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Concussion in Sport. The injury issue that will not go away

11 Mar, 14 | by Caroline Finch

Cross Fertilising Injury Prevention (IP) and the British Journal of Sports Medicine (BJSM)

Few types  of sports injury have received as much attention as concussion . It’s an issue that has witnessed increasing attention in the public media, dominating several social media discussions, and also has been the subject of previous IP Blogs. So important is it, that the British Journal of Sports Medicine (BJSM) Volume 48, Issue 2 is devoted to the topic.

As a paper by Williams et al. shows, the public is increasingly accessing information about concussion from sources such as YouTube, but the majority of this is just depictions of injury events, not preventive advice. But this lack of preventive detail is not limited to information exchange aimed at the masses. There is also now strong evidence from Australia (White et al.) that the professionals who most need the information about how to prevent and recognise concussion, namely coaches and those that provide on-field injury assessment, have poor levels of knowledge. In a study (Cusimano et al.) of the effectiveness of an educational video to inform ice hockey players about concussion, immediate knowledge gains were observed, but had disappeared again two months later. The challenge, as with much injury prevention advice, remains how to address poor knowledge and its retention. This is the classic problem of knowledge transfer and research dissemination – a problem that injury prevention professionals should prioritise addressing.

This lack of knowledge transfer is perhaps not surprising in the light of another paper in this BJSM issue by second paper by White et al. There has been considerable effort given to the development of international consensus guidelines for the management and diagnosis of concussion (as reported in the 2013 47(5) issue of BJSM). But independent appraiser assessment of these guidelines highlights major gaps in knowledge about, and guidance, for actually implementing them and ensuring appropriate action follows from their use. It never ceases to amaze me that there is still an implicit assumption that just having guidelines/published resources is enough for action.

A good example of how such limitations have been recognised and addressed is a paper by Davis and Purcell. These authors recognised that earlier iterations of the international consensus statements were developed from literature relating to adults, that was then expected to be applied to children. Their work has led to the refinement of concussion evaluation guidelines into a form that is specifically suitable for children – in that it includes testing procedures that can actually be completed by children and it addresses the manifestations of concussion and its management that are particular to young people.

It is a sad fact that almost all of the concussion in sport research literature focusses only on the diagnosis and management of concussion, with very little attention given to its primary prevention. Perhaps we are seeing this trend start to reverse a bit, as this issue of BJSM also includes two paper describing different aspects of implementation of head/neck injury prevention measures. The paper by Crowley and Crowley gives an overview of the actions taken by the Gaelic Athletic Associations’ 27-year programme leading to the mandating of helmets in Gaelic football. Donaldson and Poulos describe how they engaged directly with coaches to plan how a neck-injury prevention program should be delivered in rugby union. It will be interesting to read the final preventive outcomes of their work, when the results of their implementation are reported.

In the popular press, concussion has been most commonly linked to participation in the football codes – which code depends on the country of origin of the reports.  Regular readers of Injury Prevention, will be very aware that concussion is also common amongst among other popular activities participated in for sport and recreation such as cycling, motorcycling and horse riding. My own research shows that the football codes (collectively) only account for about one-third of all sport-related hospitalisations for concussion. Notwithstanding this, it is certainly the concussion rates in the football codes that have attracted most public attention over the recent couple of years. There is a clear need for peak football bodies, and those of other sports with particular high concussion rates such as ice hockey, to develop and implement strategies to prevent concussions and to reduce their adverse impacts when they do occur. It is fitting, therefore, that this issue of the BJSM describes some of the identified priorities and actions to date from the International Rugby Board and the (Canadian) National Hockey League.

Finally, the concussion debate has been fuelled by increasing reports of potential long-term adverse effects of sports–related concussion. This evidence should surely help to provide added priority status to the prevention of this injury type, especially if it can be demonstrated to have very significant, adverse health outcomes, even if they do not lead directly to death. Several papers in this BJSM issue describe the topic of chronic traumatic encephalopathy (or CTE), secondary to initial concussive episodes in sport, but highlight the current lack of good scientific evidence in this important area. I am expecting there to be increased research attention given to this area over the next few years.

