Search

Exertional heat stroke (EHS) is a true medical emergency with potential for organ injury and death. This consensus statement emphasizes that optimal exertional heat illness management is promoted by a synchronized chain of survival that promotes rapid recognition and management, as well as communication between care teams. Health care providers should be confident in the definitions, etiologies, and nuances of exertional heat exhaustion, exertional heat injury, and EHS. Identifying the athlete with suspected EHS early in the course, stopping activity (body heat generation), and providing rapid total body cooling are essential for survival, and like any critical life-threatening situation (cardiac arrest, brain stroke, sepsis), time is tissue. Recovery from EHS is variable, and outcomes are likely related to the duration of severe hyperthermia. Most exertional heat illnesses can be prevented with the recognition and modification of well-described risk factors ideally addressed through leadership, policy, and on-site health care.

American football athletes are frequently hypohydrated before and during activity. Hypohydration increases the risk of exertional sickling in student-athletes with sickle cell trait (SCT). The authors examined weight charts from the 2010/2011 to 2018/2019 seasons at one Division I institution to determine if differences in percentage body mass losses (%BML) exist between those with and without SCT. Seventeen student-athletes with SCT and 17 matched-controls were included. A Bonferroni correction was applied to account for multiple comparisons (0.05/8), resulting in p p = .002) but not for the number of days %BML exceeded 2% (SCT: 0 ± 1 vs. control: 1 ± 1; p = .016). Implementation of proper hydration strategies minimized %BML in athletes with SCT, decreasing the risk of hypohydration and exertional sickling. The same strategies ensured all players remained below threshold to optimize performance and reduce heat illness risk.

Context Having athletic trainers (ATs) employed at secondary schools is associated with improved preparedness for sport-related emergencies. Utilization of emergency medical services (EMS) with different access to athletic training services remains unknown. Objective Compare the incidence of EMS activations for sport-related injuries between zip-codes with varying access to athletic training services. Design Descriptive epidemiology study. Setting Data were obtained from the National EMS Information System and the Athletic Training Location and Services Project. Patients or Other Participants Zip-codes where 9-1-1 EMS activations for sport-related injuries among individuals 13–18 years old occurred. Main Outcome Measure(s) Incidence of EMS activations, athletic training service level (NONE, PART, FULL), athletic training employment model (independent contractor, IC; medical or university facility, MUF; school district, SD; mixed employment models, MIX) for each zip-code. Results There were 2.8±3.5 EMS activations per zip-code (range 1–81, n=4,923). Among zip-codes where at least 1 AT was employed (n=2,228), 3.73% (n=83) were IC, 30.83% (n=687) were MIX, 27.24% (n=607) were SD, and 38.20% (n=851) were MUF. Compared to SD, MUF had a 10.8% lower incidence of EMS activations (95%CI: 0.817, 0.974, p=0.010). IC (IRR: 0.920, 95%CI: 0.758, 1.118, p=0.403) and MIX (IRR: 0.996, 95% CI: 0.909, 1.091, p=0.932) were not significantly different from SD. Service level was calculated for 3,834 zip-codes, with 19.5% (n=746) NONE, 46.2% (n=1,771) PART, and 34.4% (n=1,317) FULL. Compared to NONE, FULL (IRR: 1.416, 95%CI: 1.308, 1.532, p Conclusions Local access to athletic training services is associated with an increased utilization of EMS for sport-related injuries among secondary school aged individuals, potentially indicative of improved identification and triage of sport-related emergencies the area. The difference in EMS utilization between employment models may represent the presence of different policies and procedures for sport-related emergencies.

Marching band (MB) artists frequently spend many hours engaged in outdoor physical activity. Anecdotal evidence and small studies have indicated that MB artists do experience heat-related health problems. Yet, unlike athletes, military personnel, or workers, there is very little research on heat-related hazards among this unique population. Here, we seek to understand the incidence and circumstances under which exertional heat illnesses (EHIs) occur among MB artists over a 31-year period (1990–2020) across the USA. Using an on-line news dataset, we identified 34 separate events and at least 393 total EHIs. Heat syncope (~ 55%) and heat exhaustion (~ 44%) comprised the majority of EHIs, although a small number of exertional heat stroke cases were also reported. EHIs were reported in all types of MB activities with ~ 32% during rehearsal, ~ 29% during parades, ~ 21% during competition, and ~ 15% during a performance. Also, the vast majority of events occurred with high school (~ 88%) marching bands. Finally, EHIs overwhelmingly occurred when the weather was unusually hot by local conditions. In light of these findings, we emphasize the need for MB specific heat polices that incorporate weather-based activity modification, acclimatization, education about EHIs, and access to on-site medical professionals.

Improper helmet fit is related to sport-related concussion symptomology. The objective of this study was to determine the prevalence of improperly fit helmets in American youth tackle football players across one competitive season. Four recreation leagues including 147 players (45.2 ± 14.7 cm, 147.5 ± 9.0 kg), aged 7–12 years, participated in pre-season and post-season data collection timepoints. Participant and league demographics were collected at pre-season. Helmet fit was assessed at pre- and post-season using a 13-item checklist. A helmet was defined as improperly fit if failed to comply with or more of the checklist items. Most players (84%) rented helmets from the league. At preseason, 71.4% of helmets, and at post-season 79.6%, were improperly fit with no significant change over time (p = 0.14). Of the 105 improperly fit helmets at the start of the season, 61% were still considered improperly fit at post season. The 11–12 year old age group had significantly more improperly fit helmets than the 7–10 year old age group at post-season (p = 0.033), but not pre-season (p = 0.655). American youth football players depend on the league to fit their helmet. Most players did not meet at least one checklist criteria. Helmets improperly fit at preseason were still not fit at post.

Exercise-associated muscle cramps (EAMC) are common and frustrating for athletes and the physically active. We critically-appraised the EAMC literature to provide evidence-based treatment and prevention recommendations. While the pathophysiology of EAMC appears controversial, recent evidence suggests EAMC are due to a confluence of unique intrinsic and extrinsic factors rather than a singular etiology. The treatment of acute EAMC continues to include self-application or clinician-guided gentle static stretching until EAMC abatement. Once the painful EAMC are alleviated, clinicians can continue treatment on the sidelines by focusing on patient-specific risk factors that the clinician believes may have contributed to the genesis of EAMC. For EAMC prevention, clinicians should first perform a thorough medical history followed by identification of the patients' unique risk factors that could have coalesced to elicit EAMC. Individualizing EAMC prevention strategies will likely be more effective than generalized advice (e.g., drink more fluids).

Background Literature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018. Methods Data were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group. Results There were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients. Conclusion Injuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events.

