Cheerleading and Catastrophic Injuries

"Cheerleaders incur two-thirds of all catastrophic injuries to female athletes in high school and college. According to the National Electronic Injury Surveillance Survey, emergency room visits increased110 percent from 1990 to 2002. In 2007 alone almost 27,000 cheerleaders ended up in the ER, one in six for head or neck injuries" Those are quite the statistics and certainly cause for concern. These statistics are from the Catastrophic Sport Injury Research 28th Annual Report 2010 by Dr. Frederick O. Mueller of the National Center for Catastrophic Sport Injury Research. Too often athletic trainers look upon cheerleaders as a nuisance.  They are not considered a sport by various governing bodies so therefore they are treated differently in regards to physicals, athletic trainer access, and practice coverage. We never see them until an injury occurs which usually happens at the same time we are covering another contest. They become a distraction from our main duty and we sometime resent them for it. This does not change the fact the fact that it is a dangerous sport/activity (you decide). The federal government does not consider cheerleading a sport for purposes of Title IX. Cheerleading has evolved from the sideline cheer to a variety of gymnastics and dance routines, and sometimes all choreographed to music.

Dr. Mueller makes some recommendations in his report:

1. Cheerleaders should have medical examinations before they are allowed to participate.Included would be a complete medical history.

2. Cheerleaders should be trained by a qualified coach with training in gymnastics and partner stunting. This person should also be trained in the proper methods for spotting and other safety factors.

3. Cheerleaders should be exposed to proper conditioning programs and trained in proper spotting techniques.

4. Cheerleaders should receive proper training before attempting gymnastic and partner type stunts and should not attempt stunts they are not capable of completing. A qualification system demonstrating mastery of stunts is recommended.

5. Coaches should supervise all practice sessions in a safe facility.

6. Mini-trampolines and flips or falls off of pyramids and shoulders should be prohibited.

7. Pyramids over two high should not be performed. Two high pyramids should not be performed without mats and other safety precautions.

8. If it is not possible to have a physician or certified athletic trainer at games and practice sessions, emergency procedures must be provided. The emergency procedure should be in writing and available to all staff and athletes.

9. There should be continued research concerning safety in cheerleading.

10. Cheerleading coaches should follow the concussion policy and guidelines published by the NFHS.

11. Cheerleading coaches should have some type of safety certification.

12. The NFHS should make cheerleading a sport, which will place cheerleading under the same restrictions and safety rules as all other high school sports (physical exams, qualified coaches, safe facility, athletic trainers, practice limits, and starting and ending dates for practice and games or competitions). The NCAA should follow this same recommendation.

As Health Care providers we need to look past our own personal prejudices and accept the fact that cheerleading is dangerous and we may be called upon to deal with injuries ranging from serious to catastrophic. The best route is to be proactive in regards to yours and your schools administration of the sport. They should be treated the same as any other sport.  Physicals should be mandatory, access to the athletic training room should be no different than it is for any other athlete, they should be included on the athletic insurance policy, and practice coverage extended to them. Cheerleading coaches should be qualified and safety certified.  This they can do through the American Association of Cheerleading Coaches and Administrators  (AACCA). It is not a governing body as much as it is a business entity promoting the sport.  Even though, they do have an interest in keeping cheerleading as safe as possible. Take a look at their Safety Rules. Guidelines that any school would be smart to implement.

The best course to follow in reducing these serious injuries in Cheerleading is to have coaches that are properly trained, have safety guidelines installed, and have access to the health care that there athletes deserve.

Software you can use

You could write a book on all the different software programs out there that can be of use to the athletic trainer.  I am just going to cover a few that I use on a routine basis.

The first is PDFcreator. It is an open source program, which means it is a program that usually has been collaboratively developed and released to the public free of charge for use and personal modification.  If you do not have Adobe Acrobat, (not the reader version which is free) to turn any file into a pdf you can install PDFcreator and it will show up as another selection in your printer list.  Print the file to PDFcreator and you have your pdf file.  You can also combine different pdf files into one file.

