International Olympic Committee consensus statement on pain management in elite athletes

Treating low back pain in athletes: a systematic review with meta-analysis

OBJECTIVE

To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement.

DATA SOURCES

Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS).

RESULTS

Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments.

CONCLUSIONS

While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

THE GAP BETWEEN RESEARCH AND CLINICAL PRACTICE FOR INJURY PREVENTION IN ELITE SPORT: A CLINICAL COMMENTARY

As clinicians strive to apply evidence-based principles, team-based practitioners have identified a large gap as it relates to published research, ideal applications of evidence-based practice, and actual clinical practice related to injury prevention in elite sport within the United States. For rehabilitation professionals, especially those intimately involved in the research of injury prevention, the solution often seems quite clear and defined. However, preventing injury by implementing the latest recommendation from the most recent prospective study on the using the FIFA 11 + warm-up, a Copenhagen Adduction exercise, or a plyometric drill with elite athletes may not be as effective as was seen among the cohort used in the study. In addition to extrapolating research, clinicians face additional challenges such as variance among professions, schedule density, and off-season contacts with athletes. There is an inherent difficulty in the application of research to practice in elite sport as it relies on the teamwork of not only the practitioner and athlete, but the entire sporting organizational structure and those involved in athlete participation. The purpose of this clinical commentary is to explore the difficulty with application of research in clinical practice and to discuss potential strategies for improving carry over from research to clinical practice.

A Contemporary Approach to Patellofemoral Pain in Runners

Patellofemoral pain (PFP) is among the most common injuries in recreational runners. Current evidence does not identify alignment, muscle weakness, and patellar maltracking or a combination of these as causes of PFP. Rather than solely investigating biomechanics, we suggest a holistic approach to address the causes of PFP. Both external loads, such as changes in training parameters and biomechanics, and internal loads, such as sleep and psychological stress, should be considered. As for the management of runners with PFP, recent research suggested that various interventions can be considered to help symptoms, even if these interventions target biomechanical factors that may not have caused the injury in the first place. In this Current Concepts article, we describe how the latest evidence on education about training modifications, strengthening exercises, gait and footwear modifications, and psychosocial factors can be applied when treating runners with PFP. The importance of maintaining relative homeostasis between load and capacity will be emphasized. Recommendations for temporary or longer-term interventions will be discussed. A holistic, evidence-based approach should consist of a graded exposure to load, including movement, exercise, and running, while considering the capacity of the individual, including sleep and psychosocial factors. Cost, accessibility, and the personal preferences of patients should also be considered.

Does the Intestinal Microbiome Impact Athletic Performance?

PURPOSE OF REVIEW

To analyze current research involving elite athletes and the gut microbiome, with the goal to expand knowledge of potential sports performance strategies and interventions.

RECENT FINDINGS

Most of the current research focuses on theoretical applications from microbiome research and known characteristics of performance, as few studies have actually been conducted in elite athletes. However, of the studies that have been conducted, the research is promising that dietary strategies may provide targeted interventions in the future. The majority of sports nutrition takes an external approach to diet: manipulating macronutrient intake based on type of training and performance goals. However, shifting to an internal focus, prioritizing the health of the gut microbiome, could be a new frontier for a competitive edge in athletics.

Epidemiological profile of pain and non-steroid anti-inflammatory drug use in collegiate athletes in the United States

BACKGROUND

Although athletic endeavours are associated with a high amount of physical stress and injury, the prevalence of pain is underreported in the sports medicine literature with only a few studies reporting pain on collegiate athletes or exploring sex difference of pain. Impact of pain on athlete availability, training and performance can be mitigated when key epidemiological information is used to inform adequate pain management strategies. This study aims to 1) provide an epidemiological profile of self-reported pain experienced by the National Collegiate Athletic Association (NCAA) athletes by sex during the first half of the 2019 season, 2) describe their self-reported non-steroidal anti-inflammatory drug (NSAID) use.

METHODS

Online survey was completed by athletes at three NCAA institutions from 1 August to 30 September 2019. Descriptive statistics were used to describe player demographic data, self-reported pain and self-reported NSAID use. Pain incidence proportion were calculated.

RESULTS

Two hundred thirty female athletes and 83 male athletes completed the survey. Self-reported pain incidence proportion for female athletes was 45.0 (95% CI 41.5-48.5) vs 34.9 (95% CI 29.4-40.4) for male athletes. Majority of the athletes did not report pain (55% female vs 62% male) during the first half of the 2019 season. Female athletes reported pain in their back (35%), knee (26%), and ankle/foot (23%) whilst male athletes reported pain in their knee (35%), back (28%), and shoulder (24%). Of all athletes, 28% female vs 20% male athletes reported currently taking NSAIDs. Of athletes that reported pain, 46% female vs 38% male athletes currently took NSAIDs. 70% female vs 61% male athletes self-purchased NSAIDs, and 40% female vs 55% male athletes consumed alcohol.

CONCLUSIONS

Half of female athletes and one in three male athletes reported pain. Most commonly back, knee and foot/ankle pain and knee, back and shoulder pain was reported in female and male athletes respectively. One in four female athletes and one in five male athletes use NSAIDs for pain or prophylactic purpose. Majority self-purchase these medications indicating need for health literacy interventions to mitigate potential adverse effects.

