ENDURANCE AND SPORTS MEDICINE The Journal of the International Institute for Race Medicine

VOLUME 3, NUMBER 2 SUMMER 2019 In this Issue: n Understanding Special Concerns of the Para Athlete n Mental Health Volunteers at the n History of the Rock ‘n’ Roll Marathon Series n Highlights of the IIRM-IAAF Boston Conference Endurance and Sports Medicine FOUNDER William O. Roberts, MD IIRM NEWS EXECUTIVE BOARD New and Improved Website Stuart Weiss, MD, Board Chair George Chiampas, DO e are happy to announce a “new and improved” IIRM John Cianca, MD website will be launched on August 21st. The revised site Cathy Fieseler, MD will have easy-to-follow menu options, including simple Mark Harrast, MD W Pierre d’Hemecourt, MD access to member-only resources such as video lectures, Matthias Krüll, MD medical forms and guidelines for endurance events, and the 92- P.Z. Pearce, MD page “IIRM Medical Care Manual.” Over time we will be adding William O. Roberts, MD more video lectures and, as mentioned, in our fundraising Martin Schwellnus, MD Sanjay Sharma, MD campaign (see back cover), we are also hoping to add distance- Ui May Tan, MD learning opportunities for medical professionals and educational Fumihiro Yamasawa, MD information for runners. If you have comments regarding the website and its content, please contact us at membership@ ADVISORY BOARD racemedicine.org. We always welcome your feedback! Douglas J. Casa, PhD, ATC Rob Galloway, MD Timothy Good Run the Marine Corps Marathon! Dave McGillivray Francis G. O’Connor, MD, MPH here are just a few IIRM charity race entries remaining Matthew D. Sedgley, MD for the October 27th Marine Corps Marathon. These are Tbeing offered through a special travel package managed RESEARCH BOARD by Destination . “Race entry only” options are also Aaron L. Baggish, MD available for runners who are local to the DC area and do Sam Cheuvront, PhD, RD Kourtney Kipps, MD (continued on page9) Anthony Luke, MD Daniel E. Lieberman, PhD Stephen Mears, PhD

EXECUTIVE DIRECTOR Chris Troyanos, ATC

EDITOR-IN-CHIEF Cathy Fieseler, MD CONTENTS

MANAGING EDITOR Barbara Baldwin, MPH Letter from Leadership • 3 Chris Troyanos, ATC JOURNAL COMMITTEE* EDITORIAL ADVISORY BOARD° Para Athletic Injury and Illness Consideration for Race Day Planning • 5 Barbara Baldwin, MPH* David J. Cormier, DO, DPT Nancy Clark, MS, RD° Cathy Fieseler, MD* The Medical Psychology Program • 10 Pierre d’Hemecourt, MD*° Daniel E. Lieberman, PhD*° John Ardizzone, PhD Stephen Mears, PhD* Thomas C. Michaud, DC° The Rock ‘n’ Roll Medicine Show • 14 Fred L. Miller, III, PhD* P.Z. Pearce, MD William O. Roberts, MD*° Martin Schwellnus, MD* Rain, Wind and Overuse Injuries: A Recap of the Interprofessional Management of GRAPHIC DESIGN Fritz Partlow Design Endurance Medicine Conference – Boston, April 2019 • 18 Daniel J. Friedman The mission of the International Institute for Race Medicine (IIRM) is to promote the health and safety Participation Requested for CRN Race Day Medical Event Study • 20 of athletes participating in endurance events through education, research, and the development of medical best practices. Follow the IIRM on Social Media Opinions expressed in Endurance and Sports Medicine are not necessarily endorsed by the IIRM. Address editorial, membership, and advertising information to Barbara Baldwin, MPH, IIRM (Satellite Office), 14520 Clopper Road, Boyds, MD 20841, Email: [email protected], TEL: 240-271-1657, racemedicine.org. LETTER FROM LEADERSHIP

Dear IIRM Members and Friends: he IIRM has seen much growth in the past year and, with your support, looks forward to continuing this forward momentum. TAs mentioned in the spring 2019 issue of Endurance and Sports Medicine, the IIRM and International Association of Athletics Federations (IAAF) signed a Memorandum of Understanding through which we will jointly develop training courses and educational seminars over the next two years for medical directors of endurance races and other health care professionals who have an interest in endurance medicine. These will be internationally focused, with courses in the U.S., Tokyo, Doha, Valencia, and Singapore (see the back cover for the calendar of events). I was delighted to present at our first IIRM-IAAF jointly held international conference on July 20th in Tokyo. IIRM Executive Board Member Fumihiro Yamasawa, MD, PhD and Yuri Hosokawa, PhD, ATC, IIRM Ambassador (), also presented at the conference. On October 5th, IIRM Member Rebecca Breslow, MD, will help instruct the workshops being held in Doha, State of Qatar, and on November 9th, IIRM Executive Board Member John Cianca, MD, will present at the conference in Valencia, Spain.

Through our partnership with the IAAF we have Yuri Hosokawa, PhD, ATC, leads a workshop on managing exercise-associated heat stroke at the been working closely with Dr. Paolo Emilio Adami, the IAAF Health IAAF-IIRM Emergency Race Medicine Workshop and Science Department Medical Manager. In addition to being a in Tokyo. well-respected sports medicine physician and advocate for providing optimal care for participants of athletic events, Dr. Adami has also become a good friend of the IIRM. We feel fortunate to be collaborating with him to provide worldwide education to health care providers.

We also have had a partnership with the Association of International Marathons and Distance Races (AIMS) since 2015. They help to promote our organization and we have been involved in three of their World Congresses, where IIRM speakers have presented on topics of endurance medicine. Starting in September, we will be contributing to the AIMS quarterly magazine Distance Running by reprising classic Running & FitNews articles (from the former American Running Association). We hope to also add some of these articles to the IIRM website when we develop a runners’ portal.

In regards to the IIRM website, we have been working with our web developers to re-do the look of the site and make it easier to navigate. Our eventual goal is to add more educational content, the runners’ portal included, and increase the number of video presentations from medical conferences. We would also like to develop a distance learning platform. Unfortunately, these endeavors require funding beyond our means. Therefore, we have initiated an online fundraising campaign.

Endurance and Sports Medicine • Summer 2019 3 Some of you may have seen the IIRM fundraiser “Saving the Lives of Endurance Race Participants” on our FaceBook page, or you received an email message announcing the fundraising campaign. Individuals can make donations to the fundraiser on the IIRM FaceBook page or by going to racemedicine.org and clicking on the “Donations” icon on our home page (which links to the IIRM fundraising campaign on imATHLETE). We hope you will consider sharing one or both of these donation pages with your fellow runners and/or colleagues. Having multiple IIRM supporters spread the message is key to our fundraising success!

In April, I was one of just over 15 individuals who convened at the Consortium for Military and Health Performance (CHAMP) in Bethesda, Maryland, to review recommended medical algorithms for managing emergencies in mass participation running events. I was honored to represent the IIRM as we dissected and revised protocols for up to 13 medical conditions including exercise-associated collapse, cardiac care, chest pain, hyperthermia, hyponatremia, and hypoglycemia. We are still carefully working through these revisions, as they are Francis O’Connor, MD, MPH, leads a discussion on algorithm revisions for managing exercise- extensive and we want to be thorough. The new algorithms will be associated collapse with race medicine experts unveiled at our Marine Corps Marathon endurance medicine conference including COL Anthony Beutler, MD (left) and on October 26th in a lecture presented by IIRM Advisory Board Member LTC Chad Hulsopple, DO. Francis G. O’Connor, MD, MPH, the chairperson of this revision endeavor. It is our goal to then share these algorithms with races around the world in our efforts to standardize medical care provided at endurance events.

