Predicting Preventable Injuries

A realization that "we were delivering performance-enhancing services to groups that were not healthy to start with" was the impetus for SportMedBC's Athlete Enhancement Program, a health screening protocol for Team BC athletes, explains Lynda Cannell, SportMedBC's, President & CEO. Team BC is formed from athletes throughout the province – mostly aged between 16 and 19 – to compete at semi-annual Canada Summer and Winter Games.

Wendy Epp, a physiotherapist who proposed the program, explains: "we lose a lot of young athletes to injuries that could have been prevented. Kids were missing a critical part of their sport development years to chronic injuries. I felt that if we could be predicting some of these things by specifically addressing their needs before they were injured, we wouldn't be losing so many kids at local to provincial level, and we might see more athletes going on to higher level performance." Epp herself experienced a chronic injury as a teenage member of the provincial volleyball team, losing a season's play. She also sees athletes in her two physiotherapy practices, sidelined by chronic injuries "all the time. They are frustrated at their inability to fully participate in a training program – and it hurts."

Cannell attributes the rise in childhood injuries to increased training demands. "I see athletes today, versus 10 years ago, who are injured at a younger age and more frequently injured. I think a lot of that is because of the introduction of dry land training – additional workouts, off-court, off-ice, whatever – that are designed to supplement their physical status. The problem with this is that the athletes may not get proper direction on volume and intensity and their technique may be poor," says Thomas. The problems are compounded in teams, she says, where individual needs may not be properly addressed by the "group" delivery. "The shift from being a teenager to an adult is where we see a lot of adults getting hurt."

How do teenage athletes, after years of coaching, reach the high level of Canada Games competition with chronic injuries? "They are masters of compensation; they will find a way to participate," says Epp, pointing out that as well as their passion to play, athletes have often used a variety of therapies and medication to help them through tough pain.

The goal of the Athlete Enhancement Program is to provide multi-disciplinary screening during training camps for Team BC's individual and team athletes, about 18 months prior to their Summer or Winter Games' competition. The program was piloted with the freestyle ski team preparing for the 1999 Canada Winter Games and has been used for Summer and Winter Games teams since 2000.

Screening of the athletes is carried out by physiotherapists, athletic therapists, physicians, strength and conditioning specialists and mental trainers. SportMedBC recruits sports medicine physicians from communities where training camps are being held, and Epp trains local physiotherapists, when possible, to help carry out that part of the assessment. The physiotherapy screening is a head to toe 45 minute evaluation, including posture, strength, range of motion and functional movement. "We are looking at everything from neck range of motion to ankle range of motion," explains Epp. The strength and conditioning specialists and coaches observe the session. Based on the findings, the therapist gives the athlete a program to address their conditioning needs, which the strength and conditioning specialist discusses with the athlete and coach. The coach then "becomes the manager of the physical prescription," says Epp. She says that coaches are generally grateful for the intervention. "The toughest thing for them is having to give up half a day of their training camps or practices," she laughs. Indeed, the process has "created a whole new level of awareness" for athletes and coaches, says Cannell. Epp agrees, calling the leap in awareness "huge." For example, during an examination of a member of the freestyle ski team, with the coach observing, she discovered that the athlete had "absolutely no internal rotation in their left hip." For the coach, "who had been struggling with this athlete for three years, trying to get him to turn left, the finding was overwhelming," recalls Epp. "His mouth just dropped – he said ' he will never be able to achieve what I have spent so much of our time and energy on trying to achieve. So we will figure out a way around this.'"

For the medical screening, athletes complete a detailed medical history questionnaire, which is reviewed by the physician. In the process, the doctor can discuss findings with the therapists. The physicians focus primarily on "red flags and the athlete's overall level of health," explains Cannell. Later, athletes meet with mental trainers after filling out an extensive questionnaire which provides an inventory of their current mental skills.. Controlling anxiety before and during competition is the major emotional factor, says Cannell.

What have the health professionals uncovered in their intensive screening? After collecting data from 600 athletes in 32 team and individual sports, weak core conditioning is the overwhelming finding. Were they surprised? "The thing that surprised me was how extensive it was," says Cannell, noting that the weakness was prevalent in every sport except judo. The weakness was also consistent across gender and age parameters. Why does poor core strength cut such a wide swath through this broad group of athletes? "Part of it is awareness," says Epp. Coaches and athletes may be familiar with the core conditioning term, and carry out abdominal exercises such as situps, but may not have encountered the concept within a context as specific as the screening. "We are trying to get them to be a little more sophisticated in their understanding of core. The goal is to make sure that coaches get the information to kids at a more sophisticated level than just curl-ups and crunches," says Epp. She notes that in the few teams she has been able to follow up, core conditioning has "definitely improved," a situation she calls "a pretty telling sign."

SportMedBC and Epp's data is unique in the world, she says, and with the ability to draw about 500 comparisons from it, the implications could be far-reaching. So how do they hope to use their ever-increasing pile of information? Ultimately, they would like to reach athletes at a much younger age – at 11 or 12 – than the Team BC age group. SportMedBC would like to identify basic trends from the wide range of sports represented by the Team BC athletes, and use that to develop a predictive model for injury prevention. That knowledge could help coaches design better training programs, says Epp. She would also like to look at improving school and community physical education and sports programs, based on physical findings at different ages. For example, "I'd like to be able to say 'young girls aged 12 to 15 have very flexible hips but they don't have a strong core'."

Epp has begun sampling data from about 900 athletes, to see how many required core strengthening prescriptions and their ages. "My hope is that we can say to coaches: 'your athletes aged from 12 to 14; 80% of them required prescriptions that were based on strength. Your athletes aged from 16 to 18 – such and such a percentage required flexibility in their program design. Or, looking at your sport, 94% of your athletes required core strengthening. You need to start including that in your program design'." These needs, and others identified by the data could therefore be used as a basis for designing more precise training programs: "we could base it on gender, we could base it on sport, we could base it on specific body segments," says Epp.

Meanwhile, Epp feels the screening program has proved to be a valuable intervention. "There hasn't been a sport so far that hasn't had one or two athletes that were just at the brink of missing significant training time. In every sport we have tested we have been able to get these athletes on track in time to compete." But Epp says the physiotherapy screening does not have an edge over examinations that could be performed by any specialized sports therapist, given sufficient time in a busy clinic: "It's not rocket science. It's information that isn't hard to find if you take a step back and look at the athlete as a whole," rather than limiting assessment to the painful area that is bringing the patient in the door. The therapist can then identify trends and predict potential injuries. And that ability to focus on prevention is the "golden opportunity" that the intensive screening program provides, says Epp. "For me, it is how can we prevent these kids from falling out of sport entirely, having chronic injuries that take them out of critical developmental years of sport or make them not enjoy sport – that is what has been motivating me throughout this whole process."

Heather Kent is a Vancouver freelance medical writer. She is a regular contributor to North American health and medical publications.
 

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