Penn Healthcare Review Fall 2023 Journal— Sports Medicine
P e n n H e a lt h c a r e R e v i e w Sport猀 Medicine Fall 2023 Rehabilitation & Recover礀 Neurosurgery & Neurolog礀 Orthopaedic Surger礀 Nutrition & Polic礀 Novel Technologies Wharton Undergraduate Healthcare Club
Editor-In-Chief Co-Vice Co-Heads of Executive Editors Presidents Design Om Gandhi Tingting Chun最 Shikhar Gupt愀 Aarsha Sha栀 Isha Bhandar甀 Arjan Kahlo渀 Jaskeerat Gujral Julia Gerbin漀 Andrew Le攀 Jenny Li Neil Tangal Writers Designers Editors Cindy Batulzi椀 Oscar Caprar漀 Olakanmi Adio Daniel Da椀 Tiffany Chan最 Nolan Anthon礀 Alex Gerlac栀 Siri Dand甀 Helen Ca椀 Saanvi Gupt愀 Laura Jannett愀 Ashrit Chall愀 Srijan Kalv愀 Irene Le攀 Ella Eseigb攀 Ryo Lindse礀 Aaron Le攀 Michael G漀 Andrew L甀 Sage Lelan搀 Anagha Gour甀 Grace Matwije挀 Erin M愀 Brianna Hes猀 Sasan Mournan椀 Janine Navalt愀 Hiba Jami氀 Wendell Oderkirk-Alvidre稀 Zachary Rental愀 Srijan Kalv愀 Sameeksha Pand愀 Antonia Sola爀 Amy Lu漀 Kayla Pate氀 Maggie Son最 Grace Matwije挀 Om Satapath礀 Ashley To Amarachi Mbadugh愀 Luna Sat漀 Maya Naran最 Andrew Schmid琀 Wendell Oderkirk-Alvidre稀 Anisa Sharm愀 Roshan Pilla椀 Anna Shel氀 Austin Pothikamjor渀 Saraswati Sridha爀 Jan Rossne爀 Ashil Srivastav愀 Luna Sat漀 Ethan Su渀 Anisa Sharm愀 Neeraj Tanga氀 Saraswati Sridha爀 Nidhi Ummettal愀 Ashil Srivastav愀 Allen Yan Vicky V漀 Sunny Wan最 Jessica W甀 Megan Zhan最 Richard Zhuang Cover Art by Jenny Li and Isha Bandaru
Dearest Readers, Medicine and sports each push the I 昀椀rst joined the Penn Healthcare limits of human performance. When Review searching for an avenue that combined as sports medicine, bridged my passions for journalism and incredible innovations emerge that healthcare, and ending up 昀椀nding that help athletes recover from injury and and so much more. Interdisciplinarity is return to play. This semester, our a hallmark of PHR, but its heartbeat is journal examines key themes in the fueled by creativity and collaboration. ever-advancing 昀椀eld of sports medicine⸀ Our incredible team of writers, editors, With a selection of 昀椀ve distinct sub and designers have been working themes, writers and editors have tirelessly this semester to put this crafted captivating articles ranging journal together, and I am thrilled to from high-tech helmet designs present to you the culmination of these protecting NFL players to minimally efforts.ꨀ invasive surgical techniques getting baseball stars back on the pitch㠀 From bio-inductive tissue engineering to virtual reality rehabilitation, this Here, we had the honor to interview issue forays into the multifaceted world two in昀氀uential trailblazers in the 昀椀eld of in which health, science, and sports sports medicine, Dr. Pravesh Gadjradj converge. With the help of experts in and Dr. John Kelly. These physicians the 昀椀eld both close to home and across provided valuable insight on the new the globe, we delve into a rapidly innovations and future advancements evolving landscape: unraveling the of sports medicine㠀 secrets behind peak athletic performance, investigating the latest Enjoy. We hope these compelling surgical developments, and exploring articles deepens your appreciation of groundbreaking rehabilitation human athletic achievement and the techniques.ꨀ incredible medical work that supports it㠀 What I truly love about this journal is that we can all 昀椀nd a little piece of Jaskeerat Gujra氀 ourselves inside it. Within these pages, Co-Vice President and Editor-in-Chie昀 you’ll 昀椀nd that our writers share the stories of numerous Penn students, of their loved ones, and even of themselves, and I guarantee you do not have to be an athlete to resonate with this issue.ꨀ Many thanks to the wonderful team at PHR for taking our vision and turning it into something far better than we could have ever imagined. We’ve had an absolute blast putting this issue together, and readers, we are thrilled to have you on this journey with us. Welcome to the Fall 2023 issue of the Penn Healthcare Review.ꨀ Aarsha Sha栀 Co-Vice President and Editor-in-Chie昀 Please note: These articles were prepared by members of the Wharton undergraduate Healthcare Club. The opinions do not represent the school or club’s of昀椀cial position on the issues. The Wharton Undergraduate Healthcare Club is an independent, student-led organization of the Wharton School of the University of Pennsylvania. All content is the responsibility of the club.
Contents Featured Interview with Dr. John Kelly IV, M䐀 Featured Interview with Dr. Pravesh Gadjradj, MD, PhD, MSc 3 Rehabilitation & Recovery Unraveling the Enigma: Phantom Limb Pain in Under Researched 㼀 Population猀 The Silent Menace of CT䔀 㜀 Ruptured Dreams: How Tissue Engineering Can Improve Recovery from 䌀 Tendo渀 In the Minds of Penn’s Student Athletes: Mental Health in Sports Medicin攀 1 Advancements in Recovery Technology: The Rise of Virtual Reality 13 Rehabilitation Programs Neurosurgery & Neurology Running the Race with Parkinson's Disease: The Impact of Parkinson's 1㼀 Disease on the Sports Worl搀 1㜀 American Football Kills — and That’s Norma氀 1䌀 Solutions Stem From Everywhere: Exploring Stem Cell Based Therapies to Address Traumatic Brain Injurie猀 2 Knocking Out Parkinson's: A New Hope in Boxing Therap礀 23 The Gruesome Road to Recovery: A Review of Athletic Spinal Cord Injuries Orthopaedic Surgery Three-Dimensional Printing in Orthopaedic Surger礀 2㔀 Quality Over Quantity: The Archetype of a Modern Pitche爀 2㜀 Innovations in Minimally Invasive Orthopaedic Surgery Technique猀 2㤀 The Cutting Edge: Bio-inductive Tissue Engineering in ACL Repai爀 3 Hyaluronic Acid: A New Potential Remedy to Achilies Tendinopathies 33
Contents Nutrition & Policy Dope or Nope? The Contentious History of Performance-Enhancing Drugs 3㼀 in Sport猀 3㜀 Celsius Energy Drinks to Enhance Athletic Performanc攀 3䌀 Advancing Women's Sports Medicine: Overcoming Challenges for a Holistic Approach to Athletic Healt栀 4 Cannabis Regulation in Sport猀 43 No Athlete Left Behind: Addressing the Inadequate Healthcare for College Athletes Novel Technologies 4㼀 Liquid Shock Absorbers: Innovative Protection from the Perennial Risk of Brain Trauma within American Footbal氀 4䄀 Video Games & Lower Back Pain: A Novel Approach to Connect Youth Athletes With Physiotherap礀 4䌀 Novel Mouthguard Sensors and Their Role in Better Understanding Head Injur礀 Wearable AI Coaches: Your New Right-Hand Ma渀 5 Heat Maps for Health: Medical Infrared Thermography 53
featured interview Dr. Joh渀 Kelly IV, MD Dr. Kelly is a highly experienced orthopedic surgery specialist with a remarkable 39-year career in the medical 昀椀eld. Specializing in sports injury treatment, with a focus on holistic orthopaedics and arthroscopic surgery for the shoulder and elbow, Dr. Kelly serves as the Director of Shoulder Surgery and Sports Medicine at the University of Pennsylvania. He has received numerous accolades, including being recognized as one of the Best Doctors in America from 2015 to 2023 and earning the Philadelphia Magazine's Top Docs honor multiple times between 1999 and 2022. 1 1
Can you tell us about what 昀椀rst Holistic orthopaedics is one of your drew you towards orthopedics and areas of research expertise. Can describe your career path䤀 you tell us a little bit more about exactly what this entails and how I played football in college at it might differ from a traditional Columbia, where I hurt my knee. We approach䤀 had a very kind team doctor and he First and foremost, it’s about took good care of me, and I just had respecting the whole person – this egosyntonic identi昀椀cation that respecting their dignity and trying I’d like to do this someday. So it to preserve as much of their really was a football injury in college! anatomy as possible. That’s why I I’ve always been service oriented migrated towards arthroscopic and it was a good 昀椀t for me. I wanted surgery, which is minimally invasive to do something to help people and and preserves anatomy. It’s also the experience I had with the doctor about respecting patients’ global really impressed me.ꨀ holistic health needs, getting them You’ve written a couple of books, plugged into the best possible place one of which is titled The Resilient where they can get the help they Physician. If there was one lesson need. It’s also about nutrition, you would want readers to take mindfulness, and exercise. Really, it’s away from your book, what would about treating the whole person, that be䤀 not just the shoulder or the knee㠀 A signi昀椀cant amount of your work You can’t give what you don’t have. has been dedicated to Take time to nourish your soul. Take arthroscopic surgery of the time for yourself. If you take time to shoulder and elbow. Looking to the help yourself, you’re going to heal future, what are steps you are the world much better than if you taking to better understand this ignore your own needs㠀 treatment? Are there any speci昀椀c Were there challenges during your aspects you’re interested in education that made you investigating further䤀 reconsider pursuing a career in sports medicine? What is I think it's important to keep asking something that you wish aspiring questions and challenge current physicians/surgeons better paradigms. I am engaging in very understood when deciding to cool research – looking at what it is pursue such a career䤀 about diabetes that makes in昀氀ammation worse and makes The challenges were the hours. The people stiff. The second question is residency is very arduous and looking at the thrower's shoulders, demanding. I think the best speci昀椀cally the biomechanics of the message for young people is to not shoulders and why shoulders fail at overthink it. What are you good at? throwing. We think that the current What do you love doing? If you mix treatments are overly aggressive. those with the world’s needs, then We may develop new ways of doing you found your vocation. Don't minimally invasive approaches to overthink it! treating thrower’s shoulders. It’s pretty cool stuff.ꀀ 2 2
featured interview Dr. Pravesh Gadjradj, MD, PhD, MSc Dr. Pravesh Gadjradj, MD, PhD, MSc is a Dutch neurosurgeon known for his largest randomized clinical trial in spine surgery. He completed his medical school training at the Erasmus MC: University Medical Center Rotterdam. Dr. Gadjradj did his post-doctoral research training under the tutelage of Dr. Roger Härtl at Weill Cornell Medicine and has been named Forbes 30 under 30 Europe for research in endoscopic spine surgery. As a medical student early in your training, how did you 昀椀rst start developing the hypothesis that endoscopic discectomy was valuable, and were there ever any doubts in your conviction that the gold-standard treatment of microdiscectomy could be revised䤀 It all started when I was watching surgeries – you can instantly see the difference. When you start doing a microdiscectomy, you open the spine from the posterior and already see blood coming out. In the preparatory work, you already notice that local sedation is less invasive than intubation. Also, with endoscopic procedures, you don’t open the muscles or remove that much bone, so you see that the procedure is less invasive. We had some suspicions about this, but there wasn’t data to back it up, so it was more clinical experience which showed doubt that another procedure might be better for these patients㠀 What are your thoughts on robotic-assisted surgery systems (i.e. DaVinci company)? In what scenarios, if any, might a traditional surgical procedure be advantageous over a machine-assisted procedure䤀 That's a controversial topic! In Europe, robotic surgery has not been made as it has been made in the States. In the States, a lot more departments, like the neurosurgery department, utilize robots. Personally, I am a bit critical about this. When I think of a robot, I think “Does a new system have added value?” and “Is it worth the cost?” Robots are very expensive. If we were to purchase a robot, I would like to see better outcomes in my patients. For most neurosurgical, if not all neurosurgical diseases they are not really that convincing, evidence of its merits. I am skeptical of it. 3
