Bread and Butter

img_1915

Bread, butter……and food for thought!

Fall sports in the USA  — sometimes in my clinics at this time of year I feel like I am swamped in concussions.  There will be stretches in a morning that I go from room to room, each one a different variant of this all-too-common injury.

But overall, in truth, the bulk of my patient encounters this time of year are of the musculoskeletal (MSK) variety.  It may not ‘feel’ that way, but when my hospital ‘numbers gal’ crunches the data, we’re still running at > 50 % MSK for patient visits.

And ankle sprains are definitely in that mix.

Ankle injuries, like knee injuries, concussions, and fractures, are part of the ‘bread and butter’ of my practice at the Division of Sports Medicine at Nationwide Children’s Hospital (NCH).  And one of the things I love about the Clinical Journal of Sport Medicine are the multiple original research articles the journal publishes that give me insight into the management of these common injuries.

I recently wrote a blog post about the four original research articles focused on concussion in our just-published September 2016 issue.  In this current post, I want to draw your attention to some more original research being published ‘ahead of print’: “Current Trends in the Management of Lateral Ankle Sprains in the United States.”

I found this to be a very interesting read using a “Big Data” approach to look at how this common injury, lateral ankle sprain (LAS), is managed in the USA.  The authors queried a database of national health insurance records for 2007 to 2011 and identified 825,718 patients with the diagnosis of LAS.  After applying select exclusion criteria (e.g. those with associated fractures,), they analyzed 725,927 isolated patients with LAS.

The authors found that 36% of all LAS occurred in patients < 20 years old (my patient mix at NCH), and that the number of patients with LAS decreased ‘exponentially’ with age (the 60+ crowd represented < 5% of the total).  Some of the more notable findings:  fully 2/3 (67.8%) received radiographs, and for treatment — 9% received a brace, and only 6.8% received physical therapy (PT) within 30 days of their diagnosis.

the end

Ankle bracing was looked at in the study, but not taping.

I think these two findings in particular should challenge us as clinicians.

First, though we cannot know in detail what the physical examination status was for the 700K LAS patients at time of initial evaluation, it strains credulity, I think, to consider that 67.8% of them met Ottawa Ankle Rules criteria.  Talk about a knowledge translation gap!  I believe the rules have been around for a good 20+ years [I did a Google scholar search on that, anyone is welcome to comment on this and let me know what they consider to be the first, the ‘Ur’ reference for the rules].  The rules have a very high sensitivity (approaching 100%).  Does anyone remember the mnemonic SnOUT? [ SnOUT = a negative finding in a highly sensitive test rules ‘out’ the problem].  I think this result reinforces for me what I need to be thinking about in my evaluations of LAS on the sideline and in the training room — apply those rules, and I’ll surely minimize my use of radiographs, saving cost and radiation exposure.

Second, the authors make a great case for the residual functional deficits that can linger for some time after a LAS. They specifically mention the evidence “…that patients with LAS are less physically active throughout their lifetime and (have) decreased health-related quality of life.”  LAS are not the benign injury we may always think them to be, and it is arguable they need some form of rehab.  I would note, again, that we cannot know in detail what access these patients had to PT, but to think that less than 7% received PT within the first month of injury……

In my own clinics, we often prescribe home rehab, and do a brief tutorial and give a handout to patients with LAS; we also prescribe PT to many.  I am not so sure how compliant my patients are with their home rehab, and I know that I get a lot of ‘no-shows’ for my prescribed PT.  Perhaps if I ‘put the hammer down’ a bit as a clinician–emphasized a bit more of the consequences of a poorly rehabbed LAS–I might get more patient ‘buy in’ to the concept of the necessity for PT/rehab to achieve a fully recovery.

LAS — bread and butter injuries, no doubt.  And this new research article — food for thought, indeed.

 

Advertisements

May Day

Unisphere-cc

CJSM: bringing you clinical sports and exercise medicine research, from around the globe

Whether you are celebrating today as International Workers’ Day, running around a May pole, or watching Leicester City try to complete the 5000:1 shot of winning the Premiership, we are sure that today, May 1, can only be a good day:  our third issue of the year has just published.  And this May Day CJSM is full of offerings we’re sure will be of  interest to you.

Two of the articles have a special focus on physical activity as an intervention for medical conditions — one is a meta-analysis from Chinese colleagues finding a protective effect for physical activity against lung cancer, and the other is a prospective, single-blinded, randomized clinical trial looking at rock climbing as an intervention in the treatment of low back pain. This study is from Austria, and had positive findings for dependent measures of disability (the Oswestry Disability Index), a physical examination maneuver, and even the extent of disc protrusion on MRI.  We’re proud to publish these high quality studies from across the globe.

We are also proud to contribute to the growing body of literature on the effectiveness of “Exercise is Medicine.” Read more of this post

CJSM Podcast 12: The Effect of Viscosupplementation in the Treatment of Knee Osteoarthritis

jsm-podcast-bg-1For our 12th podcast, we have invited Dr. Tom Trojian to talk with us about a new CJSM offering, just published ‘On Line First,” for which he is the lead author: “AMSSM Scientific Statement Concerning Viscosupplementation Injections for Knee Osteoarthritis:  Importance for Individual Patient Outcomes.”