Introduction Injuries sustained during basic combat training (BCT) result in large economic costs to the U.S. Army. The inclusion of athletic trainers (ATs) in other military branches has reduced Troop Medical Clinic (TMC) referrals. However, the inclusion of ATs during BCT has yet to be studied. The purpose of this study was to describe the frequency and nature of sick call visits during BCT and determine how the presence of an AT affects referrals to the TMC. Materials and Methods A prospective cohort study was conducted at the Fort Jackson Army Training Center for one calendar year. Soldiers in BCT, aged 18–42, who reported to sick call were included. Independent variables collected included: Soldier demographics (sex and age), visit reason, and provider impression. Training battalions were placed in three conditions: control (CON), full-time medic (FTM), and part-time athletic trainer (PAT). The dependent variable was disposition (referred or returned to duty [RTD]). Frequencies and proportions were calculated. Logistic regression compared conditions while considering the other independent variables. Return on investment was calculated. Results Fourteen thousand three hundred and four visits were documented. Most soldiers were female (n = 7,650; 53.5%) and under 20 years old (n = 5,328; 37.2%). Visits were most commonly due to physical injury (n = 7,926; 55.4%), injuries affecting the knee (n = 2,264; 15.8%) and chronic/overuse conditions (n = 2,031; 14.2%). By condition, the FTM and PAT conditions resulted in 1.303 (95%CI: 1.187, 1.430; P Conclusions Injuries were common in BCT, particularly in females. Soldiers in both the PAT and FTM conditions were more likely to be RTD compared to those in the CON condition. Athletic trainers (ATs) are effective at reducing potentially unnecessary referrals, demonstrating their value as healthcare providers in the BCT environment. Understanding variables associated with recruit disposition may aid medics and ATs in the development of triage protocols and further reduction of potentially unnecessary soldier referrals. The Certified Athletic Trainer-Forward Program resulted in significant return on investment, further supporting the inclusion of ATs in BCT.

Highlights • Uniforms were integrated over time, but once integrated were not removed when hotter environmental conditions occurred. • Players in the age-restricted league were taller, heavier, and had a higher BMI than players in the weight-restricted league, resulting in significant anthropometric differences. • Work time was significantly greater for games, as were rest times. However, work-to-rest ratios were significantly higher for practices. • Of the practices and games observed 9% were held in black flag risk conditions and 68% were held in red flag conditions. • One league's average WBGT during games was significantly higher than the other because of the time of day they were held (9:00 a.m. to 2:00 p.m.). • More than 50% of players reached a gastrointestinal temperature of 39°C or higher at least once during the observation, but no players reached a TG1 indicative of exertional heat stroke., Objective To determine which intrinsic and extrinsic exertional heat illness (EHI) risk factors exist in youth American football players and observe perceptual and physiological responses of players during events (games and practices). Methods Cross-sectional cohort study observing 63 youth football players, varying in position. Independent variables were league (weight-restricted (WR, n = 27) and age-restricted (AR, n = 36)) and event type. Dependent variables were anthropometrics, work-to-rest ratio, and wet bulb globe temperature. Descriptive variables included preparticipation examination and uniform configuration. A subset of 16 players participated in physiological variables (heart rate and gastrointestinal temperature). Data collection occurred on 7 AR and 8 WR nonconsecutive practices and the first 3 games of the season. Results Mean values for anthropometric variables were higher (p < 0.05) in the AR league than the WR league. Work time (χ2 (1,111) = 4.232; p = 0.039) and rest time (χ2 (1,111) = 43.41; p < 0.001) were significantly greater for games, but ratios were significantly higher for practices (χ2 (1,111) = 40.62; p < 0.001). The majority of events (77%) observed were in black and red flag wet bulb globe temperature risk categories. A total of 57% of the players had a preparticipation examination, and up to 82% of events observed were in full uniforms. Individual gastrointestinal temperature and heart rate responses ranged widely and no players reached critical thresholds. Conclusion Extrinsic (disproportionate work ratios, environmental conditions) and intrinsic (higher body mass index) EHI risk factors exist in youth football. Certain risk factors may be influenced by event and league type. National youth football organizations need to create thorough guidelines that address EHI risk factors for local leagues to adopt., Graphical Abstract Image, graphical abstract

Context Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited. Objective To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes. Design Cross-sectional study. Setting Middle School students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys. Patients or Other Participants Overall, 541 athletes representing 18 sports returned fully completed surveys. Main Outcome Measure(s) Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant. Results Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75). Conclusions Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

Exercise-associated muscle cramps (EAMCs) are thought to be caused by dehydration and/or electrolyte losses. In this multicenter, cross-sectional study, the authors determined whether sweat rates (SRs), sweat electrolyte concentrations, or sweat electrolyte content differed in athletes with (i.e., crampers) and without (i.e., noncrampers) a history of EAMCs and whether these variables could predict EAMC-prone athletes. Male and female collegiate athletes (N = 350) from 11 sports with (n = 245) and without (n = 105) a self-reported history of EAMCs completed a typical exercise or conditioning session. SRs, calculated from body mass, and posterior forearm sweat were analyzed for sweat sodium concentration ([Na+]sw), sweat potassium concentration ([K+]sw), and sweat chloride concentration ([Cl−]sw). The authors used SRs and sweat electrolyte concentrations to calculate sweat electrolyte content lost. Within each gender, no differences in SRs (204 males, p = .92; 146 females, p = .24); [Na+]sw (191 males, p = .55; 126 females, p = .55); Na+sw content (191 males, p = .59; 126 females, p = .20); [K+]sw (192 males, p = .57; 126 females, p = .87); K+sw content (192 males, p = .49; 126 females, p = .03); [Cl−]sw (192 males, p = .94; 77 females, p = .57); and Cl−sw content (192 males, p = .55; 77 females, p = .34) occurred between crampers and noncrampers. Receiver operating characteristic curve analysis revealed that sweat electrolyte content and SRs were predictive of EAMC-prone athletes in American football (area under curve = 0.65–0.72, p ≤ .005), but not in any other sport. EAMCs may not be solely caused by fluid or electrolyte losses in most athletes. Fluid and electrolyte replacement may help American footballers. Clinicians should individualize fluid and electrolyte replacement and understand different etiologies for EAMCs.

Objectives: To determine the prevalence of student-athletes with sickle cell trait (SCT) and describe their demographics, prior knowledge of status, and hemoglobin (Hb) profile.Methods: A retrospec...

Despite cool environments, ice hockey athletes are predisposed to hypohydration due to extensive equipment, high intensity activity, and high sweat rates. The purpose of this study was to determine hydration practices and awareness of fluid recommendations among athletic trainers (ATs) working with NCAA Division I, NCAA Division III, and professional ice hockey teams. Most professional ATs (90.1%) utilized at least one hydration status measure, while 61.7% of collegiate ATs did not measure hydration. Compared to Division I, more Division III ATs did not have electrolyte supplements (p p

An athletic trainer’s (ATs) role requires current knowledge about factors that can influence hydration status. The purpose of this study was to determine awareness of alcohol and caffeine effects on hydration. Participants were 94 ATs with NCAA Division I or III men’s and/or women’s ice hockey teams and 82 head ATs with professional ice hockey teams. The majority of ATs were correct regarding alcohol’s effects on hydration, specifically knowing alcohol increases urine output (92.1%), delays fluid recovery (81.7%), and dehydrates a euhydrated individual (83.5%). In contrast, fewer ATs were correct that moderate, regular consumption of caffeine does not cause dehydration (20.7%), delay fluid recovery (15.2%), or impair fluid regulatory hormones (9.8%). While ATs were knowledgeable about alcohol effects, there remains misconceptions about caffeine on hydration.

