Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training.

ABSTRACT: Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.

Genetics Influence Neurocognitive Performance at Baseline but Not Concussion History in Collegiate Student-Athletes.

OBJECTIVE: This study investigates 4 single-nucleotide polymorphisms [Apolipoprotein E (APOE), APOE promoter, catechol-O-methyl transferase (COMT), and dopamine D2 receptor] that have been implicated in concussion susceptibility and/or cognitive ability in collegiate student-athletes. DESIGN: Cross-sectional study. SETTING: Neuroscience laboratory at Elon University. PARTICIPANTS: Two hundred fifty division I collegiate student-athletes (66 women, 184 men) from various sports. INTERVENTION: All participants completed Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) testing at baseline concussion testing and had a buccal swab taken for DNA for genotyping. MAIN OUTCOME MEASURES: Self-reported history of concussions and neurocognitive performance were taken from ImPACT. RESULTS: Individuals carrying an ε4 allele in their APOE gene had a significantly slower reaction time (P = 0.001). Individuals homozygous for the Val allele of the COMT gene showed significantly worse impulse control scores (P = 0.014). None of the genotypes were able to predict self-reported concussion history in collegiate student-athletes. CONCLUSIONS: These results indicate that certain genotypes may influence performance on cognitive testing at baseline and that the APOE genotypes may not influence concussion susceptibility as suggested by past studies.

Concussion Baseline Testing: Preexisting Factors, Symptoms, and Neurocognitive Performance.

CONTEXT: Neurocognitive test scores are often considered an important aspect of concussion management. To best use these data, clinicians must understand potential factors that may influence baseline performance on these tests. OBJECTIVE: To determine preexisting factors that may influence performance on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 486 National Collegiate Athletic Association Division I collegiate student-athletes. MAIN OUTCOME MEASURE(S): To determine neurocognitive functioning and total symptom score at baseline, ImPACT was administered. Outcomes were verbal memory, visual memory, visual motor speed, reaction time, and total symptom score. A self-report demographic section at the beginning of ImPACT was used to gather information concerning previous treatment for headaches, migraines, and psychiatric conditions; diagnosis of attention-deficit/hyperactivity disorder; and exposure to previous strenuous exercise. We conducted multivariate analyses of variance to determine if the ImPACT composite and total symptom scores differed according to preexisting factors (P < .0083). RESULTS: Sex showed an effect on verbal memory (P = .001), visual motor speed (P < .001), and reaction time (P = .006), with women performing better than men. A previous diagnosis of attention-deficit/hyperactivity disorder affected visual motor speed (P = .008). Previous treatment for headaches (P < .001), migraines (P = .001), a psychiatric condition (P < .001), or a diagnosis of attention-deficit/hyperactivity disorder (P < .001) all showed effects on the total symptom score. Strenuous exercise did not affect neurocogntive performance or total symptom score. CONCLUSIONS: Based on our findings and the previous literature, we suggest that many preexisting factors influence baseline neurocognitive data. Baseline testing is an important aspect of concussion management. Sports medicine professionals should be cognizant of these factors when developing concussion-management protocols.

A neuroscientific approach to the examination of concussions in student-athletes.

Concussions are occurring at alarming rates in the United States and have become a serious public health concern. The CDC estimates that 1.6 to 3.8 million concussions occur in sports and recreational activities annually. Concussion as defined by the 2013 Concussion Consensus Statement "may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an 'impulsive' force transmitted to the head." Concussions leave the individual with both short- and long-term effects. The short-term effects of sport related concussions may include changes in playing ability, confusion, memory disturbance, the loss of consciousness, slowing of reaction time, loss of coordination, headaches, dizziness, vomiting, changes in sleep patterns and mood changes. These symptoms typically resolve in a matter of days. However, while some individuals recover from a single concussion rather quickly, many experience lingering effects that can last for weeks or months. The factors related to concussion susceptibility and the subsequent recovery times are not well known or understood at this time. Several factors have been suggested and they include the individual's concussion history, the severity of the initial injury, history of migraines, history of learning disabilities, history of psychiatric comorbidities, and possibly, genetic factors. Many studies have individually investigated certain factors both the short-term and long-term effects of concussions, recovery time course, susceptibility and recovery. What has not been clearly established is an effective multifaceted approach to concussion evaluation that would yield valuable information related to the etiology, functional changes, and recovery. The purpose of this manuscript is to show one such multifaceted approached which examines concussions using computerized neurocognitive testing, event related potentials, somatosensory perceptual responses, balance assessment, gait assessment and genetic testing.

Update on banned substances 2013.

CONTEXT: Doping has been pervasive throughout the history of athletic competitions and has only recently been regulated by organizations such as the World Anti-Doping Agency (WADA), US Anti-Doping Agency (USADA), and the National Collegiate Athletic Association (NCAA). These regulatory bodies were created to preserve fair play and maintain the safety of the participants. Their updated 2013 lists of banned substances and practices include a variety of drugs and practices that could cause harm to an athlete or give one an unfair competitive advantage. EVIDENCE ACQUISITION: Published websites for the WADA, USADA, and NCAA were investigated. These governing bodies update and publish their lists annually. RESULTS: The WADA, USADA, and NCAA monitor anabolic steroids, hormones, growth factors, ß-agonists, hormone and metabolic modulators, masking agents, street drugs, manipulation of blood and blood components, chemical and physical manipulation, gene doping, stimulants, narcotics, glucocorticosteroids, and ß-blockers. Some substances may be used by athletes but require formal exemption. The WADA has also recently created a category of nonapproved substances that have yet to be identified to curb athletes from experimenting with new doping agents. CONCLUSION: The lists of banned substances and practices per the WADA, USADA, and NCAA are in place to ensure the integrity of sports and maintain safe competition. Health care providers who work with athletes under the jurisdiction of these organizations should review updated lists of banned substances when prescribing medications.