Andrew W. Nichols

Complications associated with the use of corticosteroids in the treatment of athletic injuries.

Background:The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear. Objective:To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries. Data Sources:A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion. Study Selection:For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria. Data Extraction and Synthesis:Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy. Main Results:Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions. Conclusions:This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

A comparison of a preparticipation evaluation history form and a symptom-based concussion survey in the identification of previous head injury in collegiate athletes.

Objective:The purpose of this study was to compare the incidence of prior head injury reported on preparticipation physical evaluation (PPE) history forms with a retrospective symptom-based survey. Design:A comparison of 2 retrospective survey instruments. Setting:NCAA Division I varsity athletic program. Participants:A total of 93 male and 79 female athletes participating in intercollegiate contact/collision sports. Main Outcome Measures:Athletes were administered a concussion symptom survey (CSS) with questions about symptom incidence after head injury. These responses were compared with answers given about previous concussion/head injury on the universitys PPE history form. The numbers of positive responses were analyzed using descriptive statistics, and differences between the PPE medical history form and the concussion symptom survey were assessed using χ2 analysis. Factor analysis was performed to assess for possible variance structure between reported symptoms. Results:Seventy-one percent of athletes reporting symptoms consistent with concussion were not identified as having a history of head injury on the PPE medical history form. The most common symptom on the CSS was headache, which accounted for 46 (56.1%) positive responses. Conclusions:The CSS revealed greater numbers of athletes experiencing symptomatic head injuries than the screening questions on the PPE history form. Screening for signs and symptoms of concussion may enhance the sensitivity of the PPE in detecting a prior history of concussion.

Complementary and alternative medicine usage by intercollegiate athletes.

ObjectiveThe purpose of this study is to determine the prevalence and types of provider-delivered complementary and alternative medicine (CAM) used by intercollegiate student athletes attending a Division I NCAA University. Design and SettingSurvey methodology within a group of intercollegiate student athletes at a Division I NCAA university during the fall semester of 2004. ParticipantsAll incoming and returning intercollegiate student athletes were invited to participate. Surveys were completed by 309 (122 women, 187 men) of 482 (64.1%) student athletes representing 20 sports (11 womens, 9 mens teams). Main Outcome MeasurementsA 28-item reliable and valid survey instrument that measured the use of provider delivered CAM and allopathic medical care was administered. Data were analyzed using descriptive statistics, χ2 tests, and logistic regressions. ResultsFifty-six percent of subjects reported using CAM within the past 12 months, including a significantly higher percentage of women (67%) than men (49%) (P<0.01). Massage was the most commonly used type (38%), followed by chiropractic (29%), Lomilomi (14%), and acupuncture (12%). CAM usage overall did not differ significantly by sport, year in college, nor ethnicity. Hawaiian, Samoan, and Tongan subjects were more likely to use the Hawaiian-originated forms of CAM. Sixty percent of respondents have a regular medical doctor, eighty percent of which are family practitioners. Forty-two percent of subjects were referred to a medical specialist within the previous three years. ConclusionsCAM usage is common among collegiate student athletes and rates are higher than in adults nationwide and within the state of Hawai′i. This study and future investigations will increase the awareness of CAM use patterns by collegiate athletes, and hopefully improve allopathic physicians’ abilities to provide optimal athletic health care.

The Effect of Dynamic Intermittent Hypoxic Conditioning on Arterial Oxygen Saturation

