Category Archives: Sports Medicine

A New Weapon Against Concussion

Sports-related concussions are a growing concern in scholastic and professional athletics, as more studies have shown lasting effects from even a single blow to the head.  Concussions have also become a major concern for physicians, who are often pressured to clear athletes to return to play.

Courtesy Wikimedia Commons user Patrick J. Lynch/Creative Commons

Earlier today, I heard a little about what is increasingly being deployed as a new weapon in the quest to learn more about sports-related concussions: the accelerometer.  Dr. Dan Garza, an emergency and sports medicine physician at Stanford Hospital and Clinics, and medical director for the San Francisco 49ers, discussed Stanford’s use of accelerometers in the helmets of football players and of female lacrosse and field hockey players. (Virginia Tech announced a similar program back in 2007.)

The goal: to get real-time data on what kind of hits these players are taking. During practices and games, the players wear mouthpieces outfitted with accelerometers and gyrometers “that measure the linear and rotational force of head impacts,” according to the Stanford news story on the just-initiated program.

It’s also rimmed with microchips that transmit the accelerational force (known as G force) data to coaches on the sidelines. Dr. Garza said the mouthpieces are a bit eery with their red glow. “They look like Christmas trees out there,” he told his audience, attendees at the American College of Emergency Physicians Scientific Assembly in San Francisco.

Dr. Garza shared a game film from the Stanford Cardinals’ contest against Washington State on Oct. 15 in which wide receiver Chris Owusu received what looked to be a helmet-to-helmet hit (story here). He dropped to the ground and lay there for a bit. On the sidelines, Dr. Garza and his crew received the data from Mr. Owusu’s mouthpiece. They determined that the force of impact was equal to 184 Gs.

That type of accelerational force is considered deadly (for more on G forces, see here and here). For comparison purposes, astronauts only sustain up to 40 Gs at launch and an Indy race car driver might pull 3 Gs in a tight corner. Forces over 100 are usually only encountered in motor vehicle accidents.

Dr. Garza and his colleagues will use the data in a wider study. In the Stanford release, Dr. Garza said the study  “will build toward establishing clinically relevant head-impact correlations and thresholds to allow for a better understanding of the biomechanics of brain injuries.” It may also help with diagnosis and subsequent management of concussions.

Stanford’s football program is being especially closely watched these days, as its quarterback, Andrew Luck, is considered to be a potential number one pick in the NFL draft next year.

The NFL recently announced that it would restart a long, broad look at concussion among its players.  The league has also bankrolled a head-injury program overseen by the Boston University Center for the Study of Traumatic Encephalopathy.

As more attention has been focused on sports-related traumatic brain injury, Congress has gotten involved also. The Senate Commerce, Science and Transportation Committee is having a hearing this Wednesday on companies marketing supposed anti-concussion equipment.

—Alicia Ault (on Twitter @aliciaault)

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What Fuels the Athlete With Type 1 Diabetes?

A phenomenon that was virtually impossible just a couple of decades ago is now becoming increasingly commonplace: Athletes with type 1 diabetes are not only competing at elite levels in just about every sport, but in many cases are actually beating nondiabetic competitors. Gary Hall Jr. won three Olympic Gold medals in swimming after his diagnosis in 1999. Natalie Strand, an anesthesiologist, won the TV extreme-sport reality show Amazing Race with her partner last December. And bicycle racers Team Type 1 won the Race Across America in 2009 and 2010.

Of course, exercise is encouraged for people with both type 1 and type 2 diabetes as a way of improving glycemic control, cardiovascular health, and quality of life. But in competitive sports, milliseconds count and physical perturbations of any kind can mean the difference between winning and losing. With type 1 diabetes, aerobic exercise can result in hypoglycemia, while anaerobic exercise can cause glucose levels to rise. Many sports involve a combination of the two. The athlete with type 1 diabetes must perform frequent glucose checks and eat or take insulin as needed to maintain normal or near-normal glucose, while at the same time performing the athletic feat itself. It seems nearly impossible, yet they do it … with the help of both new technology and devoted health care professionals.

