Glucocorticoid prescribing habits of sports medicine physicians working in high-performance sport: a 30-nation survey.

OBJECTIVES: Glucocorticoids are commonly prescribed in medicine. When administered via certain routes, glucocorticoids are prohibited for incompetition use by WADA. The glucocorticoid prescribing habits of sports medicine doctors have not been reported. METHODS: An online survey was distributed internationally to physicians working in high-performance sports. The survey queried the doctors about their use of glucocorticoids with athletes and their understanding of WADA's regulations regarding glucocorticoid use in competition. RESULTS: 603 sports medicine doctors from 30 different countries participated. The majority (>85%) routinely injected glucocorticoids and/or prescribed glucocorticoids by other routes. There were substantial differences in the common routes of injection as well as types of glucocorticoid used among the physicians from various countries. A relatively small percentage of sports doctors (<25%) accurately identified which routes of glucocorticoid administration are prohibited in competition by WADA. There was a great variation in how long before competition the use of glucocorticoids would cause the doctor to consider applying for a therapeutic use exemption (TUE). A better understanding of the clearance rates of glucocorticoids from athletes' bodies would greatly aid sports medicine doctors' decisions on how and when to apply for a TUE. A small number of doctors had observed side effects of glucocorticoid administration, with the majority of side effects being minor in nature. CONCLUSION: Glucocorticoids are widely prescribed by sports physicians. There is a need to better educate sports physicians on the current WADA regulations in relation to glucocorticoid administration.

Trends in Pediatric Emergency Department Utilization for Mild Traumatic Brain Injury Before and After Legislation.

OBJECTIVE: To examine the effect of state youth traumatic brain injury (TBI) legislation on pediatric emergency department (ED) utilization for sports and recreation-related mild TBIs (mTBIs). PARTICIPANTS: ED visits by children ages 5 to 18 years between 2006 and 2014 in the Pediatric Health Information System database (N = 452 900). DESIGN: Retrospective analysis. MAIN MEASURES: Rates of ED visits, and injury comparison groups (mTBI, moderate to severe TBI, minor head injury, and long bone fracture). RESULTS: Of the 452 900 ED visits, 123 192 (27.2%) were for mTBI, along with visits for moderate to severe TBIs (n = 5190), minor head injuries (n = 54 566), and long bone fractures (n = 269 952). ED visits for mTBIs were more common among males (67.5%), children ages 10-14 years (42.1%), and the privately insured (50.6%). The proportion of mTBI ED visits increased significantly, particularly from 5 years prelegislation to immediately postlegislation (57.8 to 94.8 mTBI visits per 10 000 ED visits). A similar trend was observed for minor head injuries; however, no significant changes were observed for moderate to severe TBIs and long bone fractures. CONCLUSION: Pediatric ED utilization trends for the injury comparison groups differed from each other, and from pre- and post-TBI legislation. Further research assessing effects of TBI legislation on healthcare utilization is warranted.

Youth Concussion Laws across the Nation: Implications for the Traveling Team Physician.

There are an estimated 1.6 to 3.8 million sports and recreation-related concussions annually in the United States, with an average annual increase in incidence of 15.5% from 1998 to 2007. From 2009 to 2014, all 50 states enacted youth concussion legislation. This study clarifies core elements common to state concussion legislation and State Interscholastic Athletic Association (SIAA) implementation. A concussion literature, legislative, and SIAA concussion bylaw review was performed for all 50 U.S. states. Mandated concussion education varies in the frequency of certification and method of education. Student athletes and their parents/guardians in a majority of states are required to sign annual educational information sheets. Forty-nine states specifically mandate removal from play. Return-to-play protocols vary with regard to the timeline, content, and health care professional that can provide written clearance. In conclusion, it is important for sports medicine clinicians to stay abreast of current and revised concussion legislation in the jurisdictions in which they provide care.

Direct-to-consumer genetic testing for predicting sports performance and talent identification: Consensus statement.

The general consensus among sport and exercise genetics researchers is that genetic tests have no role to play in talent identification or the individualised prescription of training to maximise performance. Despite the lack of evidence, recent years have witnessed the rise of an emerging market of direct-to-consumer marketing (DTC) tests that claim to be able to identify children's athletic talents. Targeted consumers include mainly coaches and parents. There is concern among the scientific community that the current level of knowledge is being misrepresented for commercial purposes. There remains a lack of universally accepted guidelines and legislation for DTC testing in relation to all forms of genetic testing and not just for talent identification. There is concern over the lack of clarity of information over which specific genes or variants are being tested and the almost universal lack of appropriate genetic counselling for the interpretation of the genetic data to consumers. Furthermore independent studies have identified issues relating to quality control by DTC laboratories with different results being reported from samples from the same individual. Consequently, in the current state of knowledge, no child or young athlete should be exposed to DTC genetic testing to define or alter training or for talent identification aimed at selecting gifted children or adolescents. Large scale collaborative projects, may help to develop a stronger scientific foundation on these issues in the future.

