Investigation of the knowledge of South African high school rugby coaches on concussion and the return-to-play protocol

Background: Coaches are pivotal in the management of concussed players. Assessing the knowledge of high school rugby coaches with regard to concussion management will enable relevant future education on this topic to be covered. Objectives: To investigate the knowledge of South African high school rugby coaches on concussion symptom recognition, knowledge and stepwise return-to-play (RTP) protocols. Methods: A cross-sectional descriptive study involving 143 first team, high school rugby coaches was completed via an electronic questionnaire. Independent variables included coach demographics, qualifications, experience, BokSmart accreditation, and school size. Dependent variables included knowledge scores on concussion symptoms, general concussion knowledge, stepwise RTP and Maddocks questions. Relationships between total scores for different demographic groupings were established using non-parametric techniques. Results: The coaches had high general, symptom and overall concussion knowledge scores (77% - 80%) in contrast with low RTP scores (62%) and very low Maddocks questions knowledge scores (26%). The 35-44-year age group received top scores for symptom recognition (p=0.034) and total concussion knowledge (p=0.041). Larger category school coaches (p=0.008) and BokSmart accredited coaches (p=0.041) outperformed all other coaches in general concussion knowledge and total knowledge, respectively. However, respondents were not familiar with emotional symptoms or the importance of cognitive rest after a concussion. Educational programmes were the most popular knowledge source for coaches. Conclusion: In general, coaches presented with good general concussion knowledge but lesser expertise on emotional symptoms, cognitive rest and RTP management. Modifiable predictors of knowledge included the expansion of BokSmart accreditation, focussing information sessions on smaller rugby size schools and the education of coaches younger than 35 years or older than 45 years of age.

A comparison between heart rate and heart rate variability as indicators of cardiac health and fitness

Quantification of cardiac autonomic activity and control via heart rate (HR) and heart rate variability (HRV) is known to provide prognostic information in clinical populations. Issues with regard to standardisation and interpretation of HRV data make the use of the more easily accessible HR on its own as an indicator of autonomic cardiac control very appealing. The aim of this study was to investigate the strength of associations between an important cardio vascular health metric such as VO2max and the following: HR, HRV indicators and normalised HRV indicators (divided by mean RR interval). A cross sectional descriptive study was done including 145 healthy volunteers aged between 18 and 22 years. HRV was quantified by time domain, frequency domain and Poincaré plot analysis. Indirect VO2max was determined using the Multistage Coopers test. The Pearson correlation coefficient was calculated to quantify the strength of the associations. Both simple linear and multiple stepwise regressions were performed to be able to discriminate between the role of the individual indicators as well as their combined association with VO2max. Only HR, RR interval and pNN50 showed significant (p<0.01, p<0.01 and p=0.03) correlations with VO2max. Stepwise multiple regression indicated that, when combining all HRV indicators the most important predictor of cardio vascular fitness as represented by VO2max, is HR. HR explains 17% of the variation, while the inclusion of HF (high frequency HRV indicator) added only an additional 3.1% to the coefficient of determination. Results also showed when testing the normalised indicators, HR explained of the largest percentage of the changes in VO2max (16.5%). Thus HR on its own is the most important predictor of changes in an important cardiac health metric such as VO2max. These results may indicate that during investigation of exercise ability (VO2max) phenomena, quantification of HRV may not add significant value.http://www.frontiersin.org/Physiologyhb2014ay201

Managing travel fatigue and jet lag in athletes : a review and consensus statement

Athletes are increasingly required to travel domestically and internationally, often resulting in travel fatigue and jet lag. Despite considerable agreement that travel fatigue and jet lag can be a real and impactful issue for athletes regarding performance and risk of illness and injury, evidence on optimal assessment and management is lacking. Therefore 26 researchers and/or clinicians with knowledge in travel fatigue, jet lag and sleep in the sports setting, formed an expert panel to formalise a review and consensus document. This manuscript includes definitions of terminology commonly used in the field of circadian physiology, outlines basic information on the human circadian system and how it is affected by time-givers, discusses the causes and consequences of travel fatigue and jet lag, and provides consensus on recommendations for managing travel fatigue and jet lag in athletes. The lack of evidence restricts the strength of recommendations that are possible but the consensus group identified the fundamental principles and interventions to consider for both the assessment and management of travel fatigue and jet lag. These are summarised in travel toolboxes including strategies for pre-flight, during flight and post-flight. The consensus group also outlined specific steps to advance theory and practice in these areas.https://www.springer.com/journal/402792022-07-14hj2021Sports MedicineStatistic

