The viability of sports medicine academies

Recently, a high school classmate who has become a successful orthopedic surgeon approached me about becoming involved in establishing a sports medicine academy within our alma mater.

The concept of sports medicine academies has arisen from the increased number of people participating in athletic activities and subsequent sports-related injuries. Several recent surveys project a growing need for health care professionals with a background in sports medicine.

Sports medicine is generally associated with professional and collegiate sports teams. Interestingly, although highly publicized, these high profile injuries make up a relatively small percentage of the sports injuries evaluated each year.

Medical studies continue to demonstrate that many chronic illnesses can be more effectively treated with a regimen that includes regular exercise. Among these are vascular diseases, diabetes, obesity and dementia.

Health professions involved in sports are physicians, athletic trainers, physical therapists, psychologists, nurses, exercise physiologists and conditioning specialists. The goal of sports medicine academies is to provide fundamental education with transferrable skills that allow students to enter any of these areas of study.

In addition to a basic liberal arts high school course load, students are required to study anatomy, physiology, biology, biostatistics, sports conditioning and marketing. All students are also required to work in a variety of sports medicine settings to gain clinical and practical experience.

Although sports medicine is often associated with the treatment and prevention of athletic injuries, one of the most exciting areas of sports medicine involves the study and improvement of human performance.

Making the human body more efficient is one key to improving health and avoiding disease. A foundation in sports medicine may provide the necessary skills for future health care professionals.

When heading for the hills, practice avalanche safety

Seventeen people have lost their lives this year in accidents related to avalanches. Although uncommon in the northeast, many winter sports enthusiasts will soon be heading west for the spring season.

An avalanche consists of large volumes of snow sliding down a mountain at high velocity. These sudden events result in destruction of roads, homes and lives. Trees, boulders and debris often become part of the descending flow.

Snow and ice will accumulate in layers as the winter season proceeds.

As the adherence of these layers weakens, the chances of an avalanche will increase.

Many factors play a role in loosening these layers. Natural causes include rapid warming, sudden precipitation and falling rocks. Artificial influences consist of skiers, snow boarders and snowmobile riders who may disrupt the snowpack. Animals may cause stress just by walking over a weakened area. Explosive use will certainly cause an avalanche in a vulnerable zone.

Avalanche risk can be calculated based on prevailing conditions and location. They are most commonly seen on back country ski trails that are not frequently used. Warnings are posted when the chances of an avalanche are high. Sometimes they will be intentionally triggered as a way of avoiding an unsuspected downfall.

Safety equipment and measures have proven to be effective:

• Pay close attention to warning signs and closed trails. Closing trails are not arbitrary decisions and there is most likely a reasonable degree of danger.

• An avalanche beacon will emit a signal to allow others to quickly find a victim and begin digging out.

• The avalanche balloon is a device that is designed to keep a person above the rising snow when deployed.

When planning to escape the unseasonable warmth of the northeast for a northwestern adventure, remember to invest in specialized safety equipment along with common sense.

Digging deeper into exercise immunology

One of the most exciting fields of research in human physiology involves the effects of physical training on the immunologic response.

Immunology is the study of the ability to fight off attack from infection and certain forms of cancer. It consists of a response that utilizes white blood cells that isolate and destroy an offending agent.

Among the more common triggers of the immunologic response is the influenza virus. It also has a negative effect on the ability of athletes to attain their peak performance.

Pertinent findings regarding the effect of exercise on the immunologic response include:

• Studies performed on marathon runners reveal that intense exercise lasting longer than 60 minutes has an adverse effect on the ability to summon immune cells. This results in more frequent upper respiratory infections. Moderate regular exercise is associated with an improved response.

• There is a natural decline in the ability to mount a response to infection with age. Physically conditioned elderly subjects had a superior response to infection versus a sedentary group.

• Mental stress has also been shown to have an adverse effect on the immunologic response. Athletes who meditated for one hour a day for 8 weeks had an enhanced response to infection.

