National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses

Objective

 To present best-practice recommendations for the prevention, recognition, and treatment of exertional heat illnesses (EHIs) and to describe the relevant physiology of thermoregulation.

Background

 Certified athletic trainers recognize and treat athletes with EHIs, often in high-risk environments. Although the proper recognition and successful treatment strategies are well documented, EHIs continue to plague athletes, and exertional heat stroke remains one of the leading causes of sudden death during sport. The recommendations presented in this document provide athletic trainers and allied health providers with an integrated scientific and clinically applicable approach to the prevention, recognition, treatment of, and return-to-activity guidelines for EHIs. These recommendations are given so that proper recognition and treatment can be accomplished in order to maximize the safety and performance of athletes.

Recommendations

 Athletic trainers and other allied health care professionals should use these recommendations to establish onsite emergency action plans for their venues and athletes. The primary goal of athlete safety is addressed through the appropriate prevention strategies, proper recognition tactics, and effective treatment plans for EHIs. Athletic trainers and other allied health care professionals must be properly educated and prepared to respond in an expedient manner to alleviate symptoms and minimize the morbidity and mortality associated with these illnesses.Key Words: heat cramps, heat syncope, heat exhaustion, heat injury, heat stroke, dehydrationThe prevention, recognition, and treatment of exertional heat illnesses (EHIs) are core components of sports medicine services at all levels of sport. The risk of EHI is ever present during exercise in the heat but can also occur in “normal” environmental conditions. Our current knowledge base has allowed us to greatly enhance the level of care that can be provided for athletes with these medical conditions. This document serves as the current position statement for the National Athletic Trainers'' Association (NATA) and replaces the document that was published in 2002.¹The care of exertional heat-stroke (EHS) patients has come a long way in the past millennia. We now possess the knowledge to nearly assure survival from this potentially fatal injury if EHS is quickly and appropriately recognized and treated at the time of collapse.^2,3 Additionally, our knowledge base and proven management protocols allow us to establish effective prevention and management strategies to minimize the risk of and improve the outcome from EHS, thereby affecting public health via policy creation and modification.     

National Athletic Trainers' Association Position Statement: Skin Diseases

Objective:

To present recommendations for the prevention, education, and management of skin infections in athletes.

Background:

Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents.

Recommendations:

These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.     

National Athletic Trainers' Association Position Statement: Environmental Cold Injuries

Objective:

To present recommendations for the prevention, recognition, and treatment of environmental cold injuries.

Background:

Individuals engaged in sport-related or work-related physical activity in cold, wet, or windy conditions are at risk for environmental cold injuries. An understanding of the physiology and pathophysiology, risk management, recognition, and immediate care of environmental cold injuries is an essential skill for certified athletic trainers and other health care providers working with individuals at risk.

Recommendations:

These recommendations are intended to provide certified athletic trainers and others participating in athletic health care with the specific knowledge and problem-solving skills needed to address environmental cold injuries. Each recommendation has been graded (A, B, or C) according to the Strength of Recommendation Taxonomy criterion scale.     

National Athletic Trainers' Association Position Statement: Emergency Planning in Athletics

OBJECTIVES: To educate athletic trainers and others about the need for emergency planning, to provide guidelines in the development of emergency plans, and to advocate documentation of emergency planning. BACKGROUND: Most injuries sustained during athletics or other physical activity are relatively minor. However, potentially limb-threatening or life-threatening emergencies in athletics and physical activity are unpredictable and occur without warning. Proper management of these injuries is critical and should be carried out by trained health services personnel to minimize risk to the injured participant. The organization or institution and its personnel can be placed at risk by the lack of an emergency plan, which may be the foundation of a legal claim. RECOMMENDATIONS: The National Athletic Trainers' Association recommends that each organization or institution that sponsors athletic activities or events develop and implement a written emergency plan. Emergency plans should be developed by organizational or institutional personnel in consultation with the local emergency medical services. Components of the emergency plan include identification of the personnel involved, specification of the equipment needed to respond to the emergency, and establishment of a communication system to summon emergency care. Additional components of the emergency plan are identification of the mode of emergency transport, specification of the venue or activity location, and incorporation of emergency service personnel into the development and implementation process. Emergency plans should be reviewed and rehearsed annually, with written documentation of any modifications. The plan should identify responsibility for documentation of actions taken during the emergency, evaluation of the emergency response, institutional personnel training, and equipment maintenance. Further, training of the involved personnel should include automatic external defibrillation, cardiopulmonary resuscitation, first aid, and prevention of disease transmission.     

National Athletic Trainers' Association Position Statement: Lightning Safety for Athletics and Recreation

Objective:

To present recommendations for the education, prevention, and management of lightning injuries for those involved in athletics or recreation.

