Tips from your SEM Physician

Being physically active throughout pregnancy is important for the health of both mom and baby!

Pregnant women should aim for at least 150 minutes of moderate-intensity physical activity every week, ideally spread over a minimum of 3 days per week.

To learn more, click the image below:

You can also find out more by visiting the Canadian Society for Exercise Physiology at:

https://csepguidelines.ca/guidelines-for-pregnancy/

Physician Information

The importance of exercise in pregnancy has never been clearer. It has been associated with decreased risk of gestational diabetes, gestational hypertension, pre-eclampsia, excessive weight gain, and depression.

All women should aim for a minimum of 150 minutes of moderate-intensity activity split over a minimum of 3 days per week. Moderate-intensity activity has shown no negative consequences on maternal or fetal health.

For additional information, please review our Exercise for Pregnant Patients handout below:

Caring for pregnant women who engage in high-intensity physical activity can be more challenging. There is limited research to guide recommendations and many recommendations are based on expert consensus. Consulting with an experienced clinician in your area is highly recommended.

To become more comfortable caring for pregnant women, consider reviewing the following resources:

2019 Canadian Guideline for Physical Activity throughout Pregnancy
2016/2017 IOC Expert Group Meeting on Exercise and Pregnancy in Recreational and Elite Athletes

A complete list of references reviewed in the creation of the above resources can be found here.

Graphic Designer: Nils Gritters, BSc, MD candidate

A groin strain or a groin pull is an injury to any one of the adductor muscles resulting in inner thigh pain. A pulled groin muscle can range from very mild to completely debilitating. Symptoms of an acute groin strain typically include a sudden sharp pain in the groin area, either in the belly of the muscle or more proximal. There may also be rapid swelling followed by visible bruising. Groin strains are graded 1, 2 or 3 depending on the extent of the injury.

• Grade 1: a small number of muscle fibres are torn resulting in some pain but allowing full function.
• Grade 2: a significant number of muscle fibres are torn with moderate loss of function.
• Grade 3: all muscle fibres are ruptured resulting in major loss of function.

Acute complete ruptures of the proximal adductor longus tendon are rare but challenging injuries to treat. The main function of the adductors is to pull the legs back towards the midline (adduction). In day to day activity, the adductors are used to stabilize and control the movement of the legs when walking or running. In the athlete population these muscles are activated in sports that require running/sprinting, skating, kicking, hurdling and any rapid changes in direction. The rupture or tear in the muscle usually occurs during explosive movements when the leg is in a position against resistance such as kicking a ball.

Diagnosis is often based on physical exam and ultrasound or MRI imaging. It is often alarming when we see the term “full thickness tear” in an imaging report and frequently results in an urgent referral to an orthopaedic surgeon. This article was interesting and helpful in assisting with the nonoperative management of adductor/groin ruptures and reassuring to know that surgical intervention is rarely necessary.

In summary, nonoperative treatment of proximal adductor tendon rupture results in a statistically significantly faster return to play than does operative treatment in athletes competing in the National Football League and avoids the risks associated with surgery while providing an equal likelihood of return to play at the professional level. When extrapolating to the normal population it can be said that return to recreational sport and manual labour jobs can occur successfully with conservative management and physiotherapy.

As a family medicine physician that works in general practice and sport & exercise medicine, I see patients present with a variety of injuries and ailments on a daily basis. I have a second passion and career however as a group exercise instructor, and I know that there are many benefits from participation in fitness classes! What does the evidence support?

A randomized control study published in the British Medical Journal in 2007 demonstrated improvements in walking speed, shoulder mobility, mood, and breast cancer specific quality of life after 12 weeks of group exercise training. Rehab programs are now starting to include group exercise for less traditional diseases such as heart disease as a result.

Optimal treatment for Fibromyalgia has included physical activity recommendations for years. It was recently demonstrated through a RCT of 207 women that combining group exercise (strength, aerobic, flexibility) with self-management education improves functional status, self-efficacy, and decreases key symptoms of fibromyalgia.

Falls in the elderly are often a concern due to poorer balance and less strength to support their frames. Low-moderate group exercise programs that include strength, endurance, mobility, and balance have shown significant increases in activity level and a subsequent relative drop in the 3-month fall rate.

But what about younger individuals? A fitness and nutrition intervention program in 10-12 year old children was evaluated in 1995 with a few key findings. Teacher implemented health programs including fitness and nutrition training resulted in improved fitness levels and lower diastolic blood pressure. It also resulted in decreased fat intake and increases in fiber intake. Fitness training had a more significant effect than the nutrition education groups.

It is clear that I can make a difference in the health and wellness of individuals I see, both in my career as a physician, but also as a group exercise instructor.

These programs should be included as a treatment options to our patients more frequently.