“I take each athlete, learn their sport and find solutions,” said Dr. Anne Peters, the endocrinologist who managed Gary Hall Jr.’s diabetes regimen during the Olympics and is now doing the same for professional racecar driver Charlie Kimball. “Each athlete is unique and requires individualized care.”

Javier Megias of Team Type 1 checks his blood sugar while warming up for a time trial at a race in Italy. Photo courtesy of Team Type 1

New research is aimed at understanding the physiology of these athletes better in order to improve that care. Team Type 1, sponsored by Sanofi, is funding a study in which data are being collected on about 10 bike racers with and 10 without type 1 diabetes. The athletes are being evaluated before, during, and after races using continuous glucose monitors and devices placed on the bicycles that measure variables such as power, heart rate, energy expenditure, speed, and altitude. Data on the athletes’ diet, insulin doses, and other variables are also being collected in a total of five major cycling events, each of which includes 4-8 individual races. “Bottom line, it’s a lot of data,” said Team Type 1 director of research Dr. Juan Frias.

Interestingly, blood glucose values of up to 200 mg/dL – far above “normal” – have been recorded in the nondiabetic riders during very intense portions of races. This “stress hormone” effect had been seen previously in the lab and in some hospitalized patients, but has not been well documented in field-based, real-world studies of healthy people. “Ultimately we hope that this feasibility study will provide data that will help us begin to better understand the optimal glucose concentrations needed to maximize athletic performance, Dr. Frias said.

Findings from the TT1 study will likely be announced at scientific conferences during 2012 and ultimately published, he told me.

Another research project, led by Nate Heintzman, Ph.D., of the University of California, San Diego, is studying athletes who are part of Insulindependence, an organization that promotes physical fitness and sport for people with type 1 diabetes. One of Insulindependence’s recreation-specific clubs, Triabetes, trains people with type diabetes to compete in triathalons. The UCSD-supported project, called the Diabetes Management Integrated Technology Research Initiative (DMITRI), is looking at many of the same variables as in the TT1 study, but is also collecting other data, including behavioral and cognitive information and biospecimens for DNA sequencing.

Insulindependence Captains starting their track workout at UCSD in June. Every person in this photo has type 1 diabetes. Courtesy of Nate Heintzman, Ph.D.

“The idea is to use emerging wireless and device technology as well as genetics and genomics to understand more about the personalized basis of blood glucose management. I think we’ll uncover trends to help tailor therapeutic regimens, and also develop technology on a personal level,” Dr. Heintzman said.

The DMITRI project began in June, and data will begin to emerge in the coming months. In the meantime, if you’re a health care provider or person with diabetes interested in learning more, Dr. Peters recommends Sheri Colberg-Ochs Ph.D.’s Diabetic Athlete’s Handbook. And if you’re seeking inspiration, you can follow Team Type 1 founder and CEO Phil Southerland’s efforts to enter the team in the 2012 Tour de France, professional cycling’s most elite event.

Bottom line, according to Dr. Peters, “The truly gifted athletes I have known seem to be born with an ability that compels them to compete, diabetes or not.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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CDC Cautions Athletes to Stay Cool

Is it fall yet? It has been a long, hot summer in much of the U.S.

courtesy of Wikimedia commons user Wikigab

Outdoor exercise is one of the benefits of summer, but this year’s extended, extreme heat prompted the CDC to issue an official advisory, warning the public to exercise caution when exercising outdoors, in order to avoid heat-related illness.

In the press release, Dr. Robin Ikeda, CDC’s deputy director for noncommunicable diseases, injury, and environmental health, said that “Coaches, parents, teachers, and athletes should educate themselves on how to recognize and prevent heat-related illnesses.”

Doctors who are doing preseason sports physicals before those August practices begin have a great opportunity to educate young patients (and their parents) and remind them how to help the kids take the heat while they get in shape for the fall sports season.

The CDC makes it easy. Refer kids and parents to the CDC Extreme Heat Media Toolkit for reminders about how to manage working out in the hot weather and how to identify signs of trouble.

