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Marijuana and Its Effects on Athletic Performance: A Systematic Review

Kien V. Trinh, Dion Diep, Hannah Robson

Clinical Journal of Sport Medicine, Volume 28, No. 4, July 2018

Currently, many sporting organizations including the International Olympic Committee (IOC) prohibit the use of any substance that has an ergogenic (performance enhancing) effect, poses a risk to the use of the user’s health and safety, or violates the spirit of sport. The legalization of marijuana in Canada is tentatively set for October 2018, which may increase the use and normalization of the drug. Thus, it is vital that primary care physicians remain up to date regarding the rules and regulations surrounding marijuana use, as well as its effects on users. Much of the literature points to marijuana being more of an ergolytic drug, where it impairs rather than improves one’s physical performance, stamina, or recovery. Despite patient beliefs that that marijuana use can improve their performance, it’s ergogenic potential remains poorly understood.  The purpose of this study was to determine the effects of marijuana on athletic performance.

This systematic review included any primary study of any design of any clinically or laboratory-relevant outcomes on athletic performance. Studies included both male and female participants of any athletic background, between the ages of 18 and 65 with no other comorbid conditions. All studies used marijuana cigarettes for the intervention group and all studies utilized a control group (participants that were not given marijuana cigarettes). Vital signs, pulmonary measures, physical work capacity, grip strength, and exercise duration were chosen to be relevant outcomes. After identifying and screening 929 citation postings, only 3 trials met the inclusion criteria.

The effects of marijuana on heart rate, blood pressure and exercise duration remains unclear. Low-quality evidence exists for marijuana having an ergogenic on effect on exercise by inducing bronchodilation and increasing FEV1 after exercise compared to inactive controls. There was no significant difference in grip strength between treatment, sham and inactive control groups. Additionally, there is low-quality evidence that suggests marijuana use is associated with decreased physical work capacity compared with sham and inactive control groups.

There are several limitations to this study. Firstly, there were only 3 trials (one observational, one crossover, and one crossover randomized control trial) that met the inclusion criteria. When comparing these 3 trials, clear heterogeneity is noted between study type, intervention, and outcomes. Thus, no meta-analyses were performed. Furthermore, despite various available forms of consumption (e.g. edible, vaporization, tinctures, oils), all studies only assessed smoked marijuana as their treatment. There is a clear paucity of current research on marijuana and its effects on athletic performance. The banning of substances in competition is a highly debated and ever-changing field. With its legalization in Canada looming, further research is warranted on marijuana and its effect on athletic performance to help investigate and justify current and future doping policy.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

Different ways of promoting physical activity

 Article reviewed: 

Physiotherapist-Led Physical Activity Interventions Are Efficacious at Increasing Physical Activity Levels: A Systematic Review and Meta-analysis

Breanne E. Kunstler, MPhty, Jill L. Cook, PhD, Nicole Freene, PhD, Caroline F. Finch, PhD, Joanne L. Kemp, PhD, Paul D. O’Halloran, PhD, and James E. Gaida, PhD

As per the Canadian Institute for Health Information, in 2017, total health expenditures in Canada are expected to represent 11.5% of Canada’s gross domestic product (GDP). Physicians and health care professionals continue to promote preventative care as one way to tackle the ever-growing cost of health care. Primary prevention is generally low cost and has wide-reaching benefits. Specifically, physical activity has been shown to reduce the burden of disease and decrease the progression of many common non-communicable diseases (NCDs). In 2013, just over 2 in 10 adults and 1 in 10 children and youth in Canada met the Canadian Physical Activity Guidelines, which requires adults to achieve 150 to 300 minutes of moderate intensity of physical activity or 75 to 150 minutes of vigorous intensity physical activity, or an equivalent combination of both each week, as well as muscle-strengthening activities on at least 2 days each week. With so many people in Canada being physically inactive and with the rise in preventable diseases, primary care providers, including allied health professionals, have a critical role to promote physical activity and well-being. Physiotherapists are particularly well trained and positioned to promote physical activity in patients as their treatment plans often involve some type of physical activity.

