SPORT-SPECIFIC ILLNE

Medical Coverage of Winter Nordic Sports:An Overview From the FieldLawrence W. Gaul

Team Physician, Nordic Sports, United States Ski and Snowboard Association (USSA), Park City, UT; USSA FISmedical committee representative, Medical Director, Intensive Care Unit, Vail Valley Medical Center, Vail, CO;Cardiologist, Avanti Cardiology, a division of WMC, Vail, CO

GAUL, L.W. Medical coverage of winter nordic sports: an overview from the field. Curr. Sports Med. Rep., Vol. 9, No. 5,pp. 303-306, 2010. Traveling with sports teams requires flexibility and a wide range of knowledge, as well as problem-solving abilities.Dominating the medical types of problems in the Nordic sports are the respiratory illnesses, especially asthma and upper respiratoryinfections (URl). Additionally, the team physician must have an awareness of antidoping issues. This overview highlights many of theissues encountered traveling domestically as well as mtematioi-ially with high-level Nordic teams. Helpful links are included to facilitatethe care of all levels of athletes. Additionally, a few side issues such as altitude illness and minor trauma are mentioned.

INTRODUCTION

Looking back over the last 10 years of travel with the Nordicteams of the United States Ski and Snowboard Association(USSA), 1 am struck by the wide variety of illness and occa-sional injury encountered. Perhaps more to the point, I wonderwhy more don't get sick: airplanes, hotels, strange diets, andexposure to people from all environments in the setting ofstress and fatigue. Overtraining is another contributing factorto illness and is frequently overlooked. The team physicianmust play an active role in recognizing and preventing this.

This article provides a brief overview of illnesses encoun-tered focusing on common issues seen while traveling withcompetitive Nordic sport teams. Similar accounts from anorthopedic standpoint have been well chronicled, and thereader is directed to the reference list for more information(2). Finally, there is a short mention of nonorthopedic traumaissues, which fortunately are uncommon.

Nordic sports have three general categories: cross-countryskiing, including both classic and the newer free or skatingtechnique, ski jumping, and Nordic combined, which is bothof these on the same day. Additionally, Telemark skiing hascompetitions at many levels. The injuries in the latter sport

Address for círTres¡xmdí^nce: Lawrence W. Cjaul. M.D., FACC, C/O Avanli Cardiology,108 S. Frontage Rd. Wcsl « 206. Vail. CO 81658 (E-mail: lan-y_wg@comcast.nct).

1537-a90X/O9O5/30.5-î06Currenl Sports Medicine ReportsCopyright © 2010 by American College of Sports Medicine

more closely resemble those of alpine skiing (Injury Surveil-lance System, Intemational Ski Federation [FIS], and OsloTrauma Research Institute, www.ostrc.no).

At the World Cup level, the event details change frequently,but the medical issues are similar. Of note, at the FIS meetingsin Antalya, Turkey, May 2010, there is a proposal to add worldchampionships to the ski marathon series, which may increasethe risk ot hypothermia and make other issues more prevalent.

Cross-country skiers and the "combiners" race in varyingconditions at varying distances at various altitudes up to 2200 m(7150 feet). Jumpers have less variation but more exposure toinjury. Nonetheless, at the recent World Ski Flying cham-pionships in Planica, there was not a single injury (InggardLereim, personal communication. May 31, 2010). Also, theyare less likely to suffer from cold-induced problems, as they areable to wait inside until just before their jump.

ANTIDOPING

In addition to awareness of the usual illnesses and injuriesencountered, physicians and health care providers of all typesneed to be aware of antidoping considerations. While mostof the violations are the result of intentional transgressionsby athletes and their advisors, innocent, well-meaning physi-cians must he very diligent to not compromise the athleteinadvertently. Many common medications used worldwideare banned by the World Anti-Doping Agency (WADA,www.wada.org). An excellent reference for U.S.-based physi-cians is www.USAL^A.org/DRO, where medications and sup-plements can be researched. Most importatitly is awareness

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Figure 1. 2006 OWG Turm, Italy. Photo by Larry Gaul, M.D.

that these rules exist and that it is incumhent upon the pre-scriher to seek guidance relative to the athlete's goveminghody. Skiere in the collegiate system function under the U.S.Collegiate Ski and Snowhoard Association. Most others fallunder the jurisdiction of the USSA, which functions underthe EIS or International Ski Federation (www.FIS-ski.com).Most rules regarding medications and treatments are similar,hut occasionally differences exist and the athlete will henefitfrom a sav\'y physician.