Background:

Lightning is the most common severe-storm activity encountered annually in the United States. The majority of lightning injuries can be prevented through an aggressive educational campaign, vacating outdoor activities before the lightning threat, and an understanding of the attributes of a safe place from the hazard.

Recommendations:

This position statement is focused on supplying information specific to lightning safety and prevention and treatment of lightning injury and providing lightning-safety recommendations for the certified athletic trainer and those who are involved in athletics and recreation.Key Words: thunderstorms, emergency action plan, threatening weatherLightning is the most dangerous and frequently encountered thunderstorm hazard that people experience every year.^1–3 Over the past century, it has consistently been in the top 2 causes of storm-related deaths in the United States. During the most recent decade, lightning was responsible for an average of 42 fatalities yearly in the United States and an estimated 10 times as many injuries.^4–9 Data from 2005 indicated that approximately 15% of lightning casualties arose in organized sports, and an additional 25% to 30% resulted from recreational activities.¹⁰ The National Weather Service^9,11 reported more recent data from 2010 and 2011, with 48% and 62% of lightning fatalities attributed to sport and recreation, respectively (

National Athletic Trainers' Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions

Objective

To present athletic trainers with recommendations for the content and administration of the preparticipation physical examination (PPE) as well as considerations for determining safe participation in sports and identifying disqualifying conditions.

Background

Preparticipation physical examinations have been used routinely for nearly 40 years. However, considerable debate exists as to their efficacy due to the lack of standardization in the process and the lack of conformity in the information that is gathered. With the continuing rise in sports participation at all levels and the growing number of reported cases of sudden death in organized athletics, the sports medicine community should consider adopting a standardized process for conducting the PPE to protect all parties.

Recommendations

Recommendations are provided to equip the sports medicine community with the tools necessary to conduct the PPE as effectively and efficiently as possible using available scientific evidence and best practices. In addition, the recommendations will help clinicians identify those conditions that may threaten the health and safety of participants in organized sports, may require further evaluation and intervention, or may result in potential disqualification.Key Words: medical history, family history, sudden cardiac death, concussion, sickle cell trait, diabetes, heat illness, hydrationParticipation in organized US athletics continues to rise. During the 2010–2011 academic year, more than 7.6 million high school students took part in organized interscholastic sports, compared with 7.1 million in 2005–2006.¹ Similarly, an additional 444 077 National Collegiate Athletic Association student–athletes participated in intercollegiate athletics in 2010–2011, compared with 393 509 in 2005–2006.² This growth in participation has led to a concomitant rise in sudden death. Most sudden deaths have been attributed to congenital or acquired cardiovascular malformations involving male football and basketball players.^3–5 Other causes of sudden death include heat stroke, cerebral aneurysm, asthma, commotio cordis, and sickle cell trait.^4,5 As sports participation continues to increase and catastrophic death in athletes receives more attention, the medical community should consider adopting a standardized preparticipation examination (PPE) instrument that, at a minimum and to the extent possible, sets out to ensure a safe playing environment for all and to identify those conditions that might predispose an athlete to injury or sudden death.For nearly 4 decades, PPE screening has been used routinely in an attempt to identify those conditions that may place an athlete at increased risk and affect safe participation in organized sports. Few would empirically argue the potential benefits of this practice, yet considerable debate exists as to the current efficacy of the PPE, given the significant disparities that presently characterize the examination and the information gathered. Over time, the PPE has become an integral component of athletics and sports medicine programs; however, the lack of standardization in the process has created confusion. In addition, the failure to adequately define the primary objectives of the PPE has led to the consensus that, in its current form, the PPE does not address the ultimate goal of protecting the health and safety of the player.The American Medical Association Group on Science and Technology⁶ has asserted that every physician has 2 responsibilities to an athlete during the PPE: “(1) to identify those athletes who have medical conditions that place them at substantial risk for injury or sudden death and to disqualify them from participation or ensure they receive adequate medical treatment before participation and (2) to not disqualify athletes unless there is a compelling medical reason.” As the PPE has evolved over the years, it has become increasingly difficult to meet these standards given the many objectives that have been proposed for the screening instrument. Originally, the primary objectives of the PPE were to (1) detect life-threatening or disabling conditions, (2) identify those conditions that predispose the athlete to injury or disability, and (3) address legal and insurance requirements.^7,8 Today, however, those entities charged with developing and revising the PPE (eg, state high school athletic associations, medical associations, state education departments, state health departments, legislators)⁹ often have different missions, and as a result, they have sought to influence the makeup of the PPE to address their specific interests. This has led to the identification of a number of secondary objectives, including but not limited to documenting athletic eligibility, obtaining parental consent for participation and emergency treatment, and improving athlete performance.⁹ Most notably, the PPE represents the sole source of medical evaluation for 30% to 88% of children and adolescents annually^10,11 and an opportunity to identify conditions that, although not necessarily related to or requiring restriction from athletic participation, nonetheless call for additional follow-up.⁹ Some authors¹² have advocated this practice to evaluate the general health of the athlete and to provide an opening to discuss high-risk behaviors, preventive care measures, and nonathletic concerns. Others oppose this view, stating that the PPE “should not be the sole component of health care for athletes”⁶ and that the PPE can only be effective if the goals remain specific and properly directed toward the demands of sport participation.^6,13     