This article did a systematic review of studies that assessed the efficacy of one-on-one, physiotherapist-led physical activity (PLPA) interventions at increasing physical activity levels among adults in clinic-based private practice, primary care, and outpatient settings. The eight studies that met this articles inclusion criteria looked at adults over the age of 18 who either had MSK injuries, risk factors for NCDs or who were suffering from NCDs. The studies either used subjectively (questionnaire) or objectively (accelerometry) quantified change in physically activity. A meta-analysis was conducted to look at the correlation of PLPA interventions at different follow-up times, as well as looking at success rates of PLPA interventions meeting minimum recommended physical activity levels. It also looked at the effect that the length of the therapy session had on the PLPA interventions success.

Looking at 3 out of the 8 studies included in the review, there was a significant finding that PLPA interventions were efficacious at assisting adults achieve the minimum recommended physical activity levels with an OR of 2.15. The other 5 studies included in the review showed a significant finding that PLPA interventions had only a small effect on patient’s physical activity level in short and medium term follow-up which was not seen past 1 year of follow-up. When comparing the length of intervention seen in the different studies there was no difference in efficacy of PLPA interventions on the improvement physical activity level. Overall, the improvement in PA seen by PLPA interventions ranged from increasing vigorous, moderate and low-intensity PA.

In this article, it was highlighted that there was a lack of analysis on the content as opposed to the length of the interventions. There was also no emphasis on the importance of maintaining the level of physical activity achieved over time. As it was shown, the benefits of the PLPA interventions were not seen in the majority of the studies in long-term follow-up. The one study that did use intervention techniques geared towards maintenance of PA improvements resulted in such maintenance. Even though there was improvement of PA in most patients who received PLPA, the benefits of preventative lifestyle changes such as PA is truly seen when maintained over time and integrated into a person’s weekly routine.

In summary, patients ultimately are responsible for the maintenance of their lifestyles. To help them integrate physical activity into their daily lives primary care providers can play an important role. This article shows that training physiotherapists and primary care health care professionals in behavioral changing counseling can help tackle the growing rate of inactivity and ultimately decrease the risks of NCDs.

  1. Moroz M.D.C.M. CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med

 

Return to Driving After Hip Arthroscopy

Amit M. Momaya, Despina Stavrinos, Benjamin McManus, Shannon M. Witting, Benton Emblom, Reed Estes

Clinical Journal of Sport Medicine, Volume 28, No. 3, May 2018

Hip arthroscopy represents one of the most common procedures performed to help alleviate hip pain and improve quality of life. Driving represents one of the most important topics that patients will ask physicians about, especially in the primary care setting after they have been discharged from hospital and are looking to get back to their daily routine. The purpose of this study was to use a modern driving simulator and assess patients’ braking performance after undergoing a right hip arthroscopy.

This prospective study involved 14 patients scheduled to undergo right hip arthroscopy (perfumed by a single surgeon at 1 institution) and a control group (healthy volunteers who denied musculoskeletal problems) of 17 participants to account for a potential learning phenomenon. The two groups did not differ in age, sex, height, weight, and driving experience as measured by years since licensure. The control group did not undergo any type of surgical procedure. All were between the ages of 16 and 60, licensed drivers, and regularly drove using automatic transmission. All participants drove in the simulator initially to establish a baseline, and then at 2, 4, 6, and 8 weeks post-operatively. The following variables were measured:

  • Initial reaction time (IRT): time between stimulus and initiation of release of accelerator
  • Throttle release time (TRT): time from initiation to full release of foot from accelerator
  • Foot movement time (FMT): time between release of accelerator and initial contact with brake
  • Brake travel time (BTT): time to apply 200N of force from initial brake press
  • Braking reaction time (BRT): the sum of IRT + TRT + FMT
  • Total braking time (TBT): the sum of BRT + BTT

The results of the study revealed that the experimental group exhibited significant improvements in INT, TRT, FMT, and BRT at between the pre-operative and 2 weeks post-operative driving sessions in the simulator, however there was no significant change thereafter. There was no significant change in BTT in the experimental group over the 8-week period. No learning phenomenon was noted in the control group.

