Exercise-associated hyponatremia; drinking oneself to death….. Guest blog by Dr Jonathan Williams

April 9, 2012

A 22 year old male fitness instructor finished the 2007 London Marathon, collapsed, and despite immediate emergency medical care, died. His serum sodium was markedly low, and the cause of death was found to be hyponatremia. Subsequent investigations established that he had been concerned about becoming dehydrated, and had therefore drunk a large volume of fluid en route. Several other athletes have died from hyponatremia due to drinking excessively, and many others have required hospital care. Studies from the 2002 Boston Marathon and 2006 London Marathon found that 13% and 12.5% of finishers, respectively, had asymptomatic hyponatremia. Our paper in this month’s CJSM explored the 2010 London Marathon runners’ knowledge about fluid intake, their drinking strategies and knowledge about exercise-associated hyponatremia (EAH).

City marathons were established around the world in the 1970s and 1980s. Elite marathon runners of the time rarely drank much during races; when Mike Gratton won London Marathon in 1983, he drank nothing. However, in 1975, the American College of Sports Medicine published a position statement advocating regular fluid intake during endurance events, suggesting this would reduce the risk of heat stroke. During the 1980s and 1990s, increasing numbers of endurance athletes experienced EAH.  International EAH Consensus Development Conferences of 2005 and 2007 reviewed the available evidence about EAH, and advocated drinking “to thirst” rather than the higher volumes recommended by ACSM. In 2007, ACSM revised its position statement advising that fluid intake during exercise should not exceed sweat loss.

In our study, a representative sample of 217 runners was questioned. More than 93% of the runners had read or been told about drinking fluid on marathon day. However, 12% planned to drink a volume large enough to put them at higher risk of EAH, and only 25.3% planned to drink according to their thirst. Although 68% had heard of hyponatremia or low sodium, only 35.5% had a basic understanding of its cause and effects. These findings suggest that runners lack knowledge about appropriate fluid intake on race day. Effective education is needed to prevent overdrinking during marathons.

Professor Tim Noakes has researched EAH for almost thirty years. He is due to publish a book in May 2012 called ‘Waterlogged’ in which he explores the influence sports drink manufacturers have on the science of hydration, and on runners’ drinking habits. ‘Waterlogged’ is likely to be thought-provoking, controversial and fascinating.

The cause of EAH is firmly established and it is entirely preventable. It is now the responsibility of race organizers, drinks manufacturers, running publications and us as sports physicians to educate runners effectively about safe drinking strategies.

Dr Jonathan Williams is a Sports Medicine Doctor and General Practitioner, as well as an avid runner.

The photograph is of the author having just completed a London Marathon

References :

1) Williams J et al. 2012. Hydration Strategies of Runners in the London Marathon. Clin J Sport Med 22 (2): 152-156

2) Hew-Butler et al. 2008. Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference, New Zealand, 2007. Clin J Sport Med 18(2): 111-121

3) Hew-Butler et al. 2005. Consensus Statement of the First International Exercise-Associated Hyponatremia Consensus Development Conference, Cape Town, South Africa 2005. Clin J Sport Med 15(4): 208-213

4) Sawka MN et al. 2007. ACSM Position stand – Exercise and Fluid Replacement. Med Sci Sports Ex 39 (2): 377-390

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Sports pre-hospital immediate care training – not a Road Traffic Collision to be seen – Guest Blog by Dr Jonathan Hanson

March 7, 2012

Fortunately for athletes, the days of a medic in the bar in a suit are mostly behind us. The general advancement in pre-hospital care and in particular through primary care avenues has led to the recognition that there is “no place for a token Doctor” in the sporting environment.

Ethically and medico-legally, pitchside medical staff need to be trained and equipped for the service for which they provide. The exact level to which this training has taken place will vary from sport to sport, with motorsport and equestrian events requiring a level of training comparable to that of general pre-hospital care specialists dealing with immediate medical response to complex polytrauma.

However, therein lies the current problem of pre-hospital care teaching and the sporting environment – the injury profiles, or at least those that we know, of most sports are generally not comparable to the case load for which a pre-hospital care specialist would regularly manage. Although sports such as American football, Rugby, Australian rules football and ice hockey have particularly ferocious collisions, they do not cause the patterns of multiple injuries or tissue damage that one would see in a road traffic collision, a fall from a height or a blast injury. Hence, many training courses aimed at tackling standard pre-hospital care scenarios are not entirely appropriate for the pitchside sports physician or physiotherapist.