Abstract Background.—Increases in arterial oxygen saturation (SaO2) in response to intermittent hypoxic exposure (IHE) are well established. However, IHE protocols have historically involved static hypoxic environments. The effect of a dynamic hypoxic environment on SaO2 is not known. Objective.—The purpose of this study was to examine the effect of dynamic IHE conditioning on SaO2 using the Cyclical Variable Altitude Conditioning Unit. Methods.—Thirteen trained participants (9 males, age 30.1 ± 9.2 years; 4 females, age 30.3 ± 8.9 years) residing at or near sea level were exposed to a 7-week IHE conditioning protocol (mean total exposure time = 30.8 hours). Participants were exposed to a constantly varying series of hypobaric pressures simulating altitudes from sea level to 6858 m (22 500 feet) in progressive conditioning tiers, creating a dynamic hypoxic environment. SaO2 was evaluated using pulse oximetry (SpO2) 4 times: at 2740, 3360, and 4570 m, prior to and following the first 3 weeks of IHE, and at 4570, 5490, and 6400 m at the start and end of the final 4 weeks. Results.—SpO2 improved 3.5%, 3.8%, and 4.1% at 2470, 3360, and 4570 m, respectively (P < .05), and 3.3%, 3.4%, and 5.9% at 4570, 5490, and 6400 m, respectively (P < .05). At 4570 m, SpO2 increased from 81.7% ± 6.5% to 89.1% ± 3.2% over the entire 7-week conditioning period. Discussion.—The dynamic intermittent hypoxic conditioning protocol used in the present study resulted in an acclimation response, such that SpO2 was significantly increased at all altitudes tested, with shorter exposure times than generally reported.

Effects of combination oral contraceptives on strength development in women athletes.

Nichols, AW, Hetzler, RK, Villanueva, RJ, Stickley, CD, and Kimura, IF. Effects of combination oral contraceptives on strength development in women athletes. J Strength Cond Res 22(5): 1625-1632, 2008-This study was designed to investigate the effects of combination oral contraceptive agents (OCAs) on strength and torque production in collegiate women softball and water polo athletes who participated in a 12-week strength development program. A double-blind research design was used to mask subjects to the main outcome of interest. Thirty-one women collegiate softball and water polo players were divided into experimental (OCA users, n = 13), and control (non-OCA users, n = 18) groups. All subjects participated in the same supervised 12-week preseason strength development program. One-repetition maximum bench press (1RMBP), 10-repetition maximum leg extension (10RMLE), isokinetic peak torque bench press (IKBP), and isokinetic peak torque leg extension (IKLE) data were collected at weeks 0 (pre-test), 4, 8, and 12 (post-test). Significant increases in strength and torque production over time were identified regardless of group for 1RMBP, 10RMLE, and IKLE. No significant differences in IKBP torque production occurred during the 12-week strength training program. No significant differences in 1RMBP, 10RMLE, IKBP, or IKLE occurred between the OCA users and the non-OCA users groups. It was concluded that, within the limitations of the study, the use of combination OCAs did not provide sufficient androgenic effect to increase strength gains beyond the stimulus of the training protocol.

