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ObjectiveMinority student-athletes have a lower survival rate from sudden cardiac arrest (SCA) than non-minority student-athletes. This study examined the relationship between high school indicators of socioeconomic status (SES) and survival in student-athletes with exercise-related SCA.MethodsHigh school student-athletes in the USA with exercise-related SCA on school campuses were prospectively identified from 1 July 2014 to 30 June 2018 by the National Center for Catastrophic Sports Injury Research. High school indicators of SES included the following: median household and family income, proportion of students on free/reduced lunch and percent minority students. Resuscitation details included witnessed arrest, presence of an athletic trainer, bystander cardiopulmonary resuscitation and use of an on-site automated external defibrillator (AED). The primary outcome was survival to hospital discharge. Differences in survival were analysed using risk ratios (RR) and univariate general log-binomial regression models.ResultsOf 111 cases identified (mean age 15.8 years, 88% male, 49% white non-Hispanic), 75 (68%) survived. Minority student-athletes had a lower survival rate compared with white non-Hispanic student-athletes (51.1% vs 75.9%; RR 0.67, 95% CI 0.49 to 0.92). A non-significant monotonic increase in survival was observed with increasing median household or family income and with decreasing percent minority students or proportion on free/reduced lunch. The survival rate was 83% if an athletic trainer was on-site at the time of SCA and 85% if an on-site AED was used.ConclusionsMinority student-athletes with exercise-related SCA on high school campuses have lower survival rates than white non-Hispanic athletes, but this difference is not fully explained by SES markers of the school.

This study sought to determine if there were significant trends in lower extremity movement quality, as assessed by the Landing Error Scoring System (LESS) scores and plane-specific LESS subscales, across in 12 recent cohorts of incoming USMA cadets.prospective cohort study.United States Military Academy.7,591.Landing Error Scoring System (LESS) scores, adjusted for sex and ACL injury history.Statistically significant inverse trends were found between total LESS score and year (p 0.01) and sagittal plane subscale and year (p 0.01). A statistically significant direct trend was found for the frontal/transverse plane subscale and year (p 0.01). However, each of these trends had a small associated effect size, and none were considered clinically meaningful.There were no meaningful changes in lower extremity movement quality in incoming US Military Academy cadets between 2005 and 2017.

ObjectiveTo investigate the aetiology and incidence of sudden cardiac arrest and death (SCA/D) in US competitive athletes.MethodsProspective surveillance was conducted from 1 July 2014 to 30 June 2018 through the National Center for Catastrophic Sports Injury Research in collaboration with national sports organisations. Autopsy reports, death certificates, and medical records were reviewed by an expert panel to determine aetiology. Athlete participation statistics from the National Federation of State High School Associations and the National Collegiate Athletic Association (NCAA) were used to calculate incidence rates per athlete-years (AY). Comparisons of incidence rates were calculated using incidence rate ratios (IRR) with 95% CIs.Results331 cases of confirmed SCA/D (158 survivors; 173 fatalities) were identified; 15.4% in middle school, 61.6% in high school and 16.6% in college and professional athletes. Average age was 16.7 (11–29) years, and the majority were in male (83.7%), basketball (28.7%) or American football (25.4%) athletes. Common causes included hypertrophic cardiomyopathy (20.6%), idiopathic left ventricular hypertrophy (13.4%), coronary artery anomalies (12.0%) and autopsy-negative sudden unexplained death (9.6%). Coronary anomalies were more common in middle school athletes (28%), while cardiomyopathies (hypertrophic, arrhythmogenic, dilated, non-compaction or restricted) accounted for 47% of cases in college and professional athletes. Incidence was higher in male versus female athletes at the high school (1:43 932 AY (95% CI 1:38 101 to 1:50 907) vs 1:203 786 AY (95% CI 1:145 251 to 1:293 794); IRR 4.6 (95% CI 3.1 to 7.2)) and NCAA (1:34 906 AY (95% CI 1:25 385 to 1:49 173) vs 1:123 278 AY (95% CI 1:66 078 to 1:249 853); IRR 3.5 (95% CI 1.5 to 9.5)) levels. African American male NCAA Division I basketball players had the highest annual incidence rate of SCA/D (1:2087 AY (95% CI 1:1073 to 1:4 450)).ConclusionsCardiomyopathies account for nearly half of SCA/D cases in college and professional athletes, while coronary artery anomalies play a more prominent role than expected in middle school athletes. Over half of SCA cases in athletes result in sudden death, calling for improved prevention strategies.

ContextCervical muscle strains are an often-overlooked injury, with neck- and spine-related research typically focusing on spinal cord and vertebral injuries.ObjectiveTo examine the rates and distributions of cervical muscle strains in collegiate and high school football athletes.DesignDescriptive epidemiology study.SettingCollegiate and high school football teams.Patients or Other ParticipantsThe National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) collected data from collegiate football athletes. The High School National Athletic Treatment, Injury and Outcomes Network (HS NATION) and High School Reporting Information Online (HS RIO) collected data from high school football athletes. Data from the 2011–2012 through 2013–2014 academic years were used.Main Outcome Measure(s)Athletic trainers collected injury and exposure data for football players. Injury counts, injury rates per 10 000 athlete-exposures (AEs), and injury rate ratios with 95% confidence intervals (CIs) were calculated.ResultsThe NCAA-ISP reported 49 cervical muscle strains (rate = 0.96/10 000 AEs), of which 28 (57.1%) were TL (time loss; rate = 0.55/10 000 AEs). High School NATION reported 184 cervical muscle strains (rate = 1.66/10 000 AEs), of which 33 (17.9%) were TL injuries (rate = 0.30/10 000 AEs). The HS RIO, which collects only TL injuries, reported 120 TL cervical muscle strains (rate = 0.51/10 000 AEs). The overall injury rate was lower in the NCAA-ISP than in HS NATION (injury rate ratio = 0.58; 95% CI = 0.42, 0.79); when restricted to TL injuries, the overall injury rate was higher in the NCAA-ISP (injury rate ratio = 1.83; 95% CI = 1.11, 3.03). No differences were found when comparing TL injuries in HS RIO and the NCAA-ISP. Cervical muscle-strain rates were higher during competitions than during practices across all 3 surveillance systems for all injuries. Most cervical muscle strains were due to player contact (NCAA-ISP = 85.7%, HS NATION = 78.8%, HS RIO = 85.8%).ConclusionsThe incidence of cervical muscle strains in football players was low compared with other injuries. Nonetheless, identifying and implementing interventions, particularly those aimed at reducing unsafe player contact, are essential to further decrease the risk of injury and associated adverse outcomes.

Context Sudden death in sport at the high school and collegiate levels has been described extensively in the literature. However, few epidemiologic data exist on the incidence of sudden death specifically in American youth sport before secondary school athletics. Objective To describe the epidemiology of sudden death in organized youth sports in the United States from 2007 through 2015. Design Descriptive epidemiology study. Setting Organized American youth sports. Patients or Other Participants Cases of sudden death that occurred in youth athletes 17 years of age and younger in non-high school organized sports were included. Data Collection and Analysis Information on sudden deaths between August 1, 2007, and December 31, 2015, was obtained via LexisNexis and other publicly available news or media reports. Total youth sport participation rates from 2007 to 2015 were provided by the Sport & Fitness Industry Association. Athlete age, sex, sport, level of play, event type, date of death, setting, and official and speculated causes of death were examined. Data are presented as deaths per year, percentage of total sudden deaths, and deaths per 10 million participants. Results From 2007 to 2015, 45 sudden deaths were reported in American youth sports. The mean age of patients was 13 ± 2 years. The overall incidence rate was 1.83 deaths/10 million athlete-years. Males experienced a greater number of sudden deaths than females (n = 36/45, 80%). Basketball had the highest number of sudden deaths from 2007 to 2015, with a total of 16 occurrences. The most frequent cause of sudden death was cardiac related (n = 34/45, 76%). Most sudden deaths occurred during practices (n = 32/45, 71%). Conclusions Sudden deaths in organized youth sports in the United States from 2007 through 2015 were most often experienced during practices by males, were cardiac related, and occurred while playing basketball. These findings are similar to those in high school and collegiate sports. This study affirms the need for further epidemiologic research into sudden deaths at the organized youth sport level.