Caroline Finch is an injury prevention researcher and Head of the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Federation University Australia located in Ballarat, Victoria, Australia. She specialises in two areas: (1) sports injury surveillance and research methodologies and (2) implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and the Statistical Editor for Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch.

Do we have enough knowledge to prevent the sorts of injuries that occurred during the Sochi Winter Games?

7 Mar, 14 | by Caroline Finch

 

Cross Fertilising Injury Prevention and the British Journal of Sports Medicine (BJSM)

After a hiatus of about a year, I am returning to writing my Injury Prevention to British Journal of Sports Medicine cross-fertilisation blogs. As I said in my first such item on the IP Blog, we need to break down injury research silos, and share collective knowledge so that we can truly prevent injuries from occurring in the first place. Many readers will know that my own interests are in using implementation science approaches to bring injury prevention knowledge together with sports medicine understanding of sports injury risks and causes.

It is timely with the completion of the recent Sochi Winter Olympic Games, and the most recent IP Blog, to now preview the contents of the first issue of the BJSM for 2014 (Volume 48, Issue 1). This issue pre-empted the games with discussions of injury rates, patterns and risk factors for injuries occurring in skiers, snowboarders and ice hockey.

There is no doubt that increased attention to rigorous injury surveillance in these sports has helped increased knowledge about the risks inherent in these high performance sports. Adoption of the International Ski Federations’ Injury Surveillance System in several studies now means that standardised injury data is collected and reported – e.g. injuries in general for elite snowboarders, and for specific injury types, such as head injuries in alpine and freestyle skiers and snowboarders. But just having a description of the injury problem and the outcomes of such injuries is not enough if we want to prevent future injuries. Unfortunately, much winter sport injury research remains at this injury description level, as two review articles relating to snowboarding and ice hockey injuries demonstrate.

In a previous IP-Blog, I discussed some emerging studies in previous issues of the BJSM into the specific mechanics of snow sports injuries, for elite performance forms of these activities. This first issue of the BJSM for 2014, continues to publish this type of valuable etiological research. One paper presents a video analysis of injury situations in freestyle ski cross that identifies features of four main incident scenarios that lead to injury. This paper brings us closer to prevention because knowledge of the how and why injuries occur (rather than just the fact that they do happen) is crucial for the development of potential injury countermeasure solutions.

Only one paper in the issue, evaluates a specific injury prevention measure, namely helmets for speed skating. Using standard helmet impact testing and biomechanical approaches, this study shows that such helmets do not adequately dissipate peak rotational accelerations, which could lead to injury in this sport.

The visual spectacle that was the Sochi Games introduced 12 new events, many of which would be considered as “extreme sports”. Longer. Faster. Higher. More spectacular. Like the more traditional snow sport events, these require athletes to take full command of a physical environment with inherent hazards, whilst also mastering control over their own bodies to execute the increasingly difficult physical manoeuvres needed to perform at the highest level and to avoid those hazards. The IOC’s Medical Commission conducted extensive injury surveillance during the Sochi Games, and so information about injuries in these new events will have been collected, but in some sense this will have been “after the event”. As sports evolve, there is increased need for more rapid understanding of the likely injury risks and hazards that may be present. This information needs to be understood before large sporting events are hosted, so that a range of risk and hazard mitigation measures are put into place before the athletes compete. When done properly, this will ensure that viewers get to see the right spectacular – stunning athletic performances, not painful dramatic injury events – and that the athletes themselves are able to participate at the level and frequency that they strive for.

It may be hard to pre-empt the exact nature of all injury issues that might occur during a major sporting event. But that does not mean that they were inevitable or could not have been prevented with adequate foresight. Surely we have enough knowledge from injury prevention science that could be used now to guide risk management and hazard mitigation planning for snow sports.

Now that sounds like a great way to link injury prevention and sports medicine research, to me.

 

Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Federation University Australia located in Ballarat, Victoria, Australia. She specialises in two areas: (1) sports injury surveillance and research methodologies and (2) implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and the Statistical Editor for Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch.

