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

VOLUME 3, NUMBER 3 FALL/WINTER 2019 In this Issue: n Lessons Learned from Experiencing Heat at the n A Running Coach Reflects on Working with Injured Runners n Revised Medical Algorithms Unveiled at Conference n Students Present Posters on Sports Medicine Topics n Nutrition Resources for the Medical Professional Endurance and Sports Medicine FOUNDER William O. Roberts, MD IIRM NEWS EXECUTIVE BOARD Special Offer for Individual Members Rebecca Breslow, MD George Chiampas, DO For a limited time, if you refer someone to the IIRM and he/ John Cianca, MD, Board Chair she signs up as an “Individual Member,” we will add six Pierre d’Hemecourt, MD months to your annual membership. When registering, the Cathy Fieseler, MD individual must answer the “referral question” for you to Matthias Krüll, MD receive credit. This offer expires on January 31, 2020. William O. Roberts, MD Martin Schwellnus, MD Matthew Sedgley, MD Sanjay Sharma, MD Ui May Tan, MD Stuart Weiss, MD Fumihiro Yamasawa, MD CONTENTS ADVISORY BOARD Letter from Leadership • 3 Paolo Emilio Adami, MD Douglas J. Casa, PhD, ATC John Cianca, MD Rob Galloway, MD Timothy Good Combatting Extreme Heat: 2012 • 5 Mark A. Harrast, MD Katerina Lin; Aaron L. Baggish, MD; Sophia Dyer, MD; Chris Troyanos, ATC; Dave McGillivray Pierre d’Hemecourt, MD; and Lyle J. Micheli, MD Francis G. O’Connor, MD, MPH P.Z. Pearce, MD Managing an Injured Runner: A Coach’s Perspective • 10 Catherine Ayoub, PT, DPT, MPH RESEARCH BOARD Kate Ackerman, MD Protocol Overhaul: An Opportunity to Review, Revise, and Reflect • 13 Aaron L. Baggish, MD Korin Hudson, MD and COL(R) Francis G. O’Connor, MD, MPH Sam Cheuvront, PhD, RD Maria Hopman, MD, PhD Ohio University Students Enjoy Learning Experience • 15 Kourtney Kipps, MD Daniel E. Lieberman, PhD Sports Nutrition Resources: Where to Look for Credible Information • 16 Anthony Luke, MD Nancy Clark, MS, RD, CSSD Stephen Mears, PhD Feeling the Pulse of the TCS • 18 EXECUTIVE DIRECTOR Chris Troyanos, ATC Brett G. Toresdahl, MD EDITOR-IN-CHIEF Cathy Fieseler, MD Book Review: The Durable Runner: A Guide to Injury-Free Running • 19 MANAGING EDITOR Barbara Baldwin, MPH Cathy Fieseler, MD

JOURNAL COMMITTEE Barbara Baldwin, MPH Follow the IIRM on Social Media Cathy Fieseler, MD Pierre d’Hemecourt, MD Daniel E. Lieberman, PhD Stephen Mears, PhD Fred L. Miller, III, PhD William O. Roberts, MD Martin Schwellnus, MD

EDITORIAL ADVISORY BOARD* Nancy Clark, MS, RD The mission of the International Institute for Race Medicine (IIRM) is to promote the health Thomas C. Michaud, DC and safety of athletes participating in endurance events through education, research, and the development of medical best practices. GRAPHIC DESIGN Fritz Partlow Design Opinions expressed in Endurance and Sports Medicine are not necessarily endorsed by the IIRM. *If you are interested in being considered for Address editorial, membership, and advertising information to Barbara Baldwin, MPH, the Editorial Advisory Board, please write to IIRM (Satellite Office), 14520 Clopper Road, Boyds, MD 20841, Email: [email protected], [email protected]. TEL: 240-271-1657, www.racemedicine.org. LETTER FROM LEADERSHIP

Dear IIRM Members and Friends:

am currently flying to Valencia, Spain, to serve as faculty for the -IIRM Race Emergency Medicine Workshop I(November 9th). I’ll be presenting on dehydration and hyponatremia. IIRM Advisory Board Member Douglas Casa, PhD, ATC, will also be part of the presenting faculty. This collaboration is a great example of how the IIRM is extending its reach to race medical directors and their medical teams, and ultimately race participants. It has been part of our organization’s mission since its inception, and this prompts me to reflect on our journey over the years.

As you may have previously learned, the American Road Race Medical Society (ARRMS) was formed in the late spring of 2003 at the annual meeting of the American College of Sports Medicine. At that time, Bill Roberts, MD, convened a group of interested medical professionals to discuss forming ARRMS. The group moved forward and affiliated with the American Running Association (ARA) which became the host organization. ARRMS then became a division of ARA alongside its professional division, the American Medical Athletic Association (AMAA). Based near Washington, DC, the ARA supported ARRMS through its early years.

At the inaugural meeting of ARRMS, held at the Chicago Marathon in October 2003, over 40 people Endurance medicine experts gather at the WORLD ATHLETICS-IIRM Race attended including members of the Association of Emergency Medicine Workshop in Valencia, Spain. Included from left are Frederic Gerrandes, PhD; Luis Cort, MD; Paolo Emilio Adami, MD; Patrick International and Distance Races (AIMS) Baset, MD; John Cianca, MD; and Luke Hodgson, MD. and the United States Association of Track and Field (USATF). Discussion focused on the need for a national registry of adverse medical events at road races as well as a unified depository of weather and participation data. Dr. Roberts also called for the need for education and proper preparation of marathon participants. And so our journey as an organization began.

Over the next several years ARRMS met regularly at marathons around the country and in 2012, transitioned to the World Road Race Medical Society (WRRMS) when it expanded its focus to include international races. We then incorporated the following goals into our organizational plan:

1. Promote the safety of endurance events through education of medical professionals, emergency management agencies, hospitals, event administrators, public safety agencies, and other professionals providing medical care at road races, triathlons, and charity walks.

2. Promote the sharing of information as it pertains to all medical aspects and concerns when preparing for athletic endurance events.

Endurance and Sports Medicine • Fall/Winter 2018 3 3. Promote research and improvements in clinical care for participants in road races and mass participation running events.

4. Develop collaborative relationships with public safety groups.

5. Establish reliable logistical matrixes that can be followed by events of all sizes.

6. Provide event safety recommendations to event medical teams and race administrators.

7. Establish liaisons to various groups, corporations and organizations that will assist with promotion of our mission.

Not too long after we expanded our international focus, key organizational leaders met with Tim Good of the Matthew Good Foundation and changed our name for the third—and hopefully final—time. We then became the International Institute for Race Medicine (IIRM). Through the support of the foundation, Tim helped us rebrand our website and with tremendous help from Loughborough University, we published the “IIRM Medical Care Manual.” This 91-page resource is available on the IIRM website for members (under Publications/Resources). Douglas Casa, PhD, ATC, (kneeling on right) leads a hands-on training lab on exertional heat stroke at the WORLD ATHLETICS-IIRM Race Emergency The last few years have been very busy for us with Medicine Workshop in Valencia, Spain. new affiliations and a renewed relationship with our first partner as we subsumed the membership of the American Medical Athletic Association and added AMAA Board President Cathy Fieseler, MD, to the IIRM Executive Board. To carry on a component of the AMAA mission, we maintained the Boston and Marine Corps Marathon conferences but have given them a slight adjustment. Each learning activity is now a one-day format consisting of didactic lectures and hands-on workshops.