Background Despite wide availability of patient lift equipment in hospitals to promote worker and patient safety, nursing staff do not consistently use equipment. Objective To determine the influence of factors on the use or non-use of lift equipment during patient lifts/transfers. Design Prospective observational cohort study. Setting One university teaching hospital and two community hospitals in a large health system in southeastern United States. Participants 77 nurses and nursing care assistants with patient handling duties in critical care, step-down and intermediate care units. Methods Participants recorded information about all patient lifts/transfers during their shifts during a 1 week period per month for three months: type of lift/transfer, equipment use, type of equipment, and presence of 20 factors at the time of the lift/transfer. With the patient lift/transfer as the unit of analysis, the association (risk ratios (RR) and 95% confidence intervals (CI)) between factors and equipment use was examined using multivariate Poisson regression with generalized estimating equations. Results Seventy-seven participants (465 person-shifts) reported 3246 patient lifts/transfers. Frequent lifts/transfers included bed-to-toilet (21%), toilet-to-bed (18%), bed-to-chair (13%), chair-to-bed (13%), chair-to-toilet (6%), and toilet-to-chair (6%). Equipment was used for 21% of lifts/transfers including powered floor based dependent lift (41%), powered sit-to-stand lift (29%), non-powered sit-to-stand lift (17%), air-assisted lateral transfer device (6%), ceiling lift (3%), and air-assist patient lift (3%). Factors associated with equipment use included: availability of equipment supplies (RR = 9.61 [95%CI: 6.32, 14.63]), staff availability to help with equipment (6.64 [4.36, 10.12]), staff preference to use equipment (3.46 [2.48, 4.83]), equipment required for patient condition (2.38 [1.74, 3.25]), patient inability to help with lift/transfer (2.38 [1.71, 3.31]), equipment located in/by patient room (1.82 [1.08, 3.06]), sling already under patient (1.79 [1.27, 2.51]), and patient size/weight (1.38 [0.98, 1.95]). Lower patient mobility score (3.39 [2.19, 5.26]) and presence of physical or mental impairments (2.00 [1.40, 2.86]) were also associated with lift equipment use. Factors associated with non-use of equipment included: patient/family preference (0.31 [0.12, 0.80]), staff assisting with lift did not want to use equipment 0.34 ([0.17, 0.68]), patient condition (0.48 [0.20, 1.20]), and patient almost fell (0.66 [0.45, 0.97]). Conclusions Patient, worker, equipment, and situational factors influence whether nursing staff used equipment to lift/transfer a patient. Quantifying and understanding these factors associated with lift equipment use and non-use provides specific information for hospitals and safety professionals to enhance effectiveness of future organizational and ergonomic intervention efforts to prevent work-related patient-handling injuries.

Context Although sport-related internal organ injuries among athletes are relatively infrequent, combining data sources enables a more comprehensive examination of their incidence. Objective To describe the incidence and characteristics of sport-related internal organ injuries due to direct-contact mechanisms among high school (HS) and collegiate athletes from 2005–2006 through 2014–2015. Design Descriptive epidemiology study. Setting United States HS and collegiate sports data from 3 national sports injury-surveillance systems: High School Reporting Information Online (HS RIO), the National Collegiate Athletic Association Injury Surveillance Program (ISP), and the National Center for Catastrophic Sport Injury Research. Patients or Other Participants High school and collegiate athletes in organized sports. Main Outcome Measure(s) Characteristics of the athlete, event, and injury were examined and stratified by data source and sport. Descriptive statistics of internal organ injuries via direct-contact mechanisms consisted of frequencies and incidence rates (IRs) per 1 000 000 athlete-exposures and 95% confidence intervals (CIs). Results During the 10-year period, 174 internal organ injuries were captured: 124 in HS RIO and 41 in the ISP; 9 were catastrophic. Most noncatastrophic injuries occurred among males (RIO = 85%, ISP = 89%), in football (RIO = 65%, ISP = 58%), and during competitions (RIO = 67%, ISP = 49%) and were due to player-player contact (RIO = 78%, ISP = 68%). The highest injury rates were in male contact sports: RIO football (IR = 11.7; 95% CI = 9.1, 14.2) and lacrosse (IR = 10.0; 95% CI = 3.1, 16.9); ISP: football (IR = 8.3; 95% CI = 5.0, 11.6) and ice hockey (IR = 7.9; 95% CI = 1.0, 14.7). A quarter of noncatastrophic injuries were season ending (RIO = 25%, ISP = 23%). Of the 9 catastrophic injuries, most occurred in HS (7/9) and football (7/9) and were due to player-player contact (6/9). Four resulted in death. Conclusions Direct-contact internal organ injuries occur infrequently; yet when they do occur, they may result in severe outcomes. These findings suggest that early recognition and a better understanding of the activities associated with the event and use or nonuse of protective equipment are needed.

Objective To determine the etiology of sudden cardiac arrest and death (SCA/D) in competitive athletes through a prospective national surveillance program. Design Sudden cardiac arrest and death cases in middle school, high school, college, and professional athletes were identified from July 2014 to June 2016 through traditional and social media searches, reporting to the National Center for Catastrophic Sports Injury Research, communication with state and national high school associations, review of the Parent Heart Watch database, and search of student-athlete deaths on the NCAA Resolutions List. Autopsy reports and medical records were reviewed by a multidisciplinary panel to determine the underlying cause. Setting and participants US competitive athletes with SCA/D. Main outcome measures Etiology of SCA/D. Results A total of 179 cases of SCA/D were identified (74 arrests with survival, 105 deaths): average age 16.6 years (range 11-29), 149 (83.2%) men, 94 (52.5%) whites, and 54 (30.2%) African American. One hundred seventeen (65.4%) had an adjudicated diagnosis, including 83 deaths and 34 survivors. The most common etiologies included hypertrophic cardiomyopathy (19, 16.2%), coronary artery anomalies (16, 13.7%), idiopathic left ventricular hypertrophy/possible cardiomyopathy (13, 11.1%), autopsy-negative sudden unexplained death (8, 6.8%), Wolff-Parkinson-White (8, 6.8%), and long QT syndrome (7, 6.0%). Hypertrophic cardiomyopathy was more common in male basketball (23.3%), football (25%), and African American athletes (30.3%). An estimated 56.4% of cases would likely demonstrate abnormalities on an electrocardiogram. Conclusions The etiology of SCA/D in competitive athletes involves a wide range of clinical disorders. More robust reporting mechanisms, standardized autopsy protocols, and accurate etiology data are needed to better inform prevention strategies.

Background: Sudden cardiac arrest (SCA) is the leading cause of death in young athletes during sports. Hypothesis: Survival after SCA in young athletes is variable. Study Design: Prospective, active surveillance study. Level of Evidence: Level 3. Methods: From July 1, 2014, to June 30, 2016, exercise-related SCA in competitive young athletes was identified through a systematic search of traditional and social media sources, direct reporting to the National Center for Catastrophic Sports Injury Research, searching of the National Collegiate Athletic Association Resolutions List, regular communication with national and state high school athletic associations, and review of cases in the Parent Heart Watch database. Results: A total of 132 cases were identified during the 2-year study period (mean patient age, 16 years; age range, 11-27 years; 84% male; 51% white non-Hispanic/Latino, 30% black/African American, and 11% white Hispanic/Latino). High school athletes accounted for 78 (59%) cases, with 28 (21%) in middle school and 15 (11%) in college athletes. Overall survival was 48% (95% CI, 40%-57%; 64 survivors, 68 deaths). Survival was similar in male versus female athletes but higher in white non-Hispanic/Latino (40/67; 60%) versus black/African American (13/39; 33%) athletes (difference, 27%; 95% CI, 7%-45%; P = 0.008) and white non-Hispanic/Latino versus all minority (18/59; 31%) athletes (difference, 29%; 95% CI, 13%-46%; P = 0.001). Basketball accounted for 30% of cases, followed by football (25%), track/cross-country (12%), and soccer (11%). The majority (93%) of cases were witnessed. If a certified athletic trainer was on-site and involved in the resuscitation, 83% of athletes survived. If an on-site automated external defibrillator was used in the resuscitation, 89% of athletes survived. Conclusion: Exercise-related SCA in young, competitive athletes is typically witnessed, providing an opportunity for rapid resuscitation. Additional research is needed to identify factors that affect survival in different athlete populations. Clinical Relevance: Public access defibrillator programs should be universal in schools and youth sporting venues and have the potential to increase survival after SCA in young athletes.

