Are Sports Safe For Kids?

Transcription

1 Are Sports Safe For Kids? Rebecca M. Northway, MD, FAAP October 3, 2018 Internal Medicine-Pediatrics Primary Care Sports Medicine USA Hockey NTDP Team Physician

2 Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation This topic could go on for days 2

3 Objectives Risks and Benefits of Participation in Youth Sports Role of Free Play versus Organized Sport Few Common Injuries Seen in Youth Sports Possible Prevention of Injuries 3

4 Pediatric Obesity Obesity has more than tripled since the 1970s Nearly 1 in 5 school age children and young people (6 to 19 years) in the United States has obesity Physical activity declines steadily after age 6 Recommendations to target pediatric obesity get at least 60 minutes of physical activity daily 4

5 Pediatric Obesity 5

6 Pediatric Obesity and Physical Activity 19 studies, relationship between sport participation and weight status of children and adolescents (6-18 y/o) (Nelson, T et al. Curr Sports Med Rep ; 10(6): ) Youth in sports are more physically active Majority of studies found lower weight in sports participants While sport participation was associated with more fruit, vegetable and milk intake there was also more fast food, sugar sweetened drinks and overall greater calorie intake ~ th graders in Ontario Canada (Cairney J, Veldhuizen S. Organized sport and physical activity participation and body mass index in children and youth: a longitudinal study. Preventive Medicine Reports 6 (2017) ) Followed over 5 years Found BMI increased but sport participation decreased Factors other than sport are important for healthy weight 6

7 Pediatric Obesity and Physical Activity Telephone survey of 1718 HS students and parents (Drake K, et al Pediatrics Aug; 130(2): e296 e304) 29% overweight, 13% obese Team sports participation (2+/yr) inversely related to overweight/obesity Active commuting to school inversely related to obesity Suggest obesity prevalence would decrease by 26.1 if all teens played on 2 sports teams per year and by 22.1% if walked/biked to school at least 4 days per week ~ 8,000 1 st - 5 th graders Private/rural, variety of ethnicity and SES With age, PE time increased, recess decreased, sports participation increased PE helped to decrease BMI only in boys 7

8 Benefits of Physical Activity Goal to combat pediatric obesity Having fun Creative imagination Sports involvement Provide a setting for engaging in physical activity Allows interaction with adults and peers Helps to develop variety of physical and social skills Building teamwork and leadership skills Improving self esteem 8

9 Epidemiology In the US, nearly 72% of school aged youth 8-17 years old participate in at least 1 organized sport/club 69% girls 75% boys Of these 29% play year-round 9

10 Epidemiology Only 3-11% of high school athletes compete at the NCAA level 1% receive a scholarship 0.03%-0.5% of US high school athletes ever make it professional 54% of athletes report they have played while injured Majority of organized sports-related injuries- ~ 62%- occur during practice 21% of pediatric TBI occur during sport or recreational activity 70% of children drop out of organized sports by 13 years of age 10

11 Why Are Kids at Risk? 11

12 Sports Injury Definition: Resulting from participation in an organized athletic practice or competition Requiring medical attention from a certified athletic trainer or physician Restricting the athlete s participation for 1 or more days beyond the day of injury Time loss from game or practice is commonly used as a indicator for injury severity Acute, Overuse, and Serious Overuse Injuries Injury risk increases with the number of exposure hours Increased risk of injury and serious overuse injury if young athlete participates in more hours than their age/week in organized sports Higher rates during times of growth 12

13 Benefits of Organized Sports Increased scholastic achievement and engagement Increased psychological well-being Reductions in illicit substance use Improved metabolic health and bone mineral density Improved nutritional habits Brenner JS and AAP COUNCIL ON SPORTS MEDICINE AND FITNESS. Sports Specialization and Intensive Training in Young Athletes. Pediatrics. 2016;138(3) 13

14 Sports Readiness The match between child s level of growth, motor (and emotional) development and the tasks and demands of the sport Chronological age is not a good indicator PPE benefits Usually not mandated until high school Standards for coaching competency Readiness Injury recognition or prevention Following rules Sport readiness in children and youth. Paediatrics & Child Health. 2005;10(6):

15 Free Play Vs. Organized Play Play is essential element of positive youth development Structured play: Agility, Balance, Coordination, Speed Support confidence and competence Free Play: The essential element of free play is discretionary choice Semi Structured: Concern for Adultification, Early Specialization, Overscheduling accomplish a specific learning goal, less structured and more youthdriven 15

16 Organized Sport and Free Play Acquisition and reinforcement of skills through structured sport Increases in organized sport are associated with increase free play Young athletes who exceed 2:1 ratio time spent in organized vs free play are more likely to be injured 16