So, as we push to continue this forward momentum, I must ask for your support. Members are an important part of any association— after all, you are our “base,” our foundation. Please consider renewing your IIRM membership when you receive expiration notices and, if you are involved in the management of endurance events, please share information about the IIRM Event Membership. We have developed a document explaining the benefits of the event membership and how it can be used to educate medical volunteers and event personnel. If you are interested in receiving the IIRM Event Membership outline, please contact us at [email protected].

Finally, we are always looking for feedback regarding our online materials and educational activities. Is there anything you’d like to see us add to the website? Do you have comments regarding our conferences? We gladly welcome your feedback! Please write to us at [email protected].

Best wishes,

Chris Troyanos, ATC IIRM Executive Director Endurance and Sports Medicine • Summer 2019 4 Para Athletic Injury and Illness Consideration for Race Day Planning By David J. Cormier, DO, DPT

Introduction Illness Epidemiology articipation in sports provides important life Incidence of illness from Rio demonstrated that lessons about teamwork, inclusion, work across all events the average was 10 illnesses Pethic, skill mastery, and health promotion. The per 1000 athlete days (2). Focusing specifically on International Paralympic Committee has embraced endurance racing, the para-athletic track and field these principles with the goal to “make for a more data, which includes marathon racing, reflects an inclusive society” and “increase inclusion by breaking illness incidence of 10.3 per 1000 athlete-days, down societal barriers and discrimination towards which is similar to the average for all Paralympics. people with an impairment.” One of the sports The data further showed that respiratory illness it embraces is endurance racing, for which para accounted for the highest rate of illness, followed by athletic participation has been steadily increasing skin infections, digestive, genitourinary, and other in recent years (1). But with such a sport comes the signs and symptoms (2). Illness by impairment was necessity for significant medical planning. Medical highest in athletes with spinal cord injury, followed providers, race directors, and coordinators must be by limb deficiency, then central neurologic injury, aware of injury and illness considerations for para and visual impairment. When comparing illness athletes so that the proper services are available to incidence data from Rio 2016 to London 2012, treat athletes of all levels. Indeed, one of the most the rate of illness was lower. Female and older important considerations in event planning should athletes were at an increased risk of illness. And be para athlete risk for injury and illness. Athletes at respiratory system, skin, and digestive systems every level tend to compete strenuously and will push were consistently the most affected (2). themselves past pain barriers in competition. But the risks inherent with such a mentality are thought In most cases, Paralympic athletes suffer the same to be greater in the para-athletic population than kinds of illnesses as other athletes. Nevertheless in the general population. And although emerging there are unique considerations for Paralympic data indicates similarities of illness and injury athletes, including urinary tract infections, skin in the para athlete and able-bodied athletes, the lesions and breakdown, and autonomic control. medical considerations will vary given the unique circumstances of each Paralympic athlete.

Photo credit: Kevin André

Endurance and Sports Medicine • Summer 2019 5 Genitourinary System pressure ulceration includes unloading the affected area. Contact dermatitis should be cleaned and the The genitourinary system is at risk due to neurogenic allergen removed. bladder. Classic symptoms (burning/foul smell) may not be present in the Paralympic athlete, but The changing environment can affect prosthetic spasticity and fatigue will occur. Spasticity is present fit. This is because as the temperature changes, when there is a velocity dependent force given to a the residual limb size and shape can undergo muscle at a joint as part of its range of motion, when changes that affect the fit of the prosthesis. If the feeling increased tone. Neurogenic bowel and bladder prosthesis does not fit properly, skin breakdown can management in patients with impaired function arise. Similar concerns arise with a hyperthermic includes sterile catheterizing. If a genitourinary environment because increased sweating can occur illness is suspected, it is appropriate to maintain in the prosthesis, affecting its fit and causing friction hydration and optimize the subject’s environment. that can result in skin breakdown. Referral to their provider for antibiotics may be necessary. Always note their antibiotic history upon Neurologic System referral. With any race or event planning, the lack of Neurologic impairment can result in poikilothermia. appropriate, accessible restroom facilities with areas This is the failure of the body to regulate its for catheterization care could impact athlete health. temperature. With neurologic impairment, the Integumentary System athlete’s thermoregulation would be impeded by limited afferent neural input from insensate Athletes with prosthesis are well versed in their regions and diminished efferent vasomotor and prosthesis management and typically have tailored sudomotor control below the lesion. As a result, fit running prosthesis. But even with appropriate sweat glands would be impaired (3,4). Altered fit and alignment, skin breakdown is a concern sweat patterns impair how the brain regulates as fit can change with temperature and sweating. body temperature and how the body adjusts. There are a variety of prosthesis types and the Athletes with this impairment have a higher risk fit will depend on the type. They are designed of hypothermia and hyperthermia (5). They will to fit on weight bearing tolerant areas and thus demonstrate the same symptoms that are normally weight bearing areas are most affected due to present including altered mental status, dry/ interface with the prosthesis. Most commonly for a clammy skin, extreme fatigue and exhaustion. below the knee amputee they will typically have a Treatment strategies are the same as for able- patellar tendon bearing socket. Prosthesis weight bodied athletes who have hypo or hyperthermia, bearing areas are the patella ligament, anterior though they respond well to external strategies as compartment (pretibial muscles), medial tibial flare their bodies tend to match the environment more. and medial shaft of the tibia, and lateral shaft of If the athlete is hyperthermic, cool the subject as the fibular. Pressure sensitive areas include the appropriate to prevent progression to heat-related tibial crest, tubercle and condyle, fibular head, illness and consequent ice water immersion. If hamstrings, tendons, and patella. If there is a break heat-related illness presents, don’t be afraid to be in the skin, the causative factors and treatments aggressive with management. The same principles vary. Bacterial infection should be considered and also apply for hypothermic situations: remove treated by topical or oral antibiotics. Viral infection wet clothing, provide warm, mylar blankets, and responds well to supportive care. Treatment for heaters as available.

Athletes with prosthesis are well versed in their prosthesis management and typically have tailored fit running prosthesis. But even with appropriate fit and alignment, skin breakdown is a concern as fit can change with temperature and sweating.

Endurance and Sports Medicine • Summer 2019 6 Recently the European Para Athletic Championships was held in Doha Qatar. A study by Grobler et al. demonstrated the effect of countermeasure planning strategies for a successful event. Heat Para Athletic Key Summary Points countermeasures consisted of: Illness 1. Increased shade covering at warm-up track, first 1. Respiratory illness is the most common call areas, and field waiting areas. illness among para athletes regardless of 2. Increased provision of ice and cold fluids to team whether the participation is in the winter or support staff at warm-up track and to field-based summer Paralympics. athletes on the field of play during competition time. 2. For weather-related considerations, para athletes will appropriately acclimatize, but 3. Provision of a dedicated official in the field reasonable accommodations should be event area to facilitate fluid intake and cooling considered. strategies of athletes. 3. Weather can cause skin-related changes for 4. Adaptation of technical rules to allow seated prosthesis fit, resulting in increased skin throwing athletes to complete all three throws at pathology and infections. a time instead of alternating throwing order, and to allow athletes staggered access to field events 4. Genitourinary infections with relation to decreasing sun exposure time. neurogenic bladders do not present with the typical symptomatology, they are more likely 5. Scheduling of endurance events to be held at night. to present with spasticity and fatigue. 6. Increased surveillance and education regarding 5. Autonomic dysreflexia is a true medical awareness by the team medical staff throughout emergency, seen in athletes with a T6 spinal the competition to determine heat tolerance of the cord injury or higher. Identification of the athletes. cause and treatment to correct it should be done urgently. Autonomic dysreflexia may be 7. Increased additional schedule breaks to limit sun induced for performance enhancement so exposure when necessary. screening could be considered.

