Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at ...all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs.
A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review.
The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved.
These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.
Descriptive laboratory study.
To determine whether the placement of padding beneath the occiput after helmet removal is an effective intervention to maintain neutral sagittal cervical spine alignment ...in a position comparable with the helmeted condition.
Current on-field recommendations for managing football athletes with suspected cervical spine injuries call for face mask removal, rather than helmet removal, because the combination of helmet and shoulder pads has been shown to maintain neutral cervical alignment. Therefore, in cases when helmet removal is required, recommendations also call for shoulder pad removal. Because removal of equipment causes motion, any technique that postpones the need to remove the shoulder pads would reduce prehospital motion.
Four lateral radiographs of 20 male participants were obtained (age = 23.6 ± 2.7 years). Radiographs of participants wearing shoulder pads and helmet were first obtained. The helmet was removed and radiographs of participants with occipital padding were obtained immediately and 20 minutes later and finally without occipital padding. Cobb angle measurements for C2-C6 vertebral segments were determined by an orthopedic spine surgeon blinded to the study's purpose. Intraobserver reliability was determined using intraclass coefficient analysis. Measurements were analyzed using a 1×4 repeated-measures analysis of variance and post hoc pairwise comparisons with Bonferroni correction.
Intraobserver analysis showed excellent reliability (intraclass correlation = 1.0; 95% confidence interval CI, 0.999-1.0). Repeated-measures analysis of variance detected significant differences (F(3,17) = 13.34; P < 0.001). Pairwise comparisons revealed no differences in cervical alignment (all measurements reported reflect lordosis) when comparing the baseline helmeted condition (10.1° ± 8.7°; 95% CI, 6.0-14.1) with the padded conditions. Measurements taken after removal of occipital padding (14.4° ± 8.1°; 95% CI, 10.6-18.2) demonstrated a significant increase in cervical lordosis compared with the immediate padded measurement (9.5° ± 6.9°; 95% CI, 6.3-12.7; P = 0.011) and the 20-minute padded measurement (6.5° ± 6.8°; 95% CI, 3.4-9.7; P < 0.001).
Although face mask removal remains the standard, if it becomes necessary to remove the football helmet in the field, occipital padding (along with full body/head immobilization techniques) may be used to limit cervical lordosis, allowing safe delay of shoulder pad removal.
Current management recommendations for equipment-laden athletes in sudden cardiac arrest regarding whether to remove protective sports equipment before delivering cardiopulmonary resuscitation are ...unclear.
To determine the effect of men's lacrosse equipment on chest compression and ventilation quality on patient simulators.
Cross-sectional study.
Controlled laboratory.
Twenty-six licensed athletic trainers (18 women, 8 men; age = 25 ± 7 years; experience = 2.1 ± 1.6 years).
In a single 2-hour session, participants were block randomized to 3 equipment conditions for compressions and 6 conditions for ventilations on human patient simulators.
Data for chest compressions (mean compression depth, compression rate, percentage of correctly released compressions, and percentage of optimal compressions) and ventilations (ventilation rate, mean ventilation volume, and percentage of ventilations delivering optimal volume) were analyzed within participants across equipment conditions.
Keeping the shoulder pads in place reduced mean compression depth (all P values < .001, effect size = 0.835) and lowered the percentages of both correctly released compressions ( P = .02, effect size = 0.579) and optimal-depth compressions (all P values < .003, effect size = 0.900). For both the bag-valve and pocket masks, keeping the chinstrap in place reduced mean ventilation volume (all P values < .001, effect size = 1.323) and lowered the percentage of optimal-volume ventilations (all P values < .006, effect size = 1.038). Regardless of equipment, using a bag-valve versus a pocket mask increased the ventilation rate (all P values < .003, effect size = 0.575), the percentage of optimal ventilations (all P values < .002, effect size = 0.671), and the mean volume ( P = .002, effect size = 0.598) across all equipment conditions.
For a men's lacrosse athlete who requires cardiopulmonary resuscitation, the shoulder pads should be lifted or removed to deliver chest compressions. The facemask and chinstrap, or the entire helmet, should be removed to deliver ventilations, preferably with a bag-valve mask.