Within pre-hospital emergency care training there exists a niche for a separate entity of sports pre-hospital immediate care courses – courses that reflect not only the injury profiles of the sports for which they are designed, but also the speed of response of the pitchside responder, so that when they meet tachycardia, tachypneoa and distress on the pitch – they have “shock” at the back of their minds, but “recovering from sprinting” at the front. Indeed, the speed of response of pitchside medical staff means that many pre-hospital principals need viewing in a different light.

On-field trauma patients don’t really have time to bleed 2 litres of blood into the abdomen by the time they are initially assessed, unlike the patients being assessed by emergency services a few minutes following a car crash. Of course haemorrhagic shock does occur in sport so training needs to include the need to monitor and transfer those about which we are worried. Pelvic haematomas seldom have enough time to form during most sports, let alone be disrupted by particular manoeuvres, so some of the arguments about choice of equipment and techniques when pitchside staff extricate an athlete are more open for debate. Most athletes who compete in an environment with pitchside medical support are extremely fit and with massive physiological reserves – again another unique demographic for the expected caseload and training needs to reflect the physiological response in such individuals to trauma.  For some medics at least, every move can be live on TV – with both medical pressures and privacy issues for the athlete, and the pressures of a high media spotlight need also to be taken into consideration.

Fortunately the niche of sports pre-hospital immediate care courses has been recognised by the Faculties of Pre-hospital Care and of Sport and Exercise medicine of the Royal College of Surgeons of Edinburgh, and as a result excellent in-hospital courses such as ATLS are being replaced on the sports medicine curriculum by sports pre-hospital immediate care courses. This should lead to regulation about training standards and delivery and help regulate the recent explosion of sports trauma courses to a common standard for the good of the athlete and for the medics. Long may it continue.

Dr Jonathan Hanson FFSEM is a Sport and Exercise Medicine Physician / Rural Practitioner, at Broadford Hospital, Skye, Scotland

Image – Dr Jonathan Hanson (right) and a colleague in action

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Next generation of anatomy apps for learning and patient education here NOW!!

March 1, 2012 14 Comments

Regular readers of the blog may remember the previous post on anatomy applications (apps) back in June last year, when I presented my top 5 anatomy apps on the Apple apps store for both learning anatomy and educating patients.

For those of you who need a quick reminder, apps from the Apple store are computer programs that work on several Apple-platform mobile devices including iPads, iPhones and the iPod touch, with certain apps and features within apps being available only on certain devices, limited only by hardware and next generation development issues. For example, the iPad 2 has an integrated camera whereas the first generation device had none. The value of anatomy apps lies both within clinician and patient education.

The next generation of anatomy apps are now available from 3D4Medical, running on both first and second generation iPads. There are updates for both of the Skeletal System and Muscle System Pro Nova apps (now in their 3rd editions), and new dedicated apps for the hip joint, knee joint and shoulder joint which include the complete anatomy of these regions including musculoskeletal anatomy, nervous system and vascular anatomy.

I am pleased to say that there has been a significant improvement to the existing apps which were already excellent in quality. Now, they are simply outstanding in many ways. The quality of the visuals has not gone unnoticed by Apple themselves who have showcased some of the apps on their latest TV adverts. The images really are stunning when seen on the iPad.

Both Skeletal and Muscle System Pro Nova III apps come with a new interface which allows for simpler navigation. Images can be more easily manipulated than before for different viewing angles allowing for simpler rotation, single finger-swipe cuts for coronal, saggital and transverse views, and a double-tap zoom feature. This allows you to get to the images you really want to see much quicker than before. There is a hint feature to help you to get to grips with the new graphical interface features which can be turned off once you get used to these. Pin Media labels are more extensive, and these are now spoken to allow users to hear the correct pronunciation of each anatomical feature.

The pin labels themselves now come with additional media, such as animations of anatomical movements or further images. There are also linked public notes which allows for users to read notes made by other users of the apps in the public domain. The images can be easily annotated, and shared with patients or other people who may wish to view them by email and social media via twitter and Facebook.