Context: Recent data on exertional heat illness (EHI) in high school sports are limited yet warranted to identify specific settings with the highest risk of EHI. Objective: To describe the epidemiology of EHI in high school sports during the 2012/2013–2016/2017 academic years. Design: Descriptive epidemiology study. Setting: Aggregate injury and exposure data collected from athletic trainers working in high school sports in the United States. Patients or Other Participants: High school athletes during the 2012/2013–2016/2017 academic years. Intervention: High School Reporting Information Online surveillance system data from the 2012/2013–2016/2017 academic years were analyzed. Main Outcome Measures: EHI counts, rates per 10,000 athlete exposures (AEs), and distributions were examined by sport, event type, and US census region. EHI management strategies provided by athletic trainers were analyzed. Injury rate ratios with 95% confidence intervals (CIs) compared EHI rates. Results: Overall, 300 EHIs were reported for an overall rate of 0.13/10,000 AE (95% CI, 0.11 to 0.14). Of these, 44.3% occurred in American football preseason practices; 20.7% occurred in American football preseason practices with a registered air temperature ≥90°F and ≥1 hour into practice. The EHI rate was higher in American football than all other sports (0.52 vs 0.04/10,000 AE; injury rate ratio = 11.87; 95% CI, 9.22 to 15.27). However, girls’ cross-country had the highest competition EHI rate (1.18/10,000 AE). The EHI rate was higher in the South US census region than all other US census regions (0.23 vs 0.08/10,000 AE; injury rate ratio = 2.96; 95% CI, 2.35 to 3.74). Common EHI management strategies included having medical staff on-site at the onset of EHI (92.7%), removing athlete from play (85.0%), and giving athlete fluids via the mouth (77.7%). Conclusions: American football continues to have the highest overall EHI rate although the high competition EHI rate in girls’ cross-country merits additional examination. Regional differences in EHI incidence, coupled with sport-specific variations in management, may highlight the need for region- and sport-specific EHI prevention guidelines.

The dynamics of American youth football make it critical to ensure that helmets are appropriately fit to decrease the risk of injuries. Currently, there is only one researcher-developed checklist to determine helmet fit, and psychometric testing is lacking; therefore, the aim of this work was to determine the validity of the checklist. The 13-item checklist was used to measure helmet fit in 267 youth football players prior to the start of the season. Using a Principal Components Analysis to assess validity, a 5-component model was found explaining 58% of the available variance. These results suggest that a single, summative score should not be used for this checklist; rather five scores should be calculated for each component (stability, snugness, size, integrity, and accessory). A more practical and valid tool to assess fit, such as a sub-sectioned chronological American football-specific checklist, can better assist coaches/administrators responsible for helmet fit and player safety.

Exertional heat stroke (EHS) is a true medical emergency with potential for organ injury and death. This consensus statement emphasizes that optimal exertional heat illness management is promoted by a synchronized chain of survival that promotes rapid recognition and management, as well as communication between care teams. Health care providers should be confident in the definitions, etiologies, and nuances of exertional heat exhaustion, exertional heat injury, and EHS. Identifying the athlete with suspected EHS early in the course, stopping activity (body heat generation), and providing rapid total body cooling are essential for survival, and like any critical life-threatening situation (cardiac arrest, brain stroke, sepsis), time is tissue. Recovery from EHS is variable, and outcomes are likely related to the duration of severe hyperthermia. Most exertional heat illnesses can be prevented with the recognition and modification of well-described risk factors ideally addressed through leadership, policy, and on-site health care.

The purpose of this consensus document was to develop feasible, evidence‐based occupational heat safety recommendations to protect the US workers that experience heat stress. Heat safety recommendations were created to protect worker health and to avoid productivity losses associated with occupational heat stress. Recommendations were tailored to be utilized by safety managers, industrial hygienists, and the employers who bear responsibility for implementing heat safety plans. An interdisciplinary roundtable comprised of 51 experts was assembled to create a narrative review summarizing current data and gaps in knowledge within eight heat safety topics: (a) heat hygiene, (b) hydration, (c) heat acclimatization, (d) environmental monitoring, (e) physiological monitoring, (f) body cooling, (g) textiles and personal protective gear, and (h) emergency action plan implementation. The consensus‐based recommendations for each topic were created using the Delphi method and evaluated based on scientific evidence, feasibility, and clarity. The current document presents 40 occupational heat safety recommendations across all eight topics. Establishing these recommendations will help organizations and employers create effective heat safety plans for their workplaces, address factors that limit the implementation of heat safety best‐practices and protect worker health and productivity., Key Points This document presents feasible, evidenced‐based occupational heat safety recommendations to protect workers from the dangers of heatA roundtable of 51 experts created 40 heat safety recommendations within eight heat safety topics: heat hygiene, hydration, heat acclimatization, environmental monitoring, physiological monitoring, body cooling, textiles and personal protective gear, and emergency action plan implementationImplementing feasible and effective heat safety plans in the workplace will protect worker health and mitigate productivity losses

There is a paucity of research examining hydration and nutrition behaviors in youth American football players. A potentially unique risk factor are league restrictions based on weight (WR) or age (AR). The purpose of this study was to examine hydration status between WR and AR leagues. The secondary purpose was to describe eating patterns in players. An observational cohort design with 63 youth football players (10 ± 1 yrs, 148.2 ± 9.4 cm, 44.9 ± 15.3 kg) was utilized. Independent variables were league (AR (n = 36), WR (n = 27)) and activity type (practice (PX = 8), game (GM = 3)). Dependent variables were hydration status (urine osmolality, percent change in body mass (%BM)), eating attitudes (Children’s Eating Attitude Test (ChEAT-26)) and self-reported frequency of meals. On average, players arrived activity mildly hypohydrated (830 ± 296 mOsm/kg) and %BM was minimal (−0.1 ± 0.7%) during events. Players consumed 2 ± 1 meals and 1 ± 1 snack before events. The ChEAT-26 survey reported 21.6% (n = 8) of players were at risk for abnormal eating attitudes. Among these players, eating binges, vomiting, excessive exercise and drastic weight loss were reported. Youth American football players arrived activity mildly hypohydrated and consumed enough fluid during activity to maintain euhydration. Abnormal eating attitudes and the use of unhealthy weight loss methods were reported by some youth American football players.

