Sport-related concussion is a growing health concern in Australia. Research into the management of concussive injuries is progressing rapidly and so too are the guidelines for diagnosis, removal from sport, management, return to learn and return to sport.

In partnership with the Australian Medical Association, Australasian College of Sport and Exercise Physicians and Sports Medicine Australia, the AIS has developed the following resources outlining best practice management for sport-related concussive injuries.

Concussion in Sport Australia webpage

Recent advances in the field of genetics have led to an increase in use and availability of genetic testing. While genetic testing has proven to be of value in clinical medicine, there is no evidence to support the use of genetic testing for athletic performance improvement, sport selection or talent identification. Use of genetic testing as an absolute predictor of athletic prowess or sport selection is unscientific and unethical.

The following resources developed by the AIS address the implications of recent advances in the field of genetics and the consequences for athlete health and wellbeing.

Athletes with spinal cord injuries are at increased risk of developing urinary tract infections. However, information around prevention and management is limited, particularly for elite spinal cord injured athletes.

The following resource developed by the AIS and the Australian Paralympic Committee represents a set of clinical recommendations for the prevention and treatment of urinary tract infection in spinal cord injured athletes.

1. The ASMC re-affirms the well-recognised position that for the vast majority of young individuals, regular exercise is not only safe but should be encouraged.

2. Exercise has a beneficial effect on many health outcomes and may also help improve academic performance.

1. Regular moderate to vigorous physical activity (MVPA) in the childhood and adolescent years has both short and long-term benefits. These include improved aerobic fitness and strength, more favourable body composition, improved bone density, reduced symptoms of anxiety and depression, improved school performance and  reduced cardiometabolic risk.

3. The ASMC supports the WHO, Australian Government Department of Health, and New Zealand Ministry of Health guidelines for physical activity for children and youth aged 5-17.

1. Children and youth should accumulate at least 60 minutes of moderate - to vigorous intensity physical activity
   daily.
2. Amounts of physical activity greater than 60 minutes provide additional health benefits.
3. Most of the daily physical activity should be aerobic. Vigorous-intensity activities and those that strengthen muscle and bone should be performed at least 3 times per week.
4. Sitting time should be broken up and recreational screen time should be limited to no more than two hours per
   day.

4. However, the ASMC notes that there has been a growing trend toward young athletes specialising at an early age in a single sport. It appears that the major societal driver of this is a perception that early specialisation leads to increased sporting success.

5. In this position statement the following definitions are used. These reflect the most commonly accepted definitions in the relevant literature:

1. A ‘young athlete’ is defined as an athlete 18 years old or younger.
2. Sport specialisation is defined as the intensive, year-round training in a single sport at the exclusion of other sports.
3. ‘Early’ specialisation is defined as sport specialisation occurring before the age of 12.

6. A young athlete’s degree of specialisation may be ascertained by the use of three questions:

1. Does the athlete play or train for more than eight months per year in a given sport?
2. Does the athlete choose a main single sport?
3. Has the athlete stopped playing other sports to focus on a single sport?

7. The ASMC notes that, with the exception of rhythmic gymnastics, there is no evidence that early specialisation is beneficial in achieving elite status in sports where peak performance is attained in adulthood.

1. In fact, there is evidence to the contrary, suggesting that athletes who maintain a broader sporting base till after the age of 12, then specialize, are more likely to be ‘successful’ in their chosen sport.
2. There is one paper that suggests that a combination of organised training and free play based on a single sport may lead to increased sporting success at a junior level. This has not been proven or disproven to lead to success at an adult level.
3. Popular concepts that advocate early specialisation (e.g. the 10,000 hours concept), were never intended to be applied to sport and are not relevant in the sporting context.
   • The concept of early sports specialisation improving the chances of ‘future success’ largely came from retrospective studies comparing expert and non-expert musicians. Sport Specialisation in Young Athletes — Position Statement

8. There is evidence to suggest that there are physical harms associated with sport specialisation.

1. There is evidence that young athletes with overuse injuries are more likely to be highly specialised than uninjured athletes.
   • This risk is independent of age, sex, and total hours of organised sport.
2. However, athletes with acute injuries may be less likely to be sport specialised.
3. Resistance training among these at-risk populations has been shown to reduce injury risk by up to 68% and improve sport performance and health measures, in addition to accelerating the development of physical literacy.

9. There is an association between early sport specialisation and a number of more general harms. There is evidence that early sport specialisation may lead to:

1. Lower overall perception of health,
2. Earlier cessation of sporting activity and possible burnout,
3. Less fun derived from playing sport,
4. ‘Psychological needs’ dissatisfaction – which is a predictor of mental illness.

