Pedestrian Safety Among High School Runners: A Case Series.

BACKGROUND: Participation in high school cross-country and track has increased over the last few decades. At the same time, the rate of pedestrian-involved motor vehicle crashes (MVCs) has also increased. In the context of organized sport, pedestrian safety among runners is often not highlighted, despite the risk of catastrophic injury. PURPOSE: To describe incidents of pedestrian-involved MVCs involving student athletes captured by the National Center for Catastrophic Sport Injury Research (NCCSIR) at the University of North Carolina at Chapel Hill. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 5. METHODS: This study utilized surveillance data from the NCCSIR from 2011 to 2020. It presents descriptive statistics, including frequencies and percentages, detailed summaries, and a Haddon Matrix. RESULTS: There were 8 incidents involving 11 student athletes, resulting in 9 fatalities. Of these, 5 cases occurred in the afternoon or early evening, 4 occurred in the Fall, and 6 occurred in a rural area. Haddon Matrix analyses of case descriptions indicate schools should implement a runner safety program for all new runners and ensure that runner safety measures are included in emergency action plans. CONCLUSION: Runner-related MVCs are relatively rare, but tragic, incidents. Pedestrian safety measures should be incorporated into school-sponsored practices and training runs. CLINICAL RELEVANCE: Pedestrian safety should be incorporated into runner safety and injury prevention efforts.

The Effect of a Statewide Policy on High School Emergency Action Plans.

Institutions sponsoring athletics must be prepared for emergencies. Due to this, more governing bodies are requiring a sports-related emergency action plan (EAP). Yet, the effects of these policies are unknown. We compared adoption of EAPs and associated best practices in Oregon high schools before and after a policy requiring an EAP. Athletic directors were invited to complete a survey during the year before the policy went into effect and again the following year. We assessed whether the school had a written EAP and if they did, was the EAP venue specific, available at the venue, distributed to personnel, and annually reviewed and rehearsed. Pre/post-policy proportions were analyzed using Fisher exact tests for all schools and then schools that completed both surveys. There was a significant increase of schools that reported having an EAP after the policy went into effect (all schools: 55% to 99% [p < 0.001] and schools responding both years: 60% to 98% [p < 0.001]). Venue specific EAPs also significantly increased but only when analyzing all responses (59% to 71% [p = 0.03]). No best practice recommendations related to EAP availability, distribution, review, or rehearsal changed after the policy. Schools met the minimum requirements of the policy, but other related best practices did not significantly improve.

Use of Lifesaving Medications by Athletic Trainers.

The athletic trainer's (AT's) emergency management skillset requires competency in the delivery of basic lifesaving medications. Some lifesaving medications have been a part of athletic training practice for decades, but that list has grown as ATs' practice settings have expanded, increasing the types of emergent conditions that the AT may have to treat. The 2020 Commission on Accreditation of Athletic Training Education (CAATE) curricular standards require that athletic training students be trained to administer the following: supplemental oxygen, nitroglycerine, low-dose aspirin, bronchodilators, epinephrine using an automated injection device, glucagon, and naloxone. Clinically, the conditions treated by these medications can be categorized as cardiac, respiratory, hypoglycemia, and anaphylaxis. All ATs should know the indications, contraindications, administration methods, and details of patient monitoring for each medication. Generally, these medications are safe and have clear indications for use and few contraindications. Although ATs are trained to administer these medications, they must consider state laws and local policies governing administration.

The impact of high school athletic trainer services on medical payments and utilizations: a microsimulation analysis on medical claims.