As many of you know, we continue to work with AIMS and have had IIRM representatives present at their annual meetings, the most recent being Dr. Roberts who spoke at their meeting in Rio de Janeiro in 2016. We also formed a partnership with the World Athletics, formerly known as the International Association of Athletics Federation (IAAF). Through this partnership, we have been able to expand our educational efforts worldwide. To date, the IIRM with World Athletics have provided educational programs in Tokyo, ; Doha, Qatar; and as mentioned, Valencia, Spain. We are grateful for the opportunity to expand our educational efforts internationally.

On the horizon we are also exploring an affiliation with China and their vast suite of marathons. This will bring us much greater exposure and open up even more opportunities to educate race medicine professionals and endurance athletes.

I am now serving as IIRM chairman of the board; this is my second stint in the lead position of the organization. In this role, I will collaborate with IIRM board members to continue working toward goals outlined

Endurance and Sports Medicine • Fall/Winter 2018 4 in our mission and growing the organization. I would also like to work with members to be sure we are benefiting you, as well. Please contact me with any feedback you may have regarding our mission statement, educational programs and materials, the journal, our website, etc. It is important for us to hear from you to be sure we are on the right track! You can reach me at [email protected].

We have a few imperatives to achieve in the next one to three years. First and foremost, we must achieve financial sustainability. To date, we have relied on a patchwork of memberships, grants, and We currently have sponsorships. The former needs to become more robust. The latter visibility with many two are not reliable enough for us to build a sustainable organization. My first goal of this term as chairman will be to achieve financial marathons but also sustainability. I ask for the assistance from you—our members—in creating ideas and developing them into a reliable foundation for us to need to expand operate. Therefore, if you have ideas and/or leads for sponsorships, our reach to ultra- please write to me at the email address provided above. endurance venues, We also need to continue building our educational platform through the website, workshops, publications, and other “currently undeveloped” as well as smaller strategies. I would like us to build data into usable and publication- worthy research. I would also like us to develop position stands related races and other to the endurance runner. Perhaps, our first position stand might focus activities such as on acceptable/safe fluids and nutritional support available to runners participating in events. triathlons or charity

We currently have visibility with many marathons but also need to expand walks. All these our reach to ultra-endurance venues, as well as smaller races and other activities such as triathlons or charity walks. All these participants participants deserve deserve optimal care from knowledgeable medical providers. optimal care from As we continue this journey together, please help us work toward knowledgeable achieving the vision Dr. Roberts unveiled almost 17 years ago. We also need to support the exemplary leadership of IIRM Executive Director medical providers. Chris Troyanos, ATC, who has helped us grow leaps and bounds over the past few years. He is indispensable to the IIRM, as is Barbara Baldwin, MPH, our first and only employee. We would not be viable without them.

I am asking you to be part of the IIRM “team,” to help us search for answers through research and provide credible education to medical professionals and endurance athletes. We need to stay on course; we need to finish the race….and we need to do it as a team.

Best wishes,

John Cianca, MD IIRM Board Chair

Endurance and Sports Medicine • Fall/Winter 2018 5 Combatting Extreme Heat: Boston Marathon 2012 Excerpt from Mass Casualty Event Preparedness and Response: The Boston Marathon Experience Katerina Lin; Aaron L. Baggish, MD; Sophia Dyer, MD; Chris Troyanos, ATC; Pierre d’Hemecourt, MD; and Lyle J. Micheli, MD

times (24). In anticipation of the high projected The full manuscript is available at temperatures, the BAA made significant additions to racemedicine.org. It is located under race preparations. “Publications/Resources” in the pull-down menu “For All.” For the 2012 race, the BAA used its most recent experience with heat in 2004 as a model [it reached 86 degrees Fahrenheit at the finish line]. It knew that Preparations for an unusually warm 2012 Boston it must focus on efficient coordination of multiple Marathon began as early as December of the prior sectors and develop effective protocol for treating year when weather forecasts had predicted an heat-related illnesses. The BAA increased staff, extremely hot April 2012 (10). The most accurate medical coverage, and supplies on the course and and comprehensive prepared air-conditioned method to predict heat advanced tents, large illness is the wet bulb medical tents, and globe temperature busses. Caregivers were (WBGT) originally located at major stations, developed in the military. including Disaster This reading combines Medical Assistance the ambient temperature Teams, Medical Tent with the humidity and A, Medical Tent B, and the radiant heat. As April 23 Red Cross Stations. approached, the WBGT The BAA developed was predicted to be 73.4 specific protocols degrees Fahrenheit at to combat weather- the 10 AM Hopkinton related injuries and start, 80.6 degrees instructions to rapidly Fahrenheit between 2 cool runners suffering and 4 PM at the Wellesley from hyperthermia. midpoint, and 78.8 It recommended that degrees Fahrenheit at 6 caregivers take rectal Fire hydrants were turned on along the course in attempts to cool the PM at the Boston finish runners. Photo credit: Elliott Kawaoka temperatures, which are line. Excessive heat is one of the more accurate a concern for marathon indications of hyperthermia (27), and provide runners because it can be extremely dangerous cold water immersion for runners who reached to health. During a marathon, runners’ bodies temperatures over 104 degrees Fahrenheit and had are producing and dissipating excess metabolic altered mental states (10)—characteristics of heat heat from strenuous activity, potentially leading stroke, the most severe and potentially fatal form to dehydration, heat exhaustion, and stroke (19). of heat-induced illness (28). To increase adoption Hot, humid weather adds to body temperature, of these protocols, the BAA supplied hospitals with increasing the risk of health problems like thermometers, tubs, and ice. Secondary emergency exertional heat stroke (20). In prior marathon races, departments were alerted in case additional medical high heat has even led to death (21). Along with support beyond the prepared services was required. elevating risk of health issues, higher than optimal A dozen extra staff were readied at the Emergency temperatures impede running performance for male Department of Newton Wellesley Hospital, along and female runners of various abilities (22,23) and with another treatment area for more runners (26). lead to decreased running speeds (22), increased Additional variable message boards were set up to withdrawal rates (22), and slowed marathon winning better facilitate course communications.