Does eccentric training of hamstring muscles reduce acute injuries in soccer

OBJECTIVE To investigate the effectiveness of a 10-week hamstring exercise training program in reducing the incidence and severity of new and recurrent hamstring injuries among male soccer players. DESIGN Cluster-randomized (by team)controlled trial, stratified by level of play and geographic location. Sample size was calculated with 80% power to show a relative risk reduction for injury of 50% at P ≤ 0.05. SETTING Soccer community study in Denmark during the period January to December 2008. PARTICIPANTS Teams in the top 5 soccer divisions (2 professional and 3 amateur)were invited to participate. The exclusion criterion for teams was that they already used eccentric hamstring exercises, and for participants was that they joined the teams after the beginning of the season. Of 116 teams, 54 were eligible and willing to be randomized and 50 were included in the analysis (942 players). INTERVENTION Teams in both the intervention and control groups followed their normal training programs. At the beginning of the study period, the intervention teams added 27 sessions of the Nordicham string exercise (after warm-up) during the 10-week period of the mid-season break. The exercise begins with the player kneeling with the torso upright and rigid, and the feet held down to the ground by a partner. The player lowers his torso forwards toward the ground braking with his hamstring muscles until the chest reaches the ground (eccentric phase). He returns to the upright position, pushing with his hands to minimize the concentric phase load. Sessions per week and sets and repetitions per session increased to 3, 3, and 12, respectively. Team coaches supervised the sessions. MAIN OUTCOME MEASURES A hamstring injury was defined as an acute occurrence of a “physical complaint in the region of the posterior thigh sustained during a soccer match or training, irrespective of the need for medical attention or time loss from soccer activities.” Injuries were recorded by the teams’ medical staff on standardized forms. Only first injuries during the season were included and recorded as first-time injuries or recurrences of injuries sustained before the season.Severity of injury was defined by number of days lost from full participation in games and practices. MAIN RESULTS Injury rates per 100 player sessions were lower for the intervention group (3.8) than for the control group(13.1); thus, the rate ratio (RR) adjusted for age, level of competition, and previous injury was 0.293 (95% confidence interval[CI], 0.150-0.572). Both rates of new and recurrent injuries were lower for the intervention group than for the control group(new injuries: RR, 0.410; 95% CI, 0.180-0.933; recurrent injuries: RR, 0.137; 95% CI, 0.037-0.509). The 15 injuries in the intervention group resulted in absence of 454 days from soccer (mean, 30.3; SD, 18.3; range, 7-64 days per injury), whereas 51 injuries in the control group resulted in 1344 days absent (mean, 26.4; SD, 19.5; range, 4-89 days per injury). Mean severity of injuries (days absent) was not significantly different (P = 0.16) between groups. Delayed onset muscle soreness,but no other adverse effect, was reported by most members of the intervention group during the training period. CONCLUSIONS An eccentric hamstring exercise program was associated with lower rates of new and recurrent hamstring injuries in Danish male soccer players.

The use of pregame hyperhydration with intravenous fluids in National Collegiate Athletic Association Football Bowl Subdivision teams.

Objective:To determine the frequency of pregame intravenous fluid hyperhydration (PIVFH) usage, administration protocols, indications, complications, and perceived efficacy by National Collegiate Athletic Association Football Bowl Subdivision (NCAA-FBS) teams. Design:Cross-sectional survey study. Setting:National Collegiate Athletic Association Football Bowl Subdivision. Participants:Head athletic trainers from NCAA-FBS institutions. Intervention:Voluntary, anonymous 15-item validated online survey instrument. Main Outcome Measures:Number of teams reporting use of PIVFH. Results:The survey response rate was 64% (77 of 120). Thirty percent of respondents reported the utilization of PIVFH, administered to an average of 2 to 3 players. The most common reasons cited for using PIVFH were to prevent muscle cramps (95%), heat illness (79%), and dehydration (68%). Additionally, 47% of programs used PIVFH to improve player exercise tolerance and 47% per player request. Twenty-four percent of programs that used PIVFH reported the occurrence of associated complications. Only 15% of respondents believed that PIVFH improved their teams’ overall performance. Conclusions:PIVFH is a common practice among NCAA-FBS teams. PIVFH is used most often to prevent muscle cramps, dehydration, and heat illness. The relatively few numbers of players per team who receive PIVFH suggest that higher risk individuals were targeted for administration.

Two-year follow-up of injection with platelet-rich plasma versus corticosteroid for lateral epicondylitis.