A utility that I find indispensable is CCleaner.   CCleaner use to be called Crap Cleaner until they changed the name. A quote from the CCleaner website explains the software.

"CCleaner is our system optimization, privacy and cleaning tool. It removes unused files from your system - allowing Windows to run faster and freeing up valuable hard disk space. It also cleans traces of your online activities such as your Internet history. Additionally it contains a fully featured registry cleaner."

The files that it removes are not integral to your computers working.  More than likely it will speed up your computer.  When you surf the web a lot you will accumulate all kinds tracking cookies.  These cookies communicate back to their source bits of information.  If you have enough of them your computer slows down as the amount of communication increase. It also empties your temporary internet files.  If you surf a lot this can up to gigabytes of data.

The ability to remotely log into you computer remotely from another computer is a godsend. I have two offices at my school and thereby two computers.  I also have one at home along with a laptop. Windows has a program called remote desktop connection. It can be found under Program -- Accessories -- Remote Desktop Connection.  With this program I have the ability to log onto any of my computers as long as they are turned on and have an internet connection.  I can continue to work on a project that I started on one of my office computers or email myself a file.  You can use this program from any Windows computer as long as you know the remote IP address of the computer you want to remote on to.  You may need to get your ITech people to help you set this up. There are limitations to this program, see this microsoft link. You can find your computers IP address by simply going to the website "whatismyipaddress".

If that does not work for you then try Team Viewer. This is another remote access program that is free to use as long as it is not used for commercial use.  This program allows you to do much more.  You can transfer files back forth between computers, do voice and video over the internet, and even do a remote reboot and be able to log back on.  I do not use this for work but do use it to remote into my parents computer and while talking with them over the phone correct any issues they may be having.  Both computers must have the software installed and the remote computer must be on and connected to the internet.

The last program I will speak about is YouTube Downloader. This program allows you to download You Tube videos and many other video sites by pasting the URL into the programs download box.  It will automatically download the video into a .flv (flash video file) The program then gives you the option of converting that file into a number of different video formats.  These include MOV, WMV, AVI and MPEG-4.  You can also convert just the soundtrack to a .MP3 file. This is great if you are looking for videos for a PowerPoint.  You can also use the converter by itself to convert videos you already have to another format.

Athletic Training Room Design Resources

Most every athletic trainer has had to design an athletic training room at some point. Many of us have had to do this as class project along with a budget.  Some of us have had the opportunity to be involved in the design and construction of a new facility.  I would like to offer a couple of resources for the budding architect to consider.  The final result will look much better than the pencil and graph paper drawings.

The first resources is a website called www.floorplanner.com It is  very easy and intuitive to work with. You design your layout directly on the webpage.  Set the dimensions, wall thickness, windows and doors. It even offers small images of furniture to place in the layout.  You can make a simple table re-dimesioned to stand for a treatment table.  Install a sink, desk, and chairs.  There is even some images of exercise equipment.  You may have to get imaginative to place whirlpools, ice machines and rehab equipment.  For that you can insert a text description. A great resources for student projects or for the AT who like to visualize their ideas.  Floorplanner is free for one user and one project.  Up to five projects a year will cost you $14.95.

Another resource for the more serious user is Home Plan Pro.  With a much steeper learning curve it is free fro the first 30 days.  Beyond that it costs a one time fee of $39.00. The steeper learning curve allows you design in more detail.  You also have many more figures to choose from.  I purchased this product 15 years ago and have had free updates ever since.  I have used it to design remodels to three separate facilities.  I could make different layouts and have staff discussions on which one would work best.  One of the really nice features is the ability to create your own figures.  You can then insert that figure into the layout and it will be the correct dimensions for the room. Here is an example of a layout that I created sometime ago.

Within the drawing are a number of ready made figures such as the desks, chairs, and counters.  For specific athletic training equipment I created clip files.  Clip files are just smaller drawings placed within the larger design layout. Examples are below:

The item on the left is a taping unit.  The items on the right are three separate files.  A treatment table, a modality cart, and a split leg table.  I can mix and match these figures as I need.  They are also drawn to the dimensions of the actual items. If anyone is serious about using this program you can email me and I will send you the clip files I have already created.  This will save you a lot of work.

