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Background/aimRugby union (‘rugby’) presents an above-average risk of injury to participants. BokSmart is a South African nationwide intervention that aims to reduce rugby-related injuries in players. This is achieved by educating coaches and referees to improve injury behaviour of players. Thus, the aim of this study was to assess if the receipt of injury-prevention education was associated with player behaviour.MethodsJunior (n=2279) and senior (n=1642) players, who attended merit-based South African Rugby tournaments (2008–2012), completed an anonymous questionnaire. Logistic regressions investigated if player injury-prevention behaviours were associated with the receipt of education on the same topic. Additionally, players' preferred sources of education were explored through frequency and χ2 analyses.ResultsOf the 16 injury-prevention behaviours, 12 (75%) were associated with receiving education on that topic. The four behaviours not associated with education were: warming-up (before training and matches), and avoiding heat and massage post injury. Of the seven possible sources of this education, the majority of players chose either coaches or physiotherapists as their preferred media. In comparison with junior players, more senior players chose physiotherapists instead of coaches for warming-up and cooling-down education.ConclusionsThe results of this study support, to a large degree, the strategy of BokSmart—influence of player behaviour through coach education. However, these findings also suggest that BokSmart could target team physiotherapists in addition to coaches and referees with their safety education. Also, players might have different preferences for this education depending on their age.

It has recently been proposed that the tackle, an integral part of Rugby Union, be banned in school rugby, as a means to reduce the risk of injury. This proposal held that harmful contact should be removed in response to what was termed an unacceptably high-injury risk. Such a ban would represent a significant intervention that could change the nature of Rugby Union. As such, the basis and rationale for such a ban is worthy of critical evaluation. This review aims to describe the research on which such a ban is proposed. It does so through an assessment (identification), estimation (understanding of the magnitude and occurrence) and evaluation (determining acceptability) of the risk before decisions can be made about implementing any risk mitigation strategies. The body of literature describing injury risk, particularly among youths, is indeed thin and fraught with methodological differences that makes definitive conclusions impossible. We describe these, and their implications, arguing that the complete ban on the tackle may be unnecessary in young children, in whom injury risk may not be as high as is often argued, but also that it may have detrimental consequences. Finally, we propose alternative strategies and research questions which must be pursued to effectively reduce risk without creating unintended consequences or changing the nature of the sport.

Youth have very high participation and injury rates in sport. Sport is the leading cause of injury in youth. Sport injury reduces future participation in physical activity which adversely affects future health. Sport injury may lead to overweight/obesity and post-traumatic osteoarthritis. The objective of the systematic review and meta-analysis was to evaluate the efficacy of injury prevention neuromuscular training strategies in youth sport. Three electronic databases were systematically searched up to September 2014. Studies selected met the following criteria: original data; analytic prospective design; investigated a neuromuscular training prevention strategy intervention(s) and included outcomes for injury sustained during sport participation. Two authors assessed the quality of evidence using Downs and Black (DB) criteria. Meta-analyses including randomised controlled trials only (RCTs) to ensure study design homogeneity were completed for lower extremity and knee injury outcomes. Of 2504 potentially relevant studies, 25 were included. Meta-analysis revealed a combined preventative effect of neuromuscular training in reducing the risk of lower extremity injury (incidence rate ratio: IRR=0.64 (95% CI 0.49 to 0.84)). Though not statistically significant, the point estimate suggests a protective effect of such programmes in reducing the risk of knee injury (IRR=0.74 (95% CI 0.51 to 1.07)). There is evidence for the effectiveness of neuromuscular training strategies in the reduction of injury in numerous team sports. Lack of uptake and ongoing maintenance of such programmes is an ongoing concern. A focus on implementation is critical to influence knowledge, behaviour change and sustainability of evidence informed injury prevention practice.

The Executive Committee of the International Ankle Consortium presents this 2016 position paper with recommendations for information implementation and continued research based on the paradigm that lateral ankle sprain (LAS), and the development of chronic ankle instability (CAI), serve as a conduit to a significant global healthcare burden. We intend our recommendations to serve as a mechanism to promote efforts to improve prevention and early management of LAS. We believe this will reduce the prevalence of CAI and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and promotion of physical activity.