As a hrief starting point regarding illnesses and injury inskiing in general, for the physician new to caring for theseathletes, the FIS Weh site has many very short articles on avariety of topics. These are found in the medical section underthe medical tah.

RESPIRATORY ILLNESS

From the standpoint of importance, hoth in prevalence andfrom a potentially performance-limiting aspect, respiratory ill-nesses, especially reactive airways or asthma and infection, aremost prominent.

Exercise-Induced Asthma or Bronchospasm(EIA or EIB)

The entire spectrum of reactive airways is common, and itis estimated that up to 49% of racers in cold air have asthmain one form or another ( 1 ). It is this author's opinion that thisnumher is an underestimate and that in under suitahle con-ditions the numher is much higher.

EIA is a condition wherehy exercise triggers hronchospasmin a susceptible person. There has heen much debate whetherthis represents a different entity or rather a part of the reactiveairways continuum. Erom a practical standpoint, the dehateis moot.

Asthma, EIA or EIB, and reactive airways are all charac-terized hy cough as the most common symptom. The cough isdry and hacky without evidence of infection such as fever orsputum. This includes "racer's cough," which often can heeliminated with a suitahle heta agonist such as Salhutamol(albuterol). However, prior to prescribing this or anotherasthma medication, the specific medicine should he vetted

through the appropriate sport's goveming hody, as some restrictits use.

Eactors inciting an attack include cold dry air. Air pollu-tion also can contrihute, as was seen in Predazo, Italy, at theOlympic winter games in Turin, 2006. The narrow valley(Fig. 1) allowed accumulation of hoth wood smoke and auto-mohile exhaust. High race intensity and stress, especially in thesetting of inadequate warm-up and hydration, also may pre-cipitate an attack.

High on the list of précipitants of EIA, as athletes travel, areupper respiratory infections (URl). Many athletes will attemptto race while not fully recovered, which often will cause anattack. Care must he given in this circumstance to avoid thetemptation to treat with antibiotics. It usually is caused bypost-inflammatory bronchospasm. Bronchospasm can persistfor months after resolution of the inciting infection.

Travel often exposes athletes and staff to other provocativeagents, such as mites in hotel rooms, stress from travel, up-coming races, team interpersonal issues, and of increasinglyrecognized importance, exposure to ski waxes. Most notahleare the perfluorocarhons or "powder." A trip to the wax roomreveals air sparkling with the remnants of powder. Only a littlehas heen written ahout this as a precipitant of asthma, hut asany physician caring for these athletes can attest, powder canincite sudden serious attacks.

At the upper levels of racing, waxing is done hy professionalwaxers who have heen shown to have 50 times nonwaxerhlood levels of at least one of the fluros, perfluorodecanoicacid (PFDA) (3). For the vast majority of racers, wax must heapplied hy or near the athlete, causing not only possihle reac-tive airways hut also the as yet unknown effects of high hloodlevels of these agents.

For the first time, at the upcoming Nordic World Cham-pionships in Oslo, Norway (February 2011), wax cabins withspecial exhaust systems will he employed. Unfortunately, this isnot availahle to the average racer. However, special respiratormasks are availahle and should he used (Figs. 2 and 3).

Respiratory InfectionsRespiratory infections, as in most primary care clinics, are

uhiquitous and frustrating for athletes and staff alike. Often

Figure 2. Randy Gibbs, USA wax man, Vancouver Olympics, 2010.

304 Current Sports Medicine Reports www.acsm-csmr.org

Figure 3. Unidentified USA wax man with respirator in foreground;unprotected waxer in background.

athletes are quarantined by the staff in an effort to control thespread, but this seems only marginally useful. Unfortunately,by the time the patient is symptomatic, the infection, usuallyviral, has spread to others.

The classic findings are well known and include cough,sputum, sore throat, congestion, malaise, and perhaps fever.Sputum may appear purulent even with a viral etiology.

Treatment largely is symptomatic, and the avoidance ofantibiotics is encouraged. The latter often has been chal-lenging, but with more widespread knowledge of antibioticresistance, convincing both athletes and staff to abstain hasbecome easier. Work by the Finnish Study Group for anti-microbial resistance and U.S. Centers for Disease Controland Prevention (CDC) among others has been useful(www.cdc.gov/drugresistance/links.htm).

Naturally, influenza, including the recent addition of HIN 1,is a constant possibility, and physicians are advised to carryantiviral medications and be prepared for rapid spread of illness.