Feel free to go online and explore these programs.  You may find them very useful either now or in the future.

Joe Paterno's firing, a good thing for Athletic Training?

Joe Paterno the legendary coach at Penn State University was recently fired because of a sexual abuse scandal.   I am not going to talk about the scandal as it is being covering in intimate detail throughout the country by a  legion of writers. I do want to address a little know fact about Penn State Football and the profession of athletic training. You can turn on a college football game being played anywhere in the country and if you watch the sidelines close enough you are bound to see either female athletic training students, female certified athletic trainers or both working the game. This is pretty much a given. If you do not, it most likely a military academy or a school that just does not have an athletic training program. Even many schools without programs have females enlisted to help the certified athletic trainers. This is not the case at Penn State. If you watch their sideline you will not see any female athletic training students nor male student athletic trainers. This is not because Penn State does not have a program. They do.

At one time male athletic training students worked with the football team. Unfortunately, Joe Paterno did not allow females to work during the season. He did allow a limited number of females to work spring football.  This was only after he personally interviewed and approved them. One time Athletic Training Program Director, Craig Denegar decided that this was not a very fair arrangement. In a meeting with Coach Paterno, Mr. Denegar tried to convince him to allow females the same opportunity as the males. Coach Paterno refused.  Sticking to his principles Mr. Denegar had no choice but to withdraw all  athletic training students from a clinical rotation with Penn State football. The football team scrambled and filled the lose of student with graduate assistant athletic trainers.

Coach Paterno's reason for denying females an opportunity was because he did not want to offend their sensibilities with the kind of language that can be heard on a football field. It is a shame he did not share that  protective attitude when it came to young boys.

Gear Review - Rescue Hooks

While these product have been in use in the military and emergency setting in the past they were only introduced at the 2010 National Athletic Trainers' Association Convention.  These knives were developed to cut clothing, shoes, seat belts, etc. in emergency situations.  The Benchmade Knife Co. exhibited these to athletic trainers as a different tool to remove tape and in worse case scenarios to remove clothing in an expedient manner.

I had a chance to evaluate these products at the exhibits and actually purchased one.  The one I choose is the Houdini Pro which which works like a pocketknife.   The hook blade folds out of the way. It also has a LED  light and a spring loaded glass punch for breaking glass.  While my need to break glass is not something I have run into in my 25 years as an athletic trainer, I did find a use for the punch end.  Newer version of  Riddell helmets have a quick release component that allows faster removal of the facemask.  All that is needed is a pointed object to press the release pin.  The punch on the Houdini Pro fits this bill.

  

Houdini Pro - Benchmade Knife Co.

Here is a video of a hook knife in action.

I had a chance to use this tool throughout the last year and have a very favorable impression.  It cuts the tape off with no problems, including the heaviest tapings that athletic trainer devise for maximum support.  A tool that is design to cut through leather combat boots has no problems with moleskin, Elastikon, etc.  The one caveat with all these hook knives is that it is important to do your cutting with the blade perpendicular to the skin surface.  I would advise letting your athletes use these knives as they could end up slicing their skin if used improperly. 

Here is a picture of the various styles that they offer. I also have the 8 EOD and the 8 Hook.  Out of the three I still prefer the Houdini Pro.

Benchmade has a well earned reputation in their industry for high quality knives.  They come with a lifetime warranty and a lifetime free sharpening. They run aroung $40.00 apiece, but last year they offered an NATA member discount.  Enjoy!

Unethical?? Illegal??