How can the 昀椀ndings from your research on endoscopic treatment be applied to healthcare systems globally, and what recommendations do you have in implementing this level of care on a broader, more global scale䤀 Europe and the States are already behind Asia. If you look at South Korea or Japan, endoscopic procedures had been performed for years before we started doing them. There, it’s already a standard procedure, and that’s why a lot of surgeons from all parts of the world visit professors in Korea to learn how they perform endoscopic procedures. Looking at Europe itself, endoscopic procedures are increasing in practice by surgeons in the UK, Germany, and neighboring countries. In the States, though it started as an uncommon practice, research groups are being formed to study endoscopic surgery and more and more courses are being organized, so it is now booming. ꨀ A lot of your work discusses the costs associated with surgery and healthcare in general. In what ways could you see the healthcare industry take the right steps in making healthcare more affordable䤀 That's a quite dif昀椀cult question because it is very country-dependent. A lot of countries have their own healthcare systems and groups that look at when a procedure should be reimbursed. In the BMJ study, we speci昀椀cally looked at the Dutch healthcare system. We have a threshold, where we say a new intervention that has some merit should at most cost us some amount of money- that threshold could be different in varying countries. For the Netherlands, if you look at cost savings for endoscopic surgeries, the most cost savings are with shorter length of hospital stays and how quick patients resume to their jobs and daily activities; these factors are considered to be indirect costs. These are the biggest cost savings and are more social aspects of healthcare.ꨀ In the near future, what major research advancements in PTED are you excited about that would lower the recurrence and revision rates or the intraoperative radiation exposure rates䤀 I am excited about the further development of navigation systems for spine surgery. For instance, a few years to a decade ago, when we placed screws in the spine, we would take a lot of X-rays, and the radiation exposure would be huge. Operating involved wearing lead aprons and was extremely tiring. However, now we use the O-arm, where an intraoperative CT is performed before going inside to conduct the surgery. Navigating through the procedure becomes easier, and afterward, only one run is needed, reducing radiation exposure to the surgeon and making operating easier. These navigation systems can also be applied to endoscopic surgery, so one can more easily estimate where to place the broken channel and the endoscope. I am most excited about the availability of imaging techniques that make surgery easier and safer. These studies were mostly conducted for the lower back, but I am also eager to apply them to neck disc herniations, cervical disk herniations, and thoracic disk herniations, which involve more invasive surgeries than lumbar disk herniations. Furthermore, I am interested in reducing the invasiveness of these procedures by highlighting the merits of a simpler surgery.ꨀ 4
Unraveling the Enigma Phantom Limb Pain in Underresearched Populations Written by Tingting Chung | Edited by Michael Go | Designed by Laura Jannetta Within the intricate web of human physiology is a Amputation may lead to neuroma formation, perplexing and captivating enigma known as generated hyperexcitability, and spontaneous phantom limb pain (PLP): the perception of pain and discharges. Evidence depicts that this may further discomfort in a limb that no longer exists. Coined in exacerbate stump pain, including PLP. At the spinal the sixteenth century by French military surgeon cord and brain levels, increased sensitivity and Ambroise Paré, PLP remains a poorly understood and altered brain maps due to neuroplasticity may occur, difficult-to-treat condition, and there is limited which are linked to the intensity of PLP [4]. literature on its underlying pathophysiology [1]. In Psychological factors may also play a role in PLP: the United States, 30,000 to 40,000 amputations are stress and anxiety can worsen pain, particularly in performed each year, with pain after amputation as individuals who have difficulty managing such the most common symptom [2]. A 2005 emotions when confronting challenges [5]. By study estimates that as many as 1.6 understanding these various factors, we can begin to million people suffer from limb loss unravel the different dimensions of PLP.ꨀ in the US, and this number is Virtual Reality (VR) has emerged as a rather projected to more promising tool for PLP, aiming to simulate the missing than double to 3.6 limb and provide sensory feedback to the residual million people by the limb. Despite its ability to offer a multisensory year 2050 [3]. The experience that engages with the visual and sensory etiology of PLP remains cortex of the brain and its lower costs, review studies a mystery: no singular have provided low-level evidence, with most studies mechanism has been confined to case studies and report series [6]. Mirror completely recognized, with therapy is another technique introduced in 1996, most scientists only able to designed to stimulate and resolve the visual- agree upon the fact that proprioceptive dissociation in the brain. A long mirror . severed nerve endings is placed in between the patient’s legs and set to are likely responsible face the intact limb. When the patient moves and for this pain [4].⨀᐀ watches the intact limb in the reflection of the mirror, the brain is tricked into seeing the missing limb [7]. PLP is a complex Several anecdotal reports, as well as studies in larger condition with several groups of amputees, have concluded that mirror potential mechanisms that therapy is effective in relieving the intensity, challenge its previous duration, and frequency of PLP for up to 12 weeks classification as a psychiatric post-therapy [8]. Finally, cognitive behavioral therapy disorder. New research centers (CBT) is a commonly recommended effective around the impact o昀 treatment for PLP due to its reported efficacy in PLP at different clinical practice. However, while there is adequate levels on the evidence to support the use of CBT in the neural axis⸀ management of other chronic pain conditions, 5
Fig 2. Amputee Arnold Carlton receives mirror therapy at Temple University Hospital to treat his phantom leg pain. there is a lack of published studies examining the address these healthcare disparities with a efficacy of CBT for reducing PLP in people with multifaceted approach, where increased research on amputations. CBT likely offers a palliative solution by PLP should be conducted in marginalized populations targeting the secondary factors that amputees with to eliminate barriers to receiving proper care. Lastly, PLP often experience, such as depression and publications focusing on sports participation among feelings of helplessness [10]㠀 individuals with limb amputations are limited in sample size [13]. More than 50% of people with limb With this foundational understanding in place, it is amputations will participate in sports or other clear that more research is needed to understand the physical opportunities [14]. However, there is no etiology of PLP. The prevalence of PLP in the general published data on the incidence of PLP in athletes amputee population is estimated to be as high as with amputations, even though PLP can severely 85% [4]. Minority populations are increasingly hinder sports performance and psychological well- predisposed to amputations due to unequal access being [4]. Exploration and research in athlete and treatment in our modern-day society and rehabilitation of individuals with limb amputation are healthcare systems. As a result, they are essential to better understand PLP. The benefits and disproportionately burdened by PLP, underscoring limitations of existing and future methodologies of the urgency and necessity of conducting more PLP must be explored to gain a better understanding extensive epidemiology-focused research [10]. of its role in underserved communities.䃰 Specifically, people of color are likely to face chronic conditions such as diabetes and vascular disease, which are among the leading causes of limb loss. Black Americans are 4 times more likely to experience amputation for any reason than white Americans, while Latino Americans are 1.5 times more likely, and Indigenous Americans are 1.7 times more likely [11]. Another group experiencing a high rate of lower limb amputation is veterans: 10% of amputations performed in the US are in the Veterans Health Administration. These numbers are climbing due to the growing Veteran population and the increasing prevalence of diabetes and arterial vascular disease [12]. Therefore, it is imperative to Fig 3. Navy Veteran Frederick Dean Peterson uses Virtual Reality technology to help combat his phantom leg pain at the University of Texas at Dallas. 6
The SilentThe Silent Menace of CTE Menace of CTE Writer: Wendell Oderkirk-Alvidrez | Editor: Austin Pothikamjorn | Designer: Isha Bhandar甀 . hronic traumatic encephalopathy (CTE) is a unique disease that currently has no . standard for diagnosis in living persons. CTE diagnosis only occurs a昀琀er autopsy, which makes accurate reporting di昀케cult– it is commonly confused with other C neurodegenerative diseases such as Alzheimer's. Nevertheless, it possesses a few characteristic symptoms, which come in four stages. In stage I, patients experience headaches and loss of concentration. Stage II adds depression, short-term memory Fig. 1 b loss, and bouts of aggression. In stage III, executive dysfunction begins to develop. Stage IV is terminal, with dementia completely taking hold of the patient. These e昀昀ects y arise from neuron atrophy in brain regions responsible for emotion regulation, A lam memory, and executive function. For example, areas signi昀椀cantly impacted by CTE are the frontal and temporal cortices, which are critical for decision-making and logical y reasoning㠀 The neurobiological mechanisms underlying CTE progression are distinct from similar neuropathological diseases. Apart from targeting speci昀椀c areas of the brain, CTE is marked by the accumulation and aggregation of TAR DNA-binding protein 43, a protein essential in DNA repair. However, the primary biomarker of CTE is tau protein aggregates, which are the same biomarker for Alzheimer’s Disease㠀 Fig. 2 b y B uddhis tⴀ door Global 7
The main cause of CTE is repetitive traumatic brain injuries. These injuries include concussions and are most commonly su昀昀ered by athletes in contact sports, military veterans, as well as victims of abuse. Consequently, treatment of CTE mostly follows that of standard memory care, such as in patients with Alzheimer’s and other forms of dementia. As de昀椀ned by the American Association of Retired Persons (AARP), memory care provides “a safe, structured environment with set routines to lower stress” in patients. The patient can live independently initially, but as the disease progresses, it is recommended that the patient create a last will as they lose lucidity. By this stage, it is common for partners and children to begin taking care of their loved ones. A昀琀er severe progression of the disease, the recommended course of action includes cognitive behavioral therapy, to treat mood and behavior, and cognitive rehabilitation therapy, to improve cognitive abilities. This caregiving process comes with a whole host of traumas and challenges㠀 For example, caregivers must contend with violent and uncharacteristic outbursts, episodes of forgetfulness and delirium, and other challenges, all from a person they love dearly. For the caregiver, it is recommended to streamline daily living for the patient by writing things down for them, developing a permanent Fig 4. by Sacramento Injury Attorneys Blog routine, ensuring adequate sleep and exercise, and maintaining hope. This last tip is particularly prudent, especially when facing the overwhelming and all- encompassing nature of the disease. Patience is Beyond the clinical landscape, CTE has made a o昀琀entimes the 昀椀rst thing to go in this relationship㠀 tremendous impact on sports leagues such as the NFL. Such a strong relationship between this disease and Current CTE treatments are limited. Other than the football proved to be extremely controversial for the therapies discussed above, there are no medicines that league. Even before CTE had made its way to can reverse CTE progression. Therapeutics are few American headlines, scientists a昀케liated with the NFL and far between. A few companies claim to be making demanded Dr. Bennet Omalu—a pioneer in CTE progress on the matter, such as “Therapeutic Solutions research—retract one of his 昀椀rst papers that linked International, Inc.,” which aims to bring stem cell CTE with contact sports. The NFL’s denial of the link therapy to CTE patients. There are even addiction between football and CTE extended to at least 2016.