Mixed methods research is a relatively new approach in the field of sports medicine, where the benefits of qualitative and quantitative research are combined while offsetting the other's flaws. Despite its known and successful use in other populations, it has been used minimally in sports medicine, including studies of the clinician perspective, concussion, and patient outcomes. Therefore, there is a need for this approach to be applied in other topic areas not easily addressed by one type of research approach in isolation, such as the retirement from sport, effects of and return from injury, and catastrophic injury.

Context: Health care workers have high rates of musculoskeletal injuries, but many of these injuries go unreported to workers' compensation and national surveillance systems. Little is known regarding the work-related injuries of certified athletic trainers (ATs). Objective: To determine the 12-month incidence and prevalence of work-related injuries and describe injury-reporting and -management strategies. Design: Cross-sectional study. Setting: Population-based online survey. Patients or Other Participants: Of the 29 051 ATs currently certified by the Board of Certification, Inc, who “opted in” to research studies, we randomly selected 10 000. Of these, 1826 (18.3%) ATs currently working in the clinical setting were eligible and participated in the baseline survey. Main Outcome Measure(s): An online survey was e-mailed in May of 2012. We assessed self-reported work-related injuries in the previous 12 months and management strategies including medical care, work limitations or modifications, and time off work. Statistics (frequencies and percentages) were calculated to describe injury rates per 200 000 work hours, injury prevalence, injury characteristics, and injury-reporting and -management strategies. Results: A total of 247 ATs reported 419 work-related injuries during the previous 12 months, for an incidence rate of 21.6 per 200 000 hours (95% confidence interval = 19.6, 23.7) and injury prevalence of 13.5% (95% confidence interval = 12.0%, 15.1%). The low back (26%), hand/fingers (9%), and knee (9%) were frequently affected body sites. Injuries were most often caused by bodily motion/overexertion/repetition (52%), contact with objects/equipment/persons (24%), or slips/trips/falls (15%). More than half of injured ATs (55.5%) sought medical care, 25% missed work, and most (77%) did not file a workers' compensation claim for their injury. Half of injured ATs were limited at work (n = 125), and 89% modified or changed their athletic training work as a result of the injury. Conclusions: More than half of AT work-related injuries required medical care or work limitations and were not reported for workers' compensation. Understanding how ATs care for and manage their work-related injuries is important given that few take time off work.

An estimated 1.1 million high school and 75,000 college athletes participate in tackle football annually in the United States. Football is a collision sport; traumatic injuries are frequent (1,2), and can be fatal (3). This report updates the incidence and characteristics of deaths caused by traumatic brain injury and spinal cord injury (4) in high school and college football and presents illustrative case descriptions. Information was analyzed from the National Center for Catastrophic Sport Injury Research (NCCSIR). During 2005-2014, a total of 28 deaths (2.8 deaths per year) from traumatic brain and spinal cord injuries occurred among high school (24 deaths) and college football players (four deaths) combined. Most deaths occurred during competitions and resulted from tackling or being tackled. All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010-2014) of the 10-year study period. These findings support the need for continued surveillance and safety efforts (particularly during competition) to ensure proper tackling techniques, emergency planning for severe injuries, availability of medical care onsite during competitions, and assessment that it is safe to return to play following a concussion.

Background: The risk of heat-related illness and death may continue to increase in many locations as a consequence of climate change, but information on the effectiveness of policies to protect populations from the adverse effects of excessive heat is limited. In 2009, the National Athletic Trainers’ Association Inter-Association Task Force (NATA-IATF) released guidelines to reduce exertional heat illness (EHI) among U.S. high school athletes participating in preseason sports activities, including preseason practice sessions for American football. A subset of state high school athletic associations have implemented state-mandated guidelines consistent with the 2009 NATA-IATF recommendations, but their effectiveness for reducing preseason EHI is unknown. Objectives: This study examines the association between the enactment of state high school athletic association–mandated NATA-IATF guidelines and the rate of EHI among high school students during preseason American football practice sessions. Methods: We performed a quasi-experimental interrupted time-series study of EHI during high school American football practices in the 2005/2006–2016/2017 school years. We estimated state-level EHI rates using High School Reporting Information Online injury and athlete-exposure data, and used generalized estimating equations Poisson regression models to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) comparing state-years with and without mandated NATA-IATF guidelines. State-level covariates included state-year–specific average August temperatures, yearly deviations from each state’s August average temperature across the study period, and school year. Results: Data were available for 455 state-years from 48 states, including 32 state-years (7.0%) from 8 states when mandated guidelines consistent with the NATA-IATF recommendations were implemented. During an estimated 2,697,089 athlete-exposures, 190 EHIs were reported. Estimated preseason EHI rates were lower during state-years with versus without mandated guidelines (adjusted IRR=0.45IRR=0.45, 95% CI: 0.23, 0.87). Conclusions: Our findings suggest that high school athletes would benefit from enactment of the 2009 NATA-IATF guidelines. Similar analyses of the effectiveness of other public health policies to reduce adverse health effects from ambient heat are warranted.

Health care providers are encouraged to provide care according to practice recommendations because these suggestions should improve patient care and promote optimal patient outcomes. The goals of these practice recommendations are to improve patient care and promote optimal patient outcomes. However, without integration into clinical practice, the value of practice recommendations in supporting patient care is lost. Unfortunately, little is known about the success of integrating practice recommendations into clinical practice, and targeted efforts to promote integration are likely needed. Implementation research is a broad area of study that focuses on how guidelines, programs, or interventions are put into practice and delivered. The Translating Research Into Injury Prevention Practice (TRIPP) framework consists of 6 stages that support implementation science, and the framework has been used to assist in integrating injury-prevention programs into patient care. The structure of the TRIPP framework makes it applicable to other programs that would benefit from implementation science, including practice recommendations. Stages 5 and 6 of the TRIPP framework emphasize the need to explore the implementation context and factors related to uptake of a program by end users. This commentary highlights our efforts to use methods for implementation research to evaluate stage 5 of the TRIPP framework as it relates to acute care for patients with suspected spine injuries and provides 6 lessons learned that may assist in future efforts to better implement practice recommendations in patient care. Targeted efforts to assist clinicians in implementing practice recommendations may promote their use and ultimately enhance the care provided for patients with a variety of health conditions. An essential component of any implementation effort is understanding end users via stages 5 and 6 of the TRIPP framework, and this understanding may maximize knowledge translation and encourage practice change and advancement.

Background Devices to lift, transfer, and reposition patients are recommended for healthcare workers' and patients' safety, but their intended use has yet to be fully realized. Objective The aim of this study was to describe hospital nursing staff use of lift/transfer devices and the presence of factors at the time of lifts/transfers with potential to influence whether devices are used. Methods Participants were 108 US nursing staff in a university-based medical center and two community hospitals. A self-completed questionnaire was used to collect demographic and work characteristics, typical frequency of patient lifts/transfers, training in and typical use of lift equipment, and specific factors that could influence use. Proportional distributions of lifting/transferring and repositioning frequencies in a typical shift, amount of equipment use, and factors present were examined overall and across worker and work-related characteristics. Results Although trained in equipment use, only 40% used equipment for at least half of lifts/transfers. During lifts/transfers, factors often present included patient unable to help with lift/transfer (91.3%) or of a size/weight where participant needed assistance to help lift/transfer (87.5%); availability of others who could assist with manual lift (86.3%) or use of lift equipment (82.4%); and equipment functioning properly (86.4%), having supplies available (82.5%), and being easy to retrieve from storage (81.6%). During repositioning tasks, physical assistance was "always/almost always" provided from coworkers (83.3%) and often perceived as "very helpful" (92.6%) in reducing physical demands. Physical assistance from patients was less common (14.0% "always/almost always") yet perceived as "very helpful" by 66.3%. One fifth always used friction-reducing devices. Discussion Despite training in their use, nursing staff use of available lift equipment and assistive devices is limited. Factors present at the time of lifts/transfers that may influence equipment/device use reflect a complex mix of patient, worker, equipment, and situational characteristics.