This study, which was the first to address driving after hip arthroscopy, suggests that most patients may return to driving at the 2 week mark, as indicated by breaking performance. However, there are several limitations to this study. Perhaps the most obvious limitation is that the participants are operating in a simulation and not in an actual vehicle. In addition, despite the fact that all patients in the experimental arm underwent a hip arthroscopy, the procedures themselves differed with respect to degree of soft tissue and bony surgery. For example, an osteoplasty may affect braking performance significantly more than a simple debridement. The relatively small sample size was a barrier to attempt to look at whether these differences existed. Also, it is important to note that currently, there are no single legally mandated or universally accepted numbers for BRTs. While this study provides some evidence for driving after right hip arthroscopy, it is recommended that primary care physicians, surgeons and patients communicate openly with one another to create individualized timelines for safe return to driving.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

2018 Consensus statement on exercise therapy and physical interventions

Article Review:

2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017

Collins NJ, Barton CJ, van Middelkoop M, et al

Br J Sports Med Published Online First: 20 June 2018. 

doi: 10.1136/bjsports-2018-099397

 

One of the most common sources of knee pain is from patellofemoral pain and is a common condition that family physicians have to manage. Patients often report significant burden due to a limitation in activity and daily tasks, hence it is imperative to have a firm grasp of the evidence behind current treatment. This past year, the 5th International Patellofemoral Research Retreat gathered in Australia to review the interventions for patellofemoral pain and published the 2018 consensus statement for patellofemoral pain treatment.

6 systematic reviews and 13 RCTs that were published since the last meeting were reviewed and used to update the 2016 consensus statement. No significant changes were made from the previous consensus statements but several new statements were added to address new modalities.

Some highlights of the consensus-based recommendations are as follows

  1. Exercise therapy is recommended and reduces pain in the short, medium, and long terms. It also improves function in the medium and long-term.
  2. Combining hip and knee exercises is superior to knee exercises alone
  3. Combined interventions are recommended to reduce pain in the short and medium term. This means exercise therapy in conjunction with other therapies such as foot orthoses, patellar taping, or manual therapy
  4. Foot orthoses are recommended to reduce pain in the short term
  5. Electrophysical agents (ultrasound, phonophoresis, laser therapy) are not recommended
  6. Patellofemoral, knee and lumbar mobilisations are not recommended
  7. in isolation
  8. It is uncertain whether patellar taping and bracing are helpful with pain in the short, medium, or long term.
  9. It is uncertain whether acupuncture or dry needling reduces pain in the short and medium term
  10. It is uncertain whether manual soft tissue techniques are beneficial in the short term
  11. It is uncertain whether blood flow restriction training is superior to exercise therapy with regards to reducing pain in the short term
  12. It is uncertain whether gait retraining is effective in reducing pain and improving function in the short term

Given there are many areas of uncertainty, it is important for the family physician to be aware of these treatment modalities and how they may apply to the individual seeking treatment. However, there remains a lot of questions to be answered and will require physicians to continually update themselves on the latest available evidence.

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKIN, MSC, MD, CCFP (SEM), Dip Sport Med

 

 

Exercise Induced Hematuria

Jimmy: Doc, I am a healthy 23-year-old and I just ran my first marathon a day ago. Why am I peeing blood now?

Doc: Well Jimmy, there are many causes but, in your case, exercise-induced hematuria is a likely cause:

Jimmy: What is it?

Exercise-induced hematuria is a transient phenomenon which occurs after contact and non-contact sports and can be divided into traumatic and non-traumatic etiologies.

Traumatic hematuria can be external or internal. External causes include trauma to the flanks/kidneys (ex. Direct hit externally in football) or lower abdomen/bladder (eg. Bladder moving up and down and contacting peritoneum or its opposing wall due to motion from long distance running). Traumatic changes have been seen on cystoscopy in athletes with exercise-induced hematuria in ultra long-distance runners due to this sort of bladder motion and trauma. In cycling, the trauma is often associated with the bike seat constantly colliding with the perineum.

Non-traumatic hematuria is a category that encompasses everything else (eg., rowing, swimming). There are many hypotheses as to the cause, these include; renal ischemia due to blood shunting to muscles, lactic acidosis causing increased glomerular permeability and nutcracker syndrome (left renal vein pinched between the aorta and proximal SMA).

Jimmy: Wow, thanks, doc. So, what do we have to do about it?

Doc: Glad you asked, Jimmy. Exercise-induced hematuria is a benign condition and there is no evidence of any long-term morbidity. Given you are under 50 we can do some simple urine tests and then watch and wait, and I’d expect that this would entirely go away within 72 hours. We need to make sure your kidneys aren’t suffering from rhabdomyolysis. If things don’t resolve, then we’ll need further blood and urine tests to assess the health of your kidneys and urinary tract. Sometimes this involves a cystoscopy.