BACKGROUND: Increasing athletic trainer (AT) services in high schools has attracted widespread interest across the nation as an effective instrument to manage injuries and improve children's health, but there is a lack of evidence on potential medical savings. Our study aimed to address this knowledge gap and provide evidence of AT impacts on medical payments and utilizations to inform public policy decision. METHODS: We obtained medical claims of patients aged 14 to 18 years from the 2011-2014 Oregon All Payer All Claims limited dataset. We calculated payer payments and utilizations for medical claims under AT's scope of practice. We used zip codes to link patients with the enrollment boundaries of Oregon public high schools, which were classified as either "AT group" or "non-AT group". We implemented an innovative microsimulation analysis to address the uncertainty of linkage between children and schools. RESULTS: Our analysis included 64,115 and 84,968 eligible children with Medicaid and commercial insurance, respectively. Associated with high school AT services, Medicaid saved an average of $64 per patient during the study period, while commercial insurance payment rarely changed. AT services may reduce emergency visits for both insurance types but increase total visits for commercially insured patients. CONCLUSIONS: Our study provides evidence for the differential impacts of AT services on medical payments and utilizations. The legislators should consider to allocate funds for high schools to directly employ ATs. This will encourage ATs to work to their highest ability to improve children's wellbeing while containing avoidable medical cost.

Cost-Benefit of Hiring Athletic Trainers in Oregon High Schools From 2011-2014.

CONTEXT: Hiring athletic trainers (ATs) in high schools may lower medical payments by third-party payers such as Medicaid or commercial insurers by reducing injury risks or may increase medical payments due to more referrals to other health care providers. To date, evidence is lacking on the actual financial effect of high school ATs based on an analysis of medical claims. OBJECTIVE: To assess the overall cost-benefit of hiring ATs in Oregon high schools based on medical claims data across years. DESIGN: Cost-benefit study. SETTING: Oregon public high schools. PATIENTS OR OTHER PARTICIPANTS: Patients aged 14 to 18 years old. MAIN OUTCOME MEASURE(S): We analyzed the 2011-2014 limited dataset from the Oregon Health Authority's All Payer All Claims database. Paired t tests were used to compare claims payments at the zip code level between periods of having and not having ATs in Oregon high schools. We also used the percentage of AT effort to adjust for AT investment. The main outcome measure was the return on investment associated with hiring ATs in high schools. RESULTS: The presence of ATs in Oregon high schools may have had different effects on medical payments for Medicaid and commercial insurance. With every dollar invested in hiring ATs in Oregon public high schools from 2011 to 2014, Medicaid payments increased by 24 cents per month at the zip code level, while commercial insurance payments decreased by 24 cents, although the changes were not statistically significant. CONCLUSIONS: Hiring ATs in an outreach model for high schools may not necessarily generate medical savings for Medicaid or commercial insurers. Further research is needed to determine if the lack of cost savings in our study was a factor of the employment model, resulted from increased health care utilization, or reflected the need for ATs to deliver more on-site AT services.

Sports-Related Emergency Preparedness in Oregon High Schools.

BACKGROUND: Best practice recommendations for sports-related emergency preparation include implementation of venue-specific emergency action plans (EAPs), access to early defibrillation, and first responders-specifically coaches-trained in cardiopulmonary resuscitation and automated external defibrillator (AED) use. The objective was to determine whether high schools had implemented these 3 recommendations and whether schools with a certified athletic trainer (AT) were more likely to have done so. HYPOTHESIS: Schools with an AT were more likely to have implemented the recommendations. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: All Oregon School Activities Association member school athletic directors were invited to complete a survey on sports-related emergency preparedness and AT availability at their school. Chi-square and Fisher exact tests were used to analyze the associations between emergency preparedness and AT availability. RESULTS: In total, 108 respondents (37% response rate) completed the survey. Exactly half reported having an AT available. Only 11% (95% CI, 6%-19%) of the schools had implemented all 3 recommendations, 29% (95% CI, 21%-39%) had implemented 2, 32% (95% CI, 24%-42%) had implemented 1, and 27% (95% CI, 19%-36%) had not implemented any of the recommendations. AT availability was associated with implementation of the recommendations (χ2 = 10.3, P = 0.02), and the proportion of schools with ATs increased with the number of recommendations implemented (χ2 = 9.3, P < 0.01). Schools with an AT were more likely to implement venue-specific EAPs (52% vs 24%, P < 0.01) and have an AED available for early defibrillation (69% vs 44%, P = 0.02) but not more likely to require coach training (33% vs 28%, P = 0.68). CONCLUSIONS: Despite best practice recommendations, most schools were inadequately prepared for sports-related emergencies. Schools with an AT were more likely to implement some, but not all, of the recommendations. Policy changes may be needed to improve implementation. CLINICAL RELEVANCE: Most Oregon high schools need to do more to prepare for sports-related emergencies. The results provide evidence for sports medicine professionals and administrators to inform policy changes that ensure the safety of athletes.