A qualitative review of sports concussion education: prime time for evidence-based knowledge translation.

BACKGROUND: Educating athletes, coaches, parents and healthcare providers about concussion management is a public health priority. There is an abundance of information on sports concussions supported by position statements from governing sport and medical organisations. Yet surveys of athletes, parents, coaches and healthcare providers continue to identify multiple barriers to the successful management of sports concussion. To date, efforts to provide education using empirically sound methodologies are lacking. PURPOSE: To provide a comprehensive review of scientific research on concussion education efforts and make recommendations for enhancing these efforts. STUDY DESIGN: Qualitative literature review of sports concussion education. METHODS: Databases including PubMed, Sport Discus and MEDLINE were searched using standardised terms, alone and in combination, including 'concussion', 'sport', 'knowledge', 'education' and 'outcome'. RESULTS: Studies measuring the success of education interventions suggest that simply presenting available information may help to increase knowledge about concussions, but it does not produce long-term changes in behaviour among athletes. Currently, no empirical reviews have evaluated the success of commercially available sports concussion applications. The most successful education efforts have taken steps to ensure materials are user-friendly, interactive, utilise more than one modality to present information and are embedded in mandated training programmes or support legislation. Psychosocial theory-driven methods used to understand and improve 'buy in' from intended audiences have shown promise in changing behaviour. CONCLUSIONS: More deliberate and methodologically sound steps must be taken to optimise education and knowledge translation efforts in sports concussion.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

Legal responsibilities of physicians when making participation decisions in athletes with cardiac disorders: Do guidelines provide a solid legal footing?

Safe sports participation involves protecting athletes from injury and life-threatening situations. Preparticipation cardiovascular screening (PPS) in athletes is intended to prevent exercise-related sudden cardiac death by medical management of athletes at risk, which may include disqualification from sports participation. The screening physician relies on current guidelines and expert recommendations for management and decision-making. There is concern about false-positive screening results and wrongly grounding an athlete. Similarly, there is a concern about false-negative screening results and athletes participating with potentially lethal disorders. Who is legally responsible if an athlete suddenly dies after a proper PPS resulting in low risk? Several consensus documents based on expert opinion describe only a few lines on legal responsibilities in eligibility screening and disqualification decision-making in athletes. This article discusses legal responsibilities and concerns in eligibility decision-making for physicians.

Just a little bit more: when sports scientists cross the line.

Sports science has attracted controversy for the role it plays in an athlete's career and health, but Australian jurisprudence lacks any discussion of their criminal and civil liability when athletes suffer personal or professional harm. This article explores how liability may attach to both sports doctors and sports scientists in the future based on principles from current case law. It finds that criminal and civil liability attaching to personal harm could be proven, provided that consent to the risks or the treatment has not been given. Establishing professional harm caused by negligent advice regarding whether a substance does not comply with the World Anti-Doping Code is arguable considering the athlete's vulnerability to be exposed to sanctions. Expert evidence regarding what, and how a substance, is taken will be crucial to establishing causation in manslaughter prosecutions.

Evaluation of the Zachery Lystedt Law among female youth soccer players.

BACKGROUND: Despite recent increased awareness about sports concussions, few studies have evaluated the effect of concussion laws on concussion outcomes among young athletes. The purpose of our study was to evaluate the effect of the Washington State Zachery Lystedt Concussion Law on playing with concussion symptoms and being evaluated by a health care provider. METHODS: We performed a prospective cohort study of 351 elite female soccer players, aged 12 to 15 years, from 33 randomly selected youth soccer teams in the Puget Sound region of Washington State from 2008 to 2012. The Washington State Zachery Lystedt Concussion Law went into effect on July 1, 2009. Among concussed players (N = 59), we assessed the risk of playing with symptoms, the evaluation by a health care professional, and receiving a concussion diagnosis before and after the law was passed using logistic regression to estimate odds ratios and 95% CIs. RESULTS: The majority of concussed players (59.3%) continued to play with symptoms, and we found no statistically significant difference in the proportion of players who played with symptoms before and after the law was passed. Only 44.1% of concussed players were evaluated by a health care provider, with no difference before and after the law was passed. Among those evaluated by a health care professional, players were 2.1-fold (95% CI, 1.0-10.1) more likely to receive a concussion diagnosis after the law was passed. CONCLUSION: The majority of concussed female youth soccer players report playing with symptoms. Legislation mandating concussion education and evaluation prior to returning to play was not associated with an increase in concussion evaluations by health care providers.

