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.     

The effect of electromagnetic navigation in total knee arthroplasty on knee kinematics during functional activities using flexible electrogoniometry

Background

Navigated total knee arthroplasty has been shown to increase accuracy in post operative implant alignment. By contrast navigated total knee arthroplasty has not shown significant functional improvements to date, when compared with conventional surgery using subjective clinical questionnaire scores. The aim of this study was to compare the knee joint kinematics measured during functional activities using electrogoniometry 12 months after total knee arthroplasty in randomised navigated and conventional total knee arthroplasty groups.

Methods

The study design was a double blinded, randomised, prospective, controlled trial. The patients were randomised into 2 surgical groups (n = 102 navigated group, n = 98 conventional group; mean age navigated = 67, conventional = 67). Flexible electrogoniometry was used to measure patient's knee kinematics with respect to time during 12 functional activities.

Findings

No significant difference was found in terms of the maximum, minimum and excursion knee joint angle during any of the functional activities. However there was a statistically significant improvement in the level and slope gait cycle at the pre swing phase in the navigated group.

Interpretation

There were minimal functional improvements in the navigated total knee arthroplasty group 12 months after surgery. However, these are unlikely to have a significant effect on daily activity for the navigated group.     

Relative sensitivities of toxicity test protocols with the amphipods Eohaustorius estuarius and Ampelisca abdita

A series of dose-response experiments was conducted to compare the relative sensitivities of toxicity test protocols using the amphipods Ampelisca abdita and Eohaustorius estuarius. A. abdita is one of the dominant infaunal species in the San Francisco Estuary, and E. estuarius is the primary sediment toxicity species used in the San Francisco Estuary Regional Monitoring Program. Experiments were conducted with a formulated sediment spiked with copper, fluoranthene, chlorpyrifos, and the three pyrethroid pesticides permethrin, bifenthrin, and cypermethrin, all chemicals of concern in this Estuary. The results showed that the protocol with A. abdita was more sensitive to fluoranthene and much more sensitive to copper, while E. estuarius was more sensitive to chlorpyrifos, and much more sensitive to the pyrethroid pesticides. These results, considered in conjunction with those from previous spiking studies [Weston, D.P., 1995. Further development of a chronic Ampelisca abdita bioassay as an indicator of sediment toxicity: summary and conclusions. In: Regional Monitoring Program for Trace Substances Annual Report. San Francisco Estuary Institute, Oakland, CA, pp 108-115; DeWitt, T.E., Swartz, R.C., Lamberson, J.O., 1989. Measuring the acute toxicity of estuarine sediments. Environ. Toxicol. Chem. 8: 1035-1048; DeWitt, T.H.E., Pinza, M.R., Niewolny, L.A., Cullinan, V.I., Gruendell, B.D., 1997. Development and evaluation of a standard marine/estuarine chronic sediment toxicity method using Leptocheirus plumulosus. Draft report prepared for the US Environmental Protection Agency, Office of Science and Technology, Washington DC, under contract DE-AC06-76RLO 1830 by Batelle Marine Science Laboratory, Battelle Memorial Institute, Pacific Northwest Division, Richland, WA], suggest that, in general, A. abdita is more sensitive to metals, E. estuarius is more sensitive to pesticides, and both protocols have roughly comparable sensitivities to hydrocarbons. The preponderance of evidence from previous field studies indicate that E. estuarius is considerably more responsive to ambient sediment samples [Bay, S.M., Gries, T.H., Anderson, B.S., Phillips, B.M., Field, J.L., Moore, D.W., Greenstein, D.J., 2005. Comparison of marine amphipod test species responsiveness to contaminated sediments. In: Conference Proceeding: Annual Meeting of the Society of Environmental Toxicology and Chemistry. SETAC, Baltimore, Maryland; Anderson, B.S., Hunt, B.M., Thompson, B., Lowe, S., Taberski, K., Carr, R.S., in press. Patterns and trends in sediment toxicity in the San Francisco estuary. Environ. Res.]. One reason for this may be that tube building behavior of A. abdita isolates this species from contaminants in pore water, and results from the current experiments partially support this hypothesis.     