Background Injury and illness surveillance is the foundation for the development of prevention strategies. Objective To examine injuries among the aquatic disciplines in the 4 weeks prior to and during the 2013 FINA World Championships. Methods The study was comprised of two components: (1) a retrospective athlete survey recording injuries in the 4 weeks prior to the Championships and (2) a prospective recording of injuries and illnesses by the medical teams of the participating countries and the local host medical team. Results One-third of the 1116 responding athletes reported an injury/physical complaint in the 4 weeks prior to the Championships. Significantly more women (36.7%) than men (28.6%) reported injuries. Divers reported the highest rate of injury/physical complaints (55.7%). At the start of the Championships, 70% of injured respondents (n=258) were still symptomatic; however, full participation was expected by 76%. During the Championships, 186 new injuries were reported (8.3/100 registered athletes) with the highest injury incidence rate in water polo (15.3/100 registered athletes). The most common injured body part was the shoulder (21%). A total of 199 illnesses were reported during the Championships (9.0/100 registered athletes) with the most common diagnosis of illness being gastrointestinal infection. Environmental exposure (allergy, otitis and jellyfish stings) was responsible for 27% of all illnesses in open water swimming. Conclusions Injuries pose a significant health risk for elite aquatic athletes. A prospective study would improve understanding of out-of-competition injuries. Future injury and illness surveillance at FINA World Championships is required to direct and measure the impact of prevention strategies.

Background Ankle sprain is the most common sports-related injury with a high rate of recurrence and associated costs. Recent studies have emphasised the effectiveness of both neuromuscular training and bracing for the secondary prevention of ankle sprains. Aim To evaluate the effectiveness of combined bracing and neuromuscular training, or bracing alone, against the use of neuromuscular training on recurrences of ankle sprain after usual care. Methods 384 athletes, aged 18–70, who had sustained a lateral ankle sprain, were included (training group n=120; brace group n=126; combi group n=138). The training group received an 8-week home-based neuromuscular training programme, the brace group received a semirigid ankle brace to be worn during all sports activities for 12 months, and the combi group received both the training programme, as well as the ankle brace, to be worn during all sports activities for 8 weeks. The main outcome measure was self-reported recurrence of the ankle sprain. Results During the 1-year follow-up, 69 participants (20%) reported a recurrent ankle sprain: 29 (27%) in the training group, 17 (15%) in the brace group and 23 (19%) in the combi group. The relative risk for a recurrent ankle sprain in the brace group versus the training group was 0.53 (95% CI 0.29 to 0.97). No significant differences were found for time losses or costs due to ankle sprains between the intervention groups. Conclusions Bracing was superior to neuromuscular training in reducing the incidence but not the severity of self-reported recurrent ankle sprains after usual care.

Objective Intrathecal drug delivery systems (intrathecal pumps) are used to treat patients with chronic refractory pain syndromes and spasticity. The objective of our case report was to demonstrate that intrathecal pump malfunction can lead to intrathecal overdosing of drugs. Case Report We present 2 cases of intrathecal pump malfunction leading to overinfusion. The first case concerns a patient with an intrathecal pump that was implanted almost 5 years before the reported incident. During a refill procedure, 12.5 mL was aspirated instead of the expected 21.8 mL. Analysis of the pump revealed that the pump was overinfusing. The second case concerns a patient with an intrathecal pump that was implanted more than 5 years before the reported incident. Ten hours after a regular refill of the pump, she was found in a comatose state, and when the intrathecal pump was emptied, only 16 mL was aspirated instead of the 19.6 mL expected. Analysis of the pump revealed that the inner tubing was not running smoothly over the roller arms, possibly causing spurts, which could have caused an overinfusion. Conclusions We present 2 cases of intrathecal pump malfunction, which most likely led to overinfusion of fentanyl intrathecally. To reduce the risk of this complication, particular attention should be paid to drug reservoir volume discrepancies and overdose symptoms reported by patients.

Context In some cases, physicians estimate that continuous sedation until death may have a life-shortening effect. The accuracy of these estimations can be questioned. Aim The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death. Methods In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach (question: Did continuous sedation, according to your estimation, hasten the patient’s death? If yes: by how much time?) and an indirect approach (estimated life expectancy minus duration of sedation). The intrarater agreement between both approaches was determined with a weighted κ. Results According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%. The intrarater agreement between both approaches was fair (weighted κ=0.38). In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates. Conclusions The results show a discrepancy between different approaches to estimate the potential life-shortening effect of continuous sedation until death.