ꨀ centers that claim to provide “NAD/NADH” therapy to patients. In both cases, these claims are not supported Among NFL players, some have criticized the by any reputable academic or governmental body, organization itself. Others have even gone on record underscoring how sparse this area of research is㠀᐀ stating that they would never let their children or grandchildren play the sport. One such player, New York Giants Hall of Fame linebacker Harry Carson, stated: “But I don't want him [my grandchild] to play football, because I think this young, smart black kid, I want him to be intelligent; I want him to be brilliant; I want him to be able to use his brain and not his brawn.” He later states that he regrets playing football entirely, a sentiment that is shared by many other players in the NFL㠀 In conclusion, CTE stands as a nebulous and enigmatic disease. Distinctive in its unique origin— primarily stemming from injury in human physical activity—it di昀昀erentiates itself from other neurodegenerative diseases more closely linked with genetic predispositions or environmental factors. Constrained resources, therapy, and clinical research in CTE have collectively upended an entire industry, underscoring the critical need for increased attention to better understand and treat this complex issue. Someday, the frontier of science will uncover critical truths surrounding CTE, granting those who su昀昀er from the disease a new chance at life. Until then, however, it remains a scienti昀椀c puzzle, urging us to persist in our quest for knowledge.ꀀ Fig. 3 by Tedhyman Images 8
Ruptured Dreams How Tissue Engineering Can Improve Recovery from Tendon Injuries Writer: Om Satapathy | Editor: Vicky Vo | Designer: Laura Jannetta As the 2019 NBA Finals reached its pivotal Game 5, a Current Implementations andLimitations sense of shock rippled through the crowd as they Although there are several methods for performing looked in on Kevin Durant clutching his right calf. tissue engineering, many common principles are They all knew that he had suffered one of the sports’ utilized. Tissue engineering typically involves using a most dreaded injuries: the Achilles tear. Among the scaffold, or extracellular matrix, to generate the ideal most common yet profoundly damaging injuries in environment for cell growth to repair or restore sports are those to soft tissues, particularly tendons. damaged tissue [2]. These scaffolds vary in nature, Recovery times can last upwards of several months, as scientists can either construct them artificially leaving athletes unable to return to their previous from a broad range of natural and synthetic materials performance levels. Mending tendon injuries present or derive them from structures already present within a unique set of challenges, as tendons lack both the body [3]. The scaffold must ensure that the new cellularity and blood supply. However, in recent cell growth occurs in the correct location and years, developments in tissue engineering have orientation. Currently, the most commonly used demonstrated the potential to apply scaffolds for tendon repairs are made from collagen tissue engineering to tendon type I derived from animal tissues, as natural tendons injuries with promising found in humans mostly comprise this material [4]. results. Although tissue When making scaffolds from animal sources, we engineering for tendon must “clean” them before use in the human body, repair is an emerging topic meaning that all non-collagen substances must be of scientific research, tissue removed to prevent inflammation. The use of tissue engineering has already engineering for tendon repair has been tested in achieved some mainstream various animals and various locations. Some tested recognition in the form of sites include the Achilles tendon, the rotator cuff, and lab-grown skin and tendon-bone interfaces [5]. The results of this artificial meat [1]ਠ嘀 research have been promising; a 2018 meta- analysis of 35 studies found that the outcomes were largely favorable in using tissue engineering strategies in treating tendon injuries in animal models [6]. Another clinical trial showed that after 10 years, people who received collagen-based scaffold implants im showed improved activity lev activity levels, pain levels, an搀 . radiological results [7]. results [7]. Fig 1. Kevin Durant clutches his calf during Game 5 of the NBA finals. 9
Fig 2. Tissue engineering is emerging as a technique for tendon repair. Despite promising results, there are still certain suturing methods alone [11]. For this reason, athletes challenges facing tissue engineering. Before tissue who previously relied on explosiveness and engineering can see widespread use for tendon athleticism may need to alter the style and intensity repair in athletes, scaffolds must be adequately with which they play following tendon ruptures. decellularized and further optimized for cell However, a recent collaborative review suggests that adhesion. Due to the novel nature and limited use of the use of multiscale nanofiber-based scaffolds may these treatments, scaffolding tends to be an allow the previous mechanical properties of the expensive course of action [8]. Additionally, while Achilles tendon to be restored [12]. If deemed many studies observed positive outcomes in animal suitable for widespread use in humans, tissue models and in vitro settings, there remains a dearth engineering could drastically change attitudes of high-quality randomized clinical trials performed in toward seemingly career-ending injuries.ꨀ᐀ humans. Since the tendons of quadrupedal animals have different load-bearing requirements from Conclusion Even in its initial stages, the benefits that tissue humans, further research is needed in human clinical engineering may offer in the future are highly studies [9]㠀᐀ enticing. It is not hard to imagine a world where tissue engineering allows athletes to experience Future Uses for Sports Medicine Using tissue engineering for tendon repair can faster and more complete recoveries. Despite the present important advantages in treating sports promising results scientists have already begun to injuries. Currently, the most effective treatment observe, it is important to bear in mind that further methods mainly revolve around autografts and research, including clinical trials, will be crucial in allografts. Firstly, autografts involve taking tissue determining the applicability of these novel from donor areas in the afflicted individual’s body treatments to human patients. In short, we may be and using it to repair the damaged soft tissue. cautiously optimistic about the future of tissue Although this method can lead to quicker recovery engineering in sports medicine. times, the limited availability of suitable donor tissue and the fact that we can claim only so much soft tissue from the donor area can limit its usefulness. Secondly, allografts involve procuring donor tissue from another individual and using it to mend the damaged tissue. While this method does not require taking tissue from a donor area, there are more significant risks of infection and longer recovery times [10]. When used in conjunction with these methods, tissue engineering could allow athletes to make effective recoveries and return to the field much more rapidly. Moreover, experts contend that athletes often do not recoup the full elasticity of ruptured tendons when they are repaired using Fig 3. Tendon regenerated through tissue engineering. 10
11
12
n a world where the boundaries between physical and digital realities have blurred, virtual reality (VR) rehabilitation programs are emerging as a I groundbreaking solution, o昀昀ering new hope and opportunities for patients on their journey to Advancements in recovery. There’s nothing quite like the frustration felt after coming down with a season-ending injury; according to the NCAA, more than 1.3 million injuries occur among college athletes in the U.S. alone. The Recover礀 journey to a full recovery can be a long and grueling process for many athletes. Making that journey to recovery as comfortable and engaging as possible has Technology: been at the forefront of the growing 昀椀eld of recovery science. VR proves to be a promising solution to the various challenges that current rehabilitation programs face倀縀 Every clinician knows it can be difficult to keep Virtual athletes engaged “throughout a long rehab period. Realit礀 ⨀ urrently, there exist several signi昀椀cant issues with the rehabilitation techniques and ” strategies employed. These concerns span C across diverse aspects of the rehabilitation process, Rehabilitatio渀 from athlete engagement to workforce shortages. For instance, current rehabilitation programs do not stimulate the interest of the athletes and it is di昀케cult to keep the athletes motivated during the long Programs process. Conducting the same exercises daily in the same environment can become a dull and monotonous task [1]. Furthermore, shortages in sta昀昀 that aid in rehabilitation have led to a decline in the quality of care spanning longer wait times and limited individualized attention. Delayed care can hinder the Writer: Ryo Lindse礀 tender process of recovery and increase the risk of re- injury. The deterioration in the quality of care has led Editor: Sunny Wan最 to rates of return to pre-injury level of health after an ACL, shoulder, or elbow injury to be as low as 50% [2]. Designer: Oscar Capraro This 昀氀aw in the system is due to the lack of comprehensiveness, intensity, and sports speci昀椀city [3]. These problems can be addressed by the incorporation of VR technology into rehabilitation programs.Ḁ븀 13
he bene昀椀ts of VR rehabilitation are vast, induce dizziness and pose risks of falls or collisions ranging from boosting engagement and with real-world objects. [5] Finally, VR technology, motivation to improving pain management. especially high-quality systems, can be expensive to T One of the main bene昀椀ts of VR rehabilitation is that it acquire and maintain. Covering the steep cost of the o昀昀ers an immersive and enjoyable experience for the therapy can prove to limit access to many individuals athlete in a new environment. In this virtual realm, or healthcare facilities.ꨀ athletes can test the boundaries of their imagination, leading them anywhere from dribbling up a soccer istorically, visual motor training has been pitch to shooting basketballs on the court. This utilized for inducing changes in the central endless possibility of engagement with VR has nervous system and fostering adjustments in H contributed signi昀椀cantly to speeding up the sensorimotor functions and neuroplasticity. rehabilitation process, positively impacting various Conventional methods like “eyes open or closed,” sports programs across the country. For instance, the blinking, and the application of strobe glasses have University of Alabama football department has seen been employed by clinicians to alter visual input and an increase in athlete engagement through the provoke responses in the sensorimotor system. The implementation of VR in their rehabilitation introduction of VR systems elevates this approach, curriculum. Rather than taking the athletes to the o昀昀ering an immersive setting to dynamically adjust basketball courts for recovery exercises, VR allows visual training, thereby aiding or challenging them a temporary escape from their injury. [1最 movement and motor planning more extensively.