Child abuse and smoking among young women: the importance of severity, accumulation, and timing.

PURPOSE: We examined the association between severity, accumulation, and timing of abuse in childhood and adolescence and smoking status among young women. METHODS: Retrospective self-reported childhood abuse was ascertained with the modified Conflict Tactics Scale from 91,286 Nurses Health Study II participants in 2001 (68,505 returned; 75.0% response rate). Childhood abuse was categorized by severity (mile/moderate/severe), type (physical/sexual), and timing (childhood/adolescence). Smoking status during adolescence was reported at baseline (1989). Logistic regression was used to predict smoking initiation by age 14 and smoking status between the ages of 15 and 19. RESULTS: A graded association between severity of abuse and early initiation of smoking (by age 14 years) was demonstrated (odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.7-2.1 for severe physical violence). Young women with both physical and sexual abuse were two times more likely to start smoking by age 14 than were those reporting no abuse (OR = 2.0, 95% CI = 1.8-2.3). Although abuse during childhood increased risk for adolescent smoking (OR = 1.7, 95% CI = 1.8-2.1) for those with childhood physical and sexual abuse, inclusion of adolescent physical and sexual abuse (OR = 2.2, 95% CI 2.1-2.4) diminished the impact of childhood abuse (OR = 1.1, 95% CI 1.1-1.2). The degree of familial emotional support was protective against smoking, and reduced the impact of abuse by 40% among those with high emotional support versus those without (p < .0001). CONCLUSIONS: A strong and graded association was observed between both severity and accumulation of abuse and the risk of early initiation of smoking among girls. Smoking status during late adolescence was more strongly associated with adolescent abuse than childhood abuse. Early smoking onset is associated with both heightened risk for disease in adolescence but also increased morbidity and mortality in adulthood. Identifying and intervening in potentially modifiable risk factors for smoking onset in young women, such as early-life physical and sexual abuse, and building familial strengths, such as emotional support, may have significant public health implications.     

Sexual orientation, gender, and alcohol use in a cohort study of U.S. adolescent girls and boys

BACKGROUND: Sexual minority youth may be at elevated risk for alcohol use relative to heterosexual youth, but the reasons underlying higher rates and whether there may be gender differences in risk are not known. METHODS: Cross-sectional survey data from 9731 early and middle adolescent girls and boys in the Growing Up Today Study in 1999 were examined to assess sexual orientation and gender patterns in alcohol use. Multivariable regression models estimated associations between sexual orientation and alcohol-related behaviors, such as binge drinking and drinking before age 12 years. Models controlled for sociodemographic and psychosocial factors, with heterosexuals as the reference. RESULTS: Girls who described themselves as "mostly heterosexual" and lesbian/bisexual girls were at elevated risk compared to heterosexual girls on almost all alcohol-related behaviors and exposures. "Mostly heterosexual" boys were also at elevated risk. No significant differences in alcohol-related behaviors were observed between gay/bisexual and heterosexual boys. Gender-by-sexual orientation interactions were statistically significant for LGB but not other orientations, indicating that lesbian/bisexual girls experienced elevated risk above and beyond that of gay/bisexual boys relative to same-gender heterosexual peers. CONCLUSIONS: In early and middle adolescence, sexual minority girls and "mostly heterosexual" boys experienced consistent patterns of elevated risk for alcohol use.     

The nursing management of elderly patients with pain in the community: study and recommendations

This study is designed to identify factors which influence quality of life for elderly people suffering from painful conditions. It is based upon a theoretical model of control in which mood state is used as the indicator of coping. One hundred and ninety elderly patients took part in semi-structured interviews about their pain and coping experiences, and data were also collected from their nurses in the community. Multivariate statistical analysis revealed that the key determinants of mood were having regrets about the past, being occupied, perceived level of pain control, additional personal problems (notably bereavement) and feeling informed about the painful condition. Active personal coping strategies were identified as more therapeutic than passive strategies. Nurses' data revealed that pain complaints were associated with perceived exaggeration. Few nurses used formal pain assessment. Recommendations for the management of persistent pain in the community are given.     