17 Adultification and Early Specialization Over marketing and privatization of youth sports: The push to become elite at younger ages The Over and Under-Emphasis on Winning The Discouragement of Enjoyment The treatment of youth sports as a means to an end Push for early sport specialization Pre- Pubertal may lead to reduced motor skill development focus on the motor skill need for their sport only and ignore other motor skill development may stunt neuromuscular skills that are effective in injury prevention does not allow the necessary rest Athletes who participate in a variety of sports have fewer injuries and play sports longer 17

18 Adultification and Early Specialization Overscheduling High ratio of workload to recovery time 42% increase overuse injuries in year round HS athletes Keeping up with The Jones Psychological burnout More common in adult supervised activities? Early specialization or time conflicts/other interests Early drop out and increase injury Limit intense specialized training to no more than 16 hours per week and focus more on skill development over competition and winning 18

19 Sport Specialization 1190 athletes 7-18 y/o Sport specialization Pick a main sport (single sport training) Quit other sports (exclusion) Train >8 months/year Sum was categorized as highly, moderately or low Injured athletes older, more hours/week and higher specialization score Dose dependent relationship between degree of specialization and risk of injury Most injuries were overuse injuries (67%) and almost 25% serious overuse PFPS SLJ, Patella tendinopathy, OSD 4 fold RR 19

20 Spondylolysis Def Sports involving high impact, extension, and rotation forces Individual, technical sports such as gymnastics, dance, swimming, and diving my require early specialization and high intense volumes in prepubescent period High risk sports have been identified as elite gymnastics, dance, football, weight lifting, diving, wrestling, cricket and crew Prevalence in adolescent athletes is as high as 47% Incidence in adolescent athletes is 2-5 times higher than in nonathletes Higher incidence in male athletes Early diagnosis is important to prevent worsening injury and prolonged recovery Progression to nonunion ranges from 14% to 70%, with those who are untreated or delayed treatment having the highest rates 20

21 Spondylolysis Retrospective study assessing 1025 adolescent athletes y/o Diagnosis of spondy by imaging Specializing in a single sport was not associated with increased risk (p = 0.21) Male athletes were 1.5x more likely to have a spondy Baseball, soccer, hockey Literature has shown progression to spondylolisthesis of > 20% in only about 4% 21

22 High Risk Stress Fracture Stress fracture High risk overuse injuries result in significant time loss from sport and/or threaten future participation Overall, delayed union and nonunion have been reported to occur in up to 10% of athletic stress fracture Can lead to surgical intervention or degenerative joint disease Physeal stress injuries usually resolve with rest but some can result in growth disturbance and joint deformity 22

23 OCD Injury to the articular cartilage and underlying subchondral bone Results in partial or complete separation of the bone fragment Etiology is not completely well know but usually from repetitive overloading Usually unilateral, below age of 18, 2x more common in males and most often involving posterior lateral aspect of medial femoral condyle Complaints are vague Poorly localized pain, pain with activities, effusion, mechanical symptoms Treatment depends on classification Rest or surgical intervention 23

24 UCL Injuries Despite adoption of safety guidelines, pitch count recommendations, increased media coverage on injury prevention for youth baseball players, injuries in this age group do not seem to be decreasing 74% of young baseball players some degree of arm pain with throwing Pitching volume is the strongest predictor ASMI surveyed ~750 pitchers > 43% pitched on consecutive days 31% pitched multiple teams 19% pitched multiple games/day 46% encouraged to keep playing (Makhni et al) 24

25 UCL Injuries Retrospective review of the PearlDiver looking at UCLR procedures performed in (Erickson B, et al. Trends in medial ulnar collateral ligament reconstruction in the united states: a retrospective review of a large private-payer database from Am J Sport Med. 2015;3(7): ) 790 patients, 88% male majority were patients aged years (56.8%) followed by 20- to 24-year-olds (22.2%) Annual incidence was ~4/100,000 overall but 22/100,000 in y/o Number of UCLR procedures significantly increased over time (P =.039) 2012 (Ahmad et al) survey of 189 HS and college players, parents, coaches >25% felt should be prophylactic procedure to improve function >25% did not think number of pitches was a risk factor 25

26 UCL Injuries With complaints of arm pain, parents and coaches must act in the best interest of the child Young pitchers should first learn proper fastball mechanics and consistency in their motions Players should not pitch competitively > 8 months per year, and should follow pitch count limits and recommended day offs 14-little-league-baseball-pitch-count-limits-andmandatory-rest-periods 26