[2]ꨀ ohnny King, a 昀椀rst-team rehabilitation he evolution of VR in rehabilitation programs physiotherapist for the Leicester City Football addresses various problems faced by Club, shares how he integrates VR into ACL traditional recovery programs and marks a T J rehabilitation. King says that “the need to promising frontier in the healthcare landscape. integrate intense neurocognitive Despite its undeniable potential to transform demands with complex traditional rehabilitation methods, VR programs still multidirectional grapple with challenges movements is an regarding cost, expertise, VR offers us a tool to maintain essential part of ACL and long-term rehabilitation.” The e昀昀ectiveness. However, interest, even when it may not VR system allows ongoing advancements, athletes to reach mileⴀ coupled with dedicated always be the most effective stones and goals set by research and themselves by participating development, hold the training tool in progressively challenging key to addressing these football drills, where ball speed limitations and unlocking the and angle of pass can be manipulated. The parameters full potential of VR in revolutionizing rehabilitation. can be manipulated to assess certain metabolic With continued innovation and a focus on “ responses, ranging from modi昀椀cations of duration, accessibility and e昀케cacy, VR stands poised to rede昀椀ne rest, and intensity of drills. Outside of the tailored the boundaries of rehabilitation, o昀昀ering training program, VR boasts a wide range of unrelated personalized and immersive games that keep athletes engaged, which helps experiences that maintain their interest. Even if such games are not enhance patient e昀昀ective training tools for the main sport of the outcomes and ” athlete, athletes are better able to apply the skills quality of life⸀ learned and tackle various di昀케cult exercises in the training regimen.[4最 lthough there is compelling evidence supporting the e昀케cacy of VR as a valuable tool in rehabilitation medicine, its application does A come with certain limitations. For example, running complex simulations demands a signi昀椀cant amount of energy and relies upon a wide bandwidth of data. These systems also require technical expertise to set up and maintain, which means that software glitches or compatibility issues may hinder the operation of the program. Furthermore, extended VR training may 14
Running the Race with Parkinson's Disease The Impact . of Parkinson's Disease on the Sports Worl搀 arkinson’s disease (PD) is a common neurodegenⴀ erative disease affecting more than 10 million people globally. Associated with alpha-synuclein pathology P and Lewy body accumulation, PD causes damage of dopaminergic neurons in the substantia nigra and basal ganglia, leading to motor and nonmotor symptoms. This was 昀椀rst discovered by Spillantini et al. in 1997 (Figure 1).ꨀ In the sports world, where precision and agility are paramount, the motor symptoms of PD, such as bradykinesia and constant tremors, pose unique challenges. Athletes grappling with these symptoms 昀椀nd performing day-to-day tasks a demanding feat. Additionally, non-motor symptoms, including depression and anxiety, further impact an athlete's mental resilience and overall quality of life. Approximately 90,000 individuals are diagnosed with PD yearly. This demographic includes globally recognized athletes like Muhammad Ali and Davis Phinney㠀᐀ Fig 1. by Los Angeles Times Written by Jaskeerat Gujral Edited by Amarachi Mbadugha Designed by Isha Bhandaru
fatigue, and masked face㠀 Before his of昀椀cial diagnosis, physicians debated whether Ali had PD or Traumatic Brain Injury (TBI), a common condition in boxers due to repetitive hits to the head and skull. An 昀氀uorodeoxyglucose-positron emission tomography (FDG-PET) scan, however, revealed progressive bilateral striatal hyperactivity and low striatal uptake, tell-tale characteristics of PD. Degeneration of this Figure 1. Image above shows the pathology of PD; a- region of the brain is common in those with PD Synuclein positive Lewy Body in the nerve cell of the Substantia Nigra⸀ due to neuronal cell death of dopaminergic neurons. Results of such tests suggested that Davis Phinney was a prominent cyclist who Muhammad Ali may have had idiopathic young- had 328 victories in his professional career, onset PD. As a result of Ali’s case, there has setting the U.S. national record. He is also an been an increase in awareness of protective Olympic bronze medalist and a Tour de France gear usage when participating in sports, such stage winner. Over the course of his career, as boxing, to prevent debilitating injuries.ꨀ Phinney gradually developed health symptoms, such as constant fatigue with In the face of PD, these remarkable athletes episodes of numbness and weakness. In 2002, have both grappled with their personal Phinney was diagnosed with PD, prompting challenges and courageously wielded their him to retire from racing and found the Davis in昀氀uence to champion increased awareness. Phinney Foundation, a national organization Yet, their efforts remain just the tip of the dedicated to raising awareness and funding iceberg in a broader mission for heightened research for PD. Every year, the Davis Phinney visibility surrounding this condition. As we Foundation serves approximately 1.5 million stand at the intersection of groundbreaking impacted individuals. Phinney also aims to research and cutting-edge technologies, the improve the lives of those who suffer from PD prospect of a cure for PD becomes more by promoting exercise. Exercise and physical tangible. The race towards a future free from activity have proven to be advantageous for PD is propelled by advocacy, innovation, and patients with PD. They are cost-effective and the unwavering hope that scienti昀椀c endeavors promising interventions that improve both will unlock the doors to a brighter, healthier motor and non-motor symptoms. One study tomorrow.ꀀ found that individuals with PD who engaged in regular exercise reported notable enhancements in both motor function and cognition. Additionally, a separate study Fig 2. b revealed that participants in a 24-week tango y Wikipedia class exhibited signi昀椀cant improvements in overall cognitive function, as assessed by the Montreal Cognitive Assessment㠀 Muhammad Ali, commonly referred to as the greatest boxer of all time, was another athlete who famously suffered from PD. Muhammad Ali exhibited signs of PD towards the end of his career. Notably, he had a left-arm rest tremor, which was publically seen as he raised the torch at the 1996 Olympics. Ali’s disease onset, starting in his late 30s to age 74, was progressive – he gradually developed the characteristi挀 symptoms: bradykinesia,⨀᐀ 16
Gladwell’s opinion as “inappropriate and disrespectful.”[3] Nevertheless, this call to action raises a multitude of questions. Does American football culture encourage an unhealthy obsession with the sport at the expense of the players? Is the current state of football sustainable for the players㼀 17
18
19
Figure 1. UCLA Broad Stem Cell Research Center
Parkinson’s Disease (PD) was 昀椀rst clinically described by James Parkinson in 1817 [3]. Affecting approximately 10 million people knocking out globally, PD is a progressive neurological disorder that affects dopaminergic neurons in the substantia nigra. People with PD face varying symptoms, ranging from bradykinesia and tremors to apathy and amnesia. More than two centuries after its discovery, the precise causes of parkinson’s PD remain elusive. Complications arising from PD now rank as the fourteenth leading cause of death in the United States, and the connection A New Hope in between head trauma and PD has become a focal point of investigation. Given the prevalence Boxing Therapy of PD and lingering uncertainties surrounding its cause, cure, and progression, it becomes imperative to recognize new discoveries which Written by Cindy Batulzi椀 hold the promise of advancing treatments, or, Edited by Srijan Kalv愀 optimistically, uncovering a cure㠀 Designed by Jenny Li In 2010, a study aimed to shed light on this Engaging in sports carries inherent matter by investigating the prevalence of PD risks, particularly in the realm of among retired Thai traditional boxers. Utilizing heavy contact sports. In boxing, for standardized screening questionnaires and instance, the incidence of clinical examinations, the study identi昀椀ed eight P concussions and Traumatic Brain cases of Parkinsonism among 704 retired boxers, Injuries (TBIs) is notably higher than resulting in a PD prevalence of 0.71%. While this in many other sports [1]. Over the years, the sport 昀椀gure may not signi昀椀cantly differ from other has undergone transformations, incorporating Asian general populations, the study's 昀椀ndings enhanced protective gear and implementing underscore potential risk factors, indicating that new rules to establish a safer environment for accumulated head trauma from extensive boxing athletes. Despite these modi昀椀cations, the (exceeding 100 昀椀ghts) might elevate persistent concern for chronic brain injuries in susceptibility to PD [4]䈀Ḁ boxers underscores the ongoing challenges in mitigating such risks [2]. Fig 1. Glenn Brueske hits a speed bag during a grand opening event for the Rock Steady Boxing studio on Westport senior living community. 21
While there is not clear evidence for the cause of While there is currently no conclusive evidence PD, recognizing possible links is crucial for supporting the long-term success of Boxing effective prevention. By increasing education Therapy (BT) for PD, it is crucial to recognize that about the risks associated with heavy contact the positive outcomes observed might be sports and understanding exactly how these immediate and short-term rather than sustained. injuries occur, new improvements can be However, this uncertainty should not discourage implemented to reduce the chance of injury in further exploration of BT as a potential PD sports, especially those linked to treatment. There exists the prospect that BT, neurodegenerative diseases like PD [5].ꀀ alongside other forms of consistent exercise, could in昀氀uence the neural mechanisms of the disease in the long run. Moreover, emphasizing education on the risks associated with heavy contact sports is essential, along with implementing enhanced measures to safeguard athletes. In the context of boxing, there is potential to reduce the prevalence of The trend between boxing therapy neurodegenerative disorders like PD. While and a decrease in falls acknowledging the associated risks and possible injuries, it's equally important to recognize that demonstrates the potential for where there is risk, there is also opportunity䈀Ḁ decrease in serious injuries in patients with Parkinson’s disease. Since the 1920’s, there has been evidence suggesting a potential relationship between brain trauma from boxing and neurodegeneration [6]. On the other hand, boxing has shown promising results for improving the motor ability of PD patients. In an ongoing longitudinal study of boxing therapy (BT) in PD, 98 patients with PD participated in biweekly boxing therapy sessions, resulting in an 87% decrease in the average number of self-reported falls per month by participants. According to the CDC, falls are the leading cause of injury-related deaths in people older than 65 years [7]. For PD patients, motor instability can lead to an increased risk of falls and other injuries [8]. The trend between BT and a decrease in falls demonstrates the potential for decrease in serious injuries in patients with PD [9]㠀 Boxing has shown possible improvement for both physical and mental symptoms of PD. Knock Out Parkinson’s, Inc. (KOPI), a non-pro昀椀t organization in Rockford, Illinois, is at the forefront of this initiative. KOPI offers boxing classes speci昀椀cally designed for individuals with PD, aiming to Fig 2. by Fightshop mitigate their symptoms. Beyond the observable physical advantages, participants in the Boxing for Parkinson’s classes highlight the invaluable support system and overall mental well-being bene昀椀ts that have emerged from their engagement in the program [10].ꀀ 22
