#535 - Respiratory Viruses, Pickleball Injuries, We Are to First Help

From the Centers for Disease Control and Prevention (CDC)

1) Respiratory Viruses – Prevention and Control

Given the recent recognition of the “triple threat” seasonal illnesses – COVID-19, influenza, and respiratory syncytial virus – the CDC has issued general guidance about respiratory virus prevention and control. None of this should seem particularly new to us, but the recommendations are an important reminder for use in our workplaces as well as the treatment of our patients.

It is important to remember that respiratory viruses, while we do not often acknowledge their prevalence and consequences, are responsible worldwide for 3 to 5 million cases of severe illness, and about 290,000 to 650,000 respiratory deaths (PAHO.org), especially in people with immune compromise and at extremes of age. The CDC offers some straightforward measures to prevent and control these illnesses:

1.    Immunization – A cheap, readily available intervention that can reduce community transmission and decrease complications and hospitalizations from respiratory viruses. (see new COVID-19 vaccine recommendation below).

2.    Hygiene – handwashing (also prevents rotavirus!), covering coughs and sneezes and cleaning surfaces.

3.    Ventilation – we know this lesson from tuberculosis, but it is good advice for respiratory viruses – air circulation, outside activities and air purification can all decrease person-to-person spread of pathogens.

4.    Stay home when you’re sick – We and our patients are conditioned to show up to work if only mildly ill. Advocate and model responsibility and protect your colleagues and patients – stay home when you are ill. The CDC recently reduced the isolation time required for COVID-19 to align more with the typical recommendations for influenza, but this does not apply for healthcare workers yet.

5.    Wear a mask when appropriate – if nothing else, the COVID-19 pandemic taught us how to wear masks. If your patient has a respiratory illness, there is no logical reason for either of you to go without a mask – especially in a crowded, small examination room. Societally, they seem to be more accepted generally now (at least from my trips to the grocery store), which is helpful.

6.    Physical (not social) distancing – Simple aerodynamics – staying away from crowds during times of high illness prevalence – will reduce the chance you get sneezed or coughed on.

7.    Testing – Testing is important for sentinel surveillance of what’s going around and can be useful for individual exposure considerations (COVID-19, flu, etc.). It is also helpful for high-risk patients that may benefit from specific antiviral treatments. Routine testing for everyone who is sick may not be all that helpful if it won’t change management.

The following patients are at high risk of complications from respiratory viral illness: Older age (>65 but especially > 75 years), young children (< 5 years, but especially under 6 months), people with immune system diseases or reduced immunity, people with disabilities, and pregnant people.

Speaking of immunizations, repeat COVID-19 (2023-24) vaccination, i.e., a second dose for this season, is now recommended for people over age 65, in addition to people with a history of immune compromise. This new second dose should be given at least 2 months after the previous dose.

John’s Comments:

Each of these illnesses can feel like “just a cold” to healthy people, but together they cause substantial morbidity, mortality, loss of work productivity and medical expenditure in our otherwise fairly advanced society. Why do we have such a “thing” about trying to reduce our exposure to these illnesses by doing the very simple interventions listed above? In my experience, the disease of “presenteeism” (showing up to work sick) is a major cause of healthcare associated viral spread. Let’s try to do and advocate for better.

References:

·         Coronavirus Disease 2019. Centers for Disease Control and Prevention. Published March 1, 2024. Accessed March 4, 2024. Link

·         Respiratory Virus Guidance. Published March 1, 2024. Accessed March 5, 2024. Link

From the Literature

2)  Pickleball Injury Primer   

Pickleball, a sport that combines elements of tennis, ping pong, and badminton, has in recent times rapidly gained popularity among all age groups, especially among middle-aged adults.  Surprisingly, the sport is actually almost 60 years old.  According to USA Pickleball, the sport was first invented in 1965 on a backyard badminton court. 

In March of 2023, the Association of Pickleball Professionals (APP) estimated that 48.3 million adults in the US (19% of the adult population) had played at least once in the previous 12 months, while in comparison, according the US Tennis Association (USTA), 23.6 million US adults played tennis in 2022.  Surprisingly, the APP’s latest research also reveals that the average age of avid pickleball players is 34.8 (down from 41% in 2021) and more than 70% of them are between age 18-44.

Given this rise in popularity, it is surprising there is scant medical literature published on pickleball injuries.   There are some who consider pickleball a “milder” sport in comparison to tennis and thus may not be viewed as a high injury-risk sport, because it is played on a smaller court with less running, uses a small paddle, and has lower ball strike velocities.  However, because of some of the demographic who have been drawn to the game as well as the potential surprising intensity of it, there has been a reported rise in game-related injuries. 

