CHAPTER 6 First contact management
Injury prevention should perhaps be the most important topic within the field of sports medicine. The term ‘prevention’ is normally used in the context of sports injuries to refer to any measure which can stop an injury occurring. But the processes of prevention also play an important role in arresting the exacerbation of a current injury, and ensuring that the same injury does not recur.
The causes of sports injuries are many and varied. Items such as technique failure, faulty sports equipment, poor physical fitness, inadequate warm-up and psychological factors can all act as co-factors. Taimela, Kujala and Osterman (1990) divided injury risk factors into intrinsic and extrinsic groups as shown in Table 6.1.
Adapted from Taimela, S., Kujala, U.M. and Osterman, K. (1990) Intrinsic risk factors and athletic injuries. Sports Medicine, 9(4), 205–215. With permission.
Some factors will clearly affect athletes differently, and certain elements are more important in one sport than another. However, in general, the more risk factors an athlete shows, the more likely he or she is to be injured. Consequently, the aim of the coach or practitioner should be to reduce these risk factors to a minimum.
The subject of warm-up is dealt with in depth in Chapter 4. A general warm-up, intense enough to induce mild sweating without causing fatigue, is important for injury prevention. The general activity should be followed by a specific warm-up designed to produce a suitable arousal level in the athlete, and to rehearse any complex skills which will be used later in competition.
Joints, muscles and other soft tissues should be extended through their full physiological range before competition, using maintenance stretching. However, it is important that developmental stretching be separate to, and follow, a warm-up.
Maintenance stretching may form part of a warm-up. Developmental stretching must be preceded by a warm-up.
It is also important that vigorous exercise does not end abruptly, but slows gradually during a cool-down period. This period allows the cardiopulmonary system to return to resting levels without placing undue stress on the body. In addition, delayed onset muscle soreness (DOMS) may be reduced by flushing fresh blood into the muscles previously worked during exercise, and removing waste products. To achieve an increase in muscle perfusion, the activity must involve rhythmic muscle pumping actions of low intensity. The use of post-event massage in this context is described in Chapter 2.
All the components of fitness are required for injury prevention, and importantly, a balance should exist between each. For example, increased flexibility without a similar increase in strength may leave a joint hypermobile or unstable and increase the risk of injury. Similarly, strength and muscle bulk increases without adequate flexibility and skill can leave an athlete ‘muscle bound’ and lacking agility.
Symmetry of muscle development and range of motion is also important. Athletes who exercise unilaterally, for example throwers, must take care that they redress the imbalance caused by their sport with a suitable strength-training programme. Unequal muscle development across a single joint or series of joints may alter specific body segment alignment and general posture. Similarly, unequal training within an antagonistic pair of muscles will cause imbalance.
It is also important that training accurately reflects the physical demands of a sport, and exercise is specific to the physiological adaptations that the sport requires (SAID principle). Sports requiring speed and power, for example, will suffer if only strength is included in training. The ‘strong’ athlete who has trained exclusively with heavy weight training is open to injury when rapid explosive actions are used in sport. This is because the skills involved in the two actions are very different.
A variety of psychological factors may predispose an athlete to injury. Personality tests (Cattell 16PF) performed on footballers have shown that tender-minded players were more likely to be injured, and those who were reserved/detached or apprehensive to suffer more severe injuries (Jackson et al., 1978). Anxiety, and the unconscious attempt to cope with it, can cause abnormal behaviour in the athlete (Sanderson, 1981) and may also increase the likelihood of injury. Coping mechanisms for tension or anxiety can in some instances create a distortion of reality. An example is the overly tense athlete who simply denies that he/she is anxious, yet loses composure easily and in some cases actually becomes violent. Individuals of this type may harbour a sense of guilt which they try to reduce by self-punishment. A number of visible characteristics are displayed by the injury-prone athlete (Table 6.2).
|Athletes attempt to counter anxiety by being overtly aggressive and fearless. They repeatedly test their indestructibility|
|Sign of masculinity|
|Athlete uses injury as a mark of courage. Needs ‘visible scars of battle’ to show manhood. Continues to play despite injury, but exaggerates pain to seek admiration|
|Punish themselves for feelings of guilt, often about failure to reach their own unrealistic targets|
|Injury as a weapon|
|Tries to punish others, for example the young athlete who is forced to play by overzealous parents|
|The ‘training room athlete’ who fears competition because of feelings of inferiority, but cannot opt out for fear of isolation|
|No physical injury, or slight injury made worse by emotional factors|
Adapted from Sanderson, F.H. (1981) The psychology of the injury-prone athlete. In Sports Fitness and Sports Injuries (ed. T. Reilly). Faber and Faber, London. With permission.