A phase I study of oral LY293111 given daily in combination with irinotecan in patients with solid tumours

Summary Background: LY293111 is an oral agent known to be a leukotriene B4 (LTB4) receptor antagonist and a 5-lipoxygenase inhibitor resulting in selective inhibition of the lipoxygenase pathway. Lipoxygenases metabolize arachidonic acid and have been involved in cancer cell proliferation and survival. In addition, LY293111 has been found to be a peroxisome proliferator activated receptor-gamma (PPAR-γ) agonist. Antineoplastic activity of LY293111 has been identified in preclinical models both alone and in combination with chemotherapy agents including irinotecan. The NCIC Clinical Trials Group studied LY293111 in combination with irinotecan to determine the recommended dose of the combination and to describe its tolerability and pharmacokinetic interaction. In addition the anti-tumour activity of LY293111 in combination with irinotecan was documented. Patients and methods: Twenty-eight patients with advanced solid tumours were treated on seven dose levels with the combination of irinotecan and LY293111. Irinotecan was administered intravenously every 21-days as a single dose. LY293111 was administered twice daily continuously by mouth. Results: Dose limiting toxicity (DLT) of grade 3 diarrhea was seen in two patients with doses of irinotecan 300 mg/m² IV every 21-days in combination with LY293111 300 mg BID. Subsequently the dose of irinotecan was decreased to 250 mg/m² IV every 21-days with escalating doses of LY293111. A DLT of grade 3 abdominal pain was seen at dose 600 mg BID of LY293111 with irinotecan 250 mg/m². The pharmacokinetics (PK) indicated that the administration of LY293111 did not have an effect on the PK of irinotecan or its metabolite SN-38. No responses were seen; seven patients had stable disease of a median duration of 4.4 months (range 2.8–13 months). Conclusion: The recommended phase II dose of LY293111 is 600 mg orally BID in combination with irinotecan 250 mg/m² IV every 21-days. Gastrointestinal adverse effects were common but could be well managed.     

Use of carboxylesterase activity to remove pyrethroid-associated toxicity to Ceriodaphnia dubia and Hyalella azteca in toxicity identification evaluations

Increases in the use and application of pyrethroid insecticides have resulted in concern regarding potential effects on aquatic ecosystems. Methods for the detection of pyrethroids in receiving waters are required to monitor environmental levels of these insecticides. One method employed for the identification of causes of toxicity in aquatic samples is the toxicity identification evaluation (TIE); however, current TIE protocols do not include specific methods for pyrethroid detection. Recent work identified carboxylesterase treatment as a useful method for removing/detecting pyrethroid-associated toxicity. The present study has extended this earlier work and examined the ability of carboxylesterase activity to remove permethrin- and bifenthrin-associated toxicity to Ceriodaphnia dubia and Hyalella azteca in a variety of matrices, including laboratory water, Sacramento River (CA, USA) water, and Salinas River (CA, USA) interstitial water. Esterase activity successfully removed 1,000 ng/L of permethrin-associated toxicity and 600 ng/L of bifenthrin-associated toxicity to C. dubia in Sacramento River water. In interstitial water, 200 ng/L of permethrin-associated toxicity and 60 ng/L of bifenthrin-associated toxicity to H. azteca were removed. The selectivity of the method was validated using heat-inactivated enzyme and bovine serum albumin, demonstrating that catalytically active esterase is required. Further studies showed that the enzyme is not significantly inhibited by metals. Matrix effects on esterase activity were examined with municipal effluent and seawater in addition to the matrices discussed above. Results confirmed that the esterase retains catalytic function in a diverse array of matrices, suggesting that this technique can be adapted to a variety of aquatic samples. These data demonstrate the utility of carboxylesterase treatment as a viable step to detect the presence of pyrethroids in receiving waters.