10. There are a number of simple rules that can guide appropriate training loads in young athletes. These can be used by those who have a duty of care over young athletes. Therefore, the ASMC recommends that;

1. At any available opportunity, parents, coaches, athletes and sporting bodies should be made aware of both the
   lack of benefits and the increased risks of harms associated with early specialisation.
2. Athletes under the age of 12 should be encouraged to partake in a wide range of physical activities, both organised and informal, to maximise their health outcomes.
3. Informal physical activity (‘free play’) should be encouraged as a valid form of physical activity especially in those under 12.
4. Those who wish to focus on a single sport should be encouraged to delay specialisation until after the age of 12, or even until late adolescence.
5. An athlete’s readiness to specialise should not be determined by physical maturity alone. Social, emotional and psychological maturity is also required in order to successfully specialise in one sport.
6. Those individuals who have control over the training parameters of young athletes consider the use of simple guidelines in order to minimise the risk of issues relating to early specialisation, sport specialisation and training volume. These include:
   • Limiting total sport participation (training and competition) to no more than 16 hours per week, irrespective of the total number of sports played,
   • Ensuring that the ratio of hours spent in organised sport (training and competition) to those spent in ‘free play’ does not exceed 2:1,
   • Limiting hours spent in organised sport (training and competition) per week such that they do not exceed the athlete’s age. E.g. a 10 year old should not train more than 10 hours per week across all sports (this supersedes point 10.f. (first dot point) above where relevant),
   • Adhering to the evidenced-based load guidelines for a specific sport (e.g. Cricket Australia Youth Pace Bowling Guidelines).

COVID-19 is increasingly having an impact on the global community and is a rapidly evolving issue. Government organisations, public health units and the World Health Organisation (WHO) continue to provide accurate, timely and detailed updates relevant to the whole community.

This resource is intended to provide an overview of the currently available information highlighting the unique needs and challenges for elite Australian sport particularly in their preparation for the Tokyo 2020 Olympic Games.

Novel Coronavirus 2019 and sporting activity webpage

Bushfire smoke can pose a health risk to recreational and high performance athletes. The health impact of bushfire smoke can vary based on an individual’s current health status and previous medical conditions. Current public health advice is aimed at high-risk groups, including people over 65, children 14 years and younger, pregnant women and those with existing heart or lung conditions. However, athletes involved in high performance sport can also be at increased risk while performing high intensity prolonged exercise outdoors and additional caution should be taken.

When pollution exposure is at low levels, the respiratory tract’s usual defence mechanisms trap, transport and clear pollutants effectively. With elevated exposure, short-term accumulation can occur resulting in inflammation and this can exacerbate a number of health conditions with asthma being the most common in athletes.

During exercise, respiratory rate and volume increases, this in turn increases the total airway exposure to pollutants. In high performance athletes, moderate exercise can increase the total amount of air passing through the airway by more than 10 times and vigorous exercise by more the 20 times, compared to resting values. Even at moderately reduced air quality, this can represent a significant increase in pollutant exposure during a one-hour, high intensity training session.

Most State and Territory government websites (except for Tasmania and Victoria) present air quality information as the ‘Air Quality Index’ or AQI calculated from a 24-hour average. The AQI is calculated for a number of pollutants (including fine and coarse particulate matter, carbon monoxide and ozone). It was designed as a way to standardise information across these different types of air pollution. This means that the AQI number is not a raw measurement (e.g. micrograms of pollutant per metre cubed of air), but a scale based on how much the reading is above (or below) the air quality standard. Some States and Territories provide the AQI separately for different pollutants, others provide only a composite AQI that is based on the pollutant that is the worst. For more details on how the AQI is calculated in your area, please see your local air quality agency’s website.

PM2.5 are very small particles usually found in smoke. They have a diameter of 2.5 micrometres (0.0025 mm) or smaller. PM2.5 particles are a common air pollutant. Breathing in PM2.5 particles can have negative effects on your health. PM2.5 particles are small enough for you to breathe in deeply into your lungs. Sometimes particles can enter your bloodstream.

PM2.5 is measured at all air quality measuring sites in Australia. The other pollutants that make up the AQI are not measured everywhere in Australia. This means that PM2.5 has the relevance for providing a standardised guidelines for all of Australia. PM2.5 is also by far the most important air pollutant in smoky conditions.

Smoke concentrations in the atmosphere can vary markedly within a short distance (e.g. 2 km) and can change rapidly over time. 24 hour rolling average of PM2.5 is useful for knowing the average PM2.5 levels in the air over the past 24 hours, at a point in time.  The 24 hour rolling average does not however necessarily give an accurate understanding of real-time PM2.5 concentration.  For individuals wishing to make decisions about whether it is safe to exercise now, or over the next couple of hours, having real-time or hourly averages of PM2.5 is important.

For these reasons, the AIS guidelines are based on real time or hourly PM2.5 readings.

