Gaul, Lawrence W.
Looking back over the last 10 years of travel with the Nordic teams of the United States Ski and Snowboard Association (USSA), I am struck by the wide variety of illness and occasional injury encountered. Perhaps more to the point, I wonder why more don't get sick: airplanes, hotels, strange diets, and exposure to people from all environments in the setting of stress and fatigue. Overtraining is another contributing factor to illness and is frequently overlooked. The team physician must play an active role in recognizing and preventing this.
This article provides a brief overview of illnesses encountered focusing on common issues seen while traveling with competitive Nordic sport teams. Similar accounts from an orthopedic standpoint have been well chronicled, and the reader is directed to the reference list for more information (2). Finally, there is a short mention of nonorthopedic trauma issues, which fortunately are uncommon.
Nordic sports have three general categories: cross-country skiing, including both classic and the newer free or skating technique, ski jumping, and Nordic combined, which is both of these on the same day. Additionally, Telemark skiing has competitions at many levels. The injuries in the latter sport more closely resemble those of alpine skiing (Injury Surveillance System, International Ski Federation [FIS], and Oslo Trauma Research Institute, www.ostrc.no).
At the World Cup level, the event details change frequently, but the medical issues are similar. Of note, at the FIS meetings in Antalya, Turkey, May 2010, there is a proposal to add world championships to the ski marathon series, which may increase the risk of hypothermia and make other issues more prevalent.
Cross-country skiers and the "combiners" race in varying conditions at varying distances at various altitudes up to 2200 m (7150 feet). Jumpers have less variation but more exposure to injury. Nonetheless, at the recent World Ski Flying championships in Planica, there was not a single injury (Inggard Lereim, personal communication, May 31, 2010). Also, they are less likely to suffer from cold-induced problems, as they are able to wait inside until just before their jump.
In addition to awareness of the usual illnesses and injuries encountered, physicians and health care providers of all types need to be aware of antidoping considerations. While most of the violations are the result of intentional transgressions by athletes and their advisors, innocent, well-meaning physicians must be very diligent to not compromise the athlete inadvertently. Many common medications used worldwide are banned by the World Anti-Doping Agency (WADA, www.wada.org). An excellent reference for U.S.-based physicians is www.USADA.org/DRO, where medications and supplements can be researched. Most importantly is awareness that these rules exist and that it is incumbent upon the prescriber to seek guidance relative to the athlete's governing body. Skiers in the collegiate system function under the U.S. Collegiate Ski and Snowboard Association. Most others fall under the jurisdiction of the USSA, which functions under the FIS or International Ski Federation (www.FIS-ski.com). Most rules regarding medications and treatments are similar, but occasionally differences exist and the athlete will benefit from a savvy physician.
As a brief starting point regarding illnesses and injury in skiing in general, for the physician new to caring for these athletes, the FIS Web site has many very short articles on a variety of topics. These are found in the medical section under the medical tab.
From the standpoint of importance, both in prevalence and from a potentially performance-limiting aspect, respiratory illnesses, especially reactive airways or asthma and infection, are most prominent.
Exercise-Induced Asthma or Bronchospasm (EIA or EIB)
The entire spectrum of reactive airways is common, and it is estimated that up to 49% of racers in cold air have asthma in one form or another (1). It is this author's opinion that this number is an underestimate and that in under suitable conditions the number is much higher.
EIA is a condition whereby exercise triggers bronchospasm in a susceptible person. There has been much debate whether this represents a different entity or rather a part of the reactive airways continuum. From a practical standpoint, the debate is moot.
Asthma, EIA or EIB, and reactive airways are all characterized by cough as the most common symptom. The cough is dry and hacky without evidence of infection such as fever or sputum. This includes "racer's cough," which often can be eliminated with a suitable beta agonist such as Salbutamol (albuterol). However, prior to prescribing this or another asthma medication, the specific medicine should be vetted through the appropriate sport's governing body, as some restrict its use.
Factors inciting an attack include cold dry air. Air pollution also can contribute, as was seen in Predazo, Italy, at the Olympic winter games in Turin, 2006. The narrow valley (Fig. 1) allowed accumulation of both wood smoke and automobile exhaust. High race intensity and stress, especially in the setting of inadequate warm-up and hydration, also may precipitate an attack.
High on the list of precipitants of EIA, as athletes travel, are upper respiratory infections (URI). Many athletes will attempt to race while not fully recovered, which often will cause an attack. Care must be given in this circumstance to avoid the temptation to treat with antibiotics. It usually is caused by post-inflammatory bronchospasm. Bronchospasm can persist for months after resolution of the inciting infection.
