THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 2 - FEBRUARY 2021
Healing From War Injuries
A Sports Medicine Approach
Physicians who manage sports injuries have probably, at some point, thought of the analogy of treating an injured warrior. And then there are "weekend warrior" athletes, common in sports medicine practice.
What happens when the next patient that comes through the office door is a real injured warrior? As injured Iraq war soldiers return to their hometowns after their conditions stabilize, local physicians are taking over their care. Jim Turner, DO, of Terre Haute, Indiana, is one such physician, and he's using his sports medicine expertise to return his patient to play—not to the battlefield, but to a physically demanding job on the family farm.
Aaron Wernz, a 26-year-old specialist in the 1544th Transportation Unit of the Army National Guard, based in Paris, Illinois, was severely injured in September when an insurgent mortar attack hit the unit's compound near Baghdad. Wernz suffered a collapsed lung and was riddled with shrapnel; a piece still rests in his heart wall. Wernz's National Guard unit has made national headlines because the small 170-member unit has sustained more deaths (5) and serious injuries (24) than has any other National Guard unit.1,2
When word came of Wernz's injury, Turner, who had been a family physician to Wernz and his parents, began keeping track of Wernz's progress as he was hospitalized in Germany, then at Walter Reed Army Medical Center in Washington, DC. "When I first saw him in November, he was in obvious pain. He walked bent over. He needed pain medication management, and he was lucky to be alive," Turner says. Because of the lung injury, Wernz had only 60% normal pulmonary function for his age.
Besides being shocked at the sight of the shrapnel on Wernz's chest x-ray, Turner also noticed that Wernz wasn't sleeping much and was feeling down because of injury pain and isolation from his comrades. "He needed to build his cardiovascular fitness back up. I spoke with our fitness specialist and said 'Let's treat him like an injured athlete,'" Turner says, adding that Wernz was eager to return to his job on the family farm, where he needs to lift 80-lb bags of fertilizer.
Turner's office at Cork Medical Center in Marshall, Illinois, is right across the state line from the Union Hospital, which has a fitness center. Turner collaborated with Craig Gillaspy, a fitness specialist at Union Hospital Center for Fitness and Performance, in Terre Haute, to design a program for Wernz. Gillaspy says poor flexibility and range of motion were some of Wernz's biggest issues, mainly from the deconditioning. Extensive scar tissue from the lung injury treatment also was an obstacle, he says.
Wernz started slowly, with just 15 minutes on the elliptical trainer and very light weights, Gillaspy says. Leg strength returned quickly, his cardiovascular fitness has increased, and Wernz is doing shoulder presses, chest presses, and seated rows on the weight machines. "He's here sometimes 3 days a week, and some days are better than others," Gillaspy says, noting that Wernz still struggles with some pain. "But I can tell he has a better outlook," he says, adding that socialization at the fitness center is an additional benefit of the workouts.
Meanwhile, Turner has noted mood and sleep improvements and that Wernz is requesting less pain medication. He is also eager to see if the exercise routine has improved Wernz's pulmonary function. (Wernz will undergo his next pulmonary function test when he undergoes evaluation for his medical disability hearing.)
Turner says sports medicine physicians who work with fitness colleagues are uniquely equipped to manage the care of injured soldiers, though many patients will require months or even years of contact with surgeons and other specialists. "When soldiers come home, physicians have to stand back and look at the whole person and their future goals. They have to be back in the lineup—back in the game in an organized way," Turner says.
Colleagues Remember Matt Roush, MD
Matthew B. Roush, MD
Roush, a native of Ogden, Utah, spent most of his career as a team physician at Ball State University in Muncie, Indiana, where he had been a sports medicine fellow. He held a certificate of added qualifications in sports medicine. In 1996, Roush provided medical care at the mountain biking and equestrian venues at the Atlanta Summer Olympics. He also covered the Salt Lake City Winter Olympics in 2021, where he worked the speed skating events.
In 2021, Roush, a family practice physician, returned to Utah where he became director of the Utah Valley Sports Medicine Clinic in Provo and served as sports medicine fellowship director for Intermountain Health Care's southern region. He was also a team physician at BYU and Utah Valley State College. He played football and graduated from BYU in 120217.