Tens of millions of children and adults participate in organized sport in the United States each year. Although uncommon, fatal and severe nonfatal brain and spine injuries can occur during these activities. These "catastrophic" injuries have been noted in contact sports such as football, rugby, and ice hockey, as well as in noncontact sports including baseball, cheerleading, swimming and diving, equestrian, gymnastics, pole vault, rodeo, snow skiing, snowboarding, and wrestling. They happen at all levels of play, from youth to professional. Among all sports, football has the highest number of fatal brain and cervical spine injuries. While these injuries are more frequent in high school football, the rate is higher amongst college football athletes. Patterns exist in the types of brain and spine injuries most often occurring as a result of traumatic impacts in sport, but incidence and mechanisms of injury vary dramatically between sports. Understanding these patterns is essential to informing prevention efforts; football, pole vault, and cheer are all examples of sports benefiting from successful catastrophic injury prevention efforts. Participating in sport provides many benefits to physical and mental health. Despite these benefits, rare devastating injuries can be traumatic for the athletes, their families, and communities and can raise safety concerns that may reduce participation in sport. Understanding and preventing these types of injuries are critical to fostering participation in sport and ensuring both children and adults reap the physical, social, and mental benefits of sport.

Asthma is the most common medical condition in athletes with a reported prevalence of approximately 20% [1]. Over the past two decades, the impact of asthma on athletic performance has been extensively studied [2], however, research focussing specifically on asthma-related death in athletes is limited to one study; with Becker and colleagues reporting a series of sixty-one deaths over a seven year period (1993–2000), either during or in close proximity with a sporting event [3]. We therefore undertook this study to provide comprehensive insight into the incidence of asthma-related mortality in competitive athletes. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of interest: Ms. Price has nothing to disclose. Conflict of interest: Dr. Kucera reports other from National Athletic Trainers' Association, other from American Football Coaches Association, other from American Medical Society for Sports Medicine, other from National Operating Committee on Standards in Athletic Equipment, other from National Collegiate Athletic Association, other from National Federation of State High School Associations, outside the submitted work. Conflict of interest: Dr. Drezner has nothing to disclose. Conflict of interest: Dr. Menzies-Gow reports grants and personal fees from Astra Zeneca, personal fees and other from Teva, personal fees from Glaxo SmithKline, personal fees from Novartis, personal fees from Vectura, personal fees from Sanofi, outside the submitted work; . Conflict of interest: Dr. Hull has nothing to disclose.

Background:Subacromial space distance and forward head and shoulder posture are common characteristics resulting from swim training. These alterations can cause abnormal scapular kinematics and positioning, potentially increasing compression of structures in the subacromial space and increasing the risk for the development of swimmer’s shoulder.Purpose:To evaluate the effect of the swim training season on subacromial space distance and forward head and forward shoulder posture as well as to determine the relationship between these variables.Study Design:Cohort study; Level of evidence, 2.Methods:Included in the study were 43 competitive adolescent swimmers and 29 nonoverhead adolescent athletes (controls) who were not currently experiencing any shoulder, neck, or back pain that limited their participation in sports activity. All participants were evaluated 3 times: once before the start of the swim training season and then at 2 follow-up sessions 6 and 12 weeks after the initial testing session. At each testing session, each participant completed a physical examination that included evaluation of posture and subacromial space distance.Results:Swimmers had significantly greater decreases in subacromial space distance during the training season compared with nonoverhead athletes. Swimmers also demonstrated significantly greater increases in forward shoulder posture compared with nonoverhead athletes. A significant relationship was noted between changes in forward shoulder posture and changes in subacromial space distance from the baseline testing session to the assessment 6 weeks after baseline assessment. As forward shoulder posture increased, subacromial space significantly decreased.Conclusion:Because of their training load, swimmers experience a decrease in subacromial space distance and an increase in forward shoulder posture over the course of 12 weeks of training, potentially making these athletes more vulnerable to the development of shoulder pain and injury.

BACKGROUND: Scuba diving mishaps, caused by equipment problems or human errors, increase the occurrence of injuries and fatalities while diving. Pre-dive checklists may mitigate mishaps. This study evaluated the effect of using a pre-dive checklist on the incidence of diving mishaps in recreational divers. METHODS: A multi-location cluster-randomized trial with parallel groups and allocation concealment was conducted between 1 June and 17 August 2012. The participants had to be at least 18 years of age, permitted to dive by the dive operator and planning to dive on the day of participation. They were recruited at the pier and dive boats at four locations. The intervention group received a pre-dive checklist and post-dive log. The control group received a post-dive log only. The outcomes, self-reported major and minor mishaps, were prompted by a post-dive questionnaire. Mishap rates per 100 dives were compared using Poisson regression with generalized estimating equations. Intent-to-treat, per-protocol and marginal structural model analyses were conducted. RESULTS: A total of 1043 divers (intervention = 617; control = 426) made 2041 dives, on 70 location-days (intervention = 40; control = 30) at four locations. Compared with the control group, the incidence of major mishaps decreased in the intervention group by 36%, minor mishaps by 26% and all mishaps by 32%. On average, there was one fewer mishap in every 25 intervention dives. CONCLUSIONS: In this trial, pre-dive checklist use prevented mishaps which could lead to injuries and fatalities. Pre-dive checklists can increase diving safety and their use should be promoted. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01960738. Language: en

Background: Cheerleading is a specialized athletic activity that can lead to catastrophic injuries. Cheerleading rules are in place to maximize safety of participants. The purpose of this study was to describe catastrophic cheerleading injuries among high school and collegiate-level participants in the United States and to explore whether the 2006-2007 basket toss rule change was effective at reducing the number of catastrophic injuries. Hypothesis: The 2006-2007 basket toss rule change contributed to a reduction in the number of catastrophic injuries among high school and collegiate cheerleaders. Study Design: Case series. Level of Evidence: Level 4. Methods: Data on catastrophic cheerleading injuries were collected by the National Center for Catastrophic Sport Injury Research from July 2002 to June 2017. Information collected included cheerleader, event, and injury characteristics. The impact of the 2006-2007 rule change banning the basket toss on any hard surfaces was assessed by comparing injury rates and 95% CIs before and after the rule change. Results: There were 54 catastrophic cheerleading injuries, or 3.6 injuries per year. From July 2002 through June 2017, the injury rate was 2.12 per 1,000,000 cheerleaders (95% CI, 1.56-2.69). Most cheerleaders sustained serious injuries (n = 27; 50%) during practice (n = 37; 69%) to the head (n = 28; 52%) and cervical spine (n = 17; 32%). From July 2002 through June 2017, basket tosses were the stunt that accounted for the highest proportion of injuries (n = 19; 35%). The basket toss injury rate decreased from 1.55 to 0.40 per 1,000,000 cheerleaders among both high school and collegiate cheerleaders after the rule change. Conclusion: Catastrophic injury rates in cheerleading decreased dramatically after the 2006-2007 rule change banning basket tosses from being performed on any hard surfaces. In particular, there was a nearly 4-fold reduction in the rate of catastrophic basket toss injuries.

Objectives Determine the association between performance on the double-leg squat (DLS) and single-leg squat (SLS) and prospective injury incidence in athletes. Design Prospective cohort study. Setting National Collegiate Athletic Association (NCAA) Division I university. Participants 111 incoming NCAA Division I athletes from 10 varsity sports teams. Main outcome measures Performance on the DLS and SLS were assessed as “poor” or “non-poor.” Lower extremity (LE) injury data for the following year were extracted from electronic medical records. Multivariate Poisson regression was used to compare the incidence of LE injuries in athletes with poor versus non-poor performance on the DLS and SLS. Results The final models for the DLS and SLS were adjusted for sex and LE injury history and yielded an incidence rate ratio (IRR) of 1.33 (95% CI: 0.80 2.22) for the DLS and 1.62 (95% CI: 0.98, 2.66) for the SLS when comparing poor to non-poor movers. Conclusions Athletes with poor LE movement quality assessed on the DLS or SLS had greater incidence of LE injury than those with non-poor movement quality. This is the first study to demonstrate an association between performance on the double-leg squat and single-leg squat and injury risk in NCAA athletes.

