Rebecca M. Lopez

Evidence suggests that athletic trainers are not always comfortable performing emergency medical skills, but it is unclear if state regulatory language impacts their comfort or perceived ability to provide care in medical emergencies. Using a concurrent mixed-methods approach, athletic trainers were asked to review regulatory language and indicate if they would be allowed to perform specific emergency skills in different employment settings. Results indicate that athletic trainers identify barriers to performing emergency medical skills in state practice language, including supervising physician oversite and narrow definitions of patient populations. Our results provide insight specific to the potential impact of regulatory language on clinical practice.

Exertional heat illness poses a significant risk for workers, athletes, and military personnel participating in outdoor activities during hot weather. An important component of heat safety is to monitor environmental conditions through heat stress indices like the wet bulb globe temperature (WBGT) and adjust activity as conditions get progressively hotter. Traditionally, on‐site (OS) WBGT measurement devices are used, but phone applications (PAs) offering WBGT estimates have emerged as a potential alternative. However, there is little information on how closely PA‐derived WBGTs match OS measurements to guide decision‐making. This study compared the PA‐derived Zelus WBGT estimates with OS measurements from Kestrel 5400 devices and their impact on activity modification categorization. A 2‐month observational study collected 1,056 paired (OS and PA) WBGT measurements from 26 high schools across 11 states in the United States and over diverse surfaces (artificial turf 53%, natural grass 44%, others 3%). WBGT values were categorized using regional activity modification thresholds to account for local acclimatization. Our findings indicated that while exhibiting high correlation (r = 0.89), PA WBGTs were on average about 1°C cooler, with differences of 2–3°C at higher WBGTs. Findings were similar for both grass and artificial turf surfaces. Further, significant discrepancies were observed in WBGT‐based activity modification categories, with the PA more frequently indicating lower modification categories compared to OS devices, especially in hotter conditions. In light of these findings, the PA requires further validation prior to its adoption as a replacement for OS measurements.

A 19-year-old collegiate female acrobatics and tumbling athlete presented with deep shooting pain in her right thigh during impact activities. Diagnostic imaging revealed a 12-mm enchondroma in her right proximal femoral metadiaphysis. After 10 days of rest, the patient began gradually increasing the intensity of impact skills and completed the remainder of the acrobatics and tumbling season. This is the first reported case of an enchondroma in the proximal femoral metadiaphysis in a young athlete. Athletic trainers must use clinical reasoning skills and interprofessional collaboration when managing atypical presentations to improve patient care and promote a positive recovery after injury.

A 24-year-old male collegiate tennis athlete presented with pain, weakness, and numbness consistent with the ulnar nerve distribution in the left distal upper extremity following excessive wrist and forearm flexion and pronation. The patient was diagnosed with lacertus syndrome after referral for imaging. Lacertus syndrome is an exertional compartment syndrome of the forearm, typically including median nerve entrapment and surgical intervention. The uniqueness of this case included ulnar nerve involvement and resolution with interprofessional conservative management. Athletic trainers should consider including other health care professionals to conservatively manage lacertus syndrome in patients with delayed symptom onset during repetitive wrist and forearm activities.

Clinical Scenario: Due to the potential side effects in athletes, there is a need to evaluate for cardiac-related side effects due to COVID-19 infection during preparticipation examinations. Clinical Question: Does advanced cardiac testing during preparticipation examinations in athletes who have contracted the COVID-19 virus identify cardiac abnormalities? Summary of Key Findings: The literature was searched based on athletes’ post–COVID-19 infection who were tested for risk of sudden cardiac arrest/death. The initial search yielded 32 studies, but 7 were excluded based on abstract content. Of the remaining 25 studies, 17 were excluded based on patient age or non-athletic populations. Four relevant studies met the inclusion criteria and were included. The need for cardiac screening and advanced cardiac testing was supported to identify risk of sudden cardiac arrest/death during preparticipation examinations in COVID-19–positive patients. Clinical Bottom Line: The use of advanced cardiac testing along with a comprehensive symptom and history questionnaire is essential to reduce cardiac complications due to COVID-19. Symptom-based questionnaires following COVID-19 infection can detect possible COVID-19–related cardiac abnormalities better than the standard cardiac symptom-based questionnaires alone. These combined screening measures for patients with a COVID-19 infection can safely help return athletes to sports. Strength of Recommendation: This recommendation has a strength of B based on Oxford Centre for Evidence-Based Medicine due to consistently lower quality limited evidence that supports the use of advanced cardiac testing in identifying heart-related complications and risk of sudden cardiac arrest/death in COVID-19–positive patients.

