THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 5 - MAY 2021
Bethesda Conference Recommendations Cover New Ground
Clearance issues for patients who have cardiovascular conditions are some of the most difficult and sometimes contentious decisions that sports medicine physicians make, and since 120215 various iterations of the Bethesda Conference recommendations have played a vital role. To keep pace with how advances in the diagnosis and management of cardiac conditions might influence clearance decisions, physicians eagerly anticipate the release of new Bethesda recommendations, which occurred in March when the American College of Cardiology posted the document on its Web site1 in advance of the April 19th print publication in its journal.2
The consensus group for the 36th Bethesda Conference, which met in New Orleans in November 2021, didn't just address the clearance issues for each condition, they also provided guidance on a wide range of related topics such as preparticipation screening, the use of automated external defibrillators (AEDs), drugs and dietary supplements in sports, medicolegal considerations, and commotio cordis.
Staying a Safe Course
Though authors emphasize that the recommendations are intended for competitive trained athletes, they acknowledge that their consensus statement is often used to guide clearance for some recreational athletes and patients who work in physically demanding occupations such as firefighting.
Much of the report is evidence-based, but the authors state that in some instances, they had to make recommendations based on a lack of hard data. They note that the recommendations, which are not intended to be overly permissive or restrictive, should not be rigidly interpreted. "Indeed," they wrote, "the managing physician with particular knowledge regarding a given athlete's cardiovascular abnormality, psychological response to competition, and other medically relevant factors may choose to adopt somewhat different recommendations in selected individuals."
Barry J. Maron, MD, Bethesda conference chair and director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation, says that since the last recommendations were made in 1994, there has been a major evolution in the understanding of complex diseases, particularly long QT syndrome, other ion channelopathies, and hypertrophic cardiomyopathy (HCM). Despite the explosion of new information on diseases and genetic links, the new recommendations contain no radical departures, Maron says. "It's difficult to be anything but conservative. A patient's risk level unavoidably increases with competitive sports, he says.
Maron says the contemporary elements of new recommendations can be found in the expanded scope of the document, which covers topics and cardiac conditions, such as ventricular noncompaction, not previously discussed in other Bethesda documents.
Do Interventions Influence Clearance?
In their introduction to the document, the authors air their concerns about interventions that they say may provide a false sense of security to patients who have certain cardiac conditions:
Genetic Testing, Devices Change Landscape
Michael J. Ackerman, MD, PhD, a pediatric cardiologist at Mayo Clinic, Rochester, who cowrote some of the Bethesda recommendation chapters, says the writing of the new document raised complex issues that relate to postgenomics medicine for patients who have, for example, HCM. "We're recognizing that medicine is exposing or unmasking a greater portion of individuals and families that have positive genetic tests only, but do not manifest other disease features," says Ackerman, who directs the long QT syndrome and sudden death genomics labs at the Mayo Clinic in Rochester, Minnesota. "Do we levy the same uniform prohibitions in the growing cohort who are genetically positive, but are carriers only?" he asks.
Conservative activity recommendations are still in place for patients with long QT syndrome or HCM who have clinical disease. Activity is limited to low intensity sports such as billiards, bowling, cricket, golf, or riflery. However, the Bethesda recommendation authors have recognized the need to consider loosening activity restrictions for those who have the genetic disease with no manifestations. For this select but large group of patients, physicians are faced with balancing the cardiovascular risks of a sedentary lifestyle with the potential cardiac risks of activity.
Ackerman says the authors reached consensus on a conservative recommendation for patient's with cardiac conditions who have an ICD. The overall recommendation is that if a patient has a disease that would cause a Bethesda restriction or disqualification, prohibitions should continue, despite the presence of an ICD.
Risk Stratification Evolves
Christine Lawless, MD, a cardiologist at DuPage Medical Group in DuPage, Illinois, says she's happy to see such comprehensive new recommendations and that they've been needed for a long time. As a cardiologist who has done a fellowship in sports medicine, Lawless says that she has a great appreciation for the fine line that physicians tread when considering cardiac clearance decisions. "Past recommendations have focused on keeping athletes out of the game, but in sports medicine, the focus is on keeping the athlete in the game," says Lawless, who is a team physician for US Figure Skating.
Lawless says that even though the Bethesda recommendations have an overall conservative theme, she notes that the authors have stratified risks for some conditions, which may open up more sports participation opportunities for certain patients. She notes that the arrhythmia section is especially impressive, particularly where it specifies that patients who have genotype-positive/phenotype-negative long QT syndrome be allowed to play competitive sports. (Competitive swimming is still contraindicated for patients who have genotype-positive/phenotype-negative long QT syndrome type 1.) Lawless predicts that as more becomes known about individual cardiac conditions, such as dilated and restrictive cardiomyopathies, further risk stratification may provide more guidance about activity clearance.