Jimmy: That’s awesome, thanks doc. Anything I should change in my routine going forward?

Doc: I probably wouldn’t exercise for the next week to make sure this resolves but this may return when you do more intense exercise such as marathons in the future. Make sure you adequately hydrate during all sporting events and try not to run with a completely empty bladder. If you take up a contact sport, wear all appropriate padding.

Jimmy: Wow, thanks!

Doc: Have fun!

Meant as satire. Exercise-induced hematuria is a diagnosis of exclusion which requires a preceding high-intensity exercise and a rapid resolution following relative rest. No Jimmies or Docs were harmed in the making of this.

 

 

 

 

Dr. Anthony Caragianis

PGY3 SEM, BCh, MB, BaO, CCFP

PGY3 Chief Resident

The University of Ottawa

 

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

Carleton Sport Medicine Clinic

http://carletonsportmed.com/

Scapholunate Dissociation: FOOSH, no fracture but still not better

What is scapholunate dissociation?

The scapholunate interosseous ligament (SLIL) is a C-shaped structure which connects the scaphoid and the lunate and is important for carpal stability. Most injuries are degenerative in nature, occurring in patients over 80 years of age with arthritis but acute injuries are associated with FOOSH style injuries.

What are the clinical features to make me concerned for acute scapholunate dissociation?

A patient presenting with dorsal and radial-sided wrist pain with after a FOOSH, specifically with the wrist in extension and ulnar deviation. Typically, pain will be increased with pressure applied to the carpal bones (ex. push up position), clicking or catching of the wrist, “giving way” with lifting or grasping, and instability or weakness. Tenderness may occur just distal to Lister’s tubercle or in the snuffbox. There may also be swelling on the dorsum of the wrist, pain (worse with extension and radial deviation) and a positive Watson’s test. Watson’s test is performed by grasping the patient’s thumb with the 1st and 2nd digits over the scaphoid. The scaphoid is dorsally subluxed by bringing the thumb in a volar and opposed direction. A positive test is dorsal wrist pain or a clunk which indicates scapholunate instability.

Investigations:

AP and lateral views of the wrist are a start but the clenched fist view is the best radiograph. A gap between the scaphoid and the lunate greater than 3mm is called the Terry Thomas sign and is positive for SL dissociation. MRI can be considered but is considered to have a low sensitivity. Arthroscopy is the gold standard.

Management:

Non-operative management is appropriate for acute and undisplaced SLIL injuries. Requires casting or approximately 8weeks with periodic imaging and follow up. Operative management is required for any form of malaligment, failure to improve after 18 months, SL dissociation due to scaphoid fracture, presence of associated arthritis or other complicating factors. This can be achieved in multiple ways such as K-wire fixation, direct repair of the ligament or tendinous grafting, depending on injury.

Complications:

A failure to adequately identify and appropriately managed SLIL injuries can lead to scaphoid lunate advance collapse (SLAC) which causes progressive degeneration of the radiocarpal and midcarpal joints and has a significant effect on function in the hand and wrist.

Recap:

FOOSH without obvious fracture; consider ligamentous injury, especially SLIL injury. Normal xrays will not adequately assess, always order clenched fist view. Most cases treated with casting but some will require surgical management. Lack of management can lead to progressive degeneration of the wrist and serious functional impairment.

Anthony Caragianis, PGY3 SEM, University of Ottawa

Sudden Cardiac Arrest during Participation in Competitive Sports

Landry, C.H., Allan, K.S., Connelly, K.A., Cunningham, K., Morrison, L.J., and Dorian, P. (2017). New England Journal of Medicine, 337(20): 1943-53.

Family practitioners are frequently tasked with assessing fitness, such as for driving, work duties, and (return to) sport participation. In the sport setting, although many competitive athletes have dedicated physicians to perform Pre-Participation Examinations (PPEs), this responsibility frequently falls to their family physician. Reasons for this are varied, and include the lack of a physician associated with a competitive youth team, or “clubs” rather than “varsity” designated teams at the post-secondary level, for instance. Investigations as a part of this evaluation can be hard to determine, and this is especially true with respect to the cardiac system, given the potentially serious complications (e.g. sudden cardiac arrest (SCA), in the otherwise generally healthy competitive athlete.