Stressful events in a player’s life can also be a factor in injury. These can be measured as life change units (Table 6.3), and injured players tend to have significantly more of these in the period preceding injury (Kerr and Minden, 1988). One of the reasons for this increased risk is that the athlete’s attention may be affected, with life events hindering concentration. To perform well, an athlete must ‘let go’ and allow automatic or grooved motor actions to ‘flow’ freely. Stressful life events could lead to worry about performance which may prevent an athlete from letting go. In a study of gymnasts, those who had experienced recent stressful life events were four times more likely to be injured and the severity of injury was 4.5 times greater. The subjects in this study reported ‘lack of concentration’ and ‘thinking of other things’ as the major causes of their injuries (Kerr and Minden, 1988).
|Getting a better job||Redundancy|
|Passing an examination||Divorce|
Stressful life events may ultimately lead to mental fatigue, which may present as apathy where an athlete is ‘not interested’ and ‘lacks concentration’. Remedial action could involve a period of attention training from a sport psychologist, to enable the athlete to focus on a task or shift attention between different tasks rapidly. Coaches and therapists must recognize that an athlete is vulnerable to injury after a stressful life event. Training should be modified by reducing its intensity and concentrating on basic skills rather than introducing new ones.
Equipment and environment
All athletes are under pressure to buy particular sportswear. Professional athletes may receive sponsorship, and amateur athletes (particularly children) will respond to changing fashions. It is important to emphasize to the athlete that sports equipment should be comfortable and functional. If a particular shoe or item of clothing does not fit correctly, another should be tried, the fit being more important than the type.
The field of play should also be the focus of attention, particularly in amateur sport. Before training, both the environment and equipment should be inspected by the coach. If, for example, a child falls on a broken bottle that no one realized was there, part of the responsibility lies with the coach for not checking the area beforehand.
Another aspect of ‘environment’ that warrants attention is the other players. Variability of young athletes grouped by chronological age rather than biological (physiological) age may be tremendous. This is especially true at the onset of puberty, where a relatively narrow age range of 2 years in a grouping of 9–11-year-olds will give a large size variation. It was these variations (at the time within the child labour market) which gave rise to the use of physiological age groupings based on pubic hair development (Crampton, 1908).
Table 6.4 shows the difference between age, size and a selection of performance variables in small and large youth ice hockey players in the same league. It is clearly a risk to have a 37 kg athlete able to produce an impact force of just over 1000 N competing against a 74 kg athlete capable of producing an (almost double) impact force of 1700 N.
|Variable||Small (Mean)||Large (Mean)|
|Grip strength (kg)||27.7||56.5|
|Maximal speed (m/s)||7.6||8.3|
|Impact force (N)||1010.0||1722.0|
|Speed at impact (m/s)||3.2||3.7|
Adapted from Roy, M.A. et al. (1989) Body checking in Pee Wee hockey. Physician and Sportsmedicine, 17(3), 119–126. © The McGraw-Hill Companies.
Self-assessment of maturity can be made using secondary sex characteristics, including external genitalia and pubic hair in males, and breasts, pubic hair and menarche in females (Malina and Beunen, 1996). There is obviously a potential problem of under- and overestimation (by the athlete or others) to remain with peers or to gain a competitive advantage, but the possibility of random testing by medical staff should control this.
In professional sport, rule changes have had a dramatic effect, particularly with head injuries. However, the local youth club under-12 team must also have a firm policy of sports regulation. Where children are involved, it is important to lay down firm rules concerning safety and equipment. The coach who tries to be popular by allowing a ‘free for all’ is really being irresponsible and is likely to be the cause of injury.
