Matthew Bitner, MD, to Present on Topic of “Emergency Planning” at the 2013 Medicine of Cycling Conference

Posted on July 26, 2013 by jtaylor

"Medical Threat Assessments: Hope is not a Strategy - Planning for a Successful Race"

BitnerWhen planning a race, organizers often focus on the course, the participants, the permits, etc… and way at the bottom of the list is "medical." However, what does type of planning does that really entail? This course will provide the participant with the tools necessary to build a scalable medical plan that protects the riders, the staff and the providers. From the basics of performing a medical threat assessment to developing your emergency response objectives and assembling your team, the lecture will help participants ensure a safe event.

Dr. Bitner, MD, MEd, FACEP, is the Chief of Emergency Maria Parham Medical Center - Duke LifePoint Hospitals, and is the Director of Education and Training for STAT Medical Solutions.  He has worked many international-caliber events and helps to plan and organize the medical staff at the US' largest races.

WADA Publishes Sport Physician’s Tool Kit for Local Anti-Doping Education

Posted on December 18, 2012 by mabramson

The World Anti-Doping Agency WADA-ADA has published a "Sport Physician's Tool Kit" that contains materials to help sport physicians develop their own education programs. From the WADA Site:

Page on WADA's website

Direct link to the tool kit

As with a real ''tool kit'', the material contained in the Sport Physician’s tool kit is intended to help sport physicians develop anti-doping education programs which can be adapted and customized to suit local cultures, conditions and resources.

You are encouraged to adapt the tools to your specific program needs and reproduce them so that they may be shared as widely as possible with other sport physicians within your region.

The Tool Kit contains:

Ready-to-use PowerPoint presentations
Short articles
Case studies to test your knowledge

The following modules are included:

1. Introduction
2. Doping and Sports Medicine Ethics
3. Health Consequences of Doping
4. The Doping Control Process
5. The Prohibited List and TUEs
6. Performance Enhancement without Doping
7. Athlete’s Biological Passport
8. An Introduction to Gene Doping
9. Practical Issues – Case Studies

Nutrition, Facial Injuries, Lower Extremity Conditions in Cycling, and the Female Cyclist headline Day 3 of the 2012 Medicine of Cycling Conference

Posted on August 27, 2012 by mabramson

COLORADO SPRINGS, Colo. (August 26, 2012) Hip injury, sweat rate, cardiac screening, disordered eating, and dental care were just a few of the topics discussed today at the third annual Medicine of Cycling Conference. Medical experts presented a range of diverse topics from their respective fields and, casting the cyclist-as-patient into the spotlight, each presentation exposed medical issues specific to cyclists.

With the help of modern technology, Mark Greve, MD, medical director of Team Type 1, started the day with a check-in from the USA Pro Challenge. He discussed what it's like to be a team physician for a team in a major race. While this year's race was largely uneventful from a team physician perspective, Dr. Greve discussed his medical kit, how often he gets to ride his bike during events (rarely, if ever), and how he manages the language barrier with TT1 athletes from around the world.

Claudette Lajam, MD of New York University Langone Medical Center started off the day with her presentation on Lower Extremity Conditions in Cycling. Dr. Lajam highlighted IT Band Syndrome, hip dysfunction, labral tears, arthritis, and hip arthroplasty, as well as hip impingement and knee problems that affect all ages of the cycling population.

Next up Monique Ryan MS, RD, CSSD, LDN, HFS, brought her decades of experience working with endurance athletes to bear in her talk on Nutrition Strategies Designed for the High Performance Cyclist. In her presentation, Ryan detailed optimal foods for after, during, and before training, plus emphasized the need to jumpstart recovery immediately post training and racing. To support her topic, Ryan cited many studies and literature that examined carbohydrate absorption rates and sweat rates in cyclists to determine optimum intakes of carbohydrates and fluids when training and racing.

Michael Giudici, MD continued with his presentation on Pre-participation Cardiovascular Screening for Competitive Athletes. His talk examined the answer to the question, "What are the causes of sudden death in young competitive athletes, and what can we do to identify them?" and named myocarditis, coronary artery anomalies, and heat stroke effect on the heart as some of the threats to competitive athletes. He concluded with current American Heart Association recommendations for pre-participation cardiovascular screening of competitive athletes.

