Seasonal influenza vaccination for professional athletes – who’s for the jab?

November 13, 2011

It’s that time of year for many of us in the Northern hemisphere when colleagues involved in caring for participants in elite sports are being asked, ‘Doc, should I have a flu shot?’

The decision may have already been made by the athlete (or, indeed, the Club or organisation) that they either ‘need’ or ‘don’t need’ influenza vaccination, which may make life easy or hard for clinicians if there is a difference of opinion on the subject.

Whilst our patients might perhaps expect an easy and straightforward ‘yes’ or ‘no’ answer on the question of seasonal influenza vaccination, the reality is that the decision to be made on requirements for seasonal influenza vaccination requires a consideration of a number of complex factors relating to the susceptibility of individuals and populations to the disease, together with the risks of serious complications to particular groups of individuals and their contacts in society.

These can be broadly grouped into extrinsic and intrinsic factors :

1) Extrinsic factors

– Regional projected population prevalence of viral load (based on WHO Health surveillance data)

– Regional variance in delivery policies and availability of vaccines (may include rationing)

– Meteorological forecasts

– Other socioeconomic factors (occupation, housing etc)

2) Intrinsic factors

– Co-morbidities such as asthma, diabetes

– Patient choice

In the United States, seasonal influenza vaccination is recommended for all individuals over the age of 6 months, but local recommendations vary considerably in different countries. In the UK, for example, universal vaccination is not currently recommended, with a more targeted approach being adopted towards vaccinating certain individuals.

When it comes to particular groups such as athletes, all of the considerations mentioned above apply but there is the added question about the effect of moderate-to-high levels of physical activity on immune system function and susceptibility to infection to consider. It may also be important to consider the effect of travel and time-zone adjustment. In addition, when it comes to hard outcomes, it’s important to consider the evidence for the effectiveness of influenza vaccination on disease prevention in individuals, and for prevention of cross-infection of colleagues within a team environment.

There is a whole host of guidance available to clinicians from organisations such as the World Health Organisation, the Centers for Disease Control and Prevention, and the Department for Health in the UK which describe recommendations for vaccination in individual groups related to age and co-morbidities.

However, there is little information in the literature based on good quality evidence to inform clinical practice when it comes to the immunisation of professional athletes based on a consideration of the effect of high levels of physical activity on immune system functioning.

Perhaps as our understanding of exercise immunology improves, the basic science knowledge will better inform clinical practice.

An interesting position statement on immune function and exercise and maintaining immune health, published this year over two articles in Exercise Immunology Review should help us to get there. The articles provide a comprehensive review of topics in exercise immunology, and are available on the web here (Part 1) and (Part 2).

In the meantime, for those of us in the UK and other Countries where universal seasonal influenza vaccination is not currently recommended, the references at the end of this post may prove useful for those of us making decisions with our athletic patients.

CJSM would be interested to hear your thoughts and strategies for seasonal influenza vaccination of athletes, especially from team physicians.

1)  Constantini N et al. 2008. Vaccinations in sports and recommendations for immunization against flu, hepatitis A and hepatitis B.  Harefuah 140(12):1191-5

2) Daly P, & Gustafson R. 2011. Public Health recommendations for athletes attending sporting events. Clin J Sports
Med. 21(1): 67-70

3) Schaffner W. Rehm SJ. File TM Jr. 2010. Keeping our adult patients healthy and active:the role of vaccines across the lifespan. Physician and SportsMed 38(4): 35-47

4) Malm C. 2004. Exercise Immunology : the current state of man and mouse. Sports Medicine 34(9): 555-560

5) Ross DS et al. 2001. Study indicates influenza vaccine beneficial for college athletes. West Virginia Medical Journal 97(5): 235

6) Tarrant M & Challis EB. 1988. Influenza vaccination for athletes? Canadian Medical Association Journal 139(4): 282

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Quarter of a century up! What have we been talking about?

November 2, 2011

The CJSM Blog reaches its 25th blog post today since our launch back in June earlier this year. For those of you who have been on board with us since the beginning, we’d like to thank you for your interest and hope that you have found the content interesting on our journey in the World of Sport Medicine.

For those of you who may have joined us a little more recently, this is as good a time as any for a recap of some of the topics we’ve been talking about so far.

Our most recent post focuses on MRI use during clinical assessment by sports clinicians and asks the question, ‘Do Sports Medicine Clinicians overuse MRI scanning?’ This issue was recently highlighted in an article in the New York Times, with perhaps a premature conclusion being reached that MRI scans are indeed overused by Sports Medicine clinicians. What do you think? Come and let us know, and don’t forget to vote on our home page quick poll.
Just prior to that, the issue of concussion in sport was discussed relating to an incident in the recent Rugby World Cup Final where a player who left the pitch due to what looked to be a concussive injury was allowed back onto the field of play only to go off again shortly afterwards. In the context of the sideline assessment of concussion and return to play guidelines, the question asked was, ‘do we practice what we preach?’
The hype surrounding the use of platelet-rich plasma was highlighted back in august when, in the context of a recently published systematic review article in CJSM, we asked the question ‘Is PRP a magic bullet or a damp squib?’
A little earlier, the controversy surrounding the mandatory use of cycle helmets for recreational cyclists was discussed in a post which generated the most number of comments from our readers so far, some with very strong opinions either for or against mandatory use. Our quick poll on the topic was hugely against legislation and enforcement of cycle helmets, with a massive 81% of 137 responders saying ‘no’ to legislation.
Some of our other discussions have focussed on cardiac screening, pre-game hyper-hydration, ‘home or away’ care for athletes, and pre-participation evaluation. Other posts have highlighted sporting events such as the Women’s Football World Cup, Wimbledon Tennis, Le Tour de France, Boxing, Ice Hockey, Rodeo, and the Olympic preparation events in the UK, with associated information signposted relating to particular injuries in different sports. We’ve also mentioned e-learning apps for anatomy, the Ovid Sports Concussion Webinar, Ramadan and the 2012 Olympics, Abuse and Bullying in Sport and several other topics along the way.
We hope that you’re enjoying the ride. In the meantime, don’t be shy – come and share your thoughts with us on the blog. It’s not too late to add your contributions to any of our posts so far, and we’d love to hear from you. The more discussion we have, the more we’ll learn from each other. This blog belongs to all of us.
CJSM would like to know what issues you would like to see discussed on the blog. Let us know, and we’ll do our best to highlight your preferred topics of discussion related to Sport and Exercise Medicine.