Alteration of rules in sport has been shown to have a positive effect on injury rate and intensity (Table 6.5). Changes in the rules in ice hockey, making the wearing of helmets compulsory, significantly reduced the number of head and eye injuries (Vinger, 1981). In American football, the banning of ‘spear tackles’ (hitting an opponent with the vertex of the head) has reduced the number of head and neck injuries (Torg, Truex and Quedenfield, 1979). In hockey, banning high sticking (lifting the stick above shoulder level) has reduced eye injuries (Tator and Edmonds, 1984); and in karate, banning round-house kicks in competition (a rapid kick aimed at the side of the head) has prevented injury (McLatchie, Davis and Caulley, 1980). Allowing free substitution (permitting injured players to be substituted immediately) in soccer has been shown to reduce injury (Jorgensen, 1989).
Adapted from Jorgensen, U. (1989) Free substitution in soccer. Nitz, 3, 155–158.
The subject of physical screening of youngsters in sport is one which attracts much discussion. A variety of anatomical abnormalities may develop largely unnoticed to the layperson. However, these can often be readily identified by the sports medicine practitioner with a series of annual screening tests. Posture, flexibility and strength can all be measured using fairly simple field tests. These can be incorporated into a training session and educational period for youngsters, at the beginning of a season.
Pre-season screening may involve tests of a number of measures (Table 6.6). Tests should be performed 6–8 weeks prior to competition to allow for the effects of training to take place. In addition, pre-event screening should be performed to assess a player’s suitability to compete.
First aid treatment marks the beginning of the rehabilitation process. Correct management at this stage can reduce the severity of an injury and so shorten the time an athlete is away from sport. More importantly, effective first aid can save lives. In this section, a number of first aid methods relevant to the injured sportsperson are described. All therapists involved with sports injuries management are recommended to obtain certification in cardiopulmonary resuscitation (CPR) and basic first aid.
The unconscious athlete
Unconsciousness is the result of an interruption of normal brain activity. In sport this may be a result of both head injury and sport concussion.
The first international conference on concussion in sport defined sports concussion as ‘a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces’ (Aubrey et al., 2002).
Concussion occurs when the brain is rapidly ‘shaken’, and the condition can be present even though the patient is still conscious. Often, the period of unconsciousness is so brief that it may go unnoticed, and there is only transient memory loss. This is frequently the case with contact injuries where an athlete collides with another and hits his or her head. Clinically concussion may occur from a direct blow to the head or from impulsive force which is transmitted to the head from other regions of the body. There is an impairment of neurological function which is short lived and resolves spontaneously. In sport concussion there is a functional disturbance rather than structural damage and as such neuroimaging is normal (McCrory et al., 2005).
Concussion classification and evaluation
Sport concussion may be classified as simple or complex. Simple concussion is the most common type and this typically resolves without complication in 7−10 days. Formal neurophysiological screening is not normally required but medical evaluation should still be made. Training and playing are limited while the player is symptomatic, and return to sport is graded. Complex concussion is present when symptoms persist or recur, and this grouping includes those who suffer a number of concussions over time. Such symptoms include convulsions, prolonged loss of consciousness (greater than 1 minute) or prolonged cognitive impairment. Symptoms may be seen at rest or with exertion. Formal neurophysiological assessment is normally required.
Simple concussion resolves without complication over 7−10 days. Complex concussion has persistent symptoms (>10 days) at rest or with exertion.
The Glasgow Coma Scale (see below) is traditionally used to assess head injury. However, due to the mild nature of sport concussion this type of scale is no longer considered an appropriate evaluation measure for sport concussion (McCrory et al., 2005). A sport concussion assessment tool (SCAT) was developed at the International Conference on Concussion in Sport, Prague 2004, and updated at the Zurich Conference 2008 (McCrory et al., 2009). Two forms are available, the Pocket SCAT2 (Table 6.7) for general usage and the full SCAT2 for medical and health professionals.
The Pocket SCAT2 consists of three sections: (1) symptoms, (2) memory function and (3) balance testing, which enable the examiner to determine if concussion is suggested. If the test is positive (concussion suggested) the athlete should be immediately removed from play and medical assessment made.
Where concussion is suspected the athlete should be immediately removed from play and medical assessment made.
For the full SCAT 2 (http://www.sportalliance.com/Images/Sport%20Safety/SCAT2.pdf) the medical or health professional assesses the patient over eight domains which are colour coded for ease. The scores obtained on these domains are put together to give an overall score, and normative data for this score are developed. The SCAT2 domains are:
The final section of the SCAT2 gives athlete information with recommendations for a graded return to play (see Table 6.8). Concussion injury advice is presented as a cut-off section to be given to the concussed athlete. The SCAT2 documents are available on several websites. The full version is available at http://bjsm.bmj.com/cgi/reprint/43/Suppl_1/i85. The pocket SCAT2 is available at http://www.sarugby.co.za/boksmart/pdf/PocketSCAT2%20final.pdf.