This NEJM article “sought to identify all sudden cardiac arrests that occurred during participation in sports activities within a specific region of Canada to determine their cause.” From this arose a discussion of which causes may have been identifiable, to estimate the efficacy of screening systematically during a PPE.

SCA was defined as an abrupt loss of vitals resulting in death or successful resuscitation. It was considered “during sport participation”, if the event occurred during or within 1 hour following an activity estimated to have involved exerting at >3 METS. “Competitive” was defined as an organized or sanctioned event certified by an official, whereas it was classified as “non-competitive” if it was not formally organized/sanctioned. Presumably, competitive athletes were the focus, as they are the individuals who would present for a PPE.

The authors used the Rescu Epistry registry – a prospective, comprehensive registry of all EMS attended (via 911) cardiac arrests that occurred out-of-hospital. They obtained information from multiple sources (e.g. ER reports, discharge summaries, autopsies, etc.). It is unclear why events occurring in private were excluded, with inclusion criteria specifically identifying public locations only, when such events did not need to be witnessed. That is, 1681/3825 cases of out-of-hospital SCAs were excluded for “location”, which would seem to miss individuals who could have had an SCA at home within 1 hour following sport participation, for example. This region in Ontario had a population of 6.6 million, including urban and rural regions. The study period was 2009 to 2014, and individuals aged 12-45 were included in an attempt to catch young athletes potentially eligible for screening, as well as the maximum number of individuals with heritable cardiac syndromes, while reducing the overlap with SCA secondary to coronary artery disease (CAD).

Results: 74 cases of SCA in a public space occurred (as defined above) during sports; 16 during competitive and 58 during non-competitive sports. Focusing on competitive athletes (again, as defined above), there were 9 deaths and 7 survivors (43.8% survival) and sufficient data to determine the cause of the SCA in 10/16 cases. Similar survival was seen in the non-competitive category (44.8%). The incidence of SCA in competitive athletes was 0.76 cases per 100,000 athlete-years (highest rate: 1.17 for ages 12-17, lowest rate: 0.41 for ages 35-45). This rate has been reported as 4.84/100,000 person-years in the general population, of the same age range, according to the authors.

On autopsy of 2 competitive non-survivors and 4 competitive survivors, there was no identifiable cause, and they were considered primary arrhythmias. That is, these 6 cases were found to have either a normal cardiac structure at autopsy, or in the case of the survivors, normal echo or cardiac catheterization. Interestingly, most SCAs in competitive athletes were race events and soccer events (4 each). The gym (12) and running (9) were the most common activities in the non-competitive. For both competitive and non-competitive, the predominant cause varied by age: <35, structural and primary arrhythmia; 35-45, CAD. Also of note, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy were uncommon causes.

Perhaps most importantly, two competitive athletes had structural abnormalities (i.e. hypertrophic cardiomyopathy) that were likely to have been identified during a PPE with an ECG or echo. However, one of these individuals had actually been previously assessed for presyncope, and was found to have a normal ECG and echo. Amongst competitive survivors, none had a condition likely to have been identified with cardiac screening. The authors also use a broad definition of “competitive” – one that would include “beer league” hockey, university intramural or “community sport and social league” participants, for example, which frequently are organized events with referees – and exclusion of these participants (who are unlikely to present for PPE) perhaps would change these figures.

This study indicates that SCA in competitive athletes is rare, and raises questions about systematic screening for cardiac conditions in athletes, as a part of PPEs. There is a great deal of controversy ongoing and no clear consensus, and although this interesting study adds to the current knowledge, I eagerly await the forthcoming Canadian guidelines on the subject, to help inform my decision making in regards to investigations to pursue!

Alison Bagg MD, CCFP
PGY3, Sport & Exercise Medicine
University of Ottawa

Advisor: Dr. Taryn Taylor BKIN, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

Carleton Sport  Medicine Clinic

Don’t have to see it to believe it – The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy

Don’t have to see it to believe it:

The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial Arthroscopy. 2007 Nov;23(11):1167-1173.e1

Multiple pathologies of the knee cannot be picked up on x-ray and ultrasound. Increasing prevalence of MRI has led to increased use. We as physicians may not see the bill for these investigations but they are still a considerable expense for our system. Due to long wait times, the National Health Service (UK) has started to perform MRIs to try and reduce the number of patients that will actually require surgery while in the US, they are questioning whether MRI will actually add value.

