The AIS develops evidence-based position statements on new and complex topics in sports science and sports medicine, in order to provide guidance and leadership for the Australian high performance sports system.
Current positions on:
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.
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.
Urinary Tract Infections
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 Paralympics Australia (formerly, Australian Paralympic Committee) represents a set of clinical recommendations for the prevention and treatment of urinary tract infection in spinal cord injured athletes.
Sport Specialisation in Young Athletes
1. The Australian Sports Medicine Collaborative (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.
- 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 World Health Organisation (WHO), Australian Government Department of Health and New Zealand Ministry of Health guidelines for physical activity for children and youth aged 5-17.
- Children and youth should accumulate at least 60 minutes of MVPA daily.
- Amounts of physical activity greater than 60 minutes provide additional health benefits.
- 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.
- 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:
- A ‘young athlete’ is defined as an athlete 18 years old or younger.
- Sport specialisation is defined as the intensive, year-round training in a single sport at the exclusion of other sports.
- ‘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:
- Does the athlete play or train for more than eight months per year in a given sport?
- Does the athlete choose a main single sport?
- 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.
- In fact, there is evidence to the contrary, suggesting that athletes who maintain a broader sporting base till after the age of 12, then specialise, are more likely to be ‘successful’ in their chosen sport.
- 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.
- 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.
8. There is evidence to suggest that there are physical harms associated with sport specialisation.
- 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.
- However, athletes with acute injuries may be less likely to be sport specialised.
- 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:
- Lower overall perception of health.
- Earlier cessation of sporting activity and possible burnout.
- Less fun derived from playing sport.
- ‘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:
- 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.
- 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.
- Informal physical activity (‘free play’) should be encouraged as a valid form of physical activity especially in those under 12.
- 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.
- 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.
- 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).
Intravenous fluids and their use in sport
Intravenous (IV) fluid prescription in medicine mainly occurs within a hospital setting. The use, timing, type and volume of IV fluids, outside of a hospital setting has, however, evolved over recent decades.
Changes have occurred because of the lessons learnt in operational requirements of military and emergency response teams. Medical practitioners working within the elite sporting environment are required to give consideration to the World Anti-Doping Code (WADC) which places limitations on the location, indications and rate of delivery of IV fluids and infusions.1
Therapeutic Use Exemptions (TUE) can be granted for use of IV fluids with appropriate clinical justification.1,2 There is little information in the medical literature to inform clinicians in the elite sport environment about the appropriate indications for IV fluid use in balancing the medical care of the athlete against the restrictions stipulated in the WADC. This position statement seeks to assist clinicians by providing evidence-based and ethically justified guidelines for the use of IV fluids in emergency situations in elite sport.
1. Physicians must be aware that IV fluid administration is not without risk or harm. There are potential adverse effects from IV fluid administration, including;
- Complications at the injection site (infection, phlebitis and venous thrombosis)
- Fluid and solute overload resulting in electrolyte abnormalities
- Congestive conditions (central and peripheral)
- Acid base imbalances
- Financial cost to administer IV fluids, which includes appropriate staffing and monitoring
2. Recommendations for the treatment of severe dehydration include;
- Monitor clinical signs and symptoms (see Table 2) and consider measurement of plasma sodium and blood glucose
- If IV rehydration is indicated, 10-20 mL/kg bolus of 0.9% sodium chloride initially and consider repeating these boluses until adequate haemodynamics are restored
- Where severe exercise-associated hyponatremia (EAH) is present, manifesting in neurological impairment and inability to tolerate oral hypertonic salt broth, treat with IV hypertonic saline bolus of 100ml 3% Normal Saline, once low serum sodium levels are confirmed.