Endurance and Sports Medicine • Fall/Winter 2018 6 Discarded water cups littered the ground as runners did their best to stay hydrated. Photo credit: Elliott Kawaoka

Public education was a crucial component of were high in the 80s with relative humidity of 40 to preparations for the extreme heat. In the days 50 percent, corresponded closely with the predicted before the race, the BAA notified runners of the heat. It reached 75 degrees Fahrenheit at the start projected extremely high temperatures and of the women’s race in the morning and 89 degrees informed them that they would continue to monitor Fahrenheit at Framingham in midday (25). The weather conditions. It encouraged runners who were race day’s harsh hot temperatures translated into not highly fit, not acclimated to running in warm high demand for medical care. Ultimately, the 2012 weather, or had underlying medical conditions like race saw a quadrupling of ice and water orders. cardiac or pulmonary disease to defer running to the The available patient records indicate that there following year (29). The BAA also offered waivers were nearly 1,600 medical visits during the 2012 for those that deferred. For runners who decided to Boston Marathon. The male to female ratio was brave the extreme heat, the BAA provided additional 2.1:1. Among the patients who had recorded age, the guidelines, such as running at slower paces, taking average age was 40.1 ± 6.4 years. frequent walking breaks, and prioritizing safety over speed. These warnings were displayed on multiple The heat was so overwhelming that many runners’ highly visible signs along the course. Runners were core temperatures rose above 104 degrees warned about health threats of under and over Fahrenheit. Many reached as high as 108 degrees hydration and were told how to recognize symptoms Fahrenheit. Overall, there were over 260 hospital of heat illness: headaches, dizziness, confusion, transports and 43 admissions. Remarkably, fatigue, nausea, and vomiting. The BAA lengthened even in this extremely hot weather, fatalities the official course time limit from the usual six were avoided. The records show that 16 patients hours to over seven hours so that runners had received full immersion protocol. However, this more time to complete the marathon on the hot race was underreported, and one Boston Marathon Co- day (3). Providing more options for runners in the Medical Director estimated approximately 41 ice 2012 race was crucial for preventing heat-related water immersions were performed altogether. illnesses in inexperienced runners (29). Of the The most common chief complaints included 26,655 people who registered for the race, 22,485 fainting/exhaustion/lightheadedness (44%), nausea/ started and had a 96.1% completion rate (30). vomiting (42%), and cramps (34%). The mental status On Marathon Monday, the National Weather Service was recorded as alert (1,376 cases), confused (40 reported that the actual weather conditions, which cases), and unresponsive (5 cases). The orders were

Endurance and Sports Medicine • Fall/Winter 2018 7 Over the years, the BAA forged strong working relationships with medical and public safety institutions on the regional and state levels. Cooperation between the BAA, public health, and safety leaders was integral to Boston’s ability to handle medical care in extreme heat. observation (46%), IVs (21%), wound care (7%), and records, regarding the disposition of the patients cooling (4%). Regarding treatments, 67% were given who were fully immersed, 56% were released, 31% oral fluids and 22% required IV fluids after having the required medical transport, and 6% were given sodium checked. Out of all the medical visits, 33% special instructions. were given water, 33% were given Gatorade, and 11% were given Bouillon cubes for mild hyponatremia. Lessons Learned from 2012 There were 373 patients who had their serum The decision to cancel a race is influenced by the local sodium levels measured. Out of these people, 8% recourses and the willingness of the community to had hyponatremia, 68% had normal sodium levels, respond to a much higher casualty rate. The 2007 and 24% had hypernatremia. Thirty-nine EKGs were Chicago Marathon was brought to a halt when the ordered. Out of all the medical encounters, 54% were temperature reached 88 degrees Fahrenheit that dehydrated, 22% had muscle cramps, 9% required resulted in a runner’s death (33). Boston’s ability to podiatry care, 5% had GI cramps, and 2% had host one of the largest marathons in the nation in hyperthermia. Out of all the medical encounters, 91% extreme weather conditions was due to the stellar were released, 3% required medical transport, and preparation coordinated by the BAA and medical and 1% required follow-up care. safety organizations. Over the years, the BAA forged To help combat the heat, select patients were strong working relationships with medical and public administered cold-water immersion therapy. This safety institutions on the regional and state levels. type of cryotherapy involves ice water immersion Cooperation between the BAA, public health, and safety (31). This is accomplished several ways. The cold- leaders was integral to Boston’s ability to handle water baths may be specially built for immersion medical care in extreme heat. Several conference calls or may consist of shallow water tubs filled with were coordinated by the BAA with all of the hospitals, ice (32). Alternative methods include the Marine emergency medical services, department of public Corps Marathon method whereby the athlete is health, and MEMA ensuring that all were prepared and placed on a cot overlying a large tub of ice water willing to participate. Carefully planned coordination that is constantly scooped over the body and limbs. with ten supporting hospitals facilitated swift Another novel method used along the course is transportation and treatment on race day. Secondary called the taco method. This involves placing the support from six outlying hospitals provided additional athlete on an impervious tarp with the edges held up assistance so that the main hospitals did not overload by a crew of at least four. Ice water is then poured from the influx of patients. Because of the BAA’s on the subject. Water less than 59 degrees Farenheit work with local hospitals, emergency departments is used. These methods started among elite athletes were familiar with and adopted BAA hyperthermia and are now more common among amateurs (32). protocols. This ensured that hospitals responded rapidly and consistently to the influx of marathon For the patients who received the full immersion patients suffering from high body temperatures. protocol, the chief complaints included nausea/ Educational programs for runners and staff prepared vomiting (50%), fainting/exhaustion/light- them to respond to the heat. Meetings hosted by headedness (44%), and cramps (31%). The most BAA physicians for local hospital staff ensured that common orders were IVs (13%), labs (13%), and medical personnel working on race day were up to observation (13%). Six patients had their serum date with the latest practices and hyperthermia and sodium levels measured. Five had normal sodium hyponatremia treatments. The BAA even delivered levels, and one had hypernatremia. The most ice and immersion tubs to emergency rooms. The common diagnoses were dehydration (38%), GI implementation of a runner deferment policy was cramps (13%), muscle cramps (6%), and exercise- instrumental to avoiding serious medical illness in associated collapse (6%). From the available inexperienced runners. Coordinated use of the press

Endurance and Sports Medicine • Fall/Winter 2018 8 to communicate information to prospective runners 24. Miller-Rushing AJ, Primack RB, Phillips N, Kaufmann RK. and spectators before and on race day guaranteed Effects of warming temperatures on winning times in the Boston marathon. PLoS One. 2012;7(9):e43579. that all received important updates about the heat and 25. History of the Boston Marathon. (2015). Weather conditions accommodations for the extreme weather. Electronic in recent years. Retrieved from: baa.org/races/boston- media used throughout race day allowed for efficient marathon/boston-marathon-history/weather-conditions.aspx. and streamlined communications systems. 26. Springer S, Johnson C. (2012, April 14). Marathon day temperatures are a hot topic: Marathon officials are preparing Marathons are planned mass casualty events, and for temperatures in mid-80s. The Boston Globe. organizing them requires the intersection of sports 27. Darowski A, Najim Z, Weinberg J, Guz A. The febrile response medicine and disaster preparation. Because of to mild infections in elderly hospital inpatients. Age Ageing. the large number of runners and spectators at the 1991;20(3):193-8. Boston Marathon, the marathon can very quickly 28. Howe AS, Boden BP. Heat-related illness in athletes. Am J Sports Med. 2007;35(8):1384-95. overwhelm resources of local health and EMS 29. Boston Athletic Association. Warm Weather Advisory: Notice providers. Extreme weather exacerbates the burden to All 2012 Boston Marathon Participants. Retrieved from: that the marathon places on local health systems. http://www.baa.org/news-and-press/news-listing/2012/april/ High heat increases risk of heat stroke and life warm-weather-advisory.aspx. threatening exercise-related illnesses and leads to 30. Boston Athletic Association. Boston Marathon Statistics increased demand of medical care and resources. 2012. Retrieved from: http://raceday.baa.org/2012/cf/public/ iframe_Statistics.htm. The 2012 Boston Marathon provided important 31. Diong J, Kamper SJ. Cold water immersion (cryotherapy) for lessons for preparing and coordinating medical care preventing muscle soreness after exercise. Br J Sports Med. in unusual weather conditions. Educating runners 2014;48(18):1388-9. and staff about extra precautionary measures and 32. Bleakley C, McDonough S, Gardner E, Baxter GD, et al. Cold- ensuring that cold-water immersion protocol was water immersion (cryotherapy) for preventing and treating rapidly initiated avoided unnecessary morbidity and muscle soreness after exercise. Cochrane Database Syst Rev. 2012;15(2):Cd008262. mortality on race day. Organizers of large-scale 33. Golen J. (2012, April 15). Boston Marathon 2012: Heat forces marathons should determine their ability to properly runners to adjust. The Associated Press. triage and treat patients without overloading the hospital and EMS systems. Cooperation with local *References are numbered according to the excerpt. The entire hospitals and establishment of supporting hospital list of references are shown online at racemedicine.org with the staff ensure that medical care can be provided for manuscript. any person who needs it. Best medical practices need to be developed that incorporate unexpected conditions, including extreme weather conditions.