Some of the symptomatic treatments have, at one time oranother, been either banned by WADA or are on watch liststo determine whether there are abuses. This includes productscontaining sympathomimetics such as pseudoephedrine, whichis currently allowed out of competition but banned in com-petition under the stimulant classification.

Frequent questions have to do with the recovery period:what to do, for how long, and when can the athlete retum tofull activity? Here patience is required, and conservative clin-ical judgment should be used. There are no randomized con-trolled trials to shed light, but experience dictates rest withonly gentle exercise until clearly well. Centle exercise is diffi-cult to define, but unless very ill, most athletes will be able todo light activity without detriment, and this may help theirability to relax during the illness. 1 often relate an article I readmany years ago evaluating world records in running, and itwas reported that approximately one-third were set within aweek or so after retum from a viral illness. Most athletes havedone their preseason preparation and are in excellent condi-tion at the start of the competitive season. Short periods offwill be of no consequence, whereas premature retum-to-sportappears to increase vulnerability to other illness and perpetuateconvalescence.

HEENT Illness

Other related illnesses include acute pharyngitis, sinusitis,and occasional otitis media. These are generally viral in eti-ology, self-limited, and of only minor ongoing consequence tothe racer.

Acute sinusitis manifests as nasal congestion, purulentdrainage, even with viral origin, and sinus tendemess withpercussion or forward bending. It most frequently is viral andresolves with symptomatic treatment. Steam and nasal saline,as well as local nasal sprays such as oxymetazoline hydro-chloride are usually sufficient. Care must be taken to avoidbanned medications such as pseudoephedrine in competition.Antibiotics should be reserved for suspected bacterial or pro-longed (>1 wk) illness.

Much of the same applies to routine ear infections and acutepharyngitis. Of course, it is helpful if strep throat can be ruledout. Depending on the locale, the physician may choose tocarry a few rapid strep kits along, keeping in mind the limi-tations of these tests.

GASTROINTESTINAL PROBLEMS

Gastrointestinal issues are another area with great potentialto thwart an athlete's, and at times a whole team's, efforts onthe race course. At the 2003 Nordic World Championshipsin Val De Eiemme, Italy, one of the favorite nations was es-sentially eliminated from contention by diarrhea and dehy-dration. Unless a bacterial origin is suspected, symptomatictreatment with aggressive oral hydration with sport drink con-taining electrolytes is adequate. As of this writing, all intra-venous fluid use is banned unless need is documented clearly.

In years past the furtxquinolones, especially ciprofloxin, hadrisen to the top of preferred empiric treatments for true trav-elers' diarrhea. However now, because of emerging resistance(more of a problem with high prevalence of campylohacter,which is not common in ski regions) and an uncommon butwell recognized issue with tendonopathies from the quinolones,azithromycin (500 mg for 1-2 d) has become popular andgenerally appears efficacious.

Fortunately, travelers' diarrhea is less common in the regionsfrequented by skiers with most areas listed by the CDC as lowrisk. One exception is Eastem Europe, which is listed by theCDC as intermediate risk.

Generally, viral diarrhea will resolve within 2 to 3 d, whereasbacterial varieties will last longer. Prevention is of course thebest medicine, with careful attention to hygiene, fotxl prepara-tion, and frequent use of alcohol containing hand-sanitizing gels.

Another common gastrointestinal problem encountered isheartbum (gastroesophageal reflux disease). This is easily rec-ognized, and the team physician is advised to keep an adequatesupply of U.S. manufactured antacids, H2 blockers such asfamotidine, and proton pump inhibitors such as omeprazole onhand. The stress of the race is a frequent precipitant amongboth athletes and staff.

ALTITUDE ILLNESS

Generally speaking, altitude issues are uncommon, as theupper limit for races is 2200 m at ElS-sanctioned events. Most

Volunne 9 • Number 5 • September/October 2010 Medical Coverage of Winter Nordic Sports 305

bousing is at or below tbis level, and it is tbe sleep altitude tbatis most important. However, an occasional person is susceptibleto lower elevations. Symptoms can occur starting as early as12 b after arrival and witbin 4 d. Aircrafts are pressurized toabout 1700 to 2000 m, so tbis may start tbe exposure time.

Tbere are tbree main bigb altitude illness syndromes. Eirst,high-altitude sickness is characterized by headache, poor sleep,anorexia, lassitude, and nausea. Dexamethazone or acetazol-amide at 125 mg twice daily can be used in staff; bowever, botbare banned by WADA. Nifedipine extended-release 30 mgper day as prophylaxis or treatment is probably best in athletes.