ContextExertional heat stroke (EHS) is a leading cause of sudden death in high school football players. Preparedness strategies can mitigate EHS incidence and severity.ObjectiveTo examine EHS preparedness among high school football programs and its association with regional and state preseason heat-acclimatization mandates.DesignCross-sectional study.SettingPreseason high school football programs, 2017.Patients or Other ParticipantsA total of 910 athletic trainers (ATs) working with high school football (12.7% completion rate).Main Outcome Measure(s)We acquired data on high school football programs' EHS preparedness strategies in the 2017 preseason via an online questionnaire, looking at (1) whether schools' state high school athletic associations mandated preseason heat-acclimatization guidelines and (2) heat safety region based on warm-season wet-bulb globe temperature, ranging from the milder region 1 to the hotter region 3. Six EHS-preparedness strategies were assessed: EHS recognition and treatment education; policy for initiating emergency medical services response; emergency response plan enactment; immersion tub filled with ice water before practice; wet-bulb globe temperature monitoring; and hydration access. Multivariable binomial regression models estimated the prevalence of reporting all 6 strategies.ResultsOverall, 27.5% of ATs described their schools as using all 6 EHS-preparedness strategies. The highest prevalence was in region 3 schools with state mandates (52.9%). The multivariable model demonstrated an interaction in which the combination of higher heat safety region and presence of a state mandate was associated with a higher prevalence of reporting all 6 strategies (P = .05). Controlling for AT and high school characteristics, the use of all 6 strategies was higher in region 3 schools with state mandates compared with region 1 schools without state mandates (52.9% versus 17.8%; prevalence ratio = 2.68; 95% confidence interval = 1.81, 3.95).ConclusionsOur findings suggest a greater use of EHS-preparedness strategies in environmentally warmer regions with state-level mandates for preseason heat acclimatization. Future researchers should identify factors influencing EHS preparedness, particularly in regions 1 and 2 and in states without mandates.

Unintentional injury and death as a public health concern has not been established in the pediatric population. This is a commentary on a review of epidemiological data of unintentional deaths and injuries with a focus on age, sex, and racial differences in this population. The review takes in-depth look at children aged 0-19 years in the US, followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths. Lifestyle clinicians have a significant role in educating this population and their parent/guardians. Therefore providing insight into the interpretation of the data can support practical education and prevention interventions.

Improper helmet fit is related to sport-related concussion symptomology. The objective of this study was to determine the prevalence of improperly fit helmets in American youth tackle football players across one competitive season. Four recreation leagues including 147 players (45.2 ± 14.7 cm, 147.5 ± 9.0 kg), aged 7-12 years, participated in pre-season and post-season data collection timepoints. Participant and league demographics were collected at pre-season. Helmet fit was assessed at pre- and post-season using a 13-item checklist. A helmet was defined as improperly fit if failed to comply with or more of the checklist items. Most players (84%) rented helmets from the league. At preseason, 71.4% of helmets, and at post-season 79.6%, were improperly fit with no significant change over time (p = 0.14). Of the 105 improperly fit helmets at the start of the season, 61% were still considered improperly fit at post season. The 11-12 year old age group had significantly more improperly fit helmets than the 7-10 year old age group at post-season (p = 0.033), but not pre-season (p = 0.655). American youth football players depend on the league to fit their helmet. Most players did not meet at least one checklist criteria. Helmets improperly fit at preseason were still not fit at post.

Objective To provide best-practice recommendations for developing and implementing heat-acclimatization strategies in secondary school athletics. Data Sources An extensive literature review on topics related to heat acclimatization and heat acclimation was conducted by a group of content experts. Using the Delphi method, action-oriented recommendations were developed. Conclusions A period of heat acclimatization consisting of ≥14 consecutive days should be implemented at the start of fall preseason training or practices for all secondary school athletes to mitigate the risk of exertional heat illness. The heat-acclimatization guidelines should outline specific actions for secondary school athletics personnel to use, including the duration of training, the number of training sessions permitted per day, and adequate rest periods in a cool environment. Further, these guidelines should include sport-specific and athlete-specific recommendations, such as phasing in protective equipment and reintroducing heat acclimatization after periods of inactivity. Heat-acclimatization guidelines should be clearly detailed in the secondary school's policy and procedures manual and disseminated to all stakeholders. Heat-acclimatization guidelines, when used in conjunction with current best practices surrounding the prevention, management, and care of secondary school student-athletes with exertional heat stroke, will optimize their health and safety.

Context To our knowledge, no researchers have investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures. Objective To examine core temperature (Tc) and EHI risk factors in MB artists. Design Descriptive epidemiology study. Setting Three rehearsals and 2 football games for 2 National Collegiate Athletic Association Division I institution's MBs. Patients or Other Participants Nineteen volunteers (females = 13, males = 6; age = 20.5 ± 0.9 years, height = 165.1 ± 7.1 cm, mass = 75.0 ± 19.1 kg) completed the study. Main Outcome Measure(s) We measured Tc, wet bulb globe temperature, and relative humidity preactivity, during activity, and postactivity. Other variables were activity time and intensity, body surface area, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percentage of body mass loss), and medical history (eg, previous EHI, medications). The statistical analysis consisted of descriptive information (mean ± standard deviation), comparative analyses that determined differences within days, and correlations that identified variables significantly associated with Tc. Results The mean time for rehearsals was 102.8 ± 19.8 minutes and for games was 260.5 ± 47.7 minutes. Mean maximum Tc was 39.1 ± 1.1°C for games and 38.4 ± 0.7°C for rehearsals; the highest Tc (41.2°C) occurred during a game. Fluid consumption did not match sweat rates (P < .001). Participants reported to games in a hypohydrated state 63.6% of the time. The maximum Tc correlated with the maximum wet bulb globe temperature (r = 0.618, P < .001) and was higher in individuals using mental health medications (rpb = −0.254, P = .022) and females (rpb = 0.330, P = .002). Body surface area (r = −0.449, P < .001) and instrument mass (r = −0.479, P < .001) were negatively correlated with Tc. Conclusions Marching band artists experienced high Tc during activity and should have access to athletic trainers who can implement EHI-prevention and -management strategies.

IMPORTANCE: An objective, reliable indicator of the presence and severity of concussive brain injury and of the readiness for the return to activity has the potential to reduce concussion-related disability. OBJECTIVE: To validate the classification accuracy of a previously derived, machine learning, multimodal, brain electrical activity–based Concussion Index in an independent cohort of athletes with concussion. DESIGN, SETTING, AND PARTICIPANTS: This prospective diagnostic cohort study was conducted at 10 clinical sites (ie, US universities and high schools) between February 4, 2017, and March 20, 2019. A cohort comprising a consecutive sample of 207 athletes aged 13 to 25 years with concussion and 373 matched athlete controls without concussion were assessed with electroencephalography, cognitive testing, and symptom inventories within 72 hours of injury, at return to play, and 45 days after return to play. Variables from the multimodal assessment were used to generate a Concussion Index at each time point. Athletes with concussion had experienced a witnessed head impact, were removed from play for 5 days or more, and had an initial Glasgow Coma Scale score of 13 to 15. Participants were excluded for known neurologic disease or history within the last year of traumatic brain injury. Athlete controls were matched to athletes with concussion for age, sex, and type of sport played. MAIN OUTCOMES AND MEASURES: Classification accuracy of the Concussion Index at time of injury using a prespecified cutoff of 70 or less (total range, 0-100, where ≤70 indicates it is likely the individual has a concussion and >70 indicates it is likely the individual does not have a concussion). RESULTS: Of 580 eligible participants with analyzable data, 207 had concussion (124 male participants [59.9%]; mean [SD] age, 19.4 [2.5] years), and 373 were athlete controls (187 male participants [50.1%]; mean [SD] age, 19.6 [2.2] years). The Concussion Index had a sensitivity of 86.0% (95% CI, 80.5%-90.4%), specificity of 70.8% (95% CI, 65.9%-75.4%), negative predictive value of 90.1% (95% CI, 86.1%-93.3%), positive predictive value of 62.0% (95% CI, 56.1%-67.7%), and area under receiver operator characteristic curve of 0.89. At day 0, the mean (SD) Concussion Index among athletes with concussion was significantly lower than among athletes without concussion (75.0 [14.0] vs 32.7 [27.2]; P

