Hydration Strategies for Physical Activity and Endurance Events at High (>2500 m) Altitude: A Practical Management Article.

ABSTRACT: A growing number of adventurous athletes are seeking new challenges through endurance events or physical activities held at high altitude (>2500 m). This coincides with a significant increase in the numbers of trekkers who ascend into the world's mountains. Altitude itself influences and complicates the athlete's effective and safe hydration. This article considers the physiology of adaptation to altitude and the effects on hydration at altitude compared with sea level, reviews the "ad libitum versus programmed hydration" controversy in conventional endurance event hydration, examines the evidence for extrapolation of sea level hydration strategies to the high-altitude environment, and synthesizes these disparate factors into a set of practical recommendations for hydration management during high-altitude physical activity. The guidelines will be relevant to participants of physical activity at altitude and health care staff who may care for them in the preparation or performance phases of their adventure.

Clinical management of acute low back pain in elite and subelite rowers: a Delphi study of experienced and expert clinicians.

OBJECTIVES: Rowing-related low back pain (LBP) is common but published management research is lacking. This study aims to establish assessment and management behaviours and beliefs of experienced and expert clinicians when elite and subelite rowers present with an acute episode of LBP; second, to investigate how management differs for developing and masters rowers. This original research is intended to be used to develop rowing-related LBP management guidelines. METHODS: A three-round Delphi survey was used. Experienced clinicians participated in an internet-based survey (round 1), answering open-ended questions about assessment and management of rowing-related LBP. Statements were generated from the survey for expert clinicians to rate (round 2) and rerate (round 3). Consensus was gained when agreement reached a mean of 7 out of 10 and disagreement was 2 SD or less. RESULTS: Thirty-one experienced clinicians participated in round 1. Thirteen of 20 invited expert clinicians responded to round 2 (response rate 65%) and 12 of the 13 participated in round 3 (response rate 92%).One hundred and fifty-three of 215 statements (71%) relating to the management of LBP in elite and subelite rowers acquired consensus status. Four of six statements (67%) concerning developing rowers and two of four (50%) concerning masters rowers gained consensus. CONCLUSION: In the absence of established evidence, these consensus-derived statements are imperative to inform the development of guidelines for the assessment and management of rowing-related LBP. Findings broadly reflect adult LBP guidelines with specific differences. Future research is needed to strengthen specific recommendations and develop best practice guidelines in this athletic population.

Treating low back pain in athletes: a systematic review with meta-analysis.

OBJECTIVE: To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement. DATA SOURCES: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS). RESULTS: Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments. CONCLUSIONS: While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers.

PURPOSE: To synthesise evidence on low back pain (LBP) in adult rowers and to create a consensus statement to inform clinical practice. METHODS: There were four synthesis steps that informed the consensus statement. In step one, seven expert clinicians and researchers established the scope of the consensus statement and conducted a survey of experienced and expert clinicians to explore current practice. In step two, working groups examined current evidence relating to key scope questions and summarised key issues. In step three, we synthesised evidence for each group and used a modified Delphi process to aid in the creation of the overall consensus statements. Finally, in step four, we combined information from step three with the findings of the clinician survey (and with athlete and coach input) to produce recommendations for clinical practice. RESULTS: The scope of the consensus statement included epidemiology; biomechanics; management; the athlete's voice and clinical expertise. Prevention and management of LBP in rowers should include education on risk factors, rowing biomechanics and training load. If treatment is needed, non-invasive management, including early unloading from aggravating activities, effective pain control and exercise therapy should be considered. Fitness should be maintained with load management and progression to full training and competition. The role of surgery is unclear. Management should be athlete focused and a culture of openness within the team encouraged. CONCLUSION: Recommendations are based on current evidence and consensus and aligned with international LBP guidelines in non-athletic populations, but with advice aimed specifically at rowers. We recommend that research in relation to all aspects of prevention and management of LBP in rowers be intensified.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons.

AIM: To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads). METHODS: All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers' injury rates. Time lost from illness was also recorded. RESULTS: All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1-6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD). CONCLUSIONS: Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

Rib stress injuries in the 2012-2016 (Rio) Olympiad: a cohort study of 151 Australian Rowing Team athletes for 88 773 athlete days.

AIM: To describe the demographics, frequency, location, imaging modality and clinician-identified factors of rib stress injury in a cohort of elite rowers over the Rio Olympiad (2012-2016). METHODS: Analysis of prospectively recorded medical records for the Australian Rowing Team in 2013-2015 and the combined Australian Rowing Team and Olympic Shadow Squad in 2016, examining all rib stress injuries. RESULTS: 19 rib stress injuries (12 reactions and 7 fractures) were identified among a cohort of 151 athletes and included 12 female and 7 male cases, 11 open weight, 8 lightweight, 12 scull and 7 sweep cases. The most common locations of injury identified by imaging, were the mid-axillary line and rib 6. Period prevalence varied from 4% to 15.4% and incidence ranged from 0.27 to 0.13 per 1000 athlete days. There were no significant differences in prevalence by sex, sweep versus scull or weight class. There was a statistically significant increase in incidence in the pre-Olympic year (2015, p<0.001). MRI was the most commonly used modality for diagnosis. Stress fracture resulted in median 69 (IQR 56-157) and bone stress reaction resulted in 57 (IQR 45-78) days lost to full on water training. CONCLUSIONS: In our 4-year report of rib stress injury in elite rowing athletes, period prevalence was consistent with previous reports and time lost (median ~10 weeks) was greater than previously published literature. Rib stress injury limits training and performance in elite rowers and MRI should be considered as a first line investigation.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis.