Context: Overuse injuries are reported to account for nearly 50% of sports injuries and, due to their progressive nature and the uncertainty regarding date of onset, are difficult to define and categorize. Comparing the capture rates of overuse injuries between injury-surveillance systems and medical records can clarify completeness and determinants of how overuse injuries are represented in injury-surveillance data. Objective: To estimate the capture rate of time-loss medical-attention overuse injuries in men's and women's soccer in the National Collegiate Athletic Association Injury Surveillance System (NCAA ISS) compared with medical records maintained by certified athletic trainers and assess the differences in completeness of capture and factors contributing to those differences. Design: Capture-recapture study. Setting: Fifteen NCAA institutions provided NCAA ISS and medical record data from men's and women's soccer programs from 2005–2006 through 2007–2008. Patients or Other Participants: National Collegiate Athletic Association men's and women's soccer players. Main Outcome Measure(s): Time-loss medical-attention overuse injuries were defined as injuries with an overuse mechanism of injury in the NCAA ISS or medical records. Capture rates were calculated as the proportion of total overuse injuries classified as having overuse mechanisms in the NCAA ISS and the NCAA ISS and medical records combined. Results: The NCAA ISS captured 63.7% of the total estimated overuse mechanisms of injury in men's and women's soccer players. The estimated proportion of overuse injury mechanisms captured by both the NCAA ISS and medical records was 37.1%. The NCAA ISS captured more overuse injury mechanisms in men's soccer than in women's soccer (79.2% versus 45.0%, χ2 = 9.60; P = .002) athletes. Conclusions: From 2005–2006 through 2007–2008, the NCAA ISS captured only two thirds of time-loss medical-attention overuse mechanisms of injury in men's and women's soccer players. Future researchers should consider supplementing injury-surveillance data with a clinical record review to capture the burden of these injuries.

Background: Overuse injuries result from microtrauma due to repetitive loading combined with insufficient tissue recovery time and can result in both immediate and long-term time loss from sports. Hypothesis: Overuse injury rates and patterns differ across college and high school populations, sport, and sex. Study Design: Descriptive epidemiology study. Methods: Surveillance data for 16 sports from the National Collegiate Athletic Association’s Injury Surveillance System (NCAA ISS; 2004-2005 through 2008-2009) and 14 sports from High School Reporting Information Online (High School RIO; 2006-2007 through 2012-2013) were analyzed. All reported injuries had an injury mechanism of overuse/gradual onset (college) or overuse/chronic (high school). Overuse injury incidence rates were calculated, and rate ratios with 95% CIs were used to compare subgroups. Results: The rate of overuse injury was 3.28 times higher in college than high school sports (95% CI, 3.12-3.44). The rate of overuse injury among sex-comparable sports was higher in female than male athletes in both populations (college rate ratio, 1.25; 95% CI, 1.16-1.35; high school rate ratio, 1.55; 95% CI, 1.43-1.68). The lower extremity was the most commonly injured body site (college, 69.4%; high school, 70.4%). A larger proportion of overuse injuries among college athletes resulted in time loss of more than 21 days (college, 20.4%; high school, 7.7%) and surgery (college, 5.2%, high school, 2.5%). Conclusion: Overuse injuries can impose a significant burden on college and high school athletes. Interventions addressing prevention of overuse injury are needed.

IntroductionDespite detailed recommendations for sports injury data capture provided since the mid-1990s, international data collection efforts for sport-related death remains limited in scope. The purpose of this paper was to review the data sources available for studying sport-related death and describe their key features, coverage, accessibility and strengths and limitations.MethodsThe outcomes of interest for this review was death occurring as a result of participation in organised sport-related activity. Data sources used to enumerate death in sport were identified, drawing from the authors’ knowledge/experience and review of key references from international organisations. The general purpose, case identification, structure, strengths and limitations of each source in relation to collection of data for sport-related death were summarised, drawing on examples from the international published literature to illustrate this application.ResultsSeven types of resources were identified for capturing deaths in sport. Data sources varied considerably in their ability to identify: participant status, sport relatedness of the death, types of sport-related deaths they capture, level of detail provided about the circumstances and medical care received. The most detailed sources were those that were dedicated to sports surveillance. Sport relatedness and type of sport may not be reliably captured by systems not dedicated to sports injury surveillance. Only one source permitted international comparisons and was limited to one sport (soccer).ConclusionData on sport-related death are currently collected across a wide variety of data sources. This review highlights the need for robust, comprehensive approaches with standardised methodologies enabling linkage between sources and international comparisons.

Pre-dive checklists can prevent mishaps, injuries, and deaths in recreational scuba diving. However, the prevalence of checklist use remains low. Understanding the environmental and individual factors influencing a diver's checklist use may help in promoting checklists. In the summer of 2012, 617 divers were enrolled in the intervention group of a cluster randomized trial. The divers received an intervention pre-dive checklist to use before they made dives. Logistic regression analyses were used to model adherence to pre-dive checklist with generalized estimating equations. About 70% divers (n=430) adhered to the intervention pre-dive checklist. Factors associated with greater adherence were the use of a diver's own written self-checklist - odds ratio (OR) = 2.48 (95% confidence interval: 0.95, 6.44), older age (⟩ 35 years) - OR = 1.67 (1.15, 2.42), and higher average annual dives (6-10 dives vs. 0-5 dives) - OR = 1.87 (1.09, 3.21). Factors associated with lower adherence were diving in North Carolina as compared to the Caribbean - OR = 0.42 (0.20, 0.85), non-white race - OR = 0.54 (0.27, 1.09), and female gender - OR = 0.77 (0.54, 1.12). Checklist adherence is also a function of risk perception, facilitators, and barriers. Future studies should try to understand diver risk perceptions, promote facilitators, and reduce barriers to foster the use of pre-dive checklists.

BACKGROUND Scuba diver fitness is paramount to confront environmental stressors of diving. However, the diving population is aging and the increasing prevalence of diseases may be a concern for diver fitness. PURPOSE The purpose of this study is to assess the demographics, lifestyle factors, disease prevalence, and healthcare access and utilization of Divers Alert Network (DAN) members and compare them with those from the general population. METHODS DAN membership health survey (DMHS) was administered online in 2011 to DAN members in the United States (US). Health status of DMHS respondents was compared with the general US population data from the Center for Disease Control and Prevention's Behavioral Risk Factor Surveillance System using two-sided student's t-tests and Mantel-Haenszel chi-square tests. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with healthcare utilization among the DMHS participants. RESULTS Compared to the general US population, the DMHS population had lower prevalence of asthma, heart attack, angina, stroke, diabetes, hypertension, hypercholesterolemia, and disabilities (p

Deaths are considered to be rare in sport, but detailed information and specific fatality rates for different sport settings are limited owing to a paucity of data. Most research originates in the USA,1 2 and it has identified sudden cardiac arrest, traumatic injuries to the head/neck, exertional heat stroke, hyponatremia and asthma2 as the leading causes. Put simply, in sport, death can result from direct (eg, acute traumatic injuries) or indirect (eg, underlying illness/condition) causes, with external/environmental factors also implicated in some events.3 An understanding of the people that are most at risk and the leading causes of deaths in sporting environments, is a crucial first step toward implementing appropriate emergency management plans to prevent fatalities. The value and importance of surveillance to guide management and prevention of fatalities is well established, including in sport where data-driven changes have led to a reduction in …

Background and Objectives: Relative energy deficiency in sport (RED-S) has been introduced as a broad-spectrum syndrome leading to possible dysfunction in numerous physiological systems, driven primarily by low energy availability (EA). Research in females has identified specific EA cut-points indicative of risk level for developing physiological and performance disturbances. Cut-points in males have yet to be evaluated. This study examined the prevalence of low EA in competitive (non-elite), recreationally trained (CRT) male endurance athletes. Materials and Methods: Subjects were 108 CRT (38.6 &plusmn, 13.8 y, 12.2 &plusmn, 5.4 h/wk training) male endurance athletes (runners, cyclists, triathletes) who completed a descriptive survey online via Qualtrics&reg, and returned 3 day diet and exercise training records. EA was calculated from returned surveys and training records. Resting metabolic rate (RMR) and lean body mass (LBM) were estimated from self-reported survey data. Prevalence of risk group was categorized based on the female cut-points: at risk (AR) &le, 30 kcal/kg LBM, moderate risk (MR) = 30&ndash, 45 kcal/kg LBM, or no risk (NR) &ge, 45 kcal/kg LBM. Results: In this sample, 47.2% (n = 51) were classified as AR, 33.3% (n = 36) as MR, and 19.4% (n = 21) as NR for low EA. Cyclists had lower EA (26.9 &plusmn, 17.4 kcal/kg LBM, n = 45) than runners (34.6 &plusmn, 13.3 kcal/kg LBM, n = 55, p = 0.016) and all other sport categories (39.5 &plusmn, 19.1 kcal/kg LBM, n = 8, p = 0.037). Conclusions: The findings indicate this sample had a high prevalence of risk for low EA, at 47.2%. Only 19.4% of participants were at no risk, meaning ~80% of participants were at some degree of risk of experiencing low EA. Cyclists were at greater risk in this cohort of low EA, although why this occurred was unclear and is in need of further investigation. Future research should address whether the current female cut-points for low EA are appropriate for use in male populations.

