The Role of the Primary Care Physician in the Sports Medicine Chain

1. The Role of the Primary Care Physician in the Sports Medicine Chain Brian Johnston, ATC Assistant Athletic Director for Sport Medicine East Tennessee State University

2. The sports medicine umbrella has evolved over the years into a very complex system of specialties http://content.cteonline.org/resources/images/13/13861a26/13861a26d74d697a00e7ba5c1b784c86c8c015b2/SportsMedUmbrella.JPG

3. Today ……. • Sports Medicine (SM) does not fit into one area of expertise. • SM does not target one organ, system or disease - but rather a broad based area that can encompass many areas simultaneously. (McCrory 2006)

4. This need for a more broad based network of physicians has evolved into an overlapping of disciplines. • Athletic Training • Physical Therapy • Chiropractics • Orthopedics • Internal Medicine • Primary Care • Emergency Medicine • Internal Medicine • and many more….

5. Today, a sports medicine physician must be competent in three levels of care: • Sub Optimal • Exercise as management of medical problems • Optimal • Weekend Warrior • Supra-Optimal • Enhancement of performance in athletics • (McCrory 2006)

6. The Team Physician in Collegiate Athletics • #1 Priority is to “provide for the well-being of individual athletes enabling each to realize his/her full potential” • Ultimately responsible for all student-athletes as it relates to health and welfare • Must utilize resources to have a successful program (Team 2001)

7. Ultimately, the Team Physician is responsible for making medical decisions that affect the student athlete’s safe participation in any athletic event.

8. Duties and Responsibilities • Medical Management • Physicals • On-field injuries • Illness • Rehab • Return to play • Nutrition • Strength and Conditioning • Record Keeping • Administrative • Role delineation • Education of athletes, parents, coaches, etc. • EAP • Equipment • Coverage • Environmental (Team, 2001)

9. Who is the “right” person for a job of this magnitude? What specialty most appropriately can manage such a responsibility?

10. 2005 Harvard Study over a 2 year period • 73% of initial evals were musculoskeletal • 27% of initial evals were general medical • 4% of musculoskeletal injuries required surgery (Steiner 2005)

11. The results of the Harvard study very closely reflect the injury data collected at ETSU over the past 10 years.

12. What does this mean? • The old model of orthopedic surgeon as the team MD may need to be changed • A physician with a more broad scope of knowledge and a specialization in musculoskeletal medicine and exercise would be more appropriate

13. The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations (2010) “The right combination of strength, speed, cardiorespiratory fitness, and other components of athletic capacity can complement skill and enhance performance for all athletes.”

14. The Facts • Since 2000: • 21 NCAA D1 student athletes have died during conditioning sessions • 75% were football players (16/21) • 52% (11/21) occurred on day 1 or day 2 • Three most common causes of death • Sickle Cell Trait complications • Heat issues • Cardiac issues

15. From 2000 - 2011 • Number of NCAA Division I Football Bowl Subdivision players who died while practicing or playing football 0

16. Sickle Cell Trait Complication • Must know the status of every DI student athlete • Heat Issues • Recognize heat signs/symptoms • Manage acclimatization periods • Cardiac Issues • ACLS • EKG/Echo – PPE – Disqualification?

17. “Concussion Epidemic” (CDC) • ~2-4 million sports concussions/yr in US! (Langlois et al., 2006) RJ Elbin, PhD

18. Constant Media Exposure • Sports Illustrated, ESPN, National Geographic, Discovery Channel…Madden RJ Elbin, PhD

19. Prevalence & Incidence of Sport-Related Concussion • 1.6 to 3.0 million sport-related concussions occur every year in U.S. (CDC, 2006) • 5.0% of all collegiate athletic injuries are concussions (Gessel et al. 2007) • Occur more often in competition than practice (Gessel et al. 2007)

20. What do we know? Number of Concussions Knowledge/Standard of Care RJ Elbin, PhD

21. Concussion Resolution Unanimous agreement that the majority (80% - 90%) of concussions will resolve in a short (7 – 10 day) period. *college athletes on average recover within 1 – 5 days (Field et al. 2003; Macciocchi et al. 1996; Iverson et al. 2006; McCrea et al. 2003) *Young children recover slower than High School *High School recover slower than College *College recover slower than Professional *Senior recover slower than everyone

22. NCAA Return to Play Protocol(McCrory et al. 2009)

23. The answer is clear…. • The primary care physician with a certificate of added qualification in sports medicine most appropriately fits this new model of a team physician • This does not, however diminish the value of other physician specialties

24. Who are the essential members of the Sports Medicine Team? • Primary Care Sports Medicine Physician (MD, DO) • Athletic Trainer (ATC) • Strength Conditioning (CSCS, CSCCa) • Sport Science (PhD)

25. Overlapping Roles

26. Communication

27. What does strength Conditioning have to offer? • Negative Trends • Decreases in performance • Decreases in energy • Poor Technique • Mental Fatigue • Positive Trends • Increases in performance • Correcting poor technique • Mental boost • Work ethic

28. What does Sport Science have to offer? • Negatives Trends • Predictor of injury • Root of injury • “Mental” injury • Outside the Box predictor • Positives Trends • Baseline testing • Increases in training • Training Design • Boost Confidence

29. Athlete Monitoring Physician Sport Science Hydration Peak Power Rate of Force Development Asymmetry Labs • X-Rays • Labs • Manual Muscle Testing • Vitals

30. Will there be Tension? • There are going to be problems/concerns that should never be “solved” • If we always agree and get along, someone is not doing their job • If there is tension/disagreement – Does mean there is a problem? • Know what you know – not what you’ve heard

31. So….what IS the role of the Primary Care Physician? ......to be a leader

32. To have the right amount of Truth and Grace

33. To be Resolute • Admirable, purposeful, determined, unwavering • Determined, firm, decided, resolved, decisive • “tip of the spear” • “the end of the line” http://www.merriam-webster.com/dictionary/resolute

34. Thank you…. • Tom Kwasigroch, PhD • Jerry Robertson, ATC • Todd Fowler, MD • Dough Aukerman, MD • Ralph Mills, MD • Benjamin England, MD

35. Disclosure Statement of Financial Interest I, Brian Johnston DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

36. McCrory, P. “What is sports and exercise medicine?” British Journal of Sports Medicine, 2006; 40:955-957. Steiner, M., Quigley, D., Wang, F., et al, “Team Physicians in College Athletics,” The American Journal of Sports Medicine, 33:1545-1551, 2001 Team Physician Consensus Statement, “Reprinted with permission of the project-based alliance for the advancement of clinical sports medicine, comprised of the American Academy of Family Physicians, the American Academy of Orthopaedic surgeons, the American College of Sports medicine, the American Medical Society for Sports medicine, the American Orthopaedic Society for Sports Medicine, and the American Academy of Sports Medicine 2001” Casa, D. J., Anderson, S. A., Baker, L., et al; “The inter-association taskforce for preventing sudden death in collegiate conditioning sessions: Best practice recommendations”, Journal of Athletic Training, 2012;47(4):477-480.

37. Benson, B., Hamilton, G., Meeuwisse, W., McCrory, P., Dvorak, J., Is protective equipment useful in preventing concussion? A systematic review of literature, Br J Sports Med (2009);43:i56-i67.Dragoo, J., Braun, H., The effect of playing surface on injury rate., Sports Med (2010) 40(11):981-990Guskiewicz, K., Weaver, N., Padua, D., Garrett, W., Epidemiology of concussion in collegiate and high school football players, The American Journal of Sports Medicine (2010) 28(5):643-650.Maeda, Y., Kumamoto, D., Yagi, K., Ikebe, K., Effectiveness and fabrication of mouthguards, Dental Tramatology (2009):25(6) 556-564.Meyers, M., Incidence, mechanisms, and severity of game-related college football injuries on fieldturf versus natural grass., The American Journal of Sports Medicine (2010) 38(4):687-697.McCrory, P., Meeuwisse, W., Johnston, K., et al. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in zurich, november 2008., British Journal of Sports Medicine (2009) 43: i76-i84. Mueller, F., Cantu, R., Annual survey of catastrophic football injuries 1931 – 2009, American Football Coaches Association, Feb-2010.Orchard, J. Is there a relationship between ground and climatic conditions and injuries in football? Sports Med (2002); 32(7): 419-432.Scranton Jr PE, Whitesel JP, Powell JW, et al. A review of selected noncontact anterior cruciate ligament injuries in the National Football League., Foot Ankle Int (1997) Dec; 10(12):772-776.Valkeinen H, Ylinen J, Mäikiä E, Alen M, Häkkinen K. Maximal force, force/time and activation/coactivation characteristics of the neck muscles in extension and flexion in healthy men and women at different ages. Eur J Appl Physiol. 2002: 88; 247-254.