The authors found that there were actually low levels Injury of heat-related illness which demonstrated the physiological resilience of this population to adverse 1. Shoulder injuries are the most common climatic conditions, the present findings perhaps injuries among para athletes. stand in contradiction to this belief. Only one case of 2. Para athletes are at risk for osteoporosis an athlete with spinal cord injury (SCI), considered and, therefore, with any race accident, a full most vulnerable to heat, has been reported (T52 screen needs to be completed to determine if classified competitor: good shoulder and upper body there are low energy fractures in areas that control, but lack of fine motor skills in arms and are insensate. hands). The majority of athletes with impairment adequately prepare and acclimatize. Individual para 3. Proper biomechanics are essential for para athlete acclimatization and the heat countermeasure athletes as part of their rehabilitation and strategies employed by the organizing committee training. were sufficient to adequately manage the risk of the 4. Cervical spine stabilization must be heat experienced in this Championship (6). maintained with any trauma and race chair extraction needs to be accomplished with an Cardiovascular System understanding of the harness system used. Autonomic Dysreflexia (AD) is the most emergent medical consideration in athletes with SCI at or above T6. This reaction is an imbalance of the sympathetic system with an abnormal reflex response leading to abnormal sympathetic discharge and potentially

Endurance and Sports Medicine • Summer 2019 7 catastrophic hypertension and cardiovascular Summer Paralympic Games saw the first death of response. If AD is induced it can increase blood an athlete in a Games setting, through head injury pressure and heart rate causing increased cardiac during competition (cycling), demonstrating the need output oxygen delivery to active musculature and to plan and consider catastrophic events with para enhanced performance (5). Important symptoms to athletics. Ongoing efforts toward planning for trauma be on the lookout for include elevated blood pressure, and acute catastrophic events at major international headache, goosebumps, and anxious behavior. The multisport competitions need to be augmented (7). initial treatment steps include removing noxious stimuli immediately which might include tight fitting Musculoskeletal System clothing, a strap that is stuck, a tack or pin, sticks or Many para athletes may ignore musculoskeletal rocks from the race course. The next most common injuries due to their complex medical history. emergent medical consideration is a full bladder, Sports medicine providers should encourage as there may have been environmental barriers for reporting and be aware of injury considerations appropriate catheterization. Lastly, check for any other for para athletics. Common shoulder etiologies stimuli and inquire if there was a crash with a possible are rotator cuff tendinopathy/impingement, broken bone, etc. Athletes with autonomic dysreflexia rotator cuff tear, glenohumeral labral tear, biceps will need to be monitored closely. Nitropaste should tendinopathy acromioclavicular joint osteoarthritis, be available for emergent use if necessary. If the and scapulothoracic dyskinesis. The majority of athlete does not improve within minutes of nitropaste syndromes (almost all) are overuse based in nature administration, then it is a true emergency and since “relative rest” is very difficult. transport to the hospital must be arranged. Para athletes who have specific positioning for their Injury Epidemiology race chair need to be appropriately trained with Injury considerations for the para athlete were also regards to how their biomechanics and posture will evaluated between the London and Rio summer affect their shoulder and cervical spine. Assess Paralympics, as well as the Sochi and Pyeongchang shoulder biomechanics during sports activity as Winter Paralympics. Overall there was an incidence many issues can be mitigated with improvement in rate of 8.4 per 1000 athlete days. The shoulder was fit and/or technique. Physicians should implement the most common with 1.8 injuries per 1000 athlete a program with a focus on stabilizing the scapular, days followed by the wrist, hand, and fingers at 1.3 pec minor stretching, restoring range of motion, and per 1000 athlete days, and rounding out the top three rotator cuff strengthening—particularly external was ankle, foot, and toes at 1.1 per 1000 athlete rotators if pain is recalcitrant. They should also days. Para athletes with the highest impairment consider physician referral for musculoskeletal risk were those with limb deficiency (32%), visual evaluation for consideration of ultrasound impartment (20%), and spinal cord injury (18%). evaluation and/or injection options (8). Key findings broken down into anatomical region Cervical spine is another important etiology. Most of injury demonstrated that ambulant athletes had common cervical spine etiologies include disc thigh, knee, lumbar spine, and leg injuries, while degeneration with or without herniation, facet- seated athletes had higher rates at the shoulder, mediated pain, and myofascial with scapulothoracic elbow, knee, and upper arm. Key findings included dyskinesis. Spinal stenosis, which has increased injury rates which were lower than those reported for prevalence in achondroplasia, and referred pain from the London 2012 Summer Paralympic Games. The the spine are often overlooked. This is a complicated sports of football 5-a-side, judo, and football 7-a-side picture in athletes with prior spinal instrumentation were themselves independent risk factors for injury. which can lead to hypermobility around fused Pre-competition injuries had a higher injury rate than segments leading to accelerated degeneration. competition period injuries. Injuries to the shoulder Several sports require high levels of muscle were the most common (7). One key point absent in endurance, for example: neck extension anti-gravity the epidemiologic study by Derman was the lack of in wheelchair racers. Rehabilitation should start concussions reported by the athletes and medical with a postural program. If a patient presents with staff in the survey, despite descriptions of several radicular pain and/or arm weakness, there should be incidents where athletes were observed to suffer a no return to play until full strength is recovered (8). blow to the head followed by unsteady gait. Rio 2016

Endurance and Sports Medicine • Summer 2019 8 Athletes who are wheelchair dependent and non- particular, ought to plan for these considerations for weight-bearing do not have appropriate bone health athletes of all levels. and are at risk for osteoporosis. High speed activity and fragile bones create a risk for injury. If there Dr. Cormier is a sports medicine physiatrist in New is a crash, one must consider a fracture and order Hampshire at Wentworth-Douglass Hospital (Dover) appropriate imaging even after minimal trauma. and Frisbie Memorial Hospital (Rochester). He is also Energy needs will vary by impairment. Unfortunately the head team physician for the University of New little is known about how this affects the para Hampshire Wildcats and the Northeast Passage/UNH athletes, besides general lower caloric needs for Sled Hockey Team. athletes with SCI or short stature and higher caloric REFERENCES needs for athletes with amputation or cerebral palsy with athetosis or dyskinesis (9). 1. Blauwet CA, Iezzoni LI. From the Paralympics to public health: increasing physical activity through legislative and policy Race chair extraction has special considerations initiatives. PM R. 2014;6(8 Suppl):S4–10. for which to be aware. Spine precautions should 2. Derman W, Schwellnus MP, Jordaan E, et al. Sport, sex and age increase risk of illness at the Rio 2016 Summer Paralympic be followed at all times; however, since the athlete Games: A prospective cohort study of 51 198 athlete days. Br J is tightly secured in the racing chair, all straps Sports Med. 2018;52(1):17–23. and securements must be released or cut. When 3. Dawson B, Bridle J, Lockwood RJ. Thermoregulation of extracting the athlete, it is in an up and outward paraplegic and able bodied men during prolonged exercise in diagonal motion. Athletes may be insensate in hot and cool climates. Paraplegia. 1994;32(12):860–870. their lower extremities and may not immediately 4. Phillips WT, Kiratli BJ, Sarkarati M, et al. Effect of spinal cord injury on the heart and cardiovascular fitness. Curr Probl notice traumatic injury to bone, skin or soft tissue. Cardiol. 1998;23(11):641–716. Therefore, a full lower extremity survey is required 5. Cruz S, Blauwet CA, Implications of altered autonomic control after trauma. Follow-up monitoring is recommended on sports performance in athletes with spinal cord injury. Auton for swelling and bruising as this may be the Neurosci. 2018;100-104. presentation of a fracture. For para athletes with SCI, 6. Grobler L, Derman W, Racinais S, Ngai ASH, van de Vliet P. the first sign of injury may be autonomic dysreflexia. Illness at a para athletics track and field world championships under hot and humid ambient conditions, PM R. 2019; Jan 28 [Epub ahead of print]. Conclusion 7. Derman W, Runciman P, Schwellnus M, et al. High Although there are many aspects to consider for the precompetition injury rate dominates the injury profile at the Rio 2016 Summer Paralympic Games: A prospective cohort study of para athlete, illness and injury are likely the most 51 198 athlete days. Br J Sports Med. 2018;52(1):24–31. important. Although the incidence of illness and 8. Dutton RA. Medical and musculoskeletal concerns for the injury is similar in paralympic versus able-bodied wheelchair athlete: A review of preventative strategies. Curr sport participants with respiratory illness and Sports Med Reports. 2019;18(1):9-16. shoulder injuries being the most common, certain 9. Blawuet CA, Brook EM, Tenforde AS, et al. Low energy unique considerations require additional preparation availability, menstrual dysfunction and low bone mineral density in individuals with a disability: Implications for the para athlete and training. As a field, endurance racing in population. Sports Med. 2017;47(9):1697-1708.