Background Individuals who work in the construction industry are at high risk of occupational injury. Robust surveillance systems are needed to monitor the experiences of these workers over time. Methods We updated important surveillance data for a unique occupational cohort of union construction workers to provide information on long-term trends in their reported work-related injuries and conditions. Combining administrative data sources, we identified a dynamic cohort of union carpenters who worked in Washington State from 1989 through 2008, their hours worked by month, and their workers' compensation claims. Incidence rates of reported work-related injuries and illnesses were examined. Poisson regression was used to assess risk by categories of age, gender, time in the union, and calendar time contrasting medical only and paid lost time claims. Results Over the 20-year study period, 24,830 carpenters worked 192.4 million work hours. Work-related injuries resulting in medical care or paid lost time (PLT) from work occurred at a rate of 24.3 per 200,000 hr worked (95% CI: 23.5–25.0). Medical only claims declined 62% and PLT claims declined 77%; more substantive declines were seen for injuries resulting from being struck and falls to a lower level than from overexertion with lifting. Differences in risk based on union tenure and age diminished over time as well. Conclusions Significant declines in rates of reported work-related injuries and illnesses were observed over the 20-year period among these union carpenters. Greater declines were observed among workers with less union tenure and for claims resulting in PLT. Am. J. Ind. Med. 56:381–388, 2013. © 2012 Wiley Periodicals, Inc.

Little is known about the work-related injury and illnesses experienced by certified athletic trainers (AT).The incidence and characteristics of injury/illness claims filed in two workers' compensation systems were described from 2001 to 2011. Yearly populations at risk were estimated from National Athletic Trainers' Association membership statistics. Incidence rate ratios (IRR) were reported by job setting.Claims were predominantly for traumatic injuries and disorders (82.7%: 45.7% sprains/strains, 12.0% open wounds, 6.5% bruises) and at these body sites (back 17.2%, fingers 12.3%, and knee 9.6%) and over half were caused by body motion and overexertion (51.5%). Compared with school settings, clinic/hospital settings had modestly higher claim rates (IRR = 1.29, 95% CI: 1.06-1.52) while other settings (e.g., professional or youth sport, nursing home) had lower claim rates (IRR = 0.63, 95% CI: 0.44-0.70).These first known estimates of work-related injuries/illnesses among a growing healthcare profession help identify occupational tasks and settings imposing injury risk for ATs. Am. J. Ind. Med. 59:1156-1168, 2016. © 2016 Wiley Periodicals, Inc.

ContextAlterations to upper extremity physical characteristics of competitive swimmers (posture, range of motion [ROM], and subacromial-space distance) are commonly attributed to cumulative training load during a swimmer's competitive career. However, this accepted clinical belief has not been established in the literature. It is important to understand whether alterations in posture and associated physical characteristics occur as a result of sport training or factors other than swimming participation to better understand injury risk and possible interventions.ObjectiveTo compare posture, subacromial-space distance, and glenohumeral external-rotation, internal-rotation, and horizontal-adduction ROM between adolescent competitive swimmers and nonoverhead athletes.DesignCross-sectional study.SettingLocal swimming pools and high school athletic training rooms.Patients or Other ParticipantsForty-four competitive adolescent swimmers and 31 nonoverhead athletes who were not currently experiencing any elbow, shoulder, neck, or back pain that limited their sport activity.Intervention(s)Posture, subacromial-space distance, and glenohumeral ROM were measured using photography, diagnostic ultrasound, and a digital inclinometer, respectively.Main Outcome Measure(s)Forward shoulder posture, forward head posture, normalized subacromial-space distance, internal-rotation ROM, and external-rotation ROM.ResultsNo clinically significant differences existed between swimmers and nonoverhead athletes for posture, normalized subacromial-space distance, or external- or internal-rotation ROM. Swimmers presented with less horizontal-adduction ROM than nonoverhead athletes.ConclusionsFactors other than swimming participation, such as school and technology use, play important roles in the adaptation of physical characteristics in adolescents. Adolescents, regardless of swimming participation, presented with postural deviations. It is important to consider factors other than swimming participation that contribute to alterations in physical characteristics to understand injury risk and injury-prevention strategies in competitive adolescent swimmers.

This study aimed to determine the association between injury history at enrollment and incident lower extremity (LE) injury during cadet basic training among first-year military cadets.Medically treated LE injuries during cadet basic training documented in the Defense Medical Surveillance System were ascertained in a prospective cohort study of three large US military academies from 2005 to 2008. Both acute injuries (International Classification of Disease, Ninth Revision, codes in the 800-900s, including fracture, dislocations, and sprains/strains) and injury-related musculoskeletal injuries (International Classification of Disease, Ninth Revision, codes in the 700s, including inflammation and pain, joint derangement, stress fracture, sprain/strain/rupture, and dislocation) were included. Risk ratio (RR) and 95% confidence interval (CI) were computed using multivariate log-binomial models stratified by gender.During basic training, there were 1438 medically treated acute and 1719 musculoskeletal-related LE injuries in the 9811 cadets. The most frequent LE injuries were sprains/strains (73.6% of acute injuries) and inflammation and pain (89.6% of musculoskeletal-related injuries). The overall risk of incident LE injury was 23.2% (95% CI = 22.3%-24.0%). Cadets with a history of LE injury were at increased risk for incident LE injury. This association was identical in males (RR = 1.74, 95% CI = 1.55-1.94) and females (RR = 1.74, 95% CI = 1.52-1.99). In site-specific analyses, strong associations between injury history and incident injury were observed for hip, knee ligament, stress fracture, and ankle sprain. Injury risk was greater (P0.01) for females (39.1%) compared with males (18.0%). The elevated injury risk in females (RR = 2.19, 95% CI = 2.04-2.36) was independent of injury history (adjusted RR = 2.09, 95% CI = 1.95-2.24).Injury history upon entry to the military is associated with the incidence of LE injuries sustained during cadet basic training. Prevention programs targeted at modifiable factors in cadets with a history of LE injury should be considered.

OBJECTIVE: We describe medical care received through workers' compensation (WC) and union-provided insurance surrounding work-related back injuries and examine relationships between care provided and time off work among a large cohort of carpenters. METHODS AND PARTICIPANTS: Union records identified a cohort of 20,642 carpenters working in Washington State from 1989-2003 and their private health insurance claims. These data were linked to workers' compensation files from this state-run program including records of medical care. RESULTS: Over 74,000 WC medical encounters resulted from 2959 work-related back injuries. Eleven percent received private care for musculoskeletal back pain within 90 days of work-related injury; this proportion increased with increasing lost days. Delay to physical therapy was more prevalent among those out of work longest. The proportion of claimants with care from both systems and from private utilization only increased after the first 90 days and, for the subset with at least one paid lost work day, after return to work. CONCLUSIONS: Examination of medical care through both systems versus solely in workers' compensation provides a more complete understanding of back injury care while also demonstrating complexity. Differences in outcomes based upon treatment shortly after injury are worthy of further exploration. Language: en

The objective of this research was to determine the association between LBP that limited or interrupted fishing work and ergonomic low back stress measured by (1) self-reported task and (2) two ergonomic assessment methods of low back stress.Eligible participants were from a cohort of North Carolina commercial fishermen followed for LBP in regular clinic visits from 1999 to 2001 (n = 177). Work history, including crab pot and gill net fishing task frequency, was evaluated in a telephone questionnaire (n = 105). Ergonomic exposures were measured in previous study of 25 fishermen using two methods. The occurrence rate of LBP that limited or interrupted fishing work since last visit (severe LBP) was evaluated in a generalized Poisson regression model.Predictors of severe LBP included fishing with crew members and a previous history of severe LBP. Among crab pot and gill net fishermen (n = 89), running pullers or net reels, sorting catch, and unloading catch were associated with an increased rate of LBP. Percent of time in forces20 lb while in non-neutral trunk posture, spine compression3,400 N, and National Institute of Occupational Safety and Health lifting indices3.0 were associated with LBP.Tasks characterized by higher (unloading boat and sorting catch) and lower (running puller or net reel) ergonomic low back stress were associated with the occurrence of severe LBP. History of LBP, addition of crew members, and self-selection out of tasks were likely important contributors to the patterns of low back stress and outcomes we observed. Based on the results of this study, a participatory ergonomic intervention study is currently being conducted to develop tools and equipment to decrease low back stress in commercial crab pot fishing.