A radical step in injury prevention – preventing table-saw injuries

5 Mar, 14 | by Bridie Scott-Parker

 

After blogging “Table saw 1, Injury-free arm and hand 0” on the 20th of May last year, I have remained alert to news regarding installation of injury prevention devices on table saws. Pleasingly my father has left the building industry with all his digits and limbs intact, however other table-saw users have not fared to so well. Last year I noted that the injury prevention technology was available, however it was recognised that the technology was likely to increase the initial purchase price of the table saw.

In a radical step in injury prevention, over the past week I have learned that a federal antitrust lawsuit has been filed by the developer of the injury prevention technology – SawStop LLC – with the complaint naming major power tool companies who feared increased legal liability from table saw injuries if the technology was introduced by some companies and not others. As such, it is claimed that

Defendants engaged in a group boycott of Plaintiff’s safety products for table saws beginning around 2001 or 2002…”

As an injury prevention professional, this statement brings about an almost visceral response as I reflect with sheer horror on the many oft-permanent injuries that could have been prevented if product safety, instead of the almighty dollar, had been a priority for any of these companies at any point over the last dozen years. I hope other injury prevention professionals are just as outraged by this audacity.

Read more at http://www.fairwarning.org/2014/02/power-tool-makers-accused-in-lawsuit-of-thwarting-adoption-of-finger-saving-device/ and http://www.allgov.com/news/controversies/power-tool-makers-fight-against-finger-saving-device-140302?news=852569.

Grumpy over-protective Nanny Barry

2 Mar, 14 | by Barry Pless

Am I the only person in the injury prevention world who watched the Olympics with a mixture of admiration and condemnation? What struck me — and perhaps only me — was that virtually every one of the ‘sports’ were dangerous. The danger element ranged from simple falls on the ice for dancers without helmets to snowboarders flipping over from considerable heights.  Not that I understand it, but only curling seemed reasonably free of danger. I am not exaggerating when I say that as I reviewed all the others in my mind I found no other that I would want to encourage my children or grandchildren to pursue. Of course if athletes want to get on a luge sled or skeleton sled and slide down an icy track at more than 100 mph that is their choice and I would not wish to interfere. But it does trouble me that they are setting examples for children and adolescents who would like to share the fame and, dare I say it, riches that follow successes at the Olympics. The Olympics seems to be all about risk taking to an excessive degree. In Vancouver we had one luge death. In Sochi I can’t remember any serious injuries but lots of near misses to say nothing of those who bravely (but perhaps foolishly) chose to compete while injured. That includes Canada’s very own gold medal winning goalie!

So, yes, I am grumpy; and I am over-protective; and I do believe in the nanny state. By all means explain why you think I am wrong if you disagree. 

Guns on Campus in Idaho

28 Feb, 14 | by gtung

Today, the Idaho House of Representatives will be discussing legislation that has already passed the state senate that would allow individuals who have a concealed weapon’s permit to carry a gun on college and university campuses in the state.  One of the arguments in favor of this legislation is that someone who is considering carrying out a mass shooting will be less likely to attempt to do so if students and others on campus are packing heat.  And if for some reason they decide to give it a shot anyway, there will be a unit of armed citizens on campus to take them out.  This and other arguments in favor of this legislation seem insane to me but apparently they are persuasive to many others as this legislation has already passed the state senate.

In response to all of this, Greg Hampikian, a professor at Boise State (located in Idaho) published a biting and satirical opinion piece in the New York Times titled “When May I Shoot a Student?”  For me, it captures the insanity and ridiculousness of this proposed legislation.  It is a good read.

http://www.nytimes.com/2014/02/28/opinion/when-may-i-shoot-a-student.html?src=me&ref=general

Overcoming obstacles encountered in translating research into practice

28 Feb, 14 | by Bridie Scott-Parker

 

Regular readers of the injury prevention blog will know I have commented on a number of occasions regarding the need to (1) share our research findings, and (2) translate research into practice and policy. Whilst this is the ideal, I also realise that there are many obstacles to this being the actual, another topic upon which I have lamented. With this in mind, I was pleased to see an article summarising the efforts of researchers to improve the uptake of “Mayday Safety Procedure” by coaches to manage injury in one of Australia’s most popular sports, rugby union.

With challenges in translating research into practice in mind, the researchers note that

the translation of injury prevention policy into community practice can be enhanced by developing and implementing a theory-informed, context-specific diffusion plan, undertaken in partnership with key stakeholders“.