OBJECTIVES: We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching. ELIGIBILITY CRITERIA: Studies evaluating prevalence of LBP in adult athletes across all sports. RESULTS: Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport. CONCLUSION: LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Australian Institute of Sport and the Australian Paralympic Committee position statement: urinary tract infection in spinal cord injured athletes.

Patients with spinal cord injuries are at increased risk of developing symptomatic urinary tract infections. Current evidence-based knowledge regarding prevention and treatment of urinary tract infection in the spinal cord injured population is limited. There are currently no urinary tract infection prevention and management guidelines specifically targeted towards elite spinal cord injured athletes. This position statement represents a set of recommendations intended to provide clinical guidelines for sport and exercise medicine physicians and other healthcare providers for the prevention and treatment of urinary tract infection in spinal cord injured athletes. It has been endorsed by the Australian Institute of Sport (AIS) and the Australian Paralympic Committee (APC).

What Factors Do Clinicians, Coaches, and Athletes Perceive Are Associated With Recovery From Low Back Pain in Elite Athletes? A Concept Mapping Study.

OBJECTIVE: Identify factors that elite sport clinicians, coaches, and athletes perceive are associated with low back pain (LBP) recovery. DESIGN: Concept mapping methodology. METHOD: Participants brainstormed, sorted (thematically), and rated (5-point Likert scales: importance and feasibility) statements in response to the prompt, "What factors are associated with the recovery of an elite athlete from low back pain?" Data cleaning, analysis (multidimensional scaling, hierarchical cluster analysis, and descriptive statistics), and visual representation (cluster map and Go-Zone graph) were conducted following concept mapping guidelines. RESULTS: Participants (brainstorming, n = 56; sorting, n = 34; and rating, n = 33) comprised 75% clinicians, 15% coaches, and 10% athletes and represented 13 countries and 17 sports. Eighty-two unique and relevant statements were brainstormed. Sorting resulted in 6 LBP recovery-related themes: (1) coach and clinician relationships, (2) inter-disciplinary team factors, (3) athlete psychological factors, (4) athlete rehabilitation journey, (5) athlete non-modifiable risk factors, and (6) athlete physical factors. Participants rated important recovery factors as follows: athlete empowerment and psychology, coach-athlete and athlete-clinician relationships, care team communication, return-to-sport planning, and identifying red flags. CONCLUSION: Factors perceived as important to LBP recovery in elite athletes align with the biopsychosocial model of community LBP management. Clinicians should consider that an athlete's psychology, relationships, care team communication, and rehabilitation plan may be as important to their LBP recovery as the formulation of a diagnosis or the medications or exercises prescribed. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub 10 August 2023. doi:10.2519/jospt.2023.11982.

What Is an Extreme Sports Healthcare Provider: An Auto-Ethnographic Study of the Development of an Extreme Sports Medicine Training Program.

"I remember when sex was safe and skydiving was dangerous" read a popular bumper sticker during the HIV crisis. Popular perceptions of extreme sport (ES) often include the descriptor 'dangerous'. Therefore, why is the popularity of ES increasing exponentially with "dedicated TV channels, internet sites, high-rating competitions, and high-profile sponsors drawing more participants"? More importantly, how should health practitioners respond to the influx of ES athletes with novel injuries, enquiries and attitudes. This paper describes the results of a collaborative auto-ethnographic approach to answering "what is an extreme sports medicine health care provider and what are the components of an effective Extreme Sports Medicine (ESM) training program?" The study was conducted following the first ESM university course offered in Australia with the intention of assessing the learning design and reflecting on the development and practice of ES health practitioners. We explicated three overarching themes common to both the ES health practitioner and for the effective training of healthcare providers in the support of ES endeavors and athletes. These themes were individual, task and environmental factors. The impacts of these findings confirm that ESM courses are vital and should be designed specifically to ensure that practitioners are effectively supported to develop the unique skills necessary for practice in real world extreme sports events.

Nutrition factors associated with rib stress injury history in elite rowers.