In the United States, high-contact sports are among those most T h e popularly watched. Star athletes in these sports are often lauded for their physical capabilities and stamina; however, people aren’t G r u e s o m e aware of the severe repercussions that are associated with high- contact sports, such as football. The story of Ryan Shazier, Pittsburgh Steelers' linebacker, illustrates the potential dangers of R o a d t o football. On December 4, 2017, millions of viewers saw Shazier attempt a tackle gone wrong, that unfortunately caused him to fall to R e c o v e r y the ground with his head low, leading to his upper body to 昀氀ip over [1]. Shazier su昀昀ered a spinal cord injury (SCI) and was left paralyzed below his waist, requiring immediate spinal stabilization surgery–it wasn’t until approximately two years later that he could walk under his own power [2]. The injury served as a watershed moment in American sports, raising awareness of the perils of spinal cord injuries from high-contact sports㠀᐀ Role of Spinal Cord and Importance of SCIs The spinal cord, made up of sacral, lumbar, thoracic, and cervical spines, plays a role in our everyday function–it relays sensory information from the peripheral nervous system (PNS) to the brain, motor commands from the brain to the body, and enables our re昀氀exes through re昀氀ex arcs [3]. A part of the central nervous system (CNS), the spinal cord controls our rhythmic motion and generates central patterns [4], which are required for the foundational techniques within sports. In the US, 17,000 SCIs occur annually and make up 9% of sports-related injuries. Participation in high-contact sports possess a higher tendency for cervical SCIs; in diving and American football, for example, 98.2% and 96.3% of SCIs, respectively, are cervical, which is alarming considering sports- related SCIs could be one of the most dangerous blows an athlete may su昀昀er㠀᐀ Diagnosis of SCIs SCIs are characterized by the disruptions in neural communication due to nerve axon damage. Nerve damage could constitute primary trauma, the result of direct and often irreversible damage to the Athletic nerve from the in昀氀iction of a biomechanical force [5]. Alternatively, nerve damage could be due to secondary trauma, caused by pathological changes in response to the force, such as glial scarring, in昀氀ammatory responses, excitotoxicity of neurotransmitters and ionic imbalances [6]. These can be minimized but not prevented. Spinal The mildest form of a SCI, otherwise known as an incomplete injury, is characterized by the ability to transmit some information between the CNS and PNS, stimulate muscles, and maintain a degree of functionality. However, a complete SCI involves a more severe set of symptoms, with no possibility of communication between the CNS and PNS [7]㠀᐀ Cord Effects of SCIs SCIs can completely overhaul an athlete’s journey, potentially leading to chronic immobility, reduced sensory function, dysfunctional autonomic processes, disconnects in desired motion, Injuries and even death [8]. Aside from physical disabilities, the sudden change could engender depression or deteriorate one’s mental health; the reliance on wheelchairs, seemingly insurmountable 昀椀nancial debt, or the social ostracization associated with SCIs could Written by Srijan Kalv愀 lead to much more severe psychological conditions. With the spinal Edited by Hiba Jami氀 cord having such a prominent and integral role in everyday function, such injuries could be life changing.⠀䠀 Designed by Jenny Li
SCIs, moreover, generate a large economic burden for which hinder its ability to serve as a possible their families; lifetime treatment for SCIs could accrue therapeutic. As such, it’s paramount to sponsor research over a 1 million dollars [9], which does not even account that can accelerate the process of 昀椀nding interventions for losses in salary or employment due to disability㠀᐀ for SCIs, altering the way we approach sports-related injuries. Ultimately, the synergy of surgical and non- Therapeutic Interventions surgical treatments in SCI patients’ treatment plan could There are many interventions to appropriately treat reduce the spread of secondary trauma by applying sports-related SCIs. Surgical interventions, for example, personalized modern day technologies to overcome the are utilized to restore the stability and alignment of the in昀氀icted de昀椀cits㠀 spine. The surgical treatment varies depending on the injury site area and radiological and clinical Considering the signi昀椀cant role an SCI can have on assessments. To assess each area separately, surgeons everyday life, encouraging safer athletic practices and use Thoracolumbar Injury Classi昀椀cation and Severity rule changes to avoid SCIs could lengthen the career of Score and the Subaxial Injury Classi昀椀cation systems to professional athletes. In 1975, one such rule change quantify the neural degradation, injury morphology, and aimed to reduce SCIs prohibited blocking and tackling integrity of the Posterior ligamentous or techniques with the head. This led to a signi昀椀cant Discoligamentous complex (free of fractures, decrease in quadriplegia, reducing incidence from 16 to compressions, or rotations/translations). If the neural 5 cases per year, consequently leaving athletes in structure is dysfunctional, then the neural tissue must be healthier positions when retiring [13]. Similar rule properly decompressed [11]. Correcting alignment and changes must be further implemented to protect neural function as soon as possible signi昀椀cantly athletes’ futures, minimize risk of SCIs, and reduce the improves the neural tissue recovery, which is essential incidence rate of SCIs. In the meantime, improvements for minimizing the repercussions of the secondary in athlete apparel including appropriate padding and trauma [12]㠀 tailored spinal protection could reduce the risk of SCIs㠀 Alternatively, there are multiple non-surgical treatments Shazier’s example demonstrates the severity of SCIs and for SCI. Targeted physical therapy can improve motor creates a case for the serious consideration of SCI’s and function and mobility through a curated set of stretches. their e昀昀ects when contemplating participation in heavy- Braces can be used to guide regeneration and ensure contact intensive sports. Supporting the athletes, both speci昀椀ed immobility. Medications, such as from a physical and mental perspective, must be methylprednisolone could be administered to mitigate considered for each patient to truly ensure their best the injury, though they pose the risk of associated side recovery. However, as we continue to seek e昀昀ects㠀 improvements in athlete protection and SCI prevention, it is also important for athletes to advocate for themselves Moreover, recent advances in stem cell transplantation or seek ways to actively self-prevent the severe appear promising for mitigating neuronal degeneration; consequences associated with an SCI injury in sports㠀 Fig 1. Ryan Shazier sustaining an injury during the 昀椀rst quarter of the Pittsburgh Steeler's win. 24
Three-Dimensional Printing in Orthopaedic Surgery Written by Grace Matwije挀 Edited by Ola Adi漀 Designed by Janine Navalta Introductio渀 Three-dimensional (3D) printing is one of the latest technologies recently applied in healthcare, particularly in orthopaedic clinical settings. 3D printing has a wide range of applications in orthopaedics, most notably in surgical implants and templates, as well as in anatomical modeling. While 3D printing in orthopaedics is still in its early stages, with current applications being relatively limited, the technology holds immense promise to revolutionize the standard of care in orthopaedic surgery㠀 3D-Printed Surgical Template猀 FIG 1. Life size 3D model of patient’s pelvis. Surgical procedures for spinal pathological conditions, such as spinal deformities, spinal tumors, or spinal traumas, involve placing a series of 3D-Printed Surgical Modelin最 pedicle screws, typically freehanded, which, if 3D-printed modeling is also becoming more placed incorrectly, could result in serious nerve or commonplace in the orthopaedic 昀椀eld, serving as spinal damage. Although navigation tools to assist both an affordable and effective means of pre- surgeons with pedicle screw placement exist, 3D operative planning. Additionally, it offers a unique printing template devices may provide a more opportunity to educate medical students considering accurate and less expensive tool to guide screw a surgical specialty. Creating a 3D-printed model of a placement.⨀ bone based on a patient’s CT scan allows the surgeon to hold a physical representation of the patient’s Individualized 3D-printed templates are generated anatomy in their hands prior to entering a surgical from a patient's CT scan to guide the placement of setting, which makes it easier to choose both the pedicle screws in the spine. These templates, most appropriate orthopaedic hardware and the most tailored to each patient, ensure a precise 昀椀t with the effective surgical plan. Moreover, certain types of spine's surface during surgery. (see Figure 2) [1]. orthopaedic hardware, such as plates, can be pre- Thus far, studies have shown that using this bent based on the 3D model before surgery, which template resulted in fewer neurovascular can potentially provide better patient outcomes [6]. complications compared to the two most common This practice, known as templating, is important to screw-placement techniques (free-handed or ensure the best alignment possible for the hardware 昀氀uoroscopy-guided) [2]. Moreover, 3D-printed templates are a much more cost-ef昀椀cient navigation tool for hospitals. Unlike conventional surgical navigation tools like 昀氀uoroscopy-guided navigation, 3D-printed template guides can be employed in minimally invasive procedures, reducing operating room time and contributing to cost savings for the hospital [3]. Because of their cost-effectiveness, 3D- printed templates also can be useful in developing FIG 2. “Steps for Creation of Custom 3D Printed Implant” from regions where novel 昀氀uoroscopy-guided navigation JAAOS Global Research & Reviews5(4):e20.00230-11, April 2021 [5] is too costly [4]. 25
FIG 3. Sterile The next step will be the 3D plastic trials of printing of patient-speci昀椀c an implant. implants for all different types of surgical correction. We will get to a point where we will no longer be taking a tray of metal implants off “ the shelves, like plates and screws for fractures or implants for joint replacements. Instead, we will print in the patient’s body. Utilizing 3D printed models to the exact plate or implant that will bend the hardware as opposed to using conventional work the best for the individual 2D X-rays provides surgeons with more information patient for that problem. about the fractures [7]㠀 – Lisa Lattanza, MD, FAOA, FAAOS, 3D-printed modeling also can bene昀椀t medical Chair of the Department ofꀀ ” students and surgeons-in-training by allowing them Orthopaedics and Rehabilitation at to work with representations of actual patient Yale Medicine [11] anatomies without actually touching the patient. Medical residents surveyed agreed that the use of the models increased their understanding of spinal Conclusio渀 anatomy and helped them better devise their In conclusion, 3D-printing in orthopaedic surgery surgical pre-operative plans [8]㠀 offers novel approaches to existing surgical interventions to improve the 昀椀eld of orthopaedics. 3D-printing templates for screw placement in spinal 3D-Printed Implant猀 surgery and 3D-printing custom implants can 3D printing implants represent an exciting new revolutionize how orthopaedic surgeons are able to frontier for orthopaedic surgery which promise to personalize their course of treatment on an signi昀椀cantly improve patient outcomes if adopted individual patient level. Moreover, the use of 3D- widely. Unlike 3D-printed templates, 3D-printed printed models are already improving the way implants are beginning to enter the market for surgeons can formulate pre-operative plans and how generic surgical use, since they do not necessarily they teach the next generation of orthopaedic need to be manufactured to be patient-speci昀椀c. surgeons. Implants for hip and knee surgeries are slowly being tested in the 昀椀eld, and results show promising patient outcomes. A study comparing a cohort of patients who received 3D-printed implants for a hip replacement to patients who did not receive the 3D- printed implant reported that the 3D-printed implant patients had comparatively improved stability and reduced pain [9]㠀 Individualized 3D-printed implants are also being designed for patients who cannot accommodate standardized implant sizes due to unique anatomies, sometimes complications as a result of trauma or cancer. These individualized implants are being designed only on a case-by-case basis with a long approval process from the Food and Drug Administration (FDA) to determine whether such custom FIG 4. 3D printing for implants are truly complex fractures of bene昀椀cial [10]⸀ the proximal humerus.