Gloria Cohen, MD finished off the morning sessions with The Female Cyclist, where she discussed The Female Athlete Triad: Eating Disorders, Amenorrhea and Osteoporosis. In addition, Dr. Cohen pointed out to participants that estimates of disordered eating are unknown, they vary from 4-39 percent; it is still a widely under-reported condition.

The afternoon sessions began with conference organizer, Anna Abramson, MD, announcing the results of a survey-based study of team physicians, team owners and team captains.

Paul Abramson, MD, gave a talk on Integrative Medicine and Cycling, which was followed by a presentation on Evaluation and Field Management of Traumatic Facial Injuries.  Aaron Liddell, MD DMD and John Tannyhill MD DDS drew attention to the many headlines in the cycling media about serious facial crashes in the pro peloton, including facial/head lacerations and mid-face trauma, both of which are some of the hardest things to fix. They also emphasized the importance of dental care, citing a couple top pro racers who were out for a significant portion of season due to wisdom tooth infections.

Margarita Sevilla, MD offered advice on how to prevent deaths in triathlon during her presentation on Triathlon Medicine. Preparedness and education are key, according to Dr. Sevilla. She also added general tips on how to prevent injury, such as core strengthing, proper bike fit, treadmill analysis, incorporating rest, and cross training.

The third annual Medicine of Cycling Conference concluded with a presentation by Matthew Fedoruk, PhD, Science Director of the US Anti-Doping Agency, whose talk on Cycling and Anti-Doping: A Health Professional's Perspective detailed educational efforts to explain the health ramifications of doping in cycling. To help conference participants become better informed, Fedoruk offered attendees many resources for medical practitioners, athletes, and coaches, as well as websites, phone numbers.

Dates for the fourth annual Medicine of Cycling Conference will be forthcoming, please check the website for more information.

Team Type 1 Medical Director Mark Greve, MD Checks in via Skype from USA Pro Cycling Challenge

Posted on August 26, 2012 by mabramson

With the marvel of modern technology, Mark Greve, MD, medical director of TT1, checked in with the Medicine of Cycling Conference via Skype to discuss what it's like to be a team physician for a major race. While this year's event was largely uneventful from a team doc perspective, Dr. Greve discussed his medical kit, how often he gets to ride during events (he doesn't), and how he manages the language barrier with the TT1 athletes from all over the world.

Thanks to Dr. Greve for a fantastic session!

3 Tips for Aspiring Team Docs from Professional Cycling Team Physicians

Posted on March 14, 2012 by hwoodhull

For physicians who are trained and dedicated to practicing high levels of patient advocacy, becoming a pro cycling team doctor offers many the possibility to apply their professional skills to something they are equally passionate about. A pro cycling team doctor largely steers clear of any perverse sponsorship arrangements or scoreboard objectives that might compromise patient care.  Generally speaking, caring for athletes shouldn't be reactionary, as is common, but rather proactive, which means the team doctor may take command of racers' health before they even swing their legs over a bike for the first training ride of the season.  Here are some tips and comments from three team physicians.

The racing season for ProTour team, Movistar, began this year on January 15 in Australia with the Down Under Classic, which would prove a test to how well the team had prepared during pre-season training. For team physician Dr. Jesús Hoyos, it was a chance to see if his careful planning for the health and well-being of the team would pay dividends.

"I have many responsibilities as the team doctor: caring for the health of all team members, not only racers but staff as well; helping to plan out the race season with respect to specific races; supervising racers' training plans; organizing periodic health examinations to insure racers' maximum performance potential; and providing psychological support as necessary," Hoyos said.

Optimize your cyclists' health

Optimizing cyclists' health prior to the racing season starts with obtaining an assessment of athletes' baseline neurologic function so that — in case of a concussion — the information would allow for accurate diagnosis in the event of future injury. Athletes with a history of prior concussion are at an increased risk of repeat injury, so it is particularly imperative for these athletes to have a baseline cognitive assessment. This data will also be invaluable to racers who have sustained a concussion, since the team doctor can compare pre and post-concussion data to assess whether a racer is fit to return to competition.

