Medical Risk Assessment in Major League Baseball Stan Conte, PT , DPT , ATC MIT Sloan Sports Analytic Conference March 2, 2013
Why Should We Care? Prevention Programs Outcomes Risk Assessment
Lack of Clean Data Anecdotal- most frequently used in baseball Individual Centers or Practitioner’s data (selection bias) Disabled List- Most consistent MLB HITS System- The Future for MLB
Major League Disabled List Not a true injury database. Used primarily as a Roster Management Tool. Certified by the Team Physician as an actual injury. Under reports the number of injuries and days lost compared to HITS data. Can highlight trends if used over a large period of time. Rules have not changed except for 7-day concussion DL.
Observations 1998 - 2012 550 500 450 400 350 300 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Observations 1998 - 2012 550 500 450 400 “We also noted an increase in injuries after the 2005 season. The cause for this in unclear, but may be influenced 350 by the change to a stricter drug surveillance policy before the 2006 season.” Posner, et al. 300 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total DL Dollars 1998 - 2012 $700,000,000 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
MLB Injury Surveillance System Established in 2010 by MLB An Event based system Both a reporting system and data collection HITS System used to query the data-Can be very Granular Not reliant on DL or Admin Status A minimum of 180 different people entering data per day. Still determining reliability of the data
Disabled List vs HITS Data 2012 Disabled List Hits Total Injuries 504 1053 Total Days 29,706 35,258 Pitcher Shoulder Injuries 78 164 Pitcher Shoulder Days 5,866 6,516 Pitcher Elbow Injuries 100 161 Pitcher Elbow Days 9,439 11,309
Severity of Injury by Days Lost DL Days per Time Period 50% 45% 40% 35% 30% 25% 45% % 20% 15% 25% 10% 15% 11% 5% 6% 0% <30 31-60 61-90 91-120 >121
Pitcher Injury Rates Injury Rate Avg DL Days Starting Pitchers 50.3% 65.3 days Relief Pitchers 32.6% 61.3 days All Pitchers 39.2% 62.7 days Non-Pitchers 33.6% 45.5 days
Any Injury Rate by Position 60% 50% 40% 30% 20% 10% 0% RHS LHS 3B SS OF RHR 2B C 1B LHR
Elbow Injury Rate by Position 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% RHS LHS RHR LHR C SS 3B 2B OF 1B
Shoulder Injury Rate by Position 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% RHS LHS RHR LHR 3B C OF SS 1B 2B
Demographic Variables Position Age Major League Service Time BMI Handness Country of Origin
Medical Variables Injury in past season MRI/Diagnostic Tests Career Injury History Physical Exam Injuries by body part GIRD Severity of Injury by body Range of Motion part Muscle Weakness Surgery History Joint Laxity Type of surgery FMS Time duration from surgery or injury Return to Competition Biomechanics of Throwing
Baseball Performance Metrics Velocity changes Horzontal Release Points Max Velocity vs Avg Velocity Vertical Release Points ERA/FIP Changes Horiontal Movement % Strikes Vertical Movement K/BB % Strike Zone Foul balls on 2 strike counts Late Inning inconsiency GB/FB ratios Spin Rates Tyoe of Pitch % Return to Previous level of Performance
Use and Abuse Total Pitches Increase in Pitches by Year Stressful Innings Pitchers Abuse Points Innings Appearances Pitches per Inning average
Risk : Reward Ratios Players are like stocks Teams are like Portfolios Team specific
Protein Therapies for Joint Restoration and in Spine Disease for the Elite Athlete Peter Wehling, M.D., Ph.D. Affiliations: Center for Molecular Medicine and Orthopaedics, Düsseldorf, Germany Orthogen AG; Düsseldorf, Germany Faculty of Medicine, Dep. Of Orthopaedics, University of Düsseldorf Center for Neurosensory Disorders, University of North Carolina, Chapel Hill, USA Dr. Doug Schottenstein- Dr. Edward Capla, New York Dr. Chris Renna, Santa Monica, LA