The statistically significant improvements in Mayday knowledge and practice reported by the authors have bolstered my hopes that research findings can be translated into policy and practice in other safety-critical injury prevention domains.

Read more at http://www.ncbi.nlm.nih.gov/pubmed/24566099.

How to Cite Social Media in Scholarly Writing

22 Feb, 14 | by Barry Pless

I have not posted anything for a week or so but came across this useful item for those who want to get it right when they get to the references section of a paper they are submitting to this or any other scholarly journal. It is timely because, increasingly, information is being used that comes from social media. But how to cite it?   The author is Camille Gamboa at SAGE US.

She writes: ” As it seems that social media will only play a bigger role in future research of all disciplines, I took to doing my own research on how Facebook posts, tweets, YouTube videos, etc. should be cited in academic publications. I came across the following table from TeachBytes that I thought would be helpful to share …

The Chicago Manual of Style

Not included in her chart (see below) is what she out about how to cite social media outlets following the Chicago Manual of Style.  Apparently there are not yet any official guides for Facebook, Twitter, and Youtube.

Blog Posts:

Firstname Lastname, “Title of the Blog Post Entry,” title or description of the blog with (blog), Date posted, url.  * Note – “(blog)” does not need to be included if the word “blog” is part of the name of the blog already. Citations of blog posts are part of the notes and not included in the bibliography unless they are frequently cited in one paper.

Emails:

Firstname Lastname, email message to XX, Date. Citations of emails are usually provided in a note and are rarely listed in a bibliography. Email addresses should not be included.

The chart she mentions is on the website below and applies to MLA and APA publications:

http://connection.sagepub.com/blog/2013/09/17/how-to-cite-social-media-in-scholarly-writing/ 

More on Driving under the influence of Marijuana

19 Feb, 14 | by gtung

There was a fascinating article published on the issue of driving under the influence of marijuana this past Monday in the New York Times.

http://www.nytimes.com/2014/02/18/health/driving-under-the-influence-of-marijuana.html?hpw&rref=science&_r=0

Marijuana and driving is an issue of increasing relevance as US states continue to legalize medical marijuana and Colorado and Washington State have now legalized recreational marijuana.  The challenges associated with setting a specific standard for driving under the influence of marijuana have already been discussed on this blog but in a nutshell there is one major challenge. That challenge is that similar blood levels of THC can mean very different things for various people and represent very different levels of driving impairment.  Chronic users can have relatively high levels of THC regularly in their blood that correspond to much lower deficits in driving performance compared to novice users.  It also doesn’t help that marijuana blood levels currently have to be tested for with a blood or urine samples compared to a Breathalyzer test for alcohol.

The interesting position emphasized in the article and put forth by Eduardo Romano at PIRE and Mark Klein at UCLA is that alcohol is so much more dangerous than marijuana when it comes to driving under the influence that efforts to change DUI policy should focus on alcohol as opposed to marijuana and on lowering the current alcohol BAC levels from 0.08 to 0.05.  A recent paper published by Romano in the Journal of Studies on Alcohol and Drugs did not find a statistically significant increased risk of a fatal crash associated with marijuana when controlling for demographics and alcohol.  Other research suggests that any measurable THC is associated with a doubling of crash risk.  Compare this to alcohol though where the crash risk increases nine fold at the 0.08 level for adults (it is even higher for those under 21).

The data does seem to indicate that driving while under and influence of alcohol is more dangerous compared to driving under the influence of marijuana but the policy environment seems receptive to taking action on marijuana and driving while the recent recommendation by the National Transportation Safety Board to move alcohol BAC levels from their current level of 0.08 to 0.05 doesn’t seem to have much traction (at least yet).

Given the current receptivity to address marijuana related issues I think it make sense to take advantage of it by doing the relevant research and then making informed policy decisions.  This does not take away from the importance of moving alcohol BAC levels in the US from 0.08 to 0.05 but the current window of opportunity seems to be marijuana specific and it is not clear to me that advancing marijuana related DUI policies detracts from efforts to advance alcohol DUI policies.

