From the *Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford University School of Medicine, San Francisco, California; and †Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada.
Submitted for publication October 18, 2010; accepted October 22, 2010.
This publication represents work done by members of RAISEM (Research Alliance in Sport and Exercise Medicine). RAISEM undertakes group research projects on sport injury prevention, clinical treatment, and return to play. The members of the group include clinicians, content experts, epidemiologists, biomechanists, and physiologists, with associated members collaborating on specific projects.
Reprints: Gordon O. Matheson MD, PhD, Sports Medicine Center, 341 Galvez St, Stanford, CA 94305 (e-mail: firstname.lastname@example.org).
Prevention is one of those words that rolls easily off the tongue. The prevention of sport injury has been discussed widely and emphasized frequently by athletic trainers and team physicians for more than 3 decades. But actually reducing sport injury rates is another matter. The question is, “What progress have we made reducing sport injuries in the past 30 years?” The answer seems to be, “We don't know for sure, since we don't have the data to provide a conclusive answer.” The general impression, though, is that sport injury rates are the same or greater now than they were 3 decades ago.
Prevention research is a very important part of solving the problem of sport injury. Klügl et al1 recently analyzed almost 12 000 articles on sport injury prevention since 1938 and reported 3 interesting findings: (1) original research articles were 44% of the total number of articles, (2) articles that examined preventive measures were only 10% of the total, and (3) articles investigating implementation were a mere 1%. Fortunately, there has been a recent and noticeable reemphasis on sport injury prevention. One example of this is the International Olympic Committee World Congress on Prevention of Injury & Illness in Sport (http://www.ioc-preventionconference.org/index.php). Another is the new “centers of excellence in sport injury prevention” research funded by the International Olympic Committee Medical Commission. Yet another is the creation of special editions of the British Journal of Sports Medicine for the publication of injury prevention research.
However, a key element that continues to be missing from sport injury prevention research is the study of changes to the rules and regulations that govern sport. In the September 17, 2010, issue of the New York Times, veteran columnist Alan Schwarz, commenting on concussion treatment, wrote an editorial that would have been unthinkable just a few years ago.2 Schwarz said that we should be looking at “avoiding it [concussion] in the first place.” His suggestions included “eliminating the three-point stance for linemen and strengthening rules regarding headfirst tackles” and “limiting the number of hits to the head in practice.” If newspaper columnists are suggesting the rules be changed, why aren't physicians?
There are good examples of rule changes reducing injuries in sport. Both injuries and penalties related to rough play occurred 4 times more frequently during ice hockey games with regular rules compared with those using fair play rules.3 Compulsory headgear for batters in cricket reduced head, neck, and facial injuries by half.4 Strict judging and heavy penalties substantially decreased the risk of injury in karate.5 Serious cervical spine injuries and quadriplegia in American football diminished dramatically when “spearing” (tackling with the head down, direct contact with the helmet first) was banned in 1976, an effect that has been sustained.6 Most recently, many different ice hockey leagues have specifically started penalizing head hits.
It seems obvious, making sport safer through changing the rules should be a quick and easy way of reducing injuries. Yet, less than 1% of the papers published since 1938 were related to changes in the rules and regulations that govern sport.1 Why aren't we, as clinicians and scientists, more engaged in research to study the effects of rule changes on sport safety? Is it that we view the rules for sport as sacrosanct, tantamount to tampering with the culture of competition? Do we feel our research must operate within a perimeter defined by the rules that govern sport? Are we content to focus our injury prevention research on equipment or training interventions? Are we satisfied making “adjustments” to safety through research in equipment and training while what may be the real culprit, unsafe rules, remains untouched?
There are many possible answers to these questions, but one answer is clear. The core values of competitive sport are very different from those of medicine (Figure 1). This reality has crept up on us slowly over the past few decades, but when fully realized, it helps us understand how little influence sport medicine has within sport itself. For example, the National Collegiate Athletic Association (NCAA) mandates blood tests for sickle cell disease with little to no evidence as to the effectiveness of this screening. Yet, physicians have little to no input on college athlete training schedules, programs, or conditions. The relationship is basically 1-way. Sports get information from health care providers, but health care providers are seldom consulted by sport. Being cognizant of this reality is an important first step in moving forward into the arena of research and advocacy.
