulder or elbow injury.

Design:

Cross-sectional design.

Setting:

University softball facilities.

Patients or Other Participants:

Sixty-five female National Collegiate Athletic Association Division I softball position players.

Intervention(s):

Trunk-rotation flexibility was measured with 3 clinical tests. Recent injury history was obtained using a questionnaire and verified by the certified athletic trainer.

Main Outcome Measure(s):

Binomial regression models were used to determine if injury history was associated with flexibility categories (high, normal, or limited tertiles) for each of the 6 (3 tests × 2 directions) trunk-rotation flexibility measures. Trunk-rotation flexibility measures from 3 clinical tests were compared between participants with and without a history of shoulder or elbow injury using analysis-of-variance models.

Results:

When measured using the half-kneeling rotation test with the bar in the back and the seated rotation test, injury history and forward trunk-rotation flexibility were associated. However, no mean group differences were seen in trunk-rotation flexibility between participants with and without a history of shoulder or elbow injury.

Conclusions:

Limited forward trunk-rotation flexibility may be a risk factor for shoulder or elbow injuries. However, further study is needed to confirm the study finding.     

Emergent Access to the Airway and Chest in American Football Players

Context:

American football has the highest rate of fatalities and catastrophic injuries of any US sport. The equipment designed to protect athletes from these catastrophic events challenges the ability of medical personnel to obtain neutral spine alignment and immobilization during airway and chest access for emergency life-support delivery.

Objective:

To compare motion, time, and difficulty during removal of American football helmets, face masks, and shoulder pads.

Design:

Quasi-experimental, crossover study.

Setting:

Controlled laboratory.

Patients or Other Participants:

We recruited 40 athletic trainers (21 men, 19 women; age = 33.7 ± 11.2 years, height = 173.1 ± 9.2 cm, mass = 80.7 ± 17.1 kg, experience = 10.6 ± 10.4 years).

Intervention(s):

Paired participants conducted 16 trials in random order for each of 4 helmet, face-mask, and shoulder-pad combinations. An 8-camera, 3-dimensional motion-capture system was used to record head motion in live models wearing properly fitted helmets and shoulder pads.

Main Outcome Measure(s):

Time and perceived difficulty (modified Borg CR-10).

Results:

Helmet removal resulted in greater motion than face-mask removal, respectively, in the sagittal (14.88°, 95% confidence interval [CI] = 13.72°, 16.04° versus 7.04°, 95% CI = 6.20°, 7.88°; F_1,19 = 187.27, P < .001), frontal (7.00°, 95% CI = 6.47°, 7.53° versus 4.73°, 95% CI = 4.20°, 5.27°; F_1,19 = 65.34, P < .001), and transverse (7.00°, 95% CI = 6.49°, 7.50° versus 4.49°, 95% CI = 4.07°, 4.90°; F_1,19 = 68.36, P < .001) planes. Face-mask removal from Riddell 360 helmets took longer (31.22 seconds, 95% CI = 27.52, 34.91 seconds) than from Schutt ION 4D helmets (20.45 seconds, 95% CI = 18.77, 22.12 seconds) or complete ION 4D helmet removal (26.40 seconds, 95% CI = 23.46, 29.35 seconds). Athletic trainers required less time to remove the Riddell Power with RipKord (21.96 seconds, 95% CI = 20.61°, 23.31° seconds) than traditional shoulder pads (29.22 seconds, 95% CI = 27.27, 31.17 seconds; t₁₉ = 9.80, P < .001).

Conclusions:

Protective equipment worn by American football players must eventually be removed for imaging and medical treatment. Our results fill a gap in the evidence to support current recommendations for prehospital emergent management in patients wearing protective football equipment. Helmet face masks and shoulder pads with quick-release designs allow for clinically acceptable removal times without inducing additional motion or difficulty.Key Words: cervical spine injury, sudden cardiac event, protective equipment

Key Points

• Face-mask removal induced less motion than helmet removal when accessing the airway.
• Helmet face masks and shoulder pads with quick-release designs allowed for clinically acceptable removal times without inducing additional motion or difficulty.
• The actual ability to effectively ventilate a patient with a helmet on and face mask removed was not studied and has not been established in the literature.