Common injuries include repetitive use injuries of the knee (meniscal pathology, patellar tendinopathy, medial collateral ligament strains, and osteoarthritis flares), shoulder conditions (rotator cuff tendinopathy), lateral epicondylitis, Achilles tendonitis, and plantar fasciitis.  Additionally, muscle strain and ligament sprains commonly affect the wrist and elbow, calf, ankle, and hamstring.  Facial trauma (including orbital trauma) and fractures of the wrist are increasing in frequency as the demographic of active players shifts to a younger age. 

These injuries are often a result of improper warm-up and cool-down, lack of flexibility, improper technique, overuse, and inadequate equipment. Reportedly, women have a higher incidence  of shoulder, foot, and wrist injuries, whereas lower-limb injuries (knee, ankle, thigh, calf) are more common in men.  Acute injuries tend to affect lower extremities, whereas chronic injuries usually involve the upper extremities.

Recommendations to prevent pickleball injuries include proper warm-ups, dynamic stretching and strengthening exercises, and cool-downs. Proper footwear with ankle support can reduce the risk of sprains, which includes court shoes rather than running shoes, and mastering correct playing techniques can help avoid overuse injuries. Players should gradually build up their playing intensity, especially if they are new or returning to physical activity after a break.

Mark’s Comments:

In full disclosure, though I played competitive tennis through college, for multiple reasons I’ve never played pickleball.  Having watched videos of recreational and competitive play, it is easy to see how one could believe it is “safer” from an injury standpoint than tennis.  However, there is quicker movement and bending than in tennis, thus increasing the risk of what has been described as Slip/Trip/Fall/Dive injury mechanisms.   Additionally, as pointed out above, many recreational players are not well-equipped for playing, including footwear that places them at risk for lateral movement injuries.  So while pickleball offers the potential for some wonderful physical and social benefits, awareness and preventive measures are essential to avoid injury and experience recreational enjoyment.

References:

·         K Vitale, S Liu. Pickleball: review and clinical recommendations for this fast-growing sport.  Curr Sports Med Rep, 19 (2020), pp. 406-413.  Link

·         Greiner N.  Pickleball:  Injury Considerations in an Increasingly Popular Sport.  Mo Med 2019 Nov-Dec 116(6): 488–491.  Link.

From PeerRxMed ( www.PeerRxMed.org )

3) Our Oath is to First Help, not to “Not Harm”

“Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm.”  Hippocrates, from what we know as “The Hippocratic Oath”

You’ve likely heard somewhere along your professional journey that we took an oath as physicians to “first do no harm” or its Latin equivalent, “primum non noncere.”  While the phrase is attributed to Hippocrates and even more specifically, the “Hippocratic Oath,” that is not its origin.  As noted in the quote above, it seemed quite important for Hippocrates to be clear that our role as physicians is to be helpers and healers, and while doing so, to minimize harm.  The phrase “first do no harm,” has been traced back to English physician Thomas Sydenham (as in Sydenham’s chorea) in the 1600s rather than to our Greek physician predecessor in 460 BC. 

Indeed, it would seem that our role as clinicians and as healers is always to “first help” while attempting to find balance in four pillars of contemporary medical ethics; beneficence (help), non-maleficence (don’t harm), autonomy, and justice.  One doesn’t have to spend too much time reflecting on clinical practice to recognize we are continually navigating the challenges and dynamic tension of these four pillars, particularly that of “help/don’t harm.”  Every surgeon knows they often cut through healthy tissue to get to the unhealthy, and all medications are prescribed recognizing the balance of potential benefits and harms.

But what does any of this have to do with helping to support each other on our professional journey?  My intention is not to provide a lesson on ancient medical history,  but perhaps a modern one instead.  The data over the past decade has been quite clear that there are many hurting colleagues in our midst, likely including some who are reading this blog.  If we are called to “first help,” it would seem such a professional obligation extends not only to our patients, but also to each other.   

 

I am concerned that the same misunderstanding of “first not harming” rather than “first helping” for our patient care also often prevents us from reaching out to colleagues who we know, or suspect, are struggling.  Instead, we may be tempted to anchor to beliefs such as “I don’t know what to say” or “What if I say the wrong thing and they push me away?” or even “Doing so is not part of my training” – all of which I would call “not harm” talk.  Certainly, we never learned skills for professional connection and support during our medical training.    

Fortunately, there are resources available to assist us in learning how to better help and support each other.  I consider the PeerRxMed process to be one such resource.  Additionally, physician colleague Simon Mittal provides a nice overview in this brief article, “How to Approach a Colleague Who May Be in Distress—Practical Guidance to Help,” which I would summarize as “reach out, tell them you care and want to help, and let them know they are not alone.”   As we continue to collectively work to create a more supportive and sustainable professional culture, let’s remind each other that we are called to “first help,” for our patients and for each other.  I suspect Hippocrates would agree that none of us should care alone, and that our attempting to do so would be … harmful.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org