Download Acute illness in sport, Medical Complications and Return to Play

IOC Research Centre
Acute illness in sport
Medical Complications and Return to Play Decisions
Prof Martin Schwellnus
Professor of Sport and Exercise Medicine
Section Sports Medicine, Department of Orthopedics, Faculty of Health Sciences, University of Pretoria
Director: Institute of Sport, Exercise Medicine and Lifestyle Research, University of Pretoria
Director: IOC Research Centre, University of Pretoria, South Africa
Medical decision making
process
Acute illness
Can my athlete, presenting
with symptoms or signs of
an acute illness, participate
in exercise training or
competition?
IOC Research Centre
Physiological response to exercise
IOC Research Centre
Host (Athlete) response to infection
Microbe
invasion
1. Non specific
host response
2. Microbe specific
host response
•
•
End–organ / system
tissue injury
Immune response
Cellular release of proinflammatory cytokines by
macrophages and other cells
IOC Research Centre
Acute Phase Response
“The acute phase response (APR) is a
prominent systemic reaction of the
organism to local or systemic
disturbances in its homeostasis caused
by infection
(and tissue injury, trauma /
surgery, neoplastic growth or immunological
disorders)”
Gruys E, et al. J Zhejiang Univ, 2005 6B(11) 1045-1056
IOC Research Centre
Acute Phase Response to Infection
Microbe invasion
Endocrine / metabolic
Neuromuscular
Skeletal muscle
CNS
Brain
/ Brain
Liver
Muscle
breakdown
Negative
nitrogen
balance
Altered motor endplate function
Fatigue / malaise
Altered thermoregulation
Anorexia
Pathogen opsonisation
IOC Research Centre
Clinical manifestations (and biomarkers) of the APR
Liver
1.
Supression of
cytochrome P-450
enzyme system
2. Induce heat shock
proteins
3. Induce acute phase
proteins (APP)
• Growth factors
• Pro-inflammaory
• Anti-inflammatory
1.
•
•
•
2.
Biomarkers of APR
Increased plasma viscosity
– Raised ESR
Increased CRP
Increased procalcitonin
(PCT)
Also increased fibrinogen,
ferritin, haptoglobin, α-1
anti-trypsin, complement
Neuromuscular
1. Catabolism
2. Loss of muscle
protein
3. Altered motor
end-plate
function
1. Decreased muscle
function
2. Loss of muscle
mass
3. Reduced
neuromuscular
control
Endocrine /
metabolic
1. Increased
catecholamines
2. Increased ACTH
3. increased
insulin
1. Increased heart
rate (rest and
exercise)
2. Reduced
substrate
availability for
muscle during
exercise
Brain / CNS
1.
2.
3.
4.
Hypothalamus
(resetting
thermostat)
Reduced ADH
Anorexia
Malaise
1.
2.
3.
4.
Fever
Dehydration
Anorexia
Malaise (fatigue)
IOC Research Centre
The basics of infections in athletes and
medical complications / reduced performance
End organ injury
Reduced exercise
performance
Microbe invasion
Medical
complications
Endocrine / metabolic
Skeletal muscle
Neuromuscular
Liver
Breakdown
Altered motor endplate function
Fatigue / malaise
End organ injury
Altered thermoregulation
Anorexia
Pathogen opsonisation
IOC Research Centre
Negative effects of APR on exercise performance
System
Neuromuscular
Cardiovascular
Metabolic
Pathophysiology in infection
Effect on performace
• Muscle wasting (decrease in protein content)
• Mitochondrial abnormalities
• Decreased muscle enzyme activity
• Decreased muscle strength
(isometric strength reduction 515%)
• Decreased isometric muscle
endurance 13-18%
• Decreased neuromuscular transmission
• Impaired motor coordination
• Decreased performance in
precision sports
• Dehydration
• Increased heart rate at submaximal exercise
intensity
• Decreased in stroke volume → decrease in cardiac
output
• Increased plasma viscosity
• Decreased mobilisation of fatty acids from the fat
deports
• Increased proportion of energy from CHO
metabolism
• Increased glucagon, growth hormone and cortisol
• Higher lactate levels at all stages during a graded
exercise test
• Hyperinsulinemia with Inability to maintain
euglycemia
• Reduced endurance capacity up
to 25%
• Reduced substrate availability
for working muscle
IOC Research Centre
Physician diagnosed acute pre-race illness
and race completion (localised vs. systemic)
(Did not finish rate - % runners started)
*
1. *: Significantly
Illness determinants
and race perfromance:
*
different from CON group
• localised vs. systemic
• time of diagnosis before the race
2. Runners with physician diagnosed systemic
illness < 24 hours before the race had a 7 X
greater chance of not completing the race
Gordon L, Schwellnus M, et al; BJSM 2017 (in review)
IOC Research Centre
Microbe specific causes of medical complications
Common infections in athletes
1.