Yoga Participation Surges
Contemporary yoga has become a popular recreational activity, although some styles bear little resemblance to the classical Indian forms that are associated with the Hindu religion. People from all walks of life and even some physicians are discovering the benefits of modern yoga. According to Yoga Journal, about 18 million people practiced yoga in 2021, up from 7 million in 192021.1
More health clubs and fitness centers are offering yoga classes in response to economic competition from many newly opened yoga centers, and some corporations are offering on-site yoga classes to employees as part of health and wellness programs. More patients are asking their physicians about doing yoga as a way of keeping fit, relieving stress, or recovering from sports-related injuries, and clinicians are likely to see more yoga-related injuries.
As a fitness activity, contemporary forms of yoga are difficult to assess. Howard G. Knuttgen, PhD, senior lecturer in the department of physical medicine and rehabilitation at Harvard Medical School in Boston, and professor emeritus of applied physiology at The Pennsylvania State University in University Park, says that physicians and their patients should be aware that the fitness benefits of yoga are unproven, and that they should tailor their expectations accordingly. "While there are reports in the literature of the efficacy of modern yoga to promote relaxation and provide relief from nervous tension, there is no research evidence of any contribution of modern yoga to the enhancement of either muscular strength or cardiovascular function," he says. Maintaining yoga postures constitutes very low-intensity physical activity compared with strength training or aerobic activity, Knuttgen says. A physical activity grading guide commonly used in exercise physiology research contains one yoga listing: hatha yoga, at 2.5 metabolic equivalents.2
In a press release from the American College of Sports Medicine, Roger Cole, PhD, cofounder of Synchrony Applied Health Sciences of Del Mar, California, and certified yoga instructor, emphasized that proper technique is essential for preventing injury during yoga practice. He said specific poses carry the risk of injury if performed incorrectly. For example, forcing the lotus position can damage cartilage in the knees, but participants learn to direct the force away from the knees to the hips. Knee and lower back injuries tend to be more serious, but the hamstrings, sacroiliac, neck, shoulders, wrists, and ankles are also prone to injury. Problems can be avoided if the poses are done correctly and participants don't try to force themselves into difficult postures, said Cole.
Styles of Yoga
About 20 different styles of contemporary yoga are practiced. Each style has its own attributes, and the wide variety of styles allows participants to match their needs and goals with the appropriate practice. Most of the styles are based on hatha yoga, a gentle style, which seeks to balance the opposing forces of yin (feminine) and yang (masculine), tension and relaxation, or breath (spiritual) and body (physical).
Hatha yoga uses body postures or poses (called asanas) and mindful breathing to develop muscular control, relaxation, and a feeling of wellness. Each posture is held for several breaths and can be adapted to suit the needs of the individual student. In forward bends, less flexible participants may reach for a knee or calf, while more flexible students doing the same pose may reach for an ankle or great toe. The upper-body poses may be done by participants in wheelchairs, frail elderly patients, or those too obese to pursue other forms of exercise.
Ashtanga and power yoga use a fast-paced sequence of postures that are done in a continual flow, similar to tai chi. Daryl Rosenbaum, MD, team physician at Western Carolina University in Cullowhee, North Carolina, became familiar with ashtanga and other yoga styles after his wife, a yoga instructor, convinced him to practice the activity. "For someone who is not already in reasonably good shape, this [ashtanga or power yoga] would not be a good choice for a beginning yoga experience," says Rosenbaum.
Viniyoga flows from pose to pose like ashtanga but is performed at a slower, gentler pace. The poses and flows are chosen with the student's needs in mind. Because viniyoga is done with slightly bent knees, this style places less stress on the knees and other joints. This style is often used in therapeutic environments and for beginners.
Iyengar yoga is also a good choice for beginners or patients who have significant physical limitations or injuries, says Philip Cohen, MD, an internal medicine and sports medicine specialist in Piscataway, New Jersey, who practices yoga. Iyengar yoga uses props to help less flexible students attain the postures and properly flex the spine. Students may hold on to the back of a chair to aid balance, use a strap to extend their reach when stretching, lie on a folded blanket for extra back support and cushioning, or lean on a solid foam block if they can't reach the floor while bending forward in standing postures. Each pose is held for more time than most other yoga styles to allow muscles adequate time to relax and lengthen.
Bikram yoga, or hot yoga, is a vigorous series of 26 poses that are performed in a room that is heated to 85° to 100°F (29.4° to 37.7°C). The hot environment is intended to warm and relax the muscles, ligaments, and tendons to promote stretching. Each pose is usually done twice in a fixed order, progressing from standing postures to back bends, forward bends, and twists.