Abstract Background context In cases of possible cervical spine injury, medical professionals must be prepared to achieve rapid airway access while concurrently restricting cervical spine motion. ...Face mask removal (FMR), rather than helmet removal (HR), is recommended to achieve this. However, no studies have been reported that compare FMR directly with HR. Purpose The purpose of this study was to compare motion, time, and perceived difficulty in two commonly used American football helmets between FMR and HR techniques, and when helmet air bladders were deflated before HR compared with inflated scenarios. Study design/setting The study incorporated a repeated measures design and was performed in a controlled laboratory setting. Participants Participants included 22 certified athletic trainers (15 men and seven women; mean age, 33.9±10.5 years; mean experience, 11.4±10.0 years; mean height, 172±9.4 cm; mean mass, 76.7±14.9 kg). All participants were free from upper extremity or central nervous system pathology for 6 months and provided informed consent. Outcome measures Dependent variables included head excursion in degrees (computed by subtracting the minimum position from the maximum position) in each of the three planes (sagittal, frontal, transverse), time to complete the required task, and ratings of perceived exertion. To address our study purposes, we used two-by-two repeated-measures analysis of variance (removal technique×helmet type, helmet type×deflation status) for each dependent variable. Methods Independent variables consisted of removal technique (FMR and HR), helmet type (Riddell Revolution IQ RIQ and VSR4), and helmet deflation status (deflated D, inflated, I). After familiarization, participants conducted two successful trials for each of six conditions in random order (RIQ-FMR, VSR4-FMR, RIQ-HR-D, VSR4-HR-D, RIQ-HR-I, and VSR4-HR-I). Face masks, helmets, and shoulder pads were removed from a live model wearing a properly fitted helmet and shoulder pads. The participant and an investigator stabilized the model's head. A six-camera three-dimensional motion system and a three-point one-segment marker set were used to record motion of the head. Results Face mask removal resulted in less motion in all three planes, required less completion time, and was easier to perform than HR. The RIQ helmet resulted in less frontal plane motion and less time to task completion, and was easier to remove than VSR4 helmets. Inflated helmets—regardless of helmet type—required less removal time but did not result in greater cervical spine motion or difficulty. Conclusions It is safer to remove the face mask in the prehospital setting for the potential spine-injured American football player than to remove the helmet, based on results from both a traditional and newer football helmet designs. Deflating the air bladder inside the helmet does not provide an advantage.
American football has the highest rate of fatalities and catastrophic injuries of any US sport. The equipment designed to protect athletes from these catastrophic events challenges the ability of ...medical personnel to obtain neutral spine alignment and immobilization during airway and chest access for emergency life-support delivery.
To compare motion, time, and difficulty during removal of American football helmets, face masks, and shoulder pads.
Quasi-experimental, crossover study.
Controlled laboratory.
We recruited 40 athletic trainers (21 men, 19 women; age = 33.7 ± 11.2 years, height = 173.1 ± 9.2 cm, mass = 80.7 ± 17.1 kg, experience = 10.6 ± 10.4 years).
Paired participants conducted 16 trials in random order for each of 4 helmet, face-mask, and shoulder-pad combinations. An 8-camera, 3-dimensional motion-capture system was used to record head motion in live models wearing properly fitted helmets and shoulder pads.
Time and perceived difficulty (modified Borg CR-10).
Helmet removal resulted in greater motion than face-mask removal, respectively, in the sagittal (14.88°, 95% confidence interval CI = 13.72°, 16.04° versus 7.04°, 95% CI = 6.20°, 7.88°; F(1,19) = 187.27, P < .001), frontal (7.00°, 95% CI = 6.47°, 7.53° versus 4.73°, 95% CI = 4.20°, 5.27°; F1,19 = 65.34, P < .001), and transverse (7.00°, 95% CI = 6.49°, 7.50° versus 4.49°, 95% CI = 4.07°, 4.90°; F(1,19) = 68.36, P < .001) planes. Face-mask removal from Riddell 360 helmets took longer (31.22 seconds, 95% CI = 27.52, 34.91 seconds) than from Schutt ION 4D helmets (20.45 seconds, 95% CI = 18.77, 22.12 seconds) or complete ION 4D helmet removal (26.40 seconds, 95% CI = 23.46, 29.35 seconds). Athletic trainers required less time to remove the Riddell Power with RipKord (21.96 seconds, 95% CI = 20.61°, 23.31° seconds) than traditional shoulder pads (29.22 seconds, 95% CI = 27.27, 31.17 seconds; t(19) = 9.80, P < .001).