Effect of exercise on cardiac autonomic function in females with rheumatoid arthritis

The objective of this study is to evaluate the effect of exercise on cardiac autonomic function as measured by short-term heart rate variability (HRV) in females suffering from rheumatoid arthritis (RA). Females with confirmed RA were randomly assigned to an exercise group (RAE) and a sedentary group (RAC). RAE was required to train under supervision two to three times per week, for 3 months. Three techniques (time domain, frequency domain and Poincaré plot analyses) were used to measure HRV at baseline and study completion. At baseline, RAC (n018) had a significantly higher variability compared to RAE (n019) for most HRV indicators. At study completion, the variables showing significant changes (p00.01 to 0.05) favoured RAE in all instances. Wilcoxon signed rank tests were performed to assess changes within groups from start to end. RAE showed significant improvement for most of the standing variables, including measurements of combined autonomic influence, e.g. SDRR (p00.002) and variables indicating only vagal influence, e.g. pNN50 (p00.014). RAC mostly deteriorated with emphasis on variables measuring vagal influence (RMSSD, pNN50, SD1 and HF (ms2)). Study results indicated that 12 weeks of exercise intervention had a positive effect on cardiac autonomic function as measured by short-term HRV, in females with RA. Several of the standing variables indicated improved vagal influence on the heart rate. Exercise can thus potentially be used as an instrument to improve cardiac health in a patient group known for increased cardiac morbidity.http://www.springerlink.com/content/102818

Comparison of low-fat chocolate flavoured milk to the standard practice of care as a recovery intervention in Ironman athletes: A randomised control trial

The study compared whether athletes who ingested low-fat chocolate milk (LFCM), or the current standard oral intervention (water and Coca-Colaa) spent the same or shorter times in the end medical tent when presenting with exertional conditions during the 2018 Ironman South Africa (IMSA) triathlon competition. This randomised control trial included 42 athletes (aged 23 to 63 years; 7 Females; 35 Males) who completed the race and entered the medical tent due to an exertional condition. The athletes underwent a baseline assessment and were assigned to either an experimental group (EG: which consumed 350ml LFCM; n=22) or control group (CG: which ingested 350ml water and Coca-Cola; n=20). We determined ratios (After/Before) for all variables, including vital signs, venous blood gas analysis and modified Profile of Mood States (POMS) subscales. Both groups spent similar time-in-tent, recorded similar ratios and recovered as per expectation after strenuous exercise. Athletes in the EG had significantly lower heart rate (HR)(p=0.003), systolic blood pressure (p=0.041), pH (p&lt;0.001), and POMS Fatigue-Inertia (p&lt;0.001) after the recovery period, while partial pressure carbon dioxide (p&lt;0.001), potassium (p=0.001), glucose (p=0.039), and POMS Vigour-Activity (p=0.023) readings increased significantly. Athletes in the CG had significantly lower HR (p&lt;0.001) and POMS Fatigue-inertia (p=0.008) readings after the recovery period. Compared to current standard oral intervention, athletes with exertional conditions who drank LFCM did not experience any side effects or spend longer times in the final medical tent. Low-fat chocolate milk may be an acceptable alternative to conventional carbonated beverages and an optional oral recovery drink for ultra-endurance athletes in the medical tent

Subjective Sleep Patterns and Jet Lag Symptoms of Junior Netball Players Prior to and During an International Tournament: A Case Study

Purpose: To assess the impact of long-haul transmeridian travel on subjective sleep patterns and jet lag symptoms in youth athletes around an international tournament. Methods: An observational descriptive design was used. Subjective sleep diaries and perceived responses to jet lag were collected and analyzed for a national junior netball team competing in an international tournament. Sleep diaries and questionnaires were completed daily prior to and during travel, and throughout the tournament. Results were categorized into pretravel, travel, training, and match nights. Means were compared performing a paired Student t test with significance set at P < .05. Data are presented as mean (SD) and median (minimum, maximum). Results: Athletes reported significantly greater time in bed on match days compared with training (P < .001) and travel (P = .002) days, and on pretravel days compared with travel (P < .001) and training (P = .028) days. Sleep ratings were significantly better on pretravel days compared with match (P = .013) days. Perceived jet lag was worse on match (P = .043) days compared with pretravel days. Significant differences were also observed between a number of conditions for meals, mood, bowel activity, and fatigue. Conclusion: Youth athletes experience significantly less opportunity for sleep during long-haul transmeridian travel and face disruptions to daily routines during travel which impact food intake. Young athletes also experience disturbed sleep prior to and during competition. These results highlight the need for practices to alleviate jet lag symptoms and improve the sleep of young athletes traveling for tournaments in an effort to optimize recovery and performance.</p