[Recommendations for competitive sports eligibility: what's new in the 2023 COCIS protocols]. / Raccomandazioni per il giudizio di idoneità allo sport agonistico: le novità del COCIS 2023.

The benefit of physical exercise is well established, but, at the same time, it is now well known that an intense sports activity can trigger adverse cardiac events and increase sport-related death. Since 1982, Italy has a State law which obliges athletes to undergo a pre-participation evaluation, based on history, physical examination, ECG and stress test. From its introduction, a significant reduction in cardiac sport-related adverse events has been shown. During the pre-participation screening, some cardiological issues or suspects can arise and the sports medicine doctor should deal with them before releasing the certification for participation in competitive sport. In order to give precious advices to these colleagues and help athletes to securely practice sport, the Italian Society of Sports Cardiology, the Italian Federation of Sports Medicine and the other cardiological scientific societies gathered in the COCIS Committee, periodically produce and publish a booklet named "Cardiological Protocols for Competitive Sports Eligibility". The object of this review is to underline the recent 2023 version innovations when compared to previous editions.

A survey of state medical licensing boards: can the travelling team physician practice in your state?

This was a study that surveyed state medical licensing boards in the USA, to see if they have laws or exemptions for travelling team physicians to practice medicine on their own team, while travelling to that state. Surveys were sent to 58 medical boards, with legislative data being obtained for 54. Eighteen states (33%) allow team physicians travelling with their team to practice medicine with their home-state license. Thirty-six states (67%) do not have a legal pathway to allow the practice of medicine without a license: 27 (50%) do not allow the practice of medicine without a license from their state, 6 (11%) have an exemption for a 'consultant' to act in concert with a home-state physician (though this is not applicable to the team physician) and 3 (6%) do not have an exemption, but recognise that it happens without their involvement. A second survey was sent to 20 malpractice carriers, identified by an internet search to represent a diverse sample, to see if these companies offered policies that would cover the team physician, and if they also had licensure requirements. Of the 11 that responded, only 2 companies would provide coverage regardless of individual state licensing requirements, 5 companies would provide coverage to a provider who travels, but would require the provider to be licensed in any state they travel to and 4 companies would not provide coverage out of the home state, regardless of licensure. The American Medical Society for Sports Medicine is working on a Federal patch for this problem.

Testing for boosting at the Paralympic games: policies, results and future directions.

BACKGROUND: 'Boosting' is defined as the intentional induction of autonomic dysreflexia (AD) by athletes with a spinal cord injury (SCI) at or above the level of T6 for the purpose of improving sports performance. Boosting has been shown to confer up to a 9.7% improvement in race time. Additionally, to compete in a hazardous dysreflexic state, whether intentional or unintentional, would present an extreme health risk to the athlete. For these reasons, the International Paralympic Committee strictly bans the practice of boosting, and has developed a protocol to test for its presence. METHODS: Testing was performed at three major international Paralympic events. Education regarding the dangers of AD was provided to athletes and team staff. Testing was conducted on athletes from the relevant sport classes: Athletics (wheelchair racing classes T51/T52/T53) and Handcycling (H1). Key parameters included the athlete's demographics (gender, country of origin), classification and blood pressure measurements. An extremely elevated blood pressure was considered to be a proxy maker for AD, and a systolic blood pressure of ≥180 mm Hg was considered a positive test. RESULTS: A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. The number of athletes tested, by classification, was: 6 in Athletics T51, 47 in Athletics T52, 9 in Athletics T53 and 16 in Handcycling H1. Of those tested, the average systolic and diastolic blood pressures were 135 mm Hg (range 98-178) and 82 mm Hg (range 44-112), respectively. All athletes were compliant with testing. No athletes were withdrawn from competition due to the presence of AD. DISCUSSION: Testing for the presence of AD in paralympic athletes with SCI prior to competition has been carried out for the first time at three major international paralympic competitions. There have been no positive tests thus far. Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.

How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, under the auspices of the IOC Medical Commission.

A focus on low body weight and body fat content, combined with regulations in some weight-sensitive sports, are considered risk factors for extreme dieting, eating disorders (EDs) and related health consequences among athletes. At present there are, from a health perspective, no generally accepted optimum values for body weight or percentage of fat mass in different sports and there is no 'gold standard' method for body composition assessment in athletes. On the basis of health considerations as well as performance, medical support teams should know how to approach elite athletes who seek to achieve an unrealistic body composition and how to prevent restrictive eating practices from developing into an ED. In addition, these teams must know when to raise the alarm and how to advice athletes who are affected by extreme dieting or clinical EDs. However, there is no consensus on when athletes struggling with extreme dieting or EDs should be referred for specialist medical treatment or removed from competition. Based on the present review, we conclude that there is a need for (1) sport-specific and gender-specific preventive programmes, (2) criteria for raising alarm and 'does not start' (DNS) for athletes with EDs and (3) modifications to the regulations in some sports. Further, the key areas for research identified include the development of standard methods for body composition assessment in elite athletes; screening measures for EDs among athletes; development and testing of prevention programmes; investigating the short and long-term effects of extreme dieting; and EDs on health and performance.