National Athletic Trainers' Association Position Statement: Head-Down Contact and Spearing in Tackle Football

OBJECTIVE: To present recommendations that decrease the risk of cervical spine fractures and dislocations in football players. BACKGROUND: Axial loading of the cervical spine resulting from head-down contact is the primary cause of spinal cord injuries. Keeping the head up and initiating contact with the shoulder or chest decreases the risk of these injuries. The 1976 rule changes resulted in a dramatic decrease in catastrophic cervical spine injuries. However, the helmet-contact rules are rarely enforced and head-down contact still occurs frequently. Our recommendations are directed toward decreasing the incidence of head-down contact. RECOMMENDATIONS: Educate players, coaches, and officials that unintentional and intentional head-down contact can result in catastrophic injuries. Increase the time tacklers, ball carriers, and blockers spend practicing correct contact techniques. Improve the enforcement and understanding of the existing helmet-contact penalties.     

National Athletic Trainers' Association Position Statement: Evaluation of Dietary Supplements for Performance Nutrition

Objectives

To help athletic trainers promote a “food-first” philosophy to support health and performance, understand federal and sport governing body rules and regulations regarding dietary supplements and banned substances, and become familiar with reliable resources for evaluating the safety, purity, and efficacy of dietary supplements.

Background

The dietary supplement industry is poorly regulated and takes in billions of dollars per year. Uneducated athletes need to gain a better understanding of the safety, eligibility, and efficacy concerns associated with choosing to take dietary supplements. The athletic trainer is a valuable athletic team member who can help in the educational process. In many cases, athletic trainers are asked to help evaluate the legality, safety, and efficacy of dietary supplements. For this position statement, our mission is to provide the athletic trainer with the necessary resources for these tasks.

Recommendations

Proper nutrition and changes in the athlete''s habitual diet should be considered first when improved performance is the goal. Athletes need to understand the level of regulation (or lack thereof) governing the dietary supplement industry at the international, federal, state, and individual sport-participation levels. Athletes should not assume a product is safe simply because it is marketed over the counter. All products athletes are considering using should be evaluated for purity (ie, truth in labeling), safety, and efficacy.Key Words: ergogenics, Dietary Supplement and Health Education Act, World Anti-Doping AgencyFoods and dietary supplements have been used to enhance health and athletic performance (ergogenics) since the early Olympic Games. Today, athletes at all levels of competition continually work to improve performance, and many consider the use of dietary supplements or engineered foods to gain an additional performance edge or health benefit. This may concern health care professionals because athletes may receive advice and feel pressure from many well-meaning supporters and advocates. However, athletes can be vulnerable to misinformation and risk in terms of the safety, legality, and efficacy of dietary supplements.Although determining overall rates of supplement use among athletes is difficult, estimates of use by collegiate, high school, and middle school athletes have been reported in the literature.^1–6 In a 2004 study by Burns et al,¹ 88% of the collegiate athletes surveyed used 1 or more nutritional supplements, yet the perceived efficacy of those supplements was only moderate. Athletic trainers (ATs) were their primary sources of nutrition information and were perceived to have significant nutrition knowledge. The 2012 “Substance Use” report compiled by the National Collegiate Athletic Association (NCAA) presented survey data from 20 474 US athletes and compared those data with 2005 outcomes.⁷ Although survey data are limited by the perceived anonymity of the results, they can be useful to better understand trends and potential risk factors.The overwhelming industry presence and advertising appeal likely has strong influence on athlete choices. According to the 2011 “Sports Nutrition and Weight Loss Report,”⁸ 9% annual sales growth and $22.7 billion in total sales were noted for sports nutrition and weight-loss products in 2010. Energy drinks and shots (small containers of concentrated product) were the primary product category ($12 million) and were purchased through mass channels. A December 2010 press release from the US Food and Drug Administration (FDA) regarding methylhexaneamine, which has been identified as the “new ephedra” (stimulant), anticipated continued reports of adverse events, failed drug tests, and product recalls. The release also cited consumer-trust issues in the supplement industry and the joining of forces by the FDA and major trade organizations to “clean up” the industry. Obviously, health care practitioners need to be aware of the trends in supplement use and the risks the supplements may carry for athletes'' health and sport eligibility.As health care professionals, ATs must be knowledgeable regarding basic nutrition and supplement use and must be able to educate their athletes regarding the efficacy, safety, and legal issues associated with the use of supplements. If they are not knowledgeable in these areas, ATs must be aware of resources for education and proper referral, so they can provide guidance for those within the athletic community. This position statement provides suggested resources to help ATs stay current in the ever-changing landscape of dietary supplements.To formalize the position statement objectives into recommendations, we used (where appropriate) evidence-based review and the Strength of Recommendation Taxonomy (SORT) criterion scale (9 and adopted by the National Athletic Trainers'' Association. Some of the educational materials regarding dietary supplements are found in federal law; these are noted in the recommendations.