• Diet plays a big role in immunologic function. Athletes who were undernourished or involved in rapid weight loss were more susceptible to infection. This particularly applies to combat sport athletes and other athletes who must achieve a weight level.

• Adequate sleep is crucial to efficient immunological function.

After a very thorough review of the current literature in a recent lecture at the University of Connecticut, Professor Neil Walsh from Bangor University in the UK discussed the importance of hygiene.

Ironically, in addition to following solid training principles, it may be merely proper hand washing and covering the mouth and nose when sneezing that can lead to victory.

Cardiac arrest during marathons are rare, but possible

Millions of Americans participate in long-distance running events. The marathon distance (26.2 miles) and the half-marathon (13.1 miles) have become increasingly popular. It is because of the extreme physical demands of these competitions that the occasional report of sudden death during an event is not surprising.

The human heart consists of four chambers that contract and expand in sequence to pump blood throughout the vascular system. In order to do this, the heart has a carefully synchronized electrical network that must fire signals in a rhythmic manner.

The muscular heart chambers have thick walls that allow for the maximum volume of blood to be ejected with each beat. Aerobic training reduces the amount of effort necessary for the heart to function.

A recent study looked at the incidence and outcomes of cardiac arrest associated with marathon and half-marathon events from January 2000 to May 2010. The number of participants steadily grew from 1 million in 2000 to 2 million in 2010.

Of the 11 million people studied over the 10-year span, only 59 suffered cardiac arrest during a race. Cardiac arrest was most common in males who participated in full marathons as opposed to half-marathons. Men were also most likely to die from the arrest and are clearly more susceptible to exertional cardiac arrest.

Surprisingly, the most common cause of arrest was not due to blockage of coronary arteries but an oversized left ventricle. The increased size (hypertrophy) eventually blocks the outflow of blood from the heart.

Cardiac hypertrophy is most common in younger athletes and associated with poor outcome.

The rate of cardiac arrest should in no way discourage participation in long-distance athletic events. Instead, it should alert athletes to the need for proper pre-participation physical examinations.

Giants' Mark Herzlich overcomes bone cancer

Inspirational comeback stories abound in the world of sports. This year’s NFL season is no exception, such as the come-from-behind, underdog victories by the Denver Broncos, led by Tim Tebow.

One story that bears noting is the return of Mark Herzlich to the sport many thought was part of his past and not his future.

Herzlich, a 24-year-old linebacker for the New York Giants, was diagnosed with Ewing’s sarcoma, a form of bone cancer, while playing for Boston College. His treatment included chemotherapy, radiation therapy and excision of the tumor that involved the largest bone in the human body, the femur. A titanium rod reinforced the bone shaft.

A two-year course of physical therapy and intense training followed. After being invited to try out for the New York Giants, he accomplished something many thought was impossible: He made the team.

Ewing’s sarcoma is a malignant tumor that typically is seen in children and young adults. It generally appears in the long bones of the body.

The most common presenting symptom is intense bone pain. Unfortunately, in approximately one-third of patients, the tumor already has spread to the lungs and other bones at the time of diagnosis.

Treatment of Ewing’s sarcoma includes aggressive chemotherapy and radiation therapy that is focused on the tumor site. Surgical excision of the tumor follows.

Dr. Dinesh Kapur, an oncologist and director of cancer services at The William W. Backus Hospital, isn’t surprised by Herzlich’s recovery.

“Early detection, combined with the multimodality approach of chemotherapy, radiation and surgery, has dramatically improved survival from Ewing’s sarcoma,” Kapur said.

Herzlich’s return to the highest level of professional sports not only required a combination of modern medical therapies, but an unwavering spirit and commitment to succeed.

Celtics player saved from aortic aneurysm

Amidst the confusion of ending the NBA lockout and hurriedly beginning a shortened season, a young life was saved.

Jeff Green, a 25-year-old forward, had signed a one-year, $9 million contract to play for the Boston Celtics. During a routine preseason physical examination, he was diagnosed with an aortic aneurysm. Instead of heading over to the practice court, Green was headed to the operating room.

The aorta is the largest artery in the human body. It provides the main passageway for richly oxygenated blood to vital organs. The aorta is divided into two main sections:

• The thoracic aorta leads blood from the heart and downward through the chest cavity.
• The abdominal aorta continues into the abdomen feeding branches to the kidneys, liver, spleen and intestines.

An aneurysm is an abnormal enlargement of a blood vessel. It results from a weakening of the supporting tissue that provides a firm lining in an artery. Under constant pressure, the weakened area will enlarge and cause the artery to dilate and eventually rupture. This results in profuse life-threatening hemorrhage.

Aortic aneurysms can be repaired by cutting out the affected section of aorta and replacing it with a synthetic segment. Another approach is an endovascular repair. In this procedure, a new lining is inserted in the weakened area via a catheter through an artery in the groin.

Aneurysms are typically associated with high blood pressure, elevated cholesterol levels, obesity and smoking. All of these potential causes are not typically associated with professional athletes.

Green’s aneurysm will be repaired and he is expected to return to the NBA next season.

Jeff Green’s circumstance should serve as a reminder of the importance to have annual physicals performed by a physician even if you are young and in excellent health.

Fitness gifts for the holiday season

Finding an appropriate gift for someone interested in fitness can be a complex and daunting task. The vast array of offerings may be confusing and an error will result in another dust collector. This week is a good time to make some recommendations and provide some caution.

Michael Sena’s Traveling Trainer. This product provides a perfect combination of fitness equipment, instruction and dietary tips in a convenient travel case. Sena, a nationally known personal trainer, provides instruction on the use of elastic stretch tubes of varying resistances. Although the premise is for this product to be used while traveling to places where a gym isn’t available, it is a great way to begin a home workout that requires minimal cost and space.

Fitness Monitors. These devices include pedometers, heart rate monitors and computerized bands that monitor all physical activity and diets. The range is vast and the usefulness varies. In general, the more comprehensive the apparatus the more technical ability is required. The objective here is to provide feedback regarding the intensity of an individual’s activity. That feedback will hopefully encourage more effort. Much of this can be accomplished by using a simple pedometer and bathroom scale.

P90X2. This is the latest iteration in a wildly successful video workout series. Each consists of intense exercises that last approximately 60 minutes and utilize a variety of muscle groups. They provide an excellent daily fitness experience and, based on many testimonials, accomplish the goal of getting subscribers in shape in 90 days. Although the series is expensive, it requires minimal equipment and space.

The current trend in fitness programs emphasizes equal parts aerobic and resistance exercises utilizing body weight for resistance. Stretching, balance and constant movement are essential elements.

A fitness program combined with dietary moderation will lead to a healthy new year.

Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most prescribed medications worldwide. In sports medicine, they are often referred to as performance “enabling” drugs.

Common NSAIDs like Motrin, Naproxyn, Toradol, Voltaren and Celebrex can be administered orally, by injection or applied to the skin. As opposed to steroids, the NSAIDs have fewer side effects and do not build muscle like androgenic steroid drugs.

Inflammation is a normal response of the human body to injury. NSAIDs are effective in treating headache, injured nerves, arthritis and painful chronic conditions. In sports, NSAIDs are primarily used to treat acute muscle tears (strains), ligamentous injuries (sprains) and joint trauma (bursitis).

The classic inflammatory response causes signs of swelling, elevated temperature, redness and pain that are readily apparent to an observer. At a microscopic level, there is an intense cellular response where blood flow increases to the affected region allowing chemicals and white blood cells to leave the bloodstream and attack the injury.

