Injury Prevention in Youth Sports: What Works, What Doesn’t and What’s Next February 10, 2012

1. 40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM) Injury Prevention in Youth Sports: What Works, What Doesn’t and What’s NextFebruary 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation Assistant Professor of Pediatrics Vanderbilt University Medical Center Co-Chair, Youth Sports Safety Taskforce Team Physician Vanderbilt & Belmont Universities Nashville Sounds & Nashville Predators

2. Disclosures • NO commercial relationships • Research & Educational funding • NIH U54 Institutional Clinical & Translational Science Award

3. Objectives Review basic principles of injury prevention Introduce key youth sports safety topics Discuss strategies to prevent injuries in young athletes Empower you to create a safer sporting environment and culture for youth athletes

4. Injury Prevention is a Team Sport

5. Injury Prevention 101

6. Courtesy: Safe Kids USA & AOSSM Youth Sports: What We Know The Facts… • More than 38 million children and adolescents participate in organized sports in the U.S. each year. • Another 10 million in some form of athletics • Estimated 3.5 million children under age 14 receive medical treatment for a sports-related injury each year. • HS athletes account for additional 2 million injuries / 500,000 doctor visits / 30,000 hospitalization

7. ER Data: Sports & Recreation • Leading cause of presentation for injury among adolescents • Emery CA. Epi Ped Sport Injur, 2005. • CDC data (Gilchrist J et al. MMWR, 2007.) • 2.4 million visits/yr (age 5-18) • 29% of all unintentional injury visits • 48% of injuries that require hospitalization or transfer involve age 5-18 • NSW population health survey showed only 8.9% of sports injuries treated in hospital setting. • Mitchell R. J Sci Med Sport, 2010.

8. By the Numbers AOSSM 2009 Annual Meeting Pre-Conference Program. • Injury reported during sport among athletes age 5-14 • 28% of football players • 25% of baseball players • 22% of soccer players • 15% of basketball players • 12% of softball players • Canadian study = more than 1 in 3 adolescents seek medical attention from a sport injury every year • Emery CA. CJSM, 2006.

9. Public Health Relevance:Sports Matter for (and to) Kids • Physical activity effects morbidity & mortality • Physical activity patterns track from childhood  adolesc  adulthood • Injury is potential barrier to physical activity • 8% of adolescents drop out of sporting activities/yr due to injury • Grimmer KA et al. J Adolesc Health, 2000. • Leading risk for OA development • Injury Cost Model of the U.S. CPSC (2003) • $588 million in direct expenses and $6.6 billion in indirect expenses from injuries in the top five female and male HS sports

10. Public Health Relevance:We Can Make a Difference • Injury often predictable and preventable, not just “accidents” • As many as half the injuries sustained by youth while playing sports are likely preventable

11. Emery CA et al. CJSM, 2006. Safety cannot be delegated, it is a shared responsibility of… • Parents • Coaches • Youth athletes • Safety advocates • Athletic trainers • Schools • Health professionals

12. Prevention Responsibility & Child Development • Perceptual & cognitive status • Identify fewer hazards and do so more slowly • Age ≤ 10 (pedestrian data) • Overestimate physical abilities • Lack of understanding for consequences • Sense of invulnerability • Low level perceived risk + over-estimation ability = signif injury risk increase (age 11-14  OR 3.77-7.92) • Kontos AP. J Ped Psych, 2004.

13. Approaches To Prevention Clinical Care Research

14. Klugl M et al. CJSM, 2010. Sport Injury Prevention Literature Status • ~ 12,000 published articles on sports injury prevention since 1938 • < 50% of the 12K were original research • Most were incidence & etiology studies • Only 492 actually evaluated efficacy or effectiveness of interventions to prevent injury • Regulatory change rarely evaluated

15. Risk Factors for Sports Injury

16. Bahr R et al. BJSM, 2005.

17. Emery CA. Risk Factors for Injury in Child and Adolescent Sport: A Systematic Review of the Literature. CJSM, 2003. (LOE 2-4) Risk Factor Findings • Non-Modifiable • Sex: Males (OR 1.16-2.4) • Exception: soccer, basketball • Previous injury • Reinjury rates 13.1%-38% • Fball (reinjuryvs 1st time injury: RR 1.4-1.7) • Sport Played • Boys: hockey, football, basketball • Girls: gymnastics, basketball, soccer • Age: Older • Level of play: Increasing • Organized vs rec, game vs practice, playoff vs regular season