When Roush started his new position in Provo, he quickly established trust and was seen as a bridge builder, says Mitchell Pratte, DO, a family physician who served as team physician with Roush at BYU. "He had a great relationship with his fellows and the athletes he worked with, and I often saw him joking and playing with them," he says. "He was able to have a close, collegial, comfortable relationship with people, yet always was professional and respected for his medical experience." Roush was also well known for his dedication to his family and to his church, Pratte says. He was an active member of The Church of Jesus Christ of Latter-day Saints.
Through his academic connections in the Midwest and from his involvement in the American Medical Society for Sports Medicine (AMSSM) and the American College of Sports Medicine, Roush had an impact on many of his colleagues. Douglas McKeag, MD, taught Roush when he was a visiting resident at Michigan State University. McKeag, who is now professor and chair of family medicine at Indiana University School of Medicine in Indianapolis, says Roush's presence, "validated what you were trying to do as a teacher and initiator of something new." McKeag adds that Roush's strength, intellect, and high standards personified the field of sports medicine. "He was the kind of person who naturally rose above politics and gamesmanship; you just knew he would never compromise his principles," McKeag says. "To me, Matt represented all that is good about sports medicine and all that we try to teach our progeny."
Aurelia Nattiv, MD, associate clinical professor of family medicine and orthopedic surgery at the University of California, Los Angeles, collaborated on research with Roush when he was a medical student at the University of Utah. Roush presented the research results, "Bone Density in Collegiate Gymnasts With Menstrual Dysfunction," at the 1993 AMSSM meeting in Sun Valley, Idaho. "Matt Roush was the kind of person you would always want on your 'team.' He was a bright, young gentleman, a family man, a superb physician, a leader and teacher, and a major contributor to the field of sports medicine, locally and nationally," Nattiv says. "He had many friends and colleagues who had the utmost respect and admiration for him. He will be sorely missed and forever remembered."
Margot Putukian, MD, director of athletic medicine at Princeton University in Princeton, New Jersey, knew Roush well from her fellowship at Michigan State University, and kept in touch with him through AMSSM projects. "He always had a big smile on his face and an enthusiastic approach to everything in his life, from his family to his academic interests to his outside endeavors," she says. "I don't recall a single negative comment that he ever made; he was unbelievably optimistic." Putukian recalls that Roush had a variety of academic interests, including a strong interest in female bone health.
Kenneth Haller, DO, sports medicine physician at Central Indiana Orthopedics and team physician at Ball State University, worked with Roush for 9 years as a fellowship and practice partner. "Memories abound, from after-clinic football games, to Summer and Winter Olympics," says Haller. He adds that it's hard to capsulize the life of a man who enjoyed life to the fullest and touched so many people. "He drew people to him and had a unique way of making everyone feel as though they were, at any given moment, the most important person to him," Haller says. "Probably the greatest tribute to him is the impact his death had on our local community, medical and nonmedical alike, despite that he had moved to Utah a year ago."
As one of Roush's first fellows, Kim Harmon, MD, a family practice physician at the University of Washington in Seattle, knew Roush and his family well. Harmon says one of the lessons Roush passed on to fellows was the example he set in balancing priorities. "He was a terrific, involved father to his kids, active in his church, and a dedicated and energetic teacher," Harmon says. She adds that Roush was eager to try new things and was sometimes competitive. "In someone else, this may have been annoying, but with Matt, it was endearing," Harmon says. "He lived with a passion for everything he did."
In addition to his wife, Roush is survived by the couple's six children: Benjamin (16), Eli (14), Caleb (11), Madison (8), Brittany (5), and Samuel (18 months). An athletic scholarship endowment honoring Roush has been established at BYU for student-athletes who pursue careers in sports medicine. For more information about the scholarship, please contact the BYU Cougar Club at (801) 422-6754.
The AMSSM will honor Roush at its annual meeting in mid April in Austin, Texas, and has also set up a trust fund for the Roush children. Individuals can purchase a white rubber bracelet that says "In celebration of Matt Roush, MD" on the front, and "AMSSM" on the back. All proceeds will go to the trust fund. Donations will be collected up through the AMSSM annual meeting. For more information, e-mail the AMSSM office ([email protected]), or call (913) 327-1415.
Pairing Patients With the Right Diets
Patients often ask their physicians' advice on popular weight loss programs, but there have been few studies that evaluate the effectiveness of the programs or offer clinical guidance. Two new reports1,2 published in January, however, shed light on the efficacy of some of the most widely known diets and suggest ways to pair patients with diets that they're more likely to follow.
