Ramadan

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The Crescent Moon rising at sunset, marking the start of the month of Ramadan

The month of Ramadan begins tomorrow, July 9, and lasts until August 7.  As many of this blog’s readers will know, observant Muslims will fast from dawn until sunset:  no food, no liquids…..no sports drinks or power bars.  The questions of ‘carb loading’ or ‘gluten free’, (‘should i drink some chocolate milk after my workout?‘) can all be put on the table until the evening.  The diet is one of pure abstinence, morning until night.

Muslim athletes are not unique in observing a fast: Catholic Christians will consume much less than usual if observing the prescribed tenets of Lent on Ash Wednesday and Good Friday, and Jewish athletes will go a full 24 hours consuming nothing on Yom Kippur: friends have told me they will be loath to brush their teeth or even shower, lest anything whatsoever pass into their mouths on that, the holiest day in the Jewish calendar.

And, of course, there are athletes who experiment with fasts, juices and cleanses that have nothing to do with religious observance (I’ve tried the “Master Cleanse” myself once).

What may be unique, however, to Islam  is the duration of the practice:  a full 30 days, where an observant Muslim will forego all food and drink from dawn (Sahur) to dusk (Iftar).

I admire the discipline the act of fasting requires.  As a sports medicine clinician, I have often wondered how athletes observing such fasts might be impacted.  Of course, I am  not alone in this, as the subject of the Ramadan fast and its effect on athletes was, for instance, a subject of considerable interest in the 2012 London Olympics, which took place during Ramadan.  The effects of Ramadan on sports performance have even been discussed in this blog in a 2011 post.  And now  the most recent issue of the CJSM, which rolls out today, highlights a study looking at this very practice of fasting and its impact on footballers:  “Does Ramadan Affect the Risk of Injury in Professional Football.” Read more of this post

5-Minute Sports Medicine Consult app – essential Sports Medicine knowledge on your iDevice

Many of our blog readers will be familiar with the widely read text published by Lippincott Williams and Wilkins and produced in partnership with the American Medical Society for Sports Medicine (AMSSM), the 5-Minute Sports Medicine Consult, which is now in it’s second edition.

First published in 1991, the book consists of a wide range of topics relevant to Sports Medicine, arranged in alphabetical order for easy reference. The topics are presented in a structured fashion, with similar headings for each topic. These include the Basics which consist of descriptions, epidemiology, etiology, and commonly-associated conditions. Diagnosis follows on from Basics, with history, physical examination findings, diagnostic tests and differential diagnosis. Treatment and ongoing care are then presented, and finally there is a list of additional reading and references for each topic together with ICD9 and 10 codes where relevant, and clinical pearls, with the topic authors listed at the end.

Whilst the hard copy version is a great resource, it is a large text and not practical to take to locations outside of the consulting room. Recently, a kindle edition became available which is a straight copy of the text in the book. Now we have the launch of the electronic version of the text for iOS devices on the Apple App store, including the iPhone and iPad, this information is available to the Sports Physician on the go, and the app offers a whole deal more for users than either the hard copy or the kindle edition.

The startup interface includes links to favourite topics, with all of the topics arranged alphabetically as in the print version. In addition, there are links to medications, ICD-9 codes, SNOMED codes, and 3 separate appendices including musculoskeletal radiography, office rehabilitation, and joint and soft tissue injection.

The entire text of the book is available offline. Individual topics are presented as in the book, with additional features including links to citations on Medline for each reference which makes it easy for the reader to go straight to the abstracts, although this features does require an active Wi-Fi or 3G connection to work.

Where radiological plates and illustrations are included in the source text, these can be seen in the text and figures can be selected and magnified for easy viewing which makes a great improvement on the viewing size of the graphics as seen in the textbook version. The x-rays in particular are very clear when magnified, and this feature is well implemented.

Over 280 separate topics are presented in the text, including over 20 new chapters since the publication of the first edition. Topics are varied, and range from athlete heart syndrome and several bone fractures through to medical disorders including menstrual disorders in the athlete, pericarditis and onychomycosis. Particularly useful are the clinical pearls offered at the end of many of the clinical topics which give useful hints and tips for clinical management of cases.

Each topic can be put into a personal list of favourites by highlighting a ‘star’ tab, for easy reference afterwards of those topics you might want to look at on a regular basis.

The topics are mostly up-to-date, although there are some notable omissions of some reference material that would have been useful to include such as the SCAT2 criteria for assessment of concussion, although these are clearly referenced in the text. in addition, there are a few personal bug-bears such as achilles tendinitis being presented as a topic where the use of the term ‘tendinopathy’ might have been more appropriate, omission of the importance of recognising enthesopathies as possible associations with rheumatological conditions as seen in the entry for plantar fasciitis, and no mention of MRI as a useful investigation for thigh adductor injuries. However, these are minor points and to some extent of personal preference.

The medications tab takes you straight to articles where the relevant medication is listed in the main text. Where a medication is mentioned in several articles, these are all listed with direct links to the relevant article, although one has to read the whole article to find out exactly where the medication is mentioned within the text. ICD-9 and SNOMED code tabs likewise take the reader to the start of the relevant articles where these codes are referenced in the main text.

The appendices of the main text are included in full, together with all their images. Appendix A, Musculoskeletal radiography, contains general tips on ordering x-ray investigations, and is arranged in a regional format with a wide range of different x-ray plates on show. Again, the selection and magnification feature works particularly well here. Unfortunately, there are no other imaging modalities included such as ultrasound, CT, or MRI.