2.
3.
4.
Respiratory / ENT
Gastrointestinal
Dermatological
Urogenital tract
1. Myocarditis / pericarditis (viral - respiratory and
gastrointestinal)
2. Myositis – rhabdomyolysis – renal failure
3. Gastroenteritis – dehydration – renal failure,
electrolyte imbalances
4. Risk of transmission (droplets, skin contact,
blood borne, oral-fecal)
5. Organomegaly (spleen, liver) and rupture (e.g. IM)
6. Others ……
IOC Research Centre
Potential medical complications of an acute infective illness during
exercise (APR and end organ injury)
System
Pathology
Cardiovascular
• Viral myocarditis
• Myopericarditis
• Medication use
Neuromuscular
•
•
Respiratory system
•
Renal system
Thermoregulatory
•
•
•
•
Others
•
Medical complication
•
•
•
•
•
•
Aggravating / prolonging illness
Dysrhythmias
Cardiac failure
Sudden death
Myositis
Rhabdomyolysis
Impaired motor function
Joint, ligament and tendon
and neuromuscular control
injuries
Impaired immune function • Prolonging illness
• Bronchial hyper-reactivity
Rhabdomyolysis
• Acute renal failure
Dehydration
Medication use
Aletred tenperature
• Heatstroke
regulation “set point”
Impaired immune function • Increased duration and severity
of symptoms of illness
• Post-viral fatigue syndrome
IOC Research Centre
Physician diagnosed acute pre-race
illness and risk of medical complications
Medical complica ons rate (per
100 runners in each group)
(MC rate - % runners who start the race)
1,8
1,6
1,4
1,2
1
0,8
0,6
0,4
0,2
0
*
*: Significantly different from control
1,55
Runners with physican diagnosed acute
pre-race acute illness, who started the
race, have0,68a 2.3 X greater chance of
developing a medical complication
during the race
Control group (n=43 425)
Acute illness group (n=193)
Gordon L, Schwellnus M, et al; (unpublished)
IOC Research Centre
Medical decision making process
Acute illness
Can my athlete, presenting
with symptoms or signs of
an acute illness, participate
in exercise training or
competition?
IOC Research Centre
History of the medical decision making process
Acute illness
• “Neck check’ - first described
in 1993
• Clinical tool - based on an
abbreviated medical history
• “If your symptoms are “above
the neck” (stuffy or runny
nose, sneezing, watery eyes,
scratchy throat), try a “test
drive” at “half speed;” if you
feel better after 10 minutes,
you can “rev up” and finish
the workout”
• Never been systematically
studied
IOC Research Centre
Return to play guidelines for an athlete with acute
respiratory infective illness – modified “neck check”
Athlete with acute infection
Localized RTI symptoms
(above neck)
Normal examination
Systemic and RTI
symptoms (below neck)
Examination abnormal
Exercise at 70%
max for 10 min
Asymptomatic
Symptomatic
No exercise
Re-assess in 24 hrs
Continue exercise at 70% max
IOC Research Centre
Return
to play guidelines for an athlete with
2014
an infection
Scharhag, J, Meyer, T: J Sports Sci 2014; 32 (13), 1237-42
IOC Research Centre
Medical decision making process
Acute illness
Can we improve on
this approach in
2017?
IOC Research Centre
Question 1: Is there evidence of the
APR?