IIRM NEWS (continued from page 2) not need overnight accommodations. If you would the end of November and the spring/summer issue like to receive additional information about the race will be sent the end of June. Current and archived entries, please write to [email protected]. issues of the journal can also be found in the member-only area of the IIRM website. Journal Changes eginning in 2020, Endurance and Sports Medicine will be condensed to two issues per year. The Bfall/winter issue will be emailed to members

Endurance and Sports Medicine • Summer 2019 9 The Chicago Marathon Medical Psychology Program By John Ardizzone, PhD

The Need Typically, a private office, a hospital or a rehabilitation facility is where extended treatment n 2016, the Chicago Marathon established an is the norm. Research has shown that psychological integrated corps of mental health volunteers to treatments such as guided imagery, meditation, Iassist in medical services. This new group was compassionate conversation, and behavioral formed to respond to the established connections reshaping are beneficial in reducing both emotional between emotion, injury, and pain (1,2). and physical pain. However, these treatments An injury causes changes within the victim’s neural typically focus on long-term benefit and require time pathways, as well as cardiovascular, respiratory, and and patience. The immediate and short-term care muscular systems. For example, regulated beating of given to a runner in a marathon medical tent means the heart and the rhythmic flow of breath are altered that these methods must be modified. Sustained (3,4). Also, physical stressors bring physical pain (5). stress reduction is not the goal but, rather, lessened In intense situations, strong emotions unquestionably stress in the immediate situation. Reduced patient heighten the pain because “meaning” is often stress can lessen pain and help the treating attached to the occurrence. “This means I’ll never physician work more effectively. Unfortunately, there run again.” “This means I’ve failed.” “This means I’ve is still little research on tailoring these treatments let down the people who came to cheer my finish.” A to the unique challenges seen in a marathon. marathon is such a situation: it has high excitement The Medical Psychology Program for the Chicago and is physically draining with the culmination of Marathon was developed to address the unique prolonged and intense preparation. It is no wonder marathon situation that physicians and injured that an injured marathon runner attaches meaning runners encounter (11,12). For the Chicago Marathon, to injury, however unfounded it may be. The treating medical best practice is always the first goal but physicians may also feel stress if the patient cannot treatment can be challenging when physicians, be calmed in a reasonable way. attendees, and residents encounter injured runners The connection between emotion and pain is especially manifesting inconsolable crying, anxiety, worry, obvious in the marathon medical tent. Participants and/or anger. When a patient exhibits more acute range from first-time recreational runners to elite or psychological symptoms, physicians are challenged professional racers (6). For both types of athlete, an in a new way to manage the illogical, agitated person injury that results in being removed from the course so treatment can begin. may make the runner feel like a failure (7). For elites, Over time it became apparent that trained mental their ranking in the and health professionals were needed in the marathon their livelihoods may be in jeopardy. For others, the medical tent. George Chiampas, DO, the medical experience of failure may also feel acute (8). Removal director of the Chicago Marathon, in consultation from the course means they cannot return to the with the author, recognized that injured runners and race. After months of preparation, it is not surprising marathon physicians could both benefit by adding that the injury can be emotionally devastating: guilt relief of emotional stress to the physicians’ treatment for perceived lapses in training or nutrition, fear of in the medical tent. Professionals who were informed the loss of sport participation, depression, and/or and practiced in aiding distressed individuals would anxiety. In addition, there is often embarrassment at be helpful to have on hand, and this expanded disappointing the family and friends who have come medical treatment would provide fuller quality of to cheer their finish. Transferal to a busy, complex care. From that conversation, the Chicago Marathon medical tent may heighten the runner’s emotional Medical Psychology Program was born. response and further increase pain (9). Program Elements Clinical and sport psychologists practice methods can mitigate stress and pain (8,9); however, these 1. Careful screening of mental health volunteers methods typically focus on treatment over time (10). to determine whether their training in stress

Endurance and Sports Medicine • Summer 2019 10 reduction and their professional practice has of hydration, nutrients, and chemicals needed to prepared them for work in the main medical tents sustain the exertion of endurance running. It also and in strategic tents on the course. The pace of comes from the internal physical stress put on work and the numbers being treated require tight neural pathways, as well as muscular, ventricular, focus, the ability to shift attention quickly, and an and respiratory interrelated systems. As the understanding that the treating physician, not the physical systems are stressed by running, so is psychologist, is in charge. the emotional system. As noted earlier, when a runner leaves a race because of an injury, the 2. Mandatory two-hour psychological training to cover experience of failure, embarrassment, anger, abbreviated methods of stress reduction tailored anxiety, and depression are not simply “emotional,” for immediate care. and not simply the mind reacting in isolation. 3. Clarifying the work of the medical psychologist These feelings are an expression of the body volunteer, focusing on reducing patient stress breaking down. Emotional and physical suffering through brief, compassionate conversation, share similar neural pathways. The combined abbreviated sports pyschology, and brief mental physical, mental, and emotional stressors make it health treatments. Attention to the treating difficult to breathe, think clearly, or even to speak physician’s diagnosis and work is vital in order in a sustained pattern. The vast array of patients to respect the physiological substructure of the the doctor and the psychologist see may quickly patient’s behavior and to respect the patient’s switch from one who is anxious, to another who is underlying physical distress. sobbing, to another whose behavior is decidedly irrational. The volunteer’s work may, therefore, 4. Learning how to navigate the complexity of a switch from first helping a patient to then helping large medical tent. Meeting the physicians and a doctor who is bewildered by a runner angrily others prior to the race is important to make the resisting treatment. services our volunteers offer the medical staff more personal. The mental health volunteers 3. Appropriate stress reduction methods are reviewed. introduce other professionals to concepts about As licensed professionals, medical psychology underlying emotional factors often revealed in volunteers are already trained and comfortable patients’ behaviors. The conversations illustrate applying the standard psychological methods used appropriate scenarios to call upon the mental to lessen anxiety. However, many of the stress health volunteers. They explain their appropriate reduction methods they have learned are most place and their work at the injured runner’s cot. suitable for long-term use. Meditation, for example, is usually presented to a patient over successive Program Training sessions. Effective results are best seen over a period of time, a condition available in private The medical psychology training session for the therapy, rehabilitation, or in a hospital. volunteers, who are licensed professionals, includes the following: 1. A short presentation is given about the complexity The vast array of patients of the situations they will encounter. The variety of medical personnel and the numbers of the doctor and the people being treated simultaneously can seem psychologist see may intimidating to a mental health specialist who is quickly switch from more accustomed to working in a private office, seeing one person at a time. one who is anxious, to another who is sobbing, 2. Expectations of race day are reviewed. They are reminded about the type of patient they will see: to another whose a runner who started the day expecting to travel behavior is decidedly 26.2 miles on foot as fast as possible. They are also reminded that running a marathon is a irrational. grueling experience, taking a toll on both body and mind. Fatigue stems first from a depletion