Elite athletes' experiences of musculoskeletal pain management using neuroanatomical dry needling: A qualitative study in Swedish track and field

OBJECTIVES

To investigate how elite track and field athletes with a history of musculoskeletal pain (MSKP) describe their perceptions of clinical treatments based on dry needling guided by a neurological map (neuroanatomical dry needling (naDN)).

DESIGN

Qualitative study.

METHODS

In-depth interviews were conducted with eight elite Swedish track and field athletes (6 males, 2 females, median age 28.5) treated at a clinic specialised in MSKP management. All interviews were audio recorded and transcribed verbatim. The data were structured and analysed using a thematic method.

RESULTS

The athletes approached clinical MSKP treatment from a performance-orientated perspective. They explained that they inevitably suffered MSKP episodes due to the intense physical demands of their sport. The use of naDN was considered an integral part of their sports practice and the study clinic's services were readily utilised when MSKP caused minor reductions in physical capacity. The athletes appreciated an unambiguous anatomical diagnosis, preferably supported by imaging scans, as this increased their confidence in clinical services. They valued the naDN treatment as it was perceived to provide fast-acting analgesia that enabled rapid return-to-play. These factors combined to reduce performance-related stress.

CONCLUSIONS

Elite track and field athletes with a history of MSKP sought and appreciated clinical treatment with naDN largely because it provided fast-acting analgesia that enabled rapid return-to-play at a high-performance level. These athletes' expectations of MSKP diagnosis and management appear incongruent with current research indicating that MSKP sensitivity within the nervous system does not accurately reflect musculoskeletal tissue state or recovery following tissue damage.

Cannabidiol and Sports Performance: a Narrative Review of Relevant Evidence and Recommendations for Future Research

Cannabidiol (CBD) is a non-intoxicating cannabinoid derived from Cannabis sativa. CBD initially drew scientific interest due to its anticonvulsant properties but increasing evidence of other therapeutic effects has attracted the attention of additional clinical and non-clinical populations, including athletes. Unlike the intoxicating cannabinoid, Δ9-tetrahydrocannabinol (Δ9-THC), CBD is no longer prohibited by the World Anti-Doping Agency and appears to be safe and well-tolerated in humans. It has also become readily available in many countries with the introduction of over-the-counter "nutraceutical" products. The aim of this narrative review was to explore various physiological and psychological effects of CBD that may be relevant to the sport and/or exercise context and to identify key areas for future research. As direct studies of CBD and sports performance are is currently lacking, evidence for this narrative review was sourced from preclinical studies and a limited number of clinical trials in non-athlete populations. Preclinical studies have observed robust anti-inflammatory, neuroprotective and analgesic effects of CBD in animal models. Preliminary preclinical evidence also suggests that CBD may protect against gastrointestinal damage associated with inflammation and promote healing of traumatic skeletal injuries. However, further research is required to confirm these observations. Early stage clinical studies suggest that CBD may be anxiolytic in "stress-inducing" situations and in individuals with anxiety disorders. While some case reports indicate that CBD improves sleep, robust evidence is currently lacking. Cognitive function and thermoregulation appear to be unaffected by CBD while effects on food intake, metabolic function, cardiovascular function, and infection require further study. CBD may exert a number of physiological, biochemical, and psychological effects with the potential to benefit athletes. However, well controlled, studies in athlete populations are required before definitive conclusions can be reached regarding the utility of CBD in supporting athletic performance.

Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes

BACKGROUND

Little is known about how cannabis knowledge and attitudes impact cannabis use behavior.

OBJECTIVE

To test the knowledge-attitudes-behavior paradigm in active adult athletes.

DESIGN

The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data.

PARTICIPANTS

Self-defined active adult athletes (n = 1161).

MAIN MEASURES

Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use.

KEY RESULTS

A three-cluster solution was the best fit to the data. The clusters were named Conservative (n = 374, 32.2%), Unsure (n = 533, 45.9%), and Liberal (n = 254, 21.9). There was a significant difference among the clusters for all 11 attitudes items (all p < 0.001). Attitude cluster membership was significantly different by age (p < 0.001), primary sport (p < 0.05), and knowledge about cannabis (p < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user (p < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. (p < 0.001).

CONCLUSIONS

Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.

Kinesiotaping Diminishes Delayed Muscle Soreness but does not Improve Muscular Performance

This study aimed at determining the effect of kinesio-taping (KT) on muscle performance and delayed onset muscle soreness (DOMS) after exercise induced muscle damaged. Sixty-six healthy men volunteered to participate (age:18-25 y/o), who performed 200 isokinetic lengthening contractions of the dominant quadriceps. Then subjects were randomized to either control (no treatment), sham (no tape tension), or KT (10% tape tension) groups. Muscle performance was assessed by peak torque and muscular work during maximal isometric and concentric isokinetic contractions. DOMS intensity was assessed using a visual analog scale. Measurements were taken pre-exercise (Pre), 48 h and 96 h post-exercise. Repeated measures ANOVA was used for comparisons within group, and ANCOVA for comparisons among groups. Muscle damage was confirmed in all participants by an increase in CK activity level (p<0.01). Decrease in isometric and isokinetic peak torque was detected at 48 h in the control and sham groups (p<0.01). Muscular work decreased in all groups at 48 h (p<0.01). No differences between groups were detected in muscular performance variables. Increase in DOMS intensity was determined in all groups at 48 h. Comparisons between groups showed lower DOMS intensity in the KT group at 48 h. KT decreased DOMS intensity perception after exercise-induced muscle damage; however, it did not impact muscular performance.