In the April 2011 edition of Training & Conditioning there is an article entitled "Triple Trouble", written by a former Division I College Athletic Trainer now working at the high school level.  http://www.training-conditioning.com/2011/04/11/triple_trouble/index.php  It is the story of an athletic trainer's efforts to keep an athlete on the field after three separate injuries.  While I applaud the effort, I do take exception to some of the methods. In particular, the athlete sustains a a tear of the flexor tendon on the fourth finger. He is taken to the ER and eventually sees one orthopedist, who then refers him to a hand specialist. The hand specialist decides surgery is not warranted but the athlete will be out 6-8 weeks until the tendon heals.  Now comes my issue.


"I realized I would be going against what the specialist said, but he was a young physician and did not have much experience in sports medicine. I had treated several flexor tendon injuries and felt confident that I could devise a protective device and get Justin back on the field. I would not recommend a novice athletic trainer or one who hasn't dealt with this type of injury before do this, but I talked about my idea with Justin and his parents, and they had faith in my skills."


Any Athletic Trainer who takes it upon them-self to disregard a physician's instructions is in violation of their state's practice act and is crossing ethical boundaries. Parents consent or not it is outside the scope of our practice.  Other than the obvious scenario that the athlete suffers a long term disability from the actions of the athletic trainer, what precedent does it set?  What if the athlete suffers a concussion?  They are evaluated by a physician who says no play.  The parents and the athlete want to play.  What are you going to say?  The physician ruled him out?  You have already established that you can ignore the physician's direction. 




I have other issues with the article as well.  Particularly, this athlete suffered two separate tears of his plantar fascia on each foot with no mention of a physician's evaluation. Hopefully, that information was left out by the editors for the sake of brevity.


This story sends the wrong message to the public about the ability of athletic trainers to look out for the health and welfare of their athletes.  The obvious solution to the dilemma would have been to see another Orthopod for a second opinion who would agree with your plan for handling the injury. If they still do not agree, then the athlete sits, end of  discussion.   


     

Antibacterial properties of copper

Did you know that the metal Copper has antimicrobial properties? I came across an article a couple of years back when Methicillin Resistant Staphylococcus Aureus (MRSA) was in all the headlines. I was amazed at how effective this metal is and wondered why I hadn't heard more about it. As you can see by the graph below MRSA cannot live more than one and half hours on the metal. Copper alloys e.g. bronze and bronze (bronze containing more copper) with lesser amounts of copper also have antimicrobial properties but are not as efficient and need longer contact times to be effective. Stainless steel has no effect on MRSA nor any other infectious microbe.

Graph depicts survival times of Methicillin Resistant Staphylococcus aureus on three copper alloys and stainless steel (C304) at room temperature. C19700 (99% copper) limited survival to 1.5 hours. C24000 (80% copper) showed a significant reduction after 3 hours and complete inviability after 4.5 hours. C77000 (55% copper) showed significant and continuing reduction after 4.5 hours. Survival time on stainless steel continued up to 72 hours.

Wikipedia offers the following information on the effectiveness of copper:

E. coli
The bacterium produces potent toxins that cause diarrhea, severe aches and nausea in infected persons. Recent studies have shown that copper alloy surfaces kill E. coli O157:H7. Over 99.9% of E. coli microbes are killed after just 1–2 hours on copper. On stainless steel surfaces, the microbes can survive for weeks.
MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is a dangerous bacteria strain because it is resistant to beta-lactam antibiotics. In 2008, after evaluating a wide body of research mandated specifically by the United States Environmental Protection Agency (EPA), registration approvals were granted by EPA in 2008 granting that copper alloys kill more than 99.9% of MRSA within two hours.
Clostridium difficile
Clostridium difficile, an anaerobic bacterium, is a major cause of potentially life-threatening disease, including nosocomial diarrheal infections, especially in developed countries. C. difficile endospores can survive for up to five months on surfaces. The pathogen is frequently transmitted by the hands of healthcare workers in hospital environments. C. difficile rivals MRSA as the most common organism to cause hospital acquired infections in the US
The antimicrobial efficacy of various copper alloys against Clostridium difficile was recently evaluated. The viability of C. difficile spores and vegetative cells were studied on copper alloys C11000 (99.9% copper), C51000 (95% copper), C70600 (90% copper), C26000 (70% copper), and C75200 (65% copper). Stainless steel (S30400) was used as the experimental control. The copper alloys significantly reduced the viability of both C. difficile spores and vegetative cells. On C75200, near total kill was observed after one hour. On C11000, near total kill was observed after 3 hours. On C70600, near total kill was observed after 5 hours. On C26000, near total kill was achieved after 48 hours. On stainless steel, no reductions in viable organisms were observed after 72 hours (3 days) of exposure and no significant reduction was observed within 168 hours (1 week).
Influenza A
Influenza, commonly known as flu, is an infectious disease from a viral pathogen different from the one that produces the common cold.
After incubation for one hour on copper, active influenza A virus particles were reduced by 75%.  After six hours, the particles were reduced on copper by 99.999%. Influenza A virus was found to survive in large numbers on stainless steel.