Appendix B, Office Rehabilitation, contains 7 different topics including hamstring strain, patella femoral pain syndrome, ankle sprains, shin splints, plantar fasciitis, rotator cuff tendinitis, and epicondylitis. The articles are written for patients, and useful illustrations are included including exercises and stretches. A useful feature would be able to print out these topics for patients.

The final Appendix focuses on Joint and Soft Tissue Injections, and includes detailed information for the use of soft tissue injections for a wide number of specific indications. Information includes indications for injection, detailed regional anatomy with illustrations, supplies and techniques of injection, and aftercare and is very comprehensive. CPT Codes are also included for reference.

Perhaps the crucial feature that gives a big advantage over the text is the updating tab – this imports regular updates of the text via the web, and ensures that the topic information should be kept up to date.

All in all, this is a well-implemented iOS version of a valued textbook, and I’m sure that many of you will be delighted to have it available to you on the go. It will be of use to clinicians studying for board exams in Sports Medicine who want a focused yet comprehensive summary of a particular topic, and to more senior clinicians who may wish to update themselves on particular topics. Future developments for the iOS version might include the incorporation of other radiological imaging modalities such as MRI, the use of colour images, and perhaps videos of joint injection techniques. The price on the App store compares well with the cost of the hard copy and kindle versions, and with the extra features and regular updates, this one looks a winner all the way.

The 5-Minute Sports Medicine Consult app is available now on the Apple App store for $94.99

Back to the iPad – explaining spinal conditions to your patients using iSpineCare

Regular blog readers will recall previous posts describing a range of different anatomy applications for the iPhone and iPad, useful for both learning anatomy and for patient education. A particular favourite of mine thus far has been the 3D4Medical series of Apps discussed in a previous blog post, describing anatomy and pathology of various joints in the body, but these have not included an app designed specifically to cover just anatomy and pathology of the spine to date.

Anatomate-Apps (anatomical animation applications) is a Australian Company founded in 2009  by Dr John Hart, in order to develop iTunes applications designed by clinicians involved in the assessment and treatment of patients with spinal conditions, for use as patient education tools.

The over-riding idea is that patients who are given visual and spoken information in the form of interactive digital media during the consultation may experience an improved quality of care overall, as they are better informed about their condition(s) in a way that they can easily understand, and can then go on to make better informed decisions about their subsequent care.

Whilst there are some patients and clinicians such as myself who undoubtedly welcome these applications for use during the consultation, there are other patients and clinicians who will prefer a more traditional approach. Nevertheless, it is hard to argue against the view that the use of applications designed for patient education on the new iDevices is likely to significantly increase in the future, and I for one am using these more and more in my patient consultations to good effect.

iSpineCare is the first spinal anatomy and patient education application for iDevices that I have come across with such a comprehensive and accurate description of spinal anatomy and pathology. Constituting a hefty download at around 1.7GB of information on iPhone or iPad, the application consists of a main menu with folders relating to cervical and lumbar spinal anatomy, movements, and pathologies together with a folder of conservative care options and an exercise library folder.

Navigating through the different sections is easy and quick, and takes you to a context-specific menu which contains links to a series of movies which can be paused, rewound, or fast-forwarded to different points of interest, together with an image library of key stills from the movies allowing for prolonged discussion around particular points of interest. In addition, a pdf document linked to each movie is presented giving a more detailed explanation of different topics.

Another bonus is the availability of medical imaging alongside the individual movies. This section contains a series of x-rays, CT scans and MRI scans and has interactive labels  and reports to help to explain the images further to patients. This section may also be useful for junior clinicians to assist with learning about spinal pathology from a visual perspective.

The quality of the images and in particular the movies is outstanding, with crystal-clear animations allowing for easy recognition of the relevant spinal anatomy and pathologies. Some of the movies have voice-overs explaining salient points, whereas others are animation-only allowing for the clinician to talk the patient through the particular points of interest important for that individual patient to be aware of and focus on during the consultation. In addition, there is a section where particular images can be added to a list of the user’s favourite movies allowing for quick access to a particular user’s most often-used animations.

Another section of movies under the folder ‘Conservative Care’ offers a number of movies describing back-safe ways of performing everyday duties such as gardening, shopping and typing. There are also movies offering advice on a variety of lifestyle topics.

Finally, there is an ‘Exercise Library’ folder with several sub-folders offering animations describing a series of exercises for different purposes including cervical flexibility exercises and core stability exercises.

The overall package is very slick, well thought-out, and accurate in the descriptions of spinal pathologies and anatomical features. Stand-out points are the quality of the animations and the wide range of animations available. An internet connection is not necessary for the app to run, as all of the animations are downloaded embedded within the main app.

Anatomate-Apps also offers other similar applications describing spinal surgery (iSpineOperations) and pain management (iSpinePainManagement), and there are some smaller-sized applications offering information focussed on some particular aspects of spinal pathologies and operations for those who don’t need the larger apps.

As a Sport and Exercise Medicine Physician, I would have liked a little more emphasis on some of the conditions more commonly seen in my patient population including symptomatic spondylolysis, and cervical ‘stingers’ and ‘burners.’  However, most common pathologies are well represented and I can see iSpineCare and iSpinePainManagement becoming an important part of my clinical practice in the future.

Anatomate-Apps are available on the iTunes Apps store, and a video review of iSpineCare highlighting some of its features is available from the App show iPad edition on the link below.

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

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).

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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