1. Figure Skating Medical SymposiumIthaca, NY December 6, 2010 Andrew Getzin, MD agetzin@cayugamed.org www.cayugamed.org/sportsmedicine

2. Program Andrew Getzin, MD, Medical Treatment of figure skaters Jake Veigel, MD, Injury Prevention Deb King, PhD, Figure Skating Stretching and Warm Up Discussion

3. Incidence of Injuries in Elite Junior Figure Skaters- Acute Injuries Dubravcic-Simunjak, AJSM 2003

4. Incidence of Injuries in Elite Junior Figure Skaters- Overuse Injuries Dubravcic-Simunjak, AJSM 2003

5. What is a Concussion? Mild traumatic brain injury A disruption in normal brain function due to a blow or jolt to the head CT or MRI is normal Invisible injury

7. Neurometabolic Cascade(Giza and Hovda 2001) Abrupt neuronal depolarization Release of excitatory neurotransmitters Changes in glucose metabolism Altered cerebral blood flow The brain goes into an ENERGY CRISIS that usually last up to 7 – 10 days

8. Vulnerable Period There exists a window period when individual is at increased risk Should factor in return to play decision

9. Common Physical Symptoms Headache Nausea and vomiting Clumsiness and poor balance Dizziness and lightheadedness Blurred vision and light sensitivity Fatigue and lack of energy Sleep disturbance Symptoms often get worse before they get better

10. Common Emotional Symptoms Irritability Anxiety More extreme moods Easily overwhelmed Personality change Lack of motivation

11. Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ Easily confused Slowed processing Easily distracted Memory problems Trouble reading Poor mental stamina Common Cognitive Symptoms

12. Predictions Outcome after concussion is difficult to predict Don’t be fooled by severity of injury at the time of injury

13. Physical Exam Regular physical exam including HEENT, neck, and neurological exam 5 Word Recall- immediate and 5 minutes Months of the year backwards Digits backwards Speech Pronator drift: Rhomberg Finger-to-nose Gentle push with their eyes closed

14. Neuropsychological Testing Computerized tests that measure attention, memory, and processing speed (reaction time) Sensitive to effects of concussions Tests can be repeated multiple times to monitor recovery Ideally, a baseline is done but there is normative date for ImPACT

15. Who Should Have a CT Scan? GCS < 15 LOC History of emesis Severe headaches Signs of basilar skull fracture Severe mechanism Kuppermann Lancet 2009

16. Principles of Concussion Treatment No cure for concussion, but treatment can help the person feel better and function better while symptomatic Early diagnosis and education is critical, and can improve outcome Rest early (7-10 days?) and then gradually increase activity

17. Treatment Strategy Education and reassurance Medications for sleep, headache, etc. Physical & Occupational Therapy Neck & back problems Balance (fall prevention) Vision and Cognition Neuropsychological Testing

18. Academic Accommodations Out of school if necessary Communicate! Limit study time Possibly hold on testing

19. Stress Fractures Overuse from attempted skill over and over again Usually insidious onset Most common location is long bones of the feet Pecina, Stress Fractures in Figure Skaters. AJSM 1990

21. Stress Fracture Treatment Unload the affected area Pain is a helpful guide What can the skater do while he/she heals?

22. Stress Fracture Prevention Listen to your body for warning signs Ensure good bone health Sufficient Vitamin D Calcium Energy balance Increase activity by <10%/week Jump counts? Biomechanics

24. Asthma in Figure Skating 1/3 – ½ of all figure skaters suffer from exercise induced bronchospasm Symptoms exacerbated by cold, dry air, and chemicals Skaters may present with chronic cough, decreased aerobic capacity or wheezing

25. Effect of the Interaction between the Intensity of Exercise and the Thermal Environment on the Pulmonary Mechanical Response McFadden E and Gilbert I. N Engl J Med 1994;330:1362-1367

26. EIB Treatment- Non pharmacologic Increase physical fitness Warm up for at least 10 minutes at sub-threshold level (60-70% VO2max) before exercise begins (refractory period) Cover mouth and nose with a scarf or mask (balaclava) during cold weather Exercise short bouts in warm, humidified environment Avoid aeroallergens and pollutants Cool down or gradually lower the intensity of exercise before stopping Wait at least 2 hours after a meal before exercising Low salt diet?, Fish Oil Supplementation? Tan and Spector, Exercise-Induced Asthma, Sports Med. 1998;25(1):1-6

27. EIB Treatment-pharmacologic Inhaled beta 2 agonists Inhaled corticosteroids Inhaled cromolyn Inhaled nedocromil Inhaled ipatropium Oral leukotriene agonist

28. Not All Shortness of Breath is Asthma Exercise Induced Brochospasm Vocal Cord Dysfunction/Paradoxical Vocal Cord Motion Asthma Lack of Fitness Bronchitis/URI Anemia Reflux Panic Attack Overtraining syndrome Cardiac abnormalities

29. Thank You