18. Best Practice for Community and School Teams

19. Key Sports Safety Topics CONCUSSION

20. Concussion Numbers • 1.6-3.8 million sports-related concussions/yr • CDC MMWR, July 2007. • From 2001 to 2009, the number of sports and recreation-related ED visits for TBI among persons aged ≤19 years increased 62% • CDC MMWR, October 2011. • TBI represents almost 9% of all injuries reported in HS sports • National surveillance in 9 high school sports • Gessel LM et al. J Athl Train, 2007.

21. Concussion Prevention: Equipment Football Helmets Mouth Guards Head Gear

22. Football Helmet Ratings: STAR Evaluation System Virginia Tech National Impact Database. May 2011. • 5 Stars • Riddell Revolution Speed • 4 Stars • Schutt ION 4D • Schutt DNA Pro + • Xenith X1 • Ridell Revolution • Riddell Revolution IQ • 3 Stars • Schutt Air XP • 2 Stars • Schutt Air Advantage • 1 Star • Riddell VSR4 • 0 Stars • Adams A2000 Pro Elite Reduction in concussion risk

23. Mouth Guards • Effects of mouth guards on dental injuries and concussion in college basketball. • Labella et al. MSSE, 2002. (LOE 2) • Findings: • No difference in concussion rate • Significantly lower rate of dental trauma

24. Head Gear in Soccer • Withnall et al. BJSM, 2005. • Three equipment types tested • No attenuation of mechanical forces due to heading ball • 33% reduction in acceleration forces from direct head-to-head contact • Further evidence needed for effect on injury or concussion prevention

25. Navarro RR. Curr Sports Med Reports, 2011.

26. McIntosh AS et al. BJSM, 2011. Summary of Helmet Benefits in Sports

27. Heading in Soccer • Straume-Naesheime et al. Br J Sports Med, 2005. (LOE 3) • Norwegian elite footballers • Computerized neuropsychological testing • Conclusion: • No evidence of impairment due to heading exposure or previous concussions

28. Courtesy: Julie Gilchrist, MD, FAAP CDR, US Public Health Service Division of Unintentional Injury Prevention CDC’s “Heads Up” Initiative Goal: Improve prevention, recognition, and response to concussion among young athletes

29. Targeting Youth Sports “Heads Up: Concussion in Youth Sports” • 2007 • 26 member partnership • Target = volunteers, parents • Content: • Audience ready & appropriate • Fact sheets for coaches, parents, and athletes • Clipboard • Magnet • Poster • Concussion quiz

30. CDC Unpublished Data Evaluation: Youth Sports Toolkit • Changed knowledge, attitudes, behavior • 63% viewed concussion more seriously • 77% reported more skill in indentifying potential concussions • 72% educated others: athletes, parents, other coaches

31. YOUTH SPORTS LEGISLATION: CONCUSSION

32. Youth Sports Safety Legislation:National Level • Children’s Sports Athletic Equipment Safety Act (HR 1127) • Latest Major Action: 3/28/11 • Encourage and ensure use of safe football helmets. • Protecting Student Athletes From Concussions Act of 2011 (HR 469) • Latest Major Action: 2/25/2011 • Regulations establishing minimum requirements for prevention and treatment of concussions.

33. http://nflhealthandsafety.com/ Youth Sports Safety Legislation: State-Level As of October 2011, 31 states (plus D.C. & the city of Chicago) have enacted youth concussion laws

34. Key Sports Safety Topics OVERUSE INJURIES

35. Overuse Injuries • Why is it happening more often? • Sports specialization at younger ages • Intense year round competition and practice • Growing bodies more susceptible to injury • Parental and coaching pressure and unrealistic expectations • Super competitive youth sports culture

36. Overuse: Prevention Strategies • Activity modification • Avoid playing for multiple teams at same time • 1-2 days/wk off from competitive sport or training • 2-3 months/yr away from same sport • Incorporate cross training • 10% Rule: Maximum 10% increase in training program variables/week

