Orchard Sports Injury and Illness Classification System (OSIICS) Version 15.

BACKGROUND: Sports medicine (injury and illnesses) requires distinct coding systems because the International Classification of Diseases is insufficient for sports medicine coding. The Orchard Sports Injury and Illness Classification System (OSIICS) is one of two sports medicine coding systems recommended by the International Olympic Committee. Regular updates of coding systems are required. METHODS: For Version 15, updates for mental health conditions in athletes, sports cardiology, concussion sub-types, infectious diseases, and skin and eye conditions were considered particularly important. RESULTS: Recommended codes were added from a recent International Olympic Committee consensus statement on mental health conditions in athletes. Two landmark sports cardiology papers were used to update a more comprehensive list of sports cardiology codes. Rugby union protocols on head injury assessment were used to create additional concussion codes. CONCLUSION: It is planned that OSIICS Version 15 will be translated into multiple new languages in a timely fashion to facilitate international accessibility. The large number of recently published sport-specific and discipline-specific consensus statements on athlete surveillance warrant regular updating of OSIICS.

Clinical outcomes of 10 years of cardiac screening in elite New Zealand athletes.

OBJECTIVES: To report findings from the High Performance Sport New Zealand cardiac screening programme, including comparisons between sexes and ethnicities. DESIGN: Retrospective cohort study. METHODS: Elite Olympic-sport athletes were screened (2012-2022) with personal/family history, physical examination, resting 12-lead ECG and followed from the date of first screening until July 2022. An audit reviewed screening records, including demographic data, ECGs, follow-up and diagnoses. Flagged/equivocal ECGs were re-reviewed (International Criteria). RESULTS: 2075 ECGs from 1189 athletes (53 % female, mean age 21 years; 83 % European, 9 % Maori, 5 % Pacific Islander, 3 % other) were included. No athletes retired for cardiac reasons; there were no cardiac deaths or major cardiac incidents (mean follow-up from first screening: 6.1 years (range: 0.6-10.9 years)). Diagnoses included Wolff-Parkinson-White (WPW) syndrome (0.7 %) and cardiomyopathies (0.3 %). Overall, 3.5 % of ECGs were abnormal, with ECGs of females more commonly abnormal (4.4 % vs 2.5 %, p = 0.02) and with a higher proportion of ECGs with abnormal T-wave inversion (TWI) (3.1 % vs 0.9 %, p < 0.001) compared to males. Of the abnormal TWI in females (all aged ≥16 years), 47 % was limited to V1-V3 with no other abnormalities. Abnormality rates were similar between Maori, Pacific Islander and European athlete ECGs. CONCLUSIONS: WPW was the most frequent diagnosis, with very little cardiomyopathy found. The proportion of abnormal ECGs was low overall, but higher in females. This was driven by anterior TWI in V1-V3 which was not associated with diagnoses of conditions associated with sudden cardiac death (SCD). There was no difference in the proportion of abnormal ECGs of Maori or Pacific Island athletes compared to European athletes.

Sheffield Shield Cricketers Live Longer than the Age-Matched General Australian Male Population.

Background/objectives: Previous studies have shown a trend that elite athletes tend to live longer than the general population, which has been attributed to the "healthy worker hire effect" and the health benefits of exercise. There have not been any previous studies looking at survival of elite cricketers with the general population as a reference cohort. This study aimed to compare the annual mortality rates of current and retired elite male Australian cricket players to that of the age-matched general Australian male population. Methods: Analysis of publicly accessible dates of birth, death, and cricket debut data for male Australian Sheffield Shield cricket players who played before 2022 and had not died before 1971. Included persons were Sheffield Shield players who lived primarily in Australia during and after their cricket careers. Death rates from 1971 to 2021 (inclusive) were compared to the general Australian male population. Results: 1824 Sheffield Shield players had not died prior to 1971 (798 had played before the 1971 season, 1026 debuting subsequently). There were 586 deaths in the 51 years of observations, compared to 825 expected deaths, giving a Standardized Mortality Ratio of 0.71 (95% CI 0.63-0.80). Conclusion: Elite Australian male Sheffield Shield cricket players outlive the general male population with lower death rates. This is probably due to a combination of the healthy worker hire effect and the health benefits of exercise. This study provides evidence that in terms of longevity, it is safe to play elite-level cricket in Australia.

Comparison of methods for correcting QT interval in athletes and young people: A systematic review.