Prevalence of Sports-Related Injuries and Illnesses in Paralympic Athletes

BACKGROUND

With increased participation in Paralympic sports, the burden of sports-related injuries and illnesses may increase. However, there is limited knowledge about the epidemiology of sports-related injuries and illnesses in Paralympic sports (SRIIPS).

OBJECTIVE

To describe among Swedish Paralympic athletes the 1-year retrospective period prevalence of severe SRIIPS and the point prevalence of all SRIIPS and to examine differences in prevalence proportions between athletes with different impairments, behaviors, and sport characteristics.

DESIGN

Cross-sectional study.

SETTING

Swedish Paralympic Programme.

PARTICIPANTS

One hundred and four Paralympic athletes with visual, physical, and intellectual impairment.

METHODS

An eHealth application adapted to Paralympic athletes was used to collect self-report data on existing and previous SRIIPS, as well as impairment, behavior, and sport characteristics.

MAIN OUTCOME MEASUREMENTS

One-year retrospective period prevalence and point prevalence.

RESULTS

The period prevalence of severe injuries was 31% (95% CI 23-40) and the point prevalence 32% (95% CI 24-41). The period prevalence of severe illnesses was 14% (95% CI 9-23), and 13% of the athletes (95% CI 8-22) reported a current illness. More severe injuries (P <.05) were reported by athletes aged 18 to 25 years, not using assistive device, having pain during sport, using analgesics, continuing training injured, and feeling guilt when missing exercise. Athletes who reported a previous severe injury, having pain in daily life and during sport, using analgesics, and being upset when unable to exercise had a higher prevalence of current injuries (P <.05). Being female, reporting previous severe illness, using prescribed medication, and feeling anxious/depressed were features associated with ongoing illnesses (P <.05).

CONCLUSION

Paralympic athletes report a high prevalence of SRIIPS. Behavioral and psychological aspects as well as pain and use of medication appear to be associated with the occurrence of SRIIPS. The results imply that factors leading to SRIIPS are complex and call for a broad biopsychosocial approach when developing preventive measures.

LEVEL OF EVIDENCE

III.

Common Prescription Medications Used in Athletes

Athletes of various skill levels commonly use many different types of medications, often at rates higher than the general population. Common medication classes used in athletes include analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen, inhalers for asthma and exercise-induced bronchoconstriction, antihypertensives, antibiotics, and insulin. Prescribers must be aware of the unique considerations for each of these medications when using them in patients participating in physical activity. The safety, efficacy, impact on athletic performance, and regulatory restrictions of the most common medications used in athletes are discussed in this article.

A cross-species approach to disorders affecting brain and behaviour

Structural and functional elements of biological systems are highly conserved across vertebrates. Many neurological and psychiatric conditions affect both humans and animals. A cross-species approach to the study of brain and behaviour can advance our understanding of human disorders via the identification of unrecognized natural models of spontaneous disorders, thus revealing novel factors that increase vulnerability or resilience, and via the assessment of potential therapies. Moreover, diagnostic and therapeutic advances in human neurology and psychiatry can often be adapted for veterinary patients. However, clinical and research collaborations between physicians and veterinarians remain limited, leaving this wealth of comparative information largely untapped. Here, we review pain, cognitive decline syndromes, epilepsy, anxiety and compulsions, autoimmune and infectious encephalitides and mismatch disorders across a range of animal species, looking for novel insights with translational potential. This comparative perspective can help generate novel hypotheses, expand and improve clinical trials and identify natural animal models of disease resistance and vulnerability.

Retrospective study of the use of medication and supplements during the 2018 FIFA World Cup Russia

Objective

Examine the intake of medication and supplements used by top-level players during the 2018 FIFA World Cup Russia.

Participants

736 top-level players

Setting

The team doctors uploaded a list of the medications used by each player to the online reporting tool within 72 hours of each match of the 2018 FIFA World Cup Russia.

Outcome measures

Average number of medications used per player per match and during the tournament; average number and percentage of players using at least one medication per match and during the tournament.

Results

54% of the players took at least one medication during the tournament and 39% took at least one medication before each match. The most used medications were non-steroidal anti-inflammatory drug (NSAID) (38.6%), followed by other analgesics (13.8%) and medications for insomnia and anxiety (13%). On average, 0.72 medications were taken per player per match and 1.32 per player during the tournament. The mean number of medication intake per player per match was higher during the knockout stage compared with the group stage (0.88±1.36 vs 0.65±1.08, p<0.001). Players from South America and North and Central America took more medications per match compared with the players from Africa (0.9±1.14 and 0.98±1.1 vs 0.48±0.83, p<0.001 in both cases).

Conclusion

The intake of NSAIDs decreased during the 2018 FIFA World Cup compared with previous FIFA World Cups, but stayed at a high level. The high number of medications taken is a cause for concern, and therefore, players, medical staff and coaches should be made more aware of the possible side effects of a high medication intake.