There are three ways to get information on PM2.5 concentration levels (measured in µg/m³):

1. State and Territory air quality monitoring websites (hourly measures of PM2.5 concentration)
2. The AirRater App (or other similar App providing real time PM2.5 in µg/m³)
3. A handheld portable device that measures PM2.5 in real time

State and Territory air quality monitoring websites:

The following links will be useful in helping you find the relevant website in your State:

• Australian Capital Territory
• Victoria
• New South Wales
• Queensland
• Western Australia
• South Australia
• Tasmania

Unfortunately, different States and Territories have slightly different systems for measuring air pollution, different means of presenting information and varying categories and systems for different levels of pollution (good, fair, moderate etc.).

The AirRater App was originally funded by the Australian Government and is currently funded by the Menzies Institute for Medical Research. AirRater draws its air pollution information from State and Territory air quality monitoring networks. It presents information on PM2.5 concentration in mcg/m³ and applies the same system of measurement for all locations in Australia. To find out more about how AirRater sources and presents its data, go to the following site: https://airrater.org/air-quality-explainer/.

There are range of commercial handheld measurement devices available for measuring PM2.5 concentration in the atmosphere. It is important that the device used is designed for measurement of outdoor rather than indoor concentrations of PM2.5. Teams and sporting clubs may wish to utilise one of these devices for providing real-time measures of PM2.5 concentration at their specific location at the time that they wish to exercise. That value can then be used to advise athletes and officials about appropriate exercise activity.

Table 1 below has drawn on information from several of the Australian State and Territory websites and modified information specifically for application to decisions around physical exercise in smoke affected environments. There are many factors that contribute to readings found on State and Territory websites, air-quality apps and handheld devices. The numbers on the table below are a guide and should not be taken as absolutes. There is a need to use common sense in assessing the environment and utilising other factors such as visibility in making a decision about whether or not exercise is appropriate.

Table 1. Guidelines for exercise in smoke affected environments

The above table provides exercise guidelines but individuals should also remember that there is high variability in PM2.5 across relatively short distances and quite rapid changes across time. Those wishing to exercise should also take note of the visibility and keep in mind their own individual experience of sensitivity to smoke pollution. The following visibility guidelines should be considered in conjunction with the information from the above table. These visibility guidelines are based on those of the Victorian Environment Protection Authority

Table 2. Activity levels based on visibility

• Air quality information on State and Territory government websites is generally updated hourly; therefore, there can be a lag between official measurements and what is occurring in real time. This can cause limitations when it comes to determining the air quality in your local environment. If smoke is affecting usual visibility within your area, it is likely that the air quality will fall into a higher risk category.
• Consecutive days of exposure to polluted air can have a cumulative effect, lowering an athlete’s threshold for symptoms. This should be considered if your region has been exposed to increased smoke for several days in succession.
• Increases in exercise intensity and duration result in increased airway exposure to polluted air. AIS recommends modifying training, or training locations based on the table above.
• All athletes who suffer from asthma should have an updated asthma management plan and consult their doctor prior to exercising in smoke-affected environments.
• Recent respiratory infection increases the risk for development of smoke-related symptoms, even in non-asthmatics.

Overview on Guidelines

Dry needling is within the scope of Physiotherapy/Physical Therapy practice. There are however risks associated with this type of therapy and while the incidence of risk such as induced pneumothorax are classified as rare, they are still a concern identified within research literature. These guidelines outline the essential requirements in the use of dry needling, to inform the growing number of practitioners using these techniques.

Individual States and Territories may have specific legislation applicable to dry needling, covering topics such as skin penetration and infection control. Practitioners must ensure that they comply with local State and/or Territory legislation.

Practitioners engaging in dry needling treatment are encouraged to read and follow these guidelines for general safety and maintenance of clinical standards.

Safe Treatment Procedures

Evidence in the effectiveness of dry needling is limited in the current literature. The benefit to risk ratio of dry needling treatment therefore needs to be considered. In the high performance sport environment, practitioners aim to use innovative and interactive treatments.

Outcomes:

1. Limit the use of needles in anatomical areas of high risk if potential benefits of treatment are outweighed by potential side effects (this includes areas around lung fields, eyes and neurovascular structures).

2. Practitioners must have high-level knowledge of local anatomy and anatomical variations in areas of risk.

Experience in needle use differs from practitioner to practitioner. Not all practitioners are skilled in use of dry needling in high-risk anatomical areas.

Outcomes:

3. Where any doubt exists, practitioners should refer to or seek guidance from other practitioners with appropriate experience.

4. Practitioners should stay up to date with current trends and research, while engaging in continued professional development to remain competent in this field of practice.

Treatment consent

Consent must be obtained from the client before proceeding with any dry needling practice. A practitioner may be deemed liable for an unavoidable complication when the risks of that complication were not initially explained to the athlete.

Dry needling should not occur unless the risks of the procedure have been explained to, and accepted by the patient.