Effect of Exercise On Cardiac Autonomic Function In Female Rheumatoid Arthritis Patients

Introduction: Cardiovascular morbidity and mortality is increased in rheumatoid arthritis(RA) patients(1,2). Autonomic dysfunction has been mentioned as part of the explanation(3). A literature search conducted(1963-2010) found only 27 publications, using 8 different testing protocols to determine the extent of autonomic nerve involvement in RA patients. Autonomic tests included were: sweat response(4,5), cardiovascular reflex tests(6-17), divergent autonomic reactions to specific tasks(18), pre-ejection period and respiratory sinus arrhythmia(19), sympathetic skin response and RR interval variation(20,21), pupillography(22,23), heart rate variability (HRV)(3,16,17,24-28) and Heart Rate Turbulence(29). Autonomic dysfunction was reported by some but not all authors. Review results were inconclusive as study results could not be compared due to numerous disparate tests used and heterogeneous study methodology. Problems identified were incomplete information on exclusion criteria, non-stabilisation of environment, males and females in the same small study groups and use of inappropriate statistical methods(3-29) I therefore firstly executed a study that confirmed cardiac autonomic dysfunction comparing females suffering from RA (n=45) to a healthy female group (n=39). This was subsequently followed by the undermentioned study. Methods:The aim of this study was to evaluate the effect of exercise on cardiac autonomic function as measured by short-term heart rate variability (HRV) in females suffering from RA. Females with confirmed Rheumatoid Arthritis (RA) were randomly assigned to an exercise group (RAE) and a sedentary group (RAC). RAE was required to train under supervision two to three times per week, for three months. Three techniques (time domain-, frequency domain-, and Poincaré plot analyses) were used to measure HRV at baseline and study completion. Results: At baseline RAC (n=18) had significantly better HRV compared to RAE (n=19). At study completion the variables showing significant changes (p=0.01 to 0.05) favoured RAE in all instances. Wilcoxon signed rank tests were performed to assess changes within groups from start to end. RAE showed significant improvement for most of the standing variables, including measurements of combined autonomic influence e.g. RRSTD (p=0.002) and variables indicating only vagal influence e.g. pNN50 (p=0.014). RAC mostly deteriorated with emphasis on variables measuring vagal influence [RMSSD, pNN50, SD1 and HF(ms2)]. Posture change showed a mixture of outcome for both groups. Discussion: Exercise intervention has an effect on cardiac autonomic function in RA patients. Especially the standing variables indicating improved vagal influence are affected positively. Exercise can thus be used as an instrument to improve cardiac health in a patient group known for increased cardiac morbidity.References1. Meune C, Touze E, Trinquart L, Allanore Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 2009 Oct;48(10):1309-1313.2. Maradit-Kremers H, Crowson CS, Nicola PJ, Ballman KV, Roger VL, Jacobsen SJ, et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum. 2005 Feb;52(2):402-411. 3. Evrengul H, Dursunoglu D, Cobankara V, Polat B, Seleci D, Kabukcu S, et al. Heart rate variability in patients with rheumatoid arthritis. Rheumatol.Int. 2004 Jul;24(4):198-202. 4. Bennett PH, Scott JT. Autonomic neuropathy in Rheumatoid Arthritis. Ann.Rheum.Dis. 1965 Mar;24:161-168.5. Kalliomaki JL, Saarimaa HA, Toivanen P. Axon reflex sweating in rheumatoid arthritis. Ann.Rheum.Dis. 1963 Jan;22:46-49.6. Edmonds ME, Jones TC, Saunders WA, Sturrock RD. Autonomic neuropathy in rheumatoid arthritis. Br.Med.J. 1979 Jul 21;2(6183):173-175.7. Leden I, Eriksson A, Lilja B, Sturfelt G, Sundkvist G. Autonomic nerve function in rheumatoid arthritis of varying severity. Scand.J.Rheumatol. 1983;12(2):166-170.8. Piha SJ, Voipio-Pulkki LM. Elevated resting heart rate in rheumatoid arthritis: possible role of physical deconditioning. Br.J.Rheumatol. 1993 Mar;32(3):212-215.9. Toussirot E, Serratrice G, Valentin P. Autonomic nervous system involvement in rheumatoid arthritis. 50 cases. J.Rheumatol. 