4/1/14 1 Denise L. Wunderler, DO, FAOASM Primary Care Sports Medicine Physician Department of Orthopedic Surgery Fort Knox, Kentucky AOASM Annual Conference 2014, Tampa Gain an understanding of how to successfully prepare for an international sports medicine trip Review vaccines and traveler’s diarrhea Discuss performance considerations regarding altitude and jet lag Can be challenging Usually great preparation leads to a smooth, successful trip But you can’t anticipate everything Goal: be as prepared as you can be
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8.00 WUNDERLER TRAVEL SPORTS MEDICINE · malaise, abdominal pain, dark urine, clay-colored stools, jaundice, joint pain ! Tx: supportive ! Hepatitis A vaccine (inactivated/killed)
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Denise L. Wunderler, DO, FAOASM Primary Care Sports Medicine Physician
Department of Orthopedic Surgery Fort Knox, Kentucky
AOASM Annual Conference 2014, Tampa
¨ Gain an understanding of how to successfully prepare for an international sports medicine trip
¨ Can be challenging ¨ Usually great preparation leads to a smooth,
successful trip ¨ But you can’t anticipate everything ¨ Goal: be as prepared as you can be
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¨ With whom are you traveling? ¡ Athletes, coaches, other staff, family members ¡ Make contact with them early to open the lines of
communication for questions or concerns ú Allows better planning for everyone ú Be aware of any allergies or known medical problems ú standard vaccines should be UTD, including tetanus ú Gives them time to obtain needed vaccines for a specific
country
ú obtain complete list of ALL meds (Rx, OTC, herbs, “natural remedies”, vitamins, supplements; daily/PRN)
ú determine if an athlete is taking a banned substance ú need for a therapeutic use exemption (TUE)?
For athletes with a documented medical condition who need a prohibited substance/prohibited method
At least 30 days before the competition ú Old/new injuries, any taping that is needed
¨ I made a chart with the Team Delegation’s names, meds, allergies, other
¨ Where are you going? ¡ Local vs. international
ú http://www.cdc.gov/travel (specific country) ú what is allowed in the country/through customs
Some prescription meds are illegal in other countries- need to check with the embassy or consulate for that country; must have a letter from your doctor stating the med and that it was prescribed for you
I would not recommend carrying any narcotics Letter for epi pens in my luggage
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ú what can be brought on the plane in carry-on bag ú small stock of Ibuprofen, Acetaminophen, Tums, Pepto-
Bismol, Immodium, throat lozenges ú tablets in original containers or marked clearly with the name
and dose ú Depending on the destination, specific vaccinations will be
needed- check CDC website
¡ Packed supplies will be different if it is international ¡ How much are you going to bring
ú the more you bring, the more you carry ú If you need an item, how difficult will it be to obtain
i.e. Moist heat packs for shoulder/back- it took our Peruvian delegate 2 days to locate them for us in Lima
i.e. Meds- if purchased overseas, they may not be made according to US standards, may be ineffective, contain contaminants, or may be in unsafe drug combinations
¡ Encourage them to bring healthy snacks from home
¨ cdc.gov ¨ who.int
¨ Routine vaccinations need to be up-to-date (MMR, DPT, polio, etc)
¨ Hepatitis A ¨ Typhoid Fever ¨ Hepatitis B ¨ Yellow Fever ¨ Malaria ¨ Rabies
doping are prohibited ¨ Danazol- anabolic steroid for endometriosis, fibrocystic
breast disease, hereditary angioedema ¨ All beta-2 agonists
¡ except inhaled salbutamol (albuterol) max 1600 mcg over 24 hrs, inhaled formoterol max 54 mcg over 24 hrs, or inhaled salmeterol (long-acting beta agonist) when used in accordance with manufacturer’s regimen
oxycodone (in Percocet, OxyContin) ¨ Marijuana ¨ All glucocorticosteroids (prednisone)- PO, IV, IM, PR
¨ IN COMPETITION IN CERTAIN SPORTS: ¨ Alcohol ([blood alcohol] of 0.10g/L)
¡ air sports (aeronautic), archery, automobile, karate, motorcycling, powerboating
¨ Beta-blockers ¡ archery and shooting (both also prohibited out-of-
competition), automobile, billiards, darts, golf, skiing/snowboarding- ski jumping, freestyle aerials/halfpipe and snowboard halfpipe/big air
¨ MONITORING PROGRAM: ¨ substances not on prohibited list, but which WADA
wishes to monitor in order to detect patterns of misuse in sport
¨ In competition only ¡ Stimulants: caffeine, nicotine, phenylephrine, pseudoephedrine
<150mcg/mL, synephrine ¡ Narcotics: Hydrocodone (in Vicodin), tramadol