Travel often exposes athletes and staff to other provocative agents, such as mites in hotel rooms, stress from travel, upcoming races, team interpersonal issues, and of increasingly recognized importance, exposure to ski waxes. Most notable are the perfluorocarbons or "powder." A trip to the wax room reveals air sparkling with the remnants of powder. Only a little has been written about this as a precipitant of asthma, but as any physician caring for these athletes can attest, powder can incite sudden serious attacks.
At the upper levels of racing, waxing is done by professional waxers who have been shown to have 50 times nonwaxer blood levels of at least one of the fluros, perfluorodecanoic acid (PFDA) (3). For the vast majority of racers, wax must be applied by or near the athlete, causing not only possible reactive airways but also the as yet unknown effects of high blood levels of these agents.
For the first time, at the upcoming Nordic World Championships in Oslo, Norway (February 2011), wax cabins with special exhaust systems will be employed. Unfortunately, this is not available to the average racer. However, special respirator masks are available and should be used (Figs. 2 and 3).
Respiratory infections, as in most primary care clinics, are ubiquitous and frustrating for athletes and staff alike. Often athletes are quarantined by the staff in an effort to control the spread, but this seems only marginally useful. Unfortunately, by the time the patient is symptomatic, the infection, usually viral, has spread to others.
The classic findings are well known and include cough, sputum, sore throat, congestion, malaise, and perhaps fever. Sputum may appear purulent even with a viral etiology.
Treatment largely is symptomatic, and the avoidance of antibiotics is encouraged. The latter often has been challenging, but with more widespread knowledge of antibiotic resistance, convincing both athletes and staff to abstain has become easier. Work by the Finnish Study Group for antimicrobial resistance and U.S. Centers for Disease Control and Prevention (CDC) among others has been useful (www.cdc.gov/drugresistance/links.htm).
Naturally, influenza, including the recent addition of H1N1, is a constant possibility, and physicians are advised to carry antiviral medications and be prepared for rapid spread of illness.
Some of the symptomatic treatments have, at one time or another, been either banned by WADA or are on watch lists to determine whether there are abuses. This includes products containing sympathomimetics such as pseudoephedrine, which is currently allowed out of competition but banned in competition under the stimulant classification.
Frequent questions have to do with the recovery period: what to do, for how long, and when can the athlete return to full activity? Here patience is required, and conservative clinical judgment should be used. There are no randomized controlled trials to shed light, but experience dictates rest with only gentle exercise until clearly well. Gentle exercise is difficult to define, but unless very ill, most athletes will be able to do light activity without detriment, and this may help their ability to relax during the illness. I often relate an article I read many years ago evaluating world records in running, and it was reported that approximately one-third were set within a week or so after return from a viral illness. Most athletes have done their preseason preparation and are in excellent condition at the start of the competitive season. Short periods off will be of no consequence, whereas premature return-to-sport appears to increase vulnerability to other illness and perpetuate convalescence.
Other related illnesses include acute pharyngitis, sinusitis, and occasional otitis media. These are generally viral in etiology, self-limited, and of only minor ongoing consequence to the racer.
Acute sinusitis manifests as nasal congestion, purulent drainage, even with viral origin, and sinus tenderness with percussion or forward bending. It most frequently is viral and resolves with symptomatic treatment. Steam and nasal saline, as well as local nasal sprays such as oxymetazoline hydrochloride are usually sufficient. Care must be taken to avoid banned medications such as pseudoephedrine in competition. Antibiotics should be reserved for suspected bacterial or prolonged (>1 wk) illness.
Much of the same applies to routine ear infections and acute pharyngitis. Of course, it is helpful if strep throat can be ruled out. Depending on the locale, the physician may choose to carry a few rapid strep kits along, keeping in mind the limitations of these tests.
Gastrointestinal issues are another area with great potential to thwart an athlete's, and at times a whole team's, efforts on the race course. At the 2003 Nordic World Championships in Val De Fiemme, Italy, one of the favorite nations was essentially eliminated from contention by diarrhea and dehydration. Unless a bacterial origin is suspected, symptomatic treatment with aggressive oral hydration with sport drink containing electrolytes is adequate. As of this writing, all intravenous fluid use is banned unless need is documented clearly.
In years past the furoquinolones, especially ciprofloxin, had risen to the top of preferred empiric treatments for true travelers' diarrhea. However now, because of emerging resistance (more of a problem with high prevalence of campylobacter, which is not common in ski regions) and an uncommon but well recognized issue with tendonopathies from the quinolones, azithromycin (500 mg for 1-2 d) has become popular and generally appears efficacious.