Context: No research has investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures. Objective: Examine core temperature (Tc) and EHI risk factors in MB artists. Design: Descriptive epidemiology study. Setting: Three rehearsals and 2 football games for 2 NCAA Division I MBs. Participants: Nineteen volunteers completed the study (female = 13, males = 6; age = 20.5 ± 0.9 years; weight = 75.0 ± 19.1 kg; height = 165.1 ± 7.1 cm). Main Outcome Measures: We measured Tc pre-, post-, and every 15 minutes during activity and recorded wet-bulb globe temperature (WBGT) and relative humidity (RH) every 15 minutes. Other variables included activity time and intensity, ground surface, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percent body mass loss [%BM]), and medical history (eg, previous EHI, medications). Statistical analysis included descriptives (mean ± standard deviation), comparative analyses determined differences within and between days, and linear regression identified variables that significantly explained Tc. Results: Mean rehearsal time = 102.8 ± 19.8 minutes and game time = 260.5 ± 47.7 minutes. Max game Tc (39.1 ± 1.1°C) was significantly higher than rehearsal (38.4 ± 0.7°C, P = .003). The highest max game Tc = 41.2°C. Participants consumed significantly more fluid than their sweat rates (P < .003), which minimized %BM loss, particularly during rehearsals (−0.4 ± 0.6%). Mean game %BM loss = −0.9 ± 2.0%; however, 63.6% of the time, participants reported hypohydrated to game day. Max Tc was significantly predicted by max WBGT, max RH, ground surface, using mental health medications, and hours of sleep (adjusted R2 = 0.542, P < .001). Conclusions: Marching band artists experience high Tc during activity and should have access to athletic trainers who can implement EHI prevention and management strategies.

ContextDetermining an athlete's hydration status allows hydration-related concerns to be identified before significant medical or performance concerns arise. Weight charts are an accurate measure of hydration status changes, yet their clinical use by athletic trainers (ATs) is unknown.ObjectiveTo investigate ATs' use of weight charts in athletic settings and describe their subsequent clinical decisions.DesignCross-sectional survey.SettingHigh schools and National Collegiate Athletic Association Divisions I, II, III and National Association Intercollegiate Athletics colleges.Patients or Other ParticipantsA total of 354 ATs (men = 162, women = 175; 17 respondents did not answer the demographic questions) responded across athletic settings (Division I [45.7%]; Division II, Division III, National Association Intercollegiate Athletics combined [n = 19.9%]; and high school [34.4%]).Main Outcome Measure(s)The 26-question online survey was developed by content experts and pilot tested before data collection. Participants answered questions focused on weight-chart use (implementation, timing, and calculations) and clinical decision processes (policies, interventions, and referral). Frequency statistics were calculated.ResultsThe majority of ATs (57.2%) did not use weight charts. Of those who did, most (76.0%) used charts with football, soccer (28%), and wrestling (6%) athletes. They calculated changes as either an absolute (42.2%) or percentage (36.7%) change from prepractice to postpractice; only 11.7% used a baseline weight for calculations. Of those who used the percentage change in body mass, 66.0% selected a threshold of −3% to −4% for an intervention. Most ATs (97.0%) intervened with verbal education, whereas only one-third (37.0%) provided specific fluid amounts based on body mass changes.ConclusionsTypically, ATs in athletic settings did not use weight charts. They considered a body mass change of –3% the indication for intervention but did not specify rehydration amounts for hypohydrated athletes. Educational workshops or technology applications could be developed to encourage ATs to use weight charts and calculate appropriate individual fluid interventions for their athletes.

Background and objectives: Heat-related illness (HRI) can have significant morbidity and mortality consequences. Research has predominately focused on HRI in the emergency department, yet health care leading up to hospital arrival can impact patient outcomes. Therefore, the purpose of this study was to describe HRI in the prehospital setting. Materials and Methods: A descriptive epidemiological design was utilized using data from the National Emergency Medical Services (EMS) Information System for the 2017&ndash, 2018 calendar years. Variables of interest in this study were: patient demographics (age, gender, race), US census division, urbanicity, dispatch timestamp, incident disposition, primary provider impression, and regional temperatures. Results: There were 34,814 HRIs reported. The majority of patients were white (n = 10,878, 55.6%), males (n = 21,818, 62.7%), and in the 25 to 64 age group (n = 18,489, 53.1%). Most HRIs occurred in the South Atlantic US census division (n = 11,732, 33.7%), during the summer (n = 23,873, 68.6%), and in urban areas (n = 27,541, 83.5%). The hottest regions were East South Central, West South Central, and South Atlantic, with peak summer temperatures in excess of 30.0 &deg, C. In the spring and summer, most regions had near normal temperatures within 0.5 &deg, C of the long-term mean. EMS dispatch was called for an HRI predominately between the hours of 11:00 a.m.&ndash, 6:59 p.m. (n = 26,344, 75.7%), with the majority (27,601, 79.3%) of HRIs considered heat exhaustion and requiring the patient to be treated and transported (n = 24,531, 70.5%). Conclusions: All age groups experienced HRI but particularly those 25 to 64 years old. Targeted education to increase public awareness of HRI in this age group may be needed. Region temperature most likely explains why certain divisions of the US have higher HRI frequency. Afternoons in the summer are when EMS agencies should be prepared for HRI activations. EMS units in high HRI frequency US divisions may need to carry additional treatment interventions for all HRI types.