Maintaining the momentum

10 Feb, 14 | by Bridie Scott-Parker

Alcohol-fuelled violence continues on Australian streets – Google this topic, and pages and pages of hits will appear. You will also note in these pages that this has become an increasingly alarming issue over the years, with much public outcry in recent times.

The randomness of such violence, and the magnitude and variety of injuries – many of which are irreparable if not unsurvivable - has struck a chord with parents across our country. Hopefully it has also struck a chord with the young men who are likely to be the victims, and the young men who are likely to be the perpetrators. So how do we make a change for the better?

An interesting article by Professor Rod McClure appeared in The Sydney Morning Herald last month, urging us to maintain the momentum to make a real difference in alcohol-fuelled violence and citing traction gained and maintained in road safety in particular as an exemplar of how to make it work:

“There is widespread concern about the recent deaths from alcohol-fuelled violence. There is the risk, however, that in the same way the gun debate in the US flares after every shooting then fades away without change, a similar pattern will emerge in Australia….There has also been an overwhelming frustration and despair that this is an issue for which there is no answer. However, Australia has been faced with similar public health issues that at the time seemed insurmountable, that we have collectively tackled and defeated and we can learn from these to tackle alcohol and its impact on our lives….As a society we committed to a strategic introduction of a road safety program based on better cars, better roads and better road-user behaviour, all regulated by legislation that was rigorously enforced.”

I strongly support Prof McClure’s sentiments in his impassioned plea:

“If we don’t solve the problem of public safety it will not be because we can’t solve the problem. It will be because we are not sufficiently committed to doing so. It will be because the politicians are too timid to lead; the public too selfish to change their habits, or too apathetic to try to change our societal norms; and industry too focused on putting personal profits ahead of public good.

We already have the blueprint for how to change entrenched societal behaviour. We have strategies that are based in evidence and are known to work.

What we need is the collective will and government that are willing to commit to making tougher laws and tougher decisions.

The community has said it has had enough. Surely it’s time for politicians to take action until the injury and death rate from alcohol-fuelled violence is, like the road toll, actively being pushed towards zero.

We’ve done it before, with smoking and with road safety. Now it’s time to do the same with alcohol- fuelled violence, on the streets and in our homes.”

(Read the article at http://www.smh.com.au/comment/road-toll-and-smoking-campaigns-good-precedents-for-the-fight-against-alcoholfuelled-violence-20140105-30br0.html)

 

Quebecers horrified by seniors fire deaths

9 Feb, 14 | by Barry Pless

At least 24 seniors in a private nursing home at L’Isle-Verte in eastern Quebec died when fire engulfed the mostly wooden residence. Many believe the deaths were preventable if several obvious measures had been taken. Most important (and most contentious) is the absence of a sprinkler system even though the provincial code requires them – but makes bizarre exceptions depending on the mobility of the residents. Another factor was the construction of wood. Ironically, a part of the building that was added recently and used different materials was not burned. Finally, the staffing at night when the fire occurred was reduced. For me the most baffling argument is one put forward by a fire prevention officer who claimed that smoke detectors were more important than sprinklers because people die of smoke inhalation, not of burns. True; but somehow the fact that sprinklers extinguish fires before they get to the smoking stage seems to have escaped this expert. She goes to suggest that  there is no “magic solution” to fires like that at L’Isle-Verte. I see this as an invitation to inaction. The solution is  not magic; it is basic science, solid technology, and injury prevention of the highest order. In case she somehow forgot, smoke comes from fire. She acknowledges that sprinklers prevent a fire from spreading, and then argues that what is needed is more smoke detectors not sprinklers! This is an astonishing observation, especially coming from someone with her responsibilities. Her remarks would certainly lend support to those who oppose establishing sprinkler systems in all homes, and especially in facilities serving the elderly and infirm. She implies we cannot insist on requiring both. It is like saying that for car safety you cannot have both brakes and mirrors; you must choose one or the other. Just because the cost of smoke detectors is much less than that of a sprinkler system is no reason not to require both. It is nonsense to say ‘smoke detectors are more important in saving lives’ and thereby imply that sprinklers are not needed. Her bizarre views should not be used as an excuse for avoiding the installation of these systems; they have proven to be highly effective and could save many many lives.

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