Guidelines for the Sidelines: Updates on Treating Spine Injured Athletes
If a 15 year old football player with a spine injury is lying on the field, does anyone present know what to do and how to safely remove the athletic equipment? Does anyone know what kind of cervical collar to put on the athlete…or when? To clarify these and other issues, the National Athletic Trainers’ Association (NATA) has released an executive summary of a new inter-association consensus statement: “Appropriate Care of the Spine Injured Athlete.”
MaryBeth Horodyski, Ed.D., ATC, FNATA, is vice president of NATA, and chaired the task force that developed the document. She told OTW, “We have updated the 2001 guidelines due to advances in the literature regarding pre-hospital treatment protocols, as well as improvements in technology. If a physician or an athletic trainer suspects that a player has a spinal cord injury then the equipment he or she is wearing may actually be an obstruction to prompt, safe medical treatment (life support needing access to the chest and airway). Often, doctors on the field or in the emergency department are not going to know how to remove protective equipment.”
“Let me add that these are only guidelines. We know that there are going to be situations where removing the equipment is not the best course of action (such as when you do not have enough trained people present or there are extenuating medical circumstances). However, there are several studies showing that doing CPR while a player is still wearing shoulder pads is not as efficient as if the pads were removed. Additionally, if you put the athlete in the back of an ambulance with their equipment on and they deteriorate then the paramedics have to figure out what to do with the equipment. This is why we now recommend that protective athletic equipment be removed prior to transport to an emergency facility when a cervical spine instability is suspected.”
“Another updated recommendation was that equipment removal should be performed by at least three rescuers trained and experienced with equipment removal—and that it should be done at the earliest possible time. If you don’t have at least three people, then the equipment should be removed at the earliest possible time after enough trained individuals arrive on the scene or transport to the emergency department with equipment on if not able to remove in the field.”
“We continue recommend that spine injured athletes be transported using a rigid immobilization device, to ensure that moving a patient from the field to the ambulance minimizes spinal motion.”
“One of the most important updated recommendations is the ‘Time Out.’ Done before the athletic event—just like surgeons do preoperatively—it is a chance to get the sports medicine team together and review the emergency action plan for that particular event.”
“These new guidelines will also help us work with Emergency Medical Services (EMS) so as to allow for safe equipment removal. Training sessions with team physicians, athletic trainers and EMS staff are beginning to take place across the country. We have had more than one Emergency Department (ED) doctor say that when an athlete arrives fully geared that they are not sure how get the equipment off. If the situation is such that the athletic trainer [AT] travels with the athlete to the hospital then he or she may be able to assist the treating physician. There are, however, questions remaining as to whether or not it is legal for the AT to assist with equipment removal once the athlete arrives in the emergency department.”
Mark Prasarn, M.D. is an orthopedic surgeon at the University of Houston. Dr. Prasarn was a member of the task force group that developed the consensus statement. He told OTW, “It is important for colleagues to know just how valuable athletic trainers are to taking care of the injured athlete. Often times they are more educated on the appropriate management than even physicians, especially when dealing with the equipped athlete.”
Asked which recommendations might prove to be the most challenging, Dr. Prasarn noted, “For sure the removal of equipment on the field will prove to be the most challenging. I think it’s important for all to be aware these are recommendations and not hard and fast rules. In addition, every patient and clinical situation is different and the physicians, athletic trainers, and EMS at the scene should also have some autonomy and make decisions based on their best judgment.”
“In most situations equipment removal should be done given that there is a trained athletic trainer at the scene to help out; there will probably not be one at the emergency department or in the ambulance/helicopter. Athletic trainers are critical in this situation and can be integral to the appropriate management of the injured athlete. In some situations where there are trained staff (including physicians) who will accompany the injured athlete this can be done at the hospital if deemed appropriate.”
Pre-Collegiate Surgery=Future Surgery?
One lower extremity surgery prior to college could put athletes at a higher risk for another, says new research from the University of California at Los Angeles (UCLA)…and this is regardless of gender and sport.