27 UCL Injuries 305 youth baseball players aged 8 11, evaluating a novel stretching and strengthening protocol called the Yokohama Baseball-9 (YKB-9) designed to improve posture and range of motion (ROM) of the elbow, shoulder, and hip The strength exercises focus on rotator cuff, scapular function, posture, and lower extremity balance. Players who participated in the YKB-9 had approximately 50% fewer medial elbow injuries over the course of a 12- month follow-up period Likely translatable to high school and college age 27

28 ACL Injuries 1841 subjects with new onset, isolated ACL tears The incidence of isolated ACL tears decreased significantly over time in males (P \.001) but remained relatively stable in females. Agespecific patterns differed in male and female patients, with a peak in incidence (241.0 per 100,000) between 19 and 25 years in males and a peak in incidence (227.6 per 100,000) between 14 and 18 years in females. 28

29 ACL Injuries 7644 participants between y/o Overall incidence 38.9/100,000 person years Girls were significantly younger than boys 49.5/100,000 person years in girls, 28.3/100,000 person year in boys Incidence was 3x higher in level 1 sport 29

30 Concussion Direct blow to the head or deceleration causing alteration in normal brain function 1.7 million concussion occur each year, 20% are sports related 200% increase in rate in high school students in past two decade Leading sports are football, girl s and boy s soccer, girl s basketball Young athletes are more susceptible to concussions Participate more in activities and sports Larger head to body size ratio Weaker neck muscles Increased vulnerability of the developing brain Higher rates in females with also more cognitive impairment Recovery is longer in younger athletes Currently no effective headgear that prevents 30

31 Heat Illness Leading cause of preventable death in high school athletics Exercising children do not adapt to extreme temperatures as effectively Greater surface area to body mass ratio Produce more metabolic heat per mass unit Sweating capacity is considerably lower Rate of acclimatization is slower 2/3 of athletes come to practice significantly dehydrated EHS can be prevented and is 100% survivable when immediately recognized and treated on site 31

32 Sudden Cardiac Death Leading cause of death in athletes Structural or electrical cardiac disorder As many as 80% are asymptomatic until SCA occurs Greatest factor for survival is time from arrest to defibrillation With prompt recognition, CPR and early defibrillation can have >80% survival 32

33 Prevention of Injuries National Governing Bodies Implement best practice health and safety polices but each function independently without a single overseeing entity USA Football, Soccer, Hockey, Youth Baseball, NFHS, USA Cheer Position Statements AMSSM, AOSSM, AAP, NATA, CDC and Korey Stringer Institute Concussion HEADS UP, Heads Up Football, USA Soccer USA Hockey (body checking) and USA Football (max contact drills) Michigan State Law Equipment Upgrades, Proper Use and Fit 33

34 Prevention of Injuries EHI SCA Awareness of heat index/wet bulb globe Mandates for acclimatization NATA, USA Football, MHSAA Prompt recognition and treatment by health care providers CPR training For all MI high school graduates and all MHSAA varsity head coaches AEDs on site 34

35 Prevention of Injuries Education PPE Administration, Coaches, Parents, Athletes Concussion, SCA/CPR, Heat Illness, Mental Health/Burnout, Overuse Injuries Risk factors: weight/bmi, previous injuries and imbalances, hours of training, mental health Sport Readiness Removing the adults 35

36 Prevention of Injuries Integrative Neuromuscular Training general fundamental movements and specific strength and conditioning activities to enhance health and skill related components of physical fitness Regular INMT of weight lifting and plyometric exercises enhance functional biomechanics and abilities and reduce the number of sport related injuries in young athletes Seen in soccer and football knee injuries Improved landing pattern in pubertal females Reduced injury and quicker recovery No minimum age but need to follow instructions and have appropriate attention 36

37 Prevention of Injuries Fort-Vanmeerhaeghe A, et al. Integrative neuromuscular training in youth athletes part II: strategies to prevent injuries and improve performance. Strength and Conditioning Journal. 2016; 38(4):

38 Summary Are Sports Safe For Kids??? Early introduction to a sport isn t the problem, it s the early specialization Allow sport sampling Organized sports programs for preadolescents should complement NOT replace the regular physical activity Play is essential element of youth development to promote physical literacy, motor skill proficiency and strength and long term athletic development and fun The skill acquisition with diversification is important in the successful development of the young athlete Less risk of injuries vs early specialization Greater potential of minimizing dropouts 38