Microbe invasion
Endocrine / metabolic
Skeletal muscle
1.Fever
2.Dehydration
3.Anorexia
4.Malaise (general fatigue)
5.Muscle pain
6.Muscle fatigue
7.Increased heart rate (rest and exercise)
8.? Altered balance co-ordination
Neuromuscular
Liver
Breakdown
Altered motor endplate function
Fatigue / malaise
Altered thermoregulation
Anorexia
Pathogen opsonisation
IOC Research Centre
Biomarkers of the APR
Markanday A: OFID 2015; 1-7
IOC Research Centre
Biomarkers
of the APR
CRP
Hrs to 3 days
1.Produced by liver
2.More sensitive than ESR
3.Sensitive to subtle
changes
4.Starts rise about 12
hours and peaks in 2-3
days
5.Low levels (2-10mg/L)
can be measured using
“high sensitivity CRP”
IOC Research Centre
Biomarkers for the APR
Future?
Procalcitonin (PCT)
1.Secretion stimulated by cytokines / TNFalpha
2.PCT increased in bacterial infections (not in viral infections)
3.Detected 3-4 hrs and peaks in 6-24 hrs
4.Not increased in non-infectious inflammatory conditions (except
massive trauma)
5.Used as a guidelines for antibiotic treatment (RTI’s)
•
•
•
•
< 0.01ug/L – strongly discourage AB use
<0.25ug/L - discourage AB use
>0.250ug/L – encourage AB use
> 0.50ug/L - strongly encourage AB use
IOC Research Centre
Question 2: Is there tissue damage
(microbe specific) in your athlete?
2. End organ injury
Reduced exercise
performance
Medical
complications
2. End organ injury
IOC Research Centre
Make an accurate microbe specific
diagnosis!!!
What is the causes of the acute illness in athletes?
a. Clinical diagnosis: Infective
(viral, bacterial, fungal,
parasitic, other)
b. Rapid diagnostic panel
testing in future?
c. Consider other non-infective
causes of symptoms:
– Allergies
– Physical factors related to increased air
movement during exercise
(cold, dry air, increased air turbulence,
mouth-breathing, and inhaled physical or
chemical irritants)
– Other diseases
Schwellnus M, et al; Current Allergy & Clinical Immunology, June 2010; 23 (2)
IOC Research Centre
Question 3: Is there a normal physiological
response to an exercise test?
a. Submaximal exercise test
b. Symptoms
c. Measure response to exercise:
– Temperature (resting and exercise)
– Heart rate (resting and exercise)
– Respiratory response (resting and
exercise)
– RPE
– Muscle function
– Neuromuscular control
d. Performance outcomes
e. Graded return to play
IOC Research Centre
Return to play guidelines for an athlete with acute
respiratory infective illness – modified “neck check”
Athlete with acute infection
Localized RTI symptoms
(above neck)
Normal examination
Systemic and RTI symptoms
(below neck)
Examination abnormal
Exercise at 70%
max for 10 min
Asymptomatic
Symptomatic
No exercise
Re-assess in 24 hrs
Continue exercise at 70% max
IOC Research Centre
Suggested 2017 Medical decision making in the athlete with acute
infective illness
Athlete with acute infection
1. Is there clinical evidence of an Acute Phase
Response?
Systemic symptoms and signs (malaise / fatigue, anorexia,
fever, tachycardia, myalgia / arthralgia, dehydration)
Assess biomarkers for APR (ESR, CRP, PCT)
Yes
No
2. Is there evidence of end-organ injury /
damage (affecting the exercise response)?
Clinical assessment and special investigations
[respiratory, cardiac (myo-pericardial}, vascular,
renal, CNS, GIT, muscle, bone, tendon, joint, other]
No exercise
Re-assess in
24 hours
No
3. What is the response to a sub-maximal
exercise test at 70% max for 10 min?
Abnormal / Symptomatic
Symptoms, signs (HR, ECG, ventilation, RPE, other)
Normal / Asymptomatic
Continue exercise at 70% max
Graded return to play (monitor
symptoms and signs)
IOC Research Centre
Take home messages
– Acute illness is common in athletes
– Team physicians regularly make decisions about
return to play in ill athletes
– “Neck check” or modifications have been used >
20 years, but little research
– In 2017 - consider three main steps in medical
decision making in acute illness:
1. Is there evidence of an acute phase response
(clinical and biomarkers)
2. Is there clinical / laboratory evidence of microbe
specific end-organ damage (exercise performance or
medical complication risk)
3. Introduce a graded return to sport with monitoring
and re-assessment
IOC Research Centre
Thank you for your attention
IOC Research Centre