REFERENCES*

3. Clerici PC. (2014). Boston Marathon history by the mile. Cheltenham, UK: The History Press. 10. Resnick L. It takes a team. The : Preparing for and recovering from a mass-casualty event. J Orthop Sports Phys Ther/J Bone Joint Surg Am. 2014;44(3):1-56. 19. Trapasso LM, Cooper JD. Record performances at the Boston Marathon: biometeorological factors. Int J Biometeorol. 1989;33(4):233-7. 20. Roberts WO. Exertional heat stroke during a cool weather marathon: A case study. Med Sci Sports Exerc. 2006;38(7):1197-203. 21. Davey M. (2007, October 8). Death, havoc and heat mar Chicago race. The New York Times. 22. El Helou N, Tafflet M, Berthelot G, Tolaini J, Marc A, et al. Impact of environmental parameters on marathon running performance. PLoS One. 2012;7(5):e37407. 23. Ely MR, Cheuvront SN, Roberts WO, Montain SJ. Impact of weather on marathon-running performance. Med Sci Sports Exerc. 2007;39(3):487-93.

Endurance and Sports Medicine • Fall/Winter 2018 9 “But I can still run, right?” Managing an Injured Runner: A Coach’s Perspective Catherine Ayoub, PT, DPT, MPH

unners love to run. They run for exercise, goals, I brought up some concerns about running personal goals, social engagement, and stress post joint replacement. management (1). An injury affects them not only R General recommendations post total hip physically but mentally as it forces changes to their daily routine and even their identity (1,2). As a result, arthroscopy (THA) are to avoid high-impact sports experienced runners are often unwilling to listen to for the preservation of the implant, but there is medical recommendations when it involves stopping limited research showing if running post THA leads their sport. They will prolong time to seek care and to complications (6). Regardless, most surgeons frequently omit pertinent information such as current recommend against it. After extensive consultation running habits or goals because they don’t want to be with both myself and his surgeon, the client made told “no.” his choice—he wanted to run. His training plan consisted of run/walk progressions with the Runners gravitate towards providers who “get ultimate goal of running consistently for his race. it.” They look for clinicians who empathize with their values and support the goals they have set He made a well-informed decision. My role was not out for themselves. As providers, we can use simply to make a recommendation. It was to educate, coaching techniques such as shared decision guide and support (within reason) his choices. making, motivational interviewing, and goal setting Motivational Interviewing strategies to guide injured runners towards a healthy recovery that still incorporates their reasons Treating runners is difficult, especially if their for running. physical symptoms warrant behavior change, i.e. to stop running. We cannot make our patients change or Shared Decision Making police their behavior. But we can ask explicitly what Shared decision making is defined as “an approach they want and, if behavior change is warranted, listen where clinicians and patients share the best available for change talk. Change talk identifies when a patient evidence when faced with the task of making is contemplating change using words and phrases decisions, and where patients are supported to that show a desire, reason, or need for change (7). consider options, to achieve informed preferences” (3). When change talk is present, motivational It is implemented in three steps: 1) introducing interviewing (MI) can be used to explore the patient’s choice, 2) describing options, and 3) helping patients reasons—their motivation—to change their behavior explore and make decisions (3,4). When an injured (8). MI is a directive, patient-centered approach to runner seeks help, we have to accept and reinforce behavior change (7,8). The principles of MI are: the fact that the patient has autonomy in their care. Our role is to educate them on their current 1. Empathy through reflective listening condition and to explore with them the full range of options for their treatment and prognosis. For each 2. Explore discrepancy between clients’ goals or treatment option, we describe the risks and natural values and their current behavior uncertainty that comes with said choice. The patient 3. Evoke clients’ ideas about change and autonomy can then make the best decision for themselves, which reinforces their self-governance, improving 4. Support self-efficacy both patient satisfaction and the patient-provider relationship (5). 5. Avoid confrontation and advice-giving (7,9)

A 60-year-old client hired me to help him train for MI has been used extensively in counseling around a 10k after bilateral hip replacements three years addiction (9). It is being adopted by health care prior. He was motivated to get healthier by young providers to address patient behaviors such as grandchildren and the desire to finish the race with smoking, dietary changes, and alcohol consumption his son. As we talked through expectations and (8-13). However further research needs to be done

Endurance and Sports Medicine • Fall/Winter 2018 10 to determine the most effective principles and the supporting their sport. Not all of our interactions with best strategy for implementation within the time athletes will be successful. In some cases athletes constraints of medical office visits (8,9). will choose to, despite injuries, maintain their race plans, leaving them significantly injured. But by Goal Setting taking into account an athlete’s mindset and goals Runners are often goal driven. They create distance and in addition to their medical presentation, we give pace goals around specific races. When injured, they them the best opportunity to remain active while are faced with the realization that they can no longer preserving both their physical and mental health. achieve their goal. Clinicians can help athletes reframe Dr. Catherine Ayoub is a physical therapist with the their goals to meet their current physical ability. MedStar NRH Rehabilitation Network. She is also an endurance coach and health coach with Own Your Movement and an adjunct faculty member at Marymount University in Arlington, Virginia.

REFERENCES

1. Waśkiewicz Z, Nikolaidis P, Chalabaev A, Rosemann T, Knechtle B. Motivation in ultra-marathon runners. Psychol Res Behav Manag. 2019;12:31–37.

2. Fokkema T, Burggraaff R, Hartgens F, Kluitenberg B, et al. Prognosis and prognostic factors of running-related injuries in novice runners: A prospective cohort study. J Sci Med Sport. 2019;22(3):259–263.

3. Elwyn G, Coulter A, Laitner S, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ. 2010;14:341.

4. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, et al. (2012). Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med. 2012;27(10):1361–1367.

5. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decision Making. 2015;35(1):114–131. An elite athlete of mine crashed his bike, breaking 6. Abe H, Sakai T, Nishii T, Takao M, Nakamura N, et al. Jogging his collarbone and partially tearing his quadriceps. after total hip arthroplasty. Am J Sports Med. 2013;42(1):131-137. He was training for his first Ironman triathlon (2.4- mile swim, 112-mile bike, 26.2-mile run) with a sub- 7. Miller WR, Rollnick S. (2013) Motivational interviewing: Helping people change. New York, NY: Guilford Press. 10 hour goal (very fast). The race was only three months away. He was devastated. 8. Edwards EJ, Stapleton P, Williams K, Ball L. Building skills, knowledge and confidence in eating and exercise behavior We discussed tissue healing times, anticipated times change: Brief motivational interviewing training for healthcare providers. Patient Educ Couns. 2015;98(5):674-6. to peak performance, and the uncertainty with how his body would deal with high training loads and 9. Copeland L, Mcnamara R, Kelson M, Simpson S. (2015). significant stress. His goals needed to be adjusted. Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: A systematic review. We explored what he was looking for out of the race Patient Educ Couns. 2015;98(4):401–411. and if he still wanted to participate. After taking a couple weeks off, he decided to complete the race 10. Britt E, Hudson S, Blampied N. Motivational interviewing in health settings: A review. Patient Educ Couns. 2004;53(2):147–55. with a mostly walked marathon. 11. Knight KM, McGowan L, Dicken C, Bundy C. A systematic His mindset and goals shifted. He focused on review of motivational interviewing in physical health care nutrition and hydration strategies as well as the settings. Br J Health Psychol. 2006;5(11):319-32. mental stress of such a long event. He completed 12. Naik AD, Palmer N, Petersen NJ, et al. Comparative the event without exacerbating his injuries and effectiveness of goal setting in diabetes mellitus group clinics: plans to attempt his time goal again next season. Randomized clinical trial. Arch Intern Med. 2011;171(5):453-459. 13. Epton T, Currie S, Armitage CJ. Unique effects of setting Clinicians working with athletes face a difficult goals on behavior change: Systematic review and meta- challenge of managing their symptoms while analysis. J Consult Clin Psychol. 2017;85(12):1182-1198.

Endurance and Sports Medicine • Fall/Winter 2018 11 A Medical Perspective on the Coach’s Perspective

It’s interesting that the techniques of shared asked “Why didn’t I do this?” when clients see decision making, motivational interviewing, recommended workouts in a running magazine. and goal setting strategies are presented as Health care providers are cheerleaders for many strategies used by coaches. I utilize these of our patients, encouraging them to exercise, techniques on a daily basis when evaluating stop smoking, improve diet, etc. and provide the patients. There are usually a number of necessary tools to help them achieve these goals. treatments available for just about every medical disorder. A patient needs to be educated on the Time constraints are a constant issue in a clinic various options, including the risks and benefits practice but most providers learn to direct and work with the provider to create the best the evaluation to glean pertinent information, plan of care, keeping in mind the multitude leaving time to educate patients and discuss of factors that impact each of us on a daily testing and treatment options. There is no one basis, ranging from age and life expectancy to size fits all for good medical care. Involving upcoming events (vacation, wedding, race, etc.) the patient in health care decisions that meet to time out of work. Many patients want an MRI, their goals and providing the tools to do so can stem cell injections or other tests and treatments increase compliance which ultimately improves because they hear about these on a regular the likelihood of achieving the desired results. In basis and therefore assume they are the BEST this age of technology and data, with concerns available tests and treatments. It is much quicker about insurance approvals and litigation, it is to order an MRI than to perform a history and still so important to speak with our patients and physical examination, but that is not cost effective physically evaluate them to provide the best medicine and often leads to the diagnosis of an possible care. “abnormality” such as a meniscus tear that has Cathy Fieseler, MD nothing to do with the patient’s symptoms. In Endurance and Sports Medicine Editor-in-Chief the same vein, I’m sure coaches are sometimes

Adult Outcomes of Child Marathon Runners: Research Project IIRM Executive Board Member Bill Roberts, MD, and his colleagues at the University of Minnesota are looking for inidviduals who ran a marathon(s) at age less than 18 or cross country in high school and a marathon(s) as an adult. The aim of the project is to understand what happens to children and adolescents who train for and run marathon races under the age of 18 as they age in adult years. They are trying to answer the question, “Is there harm done to the body when children run marathons?”

If you are interested in participating in this survey study or finding out more about it, please go to: z.umn.edu/marathonrunners. You can follow posts about the study by visiting the FaceBook page at www.facebook.com/kidsmarathonadultoutcomes.

Endurance and Sports Medicine • Fall/Winter 2018 12 Protocol Overhaul: An Opportunity to Review, Revise, and Reflect Korin Hudson, MD and COL(R) Francis G. O’Connor, MD, MPH

e are often reminded that sports medicine is In 2007, a set of race-day protocols were developed as old as medicine itself, and that the origins to assist both the Marine Corps Marathon runners Wof the marathon lie in the story of Pheidippides and those who care for them, serving as a framework who collapsed and died at the end of his journey. It is for how to care for race-day emergencies, as well from this foundation that race medicine has continued as common conditions encountered by endurance to evolve. In the modern era we see ever increasing runners. In April 2019, a group of physicians, athletic numbers of participants in road racing and athletes trainers, and EMS professionals from around the who continue to amaze us with their talent, speed, and country gathered to embark on an update of these ability. And for nearly two decades the IIRM has served protocols. This revision was driven by the Consortium as a worldwide collaboration of medical and health for Health and Military Performance (CHAMP) of the professionals who are working together to promote Uniformed Services University and hosted at their research, education, and best practices in marathons headquarters in Bethesda, Maryland. and other endurance races throughout the world (1).

Among the many experts in attendance for the algorithm revisions were IIRM Executive Director and Boston Marathon Medical Coordinator Chris Troyanos, ATC; Chief Medical Officer of Boston Marathon Medical Tent “B” Fred Brennan, Jr., DO; Marine Corps Marathon Medical Director LCDR C. Marc Madsen, DO; Marine Corps Marathon Medical Coordinator CAPT(R)Shelly Weinstein, PT, ATC; Baltimore Running Festival Medical Director Matthew Sedgley, MD; former Marine Corps Marathon medical directors CAPT Scott Pyne, MD and CAPT(R) W. Bruce Adams, MD; Falmouth Road Race Medical Director and Korey Stringer Institute Chief Medical Officer John Jardine, MD; and Robert Huggins, PhD, ATC, the President of Research and Athlete Performance at the Korey Stringer Institute. The session was led by COL(R) Francis G. O’Connor, MD, MPH.