"This year I have brought on board a neuropsychologist who will perform baseline neuro psych concussion testing on the team at team camp," said Dr. Kristin Wingfield, a primary care sports medicine specialist who works with the Exergy Twenty12 pro women's team. "Then we will use this as a baseline for each athlete and they can re-do the test post head injury on the road. We will then receive their scores and can make decisions about return to play (training and racing in this instance) without being there."

Evaluate each racer's health individually

The team doctor should take the initiative to evaluate each racer individually since athletic performance is keenly linked to a racer's health.

"A lot of times the athletes don't have their health optimized. For example, an athlete with asthma may be overly reliant on a rescue inhaler," explained Dr. Dawn Richardson, team physician for Champion System Pro Cycling Team. "Maybe they just don't know any differently or, for financial reasons, they didn't have access to preventive medicine. I explain that if they're using a rescue inhaler, their airways are inflamed and they don't want that. Just getting on maintenance medication for an asthmatic can make a huge difference in preventing airway inflammation and this in turn improves performance."

Dr. Richardson raced professionally until she retired in 2002; she had already completed her training and board certification as an emergency medicine physician. Her experience as a racer affords her a familiar perspective of the stresses of racing so, in addition to being available to the athletes without being disruptive to their routine, she assists in many ways above and beyond the call of duty.

"It's obvious fairly quickly that the mechanics and soigneurs are working very long days, so if I can do simple errands for them like supermarket runs, gassing up the team vehicles or run the athletes' laundry bags through the laundromat, I do it," Richardson said. "Something as simple as going to the pharmacy for an over-the-counter medication is way too much hassle for the athletes during a stage race, so I end up going on pharmacy runs at least every couple days."

Plan, monitor, and maintain racers' health regularly

Stage racing, especially a Grand Tour like the Tour de France, places heightened demands on a team doctor, like being "on-call" for 21 days straight. In addition to overseeing the team's health, Movistar's Dr. Hoyos maintains a daily routine that starts with waking the racers and recording their heartbeat, blood pressure, weight, sleep quality etc. He then follows up with racers who have suffered wounds that require specific treatment and continues to work with racers on mentally preparing for the day's stage. Following the stage, he records the same data as in the morning and notes each racer's state of health. He also supervises the racers' nutrition and monitors dietary supplements, such as vitamins, protein, and adequate hydration. Lastly, he administers treatments specific to incidents outside the norm (such as lesions, road rash etc.).

Unchecked injuries that can lead to serious health problems run counter to cutthroat competition, which has led to serious medical problems long after the athlete has retired from the sport. Sports like football and basketball are learning this the hard way through federal lawsuits filed by players who say that brain injuries have left them struggling with medical problems years after their playing days ended.

By comparison, doctors — like Dr. Richardson — who are cyclists as well are bringing their professional influence to bear on the sport, which sets a precedent for unparalleled athlete care. Of course a racing career isn't obligatory to becoming a pro cycling team doctor; a successful team physician doesn't need to produce results, just healthy racers.

Interview with @BMCProTeam’s Dr. Massimo “Max” Testa on cycling team physicians, staying healthy and sports medicine

Posted on February 27, 2012 by hwoodhull

Max Testa gets ready for an Event

This week I had the pleasure of interviewing Dr. Massimo Testa.  Dr. Testa is one of the most experienced cycling team physicians and coaches in the US as well as co-author of training manual Faster, Better, Stronger: Your Exercise Bible, for a Leaner, Healthier Body in Just 12 Weeks

In this interview we get a glimps of how this national team physician ensures his athletes succeed while staying healthy, and his advice for the sport.  First, we need to understand how Dr. Testa got his start:

Q.  How did you first become a team physician?
A.  That’s actually an interesting story.  In the early 1980s, I was finishing my fellowship in sports medicine to become a team physician at the University Pavia, Italy.  Unlike the US, in a sports medicine training focuses more on exercise physiology and less musculoskeletal issues.  Additionally, all athletes are considered “employees” so they are required by law to have an overseeing physician in order to do their job.  I loved cycling and was doing a special research in health risks associated with being a full-time professional cyclist.   I was also seeing hundreds of youth athletes for their sport physicals and injuries.  Obviously very busy.  In 1985, for the first time in history, an American team called 7-11 came to race in Italy.  They were the only team in Europe without a physician and this was against UCI rules, so I was assigned to them because of my research interest.  They were very grateful and only expected me to come to the race and fix them up if they got injured.  This is not how I trained or how things were done.  I watched the team warm up, race, and saw them through the recovery, giving advice or medical help as needed.  They liked this so they asked me to be their team doctor, the first one they had.  I visited the US that year, started to understand how American teams operated.  In Italy, many times the physician is also the team coach.  This has advantages and as you can imagine some serious draw backs as that balance between medical help and medical manipulation gets shaky.  I never agreed with that.
So for the next 6 years, I was the physician for Team 7-11, then the team became Motorolla and I was again with them for another 5 years.  After that I took a short break from American teams and was the team physician for Mapei, the largest European team during the late 1990s.  At that time, Dr. Eric Haiden – rider on the Team 7-11 in the 1980s and now orthopedic surgeon, invited me to start a sports performance lab at UC Davis in Sacramento, CA.  I came for one year but stayed for 7 at UC Davis.  After that, I moved to Utah and just never left.  During the past 10 years, I’ve been working with the USA Cycling as the national team physician and more recently as the chief medical officer for team BMC.

Q.  That is an incredible amount of knowledge and experience.  What makes you so successful at what you do?
A.  First of all, I love the sport and I’m a big fan.  Athletes are a great population to work with.  They are all Type A personality, which means they demand a lot out of me, but that also means they are committed, compliant, and motivated.  I owe a lot to my initial training in fellowship, there I learned a lot about applied physiology and pathophysiology of exercise.  I understand what happens to a body during exercise, I believe in the process, and feel we should be prescribing it as physicians.  I know what happens to a hypertensive patient during exercise, know what will be safer for them and what will make them better.  We learned to do all the tests, the echocardiograms, stress electrocardiograms, tilt table tests, pulmonary function tests, and so I can couple those with physiologic processes and easy measurements to know what is happening in my athlete’s body.  Also, to be really in-tune with what happens during training and racing, I’m there for the training and racing.  I travel with the team 180 days a year.  This way the athletes are comfortable telling me about the small changes they experience and I can “see” when they are over-training by their numbers even when I’m not there.  I monitor their physiology, their weight, lactate response, power output, training intensity, heart rate to name a few to pick up early signs of fatigue and over training.  Because of our close relationship, the athletes and the team trust me to make these calls and change the training and racing plans accordingly.

Q.  How do you navigate that difficult conversation with the athlete, when you think they are too sick to race?
A.  Well, first of all we as physicians have to know the rules and have strong internal discipline to guide the team and athletes to make the right decision.  Previously, I guess I could have injected someone’s joint with cortisone to allow the athlete to compete, but that to me means that I am allowing a disease process to cause biological damage for a race.  I tell the cyclist “you can continue racing at this point, but you’re not going to win the race and you’re not helping yourself heal for the next one.”  They are smart, they understand this and with my athletes this is rarely a problem.

Q.  What have you learned as a cycling team physician?  What is your favorite part of the job?
A.  The learning never stops, I’m always travelling and meeting people from other cultures, other physicians, and seeing new perspectives on each problem.  It’s very interesting if you think about it.  Each culture has it’s own focus, a stomach upset for a Spaniard and a stomach upset for an American can simply mean two different polar extremes of urgency.  One can just think about it as a nuisance, while the other can give it the significance of the entire system coming to a halt.  We learn to be sensitive to these issues with time.