Objectives Knee osteoarthritis (OA) is a leading cause of activity limitations. The knee OA population is likely to consist of subgroups. The aim of the present study was to identify homogeneous subgroups with distinct trajectories of activity limitations in patients with early symptomatic knee OA and to describe characteristics of these subgroups. Methods Follow-up data over a period of 5 years of 697 participants with early symptomatic knee OA from the Cohort Hip and Cohort Knee (CHECK) were used. Activity limitations were measured yearly with the Western Ontario and McMaster Universities Osteoarthritis Index. Latent class growth analyses identified homogeneous subgroups with distinct trajectories of activity limitations. Multivariable regression analyses examined differences in characteristics between the subgroups. Results Three subgroups were identified. Participants in Subgroup 1 (?egood outcome?f; n=330) developed or displayed slight activity limitations over time. Participants in Subgroup 2 (?emoderate outcome?f; n=257) developed or displayed moderate activity limitations over time. Participants in subgroup 3 (?epoor outcome?f; n=110) developed or displayed severe activity limitations over time. Compared with the ?egood outcome?f subgroup, the ?emoderate outcome?f and ?epoor outcome?f subgroups were characterised by: younger age, higher body mass index, greater pain, bony tenderness, reduced knee flexion, hip pain, osteophytosis, .3 comorbidities, lower vitality or avoidance of activities. Conclusions Based on the 5-year course of activity limitations, we identified homogeneous subgroups of knee OA patients with good, moderate or poor outcome. Characteristics of these subgroups were consistent with existing knowledge on prognostic factors regarding activity limitations, which supports the validity of this classification.

Introduction To counteract the recently observed increase in forearm fractures in children worldwide, an educational programme to improve fall skills was developed. In this 8-week programme children learned basic martial arts falling techniques in their physical education classes. In this study, the effectiveness of this educational programme to improve fall skills was evaluated. Methods A cluster randomised controlled trial was conducted in 33 primary schools. The intervention group received the educational programme to improve falling skills during their physical education (PE) classes whereas the control group received their regular PE curriculum. At baseline (October 2009) and follow-up (May 2010), a questionnaire was completed by the children about their physical activity behaviours. Furthermore, fall-related injuries were registered continuously during an entire school-year. Results A total of 36 incident injuries was reported in the intervention group, equalling an injury incidence density (IID) of 0.14 fall-related injuries per 1000 h of physical activity (95% CI 0.09 to 0.18). In contrast, 96 injuries were reported by the control group corresponding to an IID of 0.26 (95% CI 0.21 to 0.32). However, because intracluster correlation was high (ICC=0.46), differences in injury incidence were not statistically significant. When activity level was taken into account, a trend was shown suggesting that the ‘falling is a sport’ programme was effective in decreasing falling-related injury risk, but only in the least active children. Discussion and conclusion Although results did not reach significance because of strong clustering effects, a trend was found suggesting that a school-based educational programme to improve falling skills may be more beneficial for the prevention of falling-related injuries in children with low levels of habitual physical activity.

Background The rapidly increasing burden of chronic disease is diffi cult to reconcile with the large, compelling body of literature that demonstrates the substantial preventive and therapeutic benefi ts of comprehensive lifestyle intervention, including physical activity, smoking cessation and healthy diet. Physical inactivity is now the fourth leading independent risk factor for death caused by non-communicable chronic disease. Although there have been efforts directed towards research, education and legislation, preventive efforts have been meager relative to the magnitude of the problem. The disparity between our scientifi c knowledge about chronic disease and practical implementation of preventive approaches now is one of the most urgent concerns in healthcare worldwide and threatens the collapse of our health systems unless extraordinary change takes place. Findings The authors believe that there are several key factors contributing to the disparity. Reductionism has become the default approach for healthcare delivery, resulting in fragmentation rather than integration of services. This, in turn, has fostered a disease-based rather than a health-based model of care and has produced medical school curricula that no longer accurately refl ect the actual burden of disease. Trying to ‘fi t’ prevention into a disease-based approach has been largely unsuccessful because the fundamental tenets of preventive medicine are diametrically opposed to those of disease-based healthcare. Recommendation A clinical discipline within medicine is needed to adopt disease prevention as its own reason for existence. Sport and exercise medicine is well positioned to champion the cause of prevention by promoting physical activity. Conclusion This article puts forward a strong case for the immediate, increased involvement of clinical sport and exercise medicine in the prevention and treatment of chronic disease and offers specifi c recommendations for how this may begin.