A randomized control trial was performed using 252 patients on a waiting list for knee arthroscopy. All patients had an MRI of their knee performed. They were then randomized into two groups; one had their MRIs read by their surgeons prior to surgery and the other did not. Even though the group whose MRIs were read had a diagnosis change in 47% of cases, compared to 1% in the control group, ultimately, the rate of surgery was the same.

Important to highlight that this is American data and they may be more likely to proceed with arthroscopy than their Canadian colleagues. Important to note that a diagnosis change occurred in 47% meaning information from MRI was still of value.

Take away message to consider: Don’t wait for an MRI report to refer to orthopaedics because it is unlikely to change the management plan in patients you suspect will require arthroscopy but still order the MRI as it can provide valuable information for operative planning.

 

Anthony Caragianis, PGY3

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Corticosteroid injections for adhesive capsulitis: A review

Ryan C. Xiao, Kempland C. Walley, Joseph P. DeAngelis, Arun J. Ramappa. Clinical Journal of Sports Medicine, May 2017, Volume 27, Issue 3, 308-320.

Adhesive capsulitis (AC) is a relatively common condition that can have a significant impact on function and quality of life. Briefly, it consists of three phases: pain at rest and progressive loss of range of motion (“freezing” stage), stiffness without pain at rest (“frozen” stage), and gradual return of range of motion (“thawing” stage). It is classified as Primary AC (idiopathic) and Secondary AC (following trauma or with diabetes, for example). It is thought to be due to chronic inflammation and (subsequent) fibrosis, though uncertainty remains regarding underlying pathophysiology. It is self-limiting, usually lasting 2-3 years (or longer) before resolution is achieved. Individuals experiencing AC often seek treatment options to manage the pain and hasten recovery. Corticosteroid injection is commonly offered.

The purpose of this review was to evaluate corticosteroid injection effectiveness, in terms of disease duration and recovery. Sixteen randomized prospective studies involving corticosteroid injection for the treatment of AC compared with a control/comparison group were included in the review. Comparison group treatments included stretching, home exercises or (multi-modal) physiotherapy; injection with normal saline or lidocaine; corticosteroid or lidocaine bursal or subacromial injection; oral NSAIDs; as well as a combination of one or more of the aforementioned treatments, including corticosteroid injection. A few studies investigated the effect of corticosteroid injection dosing (three studies), injection location (glenohumeral versus subacromial) (three studies), and the effectiveness of using ultrasound guidance (one study). Finally, two studies specifically looked at corticosteroid injections in diabetics with AC.

Notably absent in this review was hydrodistension as a comparator treatment modality. Follow-up began as early as one-week post-treatment initiation, and the length of follow-up ranged from 6 weeks to 12 months.

Nine of 12 studies found a significant benefit of corticosteroid injection in terms of short-term pain reduction and mobility restoration compared to control group(s), with effects lasting between 2 and 24 weeks. The three studies that failed to find a significant benefit had comparison groups that received formal physical therapy.

With respect to corticosteroid dosing, 2 out of 3 studies did not find a significant difference between 20 mg and 40 mg of triamcinolone for pain relief or improved function. The third study used 3 injections spaced 1 week apart, and 40 mg doses were more effective than 10 mg injections. This review concluded that an injection of 20 mg of triamcinolone seemed to be as effective as 40 mg injections. Further research would be helpful in determining if there is an optimal dosing and injection frequency that provides the most benefit.

In terms of location, the three studies suggest that subacromial injections are just as effective in reducing pain and improving function, contrary to the common belief that glenohumeral injections are superior. Furthermore, one study that examined the effect of using ultrasound guidance (versus landmarked “blind”) injections for AC over a 6 week period, found that the only significant difference was during the 2 weeks post-corticosteroid injection, with significantly improved pain, range of motion and function when ultrasound was used. This study also involved weekly follow-up hyaluronate injections, however, which makes it difficult to evaluate the effect of the corticosteroid and use of ultrasound itself.

