THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 6 - JUNE 99
Anabolic Steroids May Help Restore Muscle in HIV Patients
The pairing of anabolic steroids and resistance exercise, a practice used by some athletes but widely condemned by physicians, may gain new respect as a way to reverse muscle wasting in patients who have human immunodeficiency virus (HIV) infection.
Researchers at San Francisco General Hospital (1), as reported recently in The Journal of the American Medical Association (JAMA), conducted a double-blind, randomized, placebo-controlled trial that compared the effects of oxandrolone and progressive resistance exercise with resistance training alone in 22 HIV-infected patients. Before the study, the men had lost about 9% of their body weight.
The 11 patients in the anabolic steroid group received 20 mg of oral oxandrolone each day. The treatment group and the 11 control patients all had normal testosterone levels before the trial and received low-dose testosterone enanthate injections (100 mg per week) to make hormonal status more comparable between the groups by suppressing endogenous testosterone production, ensuring that borderline hypogonadism was not present, and avoiding the possibility of hypothalamic hypogonadism induced by exercise. All patients took part in 8 weeks of resistance training, consisting of three 1-hour sessions per week on nonconsecutive days. Standard isotonic exercise machines were used for training.
At the end of the study, both groups had increases in weight and lean body mass. However, the oxandrolone group had significantly greater gains (body weight, 6.7 kg vs 4.2 kg; lean body mass, 6.9 kg vs 3.8 kg). Both groups had strength gains, but the oxandrolone group's gains were significantly larger.
Benefits vs Cardiac Risks
Leonard Calabrese, DO, section head of clinical immunology in the Department of Rheumatic and Immunologic Disease at The Cleveland Clinic Foundation, says the gains achieved in the study were impressive. Despite the use of protease therapy, muscle wasting is still a clinically significant problem in HIV patients, especially in those who have advanced disease and those who are on highly active antiviral therapy, according to Calabrese. He notes that wasting has several causes: hypercatabolism, malabsorption, and poor nutrition. "Sometimes the wasting is stepwise, and patients will lose 5 or 6 kg after a viral illness or pneumonia and they won't gain the weight back," he says. "It's important to intervene."
Calabrese says some physicians, including himself, are already prescribing anabolic steroids and resistance exercise to reverse muscle wasting in HIV patients. However, he says he is extremely cautious about anabolic steroid use in patients who are on protease inhibitors because both drugs pose cardiovascular risks. Steroids have a negative effect on serum lipids, and Calabrese says protease inhibitors can induce a variety of lipodystrophies as well as glucose intolerance.
"We aggressively assess patients' cardiovascular risk and treat high lipid levels," Calabrese says. For patients who have controlled risk factors and are willing to exercise, he prescribes 10 to 20 mg of oral oxandrolone per day or 100 mg per week of injectable nandrolone. The route of administration often depends on the patients' insurance coverage; Calabrese estimates that the oral drug costs $500 to $1,000 per month and that the injectable form costs $30 to $50 per month.
Study Raises More Questions
The writer of an editorial (2) that accompanied the JAMA article advised caution regarding the possibility of using anabolic steroids in patients with HIV infection. Adrian Sandra Dobs, MD, MHS, associate professor of medicine at The Johns Hopkins University School of Medicine in Baltimore, wrote that before anabolic steroids are adopted into clinical practice, researchers should answer the following questions: (1) Does increasing lean body mass change the prognosis? (2) Is long-term anabolic steroid use safe? (3) Which patients are likely to benefit—those with mild disease or those with advanced infections? (4) Should steroids be use intermittently or continuously? and (5) Which anabolic drug is most effective?
She also suggested that the efficacy of resistance exercise alone should be determined. Assuming that injuries can be avoided, she wrote, exercise "is clearly the safest and least expensive approach to prevent muscle wasting."
Lung Injuries in Contact Sports: Diagnosis and Management Tips
Lung injuries in contact sports are rare but can be serious or life-threatening, as in the recent case of pro hockey's Eric Lindros, whose collapsed lung prompted surgery and kept him from the Philadelphia Flyers' playoffs lineup this year.