–Heidi Splete (on twitter @hsplete

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Sports concussions leave sneaky side effects

When he was a teenage lacrosse player, Dr. Brandon Cornejo suffered a mild concussion. He was awake during the trip to the hospital in his parents’ car. And he painfully recalls the resulting cognitive and emotional side effects that messed him up academically, socially, and psychologically.

Lacross sticks image by Yarnalgo (Wikimedia Commons).

The worst part, though, was that he spent 16 years not even knowing he had suffered the traumatic brain injury, because he had no memory of it. He wasn’t aware of a “before” or “after” the injury, so he didn’t know that his struggles were caused by the concussion. Instead he blamed himself, floundering in anger, confusion and depression.

Now a chief resident in psychiatry at the University of Wisconsin, Madison, Dr. Cornejo told his story at the annual meeting of the American Psychiatric Association to impress upon his colleagues the challenges of helping patients with traumatic brain injury, especially athletes.

“These mild injuries can have profound effects on your self-concept and your experience as a human being. They can change the course of your life,” he said.

In 1991, he was a straight-A student in his junior year at a college preparatory high school and the son of proud Latino parents who had never attended college themselves. He and his family were looking forward to him getting a scholarship to finance college.

Dr. Cornejo (Photo by Sherry Boschert)

After the concussion, his grades tanked. He barely got by with Cs and Ds. His girlfriend dumped him. He became very emotional. He remembers 6-9 months of bad fights with his parents. “The likelihood is pretty high that this was related to the loss of consciousness,” he said. “For years, I considered myself `not good at’ certain things because of my academic performance in my senior year.”

His behavior frustrated and shocked him. One time he exploded in “road rage,” which embarrassed him even though no one was there to witness it. Another time when he was ordering oatmeal in a restaurant, he could not recall the words for brown sugar.

“I developed a significant depression, a huge depression. In retrospect, I have a hard time distinguishing between depression produced by traumatic brain injury and depression because I wasn’t performing academically. My family was counting on” a scholarship, he said. That motivation and a lot of hard work eventually got him back on track academically, and somewhere in his freshman year of college he started to regain some self-esteem.

Years later, in 2007, his father casually said, “Remember that time you got knocked out, and we took you to the hospital?” Dr. Cornejo could dredge up only two memories — one of his coach staring down on him on the field, and the other of being in the back seat of the family car, with his mother saying, “Brandon, you’re really scaring us. Why do you keep repeating yourself?”

At the time of the injury in 1991, understanding of traumatic brain injury was just beginning to emerge, and the primary care physician who saw him for follow-up told his parents that their son should be fine, and they should keep an eye on him for a couple of weeks.

Today, Dr. Cornejo hopes that physicians would not allow young athletes with traumatic brain injury to return to play as quickly as he did, because repeat concussions carry much higher risks. He wishes that helmet designers would improve their products. And he urges all physicians to educate not only patients but their families and significant others about the potential sequelae of traumatic brain injury.

Because the patients may not remember.

–Sherry Boschert  @SherryBoschert on Twitter

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Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor’s] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

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Caffeine with Your Energy Drink, Kid?

The light bulb went off in Dr. Michele LaBotz‘s head soon after she watched a TV reality show in which a mother encouraged her 6-year-old daughter to down three cans of Red Bull energy drink before a competition. Dr. LaBotz was laughing about this example of bad parenting with the mother of a high-school-age girl who then admitted that her daughter was “down to two cans a day” of Red Bull.

Image courtesy of flickr user Mike Licht, NotionsCapital.com (Creative Commons)

That prompted Dr. LaBotz to take a closer look at use of these stimulant-containing drinks and at a related category — sports drinks — and to talk about them at the annual  meeting of the American Academy of Pediatrics. I’ve always been acutely sensitive to caffeine, so my nerves started buzzing just listening to her.

There are no standard definitions, but energy drinks are beverages containing carbohydrates, stimulants, and other ingredients — Red Bull being the 800-pound gorilla on the $11 billion market in energy drinks. Sports drinks are beverages containing some combination of carbohydrates and electrolytes — with Gatorade claiming 75% of the market share.

The “crime” is that these products are found side-by-side with products categorized as food, which are subject to stricter safety standards, Dr. LaBotz said.

Red Bull contains 80 mg of caffeine per 8-ounce can, more than twice as much as in two 12-ounce cans of Coca-Cola. Other brands package themselves in larger sizes to get around caffeine regulations or condense into super-caffeine “energy shots” containing 200-350 mg caffeine per 1-2 ounces. The larger 16-ounce size of SoBe No Fear, for example, contains 174 mg caffeine, roughly equivalent to a Starbucks Grande Mocha, except that No Fear also contains guarana, a plant extract that packs another 40 mg of caffeine per gram of guarana.

Photo by flickr user rynosoft (Creative Commons)

Young athletes start off using them because they think they’ll improve performance in sports or other parts of their lives. New data from a randomized, double-blind, placebo-controlled study that will be published in the December issue of the Journal of Alcohol & Drug Education says that reality is flipped. Sport psychology consultant Conrad Woolsey, Ph.D. and his associates will report that energy drinks make users feel like they’re doing better even though they’re making more mistakes on tests of coordination and multidimensional skills.

Sports drinks are a bit more benign but unnecessary and too often take the place of healthier alternatives, potentially depriving young athletes of the nutrients their bodies need to prepare for or recover from exercise. The only time they may be convenient is during exercise lasting longer than an hour, when kids need more fluids, and the bright colors, sweetness and saltiness of sports drinks may entice them to stay hydrated.

Do you know the healthy alternatives to recommend to young athletes instead of sports or energy drinks, or how to talk to them about all this? Dr. LaBotz likes the Academy’s “Sports Shorts #6” on Nutrition and Sports, and the useful handouts available from the U.S. Anti-Doping Agency such as the Joy of Sport.

And while she urges physicians to take a strong stand against child and adolescent use of energy drinks, she suggests not over-playing the dangers of caffeine, especially when talking to parents who may be regular caffeine users themselves. “I think we lose a lot of credibility if we overstate the risk,” she said.

–Sherry Boschert (on twitter @SherryBoschert)

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Not Just Surviving: More Cancer Doctors Tune in To Patients’ Post-Treatment Lives

The 2010 Breast Cancer Symposium, held last week in National Harbor, Md., dedicated an entire session to survivorship. The specific topics included sexuality, survivorship in older patients, management of osteonecrosis of the jaw, and physical activity, diet, and weight.  

courtesy of flickr user N!els (creative commons)

This is encouraging. It seems like more doctors are paying increasing attention to the quality of cancer patients’ lives after their treatments are over. Dr. Michael Krychman of Newport Beach, Calif., emphasized the importance of individualizing sexual problems in cancer survivors. The decrease in estrogen after cancer treatment can cause a range of sexual problems for which there are a range of solutions even at the most basic level, such as choosing the right lubricant for vaginal dryness, he said.

 

 

The physical activity talk stood out in light of recent guidelines issued by the American College of Sports Medicine (ACSM). Dr. Rachel Ballard-Barbash of the National Cancer Institute mentioned the guidelines and emphasized the value of a variety of types of exercise—cardiovascular activity, resistance training, and flexibility—for cancer survivors.

My colleague Kerri Wachter (@knwachter on Twitter), covered the ACSM’s June meeting, and blogged about how the recommendations said that there’s no reason why cancer patients can’t get out and do whatever exercise feels good to them. Kerri also conducted a video interview with Kathryn Schmitz, Ph.D., of the University of Pennsylvania, lead author on the ACSM guidelines.

Dr. Ballard-Barbash said that even though studies of exercise interventions for cancer patients haven’t shown significant weight loss, they have shown improvements in cardiovascular fitness and physical function. And let’s not underestimate the psychological benefits of exercise in general, and the comfort and joy of returning to a favorite activity in particular.

–Heidi Splete (@hsplete on twitter)

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