- A TUE is required if IV fluids are used >100 mL/12 hours, outside of approved settings
Table 1: Clinical signs of dehydration
|% wt. loss||3-5%||6-9%||>10%|
|Pulse||Full, normal rate||Rapid, thready||Very rapid and weak or absent|
|Respiration||Normal||Deep, may be increased||Deep, rapid or decreased|
|Systolic blood pressure||Normal||Normal to low||Low|
|Urine output||Decreased||Oliguria||Oliguria to anuria|
|Systemic signs||Increased thirst, alert||Listless, irritable||Lethargic, coma|
|Capillary refill||2 sec||2-4 sec||>4 sec, cool limbs|
3. Recommendations for the treatment of heat syncope include;
- Encourage oral fluids
- IV fluids are not indicated for the management of heat syncope and therefore no TUE is required
- If there is a failure to improve after 15-20 minutes, transfer to a medical facility for further investigation
Table 2: Simple strategies for the treatment of heat syncope
|Move to shaded, cool area|
|Lay supine with feet elevated above head|
|Oral fluids once mentally alert|
|Fanning the athlete|
|Wet ice towels|
4. Recommendations for the treatment of heat exhaustion include;
- Associated with a core body temperature of elevated to 38.3-40°C
- IV fluids should be considered in the setting of deteriorating mental status or persistent nausea or vomiting
- If there is no rapid improvement following cooling strategies transfer immediately to hospital to exclude heat stroke
- A TUE is required if IV fluids are used >100 mL/12 hours, outside of approved settings
5. Recommendations for the treatment of exertional heat stroke (EHS) include;
- Affects multiple body systems in association with high core temperatures (> 40-40.5°C)
- Aim to cool the patient first and transport second if appropriate medical staff and cooling strategies are present
- IV hydration can be considered for circulatory support in EHS, however small boluses should be given
- A TUE is required if IV fluids are used >100 mL/12 hours, outside of approved settings
6. Recommendations for the treatment of trauma in sport include;
- When there is loss of the radial pulse (or central pulse in penetrating torso trauma), IV crystalloid boluses of 250 mL are recommended
- Boluses are titrated to maintenance of a pulse
- If a significant head injury exists, consider larger volumes to maintain cerebral perfusion pressure
- Priority is to transport the patient to a trauma centre as soon as possible
- A TUE is required if IV fluids are used >100 mL/12 hours, outside of approved settings
7. Recommendations for administration of medication by IV include;
- Only utilised when there is a clear clinical indication for use of that medication
- The IV medication should be checked against the WADA Prohibited List as it may require a TUE
- If not prohibited but the volume of fluid required to deliver the medication is >100 mL in 12 hours, then a TUE is required where administration takes place outside of approved settings
This AIS position statement provides recommendations for physicians working in the elite sporting environment when considering use of intravenous fluids in adherence with the WADC guidelines. The current literature supports appropriate use of intravenous fluids to protect the health of athletes in specific clinical situations. Prioritising athlete health aligns with the WADC. Clinical scenarios within elite sport that warrant use of intravenous fluids include severe dehydration, exertional heat illness, trauma and administration of medications.
Training load in relation to loading and unloading phases of training
This can be used by coaches, performance support team members and organisations in the national high performance sport system as a resource to guide conversations relating to holistic approaches to well-periodised and individualised training load planning following unloading. In 2015, the first version of this was published as part of a multi-disciplinary project including the AIS Disciplines of Medicine, Strength and Conditioning, Sports Nutrition, Physiology, and Physical Therapies. Version 2 has been developed in consultation with representatives from the National Institute Network and National Sporting Organisations with input from experts in the wider professional sport and university sectors.
Sports performance is multifactorial in nature with exercise training, recovery, heath, nutrition, psychological skills and skill acquisition as key factors in athletic preparation.1 Systematic training prepares the athlete for the demands of their sport such that physical abilities and sport specific skills are enhanced.1 Well-planned training loads promote structural and metabolic adaptations that underpin training outcomes such as improved physical performance, injury and illness resistance, and optimised mental and physical health. Rest or ‘unloading’ may be defined as a substantial decrease in training load from the normal. A decrease in training load can be absolute (no training) or relative (as percentage drop from normal load e.g. 30%). Long periods of absolute rest cause a detraining effect and a reduced physical capacity.2
Mathematical modelling and retrospective data analysis have assisted coaches, sports science and sports medicine personnel to better understand the training dose-response relationship in elite Australian athletes. Key findings support previous anecdotal evidence:
Effectively planning load and monitoring the individual training response can enhance training exposure and improve performance.1
Consistent training availability increases an athlete’s capacity to perform in both team and individual sports.3
There is an increased risk of illness and/or injury when reloading after a planned, or unplanned period of unloading if the volume,4 intensity and frequency of training are accelerated quicker than the athletes ability to adapt to the training stress.
The time required to return to a full training load is proportionate to the length of the reduced workloads and the amount of training completed during the unloading period.2
At an individual level in a real-world setting, it is important to understand the context of loading and unloading of training for each sport and athlete. Unfortunately, there are no hard and fast rules, or formula that can accurately prescribe training or predict a performance outcome due to the vast variability in attributes of individual athletes. Therefore, it is the aim of this document to highlight factors that should be considered when an athlete is returning to training from either a planned break or returning from illness/injury.