Table. Strength of Recommendation Taxonomy (SORT)^a

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries

Objective:

To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6–18 years).

Background:

Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches.

Recommendations:

Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.     

Barriers and Facilitators Faced by Athletic Trainers Implementing National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines in US High School Football Players

ContextThe aim of the National Athletic Trainers'' Association Inter-Association Task Force (NATA-IATF) preseason heat-acclimatization guidelines was to acclimatize high school athletes to the environment during the first 2 weeks of the preseason and reduce the risk of exertional heat illness.ObjectiveTo identify barriers and facilitators that high school athletic trainers (ATs) encountered when implementing the NATA-IATF guidelines.DesignQualitative study.SettingIndividual phone interviews with all participants.Patients or Other ParticipantsThirty-three ATs (16 men, 17 women; age = 36.0 ± 12.0 years, athletic training experience = 12.9 ± 10.5 years) representing 19 states (4 with state mandates) were interviewed before data saturation was achieved. Participants were purposefully sampled from a larger investigation based on stratification of US Census region and preidentified high school compliance with the NATA-IATF guidelines.Main Outcome Measure(s)A cross-sectional, semistructured phone interview (6 steps) was conducted with each participant and then transcribed verbatim. A 7-person research team (5 coders, 2 auditors) coded the data into themes and categories, focusing on consensus of data placement to reduce bias and ensure accuracy.ResultsFacilitators and barriers that influenced successful guideline implementation were (1) perceived stakeholder access, (2) perceived stakeholder role, (3) capability and capacity, (4) school culture, (5) logistical support, (6) resources, (7) physical environment, and (8) consistency of the guidelines. Overall, participants discussed facilitators and barriers within each category based on their experiences and circumstances.ConclusionsAthletic trainers faced numerous concerns regarding compliance with the NATA-IATF preseason heat-acclimatization guidelines. Multiple levels of influence should be targeted to improve implementation. These include intrapersonal factors by giving ATs the education and self-efficacy to support advocacy for implementation, interpersonal components by establishing strong collaborative networks for change, community and environmental factors by optimizing school culture and community resources for implementation, and policy aspects by establishing consistent guidelines across all bodies.     

National Athletic Trainers' Association position statement: safe weight loss and maintenance practices in sport and exercise

Objective:

To present athletic trainers with recommendations for safe weight loss and weight maintenance practices for athletes and active clients and to provide athletes, clients, coaches, and parents with safe guidelines that will allow athletes and clients to achieve and maintain weight and body composition goals.

Background:

Unsafe weight management practices can compromise athletic performance and negatively affect health. Athletes and clients often attempt to lose weight by not eating, limiting caloric or specific nutrients from the diet, engaging in pathogenic weight control behaviors, and restricting fluids. These people often respond to pressures of the sport or activity, coaches, peers, or parents by adopting negative body images and unsafe practices to maintain an ideal body composition for the activity. We provide athletic trainers with recommendations for safe weight loss and weight maintenance in sport and exercise. Although safe weight gain is also a concern for athletic trainers and their athletes and clients, that topic is outside the scope of this position statement.

Recommendations:

Athletic trainers are often the source of nutrition information for athletes and clients; therefore, they must have knowledge of proper nutrition, weight management practices, and methods to change body composition. Body composition assessments should be done in the most scientifically appropriate manner possible. Reasonable and individualized weight and body composition goals should be identified by appropriately trained health care personnel (eg, athletic trainers, registered dietitians, physicians). In keeping with the American Dietetics Association (ADA) preferred nomenclature, this document uses the terms registered dietitian or dietician when referring to a food and nutrition expert who has met the academic and professional requirements specified by the ADA''s Commission on Accreditation for Dietetics Education. In some cases, a registered nutritionist may have equivalent credentials and be the commonly used term. All weight management and exercise protocols used to achieve these goals should be safe and based on the most current evidence. Athletes, clients, parents, and coaches should be educated on how to determine safe weight and body composition so that athletes and clients more safely achieve competitive weights that will meet sport and activity requirements while also allowing them to meet their energy and nutritional needs for optimal health and performance.     

National athletic trainers' association position statement: preventing sudden death in sports

Objective:

To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.

Background:

Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes.

Recommendations:

These guidelines are intended to provide relevant information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.