More than 2 million athletes participate in American football each year.¹ The sport has the highest rate of fatalities and catastrophic injuries of any sport,² with most resulting from neurotraumatic (brain, cervical spine) and sudden cardiovascular events. The ability to initiate immediate basic life support in these scenarios is paramount in preventing avoidable sudden death. However, the equipment designed to protect athletes from catastrophic injury challenges the responders'' ability to obtain neutral spine alignment and immobilization during delivery of emergency life support. An investigation is warranted of equipment-removal techniques that may be implemented by emergency care providers (eg, certified or licensed athletic trainers, paramedics, and emergency department staff) giving life support.Acute medical care of the American football player with a potentially catastrophic injury or illness in the prehospital setting (ie, athletic field) necessitates a careful and coordinated approach to minimize sequelae associated with misdiagnosis and mismanagement.³ The prehospital setting presents unique factors that make delivering appropriate care challenging. For example, given that isolated independent removal of football helmets has been shown to move the cervical spine out of neutral alignment,^4–6 the National Athletic Trainers'' Association⁷ recommended that the helmet and shoulder pads remain in place and airway access be achieved via face-mask removal, except under certain circumstances. However, no researchers have published reports comparing helmet removal and face-mask removal to support this recommendation. These recommendations also differ from protocols used by many providers for suspected spine injuries in patients wearing helmets without shoulder pads (eg, cycling, motorsports), when removal of the helmet is necessary to secure airway access and establish neutral cervical alignment.Recent modifications from 2 football-equipment manufacturers involve helmets with face masks that are attached with a full quick-release system designed to release the face mask without removing screws. Previous systems incorporated quick-release face-mask attachments at 2 of 4 positions and appeared to allow for faster and safer airway access than traditional attachments.^8,9 A manufacturer also has modified a shoulder-pad design to incorporate a quick-release feature. Research validating the safety of these designs will provide evidence to support clinical best practices.Therefore, the purpose of our study was to determine the safest emergency intervention to allow for airway and chest access in the presence of different styles of helmets and shoulder pads. To accomplish these objectives, we were most interested in the interaction between airway-access technique and helmet type and the effect of shoulder-pad designs on head movement, time to task completion, and perceived difficulty of removal. We hypothesized that less head movement, less time to task completion, and less perceived difficulty would exist (1) during face-mask removal than during helmet removal, regardless of helmet type, and (2) during shoulder-pad removal using a quick-release shoulder pad design versus a traditional shoulder-pad design.     

Fluid Consumption and Sweating in National Football League and Collegiate Football Players With Different Access to Fluids During Practice

Context:

Considerable controversy regarding fluid replacement during exercise currently exists.

Objective:

To compare fluid turnover between National Football League (NFL) players who have constant fluid access and collegiate football players who replace fluids during water breaks in practices.

Design:

Observational study.

Setting:

Respective preseason training camps of 1 National Collegiate Athletic Association Division II (DII) football team and 1 NFL football team. Both morning and afternoon practices for DII players were 2.25 hours in length, and NFL players practiced for 2.25 hours in the morning and 1 hour in the afternoon. Environmental conditions did not differ.

Patients or Other Participants:

Eight NFL players (4 linemen, 4 backs) and 8 physically matched DII players (4 linemen, 4 backs) participated.

Intervention(s):

All players drank fluids only from their predetermined individual containers. The NFL players could consume both water and sports drinks, and the DII players could only consume water.

Main Outcome Measure(s):

We measured fluid consumption, sweat rate, total sweat loss, and percentage of sweat loss replaced. Sweat rate was calculated as change in mass adjusted for fluids consumed and urine produced.