Factors influencing high school coaches' adoption of injury prevention programs.

OBJECTIVES: Despite documented efficacy of injury prevention programs (IPPs) to reduce sport-related lower extremity injury risk, there is evidence of a lack of widespread IPP adoption by high school coaches. This study identified factors related to non-adoption of IPPs by assessing coaches' knowledge, attitudes, and behaviors related to prevention programs and comparing attitudes between adopter and non-adopter coaches. DESIGN: Cross-sectional. METHODS: Head soccer and basketball coaches (n=141) from 15 Oregon high schools were invited to complete a web-based survey assessing their IPP-related knowledge, attitudes, and behaviors. RESULTS: Of the 66 coach respondents, 52% reported being aware of IPPs; 21% reported using an IPP with their team; and 9% reported having their student-athletes perform the IPP exactly as designed. No apparent differences in the attitudes toward the importance of injury prevention or the effectiveness of IPPs were identified between coaches that did and did not adopt an IPP. Perceptions that efficacious IPPs do not offer a relative advantage over coaches' existing practices, do not align with coaches' needs (compatibility), and are difficult to implement in their setting (complexity) emerged as key factors underlying coaches' decisions not to adopt a program. Of those that did report adopting an IPP, just 43% (6/14) reported implementing the program as designed. CONCLUSIONS: Improving preventative practices of high school coaches requires more than improved dissemination to increase coach awareness. To improve the rate of IPP adoption and implementation fidelity, coach education should directly address issues related to relative advantage, compatibility, and complexity.

The effectiveness of a web-based resource in improving postconcussion management in high schools.

PURPOSE: Because many sports concussions happen during school-sponsored sports events, most state concussion laws specifically hold schools accountable for coach training and effective concussion management practices. Brain 101: The Concussion Playbook is a Web-based intervention that includes training in sports concussion for each member of the school community, presents guidelines on creating a concussion management team, and includes strategies for supporting students in the classroom. METHODS: The group randomized controlled trial examined the efficacy of Brain 101 in managing sports concussion. Participating high schools (N = 25) were randomly assigned to the Brain 101 intervention or control. Fall athletes and their parents completed online training, and Brain 101 school administrators were directed to create concussion management policy and procedures. RESULTS: Student athletes and parents at Brain 101 schools significantly outperformed those at control schools on sports concussion knowledge, knowledge application, and behavioral intention to implement effective concussion management practices. Students who had concussions in Brain 101 schools received more varied academic accommodations than students in control schools. CONCLUSIONS: Brain 101 can help schools create a comprehensive schoolwide concussion management program. It requires minimal expenditures and offers engaging and effective education for teachers, coaches, parents, and students.

The effect of cognitive task complexity on gait stability in adolescents following concussion.

Concussion has been reported to result in disturbances to motor and cognitive functions. One way to examine these disturbances is through a dual-task assessment. Many secondary cognitive tasks have been proposed as appropriate tools during concussion assessment; however, task complexity has not been compared within a dual-task investigation. The purpose of this study was to prospectively examine how gait balance control was affected by three secondary cognitive tasks of varying complexity following concussion. Forty-six adolescents completed a dual-task walking protocol which included walking without any cognitive task (WALK), walking while completing a single auditory Stroop (SAS), multiple auditory Stroop (MAS), and a question and answer task (Q&A). Those who sustained a concussion (n = 23, mean age 15.4 ± 1.3 years) reported to the laboratory within 72 h of injury and in the following time increments: 1 week, 2 weeks, 1 month, and 2 months post-injury. Twenty-three healthy control subjects (mean age 15.4 ± 1.3 years), individually matched to each concussion subject, completed the same protocol in similar time increments. The concussion group demonstrated greater total center of mass (COM) medial/lateral displacement in the MAS and Q&A conditions compared with the control group. The concussion group also displayed the greatest peak COM anterior velocity in the least complex condition (WALK), and a significant decrease was observed as task complexity increased (SAS > MAS > Q&A). These findings indicate that gait balance control may be affected by task complexity following concussion and represent a way to identify motor recovery following concussion.