Recognition and Management of Exertional Heat Stroke:

With the summer months now upon us, there exists a possibly of athletes suffering from exertional heat stroke (EHS). Proper recognition and management of EHS is critical and can be lifesaving. The following is a summary of recommendations put forth by The American College of Sports Medicine and published in ‘Current Sports Medicine Reports’ in 2012. An article from 2011 in ‘American Family Physician’ was also referenced.

Definition of EHS: A core temperature of >40 degrees Celsius, coupled with central nervous system alteration characterized by altered behaviour (not necessarily loss of consciousness).

Predisposing factors: EHS is complex and varies from athlete to athlete. The following is a list of potential contributing factors:

• Low level of physical fitness
• Intensity of activity
• Sleep deprivation
• High ambient temperature
• Intense solar radiation
• Exercise intensity not matched to physical fitness
• Medications that alter heat dissipation (i.e.: antihistamines, anticholinergics, calcium channel blockers, amphetamines)
• Dehydration

Diagnosis of EHS: The paper outlines that most deaths from EHS, if diagnosed and managed within 10 minutes of collapse, are preventable. Proper diagnosis requires:

• That temperature is taken rectally. Any other form of temperature measurement (i.e.: oral, axillary, tympanic) is not predictive and can give a false sense of security
• Recognition of CNS dysfunction with any of the following
  • Anhydrosis
  • Mental status changes
    • Coma
    • Ataxia
    • Confusion
    • Irritability
    • Seizures

Management of EHS 

• Reducing the temperature to <40 degrees Celsius within 30 minutes is critical
• Initiate cooling methods immediately
• The gold standard for cooling is cold water immersion if available
• If a tub is available, covering as much of the athletes body as possible (except the head) should be done in very cold (1.7 to 14 degrees Celsius) or ice water
• Remember to continually stir the water in the tub
• If out in the field and there is not access to a tub, cooling can be initiated with covering of the athletes body with cold towels or ice and rotated every couple of minutes
• Rapid transport to a hospital (ideally when a temperature is <40 Celsius if cold water immersion is available)

Return to play after EHS 

• Refrain from activity for at least 7 days after EHS
• Follow-up with medical care 1 week after incident for physical exam and possible investigations (i.e.: check lytes, CK, Cr, etc.)
• When initiating physical activity again, begin in a cool setting, and gradually increase intensity, duration and temperature of setting over a period of 2 weeks
• Athlete should be back to their pre EHS activity level by 4 weeks of initiating return to play

Lastly, recognize Heat Exhaustion, a milder form of exertional heat illness and manage accordingly, in order to prevent progression to EHS. Exertional heat exhaustion is characterized by:

• A core temperature between 37-40 degrees Celcius
• Symptoms such as headache, weakness, dizziness, goose flesh, nausea, vomiting, diarrhea, irritability, and loss of coordination

Heat Exhaustion is managed by: 

• Moving the athlete into the shade, or a cooler environment if possible
• Remove excess clothing
• Rehydrate the athlete, preferably oral
• Use cold towels to cool the athlete
• Monitor vitals and transfer to hospital if no improvement after 30 minutes of treatment by the methods above

One cause of lateral knee pain that I have encountered in runners, cyclists, and soccer players is an injury to the proximal tibiofibular joint. During sport, torsional stresses originating from the ankle and resistant forces created in weightbearing deliver stress through this joint. Lower limb biomechanics such as a pes cavus foot type and supination on gait may also contribute to increased stresses.

An athlete’s complaint of pain and/or instability can be due to an acute or chronic sprain of the proximal tibiofibular ligament, or to a subluxation of the joint as the fibular head shifts anteriorly in knee flexion.

A simple, yet effective “tip” to manage the symptoms associated with a proximal tibiofibular joint injury is to use a compression type strap (ex. Levy Patellar Strap by Trainer’s Choice) to stabilize the joint and limit stress through the proximal tibiofibular ligament. To apply this strap, I locate the proximal tibiofibular ligament, and place a pen mark on the patient’s skin two- finger- breaths below this point. I position the strap centered over my mark and secure it to the proximal lateral lower limb. This should be snug, but not too compressive to the gastrocnemius or peroneal nerve. I re-test the mechanism that would reproduce symptoms, and assess for clinical improvement. I owe credit to Dr. David Levy who taught me this great tip during my sports medicine fellowship, and I use it with good success today.

1. Lie the patient prone on a table or bench with the affected arm hanging off the side of the table. (You may prefer to have the arm slightly externally rotated).
2. Apply mild downward traction on the arm. (either by slight pulling on forearm/elbow or have patient hold a 5 lb weight).
3. With your other hand, gently push the inferior tip of the scapula medially.
4. Generally you will feel/hear a 'clunk' indicating a successful reduction.

With a little practice, this method can be >90% effective on first attempt, and is often less traumatic, and can be performed on your own. Although there are many methods for reducing dislocated shoulders, in general the "best" method can be the one with which you are the most comfortable.