Quality Over Quantity: The Archetype of a Modern Pitcher Written by Andrew Schmidt | Edited by Anagha Gouru | Designed by Zachary Rentala Baseball, America’s oldest professional sport, has Over long periods of time, repetitive valgus overload drawn thousands of fans for over a century and a may cause a micro-rupture, which, if overuse is half with its leisurely pace that can suddenly be sustained, can lead to a larger rupture and eventual interrupted at any time by one swing of the bat. tear of the ligament. A 2006 study found that injured However, despite its continued popularity, America’s adolescent pitchers, before sustaining an injury, pastime is hardly recognizable as the same sport threw more months per year, games per year, from a century earlier, and few changes have been innings per game, pitches per game, and pitches per more drastic than the increasing number of injuries year compared to the uninjured control group. In suffered by pitchers. Storylines like two-time Cy addition to continuous use, increased pitch velocity is Young award winner Jacob Degrom undergoing an a second factor that has been shown to correlate with elbow procedure every year are all too common in injury risk. A study published in 2016 concluded that the MLB, and it is important to understand the root there was a 2.6-fold reduction in risk of UCL causes of these injuries so the league can make reconstruction surgery for pitchers who’s maximum strides to ensure the safety of their players. pitch velocity was less than 86.9 mph vs those who threw over 95.7. In other words, pitchers who consistently throw at high speeds are at a higher risk of sustaining an elbow injury, a scary factor considering baseball teams highly value hard- throwing pitchers㠀 Current Baseball Trends Compound Injury Ris欀 Now that key injury factors have been well- documented, why is it that pitchers are sustaining more elbow injuries than ever? The answer lies in the advent of advanced analytics. Before the Figure 1: Elbow and shoulder injuries suffered by pitchers from 1980s, pitchers were primarily 1998 to 2015 Factors That Contribute To Elbow Injur礀 Since 1997, the prevalence of elbow injuries among pitchers in the MLB has been steadily increasing (Figure 1). Many of these injuries require an ulnar collateral ligament (UCL) reconstruction procedure, colloquially known as Tommy John surgery, which can take upwards of 18 months to recover from and is frequently devastating to a pitcher’s career. Studies have shown that the primary factor contributing to injury is overuse. Each time a pitcher throws a Figure baseball, a certain amount of force is sustained by the elbow joint that causes its lateral (inner) structures to 2 : pngimg.com compress, putting the medial (outer) tendons under tension. This bending force about the elbow is called valgus torque, and a key medial ligament, the UCL, plays an essential role in bearing this force. 27
evaluated by very simple statistics like ERA (runs stretching and rest into a pitcher’s schedule to allowed divided by innings pitched).⨀ prevent overuse. It is also important, especially for young pitchers, to develop proper throwing In recent decades, statisticians have taken a more in- mechanics that minimize valgus torque. Pitching depth approach to evaluating pitching success, and mechanics refers to the motions a pitcher makes as this has led to one major finding: increasing he is throwing a pitch towards the plate, and they are strikeouts is the best way to find sustained success in different for each player. Pitchers who have a the big leagues. Now, in the Statcast era (post-2015), controlled and easily repeatable throwing technique teams can track data like launch angle, exit velocity, have been shown to be at a lower risk of sustaining and the expected result of a ball put in play. Many use an injury.⨀ these insights to conclude that the best ways to increase strikeouts are high velocity and spin rate㠀 Proper mechanics include ensuring the baseball is released from the same arm slot every pitch, that the The unfortunate consequence of these results is that throwing arm is not lagging behind the rest of the teams are now placing a premium on such factors body, and properly following through after a pitch is that are detrimental to a pitcher’s long-term health. released㠀 Furthermore, although pitchers are throwing fewer innings than ever, strikeouts take more pitches than New Treatment猀 outs that result from balls put in play. This means the Off the field, new technologies could revolutionize average number of pitches per plate appearance has treatment after an injury is sustained. Mesenchymal increased, resulting in more pitches being thrown by stem cell therapy is a novel form of treatment where a pitching staff over a full season (Figure 3). In this bone marrow aspirate concentrate (BMAC) is way, current analytical trends are compounding the delivered to the injury site. These cells can then problem of overuse as well, and it is essential for differentiate into the types required to repair the organizations to take steps to ensure the health of damaged ligament. The literature surrounding stem their pitchers. cell treatment for UCL injury is limited, but there have been promising preclinical studies conducted in animal models. The main challenge in using mesenchymal stem cells for this indication is the inability to get progenitor cells to differentiate into ligamentous tissue. Embryonic stem cells, which have the ability to develop into all cell types, could be a potential solution; however, embryonic treatment is controversial due to ethical concerns. If this issue and others can be addressed the treatment has the potential to remove the need for surgery altogether, Figure 3: Average pitches per plate appearance from 1988-2018 eliminating the risk associated with it.ꨀ Coaching Solution猀 Instead of instituting programs to increase pitcher Conclusio渀 performance in the short-term, teams should be In professional sports, there is a tendency to view concerned with the long-term health of their players. athletes as superhuman and push them to untenable For instance, using balls as limits in order to win a game. However, this as heavy as 32 oz has approach can have serious consequences over the become become commonplace course of a single season, and especially over an even for adolescent pit- entire career. Current analytical trends are creating chers as it has been shown an increasingly risky environment for the pitchers to lead to faster pitching and it is imperative that organizations take speeds. However, it preventative measures to keep their players healthy. also has been shown to Researchers can also continue to work towards increase the risk of a improving the efficacy of stem cells and other UCL tear. Such training promising therapies that could offer monumental regimens should be benefits compared to the standard of care. As these , rarely utilized, if at all. innovations come to fruition, hopefully baseball can Instead, teams should loo欀 reach a point where injury rates begin to decline and into incorporating more fans’ favorite athletes can remain on the field. 28
Written b礀 Alex Gerlach Innovations in Minimally- Edited b礀 Nolan Anthony Invasive Orthopedic Surgery Designed b礀 Janine Navalta Techniques who underwent the MITKA experienced signi昀椀cantly less Introduction blood loss when compared to those who underwent the Orthopaedic surgery traditional open procedure [5]. This reduction in blood loss has recently shifted not only lowers the need for blood transfusions but also into a transformative contributes to a quicker recovery and diminished phase with the advent postoperative complications㠀 of minimally invasive techniques. These Minimized Postoperative Pain and Shorter Hospital Stays: innovative The reduced tissue trauma and muscle damage associated approaches have with smaller incisions translate to a milder and shorter-lived gained recognition for pain experience. In a study examining Minimally Invasive their potential to Gynecologic Surgery (MIGS), for example, it was found that ameliorate patient Fig 1. A photograph of a minimally the smaller incision lengths allowed for management of outcomes by invasive surgery [1] postoperative pain without employing opioids, which is signi昀椀cantly diminishing surgical morbidity and critical considering the ongoing epidemic in their usage [7]. accelerating recovery. This article will explore the latest This factor plays a pivotal role in patient satisfaction and the developments in minimally invasive surgical techniques, ability to engage in rehabilitation more comfortably. These examining some of the newer technologies and their bene昀椀ts are only further underscored by the shortened bene昀椀ts to contemporary practice. With the world's aging postoperative recovery times, decreasing healthcare costs, population and escalating demand for orthopaedic and liberating medical resources for other patients. interventions, advancements in surgical techniques that Underscoring this idea is a study 昀椀nding that patients who reduce postoperative complications, hospital stays, and underwent minimally invasive intracerebral hemorrhage healthcare costs are paramount. Understanding how these evacuation had signi昀椀cantly shorter stays in the NeuroICU less invasive technologies are altering the landscape of compared to open surgery counterparts [8]. patient care thus paves the way for more sustainable healthcare delivery. Advantages of Minimally Invasive Approaches Minimally invasive orthopaedic surgical techniques present an array of distinct advantages over traditional open-surgery counterparts, making them a compelling option for patients and healthcare providers alike㠀 Smaller Incisions and Reduced Scarring: Minimally invasive surgeries (MIS) involve signi昀椀cantly smaller incisions that can prevent tissue damage and scarring, allowing for a more aesthetically appealing outcome for the patient. For example, an anterior hip replacement operation traditionally requires an incision of 8-12 cm; with minimally invasive advancements, the procedure today can be done with only a 4 cm incision [2]. This not only contributes to Fig 2. A minimally invasive technique in arthroplasty, the joint reconstruction surgery [6] enhanced cosmetic results but also minimizes the risk of postoperative complications related to wound healing. In a systematic review that analyzed minimally invasive total Cutting-Edge Technologies knee arthroplasty (MITKA) versus traditional open Robotics in Minimally Invasive Surgery: Minimally invasive techniques in total knee arthroplasty, quadriceps muscle orthopaedic surgery has been signi昀椀cantly augmented by mobility and function were reported to return back to the the incorporation of robotic-assisted systems. These patient following surgery in the MITKA approach. Notable systems bring a new level of precision and control to bene昀椀ts were also found in smaller incisions for reducing orthopaedic procedures. By integrating robotic assistance, the risk of surgical site infections [3][4].⨀ surgeons can achieve intricate movements and manipulations through small incisions that would be Diminished Blood Loss: Another substantial advantage is exceptionally challenging with traditional manual the reduced intraoperative blood loss associated with techniques. The Da Vinci Surgical System, being an minimally decreased bleeding during surgery. Patients emblematic example, employs a combination of robotics 29
and computer-assisted navigation, in doing so allowing surgeons to control the robotic arms with great precision and thus perform delicate tasks with utmost accuracy [10]. This is particularly valuable in orthopaedic procedures where intricate implant placements or joint reconstructions are required. Clinical studies illustrate the advantages of robotic-assisted orthopaedic surgery. In a study focused on robotic-assisted total knee arthroplasty, it was observed that the robotic system signi昀椀cantly improved implant alignment and reduced the number of outliers, ensuring that the implant placement is precise and minimally Fig 3. Mini-Navigation Tool in Hip Arthroplasty [12] invasive [11]㠀 threaten patient safety, anesthetic exposure, or surgical Navigation Systems: Navigation systems in minimally team fatigue [16]㠀 invasive orthopaedic surgery provide real-time imaging guidance, offering surgeons a visual roadmap during the On the economic side, there are challenges presented with procedure. These systems work through a combination of cost and accessibility. Minimally invasive procedures advanced imaging technologies, including 昀氀uoroscopy and sometimes incur higher upfront costs due to the need for intraoperative CT scans, coupled with specialized software specialized equipment, such as robotics or navigation that interprets the images in real-time. This technology systems. While they may lead to long-term cost savings, the essentially acts as a GPS for orthopaedic surgeons, initial investment can be a deterrent for healthcare enabling them to make precise incisions, place implants, institutions. Moreover, not all healthcare facilities have and navigate complex anatomical structures with a high access to these advanced technologies, limiting patient degree of accuracy [13]. With improved guidance, surgeons access to minimally invasive procedures [17]. As a result, the can minimize tissue disruption, making smaller incisions cost implications and limited accessibility can pose while ensuring that the surgical objectives are met with challenges, potentially exacerbating healthcare disparities. unparalleled precision. A study in the Journal of Arthroplasty demonstrates the value of navigation systems Conclusion in orthopaedic surgery. In their research, navigation- In the realm of orthopaedics, the venture into MIS assisted hip arthroplasty signi昀椀cantly improved the techniques reveals a framework teeming with potential. But accuracy of implant positioning. The real-time feedback its associated array of bene昀椀ts does not come without a set provided by navigation systems enhances surgical precision of intricate challenges and considerations. Problems like while facilitating minimally invasive procedures [14]. surgeon training and cost considerations require attention that cannot be ignored. Despite this, however, the ongoing development of cutting-edge technologies promises a Challenges and Considerations bright future for orthopaedic surgery, with the potential to While minimally invasive orthopaedic surgery techniques enhance patient care and surgical precision. It is imperative offer a wealth of advantages, several challenges and that orthopaedic practitioners heed the lessons from considerations must be acknowledged to gain a research and experience, prioritize structured training, comprehensive understanding of the approach's ensure equitable access, and uphold patient autonomy. complexities.