Protective equipment worn by American football players must eventually be removed for imaging and medical treatment. Our results fill a gap in the evidence to support current recommendations for prehospital emergent management in patients wearing protective football equipment. Helmet face masks and shoulder pads with quick-release designs allow for clinically acceptable removal times without inducing additional motion or difficulty.
Purpose: To examine perceived playing behaviors and attitudes in American football players concerning a novel, overbuilt-style football helmet facemask. Methods: Thirty-four collegiate-aged current ...or former football players reported to a one-on-one session to complete an 11-item survey to gauge what effects there might be on their attitudes or behaviors during football. Results: Fifty percent of current or former football players agreed they would be more intimidated by an opposing player wearing an overbuilt facemask and 53% felt they would be more intimidating to opposing players. Nearly 40% reported that they would feel safer wearing the overbuilt facemask, despite no evidence that it affords enhanced protection. Conclusions: The preliminary data suggest player perceptions of overbuilt facemasks may negatively influence playing behavior. Athletic Training & Sports Health Care. 2019;11(6):273–279.
To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in ...the athlete.
The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.
Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.
To provide a foundation of knowledge concerning the functional anatomy, kinematic response, and mechanisms involved in axial-compression cervical spine injury as they relate to sport injury.
We ...conducted literature searches through the Index Medicus, SPORT Discus, and PubMed databases and the Library of Congress from 1975-2003 using the key phrases cervical spine injury, biomechanics of cervical spine, football spinal injuries, kinematics of the cervical spine, and axial load.
Research on normal kinematics and minor and major injury mechanisms to the cervical spine reveals the complex nature of movement in this segment. The movement into a single plane is not the product of equal and summative movement between and among all cervical vertebrae. Instead, individual vertebrae may experience a reversal of motion while traveling through a single plane of movement. Furthermore, vertebral movement in 1 plane often requires contributed movement in 1 or 2 other planes. Injury mechanisms are even more complex. The reaction of the cervical spine to an axial-load impact has been investigated using cadaver specimens and demonstrates a buckling effect. Impact location and head orientation affect the degree and level of resultant injury.
As with any joint of the body, our understanding of the mechanisms of cervical spine injury will ultimately serve to reduce their occurrence and increase the likelihood of recognition and immediate care. However, the cervical spine is unique in its normal kinematics compared with joints of the extremities. Injury biomechanics in the cervical spine are complex, and much can still be learned about mechanisms of the cervical spine injury specific to sports.
This study determined anteroposterior knee-joint muscle activation differences among children and adult males and females landing from a self-initiated vertical jump (VJ) under normal and ...offset-target conditions to further understand physical maturation's influence on anterior cruciate ligament (ACL) injury risk.
Fifty-five recreationally active volunteer subjects grouped by age (children = 9.5 +/- 0.9 yr; adult = 23.9 +/- 2.8 yr) and gender (females = 28; males = 27) completed motion analysis, ground reaction force, and surface electromyography (SEMG) data collection during a two-footed landing under straight (midline-target) and offset-target (adult = 45.7 cm; child = 30.5 cm) conditions. Target height was 50% of maximum VJ height. Co-contraction ratios (CCR) (hamstrings (HAMS)/vastus medialis (VM) activity) from normalized SEMG root mean squares were analyzed in the prelanding (PRE) (100 ms before initial contact (IC)), reflexive (REF) (100 ms after IC), and voluntary (VOL) (end of REF to maximum knee flexion) muscle activity phases. Repeated-measures statistical analyses determined significant gender, physical maturation, and target differences (P < 0.05) in CCR and associated HAMS and VM activity across landing phases.
A significant interaction (P < 0.0001) indicated similar CCR for children and adults during the REF and VOL phases, but during the PRE phase adult CCR (619.04 + 52.01) were two times greater than children's (308.32 +/- 51.04). Significantly more HAMS activity, not less VM activity, increased adult PRE-CCR. Gender and target CCR differences were absent.
Children's decreased preparatory co-contraction about the knee does not seem to be linked to increased ACL injury risk. Thus, adults may strive for preparatory co-contraction levels about the knee that permit adaptability to varied landing tasks.
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