American Medical Society for Sports Medicine Position Statement on the Care of the Athlete and Athletic Person With Diabetes.

ABSTRACT: The American Medical Society for Sports Medicine (AMSSM) developed this position statement to assist physicians and other health professionals in managing athletes and active people with diabetes. The AMSSM selected the author panel through an application process to identify members with clinical and academic expertise in the care of active patients with diabetes. This article reviews the current knowledge and gaps regarding the benefits and risks of various types of exercise and management issues for athletes and physically active people with diabetes, including nutrition and rehabilitation issues. Resistance exercises seem to be beneficial for patients with type 1 diabetes, and the new medications for patients with type 2 diabetes generally do not need adjustment with exercise. In preparing this statement, the authors conducted an evidence review and received open comment from the AMSSM Board of Directors before finalizing the recommendations.

A Comparison of Self-Reported Unmet Healthcare Needs among Adaptive and Able-Bodied Athletes.

BACKGROUND: Studies have revealed a higher incidence of injury and illness among elite adaptive athletes when compared to able-bodied athletes in competition. However, individuals with disabilities report poorer access to health care. OBJECTIVE: The purpose of this study is to identify differences in healthcare access, satisfaction, and unmet needs between recreational adaptive and able-bodied athletes in all sports and within a single sport (hockey). DESIGN: Cross-sectional, survey-based study. SETTING: Recreation sports programs in Boston, MA and Chicago, IL. PARTICIPANTS: Adult, recreational, competitive adaptive, and able-bodied athletes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): The Short-Form Patient Satisfaction Questionnaire (PSQ-18) for healthcare access and satisfaction; percentage of athletes reporting unmet sports-related healthcare needs in the prior year. RESULTS: Sixty adaptive athletes (78% male, age 35.7 ± 12.4 years) and 65 able-bodied athletes (40% male, age 34.9 ± 11.9 years) participated. Mean access and satisfaction scores were not significantly different between groups in all sports (P = .53 and P = .19, respectively) or hockey (P = .28 and P = .55, respectively). Unmet needs were more commonly reported among adaptive athletes (18.3% all sports, 20.0% hockey) as compared to able-bodied athletes (9.2% all sports, 4.0% hockey). This reached statistical significance in the hockey group (P = .03), but not all sports (P = .12). CONCLUSIONS: No differences were seen between groups in healthcare access or satisfaction scores. Adaptive athletes of the same sport reported a higher rate of unmet sports-related healthcare needs but with few doctor's visits in the preceding year, suggesting discrepancies in expectations and healthcare-seeking behavior. LEVEL OF EVIDENCE: III.

Hyperbaric Oxygen Therapy in Sports Musculoskeletal Injuries.

Hyperbaric oxygen therapy (HBOT) is a well-established treatment for a variety of conditions. Hyperbaric oxygen therapy is the administration of 100% oxygen breathing in a pressure vessel at higher than atmospheric pressure (1 atmosphere absolute = 101 kPa). Typically, treatment is given daily for between 1 and 2 h at pressures of 2.0 to 2.8 ATA, depending on the indication. Sporting injuries are often treated over 3 to 10 sessions. Hyperbaric oxygen therapy has been documented to be effective and is approved in 14 medical indications by the Undersea and Hyperbaric Medical Society, including, but not limited to, carbon monoxide poisoning, compromised skin grafts and flaps, crush injuries, necrotizing soft tissue infections, and nonhealing ulcers with arterial insufficiencies. Recently, HBOT for sports musculoskeletal injuries is receiving increased attention. Hyperbaric oxygen therapy may allow injured athletes to recover faster than normal rehabilitation methods. Any reduction in collegiate and professional athletes' rehabilitation period can be financially significant for top-level sports teams; however, further research is required to confirm HBOT's benefits on sports musculoskeletal injuries. The purpose of this review to discuss the current understanding of HBOT as a treatment modality for common musculoskeletal injuries in sport medicine. Moreover, we will highlight the advantages and disadvantages of this modality, as well as relevant clinical and research applications.

Apps and Mobile Health Technology in Rehabilitation: The Good, the Bad, and the Unknown.

Although there is disparity in access to mobile health (mHealth) services among people with disabilities, several smartphone and tablet-based mHealth applications are available that may affect the care of patients in rehabilitation medicine. This article reviews the current evidence for and breadth of application-based mHealth interventions in rehabilitation medicine, including comprehensive self-management mHealth services; weight management mHealth services; diagnosis-specific mHealth services for individuals with brain, spinal cord, musculoskeletal, or other injury types; and nonmedical services to improve community and social integration.

High-Risk Stress Fractures: Diagnosis and Management.

Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures.

Femoral Neck Stress Fracture: Can MRI Grade Help Predict Return-to-Running Time?