Endurance and Sports Medicine • Fall/Winter 2018 13 What we initially envisioned as a “little update” Finally, we decided to address the question of when and some “minor tweaks,” quickly evolved into a and how to discharge patients from the medical tent. wholesale revision of the protocols. With an eye Because there may be many factors that play into towards evidence-based practice and drawing this decision, it is critical to recall that the primary upon the considerable experience and expertise goal of the medical tent is to treat patients on site of our assembled group, we have developed a set and triage only the most seriously ill and injured to of algorithms that we feel will continue to provide the emergency department. Still, there is risk both athletes with the best possible care while also to patient and clinician associated with discharging streamlining processes, transportation decisions, and patients who suffer from acute medical condition disposition planning. during or after a race. The new discharge algorithm strives to ensure that all critical needs have been We began with what we titled the “Master Algorithm.” addressed and that patients are safely transitioned to The purpose of this decision tree is to help quickly appropriate follow-up care. identify the most serious and life threatening conditions immediately and drive the rescuer to the These new protocols were debuted at the IIRM- specific protocols for those conditions. The algorithm IAAF Endurance Medicine Conference in October begins with a simplified evaluation of alertness, the 2019 and were used for the Marine Corps Marathon AVPU scale (2). This assesses whether the patient is the following day. The race was one of the most 1) alert, 2) responds to verbal stimulus, 3) responds challenging we have seen in decades with the to a painful stimulus, or 4) is unresponsive. For weather being our worse foe. It was at times cold, patients who are unresponsive, we move quickly hot, sunny, overcast, raining, and we briefly saw to evaluate circulation/pulse, airway patency, and thunderstorms. Over 900 patients were treated for a adequacy of breathing/respirations (CAB). Any variety of conditions, giving us ideas as to what needs patient with absent pulse or inadequate airway or to be added in the next update. For example, we will respirations will immediately be treated according to include a section on care for the adaptive athlete. the emergency cardiac care algorithm. This algorithm will be familiar to those who are comfortable with As we reflect on the Greek roots of the marathon, we basic life support CPR training with a focus on high acknowledge that this was indeed a herculean task. quality chest compressions, minimizing “hands off” We want to thank everyone who participated in this time, and rapid defibrillation when appropriate. review and update. We look forward to continuing to work together for the health and safety of the When the unresponsive athlete or athlete with athletes we serve. altered mental status is found to have pulses present, patent airway, and adequate respirations, we move REFERENCES quickly to assessing a core temperature to evaluate 1. About Us: History. Retrieved from racemedicine.org. for exertional hyperthermia. If the temperature 2. Kelly CA, Upex A, Bateman DN. Comparison of consciousness is elevated, we move rapidly to the appropriate level assessment in the poisoned patient using the alert/verbal/ algorithm and initiate active cooling measures. For painful/unresponsive scale and the Glasgow Coma Scale. Ann the hypothermic patient, we likewise transition to the Emerg Med. 2005;44(2):108–113 appropriate algorithm; however, the focus is to re- warm the athlete.

In the normothermic athlete who is unresponsive Ed. Note: The referenced document “Managing the or has altered mental status, the master algorithm Collapsed Runner: Marine Corps Marathon Medical guides us through the process of evaluating blood Triage and Algorithms 2019” is available for IIRM sugar and checking for electrolyte abnormalities. members at racemedicine.org. It is located under Again, specific algorithms exist to help guide the “Publications/Resources” in the pull-down menu management of hypoglycemia and hyponatremia. “For Members Only.” We also added a protocol for fluid management, recognizing that most athletes do not require intravenous hydration. This algorithm aids the medical team in considering the appropriate administration of IV fluids.

Endurance and Sports Medicine • Fall/Winter 2018 14 Sports Nutrition Resources: Where to Look for Credible Information Nancy Clark, MS, RD, CSSD

s a medical professional who works with NancyClarkRD.com covers topics on sports nutrition, athletes, you inevitably get asked about what, weight management, resolving disordered eating Awhen, and how to eat for top performance. patterns, and recipes for sports foods. Thanks to the Internet, athletes can easily get https://nancyclarkrd.com/blog/ bombarded with—and overwhelmed by—too much conflicting nutrition information. Google searches MySportsScience.com with exercise physiologist can leave anyone confused about carbs, calories, Asker Jeukendrup, PhD, offers “science-y” but easy- keto, inflammation, weight management, and sports to-understand material with good info-graphics supplements—not to mention the latest Netflix about fueling for performance. nutrition “shocumentaries.” https://www.mysportscience.com/

When athletes turn to you, a trusted source of health Podcasts information, do you know where to send them for Podcasts offer a handy way for athletes to learn reliable nutrition information? Your best bet is to about the latest sports nutrition topics while they refer them to a registered dietitian (RD) who is a are training, commuting, and/or traveling. The board certified specialist in sports dietetics (CSSD). hosts commonly interview researchers who are Other options are to recommend science-based conducting the latest studies with athletes. Some nutrition blogs, podcasts, websites, and books that popular podcasts include: have trustworthy information about what’s best to eat for optimal sports performance, good health, We Do Science is hosted by UK sports nutritionist and high energy. Here are some resources for you Dr. Laurent Bannock of the Institute of Performance and your clients. Nutrition. Episode #118, “Swifter, Higher, Stronger,” with Professors Louise Burke and John Hawley is Blogs well worth a listen. https://theiopn.com/podcasts/

Soundbites is authored by Melissa Joy Dobbins, the Science of Ultra is hosted by exercise physiologist “guilt-free RD” who believes food shouldn’t make and Idaho State University Professor Shawn you feel bad. This blog includes podcast interviews Bearden, PhD. Episode #69, “Training on Low with other health and nutrition experts. Glycogen,” offers some food for thought. https://www.soundbitesrd.com/blog-2/ https://www.scienceofultra.com/podcasts/

Eat + Run at U.S. News & World Report is a daily blog Phit for a Queen: A Female Athlete Podcast is hosted written by many well-known RD bloggers. The focus by sports nutritionist Rebecca McConville, RD, of the content is to help people eat healthfully and and therapist Kara Shelman, LCSW. The content stay in shape. is devoted to “female athletes wanting it all: https://health.usnews.com/health-news/blogs/eat-run performance, health, intellect, and time.” You might Health.com/nutrition covers a myriad of topics, like the episode with marathoner Allie Keiffer ranging from the benefits of flax to the red meat titled “I don’t run fast because I am light. I run fast controversy. https://www.health.com/nutrition because I am stronger.” https://phitforaqueen. podbean.com/ NutritionBlogNetwork.com offers a collection of blogs written by numerous registered dietitians. It’s a site Websites you can turn to for trusted advice on all things food, TeamUSA.org is the website for the US Olympic weight management, and nutritional benefits of dietary Committee. It provides fun cooking videos with choices. http://www.nutritionblognetwork.com/ Olympians (TeamUSA.org/Cooking-With-Team-USA) and recipes for many appetizing and healthy sports foods including entrees, snacks, smoothies, and

Endurance and Sports Medicine • Fall/Winter 2018 15 The best way to help your athletes improve their diets—and performance—is to refer them to a registered dietitian nutritionist (RD or RDN) who specializes in sports nutrition.

desserts. The website also offers sports nutrition Food and Fitness After 50: Eat Well, Move Well, Be fact sheets. Among these are the Athlete Plates Well by Christine Rosenbloom, RD, PhD, and exercise with suggested meals for easy, moderate or hard physiologist Bob Murray, PhD, is an excellent exercise days (from the www.TeamUSA.org home resource for mid-life fitness exercisers. page, click on Safe Sport, then High Performance Programs, and then Nutrition). Overcoming Amenorrhea: Get Your Period Back. Get Your Life Back. is by elite runner and podcaster Tina Ausport.gov/ais/nutrition is the website for the Muir. This is a must-read for female athletes who Australian Institute of Sport and offers abundant have developed amenorrhea. sports nutrition information. If you have questions about creatine, sodium bicarbonate, or other Many resources, such as ones mentioned, can offer ergogenic aids, the sport supplement section useful self-help information for your athletes; however, identifies which ones work, which ones need more the best way to help your athletes improve their diets— research, and which ones are bunk. and performance—is to refer them to a registered dietitian nutritionist (RD or RDN) who specializes in EDCatalogue.com provides helpful information about sports nutrition. No blog, podcast or book can replace eating disorders, including tips for families and personalized food help. To find your local RD, use the friends. The website also includes a bookstore with referral network at FindAnRD.eatright.org. Why should more than 200 self-help titles that can help an athlete your athletes just be good when they can be better by find peace with food. The site also has excellent winning with good nutrition? podcasts with top-notch experts in the field of eating disorders. Both athletes and health professionals Sports Nutritionist Nancy Clark, MS, RD, counsels both alike will glean information that helps them better casual and competitive athletes at her office in Newton, understand and manage eating disorders. . For more information, visit https:// nancyclarkrd.com/. She also provides an online workshop Books at http://www.nutritionsportsexerciseceus.com/. The Academy of Nutrition and Dietetics Complete Food and Nutrition Guide, 5th edition, by Roberta Duyff, MS, RDN, FAND, CFCS, is a hefty general nutrition resource with an abundance of nutrition topics and answers to many questions about food for health.

Nancy Clark’s Sports Nutrition Guidebook, 6th edition, provides the latest information about fueling for sports, weight management, and daily life. This book also includes many recipes.

Plant-Based Sports Nutrition by Enette Larson-Meyer, PhD, RD, provides in-depth information to help vegetarians and vegans enjoy a meatless diet while still excelling as athletes.

Endurance and Sports Medicine • Fall/Winter 2018 16 Ohio University Students Gain from Learning Experience

he 2019 IIRM-IAAF Endurance Medicine participants to review the material and discuss Conference in Washington, DC, welcomed 15 the outlined topics. This also gave the professional Tathletic training students from Ohio University as attendees a chance to share their experiences participants and attendees. This is the second year regarding the topics with the students. This is one that Ohio University’s Director of Clinical Education of the first exposures the students have had with for the Division of Athletic Training, Michele Kabay, writing about and presenting research reviews. PhD, AT, has led a team of athletic training students to Washington, DC, for the weekend to attend the The poster topics presented were: conference and volunteer with the medical team at • Rhabdomyolysis the Marine Corps Marathon. • Running Shoes To participate, the students raise funds through donations and receive a grant each year from • Nutritional Requirements for Intense, High-Volume the Dean of the College of Health Sciences and Training Athletes Professions to support the learning experience. • Exercise-Associated Hyponatremia By attending the conference, the students not only get to learn from experts in the sports medicine field, • The Overview of Heat Illness they also gain from the experience of being with • All You Need to Know about Exercise-Induced a variety of professionals in a conference setting. Muscle Cramps This gives them the opportunity to network, work on communication skills, and be exposed to many • Common Injuries Found in Runners other aspects of professionalism that are often talked about but not easy to experience prior to entering the Over time, these poster presentations will be shared profession. in Endurance and Sports Medicine and online at racemedicine.org as part of the IIRM’s efforts to The students spent the early fall researching promote student learning in sports medicine and common injuries and illnesses experienced by related fields. runners and then developed literature review posters to present during the conference. During the poster Some of the athletic training students shared their presentations, the students interacted with other thoughts in the following comments: As a student, I felt the conference was an eye- opener as to how life will be after graduation. The workshops were very informative and allowed me to indulge in experiences I have never been able to encounter such as using diagnostic ultrasound. -Haley Burke

I found the IIRM-IAAF conference to be very informational, and it was made appropriate for all professions. I not only learned how other health care professionals perform evaluations of the back, but I also learned how to read an EKG and how to adequately treat hyperthermia and hypothermia. I also found the conference to be a great way to reach out to professionals within other health care professions and educate myself more in-depth about the roles that other professions play in Attendees and presenters, including Drs. Marc Madsen and Bruce Adams, patient treatment. -Baileigh Lewis discuss the material presented in the posters.

Endurance and Sports Medicine • Fall/Winter 2018 17 Being exposed to the procedures of diagnostic At the IIRM-IAAF conference, I was able to volunteer ultrasound at the conference was a really great as a “patient” while also learning about ultrasound experience for me. When working with athletes imaging. The ultrasound imaging was performed in my everyday career, it can be a challenge to over the medial and lateral sides of my ankle—I diagnose a specific part of a muscle or tendon that was able to see attachment sites of the peroneal may be negatively affecting them. The innovation of muscles in the ankle and learned what to look for diagnostic ultrasound can greatly impact the return- to differentiate between tendon, ligament, and bony to-play process by helping to make quicker and landmarks and structures. -Jordan Miller more accurate diagnoses. This would then speed up recovery time. –Baylee Krigbaum

IIRM Executive Director Chris Troyanos, ATC, outlines a plan with the students for them to contribute to the IIRM’s online educational plans for runners and continue to be involved in future conferences. Marine Corps Marathon Medical Director CAPT C. Marc Madsen, DO, (MCM gray polo) observes the discussion.

Stanley Herring, MD, demonstrates how to perform a back exam on a conference participant.

Endurance and Sports Medicine • Fall/Winter 2018 18 Feeling the Pulse of the TCS New York City Marathon Brett G. Toresdahl, MD

here is a rhythm to autumn in Manhattan that I observe during the crosstown commute from Tmy apartment on the Upper West Side to my office on the Upper East Side. The leaves in Central Park turn from green to gold as the surrounding high rise apartments and skyscrapers of Midtown become less obstructed by the thinning of the trees. Around this time of year large groups of tourists are replaced by runners at all hours of the day. The brownstones then become adorned with Halloween scenes that are surprisingly gruesome for what is considered a family-friendly neighborhood. While costumed children wander the streets, semi-trucks carrying bleachers, gates, and tents move into the southern end of the park to create the iconic finish line for the TCS New York City Marathon.

In fall 2018 I was among the runners enjoying the change in weather and shorter miles prescribed in the final weeks of my training plan. It was a plan that looked simple enough when first printed in June. The reality that followed included weeks of being sidelined, first with a broken toe that occurred while chasing my five-year-old daughter and later with pain in my calcaneus that caused me to limp (likely as the result of switching to a zero-drop shoe— TCS New York City Marathon Medical Director Stuart Weiss, MD, waves to his medical volunteers as they gather for the runners. the only one that would accommodate my injured toe). I became the runner who opted to forego imaging citing purposeful ignorance. Between the interrupted training and bronchitis in the final few days, the race experience was not what I had hoped. I recall very little of the course from mile 16 through 20 along First Avenue on the Upper East Side until it turns south and the fall colors of the trees along The medical team at mile Fifth Avenue usher runners back into Central Park. 17 remained busy helping runners who needed stretching, This year I was again on First Avenue on Marathon Sunday but this time I was captain of the mile 17 massage, acetaminophen, medical tent. Temperatures in the mid-40s/low 50s salt packets, and most of all kept the number of medical emergencies very low at encouragement to keep going. my station, where nearly 53,000 runners passed by. Despite this, the medical team at mile 17 remained busy helping runners who needed stretching, massage, acetaminophen, salt packets, and most of all encouragement to keep going. With 2019 being the 49th running of the TCS New York City Marathon, it is a race with a long history of athletic accomplishments. This history also allows for the medical services to be optimized under the direction

Endurance and Sports Medicine • Fall/Winter 2018 19 Medical volunteers at mile 17 assess the runners as they approach and pass by the tent. of the medical director, Dr. Stuart Weiss. Decades United States, from 10Ks to marathons. Along with of experience have resulted in knowing the right Dr. Stephanie Kliethermes, AMSSM CRN Research number of tents, volunteers, ambulances, AEDs, Director, I am working to collect the experiences of and supplies necessary to provide care quickly to members of the IIRM and AMSSM involved in race runners who suffer medical emergencies anywhere medical coverage through surveys completed after along the 26.2 mile course. races. To date we have data from 26 races and are asking for your help so that we can collect much Many road races in the United States don’t have the more. Race medical directors can access the survey same historical knowledge to guide appropriate through the following link: http://j.mp/2Xtxnyg. If planning for medical emergencies. Although you have questions regarding the study, please write every race is unique, much could be learned from to me at [email protected] or contact Stephanie combining the experiences of races big and small Kliethermes, PhD, at [email protected]. to be able to provide evidence-based guidance for necessary emergency preparations given the Dr. Toresdahl is an assistant attending physician at the distance, number of runners, course type, and Hospital for Special Surgery and the research director weather. Last year the IIRM partnered with the for the HSS Primary Sports Medicine Service. He is also American Medical Society for Sports Medicine a team physician for US Biathlon and Rugby United New Collaborative Research Network (AMSSM CRN) to York, as well as an orthopedic consultant for UFC and a begin collecting data on road races throughout the medical provider for Invesco Series QQQ Tennis.

Endurance and Sports Medicine • Fall/Winter 2018 20 BOOK REVIEW The Durable Runner: A Guide to Injury-Free Running By Alison Heilig Paperback, 178 pp, MacFarland & Company, Inc., 2019

Reviewed by Cathy Fieseler, MD

he Durable Runner is a helpful The author suggests that the reader guide to improve mobility try the many different exercises in T and strength with the goals the book and stick with the ones of decreasing injury rates and that are difficult since these are improving running form. This is a addressing troublesome areas, yoga without painful exercises and such as tight psoas muscles. There impossible body positions. The topic are multiple exercises in each is presented as a lifelong process chapter, so it will certainly take time that utilizes the adaptability of the to review the entire book. body to improve movement patterns. There are individual chapters on the The book ends with some coaching foot and lower leg; knee and hip; advice on mental durability. In core and lower back; and shoulder, addition to being a yoga instructor, upper back, and neck. Each chapter the author is a level 2 RRCA presents exercises that address certified coach, a distance runner, mobility, corrective activating and and triathlete. strengthening exercises, and self- Overall, I believe this is a useful myofascial release techniques. The book for anyone who has stiff joints, chapters start with a basic discussion and finish with muscle tightness, and poor posture or provides a brief discussion on incorporating the movement care for such a person (in my experience this is just patterns into improved running technique. Equipment about everyone). The explanations are simple to used for these processes include yoga blocks, understand and the exercises are straightforward. myofascial release balls, resistance bands and a Incorporating a few of the exercises into a regular bolster, with suggestions of home items that can be workout routine can help reduce dysfunction from used as substitutes. the physical stress of running with poor form, poor This is not a medical book; it is intended for joint mobility, and muscle imbalances from both the general running population. Anatomy is running and daily life. Exercise is a critical part of a presented at a very basic level so the reader has healthy lifestyle; the goal of the book is to provide an understanding of why certain exercises and the means to allow continued exercise for a lifetime. postures are addressed. With that said, this book I have started performing a few of the exercises can be helpful for anyone who develops tightness myself to not only improve my running but to also and soreness not only from daily workouts but help deal with the stress of hours spent working on from the stress of the daily grind—spending hours electronic medical records each day. on a computer documenting notes and the usually Note: I received a pre-publication copy of this book. terrible posture that is present, especially by the There are several editorial corrections needed that end of a long, stressful day. Some of these exercises will hopefully be made before the book is released for can even be performed during the day to help publication. Common sense and reviewing the pictures address posture-induced soreness and tightness. allowed me to correct these mistakes without difficulty. One or two pictures are provided for each exercise to assist in understanding the written description.

Endurance and Sports Medicine • Fall/Winter 2018 21 Seeking Support for the IIRM Research & Education Fund

Donations to the IIRM Research & Education Fund help support our mission to educate and disseminate credible information as it pertains to all medical aspects of running and endurance events. Donations also help support research to facilitate improvements in clinical care at events as we work to standardize medical care provided at races to minimize risk of injury and illness. As a runner, medical/health provider, and/or event director, you must know the importance of these efforts to improve knowledge and care. Let’s work together to make a difference!

To make a contribution to the fund, go to racemedicine. org and click on the “Donations” icon on the home page. If you prefer to mail your contribution, please Nancy Clark, Hélenn Clochet, Tom Cox, James Culpepper, Darrell and Irene Davis*, Pierre make your check payable to the International Institute d’Hemecourt±, Reg Fields, Cathy Fieseler±, Brian for Race Medicine (or IIRM) and send to 12 Entrance FitzGerald*, Chris George, Susan G. Goodwin, John Road, Plymouth, MA 02360. Be sure to include your Halvorsen, Diane Hill*, Susan Hurley, Mark Jacob, Lou name and contact information with the check so that King, Stephanie Kliethermes, Jean M. Knaack**, Ellen we can properly recognize you for your donation. Malloy, Frank Mastrongelo*, Emmanual G. Moreno, Christina Morganti*, Steve Morrow±, Marisa Nucci**, We would like to thank the following donors for Erica Parenteau, Katie Powers*, Sue Rau±, Kelly Ryan*, making a contribution to the IIRM Research & Matthew Sedgley±, Ken Sexter*, Steve Sievert, Kevin Education Fund during our recent summer and Stuart, Karuna Sullivan, Ui May Tan, Chris Troyanos±, “Giving Tuesday” fundraisers. Matthew Underwood, Christopher Visco*, Adrienne Wald, Shelly Weinstein±, and Chris Withbroe.

Eric Almli, Elias Asch, Nicholas Bartolomeo, Chris ± Olympian level ($250) and above Bartosik, Gabrielle Breslow**, Rebecca Breslow**, ** Patron level ($175) and above Douglas Casa*, Samuel Cheuvront*, John Cianca, * Supporter level ($100) CALENDAR OF EVENTS April 18, 2020 IIRM-WORLD ATHLETICS Endurance Medicine Conference Series: Boston, MA Agenda and registration coming soon!

October 24, 2020 IIRM-WORLD ATHLETICS Endurance Medicine Conference Series: Washington, DC Location and agenda TBD.

For information about upcoming international conferences hosted by World Athletics (formerly IAAF), go to https://www.worldathletics.org/about-iaaf/ health-science/next-events.

If you have questions regarding the continuing education activities, please contact IIRM Meeting Coordinator Barbara Baldwin, MPH, at [email protected] or call 240-271-1657.

Endurance and Sports Medicine • Fall/Winter 2018 22