39 Summary Are Sports Safe For Kids??? Follow recommendations from organizations to prevent injury Monitor training volume Have at least 1-2 days off per week Take 2-3 months away from a sport each year Continued EAP and best practice recommendations Compliance with mandates and recommendations Education to coaches, athletes, parents, groups Understanding and early recognition of injuries with appropriate evaluation and adherence to treatment Consider Integrative neuromuscular training in youth activities/sports OVERALL HAVE FUN! 39

40 References AAP Committee on Sports Medicine and Fitness and Committee on School Health. Organized sports for children and preadolesents. Pediatrics. 2001; 107(6): AAP Committee on Sports Medicine and Fitness and Committee on School Health. Climate heat and the exercising child and adolescent. Pediatrics. 2000;106;158 Barreiro J, et al. Incorporating unstructured free play into organized sports. Strength and Conditioning Journal. 2017;39(2): Brenner JS and AAP Council On Sports Medicine. Sports specialization and intensive training in young atheltes. Pediatrics. 2016; 138 (3): e Cairney J, Veldhuizen S. Organized sport and physical activity participation and body mass index in children and youth: a longitudinal study. Preventive Medicine Reports 6 (2017) DiFiori J, et al. Overuse injuries and burnout in youth sports: a position statement form the american medical society for sports medicine. Br J Sports M. 2014; 48: Erickson B, et al. Trends in medial ulnar collateral ligament reconstruction in the united states: a retrospective review of a large private-payer database from Am J Sport Med. 2015;3(7): Fernandes M, Sturm R. The role of school physical activity programs in child body mass trajectory. J Phys Act Health February ; 8(2): Fort-Vanmeerhaeghe A, et al. Integrative neuromuscular training in youth athletes part II: strategies to prevent injuries and improve performance. Strength and Conditioning Journal. 2016; 38(4):9-27 Hall R, et al. Sports specialization is associated with an increased risk of developing anterior kene pain in adolescent female athletes. J Sport Rehabil February ; 24(1): Huggins R, et al. The inter-association task force document on emergency health and safety: best-practice recommendations for youth sports leagues. J Athletic Training 2017;52(4): Jayanthi N, et al. Sports specializaed intensive training and the risk of injury in young athletes. Am J Sports Med. 2015;43(4): Jayanthi N, et al. Sports specialization in young athletes: evidence based recommendatiosn. Sports Health. 2013; 5(3): Johnsen M, et al. Sport participation and the risk of anterior cruciate ligament reconstruction in adolescents: a population based prospective cohort study (the Young-HUNT study). Am J Sports Med Nov;44(11):

41 References LaPrade R, et al. AOSSM Early Sport Specialziation concensus statement. Ortho J Sports Med. 2016; 4(4)1-8 Luke A, et al. Sports-related injuries in youth athletics: is overscheduling a risk factor? Clin J Sport Med. 2011;21(4): Mahoney J, Vest A. The overscheduling hypothesis revisited: intensity of organized activity participation during adolescence and young adult outcomes. J Res Adolesc September 1; 22(3): Myer G, et al. Integrative training for children adn adolescents: techniques and practices for reductin sports-related injuries and enhancing athletic performance. The Phys and Sportsmed. 2011;39(1): Myer G, et al. Sports specialization part I: does early sports specialization increase negative outcomes and reduce the opportunity for success in young athletes? Sports Health. 2015; 7(5): Myer G, et al. Sports Specialization, part II: alternative solutions to early sport specialization in youth athletes. Sports Health. 2015; 8(1):65-74 Myer G, et al. When is too young to start training? ACSM Health Fit J. 2013;17(5) Myer G, et al. When to initiate integrative neuromuscular training to reduce sports-related injuries in youth? Curr Sports Med Rep. 2011; 10(3): Patel D, et al. Epidemiology of sports-related musculoskeletal injuries in young athletes in united states. Transl Pediatr. 2017;6(3): Pfister T, et al. The incidence of concussion in youth sports: a systemic review and meta-analysis. Br J Sports Med. 2015;0:1 6. doi: /bjsports Sakata J, et al. Efficacy of a prevention program for medial elbow injuries in youth baseball players. Am J Sport Med. 2018;46(2): Selhorst M, et al. Prevalence of spondyloysis in symptomatic adolscent athletes: an assessment of sport risk in nonelite athletes. Clin J Sport Med 2017;0:1 5 Skinner, et all. Prevalence of obesity and severe obesity in US children, Pediatrics. 2018; 141(3):e Valovich T, et al. National athletic trainers association position statement: prevention of pediatric overuse injuries. J Athletic Training. 2011; 46(20): Zaremski J, et al. Trends in sports-related elbow ulnar collateral ligament injuries. Ortho J of Sport Med. 2017;5(10)1-7 41

42 References