Integral yoga was introduced to Westerners in 1966. This style gained attention in the 1990s, because Dean Ornish, MD, diet-book author and clinical professor of medicine at the University of California, San Francisco, uses it as a lifestyle intervention for heart patients. Control of the breath, sound vibration, and meditation are emphasized along with the postures in this practice.
Uses of Yoga
Although it may be hard to separate empiric observations from science, yoga has been studied as a therapeutic intervention for many conditions, including low-back pain.3 Randomized controlled studies evaluating yoga in the treatment of stress4 and multiple sclerosis5 have been published. A Cochrane review6 suggests that yoga is among the nonsurgical treatments that show significant short-term benefits for conservative treatment of patients who have carpal tunnel syndrome. The benefits attributed to yoga vary by style, and the results of a particular study may not apply to all styles of yoga.
In an informal query posted by THE PHYSICIAN AND SPORTSMEDICINE on the American Medical Society for Sports Medicine's e-mail listserv, many physicians responded that they advocate yoga for their patients because they have experienced its benefits firsthand. Katherine Dec, MD, is a sports medicine specialist and physiatrist in Richmond, Virginia, who learned about integration of breath and movement techniques while studying in Beijing. She practiced yoga during two pregnancies and has prescribed yoga for many medical issues, such as poor hamstring and hip flexibility, degenerative spine disease, neck and shoulder muscle strains, computer shoulder syndrome, eating disorders, ankle rehabilitation, back pain in pregnancy, and stress reduction for busy executives. As a former medical director for a local affiliate of the Mind/Body Medical Institute at Harvard, Dec saw yoga used for stress management among cancer patients. Dec treats some athletes who have eating disorders. "Yoga helps with a sense of self and with improved body awareness and appreciation," she says.
Karl (Bert) Fields, MD, a sports medicine physician and family physician in Greensboro, North Carolina, says that he found yoga very helpful after experiencing three ruptured disks and having fairly significant cervical spinal stenosis. He has been able to return to reasonably high-level tennis without experiencing neck or other spine-related pain. He enjoys doing yoga once a week, although he says he uses the term loosely, because he jokes that his skill level is never going to impress anyone.
Christopher Madden, MD, a sports medicine physician in Longmont, Colorado, says he does yoga four or five times a week for relaxation, meditation, flexibility, and core strengthening. He also relates that he uses some yoga breathing techniques and postures while exercising and briefly resting during the ultraendurance cycling events. He says, "It relaxes me, allows me to monitor breathing efficiency, and attenuates sore muscles and spasm."
Finding the Right Match
When addressing concerns about yoga, experts note that clinicians should ask questions about the patients' expectations. Do they have specific fitness expectations? Are they hoping to relieve stress or speed recovery from an injury? Are they comfortable with the more spiritual aspects of some practices? Cohen has encouraged some of his patients to try yoga. "I haven't found anyone who seems uncomfortable with the spiritual or philosophical approach found in yoga, but this may be due to selection bias; if the person isn't interested, they probably won't ask about yoga," he says. Dec says she has only had one patient in 10 years who was concerned about the philosophical tenets of yoga.
Physicians responding to the e-mail listserv query say a careful assessment of the patient's current physical condition will help determine the style of yoga that suits the patient's goals. Rosenbaum points out that "a hypertensive patient on a diuretic probably shouldn't be overexerting himself in a hot room, and an elderly female may not have the muscle tone or stability to hold the demanding poses of ashtanga or power yoga."
Cohen notes that continual emphasis on proper breathing prevents Valsalva breath holding, making yoga a relatively safe way for those with hypertension or heart conditions to pursue yoga as a means of exercise. Cohen also says he generally recommends physical therapy for chronic musculoskeletal conditions, "but if the patient has the time and resources to attend both yoga and physical therapy sessions, this is a great combination. Time, money, and insurance limitations don't always allow this." Fields notes that yoga classes in his area cost $7 to $8, making them cheaper than the insurance deductible for physical therapy.
Rosenbaum suggests saving the yoga prescription until after formal physical therapy rehabilitation has been completed. "This way, the patient has been helped through the painful phase and there has also been a chance to assess and address specific deficits or imbalances," he says. He prescribes yoga for trochanteric bursitis, iliotibial band syndrome, and muscle-related back and neck pain. Cohen says, "The fitness benefits along with the relaxation and focus that come with yoga practice make it an ideal adjunctive therapy for those with myofascial pain syndromes." He adds that yoga is a useful adjunct for treating osteoarthritis, improving posture, and preventing falls in the elderly.