Key considerations in developing return to training strategies
1. Interdisciplinary planning of strategies
Planning and periodisation identifies how key training variables impacting on the acquisition and maintenance of optimal physical standards are integrated with periods of planned rest as an athlete works towards their performance goals. Effective planning can be enhanced by an interdisciplinary approach that is led by the coach of the program with collaboration from the performance support team (including but not limited to Physiology, Medicine, Strength and Conditioning, Physiotherapy, Nutrition, Psychology, Biomechanics, Skill Acquisition and Athlete Wellbeing and Engagement and other relevant practitioners). Using the collective expertise and experience of the coach, athlete and performance support team members, the following considerations can be made including (but not limited) to:
Understand the athlete and their readiness to train
Training history and environment
- What is the training, biological and chronological age of the athlete?
- What is their long term and recent training history?
- How has the athlete previously coped with the expected load and reloading process?
- What was their typical fatigue and recovery response to training dose and how may recent reductions in training alter these usual responses?
- What specific physiological/structural capacities were maintained during unloading and which may have diminished?
- Was their training environment accessible in this period?
- Are they able to train individually or with team members?
Health and nutrition factors
- What is their current mental and physical health?
- Are there any relevant historical injuries or illnesses which may influence their response to training?
- Is the athlete periodising dietary intake to reflect variable training loads and nutrition related goals?
Current physical, technical, tactical and cognitive skill level
- What is their current physical, technical, tactical and mental skill level?
- What are their current strengths and weaknesses?
Context and individual factors
- What contextual factors are important to them? (Key competition dates, whole of life considerations such as work or study, etc.)
- What are their belief systems regarding their own training capacities and response to periods of unloading?
- Which behavioural traits and patterns are typical of the athlete when in return to training, training and competition phases?
- Are there any non-sport demands on the athlete – school/work/relationships/finance/family – that may influence planning and their response to training?
Understand the load
- What is the external load considered by coaches and performance support team members required to achieve performance and what internal load this might be expected to induce?
- How will training dose be measured? How will the response be monitored (e.g. wellbeing, physiological metrics)?
- Are there specific aspects of their regular loading that present higher risk than others (e.g. total running distance versus high speed running/sprinting distances)?
- How well is the athlete adapting to training?
- Any specific provocative loads or progressions to be considered from an injury perspective?
Understand the training needed for a successful performance
- What are the specific physical standards and training load required for the sport? How does the athlete currently compare to these?
- Does the athlete have any identified deficiencies which require appropriate training strategies to address?
- What level/phase of training do they need to return to (e.g. base phase, competition preparation)?
2. Considering the many forms of loading when training
Training load is multifactorial in nature with elements of the session placing physical, physiological, technical, tactical and cognitive stress on the athlete. It is important to understand not only the overall load placed upon an athlete, but how the load will stress each specific physical, structural and/or psychological system – combined with an understanding of what type of load the athlete has recently completed. Particularly during re-loading as non-sport specific exercise completed during a period of unloading may not adequately prepare an athlete to be able to tolerate sport-specific loads. For example, a swimmer returning from a post-season break may have maintained a 40% training load through non-sport specific activities (e.g. cycling on a stationary ergo) without completing any sport specific movements (such as swimming itself). Likewise, when hockey players return to training, not only should the frequency, duration and velocity of high-speed running be carefully considered, but also changes of directions (angle, planned and unplanned) when returning to previous loads. This is of importance when athletes are returning to sport specific movements with a higher injury burden (i.e. the egg-beater kick for water polo players), or a change in environment (i.e. running on trails compared to on track) that may add additional stress to the athlete. A clear return to both the overall training load and a sport specific training plan should be developed, implemented and monitored to mitigate the likelihood of injury and/or illness and to optimise performance.
From an injury viewpoint when reloading, the stress on connective tissues including bone, tendon and the myo-tendinous junction needs to be carefully managed. Factors to be considered include:
- Athletes who have a previous injury are commonly injured again to the same or different body area.5 6
- Athletes who eventually achieve training loads in a well-controlled manner which prepare them to meet the demands of the sport during rehabilitation are less likely to sustain a subsequent injury on return to play and improve their readiness to train.7
Appropriate measures of training load should be used, comprising of (where possible) both internal and external load variables, as well as sport-specific loads (e.g. high-speed running distance, number of throws, etc.), to ensure performance is maximised through safe reloading practices.