Screening elite athletes for conditions associated with sudden cardiac death is recommended by numerous international guidelines. Current athlete electrocardiogram interpretation criteria recommend the Bazett formula (QTcB) for correcting QT interval. However, other formulae may perform better at lower and higher heart rates (HR). This review aimed to examine the literature on various QT correction methods in athletes and young people aged 14-35 years and determine the most accurate method of calculating QTc in this population. A systematic review of MEDLINE, EMBASE, Scopus, and SportDiscus was performed. Papers comparing at least two different methods of QT interval correction in athletes or young people were included. Quality and risk of bias were assessed using a standardized tool. The search strategy identified 545 papers, of which 10 met the criteria and were included. Nine of these studies concluded that QTcB was least reliable for removing the effect of HR and was inaccurate at both high (>90 beats per min [BPM]) and low (<60 BPM) HRs. No studies supported the use of QTcB in athletes and young people. Alternative QT correction algorithms such as Fridericia (QTcF) produce more accurate correction of QT interval at HRs seen in athletes and young people. QTcB is less accurate at lower and higher HRs. QTcF has been shown to be more accurate in these HR ranges and may be preferred to QTcB for QTc calculation in athletes and young people. However, accurate QTc reference values for discrete HRs using alternative algorithms are not well established and require further research.

Analysis of athlete QT intervals by age: Fridericia and Hodges heart rate corrections outperform Bazett for athlete ECG screening.

BACKGROUND: Cardiac screening of elite athletes including a 12­lead electrocardiogram (ECG) is recommended by numerous international bodies. Current athlete ECG interpretation guidelines recommend the Bazett method to correct the QT interval (QTc). OBJECTIVE: This study sought to investigate normative QTc changes by age using athlete screening ECGs and different QT correction methods in a population of elite cricketers. METHODS: Initial cardiac screening ECGs from an existing database of elite Australian cricketers aged 14-35 years were examined. Average QT interval, QTcB (corrected QT-Bazett), QTcF (Fridericia), QTcH (Hodges), and heart rate (HR) were analyzed by age and sex. RESULTS: A total of 1310 athletes (66% male, 34% female) were included with mean age 19.1 years and mean heart rate 66.9 bpm (range 38-121 bpm). With increasing age, HR decreased and absolute QT increased. The pattern of QTc change with age differed depending on the method of correction: Bazett correction (QTcB) demonstrated a "dish-shaped" or broad U-shaped appearance; while Fridericia and Hodges corrections showed a linear increase in QTc from young to older age. The Bazett method had a stronger correlation of HR with QTc (R2 = 0.32) than either Fridericia (R2 = 0.0007) or Hodges (R2 = 0.009) methods. CONCLUSIONS: The Bazett method is not the most accurate QT correction in athletes, especially during adolescence. In elite cricketers, QTcB revealed a drop in QTc from adolescence to early adulthood due to mis-correction of the QT interval. The Fridericia method has the smoothest correction of HR and least QT variation by age and may be preferred for athlete screening.

Reduced death rates of elite Australian Rules footballers compared to age-matched general population.

OBJECTIVES: To determine age-matched death rates of current and retired elite male Australian football players (Australian and/or Victorian Football League) with the general population. DESIGN: Analysis of publicly-available birth, debut and death data for all Australian Victorian Football/Victorian Football League players who debuted prior to (and were still alive at) the start of 1971 or debuted 1971-2020. METHODS: Wikipedia was used to source the dates of death (or record that the player was alive in 2021) for the cohort. New players became part of the cohort for analysis on debut and existing cohort members left it at death. Actual death rates (per year and per decade) were then compared to expected deaths, based on age-specific population death rates. RESULTS: There were 5400 players and ex-players in the cohort at the start of 1971 (average age 47.3) and a further 4532 players debuted between 1971 and 2020 inclusive (a total of 9932 players). The expected deaths for the cohort in this 50-year period were 4955, but only 3914 deaths occurred (Standardized Mortality Ratio 0.79, 95 %CI 0.76-0.82). For younger members of the cohort (age <50) the discrepancy between expected (222) and actual (98) deaths was also significant (Standardized Mortality Ratio 0.44, 95 %CI 0.35-0.56). CONCLUSIONS: We conclude that the death rates of elite male Australian footballers are lower than the reference general population, similar to other studies of elite athletes. Some of this may be explained by "healthy cohort" selection bias, a limitation which affects almost all studies in this genre.

The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review.

Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6-22.8% vs. 0-5.0%) and anterior TWI (3.7-14.3% vs. 0.6-2.0%). Black athlete subgroups in Africa had TWI (20-40%) and anterior TWI (4.3-18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.

Use of a smartphone electrocardiogram to diagnose arrhythmias during exercise in athletes: a case series.