OBJECTIVES: To investigate associations between nutrition factors (diet restriction, menstrual status, calcium intake, vitamin D and K status), bone mineral density (BMD) and rib stress injury (RSI) history. DESIGN: Cross-sectional. METHODS: 133 elite rowers completed a self-report questionnaire to collect information regarding training and injury history, menstrual status and diet restriction, and a calcium intake questionnaire (SCQ2002). BMD and body composition were assessed by dual-energy X-ray absorptiometry. A sub-group (n = 68) had vitamin D and K status assessed from fasted morning blood. History of RSI was self-reported and verified against medical records. Characteristics of injured and uninjured rowers were compared (one-way ANOVA), while relationships with BMD (multiple linear regression) and RSI (multiple logistic regression) were modelled. RESULTS: Diet restriction was inversely related to spine BMD and rib BMD. Within sex, vitamin D and K status, and calcium intake were not associated with injury. Among rowers with RSI history, lightweight males had lower total bone mass, femur BMD and rib BMD, whereas heavyweight females had lower rib BMD. In relation to RSI history, the best models included rib, spine or femur BMD with age, body fat and sex. A female-specific model included rib BMD, current menstrual dysfunction, age and body fat levels. CONCLUSIONS: BMD, including that of the rib, diet restriction, menstrual function and weight category were associated with rib injury history and should be considered in the management of elite rowers.

Intersection syndrome: an acute surgical disease in elite rowers.

OBJECTIVE: Intersection syndrome is a relatively common condition in elite rowers and continuing conjecture over its pathology and best management often includes prolonged withdrawal from training and changes to the technique that may affect rowing outcomes. METHODS: We reviewed a case series in a national rowing squad and the effect on time loss produced by the condition. We reviewed the pathophysiology. We revisited the aggressive operative management put forward in the 1960s and applied it to modern rowing workload by reviewing a retrospective case series of six international rowers who had early surgical intervention. RESULTS: Approximately 5% of the squad suffered intersection syndrome during a 3-year period. The effect on training time was between 20% and 40% of their training time in the period. Using our understanding of the pathology as a true tendinitis of the second wrist compartment caused by fascial compression from hypertrophied first compartment muscles, we advocated earlier surgery and almost immediate return to training, which occurred at a median of 7 days postsurgery. We had successful return in five of six rowers in an accelerated programme to minimise muscle wasting and technique modification caused by the condition, achieving career goals in a matter of weeks after surgical intervention. CONCLUSIONS: We encourage early surgical management of intersection syndrome of the wrist to allow almost immediate return to training, and therefore interfere less with technique modification and time out of the water. This minimises career disruption in the elite rowing community.

Normative MRI, ultrasound and muscle functional MRI findings in the forearms of asymptomatic elite rowers.

OBJECTIVES: Forearm injuries are common and debilitating to elite rowers. Chronic exertional compartment syndrome, intersection syndrome and proximal radial bone stress injuries have been documented in this population. This paper explores the imaging findings related to these conditions in asymptomatic elite rowers. DESIGN: Observational study. METHODS: 19 asymptomatic senior elite and under-23 rowers currently competing at National level or above underwent ultrasound (US), Magnetic Resonance Imaging (MRI) and muscle functional MRI evaluation of their forearms. A comprehensive evaluation sheet identifying characteristics of bone stress, intersection syndrome and chronic exertional compartment syndrome was utilised based on a literature search and review by senior clinicians working with this population. RESULTS: Peritendinous fluid of Extensor Carpi Radialis Longus (n=10, 53%) or Extensor Carpi Radialis Brevis (n=6, 32%) was a common finding on US. MRI had a higher rate of identification than US. Extensor Digitorum (Coeff=-1.76, 95%CI -3.04 to -0.49), Flexor Carpi Radialis (Coeff=-2.86, 95%CI -5.35 to -0.38) and Flexor Carpi Ulnaris (Coeff=-3.31, 95%CI -5.30 to -1.32), Pronator Teres (Coeff=-3.94, 95%CI -6.89 to -0.99), and Supinator (Coeff=-168, 95%CI -3.28 to -0.02) showed statistically significant changes immediately post-exercise. Mild proximal radial marrow hyperintensity was present (n=15, 78.9%) with three participants (15.8%) also having mild periosteal oedema of the radius. CONCLUSIONS: Imaging findings commonly seen in symptomatic populations are observed in elite, asymptomatic rowers. Care should be taken when diagnosing bone stress injuries, intersection syndrome and compartment syndrome on imaging findings alone. Data presented can be utilised as a normative dataset for future case studies.

Damage control surgery for spine trauma.

The concept of "damage control" surgery was originally developed for massive abdominal trauma and also successfully applied to the management of lone bone injuries. More recently this has been extended to severely injured patients with spine injuries. This paper provided an overview of how damage control principles can be applied to multitrauma patients with spine injuries, to patients with isolated spine injuries and to spine injuries with and without neurology. The role of neuroimaging in acute spine trauma and controversies in the pharmaceutical approach to spine injuries are discussed. Additional prospective controlled trials are required to delineate the role and timing of damage control surgery in acute spine injury. With improved neuroimaging early spinal damage control surgery will be formally established in the management of spine trauma.