Q.  About half of American cycling teams racing in the continental United States do not have a team physician.  What advice would you give the coaches and managers of those teams?
A.  It is still very strange for me to think about that, even after all of these years in the US.  I would recommend that these teams at least find a medical professional who can do a pre-participation questionnaire and screen athletes for significant risk factors such as familiar history of sudden cardiac death, personal history of exercise induced asthma, dizziness, fainting.  There are resources in each community that the team managers should take advantage of.  This can be a local clinic that would be willing to do all the physicals for a fixed fee, or a local business who is willing to sponsor a medical checkup for a team in return for some favorable publicity.  I think being a team coach in the US is very hard, often coaches are the first level of medical care for athletes.  Ideally all teams should have a coach, manager, and physician.

Q.  This year has been a difficult one for concussions and traumatic brain injuries in cycling.  What are your thoughts and practices in this area?
A.  I have always been cautious with possible head trauma.  In fact I pulled Dr. Eric Heiden out of his only Tour de France after he crashed and cracked his helmet.  I’ve seen a few riders die from head injuries, especially in the days before helmets.  No race is worth it.  I like what your group has done with the concussion recommendations and use them for our team.  This is a step in the right direction.  Our team also has Scott Nydam, a rider who unfortunately ended his career after several concussions and an intracranial hemorrhage.  He is a great advocate for the riders and makes sure he asks specific questions to elicit symptoms that a simple once over may not pick up.  The entire team has to be on the same page on an issue like this.

Q.  What are your biggest challenges as a team physician professionally?
A.  There are a few big ones.  We are lucky to have a very well-staffed team, so we can provide good support for our athletes.  If a cyclist doesn’t have insurance, this becomes a huge problem.  I’ve provided a huge number of free physicals and ECGs but in reality all riders should have insurance, and a medical professional who knows them.  Unfortunately, cycling has the highly publicized doping risk.  There are two categories here, intentional and unintentional.  Athletes are sometimes taking supplements, including recovery drinks and vitamins, they don’t think to mention to me, their physician.  But if they are caught the physician is always associated with that athlete, so we have to be super careful.  Supplement companies are selling a myth that these products will make you faster, they’re just trying to sell their product.  Though it takes time, education is the best prevention for doping.  I make sure my guys know that most of the products don’t work, in addition to risk to health and career.

Q.  What is your least favorite part of the job?
A.  I love to travel, and I love the sport.  I love Tour de France, but I’ve now been to 18 of them sitting in a car during the entire month of July.  Most team docs love to ride their bike, well forget about that when you’re travelling with a team, it’s just too busy.  The job has also become a lot more complicated.  I used to just travel to races and make sure nothing happened.  Now there are many more races in the season, biological tests, monitoring, training, keeping up with the rules, and blood tests.

Q.  What advice do you have for team physicians who are just starting out?  Especially those who are managing their athletes remotely?
A.  Know the athlete the best you can.  Have a periodical updates every 2 to 3 months.  A good way to do this is a questionnaire for each cyclist to fill out, especially looking for changes in cardiac symptoms, fainting, dizziness, shortness of breath.  When you don’t travel with the team, you don’t have the connection which encourages more open communication.  You may not hear of the daily nagging headache or some other detail that may be important but not necessarily shared during an infrequent encounter. Depending on access to a performance lab or other metrics, going through this information with the rider, is a good way to get reconnected.  This may also be a good project to do with a fellow or student.

Q.  What is your favorite medical journal?
A.  I like the British Journal of Sport Medicine.  That’s probably my favorite overall.  Now it’s easy to get articles from basically any journal so I just search for my favorite topic, and that is physiology.

Q.  What is your favorite “must attend” medical meeting?
A.  The American Medical Society of Sport Medicine is a great meeting.  It has a good balance of sport medicine, medical performance lab, exercise testing, considerations for exercise restrictions, traditional non-surgical medical management, gait management, and family medicine.

We want to thank Dr. Max Testa for this interesting interview.

 

 

 

 

Starting the Discussion About Pre-Season Concussion Screening in Cyclists

Posted on January 9, 2012 by hwoodhull

STARTING THE DISCUSSION ABOUT CONCUSSION IN THE PRE-SEASON
Anna Abramson M.D.