Cannabis use in active athletes: Behaviors related to subjective effects

Cannabis use has not been well characterized in athletes. Studies primarily examine problematic use or its categorization by anti-doping bodies as a banned substance. Patterns of use, reasons for use, and responses to cannabis consumption have not been studied in a community-based sample of adult athletes. The Athlete PEACE Survey examined cannabis use patterns and subjective effects to cannabis in a community-based cohort of adult athletes. We used mainly social media and email blasts to recruit and SurveyGizmo to collect data. 1,161 (91.1%) of the 1,274 athletes taking the survey completed it. Current cannabis use was evaluated by asking "In the past two weeks, have you used marijuana (including THC and/or CBD)?" and cannabis type used was assessed by asking "What do you primarily use THC, CBD, or both?". Cannabis benefits and adverse effects (i.e. subjective effects) and patterns of use were reported. 302 athletes (26%) currently use cannabis of whom 301 had complete data for cluster analysis. Cluster analysis was used to determine cannabis user phenotypes and exploratory factor analysis (EFA) was used to create subjective effects factors. Associations between cannabis user phenotype clusters and the subjective effects factors were explored using multivariate analysis. Cluster analysis identified three statistically distinct cannabis user phenotypes: (1) older athletes who primarily use medical CBD, (2) mixed age athletes who use cannabis mainly recreationally with both THC and CBD use, and (3) mixed age athletes who used cannabis the longest with primary THC and CBD use. EFA showed three subjective effects factors: (1) Well-being, (2) Calm, and (3) Adverse. Mean positive subjective were higher than mean adverse subjective effects (p<0.001). The cluster using THC and CBD showed the highest mean scores for all three subjective effects factors (p<0.001). Athletes who use a combination of THC and CBD exhibited the most benefit to well-being and calm with minimal adverse effects. Our methodology can be used to develop real-world evidence to inform future use of medical cannabis products.

Psychological pain responses in athletes and non-athletes with low back pain: Avoidance and endurance matter

BACKGROUND

Dysfunctional psychological pain responses, namely fear-avoidance (FAR), including catastrophizing and helplessness, as well as endurance-related responses (ER), including thought suppression and overactivity, have been shown to be risk factors for persistent low back pain (LBP). Literature suggests that athletes may differ from non-athletes regarding psychological responses to pain.

OBJECTIVES

This study set out to compare FAR and ER between athletes and non-athletes with LBP. It was hypothesized that athletes would report less frequent FAR and more frequent ER, and that both FAR and ER are associated with LBP intensity and disability.

METHODS

The 173 athletes and 93 non-athletes cross-sectionally reported how frequently they employ FAR and ER on the Avoidance-Endurance Questionnaire (AEQ), as well as LBP intensity and disability on the Chronic Pain Grade Questionnaire (CPGS). MANOVA was applied to compare FAR and ER between athletes and non-athletes. Hierarchical multiple linear regression models were used to determine the unique associations between FAR and ER with LBP intensity and disability.

RESULTS

Athletes reported lower frequencies of behavioural avoidance than non-athletes, but no other FAR variables differed between the groups. Frequencies of ER did not differ between athletes and non-athletes. Regression analysis indicated substantial associations of FAR with LBP intensity, as well as of FAR and ER with disability in athletes and non-athletes.

CONCLUSIONS

The results of the present study suggest that athletes and non-athletes with LBP differ regarding behavioural avoidance, but overall, differences regarding pain responses are marginal. FAR and ER are both reported in athletes and non-athletes and contribute to disability in both groups.

SIGNIFICANCE

Athletes train to endure pain in the course of athletic socialization, at least in the context of exercise. However, there is sparsity of knowledge about psychological pain responses in athletes with low back pain and whether they differ from those in non-athletes. The results of this comparative study suggest that endurance responses are more frequent than avoidance responses among athletes and non-athletes alike. However, both types of responses seem relevant to clinical pain management in athletes as well as non-athletes.

Compliance with needle-use declarations at two Olympic Winter Games: Sochi (2014) and PyeongChang (2018)

Objectives

We describe compliance with the ‘IOC Needle Policy’ at two Winter Olympic Games (Sochi and PyeongChang) and compare these findings to those of the Summer Olympic Games of Rio de Janeiro.

Method

All needle-use declaration(s) (NUD) received during the course of the 2014 and 2018 Olympic Games were reviewed. We recorded socio-demographic data, the nature and purpose of needle use, product(s) injected, and route of administration. Data were analysed descriptively.

Results

In total, doctors from 22 National Olympic Committees (NOCs) submitted 122 NUD involving 82 athletes in Sochi; in PyeongChang, doctors from 19 NOCs submitted 82 NUD involving 61 athletes. This represented approximately 2% of all athletes at both Games, and 25% and 20% of all NOCs participating in Sochi and PyeongChang, respectively. No marked differences in the NUD distribution patterns were apparent when comparing the two Winter Olympic Games. The most commonly administered substances were as follows: local anaesthetics, non-steroidal anti-inflammatory drug and glucocorticoids. Physicians submitted multiple NUD for 24% of all athletes who required a NUD.

Conclusion

A limited number of NOCs submitted NUD suggesting a low incidence of needle use or limited compliance (approximately 2%). A key challenge for the future is to increase the rate of compliance in submitting NUD. More effective education of NOCs, team physicians and athletes regarding the NUD policy, its purpose, and the necessity for NUD submissions, in association with the enforcement of the appropriate sanctions following non-compliance are needed.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Association of Nonsteroidal Anti-inflammatory Drug Prescriptions With Kidney Disease Among Active Young and Middle-aged Adults

IMPORTANCE

Concern about the renal effects of nonsteroidand al anti-inflammatory drugs (NSAIDs) among young, healthy adults has been limited, but more attention may be warranted given the prevalent use of these agents.

