Peri-Arthroscopic Management of Immunosuppressive Medications in Patients with Rheumatic Disease A Survey of Practice Trends Among Rheumatologists and Sports Medicine Orthopedic Surgeons.

PURPOSE: Rheumatologists and orthopedic surgeons frequently collaborate on difficult decisions regarding perioperative management of immunosuppression in rheumatic disease patients, balancing risk of postoperative infection with risk of disease flares. Current evidence-based guidelines pertain specifically to arthroplasty, thus we sought to understand the trends and common practices regarding peri-arthroscopic use of immunosuppression. METHODS: Rheumatologists and sports medicine surgeons, from a variety of New York hospitals and serving a broad range of demographics, were surveyed on immunosuppressive medication management in rheumatic disease patients undergoing arthroscopic surgeries. Physicians' preferences were elicited regarding the use of common anti-rheumatic medications with the lower risk meniscectomies and the higher risk anterior cruciate ligament (ACL) reconstructions and allografts. Physicians were asked specifically about peri-arthroscopic use of conventional synthetic diseasemodifying antirheumatic drugs (csDMARDs), biologics, and Janus kinase (JAK) inhibitors. RESULTS: During the survey period, 25 rheumatologists and 19 sports medicine fellowship-trained orthopedic surgeons completed the questionnaire. For lower-risk arthroscopies, rheumatologists favored continuing various csDMARDs (72% to 100%), biologics (50% to 64%) and JAK inhibitors (57%), while a majority of surgeons concurred for all three drug classes (csDMARDs 63%; biologics 53%; and JAK inhibitors 58%). For higher-risk arthroscopies, most rheumatologists preferred that patients continue csDMARDs (63% to 100%) but fewer supported the use of biologics (28% to 39%) or JAK inhibitors (22%). Surgeons were more hesitant to endorse any class of immunosuppressive antirheumatic medications (22% to 27%) around these higher risk surgeries. The rheumatologists were most concerned about surgeries taking place too soon after the last dose of rituximab, recommending these higher risk surgeries not take place for 7.7 ± 8.8 weeks following the last infusion. CONCLUSION: For lower-risk arthroscopies, most rheumatologists but only about half of orthopedic surgeons preferred patients continuing csDMARDs. Approximately half of both groups preferred patients hold biologics and JAK inhibitors. In more involved arthroscopies, most rheumatologists but few orthopedists supported the continued use of csDMARDs, and the consensus was to hold all other immunosuppression when possible. While the duration medications were held perioperatively were somewhat reflective of the current guidelines for arthroplasty, there is a need for evidencebased guidelines specifically regarding peri-arthroscopy immunosuppression in rheumatic disease patients.

A bibliometric analysis from 2013 to 2023 reveals research hotspots and trends in the connection between sport and regenerative medicine.

The field of regenerative medicine for sports injuries has grown significantly in the 21st century. This study attempted to provide an overview of the current state of research and key findings regarding the relationship between sport and regenerative medicine in general, identifying trends and hotspots in research topics. We gathered the literature from the Web of Science (WOS) database covering the last 10 years (2013-2023) pertaining to regenerative medicine for sporter and applied Citespace to assess the knowledge mapping. The findings demonstrated that there were 572, with a faster increase after 2018. The country, institution, and author with the most publications are the USA, Harvard University, and Maffulli Nicola. In addition, the most co-cited reference is J Acad Nutr Diet (2016) (199). Adipose tissue, high tibial osteotomy, and bone marrow are the hot spots in this field in the next few years.

Evolving Expectations of the Orthopedic Team Physician: Managing the Sidelines and Landmines.

ABSTRACT: The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

Future Directions in Sports-Related Concussion Management.

This article focuses on 3 concepts that continue to be investigated in the search for the holy grail of concussion-a valid diagnostic test. Imaging advances are discussed with optimism that functional MRI and diffusion tensor imaging may be available clinically. Biomarkers and the use of genetic tests are covered. Sideline accelerometer use may help steer discussions of head trauma risk once technology exists to accurately estimate acceleration of the brain. In the meantime, strategies including allowing athletes to be substituted out of games for an evaluation and video review in elite sports can improve recognition of sports-related concussion.

COVID-19-Myocarditis and Return to Play: Reflections and Recommendations From a Canadian Working Group.