Background: While athletes are generally very fit, intense exercise can increase the risk of atrial fibrillation. Moreover, other arrhythmias such as atrial flutter or supraventricular tachycardia can cause distressing, exercise-related symptoms. Given symptoms are infrequent and may occur during intense exertion, traditional monitoring devices are often impractical to use during exercise. Smartphone electrocardiograms (ECGs) such as the Alivecor Kardia device may be the portable and reliable tool required to help identify arrhythmias in this challenging population. This case series highlights the use of such devices in aiding the diagnosis of arrhythmias in the setting of exercise-related symptoms in athletes. Case summary: The six cases in this series included one elite non-endurance athlete, two elite cricketers, one amateur middle-distance runner, and two semi-elite ultra-endurance runners, with an age range of 16-48 years. An accurate diagnosis of an arrhythmia was obtained in five cases (atrial fibrillation/flutter and supraventricular tachycardias) using the smartphone ECG, which helped guide definitive treatment. No arrhythmia was identified in the final case despite using the device during multiple symptomatic events. Discussion: The smartphone ECG was able to accurately detect arrhythmias and provide a diagnosis in cases where traditional monitoring had not. The utility of detecting no arrhythmia during symptoms in one case was also highlighted, providing the athlete with the confidence to continue exercising. This reassurance and confidence across all cases is perhaps the most valuable aspect of this device, where clinicians and athletes can be more certain of reaching a diagnosis and undertaking appropriate management.

Exercise after pregnancy.

BACKGROUND: Exercise is a critical protective factor for most chronic medical conditions and is strongly recommended during pregnancy and the postpartum period. The preventive health effect of exercise status (versus non-exercise) is similar to the effect of being a non-smoker (versus smoker). This makes lifelong exercise habits for the population critical for public health. Childbirth is a traumatic process (whether vaginal or by Caesarean section) that temporarily prevents usual exercise postpartum. OBJECTIVE: The aim of this article is to describe the return to normal exercise in the months postpartum, including the additional challenge of commencing good exercise habits for those new mothers who were not regular exercisers before childbirth. DISCUSSION: Pelvic issues, regardless of mode of delivery, affect return to exercise postpartum. Development of musculoskeletal injuries is also a significant risk, for example De Quervain's tenosynovitis from new activities such as changing, bathing and nursing. Hormonal and postural changes, extra body weight and support networks all affect successful return to exercise.

A Review of Legal, Ethical, and Governance Issues for Team Doctors.

OBJECTIVE: To provide a review and discussion of a range of legal and ethical issues commonly faced by team physicians, with reference to high-profile international integrity crises in sport that have involved doctors. The article also presents some recommendations and guidance for team doctors and sporting organizations. DATA SOURCES: Media reports, legal cases, and journal articles describing recent sporting integrity crises that have involved medical issues and governance reforms which are emerging in response. MAIN RESULTS: Many of the modern "integrity crises" in sport have a medical aspect (eg, doping cases, catastrophic injuries and illnesses, "Bloodgate" and other "medical cheating," sexual contact between doctors and athletes, harassment/bullying of doctors, concussion mismanagement, and management of the coronavirus pandemic in sport). A key issue is that while doctors bear ultimate responsibility for any perceived medical negligence, they do not always have ultimate power in decision-making. This is common in the traditional governance structure where the coach/manager "outranks" the doctor and can overrule medical decisions. There can be a blurring of the traditional doctor-patient relationship, especially on tour, and conflicts of interests occur when the needs of the employer/sporting organization differ from the player (patient). Further issues can arise in treating other staff members and players' family members. CONCLUSIONS: Doctors must be aware of range of important legal and ethical issues that arise in the team setting. Medical integrity crises have inspired governance reforms, such as policy development, appointment of chief medical officers, medical staff reporting to integrity departments, and sanctions of teams that breach medical integrity requirements. Sporting organizations must continue to implement and strengthen frameworks reinforcing doctors' seniority in the medical area.

'Stay home when sick' advice: implications for sport and exercise.

The coronavirus pandemic has given everyone in society an education on the harms of spread of respiratory illness. Young healthy athletes are far less likely to suffer severe adverse consequences of viral illnesses than the elderly and frail, but they are not completely immune. Chronic fatigue (overtraining) is an uncommon outcome and myocarditis a rare one, but they both warrant due consideration. It is, therefore, a sensible individual strategy to 'stay home when sick' if only for these risks. Traditionally though, athletes have tended to push through (train and play when ill) because of competing concerns, such as key events/matches and 'not wanting to let teammates down'. Data from both low COVID-19 and high COVID-19 countries show that the number of cardiovascular deaths in a society correlates with the number of respiratory deaths at the same time, further linking respiratory viruses to cardiovascular deaths. We are now more aware of public health obligations to prevent the spread of respiratory illnesses, in particular to protect the more vulnerable members the community. This hopefully will correspond with a change in the culture of sport to one where it is considered 'the right thing to do', to 'stay home when sick'.