Physicians who responded to the listserv query say one of the most important considerations for any yoga prescription is to know the training and reputation of the class instructor. They note that a good instructor emphasizes that students must listen to their own bodies and not push themselves to do postures that are beyond their own safety limits. Students should be able to recognize the difference between "sweet discomfort" and pain. Qualified instructors also watch for signs of competitiveness between students, so that no one is pushed to go beyond their safe limits. Small class size is important so that each student gets individualized attention, and teachers can watch for and correct technique errors before an injury occurs.
Dec says, "I know the yoga instructors that I send patients to. I have either taken a class with them, reviewed their training background, or observed their teaching style. If patients already have a yoga teacher, I will give them a note if there are any medical conditions that may preclude full participation, or mention possible bolsters or wedges (supports) for modification of postures."
Iyengar yoga requires a minimum of 3 years' practice and extensive training for certification as an instructor.7 Some other forms allow certification after only a weekend teacher seminar. There are no state or federal regulations for who can be certified as a yoga instructor, and each style has its own requirements. The Yoga Alliance (a nonprofit group based in Reading, Pennsylvania) has a voluntary registry for instructors who have completed a minimum of 200 hours of teacher training.
Physicians who are unfamiliar with the yoga resources available in their area can call local facilities or instructors to request details about the yoga classes offered. Reputable instructors are happy to answer questions about their training, personal philosophies, and teaching methods. Rosenbaum advises patients to scout out an instructor to see if he or she has a philosophy that fits with what the patient is comfortable with. If students stick with the same teacher for several classes, the instructor can get to know them and tailor the postures and instructions for their particular needs.
Videotapes and DVDs should not be a patient's only exposure to yoga training. Dec notes that beginners will benefit from having their technique reviewed by a qualified instructor or sports medicine physician and from having their questions answered personally. Ideally, patients who live in rural areas or where instruction is hard to find may use tapes as a way to continue their practice at home, after making the investment of attending a class. When using a tape, patients should be advised to seek advice from a physician if doing any posture hurts, says Dec.
Patricia D. Mees
Golfers' Yips: A Movement Disorder?
Researchers who have studied the yips—the twitches, staggers, jitters, and jerks that some golfers say interfere with their stroke—have suggested that the cause may range from anxiety to dystonia. A recent study by Mayo Clinic researchers has pinpointed that some cases of yips may be a task-specific movement disorder that is similar to writer's cramp or musician's cramp. The results of their study were presented in April at the annual meeting of the American Academy of Neurology (AAN).
According to an AAN press release on the study, the researchers examined 20 male golfers, 10 who said they had the yips and 10 controls. All were evaluated in the laboratory using surface electromyography (EMG) to gauge muscle activity. Participants were tested while sitting at rest, arms outstretched, and during handwriting; standing at rest; holding a putter at rest; and using their own putter to putt 75 strokes varying from 3 to 8 ft. The golfers rated the quality of their strokes, noting the number of putts made and the distance from the hole for missed putts.
Charles H. Adler, MD, PhD, a neurologist at Mayo Clinic, Scottsdale in Arizona, said none of the golfers exhibited abnormal movements in the rest position, the outstretched arms position, while writing, or while standing and holding the putter. Though only 2 golfers reported they had yips in the lab, EMG evidence showed that 50% of the yips group had co-contractions of the muscles in the forearm just before impact of the putter with the ball. "The co-contractions were similar to those of task-specific dystonia," Adler said. None of the control-group subjects exhibited co-contractions.
Researchers noticed a trend among the 5 golfers in the yips group who had EMG evidence of co-contractions: They were older, had higher current and best previous handicaps, and had yips for fewer years than the other 5 with yips who did not show cocontractions.
These recent findings follow up on a 2021 Mayo Clinic study that suggested that yips may exist on a continuum, with focal dystonia at one end, and performance anxiety at the other end. In an article on yips on the Mayo Clinic Web site (https://www.mayoclinic.com/invoke.cfm?id=SA00038), Aynsley Smith, PhD, director of sport psychology and sports medicine research at Mayo Clinic, Rochester, Minnesota, said some golfers may experience symptoms of both dystonia and performance anxiety.
Mayo sources said that research has not fleshed out which treatments work for yips. They suggested that patients who have yips be urged to contact a professional who can teach anxiety-lowering skills such as visualization, relaxation, positive thinking, or goal setting. Also, they note that using an alternate grip or putter has relieved yips in some golfers; this technique may ease muscle overuse. Antianxiety drugs haven't proven effective, but Mayo researchers hope to explore the role of beta-blockers.