The COVID-19-related pandemic has resulted in profound health, financial, and societal impacts. Organized sporting events, from recreational to the Olympic level, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection-associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement as a result of COVID-19 infection have been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and the writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiography, echocardiography, or cardiac magnetic resonance imaging before return to play. However, medical assessment including history and physical examination with consideration of resting electrocardiography and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities are encountered at the initial medical assessment, then referral to a cardiologist who cares for athletes is recommended.

Predicting who responds to spinal manipulative therapy using a short-time frame methodology: Results from a 238-participant study.

BACKGROUND: Spinal manipulative therapy (SMT) is among the nonpharmacologic interventions that has been recommended in clinical guidelines for patients with low back pain, however, some patients appear to benefit substantially more from SMT than others. Several investigations have examined potential factors to modify patients' responses prior to SMT application. The objective of this study was to determine if the baseline prediction of SMT responders can be improved through the use of a restricted, non-pragmatic methodology, established variables of responder status, and newly developed physical measures observed to change with SMT. MATERIALS AND METHODS: We conducted a secondary analysis of a prior study that provided two applications of standardized SMT over a period of 1 week. After initial exploratory analysis, principal component analysis and optimal scaling analysis were used to reduce multicollinearity among predictors. A multiple logistic regression model was built using a forward Wald procedure to explore those baseline variables that could predict response status at 1-week reassessment. RESULTS: Two hundred and thirty-eight participants completed the 1-week reassessment (age 40.0± 11.8 years; 59.7% female). Response to treatment was predicted by a model containing the following 8 variables: height, gender, neck or upper back pain, pain frequency in the past 6 months, the STarT Back Tool, patients' expectations about medication and strengthening exercises, and extension status. Our model had a sensitivity of 72.2% (95% CI, 58.1-83.1), specificity of 84.2% (95% CI, 78.0-89.0), a positive likelihood ratio of 4.6 (CI, 3.2-6.7), a negative likelihood ratio of 0.3 (CI, 0.2-0.5), and area under ROC curve, 0.79. CONCLUSION: It is possible to predict response to treatment before application of SMT in low back pain patients. Our model may benefit both patients and clinicians by reducing the time needed to re-evaluate an initial trial of care.

The Training-Performance Puzzle: How Can the Past Inform Future Training Directions?

Over the past 20 years, research on the training-load-injury relationship has grown exponentially. With the benefit of more data, our understanding of the training-performance puzzle has improved. What were we thinking 20 years ago, and how has our thinking changed over time? Although early investigators attributed overuse injuries to excessive training loads, it has become clear that rapid spikes in training load, above what an athlete is accustomed, explain (at least in part) a large proportion of injuries. In this respect, it appears that overuse injuries may arise from athletes being underprepared for the load they are about to perform. However, a question of interest to both athletic trainers (ATs) and researchers is why some athletes sustain injury at low training loads, while others can tolerate much greater training loads? A higher chronic training load and well-developed aerobic fitness and lower body strength appear to moderate the training-injury relationship and provide a protective effect against spikes in load. The training-performance puzzle is complex and dynamic-at any given time, multiple inputs to injury and performance exist. The challenge facing researchers is obtaining large enough longitudinal data sets to capture the time-varying nature of physiological and musculoskeletal capacities and training-load data to adequately inform injury-prevention efforts. The training-performance puzzle can be solved, but it will take collaboration between researchers and clinicians as well as an understanding that efficacy (ie, how training load affects performance and injury in an idealized or controlled setting) does not equate to effectiveness (ie, how training load affects performance and injury in the real-world setting, where many variables cannot be controlled).

Training Load and Its Role in Injury Prevention, Part I: Back to the Future.