OBJECTIVE

To test for associations between dispensed NSAIDs and incident acute kidney injury and chronic kidney disease while controlling for other risk factors.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, longitudinal cohort study used deidentified medical and administrative data on 764 228 active-duty US Army soldiers serving between January 1, 2011, and December 31, 2014. Analysis was conducted from August 1 to November 30, 2018. All individuals new to Army service were included in the analysis. Persons already serving in January 2011 were required to have at least 7 months of observable time to eliminate those with kidney disease histories.

EXPOSURES

Mean total defined daily doses of prescribed NSAIDs dispensed per month in the prior 6 months.

MAIN OUTCOMES AND MEASURES

Incident outcomes were defined by diagnoses documented in health records and a military-specific digital system.

RESULTS

Among the 764 228 participants (655 392 [85.8%] men; mean [SD] age, 28.6 [7.9] years; median age, 27.0 years [interquartile range, 22.0-33.0 years]), 502 527 (65.8%) were not dispensed prescription NSAIDs in the prior 6 months, 137 108 (17.9%) were dispensed 1 to 7 mean total defined daily doses per month, and 124 594 (16.3%) received more than 7 defined daily doses per month. There were 2356 acute kidney injury outcomes (0.3% of participants) and 1634 chronic kidney disease outcomes (0.2%) observed. Compared with participants who received no medication, the highest exposure level was associated with significantly higher adjusted hazard ratios (aHRs) for acute kidney injury (aHR, 1.2; 95% CI, 1.1-1.4) and chronic kidney disease (aHR, 1.2; 95% CI, 1.0-1.3), with annual outcome excesses per 100 000 exposed individuals totaling 17.6 cases for acute kidney injury and 30.0 cases for chronic kidney disease.

CONCLUSIONS AND RELEVANCE

Modest but statistically significant associations were noted between the highest observed doses of NSAID exposure and incident kidney problems among active young and middle-aged adults.

More Than Just a Game: The Public Health Impact of Sport and Physical Activity for People With Disabilities (The 2017 DeLisa Lecture)

Although people with disabilities make up a large proportion of our global population and are known to be disproportionately impacted by sedentary lifestyles leading to chronic disease, programs promoting physical activity often fail to address their unique needs. Both environmental and attitudinal factors also act as barriers to full participation. In this context, increasing evidence shows the positive impact of physical activity and sport on outcomes related to physical health, mental health, community participation, and, in some cases, neurorecovery for people with disabilities. Thus, participation should be seen not only as a medical intervention but also as a rights-based issue. We, as physiatrists, can be agents of change by promoting concepts of universal design and inclusion in physical activity and sport programs.

Clinical and scientific recommendations for the use of photobiomodulation therapy in exercise performance enhancement and post-exercise recovery: current evidence and future directions

BACKGROUND

There is about ten years since the first randomized controlled trial looking for the effects of photobiomodulation therapy using low-level laser therapy and/or light emitting diodes therapy in athletic performance enhancement was published. Since then, the knowledge in this field has increasing exponentially.

OBJECTIVE

Given the fast advance in clinical interest, research and development in the use of photobiomodulation therapy for athletic performance enhancement and also to accelerate post-exercise recovery, as pioneers in this research field we felt the need to establish recommendations to ensure the correct use of the therapy, and also to guide the further studies in this area looking for the achievement of highest scientific evidence. It is important to highlight that the establishment of both clinical and scientific recommendations in this masterclass article were based on the most recent systematic reviews with meta-analysis and randomized controlled trials published in this field. It is important to stress that the recommendations of this masterclass article are based on most recent systematic reviews with meta-analysis and RCTs published in this research field. Future guidelines must follow the same direction and must be based only at the highest scientific evidence, avoiding overstatements and extrapolations based on animal experiments and case-studies.

Athletes with neurologic disease

Neurologic disease does not discriminate, even among athletes. Common neurologic diseases among athletes include multiple sclerosis, seizures, headaches, and sleep disorders. Although concrete guidelines for sport participation among athletes with neurologic diseases do not exist, evidence-based and consensus statements can aid healthcare providers in determining whether and to what extent such athletes should participate in sports. Moreover, sport participation is important, since multiple studies indicate that exercise improves disease-specific symptoms, manifestations, and overall quality of life. Although some risk is involved for athletes with neurologic disease, risk is mitigated with proper supervision and neurologic oversight, disease-specific accommodations, and counseling of the athletic staff and the athletes. Neurologic oversight entails an initial comprehensive neurologic assessment by a neurologist followed by regular follow-up. Preparation for environmental conditions encountered by athletes with neurologic disease will further improve safety during their participation in sport. With sound recommendations, neurologic oversight, and proper supervision, most athletes with neurologic disease can participate in athletics. The health benefits that they will gain from participation in athletics outweigh the risks.

