Recently in Sports medicine Category

Ira Casson—neurologist, former co-chairman of the NFL's panel on brain injury, and target of yesterday's House Judiciary Committee hearing on football-related concussion—is technically correct: Data linking repeated head injuries in American football to lasting brain damage are limited.

But as they say, absence of evidence is not evidence of absence. Moreover, a link is highly plausible, given the well-described association between repetitive brain injuries in boxing and neurologic deterioration—aka dementia pugilistica.

To remedy the shortage of evidence on sports-related head injury, the nonprofit Sports Legacy Institute partnered with the Boston University School of Medicine in 2008 to create the Center for Traumatic Encephalopathy. The Center's raison d'etre is to assess neuropsychiatric symptoms in athletes and to examine their donated brains for pathologic signs.

The Center's most recent publication, printed in July of 2009, provides a review of 48 cases of neuropathologically verified chronic traumatic encephalopathy, or CTE, in the medical literature and adds data from 1 professional football player and 2 boxers. The clinical picture of CTE features memory loss, behavior and personality changes, speech problems, parkinsonism, and other gait or movement disorders.

Pathologically CTE is typified by nearly global brain atrophy and the accumulation of tau protein in neurofibrillary tangles. Consequently CTE is classified a tauopathy, like other neurodegenerative disorders (including Alzheimer disease); however, CTE can be distinguished from other tauopathies, the authors claim, by its predilection for certain brain areas (eg, the superficial layers of the cerebral cortex). Deposits of amyloid beta, typically in the form of plaques and characteristic of AD, are evidently not as common in CTE.

In December, the Center also described postmortem CTE in an NHL player. In an effort to accumulate more data, the Sports Legacy Institute encourages athletes to donate their brains to the Center. Current Legacy donors are listed at the Institute's website, along with links to their stories. Several of these cases were discovered by pathologist Bennet Omalu* and colleagues, who recently reported microscopic evidence of CTE in 5 professional athletes who attempted or committed suicide at relatively young ages.

* Omalu is the author of Play Hard, Die Young: Football Dementia, Depression and Death.

01/06/10 addendum: While the effects of performance-enhancing drugs (eg, anabolic steroids) on mood and personality are well known, their role in the development of CTE is debated—largely because data in that area are lacking as well. The NFL case report described recently by the Center (former linebacker John Grimsley) indicated no reported use of performance-enhacing drugs (if you believe that a linebacker can escape the NFL without having used them).

The role of the apolipoprotein E (ApoE) genotype in CTE appears to be more significant, however. Of the 10 CTE case reports in which ApoE genotyping was performed, half carried at least one APOE ε4 allele—a known genetic risk factor for Alzheimer disease. The authors suggest that ApoE ε4 carriers may be more susceptible to CTE.

The 50-game suspension handed down yesterday to the LA Dodgers' power hitter Manny Ramirez brings another performance-enhancing drug to public attention: human chorionic gonadotropin, or hCG. Best known as the hormone assayed in urine or serum to confirm early pregnancy, hCG is used to treat infertility in women by stimulating ovulation (eg, Pregnyl; Organon). In men, the substance is also injected to treat infertility or to reverse hypogonadism; the hormone stimulates the testicular Leydig cells to produce testosterone.

But because hCG is less efficient than anabolic steroids for increasing muscle mass,* it is most likely injected by power athletes to treat androgen-induced hypogonadism, either during or after a course of anabolic steroids. The substance, consequently, is an indirect indicator of steroid abuse.

In healthy males, hCG normally occurs at low, but measurable, levels in serum or urine, and serum assays are sensitive. However, most doping surveillance tests are performed on urine, and the suitability of the assay in this context has not been defined, according to a recent report. No matter for Manny. His penalty for hCG doping was reportedly based on evidence in his medical files, not on a positive drug test, according to the NYT.

* hCG is also more expensive than anabolic steroids, but what does that matter to an MLB player.

Image of chorionic gonadotropin preparation from APP Pharmaceuticals.