Endurance and Sports Medicine • Summer 2019 11 4. Abbreviated techniques for anxiety reduction are assigned to small course medical tents from mile 7 taught to new volunteers. The medical psychology to mile 19. In a course tent there are a few medical group at the Chicago Marathon has adapted a variety staff and only three or four cots, not 80 as in the of methods verified in sports and clinical psychology main tent. The volunteer’s first job is to meet the studies and fitted them to the marathon situation. staff and explain their role in much the same way Pain and fear are usually what immediately occupy as their colleagues do in the main tents. They are the injured runner taken to a medical tent. In a busy expected to provide care without the complexity of situation, mental health treatment needs to be the main tent. That can be as simple as reassuring highly focused and brief. Mentally disturbed patients or refocusing the injured person, or preparing sometimes present a special challenge. Training them emotionally to being removed from the race addresses what to expect and how to handle and transported to a main tent or to a hospital. irrational, highly agitated individuals. These methods (Sometimes clinical, as well as sports psychology and situations are reviewed. skills, come into play more clearly when helping runners who may be only slightly injured or who 5. Volunteers are shown how to navigate the busy are simply fatigued.) conflux of medical students, attendees, and nurses in training who sometimes gather around 7. Volunteers engage in a series of role-plays to a patient’s cot, similar to that seen in a teaching practice mental health interactions in an urgent hospital. The team has learned over time that care situation. They answer questions and generate mental health professionals are best utilized if a common spirit for the work ahead. The training they are positioned quietly across the cot from sessions have been well-received, with the the treating physician. That placement means the participants enjoying camaraderie as well as the doctor does not have to look for a mental health opportunity to extend their knowledge and practice. volunteer while already busy in treatment, but can call upon them quickly. At the same time, the The Event psychology professional can directly observe even After the start of the race, before injured runners subtle signs of emotional distress and, with the arrive, Dr. Chiampas and other medical leaders speak physician’s nod of consent, offer assistance to the to the medical personnel to give them updates on runner. specific medical procedures and new equipment, 6. Volunteers learn how their work differs from main and to thank and encourage them. At that time, they medical tent workers. There are now 19 workers in out the availability of medical psychology volunteers, the medical psychology group. Most of them will be encouraging the medical personnel to make use of them.

There is often a long wait from the start of the race until the first injured runners arrive. During that time, while the medical staff are chatting in small groups, The team has learned the mental health providers go from group to group over time that mental to introduce themselves, talk about their role, and health professionals are explain how to contact them. They also address some common emotional reactions exhibited by runners best utilized if they are and the importance of reducing stress in order for the positioned quietly across physician to work effectively. The volunteers distribute the cot from the treating handouts that address how to lessen stress, as well as behaviors the physicians may encounter that indicate physician. a variety of underlying emotions. As the first injured runners arrive, mental health volunteers go to various points in the medical tent, ready to stand across from the doctor who is examining and treating, and ready to intervene if appropriate.

Over the past two years acceptance and appreciation of the medical psychology volunteers has grown as their contribution has been witnessed and understood. Endurance and Sports Medicine • Summer 2019 12 Two examples illustrate this development: medical pyschology program. In both the main medical tent and in the course tents, the volunteers Last year, at the Mile 19 tent, one of the runners have experienced personal enrichment and have stopped, slammed down his water bottle and appreciated the expansion of their personal and cursed loudly in frustration at his performance. professional understanding. They have been gratified “I’m done!” The medical personnel quickly backed to see the benefits of psychological intervention for away and looked at the mental health worker to the runner and to have been part of the advancement manage the case. The psychologist ignored the of medical practice at the Chicago Marathon. man’s loud angry voice, spoke to him with quiet reassurance for several minutes to calm him, Dr. Ardizzone founded and directed the neuropsychology and offered him a phone to call his family. After program at The Family Institute at Northwestern this, the runner was notably relieved and ran off University in Evanston, Illinois, where he taught to continue his race. The physician, with obvious “neuropsychological assessment” as a faculty member. relief, looked at the volunteer and smiled. He is now semi-retired, focusing on limited clinical practice and assessments of adult autism spectrum A more complex example follows: A 20-year- disorders. His publications include chapters in The old had been removed from the race by a tower School Psychologist and the Exceptional Child and spotter because he insisted on running without Affective Education for Special children and Youth. shoes. He refused to put on his shoes and would not lie down on the cot to be examined. REFERENCES The doctor couldn’t examine him standing 1. Milvy P (Ed.). The marathon: Physiological, medical, and couldn’t persuade him to lie down. The epidemiological, and psychological studies. Ann NY Acad Sci. young man said he needed to have his shoes 1977;301(1):958-1046. off and to stand because his feet needed to 2. Fallon K. (Ed). (2000) Marathon Medicine. London, England: touch the ground. The doctor then asked for an Royal Society of Medicine Press Ltd. intervention. 3. Brewer BW, Van Raalte JL, Linber, Darwin E. Role of the sport psychologist in treating injured athletes: A survey of sports After a brief conversation with the runner, I told medicine providers. J Appl Sport Psychol. 1991;3(2):83-90. the physician that the patient’s irrational behavior 4. Weinberg J. Understanding the psycho-emotional roots of seemed psychotic in nature. The doctor asked disease. Retrieved from https://chopra.com/articles. if the man should be transported to a hospital 5. Doral NM, Karlsson J. (Eds.) (2015) Sports Injuries: for psychiatric admission. I advised the doctor Prevention, Diagnosis, Treatment, and Rehabilitation, Second this was unnecessary because the man was Edition. New York, NY: Springer Publishing. not a danger to himself or others. The young 6. Nikolaidis PT, Rosemann T, Knechtle B. A brief review of person may have been diagnosed with a mental personality in marathon runners: The role of sex, age and disorder before entering the race. The physical performance level. Sports. 2018;6(3):99. and emotional stress of the marathon had led to 7. Buman MP, Omli JW, Giacobbi B, Brewer BW. Experiences and the psychotic symptoms we witnessed. Once he coping responses of “hitting the wall” for recreational marathon runners. J Appl Sport Psychol. 2008;20(3),282-300. was quieted, I recommended he see a counselor upon returning home. I spoke to him again with 8. Brewer BW, Redmond CJ. (2017) Psychology of Sport Injury. Champaign, IL: Human Kinetics. the doctor by my side. Speaking in a kind, but authoritarian voice, I firmly told the man that 9. Greenspan M, Fitzsimmons P, Biddle S. Aspects of psychology in sports medicine. Br J Sp Med. 1991;25(4):178-180. I could not release him from the medical tent without shoes because of the danger of infection 10. Schwab LM, Pittsinger RR, Jingzhen,Y. Effectiveness of psychological intervention following sport injury. J Sport Health (I knew I had no authority to release anyone). Sci. 2012;1(2):71-79 Each time the runner resisted, I calmly repeated 11. Zinner C, Sperlich B (Eds.). (2016) Marathon Running: the same phrase as we talked about his fears. Physiology, Psychology, Nutrition and Training Aspects. In a short time his agitation was settled. The New York, NY: Springer Publishing. young man put on his shoes and lay down for 12. Brewer BW. Psychological applications in clinical sports an examination. The physician later said it was medicine: Current status and future directions. J Clin Psychol helpful to watch the interaction. Med Settings. 1998;5(1):91-102.