1993 Sep;20(9):1508-1514.10. Bekkelund SI, Jorde R, Husby G, Mellgren SI. Autonomic nervous system function in rheumatoid arthritis. A controlled study. J.Rheumatol. 1996 Oct;23(10):1710-1714.11. Maule S, Quadri R, Mirante D, Pellerito RA, Marucco E, Marinone C, et al. Autonomic nervous dysfunction in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA): possible pathogenic role of autoantibodies to autonomic nervous structures. Clin.Exp.Immunol. 1997 Dec;110(3):423-427.12. Louthrenoo W, Ruttanaumpawan P, Aramrattana A, Sukitawut W. Cardiovascular autonomic nervous system dysfunction in patients with rheumatoid arthritis and systemic lupus erythematosus. QJM 1999 Feb;92(2):97-102.13. Sandhu V, Allen SC. The effects of age, seropositivity and disease duration on autonomic cardiovascular reflexes in patients with rheumatoid arthritis. Int.J.Clin.Pract. 2004 Aug;58(8):740-745.14. Stojanovich L, Milovanovich B, de Luka SR, Popovich-Kuzmanovich D, Bisenich V, Djukanovich B, et al. Cardiovascular autonomic dysfunction in systemic lupus, rheumatoid arthritis, primary Sjogren syndrome and other autoimmune diseases. Lupus 2007;16(3):181-185.15. Bidikar MP, Ichaporia RB. Autonomic (sympathetic) nervous system involvement in rheumatoid arthiritis patients. Indian J.Physiol.Pharmacol. 2010 Jan-Mar;54(1):73-79.16. Milovanovic B, Stojanovic L, Milicevik N, Vasic K, Bjelakovic B, Krotin M. Cardiac autonomic dysfunction in patients with systemic lupus, rheumatoid arthritis and sudden death risk. Srp.Arh.Celok.Lek. 2010 Jan-Feb;138(1-2):26-32.17. Aydemir M, Yazisiz V, Basarici I, Avci AB, Erbasan F, Belgi A, et al. Cardiac autonomic profile in rheumatoid arthritis and systemic lupus erythematosus. Lupus 2010 Mar;19(3):255-261.18. Geenen R, Godaert GL, Jacobs JW, Peters ML, Bijlsma JW. Diminished autonomic nervous system responsiveness in rheumatoid arthritis of recent onset. J.Rheumatol. 1996 Feb;23(2):258-264.19. Dekkers JC, Geenen R, Godaert GL, Bijlsma JW, van Doornen LJ. Elevated sympathetic nervous system activity in patients with recently diagnosed rheumatoid arthritis with active disease. Clin.Exp.Rheumatol. 2004 Jan-Feb;22(1):63-70.20. Tan J, Akin S, Beyazova M, Sepici V, Tan E. Sympathetic skin response and R-R interval variation in rheumatoid arthritis. Two simple tests for the assessment of autonomic function. Am.J.Phys.Med.Rehabil. 1993 Aug;72(4):196-203.21. Gozke E, Erdogan N, Akyuz G, Turan B, Akyuz E, Us O. Sympathetic skin response and R-R interval variation in cases with rheumatoid arthritis. Electromyogr.Clin.Neurophysiol. 2003 Mar;43(2):81-84.22. Barendregt PJ, van der Heijde GL, Breedveld FC, Markusse HM. Parasympathetic dysfunction in rheumatoid arthritis patients with ocular dryness. Ann.Rheum.Dis. 1996 Sep;55(9):612-615.23. Schwemmer S, Beer P, Scholmerich J, Fleck M, Straub RH. Cardiovascular and pupillary autonomic nervous dysfunction in patients with rheumatoid arthritis - a cross-sectional and longitudinal study. Clin.Exp.Rheumatol. 2006 Nov-Dec;24(6):683-689.24. Anichkov DA, Shostak NA, Ivanov DS. Heart rate variability is related to disease activity and smoking in rheumatoid arthritis patients. Int.J.Clin.Pract. 2007 May;61(5):777-783.25. Goldstein RS, Bruchfeld A, Yang L, Qureshi AR, Gallowitsch-Puerta M, Patel NB, et al. Cholinergic anti-inflammatory pathway activity and High Mobility Group Box-1 (HMGB1) serum levels in patients with rheumatoid arthritis. Mol.Med. 2007 Mar-Apr;13(3-4):210-215.26. Bruchfeld A, Goldstein RS, Chavan S, Patel NB, Rosas-Ballina M, Kohn N, et al. Whole blood cytokine attenuation by cholinergic agonists ex vivo and relationship to vagus nerve activity in rheumatoid arthritis. J.Intern.Med. 2010 Jul;268(1):94-101.27. Vlcek M, Rovensky J, Blazicek P, Radikova Z, Penesova A, Kerlik J, et al. Sympathetic nervous system response to orthostatic stress in female patients with rheumatoid arthritis. Ann.N.Y.Acad.Sci. 2008 Dec;1148:556-561.28. Holman AJ, Ng E. Heart rate variability predicts anti-tumor necrosis factor therapy response for inflammatory arthritis. Auton.Neurosci. 2008 Dec 5;143(1-2):58-67.29. Avsar A, Onrat E, Evcik D, Celik A, Kilit C, Kara Gunay N, et al. Cardiac autonomic function in patients with rheumatoid arthritis: heart rate turbulence analysis. Anadolu Kardiyol Derg. 2011 Feb;11(1):11-15