As you can see by the quotes above copper is a very effective antimicrobial.  So how can this help the athletic trainer?  We need to examine any frequently touched surface that have a copper or copper alloy version.  This could include doorknobs, light switch plates, faucets, pens, or countertops.  


The idea of a copper countertop peaked my interest since it is a large, frequently touched area that is a reservoir for microbes. Being that copper counter tops are expensive I decided to look into making one myself.  I have a 20 foot long counter in one of our facilities.  After searching the internet I came across Storm Copper. They specialize in a variety of copper products and I settled on copper roofing flashing. I order a 24" by 25' roll which arrived rolled up in a wooden crate.  I unrolled it  and placed weights on it so that it would take a more flattened shape.  I then sanded the old formica countertop to roughen up the surface.  I attached the sheet using an adhesive like liquid nails, used a rubber mallet to bend over the edges and tacked and glued the edges down.  It wasn't the most professional job, but it turned out okay. Certainly no one has stated that it is hideous.  I feel the benefits outweighed the aesthetics. 


The price of metals has increased drastically the last few years, a less expensive alternative would be the 0.10" (30 Gauge).  There are various widths and lengths to choose from. 


The copper will tarnish with time especially when in contact with certain chemicals like tape remover.  A good metal polish will bring it back to its original shine.  Below is a picture of a section of my counter.  It is nice to know that every couple of hours this counter is disinfected without any effort at all. 

Budget Taping with PowerTape

I received an email from Andover Healthcare, makers of PowerFlex and PowerTape.  I have spoken about these products before and am a big fan. Andover Healthcare's latest pitch to get people to use their products is cost savings.  Since PowerTape only sticks to PowerFlex or itself you need to use PowerFlex in place off underwrap.  While I have found PowerTape to be less expensive than J&J Coach, the additional cost of using PowerFlex as an underwrap is cost prohibitive.  Andover touts the use of a modified ankle taping in order stretch the amount of tape used and thereby saving money.  


See the flyer below. The link for the video of the technique is here: http://andoverhealthcare.com/videos/budget_taping.html. Basically, they recommend starting your top anchors only 2-3 inches above the malleolus.   While this cuts down on the amount of tape used you immediately question the amount of support provided.  Personally, I would only use this technique while taping prophylactically, otherwise I would revert to the more traditional technique.  I have developed my own technique combining both white adhesive tape and PowerTape.  See below for my explanation.

http://andoverhealthcare.com/videos/budget_taping.html to view video of technique

My technique combines the traditional white adhesive tape with the combination of PowerTape. I call this a hybrid. Apply the anchors and stirrups in the traditional method using your favorite white adhesive.  From here on, using only PowerTape, start with a figure eight.  This gives you the base for all subsequent strips to adhere to. After the figure eight, apply your horseshoes working your way up the ankle filling it in as you finish over your previously applied adhesive tape anchors. Now that you have a solid foundation of PowerTape, you then apply your heel locks and any other strips you prefer. To recap:

1. White adhesive tape
1. anchors and stirrups
2. PowerTape
1. horseshoes, filling in up to the top
2. heel locks
3. additional strips to your liking

This is my technique for using PowerTape on a limited budget.