BACKGROUND: Limited research is available regarding return-to-running (RTR) time after femoral neck stress fractures. While studies have shown the prognostic value of image-based grading scales for stress fractures at other sites, few have included femoral neck stress fractures. PURPOSE: To determine if the grade of femoral neck stress fractures based on magnetic resonance imaging (MRI) characteristics correlates with RTR time. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included 24 patients (mean age, 32.9 years; range, 18-51 years) who were diagnosed with 27 femoral neck stress fractures by MRI from 2009 to 2015 at a single sports medicine clinic. All fractures were compression sided and were treated nonoperatively. Charts were reviewed for patient demographics and RTR time. Images were graded from 1 to 4 using the Arendt stress fracture severity scale. Statistical analysis was performed using survival analysis and Cox proportional hazard model to compare the RTR time between grades. Cox regression was repeated, adjusted for age, bone mineral density (BMD), and body mass index (BMI). RESULTS: The mean (±standard error of the mean) RTR time in weeks for patients with fractures graded 1 to 4 was 7.4 ± 2.7 (range, 4-11), 13.8 ± 3.8 (range, 6-21), 14.7 ± 3.5 (range, 8.5-24), and 17.5 ± 3.4 (range, 10-32), respectively. Survival analysis indicated that there was a statistically significant effect of fracture grade on RTR time (P = .0065). The Cox model indicated a statistically significant difference in RTR time between grades 1 and 2 (P = .036), 1 and 3 (P = .014), and 1 and 4 (P = .002). The unadjusted hazard ratio was significant (P = .037). There were no statistically significant differences between the remaining grades (P = .82 for grades 2 and 3, P = .37 for grades 2 and 4, and P = .31 for grades 3 and 4). Age (P = .71) and BMD (P = .81) did not have an effect on RTR time. The hazard ratio remained significant (P = .05) after adjusting for age and BMD. BMI tended to have an effect on RTR time (P = .09). After adding BMI to the adjustment, the hazard ratio decreased in significance (P = .13), although sample size also decreased. CONCLUSION: Grade 2 to 4 femoral neck stress fractures require longer RTR time than do grade 1 injuries. Patients with lower BMI tend to require a longer RTR time.

Rehabilitation of Susac Syndrome: A Case Report.

A 43-yr-old man presented with headaches, forgetfulness, and personality changes. Based on imaging, there was concern for acute disseminated encephalomyelitis. He improved with steroids and immunoglobulin. When symptoms recurred, magnetic resonance imaging showed new scattered gray and white matter lesions, many within the corpus callosum. Angiogram showed multiple branch retinal artery occlusions, pathognomonic for Susac syndrome. He was treated with steroids, intravenous immunoglobulin, and cytoxan and was sent to acute rehabilitation. Functional Independence Measure score improved from 65 to 108. Follow-up at 6 and 10 mos showed continued improvement, with full return to his premorbid roles at home and work. The adjunct of acute rehabilitation to traditional treatment may have promoted faster recovery than expected based on previous reports.

Variation in 30-Day Readmission Rates Among Medically Complex Patients at Inpatient Rehabilitation Facilities and Contributing Factors.

OBJECTIVE: Few studies have focused on 30-day readmission rates in inpatient rehabilitation facilities (IRFs) and factors that contribute to this. The purpose of this study was to examine the variation in 30-day readmission rates among medically complex patients at IRFs nationally and explore how patient and facility characteristics are associated with this variation. DESIGN: Retrospective review of an administrative database. SETTING: IRFs throughout the United States. PARTICIPANTS: Patients from the medically complex impairment group treated at IRFs nationwide represented in the Uniform Data System for Medical Rehabilitation (UDSMR) from 2002 to 2011. MEASUREMENTS: Using multilevel logistic regression analysis, 16 patient and facility characteristics were examined to identify and adjust for variables with a significant effect on readmission rates. Unadjusted and adjusted readmission rates were plotted by facility rank. Facilities were grouped by decile, based on readmission rates, and the mean unadjusted and adjusted rates for the lowest and highest deciles were compared to quantify the variation due to adjustment. Patient and facility characteristics for the highest and lowest deciles were compared. RESULTS: A total of 117,156 medically complex patients from 682 IRFs nationwide were included. Patients were 46% male and 84% white with an average age of 71.5 years. Nine of 16 characteristics were identified that significantly increased the odds of readmission, including older age, male gender, poorer admission motor function, longer duration of impairment, higher Elixhauser comorbidity index, unemployed or retired status, larger facility size, lower mean facility admission motor function, and eastern or western geographic area. The average unadjusted and adjusted readmission rates for all facilities were 15.63% and 15.86%, respectively. The unadjusted readmission rates for the lowest and highest deciles were 6.71% and 26.48%, respectively. After adjustment, this narrowed to 10.33% and 21.91%, respectively. Patient and facility characteristics accounted for 41% of the variation seen in the readmission rates for these groups. Facilities with the highest readmission rates (highest decile) more commonly cared for patients at highest risk for readmission: unemployed, male patients with higher comorbidity index and poorer motor function on admission. CONCLUSION: This study shows significant variation in readmission rates for medically complex patients across IRFs. However, nearly half (41.4%) of this variation was attributed to 9 patient and facility characteristics, suggesting the need for risk adjustment if readmission rates are to be used as a quality indicator for IRFs.

The effects of exercise on decreasing pain and increasing function in patients with patellofemoral pain syndrome: a systematic review.

CONTEXT: Exercise or rest is commonly prescribed as treatment for patellofemoral pain syndrome. STUDY SELECTION: This study is based on Level I or II research studies examining the effects of exercise and rest on decreasing pain (visual analog scale) and increasing function (Kujala Scoring Questionnaire) using human participants. Articles were limited to those printed in English from PubMed (1966-September 2010), CINAHL (1982-September 2010), and SPORTDiscus (1972-September 2010). DATA EXTRACTION: Weighted aggregate effect sizes and 95% confidence intervals were calculated from means and standard deviations extracted from 10 studies, resulting in an analysis of 433 patients. RESULTS: A very large effect for exercise was found for patient-reported functional outcomes (d = 2.19) and perceived pain (d = -1.24) in treated patients, which were larger than functional outcomes (d = 0.77) and pain (d = -0.14) in controls. Short-term follow-up of 191 patients from 4 data sets in 2 studies revealed a large effect for functional outcomes (d = 1.04) and pain (d = -0.82) in patients who performed an exercise intervention. One study reported moderate effect sizes for functional outcomes (d = 0.59) and pain (d = -0.35) at 3 months postintervention. CONCLUSIONS: Exercise is the more effective treatment for immediate decrease in pain and increase in function although these differences appear to be less distinguishable over time.