Incidence of Exertional Heat Stroke
Despite recent changes in policies regarding preseason heat acclimatization for NCAA and secondary school athletics, there has been an unfortunate increase in sport-related EHS fatalities. In the past 60 years, there have been 127 recorded deaths from EHS according to the National Center for Catastrophic Sport Injury Research.26,27 More alarming than this average of just more than 2/year is that there were 12 EHS fatalities between 2005 and 2009. Since 1990, the incidence of EHS fatality was 0.16/100,000 participants, represented by 30 high school and 8 collegiate deaths.
Analysis of EHS fatalities has produced moderate associations with certain risk factors. An important note about EHS is that individual risk factors compound environmental risk factors. Extremes of temperature and humidity contribute largely to EHS onset.28 Preseason or early portions of a season account for almost all EHS fatalities, and only one fatality was a result of game participation. Eighty-three percent of these occurred during multiple practice days, and 44% occurred on the initial day of activity.26
The most recent NATA Position Statement on Exertional Heat Illnesses29 suggests that a thorough preparticipation evaluation should include a risk assessment of EHS. However, little evidence suggests that EHS risk can be identified during a screening. Most risk factors for EHS are transient, such as hydration status, presence of an illness, sleep loss, and psychological stress (Table 7-1). However, when combined, the risk factors exacerbate each other and increase EHS risk. For example, an athlete who is unacclimatized to the heat and is psychologically stressed is at risk for EHS. However, an athlete who has not gotten sleep, has an upper respiratory infection, is dehydrated, and is overzealous, combined with the lack of acclimatization and personal stress, is at much greater risk. EHS normally occurs when a myriad of predispositions contribute to the onset. Table 7-1 is an updated list of risk factors for EHS.29
One important consideration for EHS risk is the fact that extrinsic and intrinsic factors are involved. Table 7-1 is separated into these categories for clear representation of these factors. Steps should be taken to prevent each factor individually. Intrinsic factors can be addressed with education (eg, teaching athletes and coaches the importance of hydration and that regular water breaks aid in preventing dehydration and EHS).8,29 Athletes should know how to self-check their hydration status and, perhaps, their sweat rate. When athletes are educated on these factors, there is little excuse for athletes to report to activity in a hypohydrated state. If they do, the athletic trainer and coaches should be on the same page in terms of limiting activity on that day or for that particular session. Athletic trainers and coaches should agree that one activity session or practice will not be responsible for the outcome of a season and that the medical best interest of student-athletes should pervade.
Prevention of Exertional Heat Stroke
The responsibility of establishing and following preventive measures for extrinsic risk factors falls on coaches or athletic activity associations. The most effective method to reduce the incidence of EHS is to mandate heat acclimatization for every athlete.29,30 For example, a state secondary school athletic association should mandate that preseason practices include gradual increase in duration, intensity, and amount of equipment worn. Furthermore, when more than one practice is held within a day, they must be separated by at least 4 hours.30 It is up to the coaching staff and athletic trainer to ensure that good practices are in place prior to the season and that they are followed. When athletic associations establish guidelines, it is important that they regard all potential extrinsic EHS risk factors as important. This will foster a safer environment for all athletes during participation.
True prevention of EHS is difficult to gauge. Sports medicine professionals need to improve injury and outcome documentation. In terms of all heat illnesses, the NCAA’s online injury reporting system has improved reporting. Now that research has been published on incidence and prevalence of heat illness during athletic activity, there is a starting point. From this baseline, continual tracking of pathology will determine whether prevention measures are effective. Military branches have good data on prevalence and preventive strategies. However, the military data show almost no trends in prevention despite strict and consistent measures implemented.31 One of the major detriments to EHS research is the inadequate reporting and records of EHS cases. Cases of EHS are mostly known when they end in death. However, if a patient is treated appropriately and he or she survives, it often gets documented as severe heat exhaustion. Research is steadily increasing for the incidence and prevention of heat illness.
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Catastrophic Head and Spine Injuries
Injuries affecting the head and spine are inherent risks during collision sport participation, especially in American football, rugby, and ice hockey. Also, in activities such as cheerleading, diving, and gymnastics where athletes are airborne before contacting other athletes, equipment or surfaces increase potential head and spine trauma. American football has received the most attention in relation to concussion and the long-term effects of repeated blows to the head. The discussion here focuses on the incidence of sport-related head fatalities and catastrophic (fatal cases and career-ending injuries) spinal injuries. The incidence, mechanisms, and risk factors for concussion have been described in Post 6.
Determining rates of head and spine injuries is essential for keeping athletes safe during sport participation. More importantly, data after prevention strategies have been implemented provide the best evidence for preventing these injuries. For example, a rule change, such as the spearing rule in American football in 1976, should be analyzed to determine its effect on sport safety. Pre- and postinjury rates and the odds of injury at various levels of sport (high school, college, professional) are more important to have.
Monitoring head and spine injury data can demonstrate the effectiveness of prevention strategies. The best example of how surveillance data have been used as a prevention strategy to reduce the risk of head and spine injuries comes from American football. The National Football Head and Neck Injury Registry has tracked head and neck injuries since the 1950s. Prior to the 1970s, many catastrophic injuries in football involved head injuries due to the limited protection that the helmet provided. When helmets were modernized in 1970, there was a large increase in cervical neck injuries directly related to athletes using the crown of their helmet to tackle opponents. Rules prohibiting spearing in 1975 drastically reduced the number of cervical spine injuries, and injuries were further reduced in the mid-2000s with an additional rule change that removed the word intentional before spearing to include any form of spearing. The magnitude in which catastrophic cervical spine injuries were reduced after intentional spearing was banned is roughly 80%.32 In 1976, there were 34 incidents causing quadriplegia. That was reduced to 10/year in the 1980s and then 6/year in the 1990s.33
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