Physio and Medicine Podcast with Cameron Coomer

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A podcast chatting all things physiotherapy and medicine related. Giving you insight as a clinician, patient, or someone interested in the medical field! Cameron chats to sports physician Dr. Janesh Ganda about his experience of being involved in professional sports teams and the management of the player’s injuries as well as the impact COVID-19 has had on professional sport.

Infections in athletes


Dr Janesh P Ganda

Infection in athletes

INFECTIONS IN ATHLETES

Endurance training can predispose an athlete to several infections because of numerous factors:

  • Increased training loads
  • Stress – physical & mental
  • Travel
  • Dry air in the plane
  • Other passengers
  • Poor sleep
  • Increased contact with sick individuals
  • Work environment
  • Race expo
  • Training partners

The immune system is essentially comprised of 2 inter-dependant systems

1. the non-specific Innate immune system,
2. the more specific Acquired immune system.

  1. Innate “Non-specific” immune system
  • Essentially the body’s first line of defense which includes the skin and mucus membranes
  • Exercise affects this system and can lead to higher risk of infection: such dysfunction occurs at a structural level, as well as at a cellular level. Acute bouts of exercise have been shown to lead to increased immune-cellular modulators. However, chronic intense training leads to a decrease = higher risk of infection
  • The effects of this include the increased risk of various infections because of possible immune-suppression

2. Acquired “Specific” immune system

  • The body’s Acquired immune system forms a memory and attacks infectious agents which were previously recognized by the body’s immune system
  • Cellular component and antibody component – antibodies recognize antigens which then kickstarts the inflammatory process to attack the offending agent
  • Changes in the antibody status and the cellular component of this system also result in a diminished immune system

Does exercise always result in an increased risk of infection?

The simple answer is NO, in fact it has been shown that regular, moderate exercise actually decreases the risk of infection. However, the risk of infection has been shown to increase in athletes who engage in regular bouts of high intensity exercise, or in athletes who undergo high training loads. This is demonstrated by the J-curve below.

TIPS to reduce the risk of infections, focusing on Upper Respiratory Tract Infections (URTI’s)

  • Space high intensity sessions and race events far enough apart to allow for adequate recovery
  • Ensure adequate quality sleep
  • Maintain a well-balanced diet
  • Vitamin C (500mg/day) during periods of heavy training
  • Avoid over training and chronic fatigue
  • Thorough hand washing
  • Remain well-hydrated

To exercise or not to exercise, that’s the question

It’s very common for athletes to visit a Sports Medicine Practice before major events and during single/multi-stage endurance events (OMTOM, Comrades Marathon, Ironman, Cape Epic, Wines2Whales etc.) or in a team (rugby, soccer, hockey etc.) to ask for advice on whether an illness should stop them from training. Training with an illness can have severe side effects – the development of a condition called a viral myocarditis can occur. This condition could lead to severe cardiac damage, and even death.

WHEN NOT TO EXERCISE – if you have any of the following symptoms:

  • Fever
  • Muscle Pains
  • Chest pains
  • Tachycardia (elevated resting heart rate)
  • Excessive fatigue
  • Excessive shortness of breath
  • Swollen painful lymph nodes.

Disclaimer – Information supplied in articles is generalised and does not constitute individualised medical advice. Patients are always advised to seek proper medical advice from a qualified medical professional.

Concussion in the paediatric population

What is a concussion?

Concussion is defined as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanics features :

  1. Caused by either a direct blow to the head, face, neck or elsewhere in the body with an “impulsive force transmitted to the head.”
  2. Results in a rapid onset of short lived impairment in neurological function that resolves spontaneously.
  3. Functional disturbance, rather than a structural injury
  4. Results in a graded set of clinical symptoms that may, or may not, involve loss of consciousness.
  5. No abnormality on standard neuroimaging is seen in a concussion (1)

Concussion Rates in school sports

It was recently estimated that 3.8 million recreation and sport related concussions occur annually in the United States (2).

A lack of a proper Injury tracker in youth sports (2), makes this number in accurate for concussions in the paediatrics population, however, highlights the need for school injury surveillance to be able to quantify concussions in this population group. 

