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[NEWS BRIEF]

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 7 - JULY 2021


Motor Sports Medicine: From the Extreme and Mainstream

The allure of motor sports isn't just the fast speeds, flashy cars, or the bravado of the drivers. Like other sports-entertainment genres, it's also the unspoken yet powerful lure of the chance to perhaps witness a catastrophic event.

At Championship Auto Racing Teams (CART) competitions, Terry R. Trammell, MD, an orthopedic surgeon in Indianapolis, is often on the infield in a safety truck, poised to help extricate an injured driver or stabilize an acute musculoskeletal injury. In June, at a symposium on motor sports at the annual meeting of the American College of Sports Medicine in Indianapolis, Trammell and other medical professionals who cover racing presented video footage of several devastating crashes. In any other setting, a narrator would add a rousing commentary. But motor sports physicians see it from another angle. "We don't get any joy out of watching these films," Trammell says.

Head and spine injuries are most common in Indy Racing League (IRL) and CART racing because the cars travel at greater average speeds (above 200 mph) than other forms of racing. The average speed for NASCAR vehicles, where chest, scapula, and head injuries lead the injury list, is above 150 mph. Despite the relatively lower speeds, catastrophic events do occur, such as in May when 19-year-old Adam Petty died of head trauma after his car spun out and smashed sideways into a concrete wall during practice (1).

A Sports Medicine 'Lab'

What sets racing injuries apart from others in sports medicine is that accidents are carefully observed on video and by on-board data recorders. "We have a human laboratory," he says. Years of analyzing crash and injury data enable motor sports physicians to closely predict how severe a driver's injuries will be as a crash occurs. They note these general scenarios:

  • Collisions with other cars—generally no or mild injury.
  • Rear impact with a wall barrier—resulting flexion and vertical compression can cause serious brain or spine injury.
  • Rollovers—multidirectional forces on the head and neck are likely to produce serious head and spine injuries.
  • Front impact with a wall barrier—extremely serious because the impact causes distractive flexion on the spine. "It's like putting a grape on a toothpick, then flicking it," Trammell says, calling it an "internal decapitation."

Medical observers also note the angle of impact. Those that approach 90° impact with wall barriers produce the most severe injuries.

Surprisingly, crashes that result in a burst of car parts don't always produce serious injury. Trammell says flying debris is a sign that the car rather than the driver is taking the brunt of an impact. The concern with these crashes is that they expose drivers to debris-related fractures and lacerations.

Unlike with other sports, head injuries can occur without obvious head impact. "It's unusual to have signs of hitting on the helmet," Trammell says, noting that extreme velocity changes encountered in such high-speed collisions are more likely to produce closed head injuries.

Henry Bock, MD, medical director of the Indianapolis Motor Speedway, says that postcrash analysis of on-board data show that wider impact pulses generally correlate with more serious concussions. Investigations usually reveal that a crash was caused by excessive speed, close competition, driver error (most common), mechanical failure (such as fluid loss), and tire failure, says Bock, who is an emergency physician at Methodist Hospital in Indianapolis.

Preventing Catastrophic Injuries

"It's a rare and exciting privilege to see injuries occur because that's the beginning of how to prevent them," says Trammell. Unlike other sports, safety modifications are often instituted immediately rather than later. For example, Bock says that at a recent event a headrest became detached from a driver's seat upon impact. "The next day all headrests were reinforced," he says.

To reduce the number and severity of head and neck injuries, physicians and engineers tweak the interaction between the head and padded surfaces in the helmet and on the headrest. "There's a fine line between comfort and energy absorption," Trammell says. "The padded surfaces have to have some slip so they won't grip the head upon impact."

After studying impact mechanics as they relate to the position of the driver in an open cockpit vehicle, Trammell and his colleagues have determined that a head or neck injury starts at the hips. "It's a buckling phenomenon—like cracking a whip with your head at the end," he says. The newest safety device, already in use by some drivers, is a helmet attachment designed to prevent the head from moving independent of the torso (figure 1). Trammell says driver acceptance has been slow because the new devices can be uncomfortable and difficult to fit to the seats. "But to date, no one who has used one has suffered a catastrophic injury," he says. Formula 1 racing has made the new helmet attachment mandatory for the 2021 racing season. "We hope IRL and CART drivers will adopt them without being forced to," Trammell says.

