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Return To Play Issues: Acute Illness |
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Return to Play
Issues:
Acute Illness
Sports Medicine Rounds
August 26, 2004
Paul W. Baumert, Jr., M.D., FAAFP
To Exercise, or
Not to Exercise?:
That is the Question
•
Most infectious diseases occur randomly in athletes by the same
pathogenic mechanisms that lead to infection in the general population.
•
The athlete’s “lore” holds that “physical exercise will promote
resistance to infection.”
•
Substantial evidence suggests that intense exercise, e.g.
overtraining can increase susceptibility to infection
•
So: when do you recommend exercise, and when do you recommend
rest?
Effects of
Exercise on the Immune System
•
Serum granulocytes increase transiently (1-2 hours) after
vigorous exercise
•
Interleukin 1, an immunostimulant, increases acutely with
exercise, which may increase T and B lymphocyte activity”
•
“Overtrained” athletes may have a reduced ratio of helper T to
suppressor T lymphocytes; lower antibody levels in respiratory and
salivary secretions
Example of
Effects of Overtraining
1987 Los Angeles Marathon
:
Marathoners who trained 60 or more
miles a week suffered twice as many URIs as those who trained less than
20 miles a week. Also, in the week after the marathon, those who
competed in the race were six times more likely to develop a URI (12.9%
of 1,828 finishers) than those who trained and then decided not to run
(2.2% of 134 non participants)
Nieman, Am Coll Sports Med 1998
Effects of
Illness on Exercise Capacity and Performance
•
Acute, febrile viral infections decrease muscle strength and
endurance performance1
• Studies suggest widely prevalent, but
quantitatively subtle and clinically benign, cardiac effects of common
viral infections (Coxsackie)2
• Some viral infections may be substrate
or trigger factors for clinically important cardiac dysfunction3
• Acute viral respiratory infections can
impair pulmonary gas exchange4
1 Eichner
1993; 2, 3 Montague 1988; 4 Primos 1996
Effects of
Illness on Exercise Capacity & Performance (continued)
•
Fluid loss due to illness can impair endurance due to stresses to
circulatory system
•
Impaired fluid status can effect temperature regulation, since
less perspiration results in less dissipation of body heat, leading to
increased risk of heat cramps, heat exhaustion, heat stroke and
circulatory collapse
•
Fever increases metabolism, requiring a higher cardiac output for
any given level of activity and reducing maximum cardiac output
potential
•
Fever causes increased vasodilatation and subsequent drop in
blood pressure
Sports May
Increase Risk of Contracting Certain Diseases
•
Athletes come into close physical contact with other
participants, esp. contact sports (wrestling, rugby, football)
•
Athletes come into contact with fomites (mats, towels, water
bottles)
•
Training and competition often involves heavy respiration,
coughing and spitting
•
Athletes’ skin trauma increases risk of certain dermatologic
conditions
Risk of
Infecting or Injuring Others
•
The ill athlete can put others at risk for illness or injury
•
Hygiene is not stressed in many athletic situations, including
responses to bloodborne pathogens
•
An ill athlete in a high speed contact sport may injure
him/herself or others due to disorientation, slowed reflexes, dizziness
•
Cutaneous viral or bacterial infections can spread via
skin-to-skin contact
So. . .Who Plays
and Who Sits?
•
Some decisions are specific to individual disease (infectious
mono, pneumonia, HSV)
•
Avoid intense physical activity in the face of fever > 1000
F, chills, myalgias, chest cough, diarrhea or vomiting
•
Exercise for 2 days at lower- than-normal intensity for
each day of illness
•
Do Eichner’s “Neck Check” of Symptoms
The Neck Check
•
If symptoms are “above the neck” only (nasal congestion, sore
throat, etc.), an athlete may safely attempt participation. Start at
half speed for 10 minutes, and if athlete feels ok, increase speed and
finish workout or game. If feel miserable, then STOP (“participate as
tolerated”).