Fortunately, travelers' diarrhea is less common in the regions frequented by skiers with most areas listed by the CDC as low risk. One exception is Eastern Europe, which is listed by the CDC as intermediate risk.
Generally, viral diarrhea will resolve within 2 to 3 d, whereas bacterial varieties will last longer. Prevention is of course the best medicine, with careful attention to hygiene, food preparation, and frequent use of alcohol containing hand-sanitizing gels.
Another common gastrointestinal problem encountered is heartburn (gastroesophageal reflux disease). This is easily recognized, and the team physician is advised to keep an adequate supply of U.S. manufactured antacids, H2 blockers such as famotidine, and proton pump inhibitors such as omeprazole on hand. The stress of the race is a frequent precipitant among both athletes and staff.
Generally speaking, altitude issues are uncommon, as the upper limit for races is 2200 m at FIS-sanctioned events. Most housing is at or below this level, and it is the sleep altitude that is most important. However, an occasional person is susceptible to lower elevations. Symptoms can occur starting as early as 12 h after arrival and within 4 d. Aircrafts are pressurized to about 1700 to 2000 m, so this may start the exposure time.
There are three main high altitude illness syndromes. First, high-altitude sickness is characterized by headache, poor sleep, anorexia, lassitude, and nausea. Dexamethazone or acetazolamide at 125 mg twice daily can be used in staff; however, both are banned by WADA. Nifedipine extended-release 30 mg per day as prophylaxis or treatment is probably best in athletes.
High-altitude pulmonary edema (HAPE) is less common, although there have been reported fatal cases at 2200 m. Hallmarks include cough that may sound "wet," progressive shortness of breath, and eventually cyanosis with pink frothy sputum. Clearly this is a medical emergency, and rapid descent and hospital care are imperative.
Most uncommon but most severe is high-altitude cerebral edema (HACE). Although this is very unlikely at usual altitude, I have seen it in a World Cup altitude racer training at higher elevation just prior to a major event. Malaise, confusion, lassitude, and ataxia should prompt urgent evaluation.
Snow blindness or sunburned corneas rarely are seen, as almost all snow sport athletes and staff have access to excellent eye protection. Treatment, if encountered, is limited to patching the eye for 24 h. Symptoms persisting beyond this should prompt more formal evaluation.
Other issues for the team physician to be aware of and to consider addressing are immunizations and deep venous thrombosis prophylaxis.
Usually immunizations will be up-to-date in younger athletes but for seniors and staff a review at the start of each season is warranted. Special attention should be given to hepatitis B, meningoccocal meningitis, and influenza including H1N1 before major events and if boarding in dormitory-style housing.
The issue of DVT prophylaxis has not received much attention to my knowledge in the sport world. Working in a destination tourist resort with visitors from all over the world, I see DVT commonly, often with no provocative event except travel or minor injury. A recent review by Philbrick et al. (4) addressed the duration of airline travel as a risk factor, specifying as low-risk flights of less than 6 h in the absence of documented risk factors. This is at odds with my own empirical experience, however. Perhaps this is because high altitude may predispose patients or because almost any travel via an airport requires at least 6 h, including sedentary periods getting to the airport, waiting for flights, and other delays. Of note, in Philbrick's review, he points out that compression stockings prevented DVT but aspirin did not.
Fortunately with the advances in jump hill technology and design and the general characteristics of cross-country skiing, significant trauma is less common. However, as highlighted at this year's Olympic Winter Games, it can still happen. There, a female racer fell and slid off the course during warm-up for the women's sprint. She tumbled down an embankment and sustained multiple rib fractures and perhaps a pneumothorax.
Physicians traveling with teams should be at least provisionally competent to recognize and preliminarily manage injuries such as lacerations, which occur commonly to the face from swinging pole tips at race levels well below the World Cup level due to less developed skills, back, and ankle sprains, tendonitis, and most importantly concussion.
Because of the risk of sudden death from second impact syndrome, each physician or other provider treating athletes must be facile at recognizing and preliminarily managing concussion. In the field we use the "SAC or Standardized Assessment of Concussion" and then follow with more advanced computerized testing (ImPACT) once back in the hotel. Full discussion of this issue is beyond the scope of this article but an excellent review of this ever advancing and important topic is found at Clin J Sport Med. 2001 Jul;11(3):176-81.
Here I have attempted to review a few of the illnesses and other issues of travel with and care of Nordic sport athletes. Of particular importance is the avoidance of and awareness of medications and supplements banned by the WADA. Additionally, I have highlighted avoidance of unnecessary antibiotics, various viral infections, and the high prevalence of reactive airways and its treatment.