Background and objectives: Environmental monitoring allows for an analysis of the ambient conditions affecting a physically active person&rsquo, s ability to thermoregulate and can be used to assess exertional heat illness risk. Using public health models such as the precaution adoption process model (PAPM) can help identify individual&rsquo, s readiness to act to adopt environmental monitoring policies for the safety of high school athletes. The purpose of this study was to investigate the adoption of policies and procedures used for monitoring and modifying activity in the heat in United States (US) high schools. Materials and Methods: Using a cross-sectional design, we distributed an online questionnaire to athletic trainers (ATs) working in high schools in the US. The questionnaire was developed based on best practice standards related to environmental monitoring and modification of activity in the heat as outlined in the 2015 National Athletic Trainers&rsquo, Association Position Statement: Exertional Heat Illness. The PAPM was used to frame questions as it allows for the identification of ATs&rsquo, readiness to act. PAPM includes eight stages: unaware of the need for the policy, unaware if the school has this policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining. Invitations were sent via email and social media and resulted in 529 complete responses. Data were aggregated and presented as proportions. Results: Overall, 161 (161/529, 30.4%) ATs report they do not have a written policy and procedure for the prevention and management of exertional heat stroke. The policy component with the highest adoption was modifying the use of protective equipment (acting = 8.2%, maintaining = 77.5%). In addition, 28% of ATs report adoption of all seven components for a comprehensive environmental monitoring policy. Conclusions: These findings indicate a lack of adoption of environmental monitoring policies in US high schools. Secondarily, the PAPM, facilitators and barriers data highlight areas to focus future efforts to enhance adoption.

Purpose: The location of secondary school health and safety policies impacts how they are implemented by the sports medicine team and stakeholders. Yet, a comprehensive list of each state’s policy locations has not been established. The purpose of this study was to describe where secondary school health and safety policies were located at the state level within the United States. Method: Emergency related health and safety policies were designated as either being located in the state high school athletics association (SHSAA), state legislation (LEGIS), or in both SHSAA and LEGIS (BOTH). Designation was determined by two researchers who independently reviewed each individual policy. Frequencies were tabulated for the leading causes of catastrophic injury (exertional heat stroke (EHS), traumatic head injuries (THI), sudden cardiac arrest (SCA), and emergency preparedness (EP)) for the distribution of policies emanating from SHSSA, LEGIS or BOTH. Prevalence ratios (PRs) with 95% confidence intervals (CIs) were calculated between the policies categories and location. Results: Most (99.35%) EHS and EP (83.02%) policies were found in SHSAA. Whereas the majority (79.70%) of SCA policies were found in LEGIS. Traumatic head injuries were most frequently observed in SHSAA, however, had the greatest distribution across all three categories (SHSAA=45.31%, LEGIS=25.52%, BOTH = 29.16%). The category that most frequently found policies in BOTH was THI (THI= 29.16%, all others =2.25%; PR=12.96; 95% CI=7.81, 21.53). Conclusions: Emergency related health and safety policies for secondary school sports are commonly found in SHSAA. TBI and SCA are also found in LEGIS. This demonstrates great variability of policy locations.

All high schools should implement exertional heat illness (EHI) safety strategies. We determined if there were differences in the implementation of EHI safety strategies between schools with and without additional paid athletic trainers (ATs) or a team physician present at preseason football practices. High schools with multiple ATs or a team physician implemented more EHI prevention and management strategies than schools with only a single AT, including training staff in EHI recognition and treatment and having an emergency action plan. However, schools with a paid team physician were more likely to have double practices in the first week of football practice. Schools with additional medical personnel at football preseason practices were more likely to implement EHI safety strategies.

Context: Whereas researchers have provided estimates for the number of head impacts sustained within a youth football season, less is known about the number of plays across which such impact exposure occurs.Objective: To estimate the number of plays in which youth football players participated during the 2013 season and to estimate injury incidence through play-based injury rates.Design: Descriptive epidemiology study.Setting: Youth football.Patients or Other Participants: Youth football players (N = 2098; age range, 5−15 years) from 105 teams in 12 recreational leagues across 6 states.Main Outcome Measure(s): We calculated the average number of athlete-plays per season and per game using independent-samples t tests to compare age groups (5–10 years old versus 11–15 years old) and squad sizes (Results: On average, youth football players participated in 333.9 ± 178.5 plays per season and 43.9 ± 24.0 plays per game. Age groups (5- to 10-year-olds versus 11- to 15-year-olds) did not differ in the average number of plays per season (335.8 versus 332.3, respectively; t2086.4 = 0.45, P = .65) or per game (44.1 versus 43.7, respectively; t2092.3 = 0.38, P = .71). However, players from smaller teams participated in more plays per season (373.7 versus 308.0; t1611.4 = 8.15, P < .001) and per game (47.7 versus 41.4; t1523.5 = 5.67, P < .001). Older players had a greater game injury rate than younger players when injury rates were calculated per 1000 AEs (23.03 versus 17.86/1000 AEs; IRR = 1.29; 95% CI = 1.04, 1.60) or per 10 000 athlete-plays (5.30 versus 4.18/10 000 athlete-plays; IRR = 1.27; 95% CI = 1.02, 1.57).Conclusions: A larger squad size was associated with a lower average number of plays per season and per game. Increasing youth football squad sizes may help reduce head-impact exposure for individual players. The AE-based injury rates yielded effect estimates similar to those of play-based injury rates.

Purpose Recent anecdotal trends suggest a disproportionate number of head injuries in collegiate football players occur during preseason football camp. In warmer climates, this season also represents the highest risk for heat-related illness among collegiate football players. Because concussion and heat illnesses share many common symptoms, we need 1) to understand if environmental conditions, body temperature, and hydration status affect head impact biomechanics; and 2) to determine if an in-helmet thermistor could provide a valid measure of gastrointestinal temperature. Methods A prospective cohort of 18 Division I college football players (age, 21.1 ± 1.4 yr; height, 187.7 ± 6.6 cm; mass, 114.5 ± 23.4 kg). Data were collected during one control and three experimental sessions. During each session, the Head Impact Telemetry System recorded head impact biomechanics (linear acceleration, rotational acceleration, and severity profile) and in-helmet temperature. A wet bulb globe device recorded environmental conditions, and CorTemp™ Ingestible Core Body Temperature Sensors recorded gastrointestinal temperature. Results Our findings suggest that linear acceleration (P = 0.57), rotational acceleration (P = 0.16), and Head Impact Technology severity profile (P = 0.33) are not influenced by environmental or physiological conditions. Conclusions We did not find any single or combination of predictors for impact severity. Rotational acceleration was approaching significance between our early experimental sessions when compared with our control session. More research should be conducted to better understand if rotational accelerations are a component of impact magnitudes that are affected due to changes in environmental conditions, body temperature, and hydration status.

An integral part of the Heads Up Football (HUF) educational program is the Player Safety Coach (PSC), who is responsible for teaching other coaches within a youth football league about safer blocking/tackling and injury prevention. This study examines the association between youth football coaches’ interactions with the PSC (i.e., attending the PSC clinic at the beginning of the season and seeing the PSC on-field during practices) and their subsequent implementation of the HUF educational program. Data were collected via online questionnaire completed by 1,316 youth football coaches from HUF leagues. Data were analyzed with frequencies and logistic regression. Nearly half of coaches (44.8%) did not attend the PSC clinic; 25.9% reported not seeing their league’s PSC on the field on a regular basis. The lack of PSC on-site presence was significantly associated with worse implementation for “concussion recognition and response,” “heat preparedness and hydration,” and “sudden cardiac event preparedness.” PSC clinic attendance was not associated with implementation. Opportunities exist for improvement in the HUF educational program as there appears to be inconsistent implementation. Further research is warranted to understand how to optimize the role of the PSC in the youth sports context.