Represents approximately 8.9% of all high school injuries in the USA. (3) 

The 6 R’s of concussion (4)

Recognize

  1. The suspected diagnosis of a concussion can include one or more of the following domains
    1. Symptoms – Somatic(headache), cognitive (feeling in a fog) and/or emotional symptoms (labile mood)
    2. Physical signs (loss of consciousness, amnesia)
    3. Behavioral changes (Irritability)
    4. Cognitive impairment (slowed reaction times)
    5. Sleep disturbance (Insomnia)
  1. On field care
    1. Clear indicators of a concussion – immediate removal from field of play (What you see) (4)
      1. Seizure (fits)
      2. Loss of consciousness – confirmed or suspected
      3. Unsteady on feet or balance problems or falling over or poor coordination
      4. Confused
      5. Disorientated – not aware of where they are or who they are or the time of day : Dazed, blank or vacant look
      6. Behavioural changes e.g. more emotional or more irritable
    2. Suggestive of a concussion (What you see) (4)
      1. Lying motionless on ground
      2. Slow to get up off the ground
      3. Grabbing or clutching of head
      4. Injury event that could possibly cause concussion
    3. Symptoms of a concussion (What you are told) (4)
      Headache
      Dizziness
      Mental clouding, confusion, or feeling slowed down
      Visual problems
      Nausea or vomiting
      Fatigue
      Drowsiness / Feeling like “in a fog“ / difficulty concentrating : “Pressure in head”
      Sensitivity to light or noise
      Difficulty concentrating

Remove from field of play immediately if concussion is confirmed of suspected

Re-evaluate/Refer

  1. Patients who have had a concussion or suspected concussion should not be placed back on the field until being evaluated by a trained health care practitioner.
    1. Clinical evaluation should be done including the latest SCAT 5
    2. Determination of the clinical status of the patient – has the patient improved or worsened
    3. Determine the need for further concussion investigations
      1. Neuropsychiatric testing – done to evaluate the patients cognitive recovery. According tho the Berlin consensus, it forms a “cornerstone” of concussion management, however, it should never be used as the sole diagnostic marker for a concussion. 
      2. In cases of a structural brain injury being suspected, CT scans are the most predictive in assessing fractures and intra-cerebral bleeds. Generally patients with underlying structural damage deteriorate over the course of the injury. (2) 

Rest

  1. Cognitive rest
    1. Due to the functional nature of the brain injury, athletes often have trouble with focusing at school, taking tests and trying to keep up with assignments.
      1. Rest may include temporary leave from school, shortening of the athletes school day ,reduction in work loads.
      2. Taking standardized tests while recovering should be discouraged because lower than expected scores can occur.
      3. Other activities which can exacerbate symptoms such as video games, playing on a laptop etc should be avoided to ensure symptoms do not worsen. (2)

Return to school strategy (5)

  1. Physical Rest
    1. Physical rest is required to restore the energy imbalance following the concussion. 
    2. The exact amount of rest still needs to be adequately defined (5), however, a good guideline is 14 days for athletes under the age of 18. Following this minimum “stand down period” (3), athletes can enter their graded return to play.
    3. It can take some athletes under 18 almost 4 weeks to recover from a  concussion. Age appropriate symptom scores should be used (Child SCAT 5)
    4. Patients should have total rest for 24-48 hours after which they can gradually increase activity as long as it does not exacerbate symptoms.

Return to Play/Rehabilitation

  1. “When in doubt, sit them out”
  2. Although a vast majority of patients with a concussion will become asymptomatic within a week of their concussion numerous studies demonstrate a longer recovery of full cognitive function is required as compared to adults – 7-10days longer. (5)
  3. Graded Return to play protocol should be employed once the patient is symptom free. It will take an athlete a minimum of 5 days to progress through the protocol to resume full game participation, provided symptoms don’t return. If symptoms re-occur, the patient is required to go back to a previous stage before progressing.

References

  1. McCrory et al. Br J Sports Med. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Berlin, October 2016
  2. Halstead et al. Sport related concussion in children and adolescents. American Academy of Paediatrics, Volume 126, (3) September 2010
  3. Gessel et al. Concussion among United States collegiate athletes. J Athl Train.2007:42 (4):495-503 
  4. World Rugby Concussion guidance, implemented 01 August 2015
  5. McRoy et al. Br J Sports Med. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.