Lead author Dean Wang, M.D. tells OTW, “According to reports in the literature, sports-related injury requiring surgery in the young athlete has increased in recent years. We previously found that collegiate athletes with a history of prior knee surgery are at higher risk for an intra-collegiate knee injury and surgery. Thus, we wanted to perform a more comprehensive study looking at the predictive value of prior surgery on injury risk in college. We examined data from nearly 1, 200 athletes who participated in 20 different sports at one institution. Our results indicate that athletes who sustain an injury before college might be more at risk for future injury.”
Asked why this issue has not been examined previously, Dr. Wang commented to OTW, “Many athletes are able to return to a high level of sport after surgeries like an ACL [anterior cruciate ligament] reconstruction or shoulder stabilization. Therefore, any post-operative functional deficits that may put them at risk for another injury may be subtle. Additionally, this topic has been studied in professional athletes, but there is very little information pertaining to the collegiate athlete.”
“The next step is to investigate the use of functional tests to quantify any existing deficits. This will allow us to gauge the effectiveness of different surgical and rehabilitation techniques.”
Adolescent Runners: Females, Males Differ in Low BMD Risk, Risk Factors
Are adolescent runners at risk for low bone mineral density (BMD)? And what are the differences between male and female runners regarding this risk? Adam Tenforde, M.D. is an avid runner who is completing a sports medicine fellowship at Stanford University. He recently published a study entitled, “Identifying Sex-Specific Risk Factors for Low Bone Mineral Density in Adolescent Runners.” Dr. Tenforde told OTW, “The incidence rate of bone stress injuries in collegiate runners is up to 20% annually. For this study, we focused on high school runners because they have not yet reached peak bone mass and are at risk for low bone mass and bone stress injuries. Focusing on the younger population may help with prevention strategies and improve lifelong skeletal health. We obtained questionnaires and bone densitometry values in order to better understand which risk factors are most strongly associated with impaired bone health.”
“A total of 94 females and 42 males completed an online survey where they were asked about training characteristics, fracture history, eating behaviors and attitudes, and menstrual history; we used a food frequency questionnaire to identify dietary patterns and measure calcium intake. Our goal was to identify the strongest variables that would predict impaired bone mass. To that end we collected bone density values (BMD) using dual energy x-ray absorptiometry (DXA), and evaluated z-scores on a continuum. We also evaluated risk factors that were most strongly associated with BMD Z-score values of -1 or less, a threshold we defined as low bone mass.”
“In female runners, we found that risk factors for lower lumbar spine (LS) BMD included a lower android/gynoid fat mass ratio, lower fat mass, and combination of current menstrual irregularities and history of fracture. For total body less head (TBLH), later age of menarche, fewer cups of milk per day, and lower android/gynoid fat mass ratio were associated with lower BMD. The android/gynoid fat mass ratio has not been reported on in the running population prior to our report. This ratio may represent a marker for low energy availability or impaired nutrition. Additionally, it is unclear whether there is something inherent to the relative types of fat tissues that affects the overall endocrine system that in turn influences bone health.”
“In male runners, lower body mass index (BMI) was associated with lower LS and TBLH BMD. Similar to female runners, lower android to gynoid fat mass was also associated with lower TBLH BMD. Additionally, athletes who answered yes to the questions ’Do you believe being thinner helps you run faster?’ were more likely to have lower BMD. So perhaps this question is a marker for behaviors associated with impaired nutrition.”
“Finally, we found risk factors for low BMD, defined as BMD Z-scores of -1 or less. In females, those with BMI at or below the threshold of 17.5 kg/m2 or runners with the combination of current menstrual irregularities and history of fracture were more likely to have low bone mass. In males, BMI of 17.5 kg/m2 or below and belief that being thinner leads to faster running performances were associated with low BMD. It is easy for orthopedic surgeons to screen for these risk factors to help evaluate runners who may have lower BMD. Like many things, it is a matter of awareness.”