37. “BURNOUT” Parents and Coaches Beware! • 70% of kids participating in sports drop out by age 13 • Lose benefits that sports provide • Overtraining syndrome • Series of psychological, physiologic, and hormonal changes that result in decreased sports performance

38. NCAA Research. Updated September 27, 2011. Estimated Probability of Competing in AthleticsBeyond High School

39. AAP COSMF & COSH. Pediatrics, 2001. Organized Sports Participation Factors Encourage & Maintain Discourage Failure Embarrassment Competition Boredom Regimentation Injuries • Fun • Success • Variety • Freedom • Family participation • Peer support • Enthusiastic leadership

40. SPECIFIC PREVENTION STRATEGIES

41. Educational Programs & Rule Changes • Adherence to rules & limit illegal play • 6.4% of overall injuries in 9 HS sports were related to rules transgressions (98,066 injuries/yr) • Collins CL et al. Inj Prev, 2008. (RIO) • Teaching proper fundamentals & technique • Tackle with head up (↓head/neck trauma) • Educational & Awareness campaigns • Improved knowledge & attitudes, outcome data sparse on injury reduction

42. Protective Equipment • Eye goggles (lacrosse) – ↓incidence of head & face injury (RR 0.52) • Webster et al. MSSE, 1999. • Knee pads – ↓ incidence of knee injuries (RR 0.44) • Yang et al. Am J Epi, 2005. • Knee braces – no protective effect (RR 2.24) • Grace et al. JBJS (Am), 1988. • Contradictory evidence (MCL, ACL, ↑LE injury)

43. Lace-Up Ankle Braces • McGuine TA et al. AJSM, 2011 (LOE 1) • HS Football & Basketball (M & W) • Lower incidence of acute ankle injuries • Degree of severity unchanged • No effect on other LE injuries • Benefit for both 1st time & prior sprain • Findings independent of shoe type, taping, field surface

44. Proprioception & Ankle Sprains • McGuine T et al. AJSM, 2006. • Injury rate • 6.1% balance training program vs 9.9% control • 50% risk reduction if prior sprain & perform intervention

45. Abernethy L et al. BJSM, 2007. Neuromuscular Prevention Strategies • Systematic review (12 studies; RCT/controlled intervention studies) • Effective in reducing knee & ankle injuries • Preseason conditioning • Functional & sport-specific training • Proprioceptive balance training • Structured warm-up (strengthening, stretching, plyometrics, sport-specific agility, +/- education) • Optimized when sustained during sporting season (RR 0.2-0.73) • NNT: 4-10 for minor/moderate injuries; -66 for serious injury (ACL) • Not Effective • Stretching alone; stretching + warm-up & cool-down • No difference in timing of program (pregame, halftime, etc)

46. Neuromuscular Interventions • Hewett TE et al. AJSM, 2006. • Meta-analysis 6 studies • Neuromuscular training programs may reduce risk of ACL injury in female athletes • Encourage use of training programs that also emphasize performance enhancement as means to motivate compliance • Increased program effectiveness in athletes

47. Neuromuscular Training Programs • Contradictory findings regarding improvements on performance • Lindblom et al. Knee Surg Sports Trauma Arthrosc, 2011.

48. SPORT SPECIFIC STRATEGIES

49. Baseball • Safety balls • Reduced risk of ball-related head & body injury by 23% • Marshall SW et al. JAMA, 2003. • Mixed findings Re: commotio cordis • Chest protectors • No risk reduction of commotio cordis evident • Viano DC et al. J Trauma, 2000. • Sliding • Proper technique & timing • Break-away bases • Hosey RG et al. AJSM, 2000. • Faceguards • Risk reduction of oculofacial injury by 35% • Danis RP et al. Inj Prev, 2000.

50. Olsen SJ et al. AJSM, 2006. (LOE 3) Overuse Injury: Baseball • Pitchers with history of significant shoulder or elbow injury were more likely than uninjured counterparts to have… • Pitched more months per year, more innings per year, more pitches per game and more pitches per year. • Participated in showcases and pitched through arm pain or fatigue.