Comparison between a 6­lead smartphone ECG and 12­lead ECG in athletes.

Athletes sometimes experience transient arrhythmias during intense exercise, which may be difficult to capture with traditional Holter monitors. New and highly portable technology, such as smartphone electrocardiogram (ECG) devices, may be useful in documenting and contribute to diagnosis of exercise-induced arrhythmias. There are little data available regarding the new Kardia 6 lead device (6L) and no data regarding its use in athletic populations. In this short communication, we present pilot data from 30 healthy athletes who underwent a 12­lead ECG and subsequent 6L reading. Our pilot data show relatively high levels of agreement for QTc and PR interval and QRS duration, with the 6L readings slightly but significantly shorter on average.

Cardiovascular Screening of Elite Athletes by Sporting Organizations in Australia: A Survey of Chief Medical Officers.

OBJECTIVE: To compare cardiovascular screening policies of Australian elite sporting organizations. DESIGN: Online survey. SETTING: Elite/professional sports in Australia. PARTICIPANTS: Chief medical officers (CMOs) of elite/professional sports in Australia, including rugby union and league, cricket, tennis, Australian football, and cycling. ASSESSMENT OF VARIABLES: Survey questions about each sport's cardiac screening policy: which screening components were included [eg, history and physical (H&P), resting 12-lead electrocardiogram (ECG)], whether screening was mandatory, whether the policy applied to elite junior and/or adult players, and which criteria were used to interpret ECGs. MAIN OUTCOME MEASURES: Which sports had a formal cardiac screening policy, which athletes the policy applied to, components of screening, ECG interpretation criteria used. RESULTS: Chief medical officers for 22/31 (71%) sports responded, representing >5000 athletes. Of these, 19/22 (86%) perform regular screening (100% H&P; 89% included ECG) with international cyclists also having routine echocardiograms and stress testing. Thirty-three percent of CMOs used the 2017 International Criteria for athlete ECG interpretation. Screening was mandatory with enforcement (26%), mandatory without enforcement (48%), and opt-out (26%). All screened adult elite athletes, and 68% screened junior elite athletes. Forty-two percent indicated athletes were required to pay for screening tests, and 63% required athletes to pay for follow-up tests. Almost all (94%) sports with a sports physician as the CMO screened athletes. CONCLUSIONS: Most sports have a screening policy, with reasonable uniformity of components. All included H&P, and almost all included ECG. Only one sport included an echocardiogram and stress test as a standard (international players only). Promoting the latest ECG interpretation criteria may reduce false-positives and cost. Future work should explore cardiac emergency plans, screening infrastructure, cost, and long-term follow-up.

Fifteen-week window for recurrent muscle strains in football: a prospective cohort of 3600 muscle strains over 23 years in professional Australian rules football.

OBJECTIVES: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors. METHODS: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place. RESULTS: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era. CONCLUSION: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play.

Audit of a cardiac screening policy for elite Australian cricketers.

OBJECTIVES: To report the compliance and results of an electrocardiogram (ECG) cardiac screening program in male and female elite Australian cricketers. DESIGN: cross-sectional study. METHODS: Elite cricketers were offered screening in accordance with Cricket Australia policy. Players who consented provided a personal and family history, physical examination and resting 12-lead ECG. An audit (1 February 2019) examined all cardiac screening records for male and female players in all Australian Cricket state squads from 16 years upwards. Data extracted from the Cricket Australia database included the number of players who underwent screening; signed waivers opting out; and had follow-up tests. ECGs were re-reviewed according to the International Criteria. RESULTS: 710 players were included in the cohort (mean age 20.4±4.9 years, 62% male). 692 (97.5%) players underwent recommended cardiac screening or signed a waiver opting out (1.1%). 173 (24.4%) players were screened (or signed a waiver) more than once. Follow-up testing was conducted for 59 (6.9%) cases. No players were excluded from sport due to a cardiac problem and no major cardiac incidents occurred to any player in the audit cohort. Review of 830 ECGs showed benign athlete heart changes, including sinus bradycardia (33.5%), left ventricular hypertrophy (16.3%), and incomplete/partial right bundle branch block (8.4%), were common but abnormal screening ECGs were uncommon (2.0%). CONCLUSIONS: An audit of a cardiac screening program in elite Australian cricketers found excellent compliance. A small proportion required follow-up testing and no player was excluded from sport due to a cardiac problem. ECG analysis suggested cricket is a sport of moderate cardiac demands, with benign athlete heart changes common.