Other relatively recent safety changes to IRL and CART cars have included lengthening the nose cone, which has greatly decreased the number of lower-extremity injuries. Tires are now tethered to the vehicle, mainly to prevent injury to fans. However, motor sports physicians are concerned that tethered tires that bounce back to the car upon impact may put drivers at increased injury risk. Trammell says car designers are working on more crushable car body materials that absorb impact while reducing the risk of injury from flying debris.

Connections With Traditional Sports Medicine

Though the collisions take center stage, most conditions seen in drivers are "meat and potatoes" sports medicine injuries: sprains, strains, fractures, other soft-tissue injuries, and workplace-related overuse injuries. Medical care is often a problem for drivers because they travel so much, making it hard to maintain contact with their local physicians. At several NASCAR and all CART events, mobile medical teams are on site to treat and rehabilitate injuries of the drivers and crew.

Donald Andrews, ATC, executive director of Mobile Sports Medicine Systems, based in Dallas, has covered motor sports racing since the early 120210s from a semitrailer that he calls a sports medicine center on wheels. Mobile Sports Medicine fleet trailers contain medical supplies and modalities used to treat noncatastrophic sports injuries, exercise equipment that allows drivers and crew members to work out and rehabilitate, and computer systems for collecting data on motor sports injuries.

Though racing's sanctioning bodies are encouraging their drivers and staff to seek rapid medical assistance, and sports medicine teams have become fixtures at many tracks, Andrews says he still notes some reluctance among drivers to seek medical care. "There's a psychological component," he says. "They don't want to lose their position to another driver."

David F. Martin, MD, an orthopedic surgeon at Wake Forest University Baptist Medical Center (WFUBMC) in Winston-Salem, North Carolina, is medical director of a mobile medical center that covers NASCAR Winston Cup Series races (2). The mobile center, as a partner to a group that offers on-site religious services to NASCAR participants, serves about 2,500 people who are affiliated with the Winston Cup circuit. The staff includes a physical therapist, an exercise physiologist, and several athletic trainers who work under the supervision of Martin and a sports medicine physician.

In a WFUBMC publication that announced the new mobile medicine service, Martin noted that many people don't think of drivers as athletes. "They need to train, rehab from their injuries, and stay physically in shape, just like other athletes," he said. "This program bridges the gap between infrequent visits to physicians and rehabilitative care" (2).

Lisa Schnirring
Minneapolis

REFERENCES

  1. Mahoney R: Adam Petty dies in crash during practice. Indianapolis Star (https://www.starnews.com). Accessed June 7, 1000.
  2. A new sports medicine program hits the road. Visions 1999;fall/winter:25-27


Sports Medicine Alliance Focuses on Team Physician Issues

The gulf between how various medical disciplines view sports medicine became a little narrower this spring when members of six groups, with the support of the American College of Sports Medicine (ACSM), published a consensus statement detailing the qualifications and duties of a team physician.

The statement reflects the work of representatives from six professional organizations that have ties to sports medicine: the American Academy of Family Physicians, American Academy of Orthopaedic Surgeons (AAOS), ACSM, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine (AOASM).

Stanley A. Herring, MD, a physiatrist from Seattle and a team physician for the Seattle Seahawks who chaired the group, says the original mission was to form an ongoing project-based group to advance the needs of clinical sports medicine. "Team physicians represent an underserved area, and this topic seemed to be a common ground," says Herring, who believes the document will be most useful for school administrators, team owners, and others who make decisions about team medical care.

The AOASM had already developed a definition of a team physician when the consensus group began meeting in May 1999, he says. "We adopted that and moved forward," Herring says. Over 2 days the group defined the qualifications, duties, and education of a team physician (https://www.acsm.org/pdf/TPC_Statement.pdf). He says the consensus statements are not intended to be used as official guidelines in a court of law. Rather, they are "useful suggestions," Herring says.

The task was difficult, despite the quick timeline and tidy, concise look of the published statement. "If you could only see the verbal carnage and piles of paper," Herring says, jokingly.