The new dedicated apps are perhaps the ones of most interest to clinicians, for the first time including all of the relevant anatomy of the regions to give a clear picture of the entire anatomy from surface to bone. The clarity of images within these apps is outstanding, and the animations are especially helpful for explaining how certain muscles produce certain movements to patients. Structures such as the subacromial bursa in the shoulder can easily be visualised, and when combined with the animations showing movement at the shoulder joint, it is much easier than before to explain to patients how impingement of this structure can occur under the subacromial arch.

You can check out the new features in the Knee Pro Nova video below (will only show on standard site).

http://youtu.be/nGbC-0dPKOk

Having used the earlier apps during my patient consultations as an educational tool, I have now started to use these new apps and have found them easier to use both in the consulting room and at the training ground than the previous incarnations. Patients seem to gain a better understanding of the anatomy relevant to their injuries or conditions when seeing the visuals, and the multimedia content really helps to bring functional anatomy to life.

Perhaps future additions to the series might include videos specifically related to pathologies. Examples might be video image of an inflamed bursa impinging under the subacromial arch, a ruptured anterior cruciate ligament in real time, or the dynamic anatomy of a snapping hip. For now, however, these apps give clinicians an extremely powerful set of tools for patient education, and for learning anatomy.

For further information on 3D4Medical’s new apps, see the 3D4Medical website, or check out videos of the other apps on youtube via these links :

Shoulder Pro

Hip Pro

Skeletal System Pro III (Nova Series)

Muscle System Pro III (Nova Series)

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Patellofemoral pain syndrome – is this a top down or bottom up problem…or both? Guest blog by Simon Lack

February 19, 2012

Patellofemoral pain syndrome (PFPS) has a high prevalence within the sporting population, with one study of 2159 presentations to sports medicine clinics, reporting 5.4% incidence of PFPS, accounting for 25% of those presenting with knee pain (1).  Despite a more traditional approach to management having been well researched in a high quality RCT (2), the problem has been shown to have a high recurrence.  In a quest to unravel the mystery of long-term successful treatment outcomes, researchers have started looking above and below the knee to potentially identify more effective solutions.

Arguably started by the work of Lee et al (3) that identified that changes in femoral rotation angles have significant consequences for patellofemoral joint loading, in combination with consistently reported weakness of hip musculature in PFPS populations (4), multiple studies have looked to modify top down control through strengthening of the hip rotator muscles.  The outcomes of these studies have shown significant reductions in symptoms and increases in function particularly in weaker individuals.  In addition, better outcomes have been reported if a proximal strengthening programme is started prior to functional strengthening compared with an initial local knee-strengthening programme (5). Thus, a case is emerging in favour of a top-down treatment mechanism.

Distal to the knee a growing body of evidence supporting the use of foot orthoses in PFPS management has started to be established.  A high quality RCT that compared six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy, demonstrated orthoses to be superior to flat inserts, with their use resulting in comparable outcomes to multimodal physiotherapy (6).

Further more, evidence suggests foot orthoses have the ability to change pain immediately within this population of patients (7), with a further reduction of pain experienced following a 12/52 period of orthotic wear (8).  Interventions that have the capacity to reduce pain symptoms immediately, pose a valuable tool in facilitating normal movement patterns, maximising function and minimising detrimental pain inhibition.  Hence, further emerging evidence for a bottom-up treatment mechanism.

What do you think predicts treatment success in PFPS, and why ?

Simon Lack is a Physiotherapist and current PhD student at Queen Mary University, London, currently studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain.

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References

1.Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a Sports Injury Clinic. Br J Sports Med. 1984 Mar;18(1):18-21.

2. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. [Clinical Trial Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2002 Nov-Dec;30(6):857-65.

3. Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Review]. 2003 Nov;33(11):686-93.

4. Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):9-15.

5. Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70.

6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Bmj. [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2008;337:a1735.

7. Barton CJ, Menz HB, Crossley KM. The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome. Br J Sports Med. 2010 Jul 20.

8. Barton CJ, Menz HB, Crossley KM. Effects of prefabricated foot orthoses on pain and function in individuals with patellofemoral pain syndrome: a cohort study. Phys Ther Sport. 2011 May;12(2):70-5.

Filed under Anterior knee pain / patellofemoral pain syndrome, Foot orthoses, General Interest, Physiotherapy Tagged with , ,

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