Objectives To establish the effect of preventive measures and assert the optimal prevention strategy for acute lateral ligament injury to the ankle. Methods An electronic literature search was employed to look for published randomised controlled trials, a controlled trials or time interventions containing research questions regarding the prevention of lateral ankle ligament injuries. Two reviewers reviewed relevant studies for strengths and weaknesses in design and methodology, according to a standardised set of predefined criteria. A total of 24 relevant studies met the criteria for inclusion and were analysed. Results Overall taping, bracing and neuromuscular training were all effective for the prevention of ankle-sprain recurrences. The RRs of these prophylactic measures are of similar magnitude, ranging from 0.2 to 0.5 when compared with control groups. Although preventive effects have been reported in a general athletic population, evidence suggests this overall effect is due to a strong preventive effect in previously injured athletes and that any effect on fresh ankle sprains is either non-existent or very low. Conclusions Based on these outcomes, a combination of an external prophylactic measure (tape or brace) with neuromuscular training will achieve the best preventive outcomes with minimal burden for the athlete.

▸ Raymond J, Nicholson LL, Hiller CE, et al . The effect of ankle taping or bracing on proprioception in functional ankle instability: a systematic review and meta-analysis. J Sci Med Sport 2012 online doi.org/10.1016/j.jsams.2012.03.008. Ankle injuries account for up to 20% of sports-related injuries,1 of these 33–73% are sprains, most commonly of the lateral ligament complex. This high incidence and the functional consequences ensure that patients with ankle sprains present frequently to sports medical practises. The serious consequences of a sprain include ongoing instability and recurrence,2 although it is unclear as to what physiological changes following the original injury predispose an individual to these consequences. One hypothesis is that proprioception, which refers to a group of sensations, including sense of movement, sense of joint position and sensations related to muscle force,3 is impaired following the first ankle sprain. Taping or a brace placed in direct contact with the skin is thought to improve proprioceptive acuity by stimulating cutaneous mechanoreceptors. Ankle taping or bracing is commonly used by those who have experienced an ankle sprain as a means of preventing further injury. Generally, tape and braces are hypothesised to reduce ankle sprain risk by providing mechanical support to the joint and also by improving proprioception.4 ,5 To determine whether ankle taping or bracing compared to no taping or bracing improves proprioception in people with a history of ankle sprain or functional ankle instability. Eight biomedical databases including …

The review on psychoactive substance use among truck drivers by Girotto et al 1 is important from the occupational health perspective, but also has consequences from the broader public health perspective. After commenting on the review's methodology related to its findings, this commentary pays attention to both perspectives. Relevant papers for inclusion in the review were searched systematically and results of the included studies were synthesised independently by two researchers. The authors wisely decided to stratify the results from studies relying on self-reported information and those using biological samples. Still, the observed prevalence of intake of psychoactive substances showed a very large range in both strata. For example, self-reported alcohol intake varied from 9.9% (‘while driving’, Pakistan) up to 91.0% (‘current’, Brazil), and the use of amphetamines analysed from biological samples ranged from 0.2% (Norway) to 82.5% (Thailand). Apart from empirical variation across different truck driver populations (differences actually present), the authors correctly state that these …

Recent onset hypertension should prompt investigation for secondary causes Recent onset hypertension should prompt investigation for secondary causes. This search routinely includes screening for mineralocorticoid excess, renal artery stenosis, and, in selected cases, phaeochromocytoma. We present the case of an elderly woman with recent onset hypertension, hypokalaemia, and a raised erythrocyte sedimentation rate. The cause of the hypertension was presumed to be aortic dissection with compromised renal blood flow, but the erythrocyte sedimentation rate provided the clue to the final diagnosis. A 74 year old woman was referred because of general malaise and hypertension. During the previous months she had reported fatigue, lack of appetite and weight loss, and muscle weakness. About three weeks before admission she had had sudden onset abdominal pain and diarrhoea, for which no medical aid was sought and which subsided spontaneously after a few days. Her medical history was unremarkable. In particular, her blood pressure had been only mildly raised (160/90 mm Hg, measured repeatedly during previous years, most recently two months before admission). On examination she had severe hypertension (215/125 mm Hg) but no other abnormalities. Results of vascular, funduscopic, and abdominal examination were normal. Routine laboratory tests showed a raised erythrocyte sedimentation rate (85 mm/h), low plasma sodium (131 mmol/l) and potassium (2.8 mmol/l), moderately raised serum creatinine (111 μmol/l), and mild chronic metabolic alkalosis (arterial pH 7.51, bicarbonate 32 mmol/l). Urinary potassium concentration was 51 mmol/l, and there …