Online training in sports concussion for youth sports coaches.

The purpose of this study was to evaluate ACTive: Athletic Concussion Training using Interactive Video Education, an interactive e-learning program designed to train community coaches of youth ages 10-18 in effective sports concussion prevention and management practices. Seventy-five youth sports coaches from across the country completed the study over the Internet. Results of a randomized control trial demonstrated significant differences between treatment and control participants on measures of (a) knowledge about sports concussion, management, and prevention; (b) attitudes about the importance of preventing sports concussion; and (c) intention and self-efficacy in sports concussion management and prevention. The results suggest that ACTive is an effective method of training youth sports coaches who are in an important position to reduce risks associated with sports concussion.

Does shoe insole modification prevent stress fractures? A systematic review.

Stress fractures can be debilitating in athletes and military personnel. Insoles may lower stress fracture rates by improving biomechanics, lessening fatigue, and attenuating impact. The objective of this study was to systematically review the best evidence on the use of insoles as a method of stress fracture prevention in a high-risk population. Using MEDLINE, Cochrane, Current Controlled Trials, UK National Research Register, ScienceDirect, CINAHL, and EMBASE, a review of randomized (level I) and quasi-randomized (level II) controlled trials was performed using an insole as the intervention and stress fracture incidence as the primary outcome measure. Five trials were included, and a random effects model was used to generate a summary estimate and an overall odds ratio. One study found a significant reduction in overall stress fracture incidence using a semirigid insole, while four studies found no overall reduction in military personnel. However, when the data are pooled, orthotic use was beneficial. When stratified by site, there was a reduction in femoral and tibial stress fracture incidence. Shoe insoles may reduce the overall femoral and tibial stress fracture incidence during military training. It is unclear if the use of insoles would prevent stress fractures in athletes. Additional studies are necessary to determine the efficacy of insoles in an athletic population.

The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review.

To investigate whether subacromial corticosteroid injections are effective in the treatment of rotator cuff disease, an evidence-based systematic review was undertaken of nine randomized controlled trials that compared subacromial corticosteroid injection with placebo in patients with rotator cuff disease. Each study was systematically evaluated for biases, and outcome measures were scrutinized for statistical significance and clinical importance. One study demonstrated clinically important differences in pain relief. Two studies showed clinically important improvement in range of motion at final follow-up. This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.

Epidemiology of stress fractures.

Stress fractures are a frequent cause of injury in competitive and recreational athletes. Although a number of epidemiologic studies have been conducted, the populations studied and data collection methods have varied. This article presents an overview of injury epidemiology and reviews the current body of literature regarding the occurrence of stress fractures in athletes. Given the heterogeneity of the populations studied and the variations in data collection, few broad conclusions can be drawn. There is a pressing need for large prospective studies to better establish the risks of stress fracture by sport, age, and gender.

Pharmacologic agents in fracture healing.

Bone fractures are a known risk of athletic participation and can result in significant lost playing time. A variety of medications have been investigated in animal studies regarding their effects on fracture healing. Parathyroid hormone and the bisphosphonates may have future uses in the prevention and treatment of athletic-related stress fractures and acute fractures. Nonsteroidal anti-inflammatory drugs have been implicated in effecting fracture healing in some animal models, but little clinical evidence supports these findings. Large randomized clinical trials are needed to further delineate the role of these and other drugs and their effects on fracture healing.

Shoulder impingement syndrome.

Subacromial impingement syndrome is a common cause of shoulder pain. The purpose of this article is to review the clinical presentation, physical examination findings, and differential diagnosis of impingement syndrome. Using an evidence-based approach, we propose an algorithm for the management of subacromial impingement syndrome including indications for nonoperative management, advanced imaging, and operative management.

Preparticipation screening of high school athletes: are recommendations enough?