Diagnosing a sports-related lung injury can be difficult because physicians can't always depend on hemoptysis and disabling pain as clues. According to media reports, Lindros received and delivered many hard checks during an April 1 game against the Nashville Predators (1,2). One report (3) said he fell on his stick. He played the entire game, talked with reporters in the locker room afterward, and went out for dinner before symptoms (light-headedness, nausea, and shortness of breath) emerged later that night.
Robert Promisloff, MD, a pulmonary critical care specialist at Hahnemann University Hospital in Philadelphia, told the Philadelphia Inquirer that it would be rare for a player to be hit hard enough to sustain a hemothorax and not know it, but a well-conditioned athlete such as Lindros might be able to shrug off the pain.
Here are some management tips from two National Hockey League team physicians who have encountered sports-related lung injuries: Gary Dorshimer, MD, internist for the Flyers and fellow of the Association of Professional Team Physicians, and David C. Reid, MD, professor of orthopedic surgery at the University of Alberta in Edmonton and team physician for the Edmonton Oilers.
Return to Play
Beginners Should Use Care With Tae Bo and Other Kick-Boxing Workouts
Aerobic kick-boxing classes, often called cardio kick-boxing, provide an intense workout that offers multiple benefits, but beginners need to take precautions to prevent injuries, according to the American Council on Exercise (ACE), which serves as a consumer watchdog on exercise products and programs.
In a recent press release, ACE reported that cardio kick-boxing—a hybrid of boxing, martial arts, and aerobic dance—is quickly replacing step aerobics and indoor cycling as the most popular fitness class at gyms. The classes, many of which are inspired by Tae Bo workout videos, provide an intense full-body workout that uses a variety of movements that are designed to boost strength, aerobic fitness, and flexibility, as well as sharpen reflexes and improve coordination and balance. ACE notes that an hour-long kick-boxing workout burns 500 to 800 calories, compared with 300 to 400 calories for a typical hour-long step aerobics class.
Kick-boxing workouts appeal to people who get bored with "linear-type" activities such as jogging and walking, said Richard Cotton, PhD, chief exercise physiologist for ACE, in the press release. "The variety of movements found in martial-arts-based workouts may be enough to pique the interest of the easily bored and keep them working out for the long run."
ACE advises beginners and other participants to keep in mind the following safety tips:
HCM Death Speeds Revision of Indiana PPE Forms
According to a March 14 article in the Chicago Tribune, John Stewart, a 7-ft senior, collapsed in the third quarter of a regional playoff game. The cause of death listed on the coroner's report was hypertrophic cardiomyopathy.
Ray Craft, associate commissioner of the IHSAA, said the sports medicine committee of the Indiana Medical Association has always worked closely with the IHSAA and regularly recommends changes to the state's PPE procedures and forms. "There was a lot of media attention about the death, and we turned to them to review our forms again," Craft said, adding that the group added four additional cardiac screening questions to make Indiana's PPE forms address all of the PPE cardiac exam recommendations proposed by the American Heart Association (AHA) in 1996.
A 192021 report in The Journal of the American Medical Association (JAMA) found that eight states had no approved PPE forms and of the states that had forms, many omitted some of the AHA's recommended cardiac screening questions.
Thomas L. Sevier, MD, one of the physicians who worked with the IHSAA on the PPE form changes, said that the new form containing all 13 of the AHA's recommended questions probably wouldn't have prevented Stewart's death. "Unfortunately, sudden death was his first symptom," says Sevier, who is medical director of Central Indiana Sports Medicine in Muncie. Some people argue that expensive diagnostic tests should be performed during the PPE, but the tests aren't perfect and produce many false positives, he said. "This form is the best device we currently have to pick up potentially serious cardiac abnormalities," Sevier said. "The key to the success of the PPE is to make sure that these questions are carefully answered by the athlete's parents or guardians."
Young Baseball Player Dies From Baseball Impact
The boy, playing in a recreational league tournament, was trying to steal third base when he was hit on the left side of the chest. He stopped breathing seconds after he was hit. Cardiopulmonary resuscitation efforts by bystanders at the scene were unsuccessful, as was defibrillation administered by emergency medical technicians.
Rabies Vaccination Update