The mental health worker’s role has become clearer in the years since the inception of the

Endurance and Sports Medicine • Summer 2019 13 The Rock ‘n’ Roll Medicine Show By P.Z. Pearce, MD

o most race medical directors, the marathon is an exciting annual event. For me, it’s just Tanother hotel and a bunch of frequent flyer miles. I am the National Medical Director for the Rock ‘n’ Roll Marathon Series, with 20+ races in North and South America, Europe, and Asia. I thought it might be interesting to discuss the history of our medical program and how we are able to replicate it week after week in so many different cities.

The series originated in San Diego, with the first race being in June of 1998 (one that my wife and I ran). It was the brainchild of a small group of endurance athletes who decided to combine their love of music with a road race. There was a band every mile along the course and then a free concert at the end—hence, the name. After we finished the race, my wife and I sat on the grass in a small stadium and listened to Huey Lewis and the News play our favorite songs. The race was so popular that it soon was transplanted to Phoenix and then to Nashville, where it became the Country Music Marathon. From there, it continued to grow into the current series and in June of 2017, the company [Competitor Group] was purchased by the IRONMAN Corporation. Together, with its mountain bike series and other running events, it is now the largest endurance sports company in the world.

As a competitor in marathons and IRONMAN Where it all began—the San Diego Start Line by Balboa Park. races, in 1990, I was fortunate [?!?] enough to do the IRONMAN Triathlon World Championship in Director, I felt the need to enlist the services of Kona, Hawaii. The ‘Big Island,’ as it is called, had former American College of Sports Medicine a 50-bed community hospital and very limited President Bob Sallis, MD. He continues as Course medical resources. The original medical director, Chairman of the popular IRONMAN Sports Medicine Dr. Bob Laird, had the brilliant idea of ‘importing’ Conference, which is held in conjunction with physicians and nurses from the Mainland to attend our race. Many of the IIRM medical directors a conference and then help with the race. He have attended this conference and worked in our organized a small ‘field hospital,’ which may have medical tent. been the origin of the ‘treat on site’ philosophy now used at most major races. After many years volunteering at Ironman, I was asked by Graham Frasier, of the licensee IRONMAN I returned the following year to volunteer and North America, to help organize races across the attended the conference, for which Dr. Bob Bethel U.S. These included Providence, Boise, Phoenix, brought in speakers from all over the world. Soon Louisville, and Couer d’Alene. When he sold the I, too, was lecturing and when Dr. Bethel retired, interest to World Triathlon Corporation [current I helped Dr. Warren Scott with the program. With owner/operator of most IRONMAN events], I increasing responsibility for organizing the event continued with my volunteer duties in Kona. medical care and a new title of Assistant Medical

Endurance and Sports Medicine • Summer 2019 14 The original medical program for Rock ‘n’ Roll was what is known as a minimalist program—any athlete that did not improve within a certain amount of time was transported to the hospital. They called it the ‘20-minute rule.’ It was felt to be dangerous to treat anyone on-site, so 60 to 70 ‘sick’ athletes would often be dumped on a local emergency room Sunday morning, when they were not staffed for the event. What the early Ironman did out of necessity, later events adopted as a ‘good neighbor policy’ to not overwhelm the local medical system. It was and still is the right thing to do.

St. Louis 2011 Rock ‘n’ Roll was exploring a new approach to medical care and asked me to set it up the way I would do it. I recall that during the race, our CEO and one of the VPs came to Main Medical to see how things were going. Just then, they wheeled in an elderly athlete who had collapsed. I calmly triaged him to one of our ‘pods’ and they then began taking vital signs and getting labwork. Although our CEO didn’t tell me at the time, they left thinking, “Is he crazy? This guy should be on his way to a hospital!” They came back an hour later, when the gentleman was sitting up on the cot and talking on his cell phone. They asked if that was the same Drs. Bob Laird and P.Z. Pearce (right) transporting a collapsed athlete at the guy they saw being wheeled in an hour ago. When IRONMAN Triathlon World Championship. I responded, “Yeah, that’s what we do…,” my future with the company was cemented.

I have subsequently found it interesting that with over 50% women and 30 to 40% novices, we see Cardiac Arrest Location the same general types and volume of medical problems as the other major races. What really surprises me is in regard to cardiac arrest. I would have thought that with so many New Year’s Resolution runners (who may or may not train at all), we would have much higher rates; however, they are similar to the well-known study published in 2012 by Kim, et al (1). In my eight years, with roughly four million runners, we have had 30 cardiac arrests. The most significant difference in our data is the number of survivors—24 (80%). God must be a fan of Rock ‘n’ Roll music!

So how have we managed to establish this program successfully in so many different cities, dragging all of our stuff with us? Basically, over many years and hundreds of races, we have become very efficient Our data is very similar to that of Dr. Bill Roberts, at the Twin at calculating the essential numbers of equipment, Cities Marathon. supplies, and personnel needed for any given event. In our Captain’s Manual and pre-race webinar to orient the volunteers, I point out that, “We may not have everything you want to treat our athletes, but

Endurance and Sports Medicine • Summer 2019 15 we do have everything you need.” Our fleet of trucks went out on the runway at Chicago’s Midway Airport and a crew of ‘roadies’ transport the ‘hard goods,’ when we were waiting to take off on a flight to such as tents, cots, IV supplies, and our medical Philadelphia. My Medical Manager, Liz Beck, had cases. The medications and sensitive electronics, fallen asleep in the seat beside me. We were stuck such as our iSTAT, travel with me. We hire Advanced on the tarmac for well over an hour while the lights Life Support [ALS] ambulances ‘in market’ for flickered on and off. Finally the pilot gave up and monitor-defibrillators, intubation equipment, and the taxied back to the terminal, explaining that no one medications which are expensive, expire, and don’t was taking off that evening. Liz woke up as the travel well. (It can be 140 degrees Fahrenheit and, jetway was being positioned and asked, “Wow, are conversely, below zero in our trailers.) we here already?” I’ve enjoyed my eight years as Medical Director for the Rock ‘n’ Roll Marathon I’m not going to bore you with the ‘nuts and bolts’ Series and hope to have many more….before the of how to assemble a medical program but, briefly, lights go out on my runway. Rock on! we have a medical tent (with AED) every-other mile along the course beginning at mile two, alternating Dr. P.Z. Pearce is the founder of CHAMPIONS Sports with an ALS ambulance on the odd-numbered miles. Medicine in Spokane, Washington, and Associate For volunteer medical staff, we use the ‘trickle Professor of Clinical Medicine for the University of down’ method of recruiting. I appoint a local medical Washington. He is National Medical Director of the director, who then identifies individuals as station Rock ‘n’ Roll Marathon Series, and serves on the captions. These captains recruit the staff for their Board of Directors for the IIRM. Past positions include tents. We ease the burden on our volunteer director Medical Director of the Bloomsday Run and IRONMAN by arranging all of the logistics, such as permits, 70.3 Hawaii, and Assistant Medical Director of the securing ambulance services, and developing a local IRONMAN Triathlon World Championship in Kona, 911 system for communication. Hawaii. He is team physician for the Spokane Chiefs Hockey Club and USA Triathlon. He also worked for the I’ve had many funny experiences during my career Seattle Seahawks of the NFL and was a member of the with Rock ‘n’ Roll, so many that I’ve thought about 1996 U.S. Olympic Medical Staff in Atlanta. writing a book. I remember the time a waitress in Dallas told me her other job was as a pharmacist REFERENCES and she ‘helped people,’ if I knew what she meant. 1. Kim JA, Malhotra R, Chiampus G, et al. Cardiac arrest during She quit trying to sell me meth when I asked one long-distance running races. N Engl J Med. 2012;366:130-40. of our crew how his job with the Texas Rangers was going. I also remember when all of the lights