High-altitude pulmonary edema (HAPE) is less common,although there have heen reported fatal cases at 2200 m.Hallmarks include cough that may sound "wet," progressiveshortness of breatb, and eventually cyanosis witb pink frotbysputum. Clearly tbis is a medical emergency, and rapid descentand bospital care are imperative.

Most uncommon but most severe is bigh-altitude cerebraledema (HACE). Altbougb tbis is very unlikely at usual alti-tude, I have seen it in a World Cup altitude racer training athigher elevation just prior to a major event. Malaise, confusion,lassitude, and ataxia should prompt urgent evaluation.

Snow blindness or sunbumed comeas rarely are seen, asalmost all snow sport atbletes and staff bave access to excellenteye protection. Treatment, if encountered, is limited to patcb-ing the eye for 24 h. Symptoms persisting heyond this sbouldprompt more formal evaluation.

Other issues for the team physician to be aware of andto consider addressing are immunizations and deep venousthrombosis prophylaxis.

Usually immunizations will be up-to-date in younger atbletesbut for seniors and staff a review at tbe start of eacb season iswarranted. Special attention sbould be given to bepatitis B,meningoccocal meningitis, and influenza including H INI be-fore major events and if hoarding in dormitory-style housing.

The issue of DVT prophylaxis has not received much at-tention to my knowledge in the sport world. Working in adestination tourist resort with visitors from all over the world,I see DVT commonly, often witb no provocative event excepttravel or minor injury. A recent review by Pbilbrick et al.(4) addressed tbe duration of airline travel as a risk factor,specifying as low-risk flights of less than 6 h in the absence ofdocumented risk factors. TTiis is at odds with my own empiri-cal experience, bowever. Perbaps this is because bigh altitudemay predispose patients or because almost any travel via anairport requires at least 6 h, including sedentary periods gettingto the airport, waiting for flights, and other delays. Of note, inPhilbrick's review, be points out tbat compression stockingsprevented DVT but aspirin did not.

TRAUMA

Fortunately witb tbe advances in jump bill tecbnology anddesign and tbe general characteristics of cross-country skiing,significant trauma is less common. However, as highlighted atthis year's Olympic Winter Games, it can still happen. Tbere, afemale racer fell and slid off tbe course during warm-up for tbewomen's sprint. Sbe tumbled down an embankment and sus-tained multiple rib fractures and perbaps a pneumotborax.

Physicians traveling with teams should be at least provi-sionally competent to recognize and preliminarily manage in-juries sucb as lacerations, wbicb occur commonly to tbe facefrom swinging pole tips at race levels well below tbe World Cuplevel due to less developed skills, back, and ankle sprains, ten-donitis, and most importantly concussion.

Concussion

Because of the risk of sudden death from second impactsyndrome, each physician or other provider treating athletesmust he facile at recognizing and preliminarily managing con-cussion. In the field we use the "SAC or Standardized Assess-ment of Concussion" and then follow with more advancedcomputerized testing (lmPACT) once back in the hotel. Eulldiscussion of this issue is beyond the scope of this article hutan excellent review of this ever advancing and important topicis found at Ciin J Sport Med. 2001 Jul;ll(3):l 76-81.

CONCLUSION

Here I have attempted to review a few of the illnesses andother issues of travel with and care of Nordic sport athletes.Of particular importance is the avoidance of and awarenessof medications and supplements banned by tbe WADA. Ad-ditionally, I bave bigbligbted avoidance of unnecessary anti-biotics, various viral infections, and tbe bigh prevalence ofreactive airways and its treatment.

References

1. Larssim K, Ohlsen P, Larsson L, et ai High prevalence ot a.sthma in crosscountry skiers. BMJ. 1993; 307(691 5):1326 9.

2. Moeller JL, Ritat SF. Winter Sports Medicine Harulhook 2004. McGraw-Hill.

3. NiLsson H, Kärrnian A, Westherg H, et ai A time trend study of sig-nificantly elevated pertluorocarboxylate levels in humans after usinf;tluorinated ski wax. Envir. Sei. Tech. 2010; 44(6):2150-55.

4. Philhrick JT, Shumate R, Siadaty M, Becker D. Air travel and venousthromhoembolism: a systematic review. Soc. Gen. ¡ntem. Med. 2007;22:107-14.

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