Therapeutic use exemptions (TUEs) at the Olympic Games 1992-2012.

The need for therapeutic use exemptions (TUEs) or the permitted use of Prohibited Substances and Prohibited Methods by athletes to treat significant medical conditions arose when several classes of drugs used commonly in medicine were prohibited in sport by the International Olympic Committee (IOC) during the 1980s. However, although the IOC Medical Commission (IOC-MC) gave qualified support for the concept to formally start at the 1992 Barcelona Olympics, the Commission's fears that athletes might abuse the mechanism resulted in minimal publicity and its non-inclusion in the Medical Code of the Olympic Movement for 8 years. TUEs would not be widely publicised until the advent of the World Anti-Doping Agency which not only approved the principles of TUEs as developed by the IOC's Medications Advisory Committee (MAC) in 1991, but also introduced the name of TUE. Several changes to the Prohibited List have resulted in TUEs being necessary for substances that were permitted 20 years ago as disclosed in a review of TUEs approved at the 11 Olympic Games that the IOC's MAC, later the TUE Committee (TUEC), has operated. The IOC and its TUEC played a pivotal role in developing the concept of TUE which is now globally accepted.

Medical malpractice and the professional legal responsibility of the sports physician.

As with other medical specialties, litigation in sports medicine appears to be on the increase. In most countries, the applicable legal standard is "good medical practice" as identified with reference to the physician's own field of specialisation: what is commonly done by physicians in the same specialty generally serves as the standard by which a physician's conduct is measured. To enhance the quality of sports medicine practice, medical societies have been issuing guidelines for use by sports physicians, and a number of courts have recognised guidelines as evidence of good medical practice. One potential field of malpractice in sports medicine relates to privacy issues: an athlete should be asked to fill in a consent form if the medical information needs to be shared with other parties. Another relevant field is doping: for any act of drug prescription to be legally sound, sports physicians have to be aware of the requirements of the World Anti-Doping Agency Code and its international standards. Ultimately, the best way for sports physicians to avoid sources of liability is for them to keep up to date with the latest research and to act in a careful and diligent manner.

[The importance and composition of pre-season examination in sportsmen].

Every competitive athlete in Israel is required by law to undergo a periodical pre-participation physical examination (PPE), before the competitive season. The PPE is intended to discover medical problems which might affect the health of the athletes, and rarely, may even pose a risk to their lives. It includes a sports-oriented medical questionnaire, a thorough physical examination, and a resting electrocardiogram (ECG). From a certain age onwards, it also includes a graded exercise test (GXT). Numerous studies and standpoints of several professional committees and sports medicine organizations in Europe have emphasized the importance of the first 3 parts of the PPE, namely the questionnaire, physical examination, and resting ECG. Currently, the role of the GXT in the PPE remains debatable. In this review, we will discuss the latest available scientific information in favor of including a resting ECG and, sometimes, a GXT in the PPE of competitive athletes, as mandated by the Israeli Sports Law.

Sudden cardiac death: mandatory exclusion of athletes at risk is a step too far.

Sudden cardiac death (SCD) in young athletes is a distressing event and it is not surprising that some physicians working with sports people are proposing that preventive action should be taken. There is a push for a system similar to that established in some countries, which involves screening and mandatory exclusion of those at risk. We argue that while screening can provide useful information to at-risk athletes making decisions about their future athletic careers, mandatory exclusion of athletes is paternalistic and such decisions are not rightfully within the domain of medicine.

Restricting sports for athletes with heart disease: are we saving lives, avoiding lawsuits, or just promoting obesity and sedentary living?

Sudden cardiac death in young competitive athletes is tragic and usually due to unsuspected cardiovascular disease. Screening programs for athletes remain debatable, and restriction of athletes from sports can have physical, emotional, and legal ramifications. In this article, we review the epidemiology of the more common inherited arrhythmias and congenital heart diseases that are of concern in a newly diagnosed athlete. A comparison of the current American Heart Association/American College of Cardiology and European Society guidelines, which are primarily based on expert opinion due to lack of randomized studies, is then undertaken. Furthermore, certain legal repercussions associated with both qualifying and restricting athletes from competitive sports are discussed. Lastly, we urge physicians to keep in mind that disqualifying an athlete from competitive sports does not mean restriction of all activities, and even patients with inherited arrhythmias and congenital heart disease can participate in low to moderate activity complementary with a healthy lifestyle.