Personal and Professional Physical Activity Practices among Sports Medicine Physicians.

ABSTRACT: Less than a quarter of the population achieves the recommended Physical Activity Guidelines for Americans. Physicians who achieve the guidelines themselves may be more likely to promote them to patients given strong evidence physicians' personal health habits influence their patient counseling practices. We surveyed primary care and sports medicine specialty physicians about personal exercise habits and beliefs and patient counseling practices. Sports medicine physicians were significantly more likely to meet the Physical Activity Guidelines for Americans and believe that as physicians, they have an obligation to do so. They also were more likely to ask about, counsel, and refer patients to physical activity resources than other primary care physicians. Our results are consistent with previous evidence that physicians' personal habits influence their practice recommendations. This provides support that physicians' personal beliefs about the importance of exercise and sense of obligation to achieve recommended levels themselves plays a strong role in their patient care practices.

Team Approach: Treatment of Shoulder Instability in Athletes.

¼: Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology. ¼: Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program. ¼: Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing. ¼: A team-based approach is necessary to optimize the care of this high-demand, high-risk population.

Understanding Cannabis-Based Therapeutics in Sports Medicine.

CONTEXT: With increased use of cannabis-based products by the public for both recreational and medical use, sports medicine clinicians should be informed of historical context, current legal considerations, and existing evidence with regard to efficacy, safety, and risks in the athletic community. EVIDENCE ACQUISITION: A review of ClinicalTrials.gov, MEDLINE, and CINAHL from 2015 to present was conducted with emphasis on the most recent literature using search terms, cannabis, nabiximols, cannabinoids, pain management, THC, CBD, and marijuana. Bibliographies based on original search were utilized to pursue further literature search. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: At present, limited high-quality studies exist for use of cannabinoids for acute pain, chronic pain, or concussion. None of the trials involving cannabinoids included the athletic population. Thus, results from this clinical review are extrapolated to conditions of the sports medicine population. For acute pain, 2 small-randomized double-blinded crossover trials concluded no immediate effect of cannabinoid therapy. More robust evidence exists for treatment of chronic pain conditions through meta-analysis and systemic reviews. Cannabinoid therapy exhibits moderate efficacy as a treatment for some chronic pain conditions. Investigations included a broad spectrum of chronic pain conditions, including neuropathic, musculoskeletal, inflammatory, and central pain conditions, and reveal reduction in pain and improvement of quality of life with limited adverse effects. For concussion, evidence is based on preclinical in vitro and animal models revealing possible neuroprotective effects as well as 2 clinical studies involving the presence of cannabinoids for concussion (some sports-related), but there are no high-quality trials evaluating efficacy for treatment with cannabinoids at this time. CONCLUSION: Although various biochemical explanations exist on the use of cannabinoid therapy through modulation of the endocannabinoid system for several medical issues affecting athletes, recommendations from clinicians must be extrapolated from a majority of research done in the nonathletic population. Lack of strong-quality clinical evidence, coupled with inconsistent federal and state law as well as purity issues with cannabis-based products, make it difficult for the sports medicine clinician to widely recommend cannabinoid therapeutics at present. Future larger, higher quality clinical research studies with standardized pure extracts will better guide appropriate medical use going forward. At present, evidence for a multitude of therapeutic applications is emerging for cannabinoid treatment approaches. With emphasis placed on patient-centered clinical decisions, cannabinoids hold promise of treatment for athletes with chronic pain conditions. Clinicians who treat the athletic community must consider legal and ethical issues when discussing and recommending the use of cannabinoids, with acknowledgment of inconsistencies in purity of various formulations and concerns of drug testing.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Family Medicine Residency Training.

Patients often seek care from a family physician when they have a musculoskeletal injury or sport-related ailment. Family physicians must be adequately trained to provide this care. While general guidance is provided by the Accreditation Counsel for Graduate Medical Education (ACGME) it is left up to the individual programs to develop, implement, and execute their orthopedic and sports medicine curriculums. The American Academy of Family Physicians' (AAFP) Recommended Curriculum Guideline for Family Medicine Residents - Musculoskeletal and Sports Medicine provides a basic outline format for curriculum content and reference resources. The aim of this article is to elaborate on those training requirements and help programs to develop a curriculum implementation plan that will deliver a baseline level of competence for family medicine trainees.

A Case Series and Literature Review: Isolated Traumatic First Rib Fracture in Athletes.

OBJECTIVE: To present a case series of 14 isolated traumatic first rib fractures sustained in sport and review the literature on clinical presentation, mechanism of injury, diagnosis, and management of sport-related traumatic first rib fractures. DESIGN: We compiled a series of isolated traumatic first rib fractures seen in 2 Division 1-associated sports medicine clinics. We also performed a literature search for additional publications of isolated traumatic first rib fractures in sport. SETTING: Patients in our case series were all evaluated and treated at 2 tertiary care center sports medicine clinics. PATIENTS: Patients were those who sustained isolated traumatic first rib fracture during sport. INTERVENTIONS: None. MAIN OUTCOME MEASURES: None. RESULTS: None. CONCLUSIONS: Traumatic fracture of the first rib in sport is certainly not a common diagnosis, but it is likely more widespread than sports medicine providers realize. Considering the diagnosis of first rib fracture for athletes with shoulder pain after trauma is essential for identifying this injury. Although more study is likely needed to make definitive recommendations on treatment and return to play protocols, the case series and literature review presented suggests that rehabilitation and return to play when the patient is asymptomatic may be appropriate care.

Delayed-Union of Acetabular Stress Fracture in Female Gymnast: Use of Teriparatide to Augment Healing.

Pelvic stress fractures are rare and present unique challenges for medical personnel. Delayed healing can lead to increased physical, psychological, and social stress for athletes. Recent literature suggests effective use of a synthetic derivative of parathyroid hormone, teriparatide, to augment healing of delayed-union stress fractures. We present a case of a female National Collegiate Athletic Association Division I gymnast successfully returned to play after a 12-week course of teriparatide injections for an ischioacetabular stress fracture.

A case report: Glycopyrrolate for treatment of exercise-induced hyperhidrosis.

OBJECTIVE: Hyperhidrosis can cause dehydration and exercise intolerance. There are several case reports of extremely high sweat rates in athletes. We present as case report of a 17-year-old male with the highest sweat rate recorded in the literature (5.8 L/h). Our goal was to determine if glycopyrrolate, an anticholinergic medication with primarily anti-muscarinic effects that is known to decrease sweat production, would reduce the sweat rate of our subject in a controlled exercise setting. METHODS: Our patient and a control subject were subjected to an exercise protocol consisting of running on a treadmill (5.4-6.7 mile/h at 1° of incline) in a warm climate-controlled chamber after receiving 0, 2, or 4 mg of glycopyrrolate. Core temperature, heart rate, rater of perceived exertion, and sweat rate were monitored in both subjects. RESULTS: Glycopyrrolate dose was not significantly correlated with decreased sweat rate and maximal core temperature. However, the clinical effect of reducing the sweat rate was very strong. The improvement of the subject's sweat rate allowed him to successfully return to sport. CONCLUSION: Our findings suggest that low-dose glycopyrrolate may be a safe and effective method of controlling exertional hyperhidrosis.