D'oh! Just when you thought you dodged an IOC bullet, the overseer of the Olympic Games announced yesterday that it will further analyze blood and urine samples collected from athletes at this summer's Beijing games. First on the retroactive testing list is Roche's long-acting red-cell booster Mircera.* But the IOC also warns that it will store the Beijing samples for 8 years to enable additional analyses when new drug tests become available.

In Beijing, 4770 doping tests were conducted on blood or urine, covering the period from July 27th to August 24th. But only 6 out of approximately 11,000 athletes suffered sanctions as a result of positive tests, an unexpected, low number (Table). Therefore the IOC will retest samples with a recently validated assay for Mircera. The announcement comes on the heels of news this week that 3 more Tour de France racers tested positively for the substance.

Disqualified Athlete		Country	Sport	Highest Placement	Detected Substance
1	Lyudmila Blonska	Ukraine	Heptathlon	2nd	methyltestosterone
2	Igor Razoronov	Ukraine	Weightlifting	6th	nandrolone
3	Fani Halkia	Greece	Hurdles	—	methyltrienolone
4	Jong Su Kim	North Korea	Shooting	2nd	propanolol
5	Isabel Moreno	Spain	Cycling	—	Epo
6	Thi Ngan Thuong Do	Vietnam	Gymnastics	15th	furosemide

(IOC decisions regarding 3 other alleged Olympic doping cases, Belarussian hammer throwers Vadim Devyatovskiy and Ivan Tiskhan [testosterone] and Polish kayaker Adam Seroczynski [clenbuterol], are pending.)

* A pegylated version of recombinant erythropoietin.

Image of a freakishly bulked-up Lyudmila Blonska from Wikipedia.

Asked on behalf of mothers everywhere, given Michael Phelps's crazy calorie consumption.

HT: NY Post by way of the WSJ Health Blog and every other conceivable media outlet.

At Saturday's Olympics, the black, vaguely calligraphic design on the shoulder of volleyballer Kerri Walsh most certainly prompted the following question in a range of languages: What the hell is that?

A few curious Web posters thought it might be a fierce tattoo. But no, NBC's Olympics coverage says it's black Kinesio tape on Walsh's right shoulder, which was surgically treated last winter. One commentator said the tape eases pain, stabilizes joints, increases circulation, and reduces lymphedema. If so, that's some tape.

The official web site for the product emphasizes the benefits of the tape—it's particularly elastic and sticky—and the all-important taping method—which accounts for the funky design on Walsh's shoulder. The 4-inch-wide tape can be cut lengthwise for "Y" applications (which are designed to stabilize muscle or prevent its contraction or otherwise do something nice), like that along Walsh's scapular spine and posterior deltoid (see graphic below). In Walsh's case, another Y application was applied to her middle deltoid, along with uncut tape that crisscrossed the joint. Kinesio tape evidently comes in a variety of colors, which (as far as I can tell) are for fashion purposes alone—or in the case of black, to intimidate.

The Kinesio web site claims that taping "alleviates pain and facilitates lymphatic drainage by microscopically lifting the skin. The taped portion forms convolutions in the skin, thus increasing interstitial space. The result is that pressure and irritation are taken off the neural and sensory receptors, alleviating pain. Pressure is gradually taken off the lymphatic system, allowing it to channel more freely." Nice-sounding words to the medically uneducated, and bullshitty to the rest of us. Moreover, I'm not entirely sure how one would even go about proving these physiologic effects.

Evidently only one randomized clinical trial has been conducted to evaluate Kinesio taping for any musculoskeletal condition. A quasi-double-blind* study, published just last month in the Journal of Orthopaedic and Sports Physical Therapy, assessed the short-term self-reported effects of Kinesio or sham taping in 42 young adults with rotator-cuff conditions. The investigators observed immediate improvement in pain-free shoulder abduction with Kinesio taping but no other statistically significant benefit (range of movement, pain, or disability) over sham taping during a 6-day treatment period. The authors suggest why Kinesio taping may improve immediate pain-free movement (gate-control theory, anyone?) but acknowledge their complete speculation on the subject.

* One author was blinded to the taping methods used, and taping methods were different between Kinesio and sham subjects.