If we accept this reality, that the values accorded primacy at the interface between competitive sport and medicine are indeed very different, then health care providers in the sport medicine community should be ready to start the heavy lifting required to effect changes to rules and regulations. Concussion is a good example. Concussion has been a long-standing, underreported, undertreated condition notoriously difficult to diagnose accurately and clearly influenced by both the implicit and explicit pressures of sport culture to “play through it.” It was not until very recently that the National Football League and NCAA placed restrictions on same-day return to play after a concussion. This ruling did not arise from basic science research into the central nervous system and clinical sequelae of repetitive brain trauma. Nor did it come from a deliberate attempt to advocate change to sport-governing bodies. These changes were the result of a systematic and deliberate attempt by a committed group of clinicians to publish, in the Vienna, Prague, and Zurich consensus statements, a best-practice approach to concussion.7-9 These 3 articles, published over an 8-year period, gradually shifted the momentum regarding clinical management using a process of critical appraisal of the literature and the National Institutes of Health-type consensus meetings. It is very important to realize how significant those 3 publications were in providing the foundation for medical practitioners' understanding of concussion treatment. The shift in thinking brought about by those publications, coupled with an increased awareness in the media of the long-term effects of concussion, has been instrumental in the National Football League and NCAA rule changes to restrict same-day return-to-play.
There are several benefits in reducing sport injury through rule changes. One is that it is a “higher level” intervention. It effects a more widespread and deeper change within sport. Policy change is unlikely to influence the risk tolerance effect, particularly if the proposed changes have been carefully thought out or decision makers are able to adapt quickly to new situations that arise because of the rule change. For example, when spearing was banned in football, the maneuver was not replaced with another type of hit that caused cervical spine fractures. The incidence of cervical spine injuries went down and stayed down.6 Another benefit of advocating rule changes to reduce sport injury is that it is the clinicians involved with teams who have the best opportunity to see sport injury up close. Because of this, clinicians will have some of the best ideas as to what changes need to be made.
Critical appraisal and systematic reviews focused on specific clinical dilemmas and questions are essential foundation pieces for rule change advocacy. The process becomes one of the following: (1) formulation of the research question (related to the clinical problem), (2) systematic review of the literature, (3) development of best-practice clinical guidelines for treatment, (4) observation of outcomes of implementing this new treatment, (5) optimizing treatment, and (6) dissemination/knowledge translation of results. These publications would serve as a “stake in the sand” to create a platform for advocacy and policy change with sport-governing bodies and the media. One thing we can do right now is to form alliances within and between our respective sport medicine associations aimed at accomplishing the goal of best practices in areas of clinical dilemma.
Robust analysis of the literature (critical appraisal and systematic reviews) accompanied by discussion and debate (“consensus”) can have a profound effect on the way we practice sport medicine. The distillation of thought that is a part of this process, as in the concussion example, can lead to clinical guidelines for the treatment of difficult problems. If these types of initiatives are multiplied by the strength of alliances between major sport medicine organizations nationally and internationally, sufficient momentum will make possible the type of advocacy and rule change seen in the isolated examples above. The study of rules governing sport is an underrepresented area of research in sport injury prevention, and this should be seen as a research opportunity requiring careful thought and deliberate attention.
1. Klügl M, Shrier I, McBain K, et al. The prevention of sport injury: an analysis of 12 000 published manuscripts. Clin J Sport Med
2. Schwarz A. For head injuries, a problem in team practices. New York Times
. September 17, 2010:B9.
3. Roberts WO, Brust JD, Leonard B, et al. Fair-play rules and injury reduction in ice hockey. Arch Ped Adol Med
4. Shaw L, Finch CF. Injuries to junior club cricketers: the effect of helmet regulations. Br J Sports Med
5. Macan J, Bundalo-Vrbanac D, Romic G. Effects of the new karate rules on the incidence and distribution of injuries. Br J Sports Med
6. Heck JF, Clarke KS, Peterson TR, et al. National Athletic Trainers' Association position statement: head-down contact and spearing in tackle football. J Ath Train
7. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med
8. McCrory P, Johnston K, Meeuwisse WH, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med
9. McCrory P, Meeuwisse WH, Johnston K, et al. Consensus statement on concussion in sport, 3rd International Conference on Concussion in Sport, held in Zurich, November 2008. Clin J Sport Med