Dr. Trojian is a member of our partner society, the American Medical Society for Sports Medicine (AMSSM), and is a professor in the Department of Family, Community & Preventive Medicine at Drexel University College of Medicine, and the director of the Sports Medicine Fellowship program there.

He is also a wonderful guest to have on  the podcast–I learned a great deal from him about not only viscosupplementation in the treatment of knee osteoarthritis, but also the specific study design of a ‘network meta-analysis’ he and his co-authors used to evaluate the clinical importance of this intervention in our patients.

Knee osteoarthritis (OA) is such a common condition–and is one which so many sports medicine clinicians treat as part of their practice–that we find ourselves publishing a great deal of research on the topic.  Just this month, in the November 2015 CJSM, we have three pieces of original research on managing knee OA: i) the relative effectiveness of hip vs. leg strengthening  in treating the problem; ii)  the effect of lower body positive pressure (LBPP)-supported low-load treadmill walking program on knee joint pain, function, and thigh muscle strength in overweight patients with knee osteoarthritis (OA);  and iii) a prospective study on the safety and efficacy of intrarticular platelet lysates in early and intermediate knee OA.

T Trojian Screen Shot

Dr. Trojian, ‘in action’ on the podcast.

Check all those studies out.  And check out our newest podcast:  get out those headphones, tune up that iPhone, and listen to what Dr. Trojian has to say on the subject of viscosupplementation in the treatment of knee OA.

Thanks very much for the time you spent with us Tom!

 

Dr. Lyle Micheli

IMG_1133

Dr. Lyle Micheli (R): The Godfather of Sports Medicine? Dr. Kevin Klingele (L) is inclined to agree

Jamesbrown4

The undisputed ‘Godfather of Soul’: James Brown Picture: Dbking @ Flickr

If there is a ‘Godfather of Soul’ is there a ‘Godfather of Sports Medicine’?

I think there may be……..and I’m very lucky to have trained under him.

Speaking as an editor of a clinical journal, I am aware of the phenomenon of bias, and I would acknowledge at least one ‘limitation’ of this blog post is that I am guilty of selection bias.

In truth, however, there could be a very strong case made for Dr. Lyle J. Micheli‘s candidacy for that mythical title.  One argument for the (perhaps) uncanny resemblance between the two ‘Godfathers’ is Mr. James Brown’s nickname:  “The Hardest Working Man in Show Business.”  No doubt, if there were a “Hardest Working Man” in Sports Medicine, the award would be given to Dr. Lyle Micheli:  even still, at age 70+, it is rumored that he performs more surgeries than any other orthopedist in the New England region of USA.  This is a man who works six days a week, and on the seventh…..well, unlike God, Dr. Micheli doesn’t rest:  he writes. Research Manuscripts.

At CJSM, we have been the recipient of several of his studies that have made the peer review grade and been published.  They span a period from 1992 (Arthroscopic Evaluation and Treatment of Internal Derangements of the Knee in Patients Older than 60 Years) to 2015 (A Closer Look at Overuse Injuries in the Pediatric Athlete).  Recognize that CJSM itself is celebrating its 25th year, and so, in essence, Dr. Micheli has been publishing in our journal for as long as we have been in existence.

His career goes back farther, into those dim reaches of the sports medicine universe that precede the Big Bang, er, the birth of CJSM in 1990.  His career in sports medicine dates back to the 60’s.  He was treating athletes before Jim Fixx gave birth to a  running boom in the United States.  Put another way, he was Medical Director of the Boston Marathon when Americans were still winning the thing…..and he is still at the Finish Line: in 2015 and in the infamous 2013 Marathon about which I have written in this blog.

He is currently visiting here in Columbus, Ohio, ready to give Grand Rounds on ‘Spinal Injuries in Young Athletes,’ and it’s great to see him.  We’ll be doing a podcast together, and I plan on sharing a link to that on our CJSM Social Media.

For now, let me end this encomium with one last parallel between the two Godfathers.  Sure, James Brown was prolific:  over his career he produced how many hits? married how many times (4)? had how many children (6)?  Dr. Micheli?  Well, let’s just say he has ‘given birth’ to many sports medicine children, who continue to follow his path in the field of sports medicine practice and research:  Meehan, Stracciolini, d’Hemecourt, Luke, Loud.…even myself.  And so many, many more!   There are seemingly untold disciples spread across the globe continuing his example of hard work and research productivity. Micheli?  Prolific? Oh my, yes.

He’d be the first to say, however, that it’s all about evidence-based (not eminence-based medicine), and so I hear his voice in my conscience, telling me to stop this now!  And get to doing some real work:  run a regression, do those edits on the manuscript that is due, figure out the solution to a problem in the athletes you care for!

Besides, the day has passed, it’s the middle of the night, and I hear the Chimes of Midnight……Grand Rounds is less than 6 hours from now.  Good night!!!!!

%d bloggers like this: