By Kyle A. Winik, Lisa Erasmus and Robyn Paulse

The SASMA conference is a biennial event and the latest instalment – the 17^th of its kind – was held in Cape Town. This year’s theme was “Integrate-Accelerate Elevate”. As medical students attending our first conference, we were made to feel extremely welcome and we highly recommend all readers look into attending in 2019! This is PART 2 of our take home messages. You can find PART 1 here!

The Aging Runner: Presenter: Blaise Williams

Dr Blaise Williams addressed the problems associated with the aging runner. The following factors influencing running injuries were mentioned with an emphasis on the aging process:

• Training errors – adaptable
• Lower extremity structure
• Running mechanics
• AGING
  • ↓ROM and lose dorsiflexion in ankle
  • Sarcopenia – ↓muscle mass, strength and tissue quality
  • Altered stride pattern – ↓velocity, stride length and swing time
  • Altered lower extremity biomechanics – ↓knee flexion and loading power, ↑loading time
  • ­Vertical joint stiffness
  • ↓ Shock attenuation

TOP TIPS: Single leg stance and balance activities are used as optimisation techniques. Softer shoes are recommended however this is done on a case-by-case basis.

Youth sports injuries: presented by Dr Angela Smith

Five common problems were highlighted in Dr Angela Smith’s lecture, ‘Correct alignment: preventing and treating youth sports injuries’:

1. Head forward/”turtling”
   1. Neck, upper back and shoulder pain
2. Scapular dykinesis
   1. Biceps tendinopathy and shoulder impingent
3. Lumbar hyperlordosis
   1. Tight hip flexors and lumbodorsal fascia
   2. Weak abdominal muscles
4. Knees not over toes
   1. Angular-rotational issues with resultant cruciate ligament damage
   2. Patellofemoral pain
   3. Poor posture = ACL issues
5. Foot not aligned with tibia

TOP TIPS: Development of a strong base is important. An important analogy mentioned at the conference was that “you cannot fire a cannon from a rowboat” further implying the importance of a strong base. A key component for core stability is hip strength which can be optimized by doing clam shells for external rotators and resistance band exercises.

Cardiology Symposium: presented by Leigh Gordon and Efraim Kramer

Both clinically and financially, cardiac screening needs committed resources. This includes ECG interpretation and cardiology support. For a sports team or sports physician, having a cardiologist on hand can be a costly affair. However, it is extremely important to screen and identify risk factors in every patient/ athlete. The amazing discovery of the CDH2 gene for arrythmogenic RV cardiomyopathy at the University of Cape Town opens up doors for new research and pathways to be explored in dealing with heart disease. Genetic testing is expensive, which is why it is crucial to screen patients and identify those at risk. It is important that sudden cardiac death is preventable and it is imperative as a medical professional at a sports match, sports physician, or even coach to have a medical plan for any emergency on the field of play.

TOP TIPS:

• ICD contraindication for contact sport
• How to deal with Sudden cardiac arrest: 4 R’s
  • Recognition, which comprises of
    • Non-contact collapse
    • Unresponsiveness/ loss of consciousness
      • NO OTHER SIGNS NEEDED! There is NO need to evaluate breathing as often athletes are well oxygenated and seem to be breathing fine when in fact they are in cardiac arrest. Ventilation only required after 10 minutes of collapse.
  • Response
    • Defibrillate the player within 2 minutes ON the field of play
  •  Resuscitation
    • Assess for signs of SCA
    • Place player onto Back- carefully and slowly
    • Chest compressions commencement
      • HANDS-only CPR for 10 minutes
      • Hard and Fast
  • Remove from Football field
    • Do not stop CPR for more than 10 seconds

Jet lag presented by Christa Janse van Rensburg

Any environmental chance, as little as 500km can have an effect on the travelling athlete. It is important to note that with travel, our circadian rhythm shifts with every 15 degrees travelled. Thereafter, our body clock has to move 1 hour into a new time zone. Travelling east is usually worse than west but it is important to control our meals, sleep and drinks. Through correct timing of those, we can decrease travel fatigue, illness and injury and jet lag as a whole.

Interesting fact provided by Phato Zondi

International travel to foreign locations >5hr time zone difference from home country = 2-3X greater incidence of illness

TOP TIPS:Prevention tactics/tools for Jet lag:

1. Bright Light:
   • Bright light exposure in late evening delays one’s body clock
   • Bright light exposure in morning advances one’s body clock
2. Diet:
   • Timing of meal is more important than type of meal
3. Sleep:
   • Shift schedule 1 to 2 hours towards destination time zone.
   • Power naps are worthwhile.
   • Quality > Quantity
4. Exercise:
   • Cannot reliably shift circadian rhythms, but may maintain arousal level
5.  Pharmacological:
   • Low dose melatonin very late evening to morning delays body clock.
   • Low dose melatonin mid-afternoon to bed-time advances our body clock.

Concussion presenters: Jon Patricios, Stan Herring, Michael Turner and Wayne Derman

TOP TIPS:

• Previous assessment protocols were subjective + inconsistent
• Neurological + cognitive serial assessments are cornerstones of management
• Computerised tests can be useful diagnostic tool but it has its limitations
• Education is key!

SCAT 5 is the new protocol and is used from paediatrics to professional athletes. However, with impaired athletes it needs to be adapted since balance tests cannot be done in athletes in wheelchairs. Visual tests cannot be conducted on the blind and cognitive tests cannot be conducted on mentally impaired. Therefore, we must be ready to adapt and assess appropriately.  The new consensus from Belin conference summarised this into 11 R’s:

• 11 R’s:
  1. Recognise
     • Trauma related
     • Short-lived and should get better
     • Functional change
     • Check if symptoms are not caused by drugs
  2. Remove
     • Rapid screening NB
     • SCAT5 takes 10 minutes- DO NOT rush! No less than 10 minutes
       • Issue is at FIFA level currently where a concussion check is done in a couple of minutes on field of play

3. Re-evaluate
   • Healthcare Professionals
   • Medical doctor
   • History, Mechanism of injury, Examination
   • Neuropsychological testing is only 1 tool
4. Rest
   • BIG CHANGE: Not complete rest
   • 24-48 hours complete rest then:
   • Gradual exercise and cognitive loading
5. Rehabilitation
   • BIG CHANGE!
   • Concussion & associated injuries can be treated

6. Refer!
   • Refer a;; suspected cases to medical Dr
   • Access a multi-disciplinary approach and network with SRC experiences
7. Recovery
   • Number & severity of symptoms
   • Psychological factors
   • There is probably more to this
8. Return to school + Return to play
   • RTS:
     • Under-utilised
     • Customise to individual patient
     • Before Return to play/sport
   • RTP:
     • “Typically” 7 days
     • No real change here

9. Reconsider
   • Individual:
     • Age
     • Risk profile
   • Setting
     • Policy
     • Co-operation

10. Residual effects
    • CTE? DO we really know yet??
11. Risk Reduction
    • Equipment
    • Exposure

Most athletes (80-90%) recover in 7-10 days. However, we allow 10-14 days in adults and up to 1 month in children. Risk factors for longer symptoms include depression, migraine headaches, previous concussion. Late onset may occur if the person “plays on” with concussive symptoms, and the rest are psychosocial.

We need to be aware of CTE. However, it is a post-mortem diagnosis and limited research means that we do not truly understand it at this point.

Interesting point made by Michael Turner:

• 110/111 NFL players have Chronic Traumatic Encephalopathy (CTE) in a study.
  • There is definitely an association between concussion and CTE but there is no proven causation as of yet.

Interested to read further? Check out these sources: 

1. Kramer EB, Serratosa L, Drezner J, et al. Sudden cardiac arrest on the football field of play—highlights for sports medicine from the European Resuscitation Council 2015 Consensus Guidelines. Br J Sports Med 2016;50:81-83.
2. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5^thinternational conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.

Kyle A. Winik is a 4th year medical student from the University of Pretoria, South Africa. Kyle is extremely passionate about developing his skills in Sport and Exercise Medicine and looks forward to a future profession in the field.