Occupational exposure limit guidelines using wet bulb globe temperature (WBGT) distinguish between acclimatized and unacclimatized workers with about a 3°C difference between them. For the first time, empirical data from two laboratories provide support for acclimatization state adjustments. Using a constant difference rather than increasing differences with metabolic rate better describes the limit for unacclimatized participants. Furthermore, the lower upper limit of the prescriptive zone (ULPZ) values set forth for women do not relate to fitness level but are partly explained by their smaller body surface area (BSA). An examination of individual ULPZ values suggests that many unacclimatized individuals should be able to sustain safe work at the exposure limit for acclimatized workers.

Clinical Scenario: Athletic trainers should be aware of how physical activity may influence the risk of nocturnal hypoglycemia in adolescents with type 1 diabetes (T1D). Clinical Question: Does the timing and intensity of physical activity affect the occurrence and risk of nocturnal hypoglycemia in adolescents with T1D? Results of the Search: Four studies meeting the inclusion criteria were found and included in the appraisal. Three studies were prospective observational cohorts, and one was a randomized case-crossover study. Clinical Bottom Line: Adolescents with T1D may be at greater risk of nocturnal hypoglycemia after performing 30–60 minutes of moderate-to-vigorous physical activity during the late afternoon or evening. Implications: Athletic trainers should educate adolescents with T1D and their parents about the risk of nocturnal hypoglycemia after MVPA, and work in collaboration with the diabetes care physician to ensure prevention techniques are included in the patient'’s diabetes care plan. Level of Evidence: Strength of Recommendation Taxonomy Grade B.

Clinical Question: During bouts of exercises in a hypohydrated state, do patients with sickle cell trait compared with patients without sickle cell trait demonstrate higher blood viscosity? Clinical Bottom Line: There is evidence that there is a difference in hematocrit levels in patients with sickle cell trait and patients without sickle cell trait both pre- and postexercise with suboptimal hydration status. Moreover, the effects on hematocrit levels increase over baseline levels in the recovery stages postexercise in patients with sickle cell trait.

Lopez, RM, Ashley, CD, Zinder, SM, and Tritsch, AJ. Thermoregulation and hydration in female American football players during practices. J Strength Cond Res 35(9): 2552–2557, 2021—Little is known about hydration practices and thermoregulation in female tackle football players. The purpose of the study was to examine the thermoregulatory and hydration responses of female professional American football players. Fifteen females from the same tackle football team volunteered for this observational field study. Each subject was observed for 4 practices for the following measures: gastrointestinal temperature (T _GI ), maximum T _GI , heart rate (HR), maximum HR (HRmax), fluid consumption, sweat rate, percent body mass loss (%BML), urine specific gravity (U _SG ), urine color (U _col ), perceptual measures of thirst, thermal sensations, and rating of perceived exertion (RPE). Descriptive data (mean ± SD ) were calculated for all measures. Main measures were analyzed using a repeated-measures analysis of variance. Trials took place during evening practices. Average T _GI during practices was 38.0 ± 0.3° C while maximum T _GI was 38.4 ± 0.3° C ( n = 14). Average practice HR was 118 ± 11 b·min ⁻¹ , while HRmax was 148 ± 13 b·min ⁻¹ . Subjects arrived at practices with U _col of 3 ± 1 and U _SG of 1.018 ± 0.007. Postpractice U _SG (1.022 ± 0.007) was significantly higher than prepractice across all days ( p < 0.001). The average sweat rate across 4 practices was 0.6 ml·h ⁻¹ . Average %BML was 0.3 ± 0.4%. Thirst and thermal sensations were moderate (4 ± 1 and 5 ± 1, respectively), while RPE was 11 ± 1. Female football players tended to have similar physiological responses to males. Although subjects seemed to adequately match their sweat losses with fluid consumed during practice, there was considerable variability in hydration indices and hydration habits, with some subjects experiencing hypohydration and others overestimating their fluid needs. Those working with this population should emphasize the need for hydration education and establish individualized hydration regimens.

Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient’s core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14–0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.