•
If symptoms are “below the neck” (myalgias, fever, chills, deep
cough, vomiting, etc.), then it is wise not to
participate.
Eichner, Phys Sportsmed 1993
Fever Fails the
Neck Check
Viral URIs
•
Most common infection in athletes.
•
Usually self-limited, rhinoviruses or adenoviruses.
•
Supportive Rx, fluids and rest. Avoid medications banned from
competition.
•
Good hand washing and hygiene to prevent spread to other athletes
and staff.
•
Neck check and go.
American College
of Sports Medicine: Exercise and the Common Cold 1998
•
If an athlete has common cold symptoms without fever or general
body aches and pains, intensive exercise training may be safely resumed
a few days after the resolution of symptoms.
•
Mild-to-moderate exercise (e.g. walking) does not appear to be
harmful for individuals with common cold symptoms.
•
In general, if the symptoms affect areas from the neck up,
moderate exercise is probably acceptable and possibly beneficial, while
bed rest and a gradual progression to normal training are recommended
when the illness is systemic.
•
ACSM supports the view that moderate physical activity exerts
less stress on the immune system than does prolonged and intense
exercise. Regular and moderate exercise lowers the risk of respiratory
infections.
Nieman 1998
Tonsillitis/Pharyngitis
•
Caused by viruses and bacteria, esp. Streptococcus
•
Treated with symptomatic measures, rest and, when indicated,
antibiotics
•
Passes the neck check if afebrile, well hydrated and not dizzy
Infectious
Mononucleosis (EBV)
•
Causative agent = Epstein-Barr virus, a herpes virus.
•
Acute, generally self-limited lymphoproliferative disease, where
many of the symptoms are auto-immune and not due to the virus itself.
•
Peak incidence ages 14-24, effects 1-3% of all college students
each school year.
•
Incubation period 30-50 days.
Mono and Return
to Competition
•
May return to easy and graduated training at 3 weeks if: (1)
spleen is not palpably enlarged or painful, (2) afebrile, (3)
pharyngitis and any complications have resolved and (4) liver enzymes
are not grossly abnormal.
•
May return to contact sports and vigorous training
(reconditioning necessary) at 4 weeks if above conditions met.
•
When in doubt: Ultrasound
Otitis Media
•
Otitis media = middle ear infection
•
URI, fever, decreased hearing, ear pain
•
H. flu & Pneumococcus
•
Oral antibiotics
•
Check for perforation, neck check and go
Normal Tympanic Otitis
Membrane Media
Gastroenteritis
•
International travel = diarrhea in up to 60% of athletes
•
Viruses (rotavirus, noroviruses), bacteria (toxigenic E. coli,
salmonella, shigella), protozoa (Giardia)
•
Prophylaxis: Pepto Bismol, TMP-sulfa, fluoroquinolones
•
Fails the Neck Check! Participation limited by hydration status,
fever, dizziness. . .and cleanliness of uniform!
Influenza
•
Vaccine preventable, severe lower respiratory tract infection
•
Fever, headache, myalgias, cough, prostration
•
Automatic Neck Check failure
Pneumonia
•
Viral, Mycoplasma pneumoniae or streptococcus pneumoniae
•
Fever, shaking chills, sputum (often rust-colored with
pneumococcus), shortness of breath, chest pain, fatigue
•
Appropriate lab and CXR
•
Erythromycin, azithromycin, fluoroquinolones, IV antibiotics
•
Automatic neck check failure
Bibliography
•
Eichner, ER, Infection, Immunity and Exercise, Phys SportsMed 21
(1): 125-135, Jan 1993.
•
Nieman, David C., et al, Current Comments from the American
College of Sports Medicine: Exercise and the Common Cold, Feb 1998.
•
Montague, TJ, et al, Cardiac Effects of Common Viruses, Chest
94(5): 919-925, Nov 1988.
•
Primus, WA, Sports and Exercise
During Acute Illness, Phys SportsMed 24 (1): 44-55, Jan 1996.
•
2003-04 NCAA Sports Medicine Handbook
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