May Day

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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

Ebola and the Athlete

twitter rsa pic

The South African Minister of Sport has tweeted a ‘no, thank you’ to being host.

The biennial Africa Cup of Nations (AFCON) is set to begin in January 2015. Organizers are still looking for a host.

Morocco was set to host the tournament but has pulled out because of the fears over Ebola contagion. The Republic of South Africa has already served notice that they will not volunteer to be alternative hosts:  the country’s Minister of Sport has tweeted that the RSA is “…not the Big Brother of Africa….” and will not be standing in as host for the Cup. As I understand it, the Confederation of African Football organizers are meeting November 2 to discuss solutions for what seems to be an impasse.

If sports is indeed a mirror of the culture, then it stands to reason that concerns regarding the Ebola virus would show up in sporting venues, training rooms, sport talk shows, and athletes’ twitter feeds.  The current outbreak of the virus is still largely confined to certain nations in W. Africa, but it  is the largest and most deadly one in history.  Sport, like society at large, is concerned.  How might teams handle potential exposures?  Must consideration be given to quarantining? Is it reasonable to target only those countries at the epicenter in W. Africa?  Is ‘quarantine-lite’ the way to go? Is it wise to consider having large numbers of people travel to and from one country, as in the case of hosting AFCON?

Carrier_of_diphtheria_keep_out_of_this_house_by_order_of_board_of_health.

A sign of things to come?

A generation or two ago–most especially in the pre-vaccine and pre-antibiotic era–the quarantine was a standard measure for handling outbreaks of contagious diseases in communities.  My mother describes how she and her whole family were quarantined after she developed strep throat as a young girl in the 1930’s.   In the modern world, however, the quarantine as a response to controlling Ebola has already come under heavy fire, at least here in the United States.

The intersection of public health, international sporting events, and an infectious virus is not unique to this moment in time, of course.  In 2010 CJSM published a thematic issue on “Emerging Issues in Sport Medicine,” and included among the many offerings an article on International Travel and the Elite Athlete as well as an article on Public Health Recommendations for Athletes Attending Sporting Events.The 2009 CJSM published original research on a novel, web-based approach to more carefully monitor illnesses in professional rugby union players.  These documents are potentially useful resources to help teams and sporting federations formulate responses to this newest challenge.

But I want to acknowledge that the Ebola virus raises issues which require a great deal more work to determine appropriate, evidence-based interventions.  Winter is coming in the Northern Hemisphere, and we know we should be offering our athletes influenza vaccinations. We have a ‘system’ to handle the flu.  What to do with a disease like Ebola for which there is no current vaccine let alone an established treatment?  Likewise, what to do in the case of a virus which does not pose an airborne exposure risk like the flu, but has a much higher case fatality rate when the virus is contracted?

Already, popular sentiment has begun ‘making’ decisions of a sort.   Read more of this post

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

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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