While the inflammatory response is essential to good health, it can cause damage if it becomes chronic. NSAIDs are designed to reduce inflammation by blocking the cyclooxygenase enzymes (COX-1 and COX-2) and subsequently halting the production of prostaglandins, essential components of the inflammatory response.

Although NSAIDs have an analgesic effect, they reduce pain by altering the actual process causing the pain, as opposed to opiate drugs that merely block pain receptors.

It is not uncommon in sports to have more than one ongoing injury. NSAIDs do not target a specific injury and work at multiple areas simultaneously.

Although generally safe, potential side effects of NSAIDs include stomach ulcers, kidney damage and elevation of blood pressure.

In sports, where chronic musculoskeletal injuries are common NSAIDs have extended the careers of many athletes. After consultation with a physician, NSAIDs may be able to keep you in the game.

Sports injuries can't hide from imaging techniques

Sports injuries often require the use of x-rays and more sophisticated diagnostic imaging studies to determine the nature and severity of the injury. These studies and techniques have evolved significantly over recent years.

Among the most commonly used imaging studies are x-ray, computerized tomography (CT) and magnetic resonance imaging (MRI). X-rays were first used in the late 19th century, primarily to determine fractures and other boney injuries. CT scans came into use in the early 1970s and are designed to measure differences in density, especially in bones. MRIs create images based on changes in tissues such as tearing and swelling.

Dr. Nathaniel Dueker is a board certified musculoskeletal radiologist at The William W. Backus Hospital. He took time to review some of the most common sports injuries that require imaging:

• Head injuries. Concussions are among the most common injuries seen in sports. While there is no image that can diagnose a concussion, a CT scan should reveal any evidence of acute hemorrhage or skull fracture. Persistent symptoms may warrant the eventual use of an MRI to look for chronic damage.

• Shoulder injuries. These injuries typically involve tendons and ligaments. After a plain x-ray to rule out a fracture, an MRI is the best diagnostic tool. This study can demonstrate structural changes in the complex system that makes up the shoulder joint. An MRI of the shoulder can be performed with dye injected into the joint. This exam, called an MRI arthrogram, can be performed in different positions and may reveal subtle tears.

• Knee injuries. Traumatic sports injuries to the knee typically result in ligament and cartilage tears. While x-rays will rule out bone injuries, MRI is an outstanding technique for viewing damage to these structures.

Appropriate diagnostic imaging studies can limit the need for surgery and get athletes back in the game sooner.

The heart is a muscle that needs training too

When athletes are described as “having a lot of heart” it often refers to their desire to compete even in the face of overwhelming adversity. In sports medicine, an “athlete’s heart” has an entirely different meaning.

The human heart is composed of four chambers: the right atrium, right ventricle, left atrium and left ventricle. The heart functions as a pump moving blood from the right side of the heart to the lungs where it becomes infused with oxygen. The left-sided chambers then jettison oxygenated blood throughout the circulatory system to other organs.

The left ventricle has the greatest demand and tends to become enlarged, creating a condition known as “left ventricular hypertrophy.”

If blood vessels become narrowed due to atherosclerosis, it requires more work for the heart to pump against resistance. The pumping mechanism must work harder and faster. That strain can lead to heart failure and death.

Like all muscles, the heart can be trained to increase in size and work more efficiently. A fitness regimen that will improve cardiac efficiency should consist of several forms of exercise:

• Aerobic activities such as running, rowing or cycling will maintain a high heart rate over an extended period of time.

• Resistance activities include weight lifting and other strength-oriented sports.

• Cross-training programs include a combination of aerobic and resistance activities. Boxers and other athletes who participate in sports where high levels of strength must be maintained over long periods of time rely heavily on these programs.

“The enlarged, more efficient athlete’s heart is a normal response to exercise training,” said Dr. Craig Denegar, a professor of kinesiology at the University of Connecticut. Screening athletes before athletic participation can be challenging since an enlarged left ventricle can also indicate significant cardiac disease.

A regular exercise program can produce a heart that pumps more blood with less effort.