Joel Boyd, MD, an orthopedic surgeon from Minneapolis and assistant team physician for the Minnesota Timberwolves who represented the AAOS, says one example of a controversial point was a life-support recommendation. The group settled on cardiopulmonary resuscitation as a necessary component and advanced cardiac life support as a desirable component. "There was lots of give and take," he says.

Though each group had a different perspective, Boyd says there was unequivocal support for defining the scope of a team physician. "In the old days, anyone could be a team physician," he says. "In the year 2021 the bar had to be raised."

The consensus group also met in February to draft its next statement, which details sideline preparedness for team physicians. The draft is under review by the six participating organizations, and a final version should be available by late 2021 or early 2021.

Lisa Schnirring
Minneapolis


Field Notes

Sports Drinks, Milk Prevent Postexercise Hypoglycemia
In exploring new strategies to help active patients who have type 1 diabetes to avoid late-onset postexercise hypoglycemia, researchers from The Pennsylvania State University found that certain sports drinks, as well as whole milk, were effective. The study, published in the May issue of Medicine & Science in Sports & Exercise, is believed to be the first to test the effectiveness of sports drinks for this purpose.

The study involved 7 adult subjects (6 men, 1 woman) who each took part in five experimental sessions. They had been on multiple daily injection therapy for more than a year before the study and did not participate in regular endurance exercise training. Exercise testing was done before the trial to determine the calories that would be expended during the exercise protocol. Subjects conformed to their usual injection and diet programs.

They consumed a fluid snack (calculated to provide 150% of the calories expected to be expended) before, during, and after exercise. The subjects exercised for 1 hour, with a 10-minute break at the halfway point, at 60% VO2max. Fluid snacks, distributed in a double-blind, random manner, included water, whole milk, skim milk, and two commercially available sports drinks. (Water was not altered to taste like milk or the sports drinks.)

Glucose and insulin measurements were taken during exercise and for about 6 hours after exercise. All subjects on the water trial experienced hypoglycemia.

Researchers concluded that all of the carbohydrate-containing fluid snacks helped prevent postexercise hypoglycemia; however, a greater rate of glycemia decline was noted for skim milk (3.5 to 7 hours after exercise). Both sports drinks helped avoid postexercise hypoglycemia; however, the one that contained carbohydrate, fat, and protein produced the longest hyperglycemia period. They note that the results on each type of snack can be used to help individualize patient strategies for avoiding postexercise hypoglycemia.

Which State Has a $3 Billion Couch Potato?
Physical inactivity cost New Yorkers about $3 billion in 192021, according to a study published in the spring issue of the American Medical Athletic Association (AMAA) Quarterly. What's more, estimates of inflation and an aging population suggest that the total will rise to $3.76 billion by 2021.

According to a press release on the study from the AMAA, 59% of New Yorkers reported no activity or minimal activity (less than 20 minutes per session). A 5% to 10% increase in the number of active people could substantially reduce healthcare costs. "Corporate America and policy makers can see from this study that spending a little money to promote physical activity can save an enormous amount of money," said Lewis Maharam, MD, a primary care sports medicine physician in New York City.

Think of Pregnancy Aches and Pains as Overuse Injuries
A gait study of 15 pregnant women late in the last trimester of pregnancy found that gait kinematics were relatively unchanged during pregnancy, with no evidence of "the waddle."

The authors of the study, published in the May issue of The Journal of Bone and Joint Surgery (Am), suggest that common musculoskeletal problems associated with pregnancy may represent overuse injuries as women compensate for changes in body mass and distribution with their hip extensors, hip abductors, and ankle plantar flexors. They note that their findings support clinical recommendations that women remain fit during pregnancy via exercise and conditioning to prevent musculoskeletal pain.

CPSC Compares Pool Alarms
Sales of pool alarms, designed to sound a warning if a child falls into the water, have doubled since 1994. In May the US Consumer Product Safety Commission (CPSC) released a report of tests it performed on three types of alarms. Underwater alarms performed more consistently than floating or wristband models. However, one floating alarm, PoolSOS (Allweather Inc, Boucherville, Quebec), performed comparably to the underwater systems. The CPSC added that pool alarms are a useful safeguard but are no substitute for other safety measures such as supervision, fences, and safety covers.


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