UNLABELLED: The American Heart Association (AHA) recommends cardiovascular screening and injury history for all student-athletes to prevent sudden cardiac death and related problems. No standard preparticipation physical evaluation (PPE) form is currently required, and the qualifications of those who perform these evaluations vary. OBJECTIVE: To assess the PPE process of high school student-athletes in Oregon. METHODS: A survey was mailed to the athletic directors at 258 Oregon high schools that were members of the Oregon Schools Activities Association (OSAA) and had interscholastic athletic programs for the 1999-2000 school year. Directors were asked to complete the survey and return it with a copy of the PPE form they used if they were not already using the recommended form. RESULTS: Responses were received from 154 (60%) of the 258 high schools surveyed. Seventy-five (53%) of the 142 forms evaluated contained fewer than 5 of the AHA recommendations for cardiac screening. Forty-two schools (27%) were implementing the PPE form recommended by the OSAA. CONCLUSION: Most Oregon high schools were not adequately screening student-athletes for injury history or for cardiovascular conditions as recommended by the AHA. We recommend required use of an approved PPE form and specific guidelines for healthcare providers who perform the exam.

Seeing the Forest Through the Wheeze: A Case-Study Approach to Diagnosing Paradoxical Vocal-Cord Dysfunction.

OBJECTIVE: To present for discussion a case of paradoxical vocal-cord dysfunction (PVCD), an uncommon disorder that may be misdiagnosed as, or coexist with, exercise-induced asthma (EIA). BACKGROUND: Vocal-cord dysfunction results from paradoxical closure of the vocal cords during the inspiratory phase of respiration and may be mistaken for EIA, resulting in unnecessary medical treatment and a delay in diagnosis. Although PVCD is uncommon, athletic trainers should be aware of the disorder, as they may play an important role in its diagnosis and treatment. DIFFERENTIAL DIAGNOSIS: Exercise-induced asthma, foreign body aspiration, anaphylactic laryngeal edema, bilateral vocal cord paralysis, extrinsic airway compression, laryngomalacia, subglottic stenosis, traumatic edema, or hemorrhage. UNIQUENESS: This case report describes a common presentation of an unusual disorder. By obtaining a detailed history from the athlete and having a high index of suspicion for the disease, we were able to diagnose PVCD, discontinue all EIA medications, and begin treatment. CONCLUSIONS: The athletic trainer can play a valuable role in the diagnosis of PVCD, which must be considered in the differential diagnosis for any athlete who is compliant with the medications prescribed for the treatment of EIA yet shows little or no improvement in symptoms. A high index of suspicion for PVCD will greatly aid health care professionals assessing the athlete.

An Unusual Scalp Lesion in a 15-Year-Old Girl: A Case Report.

OBJECTIVE: To present an unusual congenital malformation of the central nervous system. BACKGROUND: Neural tube defects (NTDs) are potentially serious congenital malformations. When undiagnosed in childhood, such lesions may later be mistaken for a variety of other soft tissue abnormalities. Athletic trainers should be aware of the clinical findings associated with NTDs and the potential for infection in the event of an injury, thus ensuring proper treatment for injured athletes and referral of any athletes with suspicious lesions. DIFFERENTIAL DIAGNOSIS: Atretic meningocele, hemangioma, lipoma, sebaceous nevus, dermoid cyst, scar tissue, aplasia cutis congenita, and hematoma. TREATMENT: The consulting pediatric neurosurgeon thought that repairing the atretic meningocele was only necessary if symptoms recurred and persisted. This young woman is at increased risk for having a child with an NTD and will benefit from high doses of folic acid early in a future pregnancy. UNIQUENESS: Typically, NTDs are diagnosed in infancy or early childhood. This case represents a young woman whose NTD was not properly diagnosed until adolescence. In addition, NTDs can be mistaken for a variety of other skin lesions. The location and appearance of an NTD are typically distinctive to the knowledgeable examiner. CONCLUSIONS: Although NTDs are unusual, athletic trainers should be aware of such pathologic conditions to avoid mistaking these lesions for traumatic sequelae and to identify those athletes who may need further evaluation to rule out a potentially serious condition.