BACKGROUND: We compared injury incidence and mechanisms among youth, high school (HS), and National Collegiate Athletic Association (NCAA) boys’ and men’s lacrosse athletes for the 2014–2015 to 2016–2017 lacrosse seasons. METHODS: Multiple injury surveillance systems were used to capture 21 youth boys’, 22 HS boys’, and 20 NCAA men’s lacrosse team-seasons of data during the 2014–2015 to 2016–2017 seasons. Athletic trainers reported game and practice injuries and athlete exposures (AEs). Injuries included those occurring during a game and/or practice and requiring evaluation from an athletic trainer and/or physician. Injury counts, rates per 1000 AEs, and injury rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. RESULTS: The injury rate in youth was higher than those reported in HS (10.3 vs 5.3 per 1000 AEs; IRR = 2.0; 95% CI: 1.6–2.4) and the NCAA (10.3 vs 4.7 per 1000 AEs; IRR = 2.2; 95% CI: 1.9–2.5). When considering time loss injuries only (restricted participation of ≥24 hours), the injury rate in youth was lower than those reported in HS (2.0 vs 2.9 per 1000 AEs; IRR = 0.7; 95% CI: 0.5–0.95) and the NCAA (2.0 vs 3.3 per 1000 AEs; IRR = 0.6; 95% CI: 0.4–0.8). The concussion rate in youth was higher than those in HS (0.7 vs 0.3 per 1000 AEs; IRR = 2.4, 95% CI: 1.1–5.2) and the NCAA (0.7 vs 0.3 per 1000 AEs; IRR = 2.1, 95% CI: 1.2–3.7). Injuries at the youth, HS, and NCAA levels were most commonly associated with stick contact, inflammatory conditions (including bursitis, tendonitis, and other unspecified inflammation), and noncontact mechanisms, respectively. CONCLUSIONS: Although the time loss injury rate was lowest in youth boys’ lacrosse, the concussion rate was the highest. Injury prevention approaches should be specific to the mechanisms associated with each level of play (eg, equipment skill development in youth).

Context Exertional heat illnesses (EHIs) among football athletes have been widely researched, but data examining all collegiate sports are limited. Objective To describe the epidemiology of EHI in 25 National Collegiate Athletic Association (NCAA) sports. Design Descriptive epidemiology study. Setting The NCAA Injury Surveillance Program during the 2009–2010 through 2014–2015 academic years. Patients or Other Participants A voluntary sample of 166 NCAA institutions over 2048 team-seasons. Main Outcome Measure(s) Athletic trainers reported EHIs to the NCAA Injury Surveillance Program. Only EHIs sustained during a sanctioned practice or competition were included. The EHI rate, specific diagnoses, and number of emergency transports were measured. Results Overall, 232 EHI events were reported (0.47/10 000 athlete-exposures [AEs]; 95% confidence interval [CI] = 0.41, 0.53). Football comprised 75% of all EHI events and had the largest rate (1.55/10 000 AEs; 95% CI = 1.32, 1.78). The overall EHI rate was higher in preseason practices (1.16/10 000 AEs) than all other time periods (regular and postseason practices and all competitions; 0.23/10 000 AEs, injury rate ratio [IRR] = 4.96; 95% CI = 3.79, 6.50). This result was retained when examining the individual sports of football (3.65/10 000 versus 0.63/10 000 AEs, IRR = 5.82; 95% CI = 4.18, 8.10), men's soccer (1.11/10 000 versus 0.07/10 000 AEs, IRR = 16.819; 95% CI = 1.89, 138.55), and women's soccer (1.10/10 000 versus 0.05/10 000 AEs, IRR = 22.52; 95% CI = 2.77, 183.05). The EHI rates were highest in states with elevated annual temperatures (1.05/10 000 AEs). Heat cramps (39%), heat exhaustion (27%), and dehydration (29%) were the most common types of EHI. Nineteen athletes with EHI (8%) required emergency transport. Conclusions Football players continue to experience the most EHIs; however, EHIs can potentially occur in all NCAA sports. Continued emphasis on preseason EHI policies and institution-specific environmental guidelines is needed to address EHI rates.

Objective Prompt, accurate, objective assessment of concussion is crucial as delays can lead to increased short and long-term consequences. The purpose of this study was to derive an objective multimodal concussion index (CI) using EEG at its core, to identify concussion, and to assess change over time throughout recovery. Methods Male and female concussed ( N = 232) and control ( N = 206) subjects 13–25 years were enrolled at 12 US colleges and high schools. Evaluations occurred within 72 h of injury, 5 days post-injury, at return-to-play (RTP), 45 days after RTP (RTP + 45); and included EEG, neurocognitive performance, and standard concussion assessments. Concussed subjects had a witnessed head impact, were removed from play for ≥ 5 days using site guidelines, and were divided into those with RTP Results Sensitivity = 84.9%, specificity = 76.0%, and AUC = 0.89 were obtained on a test Hold-Out group representing 20% of the total dataset. EEG features reflecting connectivity between brain regions contributed most to the CI. CI was stable over time in controls. Significant differences in CI between controls and concussed subjects were found at time of injury, with no significant differences at RTP and RTP + 45. Within the concussed, differences in rate of recovery were seen. Conclusions The CI was shown to have high accuracy as a marker of likelihood of concussion. Stability of CI in controls supports reliable interpretation of CI change in concussed subjects. Objective identification of the presence of concussion and assessment of readiness to return to normal activity can be aided by use of the CI, a rapidly obtained, point of care assessment tool.

During physical activities, youth consume fluids from various delivery methods that may influence hydration behaviors. The purpose of this study was to determine the drinking efficiency of these different methods. Children’s fluid intake was more efficient when drinking from a cup compared with a bottle with no mouth contact and a water fountain, but not compared with a bottle with direct mouth contact. Drinking from the water fountain was the least effective compared with all other methods. Children drink more efficiently when using cups and water bottles with direct mouth contact as the delivery method compared with methods with no mouth contact.

Context: Data regarding the epidemiology of emergency-transport incidents (ETIs) of patients with sport-related injuries are lacking. Understanding the use of emergency services by athletic trainers can help improve emergency preparedness and prehospital care for injured student-athletes.Objective: To determine the frequencies and types of ETIs resulting from athletic participation.Design: Descriptive epidemiology study.Setting: Participating colleges and high schools during 2009–2010 to 2014–2015 and 2011–2012 to 2013–2014, respectively.Patients or Other Participants: Student-athletes in 23 high school and 25 intercollegiate sports.Main Outcome Measure(s): Data on injuries requiring emergency transport were collected by each team's athletic trainer via their respective online injury-tracking software. Athletic trainers also collected data on athlete-exposures (AEs). Emergency-transport incident frequencies and injury rates per 10 000 AEs with 95% confidence intervals (CIs) were reported. For each ETI, the sport, body part, injury mechanism, and final diagnosis were recorded.Results: A total of 339 and 146 ETIs were reported in collegiate and high school players, respectively. Collegiate women's ice hockey had the highest ETI rate (1.28/10 000 AEs; 95% CI = 0.71, 1.86). In high school, football had the highest rate at 0.80 per 10 000 AEs (95% CI = 0.64, 0.97). Athletes with head or face injuries required the most transports in college (n = 71, 20.9%) and high school (n = 33, 22.6%) across all sports. Strains (n = 50, 14.7%) and fractures (n = 35, 24.0%) were the leading diagnoses for patients undergoing transport in college and high school, respectively.Conclusions: Athletic trainers should maintain a high level of emergency preparedness when working with sports that have high rates and numbers of ETIs. Athletes with injuries to the head/face required the most frequent transport across competition levels. Athletic trainers should have the appropriate equipment and protocols in place to handle these patients. Future researchers should examine the differences between field and hospital diagnoses to help improve prehospital care and decrease the likelihood of unnecessary emergency transports.