The use of skeletal muscle relaxants in musculoskeletal injuries: what is the evidence?

Skeletal muscle relaxants (SMRs) consist of a heterogeneous group of medications with a side effect profile of concern. The aim of this paper was to review the evidence of use of SMRs in the treatment of sports injuries. A literature search between 2005 – 2018 (Ovid MEDLINE, SPORTDiscus and SCOPUS) were conducted. In addition, citations within articles were searched, and the most commonly prescribed SMRs in South Africa were also used to explore the literature for additional publications. Relevant studies that met the inclusion criteria were selected. Clinical recommendations for general practitioners are given based on the Strength of Recommendation Taxonomy (SORT) level of evidence. Combination drugs rather than single agents are mostly used, however the effectiveness of SMR agents, single and in combination, as well as its significance as opposed to analgesics and non-steroidal anti-inflammatory drugs, still has to be evaluated. Evidence suggest SMRs to be probably effective for use in non-specific lower back pain (acute and chronic lower back muscle strains, ligament sprains, soft tissue contusions), as well as for whiplash associated disorder, mechanical neck disorders, piriformis syndrome, lateral epicondylosis, and plantar fasciitis. It does not appear if there is a role for SMRs as part of combination management for acute cervical strains, post-exercise muscle soreness or myofacial pain syndrome. However, substantial evidence to confirm the use of SMRs in the treatment of sports injuries have not been adequately investigated and is currently largely based on case reports and general reviews

A prospective cohort study of 7031 distance runners shows that 1 in 13 report systemic symptoms of an acute illness in the 8–12 day period before a race, increasing their risk of not finishing the race 1.9 times for those runners who started the race: SAFER study IV

BACKGROUND : Data on the prevalence of acute illness in the period prior to a distance running race are limited. Currently, the presence of systemic symptoms (failed 'neck check') is used to advise athletes on participation. AIM : To determine (1) the period prevalence of pre-race acute illness symptoms before a distance running event, (2) if symptomatic runners receiving educational material on acute illness did not start (DNS) the race and (3) if symptomatic runners who chose to start the race, did not finish (DNF) the race. METHODS : 7031 runners completed an online pre-race acute illness questionnaire in the 3-5 day period prior to a race. Symptomatic runners received educational information on exercise and acute illness. Runners were followed prospectively to determine DNS and DNF risk. RESULTS : 1338 runners (19.0%) reporting symptoms (7.5% reporting systemic symptoms-failed 'neck check') and receiving educational information had a higher DNS frequency (11.0%) compared to controls (6.6%)(p=0.0002). Symptomatic runners who started the race had a higher DNF frequency (2.1%) compared to controls (1.3%) (p=0.0346), particularly runners with systemic symptoms (2.4%; RR=1.90). CONCLUSIONS : In summary, 19% (1 in 5) runners reported pre-race acute illness symptoms, with 7.5% (1 in 13) reporting systemic symptoms. Although runner education reduced the percentage symptomatic race starters, the majority of them still chose to race, resulting in a two times higher risk of not finishing in those with systemic symptoms. Pre-race acute illness symptoms are common; an educational intervention affects an athlete's decision to compete yet most symptomatic runners still competed, and systemic symptoms negatively affect performance, with possible health implications.http://bjsm.bmj.comhb2017Sports Medicin