Medical Emergency at a 5K: Two Perspectives

From the Medical Director: CPR and Liz brought the AED out of the tent. She then ran to get the paramedics, who were stationed “Medical!” Liz [Elizabeth Beck, our medical half-a-block away (after all, nothing happens at a manager] and I were mindlessly answering emails 5K). An off-duty firefighter asked if he could help, on our phones when the announcer made that call. so while I did compressions, he set up the AED. “Nothing ever happens at a 5K,” I told myself as Ours are refurbished Seattle Fire Department units I exited the finish line tent. I saw a middle-aged and they allow you to see the rhythm. It showed a woman lying face down on the street, about 50 feet coarse V-fib, so we shocked her. Things happened from the finish line itself, and thought about how fairly quickly then; I believe we got a rhythm after many times I have lectured to residents about such one shock. She moaned and started breathing again, an occurrence—when athletes collapse short of the then the paramedics arrived and started an IV. finish line, it’s never good. A nurse was kneeling Ultimately she was resuscitated and ‘packaged’ for beside her and I asked if she had a pulse. She didn’t transport to the hospital. know, so I rolled her over and…no pulse! I started (continued on page 17)

Endurance and Sports Medicine • Summer 2019 16 (continued from page 16) The funniest part of the whole incident involved the collapsed walker’s sister. Initially she was kneeling beside me pleading, “Don’t let my sister die!” No pressure there. Once it was obvious she was alive, the sister grabbed her running shoes with the timing tag and carried them across the finish line. That way she would ‘officially’ finish the race!

From the Race Participant: At 8:00 am on October 15, 2016, Gloria Stukenbroeker and her older sister Lisa began the Rock ‘n Roll St. Louis 5K as walkers. Gloria, who was age 57 at the time, had been regularly walking as part of her goal to lose weight and combat her family history of heart disease. Both her parents died of cardiac arrest at age 75 and her youngest brother died from aortic dissection at age 50, although he also had contributing factors such as being a smoker, having untreated high blood pressure, and being an avid drinker of Mountain Dew. He was also obese. “My brother’s sudden death was a wake-up call to focus on my own weight and health,” said Gloria.

Fast forward to the finish line of the 5K and, as P.Z. recounted, Gloria collapsed immediately prior to the end of the race. “I felt light headed and the next Gloria with her husband Jim and P.Z. at the June 2nd San Diego 5K. thing I remember I was lying on the ground with a bunch of medical people around me,” recalled Gloria. She was then transported to the local and as she headed back to her office at Washington emergency room where she was treated for not only University in St. Louis, she felt light-headed. She the cardiac condition but also injuries from her fall— sat down to recover but lost consciousness. Her ICD multiple skull fractures (forehead, cheek, and chin), then kicked in….twice. A hospital admission, cardiac a head laceration which required multiple stitches, stress test—which ended with Gloria going into and a brain hemorrhage. She was admitted to the v-tach—then a cardiac catherization revealed she neurologic ICU for observation for two days until had an 85 percent blockage in her right coronary the brain hemorrhage finally resolved itself; she artery. She then received two stents and spent was then admitted to cardiac ICU and put through another five days in the hospital. testing to try to determine the cause of cardiac arrest. After a couple of days of inconclusive testing, Although it appears the “universe” is telling Gloria a cardioverter-defibrillator (ICD) was implanted and to give up on her goals, she is not a quitter. Recently, Gloria was released. “P.Z. and Liz visited me while I she and her husband flew to California to participate was in the hospital,” she commented, with obvious in the Rock ‘n’ Roll San Diego 5K held on June 2nd. appreciation of the care and support they provided. They successfully walked the course and finished without incident, and were also able to reunite with Gloria has continued to stay active, walking two to P.Z., who was there to manage the medical care at three miles every day, and in 2017 she joined Weight the race. She also participated in another 5K on Watchers to focus even more on her weight loss June 16th with the GO St. Louis fitness group. goals (she lost an impressive 50 lbs). However, she still has been plagued with cardiac issues. In April 2019, she participated in another 5K walk after work

Endurance and Sports Medicine • Summer 2019 17 Rain, Wind and Overuse Injuries: A Recap of the Interprofessional Management of Endurance Medicine Conference – Boston, April 2019 By Daniel J. Friedman

s part of the IIRM-IAAF 2019 Endurance Medicine Conference Series, the Interprofessional AManagement of Endurance Medicine conference was held on April 13, 2019, at Northeastern University in Boston. Eager to refresh knowledge and clinical skills of mass-participation endurance events in the lead up to the 123rd Boston Marathon being held two days later, close to 150 delegates attended the conference and workshops.

As a consequence of the chaos of last year’s Boston Marathon due to gruelling weather conditions, much of the conversation during the conference focused on the weather forecast. A predicted marathon day of all four seasons gave delegates even more reason to learn about the effects of the extremes of heat, cold, and everything in between, to ensure the safety of the 33,000 runners set to cross the finish line.

In front of a full auditorium of doctors, nurses, physical therapists and athletic trainers, renowned sports medicine cardiologist Paul D. Thompson, MD, After leading a workshop on how to effectively use ultrasound started proceedings by presenting a series of short in the medical tent, Pierre d’Hemecourt, MD, treated injuries case studies that explored differential diagnoses on Marathon Monday using the diagnostic tool. of collapse in athletes. Dr. Thompson emphasized the importance of looking beyond cardiovascular aetiology and engaged the audience as they year?” Of course, the aetiology of these injuries attempted to diagnose each incidence of collapse. is multifactorial—resulting from a combination of dosage, structure, and mechanics. However, one Testing delegates’ knowledge of Long QT syndrome, tangible change in recent decades is the footwear exercise-associated collapse and “athletic swoon we use. Modern running shoes have become syndrome,” Dr. Thompson highlighted athletes increasingly cushioned and supportive, and have may collapse before, during or after activity from altered our footstrike pattern from a predominantly many possible causes. The clinician’s first priority forefoot to rearfoot strike. Dr. Davis explained is to determine whether the collapse is likely life- that this change alters the way in which forces threatening or benign. In the setting of endurance are transmitted throughout the body and may be events, always start by ruling out cardiac arrest, contributing to the high rate of injuries today. exertional heat stroke, and exercise-associated hyponatraemia before considering other causes. With mechanics in mind, Dr. Davis stressed that the key to preventing running injuries is correct Shifting the focus from diagnosis to prevention, alignment and soft landings. Faulty alignments biomechanist Irene Davis, PhD, PT, followed by that lead to increased risk of injury can be changed presenting on how we can optimize biomechanics through gait retraining, and those changes can to minimize running-related injuries. Dr. Davis indeed persist with commitment. Forefoot striking began her presentation by asking delegates “Why results in the softest landings, promotes stronger are up to 80% of runners getting injured every feet and calves, reduces knee loads, and is likely the

Endurance and Sports Medicine • Summer 2019 18 In keeping with the theme of overuse injuries, sports medicine physician Rebecca Breslow, MD, presented on increasing runner resilience and ability to tolerate training load in regards to stresses placed on the musculoskeletal system. Dr. Breslow discussed the mechanical fatigue model of overuse injuries—which postulates that repetitive loading of biological tissues without time for recovery results in damage accumulation and failure consistent with mechanical fatigue (4).

So how can we help runners prevent overuse injuries? Dr. Breslow recommended that we start by educating runners about injury prevention and rehabilitation, the importance of resistance training, and load management. We need to find each individual runner’s therapeutic window of load and consider the psychosocial factors that influence their Kathryn Ackerman, MD, MPH, leads a workshop on exertional performance and recovery every step of the way. hyponatremia, stressing the importance of not confusing symptoms with those of dehydration. The morning session concluded with a talk from Michele Weinstein, PT, ATC, who shared lessons learned as the Medical Coordinator for the Marine way we were adapted to run. However, converting to Corps Marathon and how they can be applied to a forefoot striking pattern in minimal shoes should other endurance events. be done gradually and be accompanied by lower The afternoon was divided into multiple workshops, body strengthening to minimize risk of injury during allowing delegates to rotate through different the transition (1).