ꨀ These pursuits are instrumental in realizing the full potential of minimally invasive techniques, and their completion will One of the primary challenges in the adoption of MIS lies in continue to rede昀椀ne the boundaries of orthopaedic care. the surgeon's training and the associated learning curve. Surgeons must become pro昀椀cient in performing procedures through smaller incisions, which necessitate a Fig 4. DaVinci Surgical higher degree of dexterity and precision that forms a barrier System [10] to more widespread adoption of less invasive approaches [15]. Even despite this training gap, there are also worries regarding the surgery itself, with potential complications that create a less ideal risk pro昀椀le. In orthopaedic robotics, for instance, there is a potential for technical malfunctions or errors in the Da Vinci system that may leave patients contemplating the value of the decreased scarring or recovery time. Surgery time itself is also threatened by these minimally invasive techniques, as some critics contend that the meticulous precision required in minimally invasive surgery can result in longer procedures. This concern is particularly relevant in complex orthopaedic surgeries where precision is paramount; these longer durations might 30
31
32
33
34
DOPE OR DOPEOR Written by Shikhar Gupt愀 Edited by Ella Eseigbe & Amy Lu漀 NOPE? Designed by Antonia Solar NOPE? The Contentious History of Performance-Enhancing Drugs inSports nitida) to compete in races since football, began using these From Ben Johnson to Brittney ancient times. For millennia, the substances to enhance their Griner, the use of performance- Andean Native Americans of Peru strength and increase their muscle enhancing drugs (PEDs) have long have consumed coca tea or mass. Some of the most famous been a source of high-profile chewed coca leaves to boost their athletes of the time, such as controversy in the sports world. resistance to altitude sickness [1]㠀 Canadian sprinter Ben Johnson, PEDs are substances used to were found guilty of using anabolic improve athletic performance, and steroids, which not only tarnished their use often raises critical Emergence of Modern PED猀 legacies but also the reputations of ethical and health concerns. This While PED usage continued, the sports regulatory agencies around article delves into the history and 1960s-1980s marked a turning the world as well.⨀ current state of PEDs in sports, point as East Germany infamously drawing on famous cases and sponsored doping programs, which events to explore the evolution of The Ben Johnson Scandal aimed to create elite sports teams PEDs use and the ongoing ethical by administering anabolic steroids (1988⤀ debate surrounding substance use and other drugs to athletes [2]. The Ben Johnson scandal during in sports㠀 Athletes from East Germany the 1988 Seoul Olympics was a became a dominant force in watershed moment for the world of international competitions, with Ancient Use of PED猀 sports. Johnson, a Canadian backlash from the community. The The use of PEDs can be traced sprinter, tested positive for consequences of these programs back to ancient times, as plants stanozolol, an anabolic steroid that were profound, not only for the were the source of many of the promotes strength and lean muscle athletes themselves but for the first stimulants. Records of Norse growth [3]. This discovery international sporting community. mythology include references to disqualified Johnson from the PEDs appeared at the forefront of boosted fighting ability via the competition and sent shockwaves sports news, and international anti- usage of the hallucinogen throughout the sporting world. doping campaigns gained traction㠀 bufotenin, a drug sourced from the Subsequent testing at the fly agaric (Amanita muscaria) Olympics revealed that at least half At the same time, anabolic fungus. Norpseudoephedrine, a of the athletes who trained in Seoul steroids, such as synthetic psychomotor stimulant found in the used anabolic steroids to enhance testosterone, were gaining African plant kat (Catha edulis), their performances, prompting popularity in professional American was used to boost energy. West widespread outrage and worldwide sports. Athletes, particularly in Africans have been using cola media coverage [4]. These bodybuilding and American plants (Cola acuminita and Cola 35
controversies led to the nutritional condition. As a result, there is significant variation in hGH establishment of anti-doping secretion internally and cross comparatively between athletes. Due to it agencies and policies to prevent being difficult to detect, hGH has become one of the most controversial similar incidents in the future㠀 PEDs in the modern era㠀 The 2003 Bay Area Laboratory Co-Operative (BALCO) Scandal exposed a Current State of Anti- network of athletes, coaches, and suppliers involved in doping practices. Doping Measure猀 Balco had provided hGH to several prominent American athletes, including To combat the ongoing challenge Marion Jones and Tim Montgomery. This was revealed following a raid on of PEDs, the World Anti-Doping BALCO's Agency (WADA) was established in offices on ... many of these substances can have 1999 [5]. WADA plays a central role September 3, “ serious, long-term consequences for in setting global anti-doping 2003, when standards, conducting tests and athletes, such as ‘hematologic, cardio- proof of implementing sanctions. For systematic vascular, psychiatric and neuro- instance, WADA’s Athlete Biological doping was Passport initiative strictly monitors psychological, and hormonal and discovered, changes in an athlete's blood implicating metabolic effects’ [11崀 profile, making it harder for numerous athletes to manipulate their ” high-profile figures in American The Ethical Dilemm愀 physiological parameters to hide football, baseball, and athletics [7, The use of PEDs in sports raises doping. Anti-doping measures have 8]. This investigation highlighted critical ethical concerns, as it also become more stringent, with the persistence of doping and challenges the notion of fair lifetime bans and the forfeiture of prompted concerns about the competition, because athletes who medals as potential consequences credibility of athletic achievements 8 use PEDs gain an unfair advantage for athletes found guilty of using over their competitors. Moreover, these PEDs㠀 High-Profile Cases and the health risks associated with Their Impac琀 PEDs are a major concern, as many The Modern Doping Numerous high-profile cases have of these substances can have Landscap攀 exposed the pervasive nature of serious, long-term consequences The 21st century has seen the PED use in sports. One of the most for athletes, such as hematologic, emergence of more sophisticated infamous cases involved Lance cardiovascular, psychiatric and and elusive performance- Armstrong, a seven-time Tour de neuropsychological, and hormonal enhancing substances. Athletes France champion. In 2012, and metabolic effects” [11]㠀 have turned to substances such as Armstrong admitted to using PEDs growth hormone, erythropoietin throughout his career. In 2015, Conclusio渀 (EPO), and designer steroids, Russia faced allegations of state- The history of PEDs in sports is which are harder to detect and sponsored doping, which led to a riddled with controversies and offer significant performance widespread ban of Russian ethical dilemmas. From the early advantages. Human growth athletes from international use of stimulants in ancient Greece hormone (hGH) is a peptide that competitions [9]. The scandal to the emergence of state- has a brief blood half-life and a low sparked controversies and raised sponsored doping programs and urine concentration. The primary questions about the extent of modern sophisticated substances, 22 kDa isoform released by the doping in professional sports and PEDs have significantly impacted pituitary gland shares the same the integrity of international the world of sports. The efforts of sequence of amino acids as the competitions. More recently, in anti-doping agencies like WADA recombinant manufactured version. 2022, WNBA star Brittney Griner have made strides in curbing PED A post-transcriptional change of faced a high-profile detainment for use, but high-profile cases and the molecule cannot be used to cannabis possession, a banned evolving substances continue to discern the differences between WADA substance, raising questions test their integrity. Striking a the recombinant and natural forms about the effectiveness of anti- balance between fair competition [6]. Furthermore, hGH is a stress doping policies and the regulation and athlete health remains a hormone that is influenced by a of substances deemed legal in complex issue, with no clear number of variables, including certain jurisdictions, but not in solution㠀᐀ mood, sleep, physical activity, and athletics [10]㠀 36
37
38
39
40
Written by Anisa Sharm愀 Edited by Brianna Hes猀 Designed by Antonia Solar Cannabis Regulation in Sports Prohibited List, outlining all substances and Cannabis testing has become a widely methods considered as doping given their integrated practice for athletic competitions ability to enhance performance or conceal the even though it does not enhance performance. usage of a banned drug or substance at all Currently, both the World Anti-Doping Agency times and during competitions. Prohibited (WADA) and the National Collegiate Athletic substances and methods include narcotics Association (NCAA) forbid the consumption of and gene doping, respectively. However, many cannabis in competition. Athletes are American professional leagues are not frequently evaluated for performance eligibility signatories; therefore, they are not required to based on a threshold level of comply with these cannabis regulations. WADA tetrahydrocannabinol (THC), a psychoactive bans substances or methods if athletes meet biological compound present in marijuana. at least two of three of the following Especially in the United States, there is an categories: “posing a health risk to athletes, emphasis on restricting the consumption of potentially enhancing performance, or marijuana in athletics over other substances violating ‘the spirit of sport’” [2]⸀ like alcohol largely due to a greater knowledge Currently, there is substantial debate around of the latter’s impacts on the body. However, whether marijuana enhances the athletic marijuana is beginning to adopt an outlook performance of competitors. Dr. Margaret more like alcohol in sports, with looser Henney, a neurobiology professor at the restrictions and a focus on harm-reduction Columbia University Irving Medical Center, strategies in athletes. This often entails disagrees with WADA’s defense of its decision educating athletes on drug usage and to ban cannabis because of performance enrolling them in programs seeking to reduce enhancement capability as she believes that usage᐀䈀 the related data is inconclusive and antithetical. Henney highlights findings that recorded reduced endurance after cannabis consumption. This article also pins the World Anti-Doping Cod漀᐀ potential performance augmenting abilities of cannabis on cannabidiol (CBD), a biological compound present in cannabis that can WADA’s World Anti-Doping Code, a improve anxiety and sleep. CBD, however, was periodically-revised compilation of WADA’s removed from WADA’s Prohibited List in 2018. anti-doping policies and standards for all In the 2018 Clinical Journal of Sports medicine, sports, applies to all 660 of its compliant Dr. Alan Vernec, WADA’s current Chief Medical organizations, or signatories, notably including Officer, asserted in an article that no evidence the International Olympic Committee and U.S. Anti-Doping Agency. The Code includes a 41