¨ NOTE: Intramuscular PRP was removed from the prohibited list
¨ *To inquire about a certain ingredient by sport, look at http://www.globaldro.com/
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¨ Meet the Head Physician of the event (which could be you), other local event medical staff
¨ Protocol to contact emergency staff ¨ AED location ¨ Ambulance access to facility ¨ Training room facilities ¨ local hospital locations ¨ Bring contact information of people in case of
problems (trusted physicians, NGB staff)
¨ Be familiar with the World Anti-Doping Code ¡ I kept a full printed copy in my binder
¨ M-5 declaration of medications of each athlete (before match)
¨ M-10 injury report form (after match) ¨ Random doping controls occurred
¡ team physician is present for this
¨ When preparing for travel, prepare for the most common problems ¡ *food/water contamination-leading cause of illness in
travelers ¡ Altitude ¡ Jet lag
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¨ GI meds- Loperamide, Tums, Pepto-Bismol, ABX, Anti-emetics, MVI, Docusate
ú viral gastroenteritis in US ¡ Less common causes:
ú protozoal parasites ú if diarrhea lasts >2 weeks OR if no response to ABX- Giardia
Iamblia, Entamoeba histolytica, Cyclospora cayetanensis- seen in returning travelers
¡ norovirus on cruise ships
¨ Classic definition: ¡ 3 or more unformed stools in 24 hours with at least 1 of
the following symptoms: Fever, N/V, abdominal cramps, tenesmus (urge to pass stool), bloody stools
¨ Milder forms can present with less than 3 stools ¨ Can also have bloating, general fatigue ¨ Most occur within the first 2 weeks of travel and
last 4 days without treatment
¨ Rarely life-threatening ¡ 1 in 5 travelers is bedridden for a day ¡ > 1/3 must alter their activities
¨ Those more susceptible: immunocompromised, those with lowered gastric acidity (taking histamine H2 blockers or proton pump inhibitors), younger age and adventurous travelers; luxury resorts or cruise ships
¨ “Food poisoning” is part of the differential dx of TD: ¡ gastroenteritis from preformed toxins (Staph aureus, Bacillus
cereus) has a short incubation time (1-6 hours) and symptoms usually resolve within 24 hours
¡ Distinguish from TD by perioral numbness, flushing and warmth
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¨ Prevention: ¡ A fluoroquinolone can be used for a maximum of 3 weeks in
a “critical” competition ¡ Bismuth subsalicylate (Pepto-Bismol)
ú ideally two 262 mg tables QID (with meals and in evening) ú Even though it has a 60% rate of protection, it is impractical for
athletes ú Not for those taking anti-coagulants or other salicylates ú Interferes with doxycycline absorption (malaria prophylaxis) ú Side effects include: black stool, black tongue, constipation,
tinnitus ¡ Lactobacillus may protect up to 47%; more studies needed
¡ wash hands often with soap/water, esp before eating ú Antibacterial hand wipes/alcohol-based hand sanitizer (at least 60%
alcohol) ¡ Only use bottled water with an unbroken seal, boiled water
(best way to purify water), or carbonated beverages in cans/bottles
¡ avoid tap water, fountain drinks, and ice cubes ¡ use bottled water for teeth brushing ¡ Inspect hotel kitchens and inquire re: the source of fruits and
vegetables and the water in which they are washed and prepared
¡ confirm that water in a hotel setting is filtered, boiled, or bottled
¡ no food from street vendors ¡ Eat only fully cooked food ¡ eat hot foods when they are hot; cold foods when they are cold ¡ no room temp sauces
ú microbes can multiply in foods that are allowed to cool or warm to room temp
¡ avoid raw/undercooked meat, fish, or shellfish ¡ Do not eat reheated, cooked food ¡ avoid leafy salads, unpeeled fruit/vegies in developing
countries ¡ avoid dairy, unless it is pasteurized ¡ boiled/baked/peeled foods are the safest ¡ Boiling water is the best way to purify water
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¨ Treatment: ¡ Boiled soups/bouillon/broth and electrolyte-
replacement solutions (have salt which was depleted during diarrhea episodes)
¡ Hydration ¡ Complex carbohydrates- bananas, rice, bread, potatoes ¡ Empiric tx with ABX and loperamide
¨ Loperamide (Imodium) ¡ two 2mg tablets after 1st loose stool, then 1 tab after each
subsequent loose stool; max 8 mg in 24 hours x 2days ¡ limits symptoms to one day ¡ Can be started after the 1st episode of diarrhea ¡ if symptoms resolve within 24 hours, no further tx
¨ Ciprofloxacin ¡ 500 mg BID x 1-3 days ¡ drug of choice (for most parts of the world) where
invasive organisms like Campylobacter and Shigella are common
¨ Azithromycin ¡ in areas with quinolone-resistant Campylobacter (i.e.