Results:

Mean sweat rate was not different between NFL (2.1 ± 0.25 L/h) and DII (1.8 ± 0.15 L/h) players (F_1,12  =  2, P  =  .18) but was different between linemen (2.3 ± 0.2 L/h) and backs (1.6 ± 0.2 L/h) (t₁₄  =  3.14, P  =  .007). We found no differences between NFL and DII players in terms of percentage of weight loss (t₇  =  −0.03, P  =  .98) or rate of fluid consumption (t₇  =  −0.76, P  =  .47). Daily sweat loss was greater in DII (8.0 ± 2.0 L) than in NFL (6.4 ± 2.1 L) players (t₇  =  −3, P  =  .02), and fluid consumed was also greater in DII (5.0 ± 1.5 L) than in NFL (4.0 ± 1.1 L) players (t₇  =  −2.8, P  =  .026). We found a correlation between sweat loss and fluids consumed (r  =  0.79, P < .001).

Conclusions:

During preseason practices, the DII players drinking water at water breaks replaced the same volume of fluid (66% of weight lost) as NFL players with constant access to both water and sports drinks.     

Pilot Evaluation of a Novel Clinical Test of Reaction Time in National Collegiate Athletic Association Division I Football Players

Context:

Evidence suggests that concussion prolongs reaction time (RT). We have developed a simple, reliable clinical tool for measuring reaction time that may be of value in the assessment of concussion in athletes.

Objective:

To compare baseline values of clinical RT (RT_clin) obtained using the new clinical reaction time apparatus with computerized RT (RT_comp) obtained using a validated computerized neuropsychological test battery.

Design:

Cross-sectional study.

Setting:

Data were collected during a National Collegiate Athletic Association Division I collegiate football team''s preparticipation physical examination session.

Patients or Other Participants:

Ninety-four Division I collegiate football players.

Main Outcome Measure(s):

The RT_clin was measured using a 1.3-m measuring stick embedded in a weighted rubber disk that was released and caught as quickly as possible. The RT_comp was measured using the simple RT component of CogState Sport.

Results:

For the 68 athletes whose CogState Sport tests passed the program''s integrity check, RT_clin and RT_comp were correlated (r  =  0.445, P < .001). Overall, mean RT_clin was shorter and less variable than mean RT_comp (203 ± 20 milliseconds versus 268 ± 44 milliseconds; P < .001). When RT_clin and RT_comp were compared between those athletes with (n  =  68) and those without (n  =  26) valid CogState Sport test sessions, mean RT_clin was similar (202 ± 19 milliseconds versus 207 ± 23 milliseconds; P  =  .390), but mean RT_comp was different (258 ± 35 milliseconds versus 290 ± 55 milliseconds; P  =  .009).

Conclusions:

The RT_clin was positively correlated with RT_comp and yielded more consistent reaction time values during baseline testing. Given that RT_clin is easy to measure using simple, inexpensive equipment, further prospective study is warranted to determine its clinical utility in the assessment of concussion in athletes.     

Cultural Barriers to African American Participation in Anxiety Disorders Research

Anxiety disorders are understudied, underdiagnosed, and undertreated in African Americans. Research focused on the phenomenology, etiology, and treatment of anxiety in African Americans has been hampered by lack of inclusion of this population in clinical research studies. The reason for exclusion is not well understood, although cultural mistrust has been hypothesized as a major barrier to research participation. This article reviews the relevant literature to date and examines the experience of 6 African American adults who participated in a larger clinical assessment study about anxiety. Drawing upon in-depth semistructured interviews about their subjective experiences, we examined participant perspectives about the assessment process, opinions about African American perception of anxiety studies, and participant-generated ideas about how to improve African American participation. Based on a qualitative analysis of responses, feelings of mistrust emerged as a dominant theme. Concerns fell under 6 categories, including not wanting to speak for others, confidentiality, self and group presentation concerns, repercussions of disclosure, potential covert purposes of the study, and the desire to confide only in close others. Suggestions for increasing African American participation are discussed, including assurances of confidentiality, adequate compensation, and a comfortable study environment.