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MRI scans in Sports Medicine – use or abuse?

October 31, 2011 2 Comments

There was an interesting article in the New York Times this week that caught my eye, thanks to an alert from our Publisher at CJSM (thanks, Paul!)

In the article by Gina Kolata, a science journalist for the New York Times, Dr James Andrews, of the Andrews Institute for Orthopaedics and Sports Medicine, was quoted as saying ‘If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.’

The article claims that Dr Andrews was involved in a piece of research where the pitching shoulders of 31 asymptomatic Professional Baseball pitchers were scanned using MRI, with findings of ‘abnormal shoulder cartilage’ in 90% of the shoulders, and ‘abnormal rotator cuff tendons’ in 87% of the shoulders. There was no indication as to whether or not this research was published.

Other clinicians are subsequently quoted, including Professor Bruce Sangeorzan, Vice Chairman of the Department of Orthopaedics and Sports Medicine at the University of Washington saying ‘an MRI is unlike any other imaging tool we use… It is a very sensitive tool, but it is not very specific. That’s the problem.’

In addition, Professor Christopher DiGiovanni, Sports Medicine and Orthopaedic Specialist at Brown University, is quoted as saying ‘It is very rare for an MRI to come back with the words “normal study” … I can’t tell you the last time I’ve seen it.’

Following quotes from these clinicans, the author goes on to make what some might call a leap of faith in then stating that ‘MRIs are not the only scans that are overused in medicine, but in sports medicine where many injuries involve soft tissues like muscles and tendons, they rise to the fore,’ the statement regarding ‘overuse’ having been drawn, presumably, from inferences from some of the clinicians quoted in the article.

Later on in the article, a retrospective study from 2005 by Bradley and colleagues  of 101 patients with chronic atraumatic shoulder pain is mentioned which examined the effect of pre-evaluation MRI on patient treatment and outcome, and concluded that MRI was not helpful as a screening tool for atraumatic shoulder pain before a comprehensive clinical evaluation of the shoulder.

In addition, another retrospective study from 2007 was mentioned by Tocci and colleagues who set out to prove the alternative hypothesis that rising accessibility of MRI may be resulting in it’s overuse by retrospectively reviewing 221 patients seen over a 3 month period for the treatment of a lower extremity problem. The authors concluded that ‘many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary.’

The New York Times article certainly seems to have sparked a flame of interest spreading amongst other newspaper and website authors and has been widely quoted in the few days since it has been published.

There is no doubt that there are a number of factors that could lead MRI scans to become overused as an investigation in the assessment of patients seen by Sports Medicine clinicians. These could include improved accessibility to MRI scanners, reduced cost for examinations, inadequate clinician history taking and / or examination skills, laziness on the part of clinicians in performing an appropriate assessment, financial incentives, patient pressure for scans, and defensive medical practice.

However, any clinician worth their salt surely recognises the need for an excellent history, targeted clinical examination, formulation of a differential diagnosis and appropriate investigation on the basis of these.

They would also surely realise issues regarding the sensitivity and specificity of MRI scans for detecting lesions, and the fact that the natural history of some lesions detected by MRI scans that have hitherto been undetectable is not well known, limiting the conclusions that can be drawn from some scans relating to treatment and prognosis.

In addition, the limitations of MRI scanning as a screening tool should also be known by responsible clinicians, although there is no doubt in my mind that some colleagues are using MRI scanning in a non-evidence based way for screening and that this may ultimately lead to unnecessary procedures and psychosocial harm.

I don’t agree with the quote from Dr Andrews implying that if one wants to operate on a pitcher’s shoulder then all one needs to do is order an MRI scan – good surgeons operate on patients, not scans, and should surely follow the time-honoured approach I have highlighted above.

The article by Kolata in the New York Times presents little if any evidence that MRI scans are indeed overused in Sports Medicine, and it is my opinion that the views of a few individuals plus a couple of retrospective studies don’t really form a convincing argument to support the inference in the title of author’s article, that MRIs are indeed overused in Sports Medicine.

It’s interesting that our Specialty was targeted in this article.

Is this a thinly-veiled attack on Sports Medicine clinicians?

What do our readers think?

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Sideline assessment of concussion and return to play – are we practising what we preach?

October 27, 2011 9 Comments

The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.

The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.

Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.

He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.

The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.

Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’

Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’

What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines – see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’

In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.

Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.

The Rugby Law blog was particularly vociferous on these events.

For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.

Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?

CJSM would like to hear your experiences and opinions.

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