Sport-related injury and pain classification

Pain is common in athletes, and pain management in sport has traditionally been equated with injury management. Although both pain and injury interfere with sport performance, they are not synonymous. Acute musculoskeletal injury commonly manifests as nociceptive pain, inflammatory pain, or both. Pain that persists beyond expected injury recovery must account for all potential contributors to pain, including ongoing biomechanical abnormalities, underlying pathophysiology, and psychosocial issues. Pain chronification involves multiple pathophysiologic and neurobehavioral processes that lead from acute injury-related pain to subacute and chronic pain, and must be distinguished from an ongoing biomechanical overuse pattern. The foundation of pain management in athletes is proper pain classification, which involves assessing for any combination of nociceptive/inflammatory pain, neuropathic pain, central sensitization, and autonomic/motor/affective manifestations of pain. Understanding this foundation is critical because there are scant evidence-based guidelines for the management of pain in sport. This chapter will explore the relationship of sport-related injury and pain, and will provide a management framework that is consistent with International Olympic Committee consensus.

Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis

Objectives

To characterise the sleep of elite athletes and to identify factors associated with training and competition that negatively affect sleep.

Design

Prognosis systematic review.

Data sources

Three databases (PubMed, SCOPUS and SPORTDiscus) were searched from inception to 26 February 2018.

Eligibility criteria for selecting studies

Included studies objectively reported total sleep time (TST) and/or sleep efficiency (SE) in elite athletes. Studies were required to be observational or to include an observational trial.

Results

Fifty-four studies were included. During training, many studies reported athletes were unable to achieve TST (n=23/41) and/or SE (n=16/37) recommendations. On the night of competition, most studies reported athletes were unable to achieve TST (n=14/18) and/or SE (n=10/16) recommendations. TST was shorter (60 min) the night of competition compared with previous nights. SE was lower (1%) the night of competition compared with the previous night. TST was shorter the night of night competition (start ≥18:00; 80 min) and day competition (20 min) compared with the previous night. SE was lower (3%–4%) the night of night competition but unchanged the night of day competition compared with previous nights. Early morning training (start <07:00), increases in training load (>25%), late night/early morning travel departure times, eastward air travel and altitude ascent impaired sleep.

Conclusion

Athletes were often unable to achieve sleep recommendations during training or competition periods. Sleep was impaired the night of competition compared with previous nights. Early morning training, increases in training load, travel departure times, jet lag and altitude can impair athletes’ sleep.

PROSPERO registration number

CRD42017074367.

Nonpharmacological Management of Persistent Pain in Elite Athletes: Rationale and Recommendations

Persistent pain is common in elite athletes. The current review arose from a consensus initiative by the International Olympic Committee to advance the development of a standardized, scientific, and evidence-informed approach to management. We suggest that optimal management of persistent pain in elite athletes requires an understanding of contemporary pain science, including the rationale behind and implementation of a biopsychosocial approach to care. We argue that athletes and clinicians need to understand the biopsychosocial model because it applies to both pain and the impact of pain with special reference to the sport setting. Management relies on thorough and precise assessment that considers contributing factors across nociceptive, inflammatory, neuropathic, and centrally acting domains; these can include contextual and psychosocial factors. Pain management seeks to remove contributing factors wherever possible through targeted education; adjustment of mechanical loading, training, and performance schedules; psychological therapies; and management of inflammation.

Injectable Nonsteroidal Anti-Inflammatory Drugs in Sport

OBJECTIVE

The primary objective of this article is to review the basic science of nonsteroidal anti-inflammatory drugs (NSAIDs), their clinical effects, indications, potential complications, and ethical issues associated with the use of injectable NSAIDs in the treatment of athletes. These objectives are presented taking into consideration the contemporaneous issues associated with the treatment of amateur and professional athletes.

DATA SOURCES

A nonformal review of the published medical literature and lay media focusing on the use of injectable NSAIDs in athletes was used for this article.

MAIN RESULTS

All NSAIDs work through the inhibition of the cyclooxygenase (COX) pathway (either one or both subtypes) to reduce inflammation and inhibit pain by reducing prostaglandin and thromboxane synthesis. Complications related to NSAID use involve primarily the gastrointestinal, renal, and cardiovascular systems through this COX pathway inhibition. Ketorolac is the only NSAID currently available in an injectable form. Despite its analgesic efficacy comparable with opioid medication, injectable ketorolac has the potential to cause bleeding in collision athletes resulting from impaired hemostasis.

CONCLUSIONS

Nonsteroidal anti-inflammatory drug medications are currently used at every level of competition. Injectable ketorolac is an effective analgesic and anti-inflammatory drug. However, its potential effectiveness must be weighed against the risk of potential complications in all athletes, especially those who participate in contact/collision sports. The team physician must balance the goal of treating pain and inflammation with the ethical implications and medical considerations inherent in the administration of injectable medications solely to prevent pain and/or return the athlete to competition.

Injectable Corticosteroids in Sport

OBJECTIVE

To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes.

DATA SOURCES

An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles.

MAIN RESULTS

Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits.

CONCLUSIONS

Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

Analgesic Management of Pain in Elite Athletes: A Systematic Review

OBJECTIVE

To identify the prevalence, frequency of use, and effects of analgesic pain management strategies used in elite athletes.

DESIGN

Systematic literature review.

DATA SOURCES

Six databases: Ovid/Medline, SPORTDiscus, CINAHL, Embase, Cochrane Library, and Scopus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical studies involving elite athletes and focused on the use or effects of medications used for pain or painful injury. Studies involving recreational sportspeople or those that undertake general exercise were excluded.