3. Understanding and monitoring the individual training response
Understanding the athlete’s psychophysiological and musculoskeletal response to the training is important. As the athlete’s response to an external training load is variable and is based on the interaction of numerous factors that drive adaptation and recovery (e.g. sleep, psychological state, nutrition, life stressors).8 Additionally, athletes can tolerate different ‘re-loading’ training loads depending on their genetic pre-dispositions and previous training history. Regular review of athlete reported validated subjective questionnaires9 (e.g. Acute/Short Recovery Stress Scales,10 or Health Problems Questions (OSTRC-H))11 and other training response measures12 13 (e.g. neuromuscular function, heart rate measures, submaximal fitness testing) can facilitate a deeper understanding of the acute individual athlete recovery/fatigue response and health status. Moreover, the integral role of coach observation and expertise in understanding athlete performance has been highlighted.14 It is important that programming and load management decisions are responsive to this collective information from the athlete, coach and selected objective measures. Lastly, where monitoring of internal and/or external loads are not possible or feasible, monitoring of the response may still provide value to decision-making processes. This knowledge can then help implement a ‘criterion-based’ and iterative progression and/or modification of training load relative to their response and health status in line with the overall objectives of the periodised plan (see Figure 1).
Summary and conclusion
A coach-led collaborative effort between all team members supporting the athlete is recommended to ensure that progression of load following an unloading period is appropriately planned and contextualised with their individual responses to training. This approach captures the multifactorial nature of the training-dose relationship and promotes a safe return to the training loads required for optimal performance.
Figure One: Individual characteristics, training dose, performance and planning considerations of training load in relation to loading and unloading phases of training
This position statement received contributions from: Katie Slattery, Rod Siegel, Alison Campbell, Peter Culhane, Miranda Menaspa, Damian Raper, Craig Purdam, Chris O’Brien, Harry Brennan, Paul Goods, Tim Gabbett, Ben Raysmith, Will Morgan, Gary Slater, Julian Jones, Tudor Bidder, Peter Blanch, Dale Chapman, Jen Cooke, Kate Watson, Nirmala Perera, Lauren Dixon, Rosie Stanimirovic, Liam Toohey, Renee Appaneal, Rebecca Wiasak and Michael Drew.
Best practice guidelines on:
Novel Coronavirus 2019 and Sporting Activity
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.
Smoke Pollution and Exercise
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.
Air Quality Index (AQI) or PM2.5 in µg/m³?
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.
How do I find out the PM2.5 levels at my location?
There are three ways to get information on PM2.5 concentration levels (measured in µg/m³):
- State and Territory air quality monitoring websites (hourly measures of PM2.5 concentration)
- The AirRater App (or other similar App providing real time PM2.5 in µg/m³)
- 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
- New South Wales
- Western Australia
- South Australia
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
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 visit: https://airrater.org/air-quality-explainer/.
Handheld devices for measurement PM2.5
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.
Exercise-specific categories for smoke affected environments
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
Caution for those who are sensitive to air pollution
Poor conditions for exercise
Very poor conditions for exercise
Likely to be hazardous to exercise outdoors
Activity levels based on visibility, air health category and smoke sensitivity
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 health category
Activity levels – people sensitive to smoke
Activity levels – everyone else
About 20 km
It's a good day to be outside.
It's a good day to be outside.
About 10 km
It's okay to be outside but watch for changes in air quality around you.
It's okay to be outside but watch for changes in air quality around you.
About 5 km
Reduce prolonged or heavy physical activity.
Normal activity, but be alert to changes in air quality
About 1.5 km
Avoid physical activity outdoors.
Reduce prolonged or heavy physical activity.
Less than 1.5 km
If you can, stay indoors and keep physical activity levels as low as possible.
Avoid all physical activity outdoors.
- 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. The 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.
These guidelines are intended to inform the safe practice of dry needling in sport-related physical therapies. They may also be used as a reference for the development of minimum standards by National Sporting Organisations (NSOs), the National Institute Network (NIN) and other system partners. It is recommended that NSOs and NIN partners consider adopting these guidelines.
It should be noted that these guidelines refer only to trigger point dry needling or dry needling, and do not address other forms of invasive needle therapies such as pharmacological trigger point injection or traditional acupuncture.
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.
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
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
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.
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 Athlete Management System (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
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 (Australian Quality Training Framework 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 (Association of Massage Therapists 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 the AIS campus
- 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 Australian Physiotherapy Association 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 to 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.