Trial Compares Four Diets
Researchers from Tufts University compared the weight loss and heart disease risk reduction effects of the Atkins, Ornish, Weight Watchers, and Zone diets.1 The 1-year, randomized, single-center trial enrolled 160 participants. The population included adults who were overweight or obese and had at least one metabolic cardiac risk factor. Forty patients were randomized to each diet group, which met with a dietician and physician for the first 2 months of the study.
Researchers focused on the dietary component of each plan by standardizing recommendations about supplements, exercise, and external support. All participants were urged to take a multivitamin each day, obtain at least 60 minutes of exercise each week, and avoid commercial support services. To realistically assess long-term adherence after the first 2 months of supervision, subjects were encouraged to follow their assigned diet according to their own interest level. Adherence was measured by asking participants to complete 3-day food records at baseline, 1, 2, 6, and 12 months. Researchers also called the participants at home each month to ask them to rate their adherence level on a 10-point scale.
Adherence to the diets was relatively low, and ranged from 50% in the Ornish group to 65% for the Zone and Weight Watchers groups. In those who discontinued the study, researchers assumed no weight change from baseline. Among those who completed the study, each of the four diets significantly reduced the low-density lipoprotein:high-density lipoprotein (HDL) cholesterol ratio by 10%. No significant effects on blood pressure or glucose levels were seen at 1 year.
The amount of weight lost was associated with subjects' adherence level, but not with the diet type. Levels of total cholesterol:HDL cholesterol, C-reactive protein, and insulin decreased as subjects lost weight, but there were no significant differences between diets.
Researchers concluded that each popular diet modestly reduced weight and cardiac risk factors at 1 year and that increased adherence was associated with greater weight loss and cardiac risk factor reductions. They also added that more research is needed to identify the factors that could increase dietary adherence, such as matching individuals with diet programs that complement their food preferences, lifestyle, and medical conditions.
Vast Weight Loss Options
While Zone, Atkins, and Ornish are probably well-known diet concepts among physicians because they were all the subjects of bestselling books, the details of the many commercially available diet programs might not be as familiar. In a recent review,2 two researchers from the University of Pennsylvania evaluated nine diet programs in terms of components, cost, and efficacy. They reviewed company Web sites, talked to company representatives, and searched Medline for efficacy studies. The nine programs include three storefront commercial programs (Weight Watchers, Jenny Craig, LA Weight Loss), three medically supervised programs (Health Management Resources, Optifast, Medifast/Take Shape for Life), one Internet-based program (eDiets.com), and two organized self-help programs (Take Off Pounds Sensibly [TOPS] and Overeaters Anonymous).
Storefront commercial programs typically feature a low-calorie diet, physical activity motivation, behavior modification, and support. Most feature a membership fee with regular fees. Of the three programs included in the study, randomized, controlled trials were only available for Weight Watchers. In their analysis of three published Weight Watchers trials, researchers summarized that the program produces a mean loss of approximately 5% of initial weight, which may prevent or minimize weight-related health problems.
Medically supervised proprietary programs usually consist of a very-low-calorie diet; two of the programs that were reviewed—Optifast and Health Management Resources—also offer a low-calorie diet option. These programs are usually more expensive than other program because they typically include medical monitoring.
Summarizing the randomized trials and case reports found for these programs, researchers concluded that patients lost about 15% to 25% of their weight during 3 to 6 months of treatment and may maintain a loss of 8% to 9% at 1 year, 7% at 3 years, and 5% at 4 years. However, they point out that the studies present a best-case scenario because many patients didn't complete treatment or participate in follow-up assessments.
Researchers concluded that while very-low-calorie diets may be appropriate for some obese patients who need to reduce their weight-related risk factors quickly, medical supervision is needed to monitor and manage side effects. They note that the Medifast program was not consistently supervised and that physicians should be cautious about referring patients to other very-low-calorie programs that don't mandate medical supervision.
Internet-based diets are the most recent development among commercial weight loss programs. Though several programs are available, researchers focused on eDiets because it was the only program of its kind that was the subject of a published study. A randomized trial comparing eDiets with a behavioral weight loss manual found that eDiets participants had lost 1% of their initial weight at 1 year. Those using the weight loss manual lost 4%. Researchers concluded that until larger controlled studies are done on Internet-based diets, there is little evidence that they are effective.