supports that cannabis can improve athletic professional sports organizations, has begun performance. However, it is largely to shift attitudes towards marijuana as it has uncontested that WADA can maintain cannabis become more conventional for both medical on their list because of the other two and recreational usage. These organizations standards [3]⸀ hold major influence over the American public, The U.S. Anti-Doping Agency’s adherence to such as Major League Baseball (MLB) and the WADA’s Anti-Doping Code was underscored National Football League (NFL) which are both when track athlete Sha’Carri Richardson was not WADA signatories [7].ꀀ restricted from competing in the 2021 Tokyo Starting in 2020, natural cannabinoids, Summer Olympics. Despite winning the which include THC, CBD and marijuana, were American Olympic trials in the 100-meter race removed from the MLB’s “drugs of abuse” list, in June 2020, making her eligible for a spot on indicating these compounds are being treated the Tokyo roster, Richardson's name was like alcohol for athletes with conducts absent from the roster released in early July prompting “mandatory evaluation, voluntary due to a positive marijuana test. Richardson treatment and the possibility of discipline by a acknowledged her marijuana use, attributing it Player’s Club or the Commissioner’s Office” [8]. to coping with the recent passing of her Also, reflecting a more relaxed outlook biological mother. Despite accepting a 30-day towards cannabis, the NFL stopped including suspension, she was unable to compete in the THC in their random drug tests for players Olympics [4]⸀ during the preseason in 2021 [9]⸀ After Richardson’s disqualification from Cannabis testing mechanisms have also competing in Tokyo, the U.S. Anti-Doping been modified in recent years largely due to Agency supported WADA in reevaluating inaccuracies with current testing. For instance, whether cannabis belonged on their Prohibited the Ultimate Fighting Championship (UFC) List in 2021. However, WADA’s scientific review now allows competing athletes to consume did not prompt a modification of their list. cannabis, and the organization eradicated the Although it is accepted that marijuana can banning of natural cannabinoids (including have deleterious effects on health, according THC), barring consumption for “performance- to Scientific America, current research enhancing purposes,” in January 2021 [10]. suggests that cannabis is not more harmful UFC Chief Science Officer Matthew Fedoruk than alcohol [6]㠀᐀ explained cannabis usage “to deal with grief” is permitted. Had these guidelines been relevant to the 2021 Tokyo Olympics, Richardson, acting in accordance with state The Changing Marijuana Testing legislation when she smoked, could have Landscap漀 participated without issue⸀ In September 2023, NCAA’s Committee on With a drug-testing program dating back to Competitive Safeguards and Medical Aspects 1986, the NCAA, as well as other American of Sports recommended a removal of cannabinoids from their list of banned substances, which was heavily rooted from the December 2022 Summit on Cannabinoids in College Athletics hosted by the NCAA to discuss and review the current “literature, policies and research about cannabinoids.” This recommendation hopes to align the NCAA with “membership opinions and the shifting cultural and legal landscapes.” The Committee noted the lack of efficacy in the current policy of “banning, testing and penalizing” and their list’s focus on performance-enhancing drugs [11]. Policy will likely continue to adapt as cannabis is further studied. Marijuana, and its role in athletics, will continue to be a major conversation in the world of athletics, especially in the US as marijuana becomes more integrated throughout society⸀ Fig. 1 : Athlete Sha’Carri Richardson at the 2021 Tokyo Olympic Trials. Named USATF track and field athlete of the year in 2023⸀ 42
43
What needs to chan e movin forward? g g
45
46
Wearable AI Coaches: Written by Ethan Sun | Edited by Richard Zhuang | Designed by Zachary Rentala Artificial Intelligence (AI) is quickly becoming For athletes specifically, a team of researchers in pervasive in our everyday lives, and health India has recently performed a literature review of monitoring and coaching is no exception. In a number of AI systems that take information from recent years, Apple watches, fit-bits, and other wearable sensors to make health wearable health devices have essentially become recommendations to athletes. These AI techniques wardrobe essentials for many of us, and with a can detect patterns in an athlete’s physiology as market-size valued at $26.8 billion in 2022, the well as their positional and kinematic data to field of wearable health coaches is primed for inform how athletes can improve their innovation. AI fulfills this need perfectly: as performance. These algorithms help athletes train generative AI and machine learning technology before competitions, optimize their performance have advanced extensively in recent years, during events, predict the possibility of injury people have become hyper-aware of the prior to its occurrence, and finally diagnose potential of AI to fulfill needs in their personal ailments post-competition.ꨀ lives, and several companies have launched new AI-powered product lines to meet consumer demands㠀 These wearable devices can take health-related information from a variety of different sources, such as heart rate, blood oxygen, physical exertion, and sleep duration and quality. These metrics are considered by AI algorithms, which produce a range of health recommendations. Your AI coach could suggest how much energy to exert in a certain day and what habits are hurting or helping your body. From the Fitbit Versa to the Apple Watch Series 6, major companies are already putting out AI-powered wearables that will analyze large stores of biometric data㠀 Fig 1. freepik 47
Notably, it was revealed in a recent report that For example, by tracking movement, breathing, even Apple is working on an AI health coach, and heartbeat, the Quartz app could analyze the codenamed “Quartz.” The coach will take the overall quality of your sleep and suggest a new form of a standalone app, using various health sleep schedule, remove distractions from your metrics and motivational techniques to create sleep environment, or recommend different personalized coaching programs for the app’s sleeping positions to increase comfort. users. Forget closing your rings on your Apple While AI-powered health coaches are about to Watch – Quartz, which is yet to be officially enter the market in a big way, there is always announced but may launch next year, could room for improvement – for instance, there will be become the next industry standard for health inherent socioeconomic bias, as only those with and sports coaching, used by millions to enough money to buy and use wearable health accomplish athletic and health-related goals. devices will be the ones to provide data for models to train on. As such, the model may be predisposed to more affluent lifestyles and less equipped to coach other demographics, though this may resolve itself as AI-powered devices become more affordable and accessible. AI can also be optimized by reducing sensor misdetection–for example, what does a heartbeat feel like versus the natural movement of your wrist? Finally, as people begin to strap on their first AI coaches, we must begin to analyze the stakeholders that will be impacted by these novel devices, including users, programmers, policy makers, and of course, human coaches and personal trainers. Indeed, users may benefit from Fig 2. 昀椀tness tracking watch cheap and ready access to an AI health coach, but While Apple has been relatively secretive about may have concerns over data privacy. Likewise, their new product, the advantage of an AI-based programmers and policymakers will have to health service is easily understandable. Whereas regulate and compromise over the integration of the Health app and similar products functioned these AI systems in our everyday lives, and human mostly like trackers–recording and displaying a coaches will likely need to find a way to limited number of metrics like steps or estimated incorporate AI in their training programs, working sleep duration–an intelligent app like Quartz with this innovation to provide a more thorough would be able to analyze considerable amounts of health service. In any case, AI-powered wearable data and, rather than display it in raw form, utilize devices are entering the market rapidly, and may these inputs to make health recommendations. revolutionize the way you shape your new lifestyle. 48
49
50
Figure 1. University of Wisconsin-Madison are collaborating with the NFL on designing an effective mouthguard to reduce head injuries Novel Mouthguard Sensors and Their Role in Better Understanding Head Injuryꀀ Writer: Daniel Dai Editor: Jan Rossner Designer: Siri Dandu CITATION Every year, concussions and head trauma reemerge as a major talking point in the NFL㠀 In 2022, the NFL faced great scrutiny over its The NFL issued a statement in which “ataxia”, a lack concussion protocol as Miami Dolphins quarterback of coordinated movements, was added to the list of Tua Tagovailoa suffered repeated head injuries symptoms that would bar a player from returning to throughout the season [1]. The NFL’s game day the game. The addition of ataxia to the no-go concussion protocol consists of a list of “no-go” symptoms will likely protect a greater number of symptoms: in the event of a collision, game day players who sustains head injury by allowing them medical personnel will evaluate whether or not the rest and barring them from returning to the 昀椀eld. player is experiencing any of these immediate no-go Despite this new policy, players are still susceptible symptoms. Prior to Tagovailoa’s injuries, the no-go to head injury. Though the NFL reports a downward criteria included loss of consciousness (including trend in concussions (from 275 in 2015 to 187 in fencing posture and/or impact seizure), gross motor 2021), former players and legal experts are instability (GMI) as well as amnesia. It was skeptical of whether or not the protocols are always concluded that the GMI suffered by Tagovailoa in a followed and cases documented [2].ꨀ previous game was the result of a previous back In response to this scrutiny, the NFL has expanded injury, which was examined by other members of upon its efforts to collect data from on-昀椀eld head the medical staff. The failure of medical judgment impacts by partnering with an expanding network of displayed in Tagovailoa’s recurrent injuries has research universities. How do they plan on elicited former players to call for a change in the collecting this data?⨀ concussion protocol to better protect its players. In response to this, the National Football League Through novel mouthguard sensors⸀ Players Association (NFLPA) terminated the unaf昀椀liated neurotrauma consultant (UNC) who had dismissed protocol during Tagovailoa’s 昀椀rst injury. 51
In the past two years, the NFL has partnered with ZERO2 MATRIX QB, according to the NFL, Align Technology, the same company that demonstrated a 7% improvement in quarterback- manufactures Invisalign, to design high-tech mouth speci昀椀c testing compared to the most widely used guard sensors. These mouthguards are used to helmets among quarterbacks to date [7]. This collect kinematic data such as “impact speed, development allows for customizable gear to help direction, force, location and severity” by players at players better protect themselves from head injury.ꨀ 10 NFL clubs and numerous collegiate teams [3]. Understanding the dynamics of on-昀椀eld collisions is The mouthguard is then able to calculate the force crucial for developing effective protocols to and identify the location of each impact [4]. The safeguard professional athletes from concussions purpose of implementing these mouthguards is to and head injuries. Athletes engaged in contact accumulate larger sample sizes of data in order to sports face an elevated risk of traumatic brain observe contact trends during play that lead to injuries, including concussions and recurrent head increased risk factors for concussion. The data is trauma. Prolonged exposure to such trauma currently being analyzed by the Center for Injury increases the likelihood of chronic traumatic Research and Prevention at The Children's Hospital encephalopathy, characterized by the accumulation of Philadelphia to identify risk factors for speci昀椀c of tau protein—similar to the phenotype seen in kinds of head trauma such as player . Alzheimer's disease. Th攀 position [5].ꨀ . . initiative to gather head In essence, the deployment of this impact data is instrumental i渀 technology and the resultant data empowering professional sports promise to better our understanⴀ leagues to devise enhanced ding of head trauma in football. It protocols for the long-term enables insights into speci昀椀c details protection of players. This such as the impact zones for differⴀ not only alleviates concerns ent positions, the vulnerability of about safety but also enables certain positions to speci昀椀c pla礀 athletes to perform at their best. sequences, and whether recurren琀 Consequently, the integration minor collisions can contribute to of real-time game data from concussions or long-term head these innovative mouthguards injuries. The conclusions drawn from heralds a transformative era in this data may pave the way for adⴀ football, maximizing player safety⸀ justments in rules, changes in concussion protocols, and the development Figure 2 from Wired of more position-speci昀椀c protective gear㠀 One recent application of this data has emerged in position speci昀椀c helmets. Previous studies have already shown a variability of head trauma area by position: positions such as offensive linemen sustain a greater proportion of impacts to the front of their helmet; whereas quarterbacks often sustain more hits to the back of their helmet [6]. Bringing together data collected from mouthguard impact assessments and continuous helmet testing, the NFL and NFLPA made a groundbreaking announcement in April 2023. For the upcoming 2023 season, they unveiled the inaugural quarterback-speci昀椀c helmet. Notably, the VICIS ᐀㐀 Figure 3 from Twitter 52
53
54
A special thanks to WUHC’s Sponsors Our Platinum Sponsors Our Gold Sponsors Our Silver Sponsors
Scan the QR code to access all endnote and image citations.
Wharton Undergraduate Healthcare Club