that described stretching for,30 seconds as a common practice are a textbook and a study on rabbits. Second, stretches of such a short duration do not impart meaningful changes in the mechanical properties of muscle, and the effects are not sustained beyond a few minutes. For example, Ryan et al described the dose response of the plantar flexors with respect to retention of the stretch-induced decreases in passive resistance to stretch. The effects of a total stretch duration of 2 minutes lasted ,10 minutes, whereas the effects of stretch durations of 4 minutes lasted .10 minutes. The effect of a stretch duration of 8 minutes lasted at least 30 minutes. Kay and Blazevich concluded, “Static muscle stretches totaling ,45 s can be used in preexercise routines without risk of significant decreases in strength-, power-, or speed-dependent task performances.” If there is no clinically meaningful change in range of motion, our question is, “Why stretch?” Would one prescribe a very low dose of a drug to avoid known side effects without considering the dose required to have the desired effects? The larger clinically meaningful question is whether a stretching intervention, sufficient to result in a prolonged decrease in passive muscle stiffness, confers any benefit with respect to injury prevention (or other desirable effects) that might outweigh the potential impairments in muscle function shown in this review. One of us (M.M.) believes yes, and the other (I.S.) believes no; we both believe that researchers and authors should focus on relevant clinical questions that have not yet been adequately addressed. For injury prevention, we believe this includes whether injury risk is decreased with regular stretching and/or warm-up and whether these effects are dependent on the type of activity (eg, high vs low intensity or extent of range of motion).

Comparison of imaging techniques for diagnosing suspected scaphoid fractures: a review.

Objective: To assess and compare the diagnostic performance of bone scintigraphy, magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound for diagnosing suspected scaphoid fractures, against clinical or imaging follow-up reference standards, by means of a systematic review. Data sources: PubMED and EMBASE were searched to October 2008 using words and terms including scaphoid bone, carpal bone, fracture, test, accuracy, sensitivity, specificity, and diagnosis. References of relevant studies were searched by hand. Study selection: Selection criteria were: the study was a clinical investigation that assessed the diagnostic performance of an imaging technique; follow-up imaging or clinical follow-up was the reference standard; 2 3 2 tables of the performance of the index test could be constructed to allow sensitivity, specificity, and other parameters to be calculated; and the article was full-text, published in English, and the fullest description of the data, if there were several linked publications. Two investigators independently selected the studies, and differences were resolved by consensus. Of 2440 citations screened, 56 full-text articles were retrieved, and 26 studies met the criteria. Data extraction: Details of the samples, imaging techniques, reference standards, results, and quality of the methods (rated on 14 QUADAS criteria) were independently extracted by 2 reviewers. Main results: The diagnostic accuracy of bone scintigraphy was reported in 15 studies (1102 participants), of MRI in 10 studies (513 participants), of CT in 6 studies (211 participants), and of ultrasound in 2 studies (72 participants). Bone scintigraphy had a pooled sensitivity of 97% (95% CI, 93%–99%), a specificity of 89% (95% CI, 83%–94%; heterogeneity, P , 0.001), and natural logarithm of the diagnostic odds ratio (ln DOR) of 4.78 (95% CI, 4.02–5.54). For MRI, results were: sensitivity, 96% (95% CI, 91%–99%), specificity, 99% (95% CI, 96%–100%), and ln DOR, 6.60 (95% CI, 5.43–7.76); and for CT, sensitivity, 93% (95% CI, 83%–98%), specificity, 99% (95% CI, 96%–100%), and ln DOR, 6.11 (95% CI, 4.56–7.66). With a mean prevalence of 18% of true fracture (derived from 1165 patients in 21 prospective studies) negative findings from bone scintigraphy, Magnetic resonance imaging, and CT would result in a post-test probability of fracture of 0.7%, 0.9%, and 1.5%, respectively, and positive findings from bone scintigraphy, MRI, and CT would result in a post-test probability of fracture of 66%, 95%, and 95%, respectively. The 2 studies of ultrasound could not be pooled. They found sensitivities of 100% and 78% and specificities of 98% and 89%, respectively, with wide confidence intervals. Two studies met all the QUADAS methods criteria, 18 studies met

Selective Serotonin Reuptake Inhibitors and Rhabdomyolysis after Eccentric Exercise

70% of the criteria, and 5 studies met #50% of the criteria. Conclusion: Magnetic resonance imaging and CT identified scaphoid fractures accurately, and bone scintigraphy had high sensitivity but lesser specificity. Limitations in the methods of most of the studies may have biased the results.