Looking ahead to the Boston Marathon Wheelchair Division, physiatrist David Cormier, DO, DPT, presented about injuries and medical conditions commonly experienced by athletes with disabilities. Dr. Cormier explained that the majority of the sports medicine needs in athletes with disabilities are the same as with all athletes, with some exceptions. Clinicians must be vigilant for skin-related illness (e.g. pressure ulceration), disuse osteoporosis, and low-trauma fractures, genitourinary illness due to neurogenic bladder, and autonomic dysfunction.

According to data from previous Paralympic games, Paralympic athletes experience a greater proportion of injuries to the upper extremity, particularly the shoulder (2,3). The majority of injuries seen in Paralympic athletes are overuse in nature, as “relative rest” can be difficult for those who use their upper limbs for both daily Following the conference, key individuals from around the world observed how the BAA medical team manages exertional heat stroke. From left: Ray mobility and physical activity. These individuals are Bennett, RN (NYC Marathon); Lowell Greib, ND (Toronto Marathon); Linda Hart, predisposed to early-onset degenerative rotator cuff RN (Clinical Director, Event Health Management, Perth, ); Hugh Singe, MD (Managing Director, Event Health Management, Perth, Australia); Simone pathology, glenoid labral pathology, and subsequent Salzgar, PT ( Marathon), and Paolo Adami, MD (IAAF Health & Science osteoarthritis. [See Dr. Cormier’s article on para Department Medical Manager, Monaco). athletic injury and illness on page 5 of this journal.]

Endurance and Sports Medicine • Summer 2019 19 practical sessions to learn about massage, Medicine and Technical Advisor to the WHO, Daniel’s ultrasound, and EKG use in the medical tent. Sports interests span physical activity for public health, injury medicine physician Kathryn Ackerman, MD, MPH, prevention, and knowledge translation. discussed prevention, diagnosis, and treatment of exertional hyponatraemia, and revealed how mixed REFERENCES messaging has led to excessive fluid consumption 1. Davis IS, Rice HM, Wearing SC. Why forefoot striking in in endurance sport. Athletes should be advised to minimal shoes might positively change the course of running drink to thirst (5) and monitor their weight before injuries. J Sport Health Sci. 2017;6(2):154-61. and after activity to determine fluid status. Leaving 2. Willick SE, Webborn N, Emery C, et al. The epidemiology of delegates with an easy-to-remember rule of thumb, injuries at the London 2012 Paralympic Games. Br J Sports Med. Dr. Ackerman explained that hyponatremia presents 2013;47(7):426-32. late (think slower runners who drink more), while 3. Derman W, Runciman P, Schwellnus M, et al. High hyperthermia presents early (faster runners). precompetition injury rate dominates the injury profile at the Rio 2016 Summer Paralympic Games: A prospective cohort study of For more information about conferences held by the 51 198 athlete days. Br J Sports Med. 2018;52(1):24-31. IIRM and IAAF, see the back cover of this journal for 4. Edwards WB. Modeling overuse injuries in sport as a the “Calendar of Events” or go to “Medical Meetings” mechanical fatigue phenomenon. Exerc Sport Sci Rev. on the IIRM website at racemedicine.org. 2018;46(4):224-31. 5. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement Daniel Friedman is a final year medical student at of the 3rd International Exercise-Associated Hyponatremia Monash University in Melbourne, Australia. As an Consensus Development Conference, Carlsbad, California, 2015. Associate Editor for the British Journal of Sports Br J Sports Med. 2015;49(22):1432-46.

Participation Requested for CRN Race Day Medical Event Study Data collection will help key organizations learn more about medical incidents at races.

The American Medical Society for Sports the United States with a distance of 10K to 26.2 Medicine (AMSSM) Collaborative Research miles, please provide contact information at Network has partnered with the International https://goo.gl/forms/0E89sR4bOUR7iu6E2. Institute for Race Medicine to conduct a cross- sectional study of medical incidents at running Second, if you are a medical director/ road races in the United States. coordinator and the race recently took place, we encourage you to complete the full post- The goals of the study are to better describe the race survey about the race details and medical number and type of race day medical incidents incidents at http://j.mp/2Xtxnyg. at race events and evaluate the effect of weather and other race-related factors on the occurrence Participation in this study is voluntary and the of medical incidents. The results of this study results will be reported in aggregate so that no will help race organizers to determine the identifying information or specific race details appropriate medical needs in anticipation of race will be shared. day so as to be able to keep participants safe. For more information about this study, contact There are two primary ways to contribute to this AMSSM Co-PIs Brett Toresdahl, MD (toresdahlb@ study. First, if you or one of your colleagues is a hss.edu) or Stephanie Kliethermes, PhD medical director/coordinator for a road race in ([email protected]).

Endurance and Sports Medicine • Summer 2019 20 2019 CALENDAR OF EVENTS

July 20 IAAF-IIRM Emergency Race Medicine Workshop: Tokyo, Japan https://www.iaaf.org/about-iaaf/health-science

October 4-5 International Conference on Road Races in Urban and Extreme Environments - R2UE2 IAAF-IIRM Emergency Race Medicine Workshop: Doha, State of Qatar https://www.iaaf.org/about-iaaf/health-science

IIRM FUNDRAISING EFFORTS October 26 IIRM-IAAF 2019 Endurance Medicine Saving the Lives of Endurance Race Participants Conference Series: Washington, DC he IIRM is holding a fundraising campaign on MedStar Washington Hospital Center imATHLETE and on FaceBook (FB) to help support 110 Irving Street, NW Tits educational outreach to race and medical https://conta.cc/2Y422B3 directors worldwide (go to racemedicine.org and click on the “Donations” button). We are trying to impact November 9 them with live educational conferences/workshops IAAF-IIRM Emergency Race Medicine and with online learning to ensure that every health Workshop: Valencia, Spain care provider treating endurance race participants has https://www.iaaf.org/about-iaaf/health-science accurate medical information and guidelines. This, in turn, will improve the overall experience for the race November 28 participants while keeping them healthy and safe. Also, IAAF-IIRM Emergency Race Medicine if the IIRM is able to raise enough funds, we can further Workshop: Singapore City, Singapore expand our website to include educational information https://www.iaaf.org/about-iaaf/health-science for the endurance participant. If you have questions regarding the IIRM’s To meet these goals, the IIRM needs your help—please conferences, please contact IIRM Continuing consider donating or sharing the fundraising campaign Education Activity Coordinator Barbara Baldwin, on your FB page and/or other social media platforms. MPH, at [email protected] or call The FB campaign can only receive donations from 240-271-1657. individuals with FB accounts; however, anyone can donate to the fundraiser on imATHLETE.

If you have difficulty following the links above, please write to [email protected] to receive the links via email. Thank you for your support!

Research & Education Fund Olympian Patron Supporter The following IIRM members have contributed in 2019 ($250) ($175) ($125) Scott Clark James Culpepper Steve Coffman to the ongoing IIRM Research & Education Fund at Lawrence Frank Edmund Feuille the Olympian, Patron or Supporter level. To make a Steve Morrow*± Bill Snyder contribution to this fund, go to racemedicine.org and click on the “Donations” icon on the home page. The *Contributions surpass Olympian level following individuals contributed to the IIRM Research ± Life Member & Education Fund at the Olympian, Patron, or Supporter level from January 1, 2018 to March 1, 2019.

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