The purpose of this 2-part commentary series is† to explain why we believe our ability to control injury risk by manipulating training load (TL) in its current state is an illusion and why the foundations of this illusion are weak and unreliable. In part 1, we introduce the training process framework and contextualize the role of TL monitoring in the injury-prevention paradigm. In part 2, we describe the conceptual and methodologic pitfalls of previous authors who associated TL and injury in ways that limited their suitability for the derivation of practical recommendations. The first important step in the training process is developing the training program: the practitioner develops a strategy based on available evidence, professional knowledge, and experience. For decades, exercise strategies have been based on the fundamental training principles of overload and progression. Training-load monitoring allows the practitioner to determine whether athletes have completed training as planned and how they have coped with the physical stress. Training load and its associated metrics cannot provide a quantitative indication of whether particular load progressions will increase or decrease the injury risk, given the nature of previous studies (descriptive and at best predictive) and their methodologic weaknesses. The overreliance on TL has moved the attention away from the multifactorial nature of injury and the roles of other important contextual factors. We argue that no evidence supports the quantitative use of TL data to manipulate future training with the purpose of preventing injury. Therefore, determining "how much is too much" and how to properly manipulate and progress TL are currently subjective decisions based on generic training principles and our experience of adjusting training according to an individual athlete's response. Our message to practitioners is to stop seeking overly simplistic solutions to complex problems and instead embrace the risks and uncertainty inherent in the training process and injury prevention.

"To Tech or Not to Tech?" A Critical Decision-Making Framework for Implementing Technology in Sport.

The current technological age has created exponential growth in the availability of technology and data in every industry, including sport. It is tempting to get caught up in the excitement of purchasing and implementing technology, but technology has a potential dark side that warrants consideration. Before investing in technology, it is imperative to consider the potential roadblocks, including its limitations and the contextual challenges that compromise implementation in a specific environment. A thoughtful approach is therefore necessary when deciding whether to implement any given technology into practice. In this article, we review the vision and pitfalls behind technology's potential in sport science and medicine applications and then present a critical decision-making framework of 4 simple questions to help practitioners decide whether to purchase and implement a given technology.

Ten Years of Sports Health: Authorship Characteristics and Levels of Evidence.

CONTEXT: Sports Health: A Multidisciplinary Approach, now 10 years into production, has been ranked a top-25 journal in sport sciences and has tripled its impact throughout its existence. OBJECTIVE: To evaluate authorship trends and levels of evidence (LOE) of articles published in Sports Health from 2009 to 2018. The secondary aim was to analyze funding sources and internationalization throughout the journal's tenure. DATA SOURCES: All clinical studies published in Sports Health between the years 2009 and 2018 were examined. STUDY SELECTION: All publications from the provided years were electronically reviewed by 2 reviewers and evaluated for inclusion criteria. Editorials, society news, memorials, letters to the editor, and corrigenda were excluded. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 5. DATA EXTRACTION: Articles were examined for number of authors, presence of female authorship, funding, country of origin, international collaboration, academic degree or certification of first and senior authors, and LOE. Clinical articles were assigned LOE based on guidelines from the University of Oxford's Centre for Evidence-Based Medicine. RESULTS: A total of 654 articles were examined. The percentage of high-LOE studies increased throughout the study period. The percentage of publications with female authors also increased throughout the study period. The mean number of authors per article increased from 3.2 to 4.6 over the 10-year period (P < 0.05). The percentage of publications with international collaboration stayed consistent, while the number of countries per year increased during the study period. Overall, institutions from 23 countries have published in Sports Health since its inception to the time of this study. CONCLUSION: Female authorship in Sports Health surpasses industry standards, and the percentage of high-LOE studies remains remarkably high. Sports Health has stayed true to its multidisciplinary scope, as evidenced by the authors' varying degrees and numerous countries that publish in the journal.

Telemedicine Experiences of Athletic Trainers and Orthopaedic Physicians for Patients With Musculoskeletal Conditions.