Each stage should last for 24 hours or longer. Athlete returns to previous stage if symptoms recur.
Modified from McCroy et al. (2009).
To form a baseline assessment the SCAT2 should be given to each athlete at the beginning of the season and results recorded for normal activity.
Multiple concussion incidents
The cumulative effects of concussion are important in sports such as boxing, steeplechase and football (Corsellis, 1974; Sortland, Tysvaer and Storli, 1989; McLatchie, 1993). EEG disturbances due to neuronal damage through repeated trauma are seen, especially where a series of EEGs are performed. In addition, neuropsychological performance is impaired, often in the presence of a normal CT scan (McLatchie, Brooks and Galbraith, 1987).
Failure to allow adequate recovery from a concussion incident may result in second impact syndrome (SIS), where a second blow to the head causes further swelling and bleeding. The second blow may be minor and may not appear sufficient to affect the brain. However, the two combined insults cause rapid and profuse swelling. Athletes usually develop respiratory failure and collapse. The mortality rate for this condition is as high as 50% (Cantu, 1998).
Second impact syndrome occurs when a second blow is received before the effects of the first concussion have worn off. Massive swelling develops in the brain, the athlete collapses and may go into respiratory failure. The syndrome is often fatal.
Because of the risk of persistent swelling or late bleeding, the return to sport should be delayed following multiple concussion. All athletes sustaining this type of injury should be given a head injury advice card (Table 6.9). Medical examination is essential where there is a failure to remember the event which gave the head injury however minor it may seem. All cases where consciousness has been lost for longer than 3 minutes warrant x-rays of the skull and cervical spine and/or neuroimaging (Buxton and Firth, 1999).
Becomes drowsy or difficult to rouse
The danger from any head injury is an expanding intracranial lesion resulting from a torn blood vessel, causing epidural (extradural) haemorrhage, subarachnoid haemorrhage or subdural haematoma (Fig. 6.1), so assessment is vital.
The brain has three covering membranes called (from inner to outer) the pia, arachnoid and dura mater. Epidural haemorrhage is bleeding between the skull and the dura mater. Subdural haemorrhage is bleeding between the arachnoid and dura mater. A subarachnoid haemorrhage is bleeding between the pia and arachnoid mater.
These conditions are indicated by an alteration in consciousness (lucid state) and the signs and symptoms shown in Table 6.10. Normally, the intracranial pressure is 4–15 mmHg and an intracranial pressure of 40 mmHg will cause neurological impairment.
After Magee (2002).
After such an incident, an athlete should only be allowed to continue providing he or she did not lose consciousness. Tests such as the ability to stand up without assistance, stand alone with eyes closed and run to a mark and change direction rapidly are all useful for initial assessment.
The first decision to be made with an unconscious athlete is whether he or she is still breathing. If not, resuscitation must be started immediately. If the athlete regains consciousness, the level of potential damage should be assessed. Response of the eyes, body movements and speech all give clues to the level of consciousness, and the Glasgow Coma Scale is the standard examination method.
The Glasgow Coma Scale
The Glasgow Coma Scale (Teasdale and Jennett, 1974) is a series of tests that are given a numerical value which can then be used to objectify an athlete’s state of consciousness (Table 6.11). The scale also forms domain 3 of the SCAT2 evaluation. The first test relates to the eyes, and determines whether the athlete opens the eyes spontaneously or in response to sound (verbal command) or pain. Opening the eyes to verbal command merely means that the person has registered sound; it does not imply that they necessarily understand the command. The second test is of verbal response, and assesses the athlete’s reaction to simple questions such as ‘where are you’ or ‘what is your name’. The test assesses whether the athlete is aware of him/herself and the environment. The third test is of motor response. The maximum score is 6 if the athlete is able to perform actions correctly to verbal commands such as ‘move your arm’. If the athlete fails to respond, a painful stimulus is applied by the practitioner pressing their knuckles into the athlete’s sternum, or pressing the athlete’s fingers together around a pen. Painful stimuli to the face or palm of the hands should be avoided as these can give reflex eye closing and hand closing respectively (Magee, 2002). Where reflex responses alone result, flexion of the arms and hands together with adduction of the upper limb and extension of the lower limb with plantarflexion of the feet (decorticate posturing) indicates a lesion above the red nucleus. Extension of the arms with pronation of the forearm (decerebrate posturing) indicates a lesion of the brainstem. The time of the test should be noted and the test repeated every 15–30 minutes to note any degeneration of results.