Remarkably, as diabetics are widely recognized as being at a significantly greater risk of developing AC, there is a paucity of research specifically investigating this population in the setting of AC. One study compared corticosteroid injection with NSAIDs, and another study compared corticosteroid injection with home exercises. Interestingly, the first study reported no difference in outcome at 24 weeks, and the second found reduced pain at, but not beyond 4 weeks, and improved function at, but not beyond 12 weeks. This suggests that diabetics may benefit less from corticosteroid injection for AC, than their nondiabetic counterparts.

In terms of adverse effects of corticosteroids injected into various joints in the body, the most common are injection-related pain and injection site skin discolouration. Transiently increased blood glucose levels in diabetics have also been noted. There is the possibility of weakening tendons in the shoulder, especially with repeated injections or those that are improperly placed, and the risk of tendon rupture exists, although reportedly this is a small risk when done infrequently. Finally, the authors note that antiretroviral therapy (i.e. protease inhibitors) can interact with corticosteroids that are injected, resulting in an iatrogenic Cushing syndrome via respective inhibition of, and metabolism by, the P450 CYP(34A) pathway.

Overall, the authors of this review conclude that corticosteroids injected for AC can provide significant short-term pain reduction, with evidence of effect for at least 2 weeks, but up to 24 weeks post-injection. The evidence suggests that these injections can be intra-articular or subacromial and that 20 mg may be as effective as 40 mg when triamcinolone is used. At this time, there is insufficient evidence to suggest the superiority of ultrasound-guided versus landmarked injection. As well, formal physical therapy may be as effective as an injection. Unfortunately, diabetics may not benefit as much from such injections for AC and they can experience transiently raised blood sugar. Caution should be used when protease inhibitors are being taken, as an iatrogenic Cushing syndrome can develop.

This review certainly adds to the current knowledge regarding treatment and use of corticosteroid injections for AC. The conclusions can be used to more accurately discuss the potential benefits of injections, with special consideration for diabetics, and perhaps set more realistic expectations of the improvement they can expect. Furthermore, given the range in costs associated with different treatments, when funds and insurance coverage are limited, these conclusions can also help guide treatment decisions (i.e. physiotherapy versus injection, use of ultrasound guidance, etc).

Alison Bagg MD, CCFP

PGY3, Sport and Exercise Medicine

University of Ottawa

Supervisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

Concussion Update 2017

In October 2016, world leaders in the field of sport-related concussion (SRC), of which a large proportion are Canadian, met in Berlin to develop the latest statement on our current knowledge of the science of SRC. As a quick review, an SRC is a traumatic brain injury induced by biomechanical force transmitted to head causing functional disturbance. It does not require a direct blow to the head. Some of the new developments and highlights from the statement include:

Office evaluation

–        Assessment of mental status, cognitive functioning, sleep/wake disturbance, ocular function, vestibular function, gait, and balance is recommended

–        Insufficient evidence for investigations such as EEG or MRI

–        A new Sports Concussion Assessment Tool Version 5 (SCAT) was developed

Management

–        A brief period (24–48 hours) of cognitive and physical rest is appropriate for most patients

–        Subsymptom threshold activities and submaximal exercise are encouraged (as long as symptoms are not exacerbated)

–        Cervical spine rehab is recommended for neck pain/headaches

–        Vestibular rehab is recommended for dizziness

–        Return-to-play and return-to-school/work protocols can advance in parallel

–        Children and adolescents should not return to sport until they have successfully returned to school

–        Physiological dysfunction may be delayed relative to clinical recovery, suggesting that using a ‘buffer zone’ of a graduated return to activity/return to play progression before full return to contact risk may be appropriate

Prognosis

–        Preinjury mental health problems and prior concussions appear to be risk factors for persistent symptoms.

–        Greater acute and subacute symptoms are a consistent predictor of worse clinical outcome.

–        The teenage years might be a particularly vulnerable time for having persistent symptoms—with greater risk for girls than boys.

Prevention

–        Strongest evidence exists for disallowing body checking in youth ice hockey

–        Strong recommendations to mandate helmet use in skiing/snowboarding

–        Mixed evidence for mouthguard but there may be an overall protective effect

The top 5 key messages from the 5th International Consensus Statement on Concussion in Sport
See: 5-key-messages-from-Berlin_ENG.pdf

Reference

  1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.

 

  1. Shields, MD, CCFP, Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Taryn Taylor, MD, CCFP (SEM), Dip Sport Med