Thailand) and for children and pregnant women ¡ 1 gram x1 dose OR 500 mg x 1-3 days ¡ 10mg/kg daily x 3 days
¨ Rifaximin (newer ABX) ¡ can be used where noninvasive E.Coli is the main
pathogen (i.e. Mexico) ¡ decreases symptoms x 1 day ¡ 200 mg PO TID x 3 days
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¨ Athletes face many challenges at altitude that can effect performance: ¡ Lower oxygen saturation in the air ¡ increased radiation (sun) ¡ compromised immune system ¡ increased fatigue ¡ Malnutrition and dehydration ¡ overtraining
¨ Therefore, acclimatization, proper sleep, sun protection, hydration, good nutrition, and appropriate training are important to help minimize these challenges
¨ Acclimatize to help prevent altitude illness: ¡ avoid flying into high altitude cities ¡ if going to higher altitude destination (above 8000 ft) consider
sleeping one night at a lower altitude ¡ increase altitude gradually ¡ Hydrate ¡ limit activity initially ¡ avoid alcohol ¡ high carbohydrate diet can improve oxygenation and exercise
performance
¨ There is no ideal preventative med for athletes traveling to altitude ¡ Ibuprofen (600 mg TID, 6 hours before ascent) can help
¨ Recommended: athlete arrives early and resides x 2 weeks at the competition altitude
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¨ At altitude, lack of hydration (due to plasma volume drop à lower COà lower maximal aerobic power) and iron (due to strong demand on erythropoiesis at altitude) may negatively impact performance
¨ Recommended that athletes are screened for serum ferritin levels 8-10 weeks prior to going to altitude, allowing time for supplementation; recommend increased dietary iron intake through various foods
¨ Rapid ascent above 2500 m (8200 ft) to a more hypobaric, hypoxic environment is the main cause of altitude illness
¨ AMS ¨ HACE ¨ HAPE
¨ AMS ¡ HA, dizziness, insomnia, anorexia, nausea, dyspnea,
mask or helmet, rehydration, Sildenafil, Tadalafil, Nifedipine, Diamox, Albuterol/salmeterol inhaler
¨ Athletes traveling to altitude for training/competition are at risk for poor sleep quality as a result of both jet lag and the altitude itself
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¨ Considered to be a significant source of disturbance to athletes, especially when traveling from west to east
¨ Goal is to increase adaptation and minimize decrease in performance
¨ Sleep deprivation exacerbates the magnitude and duration of jet lag
¨ sleep when you can ¨ hydrate before and during the trip ¨ avoid alcohol ¨ 1 day of adjustment needed for each time zone crossed* ¨ Travel Management Program (Samuels) – Preflight,
inflight, postflight components
¨ Preflight: ¡ Within 7 days of travel ¡ Getting a solid night sleep at least the night before the
flight ¡ Decrease volume and intensity of training ¡ adjust training to the destination time zone a few days
before departure ¡ evening flight for eastward travel and layovers for travel
across 10 or more time zones to help with adapting
¨ Inflight ¡ adjust watches to destination time zone ¡ comfortable environment (pillows, etc) to facilitate sleep
and rest ¡ minimize distractions (electronics) ¡ eyeshades/earplugs to aid rest ¡ noise-canceling listening devices to help relaxation ¡ sleep and eat meals on the destination schedule (athletes to
bring meals if possible) ¡ hydration is a priority
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¨ Postflight: ¡ 2-4 days after arrival ¡ Modification of behavior, not necessarily meds ¡ scheduled light therapy, light avoidance, melatonin ¡ napping and caffeine (improve alertness, minimize
fatigue) ¡ ? sedatives if insomnia for 1-2 days or not responding to
melatonin
¨ Any special considerations re: the injured athlete and returning home by air? ¡ Athlete with a pneumothorax may not be able to fly ¡ A cast needs to be bivalved ¡ Special seating- ie. if GI issues- obtain an aisle seat near a
bathroom; if lower extremity injury, obtain an aisle seat
¨ Traveling in sports medicine can be challenging ¨ However, the key to a successful trip is great
preparation and being proactive with the care of your team
¨ And remember, always strive to be a positive ambassador- You are representing our country!
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¨ www.cdc.gov ¨ www.fivb.org ¨ http://list.wada-ama.org ¨ www.globaldro.com ¨ www.cdc.gov ¨ www.who.int ¨ Epocrates ¨ Yates, J. Traveler’s Diarrhea. Am Fam Physician. 2005. 71(11):2095-2100. ¨ Harrison, L. New Rifamycin Formulation Curtails Traveler's Diarrhea.
http://www.medscape.com/viewarticle/812427.2013. ¨ Lipman GS, et al. Ibuprofen prevents altitude illness: A randomized controlled trial for prevention
of altitude illness with nonsteroidal anti-inflammatories. Annals of Emergency Medicine. 2012. 59(6): 484–490.
¨ Samuels, C. H. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High-Performance Support Teams. Clin J Sport Med. 2012. 22(3):268-273.
¨ Pipe, A.L. International Travel and the Elite Athlete. Clin J Sport Med. 2011. 21 (1): 62-66. ¨ Koehle, M.S., et al. Canadian Academy of Sport and Exercise Medicine Position Statement:
Athletes at High Altitude. Clin J Sport Med. 2014. 24 (2): 120-127. ¨ Koch, et al. A Successful Therapy of High Altitude Pulmonary Edema With a CPAP Helmet on
Lenin Peak (Case Report). Clin J Sports Med. January 2009; 19 (1): 72-73.
¨ Michael Savino, D.O. ¨ Lori Boyajian-O’Neil, D.O. ¨ David Dyck, D.O. ¨ Bill Feldner, D.O. ¨ Andy Gregory, M.D. ¨ Zenos Vangelos, D.O. ¨ USA Volleyball ¨ AOASM