As your teams and athletes head into the new season, consider the events from the previous year. Multiple high profile athletes had a race or season ending fall resulting in concussion. Cycling like many other sports is now taking a closer look at the previously unrecognized risk associated with brain injury. The most crucial step in concussion is awareness. The Medicine of Cycling Concussion Task Force is making strides in setting guidelines but the first step is ensuring that athletes, teams, team managers, and coaches know the facts about concussion. The Medicine of Cycling website has the complete guidelines at http://www.medicineofcycling.org/publications.aspx.

WHAT IS A CONCUSSION?

Concussion is a form of brain injury resulting from a direct blow or rapid acceleration and deceleration of the brain inside the skull altering the cellular processes in the brain. Concussion or other types of brain injury can occur without direct impact or loss of consciousness. It produces characteristic signs that are evident immediately, and can result in symptoms that may evolve over the course of minutes, hours, days, or even months. Some symptoms are only evident with specific testing or questioning. Concussion evaluation is important because after an initial injury, the brain is susceptible to repeat injury. Resultant disequilibrium and slowed reaction times that may be caused by an initial injury increase the athlete’s risk for further head injuries.

WHAT TO DO IN PRE-SEASON

  1. Discuss the definition, symptoms, and risks of concussion with the athletes.
  2. Encourage athletes to disclose history of concussion and events that occur in training or competition.
  3. In event of a fall that may have resulted in concussion, encourage cooperation with exam. This will allow for a quick return to competition.
  4. Let a concussion ruin a race or even a season, don’t let it ruin a career or a life.

HOW TO EVALUATE FOR CONCUSSION?

The most important evaluation starts with suspicion of concussion. If any of the following signs of concussion are positive, the rider should be off the bike and ideally seen by a medical personnel.

  1. Did the rider lose consciousness? Was the rider unresponsive after crashing their bike?
  2. Does the rider have amnesia? Can the rider remember and describe the crash, the period before and after the crash?
  3. Does the rider seem confused, disoriented, slow, or foggy? Ask 4 questions about current events that the athlete should know the answers to, that you know as well. For example: What city are you racing in? What lap are you on (criterium)? How far are you from the finish of the race? Was there a break in the race? What teams or riders are in the break? What's in the pocket of your jersey?
  4. Does the rider seem “slow” or “off their game”?

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

HeadachesNauseaFatigue

Sleep disturbances

Vision changes

Ringing in the ears

Dizziness

Balance problems

Sensitivity to light and noise

ConfusionSlowed thinkingSlow reaction time

Impaired judgment

Impaired attention

Distractibility

Impaired memory

Disorganization

Poor problem-solving

FrustrationIrritabilityRestlessness

Mood lability

Depression

Anxiety

Personality changes

WHAT IS THE RISK OF CONTINUING TO TRAIN AND RACE WITH SYMPTOMS OF CONCUSSION?

A rider with concussion is at risk of:

  1.  Repeat crash due to poor balance, concentration problems, or slow reaction time.
  2. More severe injury next crash because the brain is already in a vulnerable state.
  3. Prolonged or incomplete recovery
  4. Hurting another rider.

WHAT IS THE TREATMENT OF CONCUSSION?

The only treatment for concussion is brain rest and time. The brain is taxed by even daily activities such as reading, using a computer, riding a bike, driving. Instruct the athlete to abstain from alcohol and non-steroidal medications such as aspirin and ibuprofen. Use a step-wise approach to returning to training and racing which minimizes the likelihood of long-term side effects and high-risk trauma of in-race high-speed falls.

CONTACT CYCLING PHYSICIANS TRAINED IN CONCUSSION:

Matthew Bitner M.D. matthew.bitner (at) duke.edu
Jason Brayley M.D. jaybray1 (at) yahoo.com
Julie Emmerman Psy.D. Juliliz1 (at) aol.com
Mark Greve M.D. markgreve (at) hotmail.com
Ramin Modabber M.D. rmodabber (at) smog-ortho.net
Kristin Wingfield M.D. kristinwingfield (at) yahoo.ca

See the complete guidelines at http://www.medicineofcycling.org/publications.aspx.