CONTEXT: Telemedicine is the delivery of medical care from a distance using technology. The integration of telemedicine as a supplement to musculoskeletal-based patient encounters may be feasible in sports medicine. OBJECTIVE: To investigate health care professionals' perceptions of and experiences with telemedicine. DESIGN: Cross-sectional explanatory sequential mixed-methods study. PATIENTS OR OTHER PARTICIPANTS: A purposeful sample of 17 athletic trainers from a National Collegiate Athletic Association Division I institution and 5 orthopaedic physicians from a sports medicine clinic located 92 miles from the campus. INTERVENTION(S): Participants were trained on the telemedicine platform and used it over 5 months for initial, follow-up, and discharge patient encounters. MAIN OUTCOME MEASURE(S): Participants completed a preintervention survey containing the Theory of Planned Behavior and Technology Acceptance Model tool. Responses were analyzed using descriptive statistics and an independent-samples t test. After the intervention period, participants completed individual semistructured interviews that we coded using the consensual qualitative research tradition. RESULTS: From the interviews, the clinicians were characterized as telemedicine adopters (n = 14) or nonadopters (n = 8). The adopters reported higher levels of agreement on the Theory of Planned Behavior and Technology Acceptance Model tool as compared with nonadopters for all constructs. When comparing adoption status, we identified a difference (P < .01), with nonadopters reporting a low level of agreement for the subjective norm construct. The interviews revealed 5 domains: integration challenges, integration opportunities, collaborative practice, anticipatory socialization to future use, and benefits of integration. The participants indicated that integration challenges centered on "buy in," whereas opportunities aligned with the patient's condition and technology ease of use. They reflected that the telemedicine encounters required more preparation and yet allowed for cooperative behaviors between clinicians. The benefits of telemedicine included convenience and scheduling preferences that encouraged future use. CONCLUSIONS: The integration of telemedicine in sports medicine brought about both challenges and opportunities for collaboration among athletic trainers and physicians that were heavily predetermined by the social pressures of colleagues.

Advances in Sports Medicine and Care of the Adolescent Athlete.

Over the past several decades there has been a dramatic change in the landscape of youth sports. This article provides an overview of sport-related injuries in the child and adolescent populations, looking at changes over the past 10 to 15 years. A closer look at frequently seen injuries, including assessment, diagnosis, and management in osteochondritis dissecans, sprains, fractures, anterior cruciate ligament, and meniscus tears, is provided. Current protocols and screening tools for this population are discussed, including preparticipation screening. The nursing implications in the clinical and community setting are identified, with ways to incorporate this information into practice.

Sideline Concussion Assessment: The Current State of the Art.

More than 200 million American adults and children participate in organized physical activity. Growing awareness has highlighted that concussion, especially when repeated, may be associated with prolonged neurological, cognitive, and/or neuropsychiatric sequelae. Objective diagnosis of concussion remains challenging. Although some concussion symptoms may be apparent even to nonmedical observers, diagnosis and removal from play for evaluation depend on validated assessment tools and trained, vigilant healthcare personnel. Over the past 2 decades, sideline concussion measures have undergone significant revision and augmentation to become more comprehensive batteries in order to detect a wide spectrum of symptomatology, eg, neurocognitive function, postconcussive symptoms, gait/balance, and saccadic eye movements. This review summarizes the current state-of-the-art concussion evaluation instruments, ranging from the Sports Concussion Assessment Tool (SCAT) and tools that may enhance concussion detection, to near-term blood-based biomarkers and emerging technology (eg, head impact sensors, vestibulo-ocular/eye-tracking, and mobile applications). Special focus is directed at feasibility, utility, generalizability, and challenges to implementation of each measure on-field and on the sidelines. This review finds that few instruments beyond the SCAT provide guidance for removal from play, and establishing thresholds for concussion detection and removal from play in qualification/validation of future instruments is of high importance. Integration of emerging sideline concussion evaluation tools should be supported by resources and education to athletes, caregivers, athletic staff, and medical professionals for standardized administration as well as triage, referral, and prevention strategies. It should be noted that concussion evaluation instruments are used to assist the clinician in sideline diagnosis, and no single test can diagnose concussion as a standalone investigation.

Shared Decision Making and the Cardiovascular Care of Athletes: Is It Time to Get Back in the Game?

Prevention of sudden cardiac arrest/death and disease progression has traditionally been the primary basis for determining exercise recommendations for those with underlying cardiovascular disease. Potential harms of exercise restriction, including physical inactivity's impact on obesity, chronic disease, and negative psychological and emotional consequences, have been considered ancillary, if considered at all. Accumulating evidence suggests the relative safety of continued sport and exercise participation in the vast majority of those with a variety of cardiac conditions that were previously considered to be criteria for exclusion. Despite ongoing clinical uncertainty however, respect for patient autonomy and the inclusion of patient values and preferences is now required in the decision-making process. The shared decision-making construct, a cornerstone of patient-centred care, should be applied for determining exercise and participation recommendations for those with cardiovascular disease. Safe exercise principles should be employed in all cases, regardless of whether athletes chose to follow recommendations, following a harm-reduction model. This approach is recommended by the 2019 Canadian Cardiovascular Society and Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes, and other contemporary societal guidelines, for all aspects of cardiovascular care of athletes.