Context: Without a true criterion standard assessment, the sport-related concussion (SRC) diagnosis remains subjective. Inertial balance sensors have been proposed to improve acute SRC assessment, but few researchers have studied their clinical utility. Objective: To determine if group differences exist when using objective measures of balance in a sample of collegiate athletes with recent SRCs and participants serving as the control group and to calculate sensitivity and specificity to determine the diagnostic utility of the inertial balance sensor for acute SRC injuries. Design: Cross-sectional cohort study. Setting: Multicenter clinical trial. Patients or Other Participants: We enrolled 48 participants with SRC (age = 20.62 ± 1.52 years, height = 179.76 ± 10.00 cm, mass = 83.92 ± 23.22 kg) and 45 control participants (age = 20.85 ± 1.42 years, height = 177.02 ± 9.59 cm, mass = 74.61 ± 14.92 kg) at 7 clinical sites in the United States. All were varsity or club collegiate athletes, and all participants with SRC were tested within 72 hours of SRC. Main Outcome Measure(s): Balance performance was assessed using an inertial balance sensor. Two measures (root mean square sway and 95% ellipse sway area) were analyzed to represent a range of general balance measures. Balance assessments were conducted in double-legged, single-legged, and tandem stances. Results: A main effect for group was associated with the root mean square sway measure (F1,91 = 11.75, P = .001), with the SRC group demonstrating balance deficits compared with the control group. We observed group differences in the 95% ellipse sway area measure for the double-legged (F1,91 = 11.59, P = .001), single-legged (F1,91 = 6.91, P = .01), and tandem (F1,91 = 7.54, P = .007) stances. Sensitivity was greatest using a cutoff value of 0.5 standard deviations (54% [specificity = 71%]), whereas specificity was greatest using a cutoff value of 2 standard deviations (98% [sensitivity = 33%]). Conclusions: Inertial balance sensors may be useful tools for objectively measuring balance during acute SRC evaluation. However, low sensitivity suggests that they may be best used in conjunction with other assessments to form a comprehensive screening that may improve sensitivity.

Context: During team athletic events, athletic trainers commonly provide fluids with water bottles. When a limited number of water bottles exist, various techniques are used to deliver fluids. Objective: To determine whether fluid delivered via water-bottle administration influenced fluid consumption and hydration status. Design: Crossover study. Setting: Outdoor field (22.2°C ± 3.5°C). Patients or Other Participants: Nineteen participants (14 men, 5 women, age = 30 ± 10 years, height = 176 ± 8 cm, mass = 72.5 ± 10 kg) were recruited from the university and local running clubs. Intervention(s): The independent variable was fluid delivery with 3 levels: self-administration with mouth-to-bottle direct contact (SA-DC), self-administration with no contact between mouth and bottle (SA-NC), and external administration with no contact between the mouth and the bottle (EA-NC). Participants warmed up for 10 minutes before completing 5 exercise stations, after which an ad libitum fluid break was given, for a total of 6 breaks. Main Outcome Measure(s): We measured the fluid variables of total volume consumed, total number of squirts, and average volume per squirt. Hydration status via urine osmolality and body-mass loss, and perceptual variables for thirst and fullness were recorded. We calculated repeated-measures analyses of variance to assess hydration status, fluid variables, and perceptual measures to analyze conditions across time. Results: The total volume consumed for EA-NC was lower than for SA-DC (P = .001) and SA-NC (P = .001). The total number of squirts for SA-DC was lower than for SA-NC (P = .009). The average volume per squirt for EA-NC was lower than for SA-DC (P = .020) and SA-NC (P = .009). Participants arrived (601.0 ± 21.3 mOsm/L) and remained (622.3 ± 38.3 mOsm/L) hydrated, with no difference between conditions (P = .544); however, the EA-NC condition lost more body mass than did the SA-DC condition (P = .001). There was no main effect for condition on thirst (P = .147) or fullness (P = .475). Conclusions: External administration of fluid decreased total volume consumed via a decreased average volume per squirt. The SA-DC method requires fewer squirts within a specific time frame. Fluid breaks every 15 minutes resulted in maintenance of euhydration; however, loss of body mass was influenced by fluid administration. Athletic trainers should avoid external administration to promote positive hydration behaviors. When fluid is self-administered, individual bottles may be the best clinical practice because more volume can be consumed per squirt.

Purpose Examinations of injury among younger populations of lacrosse players that are beginning their development is limited. This study describes the epidemiology of youth boys' and girls' lacrosse injuries during the 2015 to 2016 seasons. Methods Surveillance data originated from a convenience sample of 10 leagues in five states with 1090 boy lacrosse players and 408 girl lacrosse players from the U9-U15 divisions. Athletic trainers reported injury and exposure data at games and practices. Time loss (TL) injuries were defined as resulting in ≥24 h of participation restriction time. Injury counts and rates per 1000 athlete games/practices were calculated. Injury rate ratios (IRR) with 95% confidence intervals (CI) compared rates by sex and age division. Results Overall, 241 and 59 injuries were reported in boys' and girls' youth lacrosse, respectively, of which 17.0% and 18.6% were TL. Compared with girls, boys had a higher overall injury rate (12.7 vs 8.7/1000 athlete games/practices; IRR, 1.5; 95% CI, 1.1-1.9). U13/U15 boys had a higher TL injury rate than U9/U11 boys (2.6 vs 1.0/1000 athlete game/practices; IRR, 2.6; 95% CI, 1.1-6.1). Most injuries were diagnosed as contusions (boys, 53.7%; girls, 47.2%) and resulted from stick contact (boys, 34.1%; girls, 30.6%) and ball contact (boys, 17.1%; girls, 25.0%). Among girls, ball contact contributed to 75.0% (n = 9) of all head/face injuries. Among the 14 concussions reported in boys, player contact was the most common injury mechanism (50.0%, n = 7), followed by stick contact (35.7%, n = 5). Conclusions Boys' lacrosse has a higher injury incidence than girls' lacrosse, reflecting the contact nature of the boys' game. The high incidence of stick- and ball-related injuries suggests the need for youth-specific rules to better protect youth players.