MAIN RESULTS

Of 70 articles found, the majority examined the frequency with which elite athletes use pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anesthetics, and opioids. A smaller set of studies assessed the effect of medications on outcomes such as pain, function, and adverse effects. Oral NSAIDs are reported to be the most common medication, being used in some international sporting events by over 50% of athletes. Studies examining the effects of pain medications on elite athletes typically involved small samples and lacked control groups against which treated athletes were compared.

CONCLUSIONS

Existing empirical research does not provide a sufficient body of evidence to guide athletes and healthcare professionals in making analgesic medication treatment decisions. Based on the relatively robust evidence regarding the widespread use of NSAIDs, clinicians and policymakers should carefully assess their current recommendations for NSAID use and adhere to a more unified consensus-based strategy for multidisciplinary pain management in elite athletes. In the future, we hope to see more rigorous, prospective studies of various pain management strategies in elite athletes, thus enabling a shift from consensus-based recommendations to evidence-based recommendations.

Pain Management in Athletes With Impairment: A Narrative Review of Management Strategies

OBJECTIVE

To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population.

DATA SOURCES

A comprehensive literature search was performed linking pain with terms related to different impairment types.

MAIN RESULTS

There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete.

CONCLUSIONS

It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.

Novel Factors Associated With Analgesic and Anti-inflammatory Medication Use in Distance Runners: Pre-race Screening Among 76 654 Race Entrants-SAFER Study VI

OBJECTIVE

Analgesic/anti-inflammatory medication (AAIM) increases the risk of medical complications during endurance races. We determined how many runners use AAIM before or during races, AAIM types, and factors associated with AAIM use.

DESIGN

Cross-sectional study.

SETTING

21.1-km and 56-km races.

PARTICIPANTS

Seventy-six thousand six hundred fifty-four race entrants.

METHODS

Participants completed pre-race medical screening questions on AAIM use, running injury or exercise-associated muscle cramping (EAMC) history, and general medical history.

MAIN OUTCOME MEASURES

Analgesic/anti-inflammatory medication use, types of AAIM (% runners; 95% confidence interval), and factors associated with AAIM use (sex, age, race distance, history of running injury or EAMC, and history of chronic diseases) [prevalence ratio (PR)].

RESULTS

Overall, 12.2% (12.0-12.5) runners used AAIM 1 week before and/or during races (56 km = 18.6%; 18.0-19.1, 21.1 km = 8.3%; 8.1-8.6) (P < 0.0001). During races, nonsteroidal anti-inflammatory drugs (NSAIDs) (5.3%; 5.1-5.5) and paracetamol (2.6%; 2.4-2.7) were used mostly. Independent factors (adjusted PR for sex, age, and race distance; P < 0.0001) associated with AAIM use were running injury (2.7; 2.6-2.9), EAMC (2.0; 1.9-2.1), cardiovascular disease (CVD) symptoms (2.1; 1.8-2.4), known CVD (1.7; 1.5-1.9), CVD risk factors (1.6; 1.5-1.6), allergies (1.6; 1.5-1.7), cancer (1.3; 1.1-1.5), and respiratory (1.7; 1.6-1.8), gastrointestinal (2.0; 1.9-2.2), nervous system (1.9; 1.7-2.1), kidney/bladder (1.8; 1.6-2.0), endocrine (1.5; 1.4-1.7), and hematological/immune (1.5; 1.2-1.8) diseases.

CONCLUSIONS

12.2% runners use AAIM before and/or during races, mostly NSAIDs. Factors (independent of sex, age, and race distance) associated with AAIM use were history of injuries, EAMC, and numerous chronic diseases. We suggest a pre-race screening and educational program to reduce AAIM use in endurance athletes to promote safer races.

Management of Pain in Elite Athletes: Identified Gaps in Knowledge and Future Research Directions

OBJECTIVE

For elite athletes to train and compete at peak performance levels, it is necessary to manage their pain efficiently and effectively. A recent consensus meeting on the management of pain in elite athletes concluded that there are many gaps in the current knowledge and that further information and research is required. This article presents the crystallization of these acknowledged gaps in knowledge.

DATA SOURCES

Information was gathered from a wide variety of published scientific sources that were reviewed at the consensus meeting and the gaps in knowledge identified.

MAIN RESULTS

Gaps have been identified in the epidemiology of analgesic use, the management of pain associated with minor injuries, and the field of play management of pain for athletes with major injuries. From a pharmacological perspective, there is a lack of information on the prescribing of opioid medications in elite athletes and more data are required on the use of local anesthetics injections, corticosteroids, and nonsteroidal anti-inflammatory drugs during training and in competition. Pain management strategies for the general population are widely available, but there are few for the elite sporting population and virtually none for elite athletes with a disability. More research is also needed in assessing cognitive-behavior therapies in improving specific outcomes and also into the new process of psychologically informed physiotherapy. A key issue is the paucity of data relating to incidence or prevalence of persistent pain and how this relates to persistent dysfunction, exercise performance, and physiological function in later life.

CONCLUSIONS

The identification of the gaps in knowledge in the management of pain in elite athletes will provide a unified direction for the retrieval of information and further research that will provide reassurance, speed return to active sport, and benefit performance.

Musculoskeletal pain and its association with maturity and sports performance in 14-year-old sport school students

OBJECTIVES

In youth sports, musculoskeletal pain is often studied from the standpoint of sports injuries, but little is known about pain conditions in which athletes still participate. The aim was to study the frequency of pain and associations with maturity offset, health status and sports performance in 14-year-old sport school students.