There are challenges in evaluating physical demands of commercial fishing, including identifying sources of exposure variability. Low back biomechanical stresses associated with crab pot and gill net fishing were estimated; the variability was partitioned between and within fishing type, crew size, job title, and worker to improve understanding of risk factors for low back injury. The authors observed 162 person-hours of work among 25 North Carolina commercial fishermen on 16 crews. Postures and forces during fishing tasks were measured through direct and indirect observation using two methods to determine the percentage of time fishermen were exposed to high levels of low back stress. A multilevel linear model estimated exposure variability for the dependent variables by four nesting variables: fishing type, crew size, job title, and worker. Fishermen set and pulled crab pots or gill nets for 80% of the workday. Twenty-five percent of that time was spent handling gear. For both fishing types, handling heavy loads produced high peak compression values (3586 N to 5315 N) and high NIOSH lifting index values (3.3 to 5.4), but these tasks represent a small percentage of the overall work time (0 to 14%). The majority of exposure variation in non-neutral trunk posture and/or force9 kg, handling materials, NIOSH Lifting Index1, and Lumbar Motion Monitor probability of high-risk group membership70% was accounted for by fishing type (range 60 to 91%). Crew size was not an important source of variability for these six variables when fishing type and job title were accounted for in the model; but in the model restricted to crab pot fishing, crew size accounted for 51 to 88% of the variability in low back stress. For both models, job title comprised the majority of exposure variability for NIOSH Lifting Index3.0 (46 and 65%) and worker comprised the majority of variability for spine compression3400 N (54 and 65%). The magnitude and duration of musculoskeletal loads experienced by fishermen vary by the type of fishing and the tasks performed by the worker. Understanding this variability may help researchers target ergonomic interventions for this work population.

Background Commercial fishing is carried out worldwide, often in non-industrialized forms, and is associated with high rates of fatal and non-fatal occupational injury. Problem Fishermen who work independently in non-industrialized settings do not have access to union or industry sponsored safety services and must make their own decisions about safety practices. Learning the meaning of safety for them and the safety measures they employ is important before developing interventions. Methods Two fieldworkers conducted in-depth ethnographic interviews with 31 commercial fishermen in North Carolina. Interviews and fieldnotes were analyzed using QSR N5. Results Fishermen primarily related staying safe to work practices and attitudes. They identified specific safety measures, appropriate gear and boat maintenance, weather decisions, and working cooperatively when ocean fishing. Discussion The ethnographic research process can produce information about a group's norms of preventive behavior and safety concerns. Knowledge of workers' concepts and practices will inform researchers' inquiries.

Musculoskeletal symptoms and disorders (MSDIs) are common reasons for visits to medical providers in the general population and they are common work-related complaints. Prior reports raise concerns as to whether declines in workers' compensation (WC) rates represent true improvement in occupational health and safety or shifting of care to other payment systems.By linking administrative records, we compared patterns of WC claims and private health care utilization for disorders of the upper extremity (UE) and knee among a large cohort of union carpenters over a 20-year period.As WC claim rates declined, private health care utilization increased. The increase was muted somewhat but sustained when adjusting for other patterns of health care utilization.Findings suggest the decline of WC claim rates do not solely represent improved occupational safety in this population, but also a considerable shifting of care to their private insurance coverage over time.

Numerous aspects of construction place workers at risk of musculoskeletal disorders and injuries (MSDIs). Work organization and the nature of MSDIs create surveillance challenges.By linking union records with workers' compensation claims, we examined 20-year patterns of MSDIs involving the upper extremity (UE) and the knee among a large carpenter cohort.MSDIs were common and accounted for a disproportionate share of paid lost work time (PLT) claims; UE MSDIs were three times more common than those of the knee. Rates declined markedly over time and were most pronounced for MSDIs of the knee with PLT. Patterns of risk varied by extremity, as well as by age, gender, union tenure, and predominant work. Carpenters in drywall installation accounted for the greatest public health burden.A combination of factors likely account for the patterns observed over time and across worker characteristics. Drywall installers are an intervention priority.

Objective: To describe the epidemiology of work related injury in a group of small scale, independent commercial fishers. Design: Cross sectional survey (baseline instrument of a prospective cohort study). Setting and subjects: Commercial fishers in eastern North Carolina. Results: A cohort of 219 commercial fishers was established and 215 subjects completed an injury questionnaire. The main types of fishing conducted by the cohort were finfishing (159/215) and crabbing (154/215). Of the 215 fishers, 83 reported that they had suffered an injury event in the previous 12 months, a retrospective recall incidence proportion of 38.6 per 100 workers (95% confidence interval 32.1 to 45.1). The 83 injury events resulted in 94 injuries; 47% were penetrating wounds and 24% were strains/sprains. Half of injuries were to the hand/wrist/digits and 13% were to the back. Of the penetrating wounds, 87% were to the hand/wrist/digits, 32% became infected, and 80% were caused by contact with finfish, shellfish, or other marine animal. Of the strains/sprains, 48% were to the back and 26% were to the shoulder. Seventy percent of strains/sprains were caused by moving heavy objects, mainly either while hauling in nets, pots, or lines or loading/unloading the boat. Conclusion: In this group of small scale, independent fishers, the most common reported injuries were penetrating wounds to the hand/wrist/digits from marine animals and strains/sprains to the back while moving heavy objects.

Background Understanding job tasks and estimating occupational exposures is difficult for self-employed or autonomous workers, who tend to be dispersed, with no fixed workplace, employment records, or historical exposure measurements. Methods We used ethnographic methods to collect work information for southern commercial fishermen. Major activities were mapped using the seasonal round, an anthropological tool that records activities of groups whose lifeways depend on natural cycles. Results Fishermen's work schedules depended on boat size, gear, market fluctuations, and regulations, as well as season. The seasonal round guided the analysis of qualitative data on annual cycles of activities increasing understanding of exposures and their variation. Conclusions Combined with detailed exposure information this framework for organizing and categorizing seasonal activities could improve accuracy of exposure information and guide quantitative analysis in work settings that challenge standard exposure assessment methods. Am. J. Ind. Med. 46:23–31, 2004. © 2004 Wiley-Liss, Inc.

Falls from height (FFH) are a longstanding, serious problem in construction.We report workers' compensation (WC) payments associated with FFH among a cohort (n = 24,830; 1989-2008) of carpenters. Mean/median payments, cost rates, and adjusted rate ratios based on hours worked were calculated using negative-binomial regression.Over the 20-year period FFH accounted for $66.6 million in WC payments or $700 per year for each full-time equivalent (2,000 hr of work). FFH were responsible for 5.5% of injuries but 15.1% of costs. Cost declines were observed, but not monotonically. Reductions were more pronounced for indemnity than medical care. Mean costs were 2.3 times greater among carpenters over 50 than those under 30; cost rates were only modestly higher.Significant progress has been made in reducing WC payments associated with FFH in this cohort particularly through 1996; primary gains reflect reduction in frequency of falls. FFH that occur remain costly.

Falls from height (FFH) continue to cause significant morbidity and mortality across the construction industry.By linking data on work hours with workers' compensation records, rates of work-related injuries resulting from FFH and associated days away from work were evaluated among a large cohort (n = 24,830) of union carpenters in Washington State from 1989 to 2008. Using Poisson regression we assessed rates of FFH over the 20-year period while adjusting for temporal trend in other work-related injuries. Patterns of paid lost days (PLDs) were assessed with negative binomial regression.Crude rates of FFH decreased 82% over the 20-year period. Reductions were more modest and without demonstrable change since 1996 when adjusting for the temporal reduction in other injuries. Younger workers had higher injury rates; older workers lost more days following falls. Rates of PLDs associated with falls decreased over time, but there was not a consistent decline in mean lost days per fall.These patterns are consistent with decreased FFH for several years surrounding state (1991) and then federal (1994) fall standards; the decline during this time period exceeded those seen in injury rates overall in this cohort. While crude rates of FFH have continued to decline, the decline is not as substantial as that seen for other types of injuries. This could reflect a variety of things including more global efforts designed to control risk (site planning, safety accountability) and changes in reporting practices.