Several components constitute valid treatment consent:

• Consent must be voluntarily given,
• Consent must be informed; practitioners breach their duty of care if they fail to warn the athlete of the risks associated with treatments or procedures they are going to perform, and
• Consent must be obtained from those with legal capacity to do so; adults (18 years and over); children require parental or legal guardian consent [NSO coaches within the AIS daily training environment are seen as holding legal guardianship].  While common law recognises that the rights of a child to consent increases as their ability to understand and comprehend increases, caution must always be exercised.

Outcomes:

5. Consent to have dry needle techniques administered must be voluntary from the athlete.

6. Information of the treatment to be given must be explained in full to the athlete.

7. Informing athletes of the potential risks associated with dry needle techniques is an important and essential part of any treatment regime.

8. Consent can be provided in either a verbal or written form. Where provision of consent is verbal, the obtaining of consent must be noted in the AMS medical record at the time of treatment.

An information sheet (example provided in Appendix A) must be provided to the patient receiving treatments over and around the trunk area. This sheet should detail warning signs relating to pain or treatment complications as well as the emergency procedure to follow if significant symptoms occur after treatment.

Outcomes:

9. Explain adequate warning signs and management protocols if utilising skin penetration in areas over or adjacent to lung fields.

10. Provide the client with an information sheet with warning signs and emergency protocols to ensure they are adequately informed of the appropriate post-treatment care.

Practice specific requirements

• Any practitioner conducting dry needling in clinical practice will have undertaken an appropriate formal course of training. This includes massage therapists who must hold a nationally recognised diploma or advanced diploma (AQTF standard). If dry needling has been learnt at a post-graduate workshop, practitioners must complete a minimum of 60 hours face to face training and 15 hours supervised clinical practice (AMT – massage therapy code of practice).
• Practitioners must ensure they have appropriate indemnity insurance that covers dry needling practice.
• Within certain controlled environments outside of the AIS, such as at Olympic or Commonwealth Games, practitioners will not perform dry needling unless they have received prospective approval to do so by the Medical Director and/or the Head of Physical Therapies.
• It is recommended that in an NSO environment, no practitioner performs dry needling unless they have received prospective approval to do so by the Medical Director, Head of Physical Therapies and/or High Performance Director
• A greater degree of caution must be exercised in environments where there is reduced opportunity for backup support in the event of any adverse outcome from dry needling. Such environments include overseas travel and remote locations. NSOs and practitioners should consider whether dry needling is appropriate in situations where teams are remotely located and/or there is no doctor located with the team.
• All dry needling treatments must be recorded in the AMS medical record

Dry Needling on AIS Campus site

• All Dry Needling conducted within the AIS campus must follow the AIS Dry Needling Protocols, this includes treatment administered at training venues or in the athlete Residential Village.
• The practice of dry needling at the AIS must at all times be conducted in accordance with government regulations pertaining to safety and hygiene. The AIS is subject to annual inspections in relation to the infection control activity license from the ACT government, specifically for the purpose of dry needling.

Sharps and body penetration procedures

These requirements are in line with the APA position statement on skin penetration (November 2007), ACT Health, Infection Control Guidelines for office practices and other community based services (2006) and Australian Guidelines for the Prevention and Control of Infection in Healthcare NHMRC.

• Wash hands appropriately before treatment and handling of needles, prior to insertion and removal of needles (hand washing is the first step in infection control programs).
• Treatment area must be appropriately conducted within a treatment cubicle or an area of low traffic to prevent accidental movement of needles or an athlete (particularly in the case of treatment of high-risk areas such as the thoracic spine).
• The work area must be clean and tidy.
• Cover work surfaces with disposable coverings (sheet/ towel/disposable covers).
• Disinfect skin in treatment region with swab (70% isopropyl alcohol or povidone-iodine).
• Sharps should be handled with care in order to prevent accidental needle stick injury.
• All sharps must be immediately and appropriately disposed of in a recommended Australian Standards container after use. This applies in both clinic and team travel environments.
• All practitioners performing dry needling should be immunised against hepatitis B infection
• A new swab is required be used for each separate area of the body. For example, if needles are to be inserted into the back and the legs, a separate swab is required for the back and each leg.
• All appliances used in the penetration of skin in acupuncture procedures are required to be sterile and single use only. This includes: acupuncture needles, ear press needles, dermal hammers and guide tubes.
• When necessary to grasp a needle shaft to facilitate insertion, the following methods must be used:
  • use a fresh pre-packaged sterile alcohol swab or fresh sterile dry swab
  • use a sterile glove.
• Suction cups and other non-sharp devices applied to a skin area directly after the use of a dermal hammer, lancet or prismatic needle, are required to be cleaned and disinfected or sterilised prior to being reused.
• Bamboo suction cups are single use appliances and must not be reused, as bamboo is porous and difficult to clean after use.