METHODS

Cross-sectional design. One hundred and seventy-eight students (108 boys and 70 girls) completed anthropometric measures for maturity offset (height, weight and sitting height), questionnaires (pain mannequin and EQ-5D for health status) and sports performance tests (sprint, agility, counter-movement jump and grip strength). Differences between groups were analysed with Student's t-test and analysis of covariance.

RESULTS

Thirty-one students (18.6%) reported infrequent pain, 85 (50.9%) frequent pain and 51 (30.5%) constant pain. Students in the constant pain group had worse health status than those in the infrequent pain group. Boys with constant pain (n=27) had a lower mean maturity offset (-0.38 vs 0.07 years; p=0.03) than boys with infrequent pain (n=22), and pain was associated with worse sports performance. There was no difference in maturity or sports performance between girls with constant pain (n=24) and girls with infrequent pain (n=9).

CONCLUSION

Musculoskeletal pain is common in sport school students and coincides with worse health status and with a younger biological age in boys. The high prevalence of pain should be acknowledged by coaches and student healthcare workers in order to promote a healthy and sustainable development in young athletes.

Sport-Specific Limb Prostheses in Para Sport

Prostheses form an essential part of participation in sport and physical activity for athletes with lower or upper limb amputation. These prostheses come in the form of everyday nonsport-specific prostheses, as well as sport-specific prostheses designed to enable participation in specific sports. Sport-specific prostheses are designed to the requirements of the sport to facilitate the achievement of peak performance without causing significant risk of injury. This article addresses the various factors associated with participation in sport and physical activity for individuals with amputation, including the various prostheses for upper and lower limbs and prostheses for different sports.

'Recover quicker, train harder, and increase flexibility': massage therapy for elite paracyclists, a mixed-methods study

Objectives

Massage therapy (MT) enhances recovery by reducing pain and fatigue in able-bodied endurance athletes. In athletes with disabilities, no studies have examined similar MT outcomes, yet participation in sport has increased by >1000 athletes from 1996 to 2016 Olympic games. We examined the effect of MT on pain, sleep, stress, function and performance goals on the bike, as well as quality of life off the bike, in elite paracycling athletes.

Methods

This is a quasi-experimental, convergent, parallel, mixed-methods design study of one team, with nine paracycling participants, in years 2015 and 2016. One-hour MT sessions were scheduled one time per week for 4 weeks, and then every other week for the duration of the time the athlete was on the team and/or in the study. Closed and open-ended survey questions investigating athlete goals, stress, sleep, pain and muscle tightness were gathered pre and post each MT session, and every 6 months for health-related quality of life. Quantitative analysis timepoints include baseline, 4-6 months of intervention and final visit. Additional qualitative data were derived from therapists' treatment notes, exit surveys, and follow-up emails from the athletes and therapists.

Results

Significant improvement was found for sleep and muscle tightness; quantitative results were reinforced by athlete comments indicating MT assisted in their recovery while in training. There were no improvements in dimensions measuring quality of life; qualitative comments from athletes suggest reasons for lack of improvement.

Conclusion

This real-world study provides new information to support MT for recovery in elite paracyclists.

Common peripheral nerve injuries in sport: diagnosis and management

Peripheral nerve injuries are unusual in sport but impact an athlete's safe return to play. Nerve injuries result from either acute trauma (most commonly in contact/collision sports) or from repetitive microtrauma and overuse. Diagnosis of overuse nerve injuries includes nerve localization and surrounding soft-tissue anatomy, and must account for possible causes of repetitive microtrauma, including biomechanics, equipment, training schedule, and recovery. Prognosis is related to the type of nerve injury. Management should not simply be rest and gradual return to sport but should address biomechanical and training predispositions to injury. Understanding the type of injury and the tissues involved will guide appropriate rehabilitation decisions. Recognizing acute care considerations and implementing appropriate strategies can help minimize secondary trauma to an area following acute injury.

Needle-use declarations at the Olympic Games Rio 2016

AIM

We report on the results of the 'IOC Needle Policy' applied during the course of the Games of the XXXI Summer Olympiad in Rio de Janeiro, Brazil. The policy was intended to empower physicians to ensure appropriate clinical use of needles within team medical environments, enhance the safety of those responsible for housekeeping services and others in the Olympic environment, and permit documentation of such procedures as an adjunct to the doping control programme. Any needle use required the submission of an 'Injection Declaration Form' to IOC medical officials.

METHOD

All 'Injection Declaration Forms' were reviewed and archived. The declarations provided basic information regarding the nature of the needle use and the product(s) involved, the physician, athlete and respective National Olympic Committee (NOC). The details of the declarations were subsequently categorised.

RESULTS

A total of 367 declarations were received from physicians representing 49 NOCs. Needle-use declarations were more common in athletics, gymnastics, football and aquatics. A single product was administered in 60% of the cases, and more than one product was administered in 40%. The majority of declarations indicated the use of local anaesthetics, glucocorticoids, non-steroidal anti-inflammatory drugs and analgesics.

CONCLUSION

The introduction of a 'Needle Policy' in the Olympic Games setting was intended to minimise the use of needles by non-physicians, promote evidence-based practice and to deter needle-based doping practices. Declarations were received from 49 of 209 NOCs suggesting either that needle use is minimal among certain teams or opportunities remain to enhance compliance with such policies at future games.