Workers in the Agriculture, Forestry, and Fisheries (AgFF) sector experience exposures directly related to the work itself, as well as the physical environment in which the work occurs. Health outcomes vary from immediate to delayed, and from acute to chronic.We reviewed existing literature on the health outcomes of work in the AgFF sector and identified areas where further research is needed to understand the impact of these exposures on immigrant Latino workers in the southeastern US.Outcomes related to specific body systems (e.g., musculoskeletal, respiratory) as well as particular exposure sources (e.g., pesticides, noise) were reviewed. The most extensive evidence exists for agriculture, with a particular focus on chemical exposures. Little research in the southeastern US has examined health outcomes of exposures of immigrant workers in forestry or fisheries.As the AgFF labor force includes a growing number of Latino immigrants, more research is needed to characterize a broad range of exposures and health outcomes experienced by this population, particularly in forestry and fisheries.

An observational work-sampling technique--Posture, Activity, Tools, and Handling (PATH)--was used to describe the prevalence of awkward postures and other physical risk factors for shoulder symptoms among a purposive sample of 11 small-scale commercial crab pot fishing crews. Fishing activities with awkward shoulder postures included hooking the buoy, feeding the rope into the hydraulic puller, and handling the crab pots. Increasing the size of the crew decreased the frequency of awkward shoulder postures for the captain but not for the mate. Awkward shoulder postures varied by technique, task distribution, equipment, and boat characteristics and setup, indicating these factors may be important determinants of exposure. Care should be taken in assuming personal techniques drives ergonomic exposure variability among these small-scale commercial fishermen.

Objective The purpose of this study was to describe occupational exposures and the incidence of non-fatal injuries among a group of southeastern US small-scale fishermen. Methods Participants (n=219) were enrolled in a prospective cohort study and followed from August 1999 to May 2002. Demographic information was obtained at baseline, and weekly and biweekly telephone interviews elicited information on number of days worked, fishery, fishing gear used, maintenance work, glove use and any work-related injury events. Incidence rate ratios (IRR) and 95% CIs were calculated with Poisson regression for each factor and multivariate models controlled for potential confounders. Results Over a third of participants (81/217) reported 125 injury events over 46 153 work-days for rate of 2.74 per 1000 work-days (95% CI 2.19 to 3.41). The majority of injuries were penetrating wounds to the hand, thumb and finger (35%) or back sprains and strains (8%); most required no medical care or time off work (67%). Injury rates were similar for on and off the water work (1.9 per 1000 work-days). Injury rates differed by fishery, water location and month. Factors associated with an increased injury rate included working on someone else9s boat and maintenance work. Glove use was protective. Conclusion Similar injury characteristics were observed in small-scale fishing as compared to large-scale. For small-scale fishermen, off and on the water work locations, and particularly maintenance work, were important predictors of injury. Despite the protective association for glove use, penetrating wounds to the hand, thumb and finger were common.

We thank the Journal of Athletic Training (JAT ) and Deits et al1 for allowing us to comment on the analysis of national emergency department (ED) surveillance data on hockey injuries appearing in this issue. This commentary focuses on the use in descriptive epidemiology of the injury proportion ratio (IPR). We are prompted to comment on the IPR due to its increasing use in the sports injuryprevention literature, including JAT. Our comments are aimed at examining the IPR and highlighting the usefulness and limitations of the measure in relation to other measures in injury-prevention research, notably the injury rate ratio. Our concern is that, without understanding the assumptions underlying these measures, the IPR can be easily misinterpreted, thereby leading readers to draw false conclusions. Published research2–6 has used IPRs in the context of hospital-based surveillance data as well as a Web-based high school surveillance system.7–16 By design, hospitalbased ED injury surveillance systems, such as the National Electronic Injury Surveillance System (NEISS), collect information only on injured individuals. Such surveillance systems provide useful descriptive information about severe injury patterns, such as who was injured, what types of injuries occurred, what was happening at the time of injury, and the type of care provided for that injury. However, NEISS does not collect information about the population among whom these injuries occurred or arose: the population of hockey players, in this case. Additionally, NEISS does not collect information on hockey injuries that do not result in a visit to the ED, an issue we will ignore for the purposes of this commentary.

Methods Union administrative records identified 20,642 union carpenters who worked in Washington State from 1989 to 2003. The Department of Labor and Industries provided records of workers' compensation claims and associated medical care. Work-related back claims (n = 4,241) were identified by ANSI codes (back, trunk, or neck/back) or ICD-9 codes relevant to medical care consistent with a back injury. Cases (n = 738) were defined as back injury claims with >90 days of paid lost time; controls (n = 699) resulted in return to work within 30 days. Logistic regression models estimated odds ratios and 95% confidence intervals (OR, 95% CI) of delayed return to work (DRTW). Results Thirty percent of case claims and 8% of control claims were identified by an ICD-9 code. DRTW after back injury was associated with being female (2.7, 95% CI: 1.3–5.5), age 30–44 (1.2, 95% CI: 0.9–1.7) and age over 45 (1.6, 95% CI: 1.1–2.3), four or more years union experience (1.4, 95% CI: 1.1–1.8), previous paid time loss back claim (1.8, 95% CI: 1.3–2.5), and ≥30-day delay to medical care (3.6, 95% CI: 2.1, 6.1). Evidence of more acute trauma was also associated with DRTW. Conclusions Use of ICD-9 codes identified claims with multiple injuries that would otherwise not be captured by ANSI codes alone. Though carpenters of younger age and inexperience were at increased risk for a paid lost time back injury claim, older carpenters and more experienced workers, once injured, were more likely to have DRTW as were those who experienced acute events. Am. J. Ind. Med. 52:821–830, 2009. © 2009 Wiley-Liss, Inc.

Objective. Nail gun injuries are among the most common in wood frame construction. Despite evidence that the majority of injuries from unintentional firings could be prevented with a sequential trigger mechanism on the tools, the safer trigger has not been embraced in the fast-paced residential construction industry. An experiment was conducted in an attempt to realistically evaluate the magnitude of productivity concerns. Methods. Ten journeymen carpenters built a yard shed on two occasions, using nail guns with two different trigger configurations, alternately, under controlled conditions. Mean differences in time required, nails used, and proper placement were evaluated considering the trigger used and whether the building was the carpenter's first or second project. Results. The sequential trigger tool required a mean of 10 additional minutes of active nailing time, which represented 10% of mean nailing time (97 minutes) but only 0.77% of the total mean work time (1,298 minutes) to construct each shed. No significant differences were observed in nail count or placement. The majority of the time variability was related to who was using the tool, rather than the type of tool in the person's hand. Conclusions. Productivity concerns should focus more on improving the skill of the carpenter rather than on the trigger mechanism. Failure to place tools with the safer trigger configuration, which requires the nose piece to be depressed before the trigger is pulled, in the hands of workers does not make sense given the frequency and potential repercussions of injuries associated with the use of these tools in wood framing.

Background We evaluated musculoskeletal problems among women employed in poultry processing in rural northeastern North Carolina. Poultry processing is the largest single employer of women in this economically depressed region with a black majority population. Methods Data were collected from a cohort of 291 women through interviews and physical exams conducted at 6-month intervals over 3 years. An index of cumulative exposure, based on departmental rankings and work history, was the primary exposure variable. Other variables of interest included work organization factors, other medical conditions, depressive symptoms, children in the home, and hand intensive home activities. Poisson regression with generalized estimating equations was used to evaluate factors associated with occurrences of upper extremity symptoms and incidence of disorders at follow-up. Results Symptoms making it difficult to maintain work speed or quality and depressive symptoms at baseline were associated with symptoms at follow-up; age, being overweight, and job insecurity at baseline were associated with incident disorders. After considering these factors, the exposure response pattern was J-shaped with risk decreasing in the second quartile of cumulative exposure and then going steadily up; the effect was stronger for disorders. Conclusions The pattern of risk is consistent with onset of early musculoskeletal problems among women new to the industry followed by a later increase with continued exposure. Among this highly exposed population, the effects of depressive symptoms and work organization factors were diminished when cumulative exposure was considered, illustrating the contextual nature of the complex relationships between physical work exposures and psychosocial factors. Am. J. Ind. Med. 51:24–36, 2008. © 2007 Wiley-Liss, Inc.