|Eye opening||Spontaneous eye opening||4|
|Eyes open to command||3|
|Eyes open to pain||2|
|No eye opening||1|
|Verbal response||Coherent appropriate response||5|
|Coherent but inappropriate response||4|
|Non-speech noises (moans and groans)||2|
|Motor response||Obeys commands||6|
|Localizing purposeful response to pain||5|
|Non-localizing purposeful withdrawal from pain||4|
|Reflex flexion to pain (arm, decorticate posturing)||3|
|Reflex extension to pain (arm, decerebrate posturing)||2|
|No motor response||1|
Where the score is between 3 and 8 on the coma scale, emergency care is required immediately as a severe head injury is present. Those with scores of 9–11 are considered to have a moderate head injury, and those with a score of 12 or higher are considered to have a mild head injury.
Caution must always be exercised with head injuries. Unfortunately, the practitioner or coach who has to decide whether to allow an athlete to continue playing has no way of knowing if secondary brain damage is going to develop. At the time of injury, bleeding may have occurred which could accumulate and give rise to a subdural haematoma.
An athlete who remains unconscious should be placed in the recovery position until an ambulance is available to take him or her to hospital. If there is bleeding or discharge from an ear, the athlete should be turned so that the affected ear is dependent. Nothing should be given by mouth, and the athlete should not be left unattended. Testing for responses should continue regularly (every 10 minutes or more frequently) and any changes in the athlete’s condition should be recorded.
Epilepsy is due to a disturbance in the electrical activity in the brain. There are two major types, convulsions or generalized seizures (grand mal) and absence seizures (petit mal). In a grand mal attack the person loses consciousness, begins to convulse, and the back may arch into extension. Rigidity may last for a few seconds and cyanosis of the mouth and lips can occur. Fitting athletes should be protected by clearing a space around them. Any tight clothing around the neck should be loosened, and something soft placed under the head.
No attempt should be made to move or restrain the fitting athlete, and nothing should be given by mouth until there is full recovery. No object should be placed in the mouth, as the athlete may choke. In addition, it has been known for an epileptic to break a tooth in this way and inhale it.
Absence seizures (petit mal) may also occur, particularly in young athletes. In these cases the person appears to suddenly go distant or ‘switch off’. There may be slight twitching of the eyelids or lips. Again, clear a space and remove any potentially dangerous items such as hot drinks or sharp objects. Give reassurance and, if the person is unaware of their condition, ensure that they seek medical advice.
In diabetes mellitus, both hyperglycaemia and hypoglycaemia may give rise to unconsciousness. Hyperglycaemia usually develops gradually and so is rarely a first aid problem.
With intense unaccustomed exercise, the blood sugar level may fall, and hypoglycaemia can then result. An athlete may initially feel faint, dizzy or light-headed, and may be confused or disorientated. The skin becomes pale, the pulse rapid, and sweating occurs. Breathing often becomes shallow, and muscle tremor may be apparent. The level of consciousness drops rapidly.
If the athlete is conscious, a rapidly metabolized sugar (glucose tablet, sugary drink, or glucose gel) will help, together with some slowly absorbed carbohydrate (bread) to prevent recurrent blood glucose fall. If the athlete is unconscious, nothing should be given and hospital treatment should be sought as a glucagon injection may be required.
If the coma is due to hypoglycaemia, the response to sugar is usually rapid and the danger of secondary symptoms is averted. If hyperglycaemic coma is present, slightly more sugar will not harm the patient (Sperryn, 1985).
Where someone collapses and it is not known whether they have simply fainted or are hypoglycaemic, a glucometer may be used. This measures the blood sugar level from a finger pinprick. Normal blood sugar values are in the region of 4–7 mmol/litre. A reading of 1–2 mmol/litre indicates a possible hypoglycaemic state.
Glucagon is a hormone secreted by the pancreas which increases blood glucose levels. A glucometer is a battery-operated blood sugar meter which uses a finger pinprick drop of blood.