Organized self-help programs are typically run by volunteers and vary in treatment technique, say the researchers, who analyzed the two biggest such programs: TOPS and Overeaters Anonymous. They found no efficacy studies on these programs and projected that participants in these nonprofit programs could be expected to lose 5% of their initial weight. They concluded that the costs and risks of such programs are low and that Overeaters Anonymous may be most appropriate for dieters who seek focused emotional support.
Studies Yield Practical Messages
L. Tyler Wadsworth, MD, medical director of the St John's Mercy Sports and Therapy Center in St Louis, is a sports medicine physician who has long had a special interest in nutrition. (Wadsworth has a nutrition Website: https://www.fitpronutrition.com). He says it's good to see more medical evidence on the popular diets and programs. "The main message is that they all work, and that more compliance fosters more success," he says. "The real challenge is getting people to stick to them. With more radical diets, they have a harder time," he says.
Another take-home message, Wadsworth says, is that both studies cast a favorable light on Weight Watchers. "I've always recommended Weight Watchers to patients because they provide ongoing supervision with accountability and have a balance between healthy eating and regular physical activity," Wadsworth says.
The results of the study by Dansinger et al1 may soften some physicians' cautions to patients about the Atkins and Zone diets, he says, noting that the study showed reduced cardiac risk results from both, despite the higher ratio of fat to carbohydrates. Wadsworth says he has typically swayed patients away from the Atkins diet because he believes it's important to improve the physical activity level, even if there is no weight loss. "And you need carbs to support exercise," he says.
These studies will do much to help physicians counsel about diet. "This helps us nudge them along the right path, then we can schedule follow-ups. When we talk about this, they listen, and they see it as concern," Wadsworth says. REFERENCES
Tracking Transient Spinal Cord Injury
Transient spinal cord injuries (TSCI) are dramatic, and they present clinical management challenges, especially because there are few studies that guide return-to-play decisions. A new study, published in the January issue of the Journal of Neurosurgery: Spine, however, sheds new light on whether a patient who has a single episode of TSCI is at risk of future catastrophic spinal cord injury.
The author, Julian Bailes, MD, chair of the neurosurgery department at West Virginia University, in Morgantown, followed 9 men and 1 woman who were diagnosed as having TSCI based on physical and neurologic exams, plain radiographs with flexion-extension dynamic studies, computed tomography, and magnetic resonance imaging (MRI). The patients' clinical courses were followed, as well as return to play in those who chose to resume contact sports.
TSCI symptoms included paralysis, weakness, and numbness in all four extremities (from 15 min to 48 hr). Radiographs revealed no evidence of fracture, dislocation, or ligament instability. In all patients, spinal stenosis of 8 to 13 mm was evident at three or more levels.
Four of the 10 patients returned to competition without recurrent TSCI (mean follow-up, 40 mo); 6 patients retired from their sport. Bailes concluded that a single episode of TSCI in an athlete with spinal stenosis does not appear to substantially increase the risk of subsequent catastrophic spinal cord injury in patients whose MRI demonstrates preserved cerebrospinal fluid signal.
Exercise Counseling: It Works
Professional counseling and support can moderately increase physical activity and cardiorespiratory fitness among adults, according to authors who reviewed several physical activity intervention studies. The report, which appeared in the January 2021 issue of The Cochrane Database of Systematic Reviews, didn't determine what kind of advice worked best to encourage exercise, and they found no evidence that counseling can help people reach a specific exercise goal. The Cochrane Collaboration is an international organization that evaluates medical research.
The Cochrane study included 11 randomized, controlled trials that reported results of counseling on self-reported physical activity, and 7 studies that evaluated the cardiorespiratory effect of the interventions. In total, the Cochrane study included 6,255 sedentary, noninstitutionalized adults. Studies required at least 6 months of follow-up and used an intention-to-treat analysis or had no more than 20% loss to follow-up. Interventions evaluated included individual and group counseling, telephone calls, written motivational materials, and supervised and unsupervised exercise. Some weaknesses of the studies are that many of the studies did not consider current activity levels, while others did not report the type of activity that was performed.
Researchers found no increased incidence of exercise-related cardiac problems or musculoskeletal injuries in the study participants. The authors concluded that future studies are needed to detail the components of physical activity counseling.