Clinical Problems of Therapy Surgery hardly influences underlying pathology Drugs address pain, but not pathology Drugs do not reach target area Proteins have high therapeutic potential
Problems with Drug Delivery Targeting Side effects Chronicity of disease
Original Basis for Autologous Conditioned Serum (ACS) • Interleukin-1(IL-1) is an important mediator of tissue destruction and pain in OA • IL-1 receptor antagonist (IL-1Ra) is a naturally occurring inhibitor of IL-1 • PBMC secrete large amounts of IL-1Ra when stimulated with different techniques. Also make other anti- inflammatory factors as well as growth factors. • ACS is different to PRP, ACP and stem cell technologies
Monocyte Adherence Monocyte adherence plays a critical role in production of proteins (esp. IL-1ra,) in the ACS syringe Production of proteins
Cytokine- Induction in the ACS-Syringe Inflammation Res., 2003 Parameter T = 0 T = 0,5 hrs T=24 hrs Increase hrs (pg/ml) (pg/ml) (factor) (pg/ml) IL-4 ND 7,8 ± 2,3 17,2 ± 2,2*** 2,8 IL-10 ND 2,1*** 4,3 ± 0,4 8,9 ± 1,2 IL-13 ND 192 ± 13,0 189 ± 9,6 - IL-1Ra 73 ± 778 ± 58 10254 ± 140*** 4,8 165 IL-1ß < 3.9 < 3.9 < 3.9 - TNF- < 15,6 < 15,6 < 15,6 -
Processing
ACS • Used clinically for osteoarthritis, lumbar radicular pain and muscle injuries. • Approximately 60,000 (280,000 injections) individuals treated in Europe • Approximately 10,000 (30,000 injections) horses treated for OA worldwide.
ACS Studies in Humans • Muscle Regeneration • Knee OA • ACL Injury • Lumbar Radiculopathy
Efficacy in a Comparative Metaanalysis Therapies (OA) Percutan./ Oral Nutritional Intra-articular Gene/cell therapy physical The- therapy therapy (surgical) therapy rapy Weight reductions Corticosteroids NSAR/COX-2 strengthening Arthroscopic Transposition Acupuncture Paracetamol Arthroscopic debridement Hyaluronan osteotomy Muscular inhibitor lavage ACS TEP Rating categories Definition of the rating Provability of the effect: Level of Evidence (LoE) Level of evidence 1++ 1++ 1+ 1++ 1++ 1++ 1++ 1+ 1- 1- 3 2 1++ very good to 5 very poor (LoE) Med- Med- medi Med- Med- Number of recommendations/ Recommendation High High High High High High High ium ium um ium ium number of mentions 0.29 – Effect size reg. pain Effektgröße bzgl. Schmerz 0.2 0.32 0.36 0.15 0.55 0.32 0.44 0.09 0.01 0.44 No change = 0/improvement in case of value Effektgröße bzgl. Funktion Effect size reg. function 0.69 0.32 0.06 0.00 0.68 -0.1 0.09 increase/deterioration in case of values < 0 (Max. 1.0) Effect size reg. stiffness 0.36 0.60 Number of treatments mentions Anzahl Behandlungen No. needed to 3 3 4 2 4 for achieving a relief of the (NNT) treat(NNT) symptoms Relative risk of Relatives Risiko No No Yes Yes Yes Low Low undesired events unerwünschter Ereignisse Comparison of study results/literature and contrasting of the effectiveness of ACS and other selected therapies under application of statistical analysis methods
Summary and Acknowledgments
The Concussion Conundrum in Sports Stephania Bell, PT, OCS, CSCS ESPN.Com Senior Writer, Injury Analyst
What is a concussion? “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” – Consensus Statement on Concussion in Sport: The 3 rd International Conference on Concussion in Sport Held in Zurich, November 2008
Concussion Features may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head typically results in rapid onset of short- lived impairment of neurologic function that resolves spontaneously symptoms largely reflect a functional disturbance rather than a structural injury
Concussion Features may or may not involve loss of consciousness No abnormality on standard structural neuroimaging studies is seen in concussion – Zurich, 2008
Why is it such a difficult entity to manage? No two are alike, even within same person Still a lot to learn
Recognition Past: – Athlete self report – How many fingers? Present: – Self report and observation – Sideline assessment (Apps – SCAT-2 (NFL adding I-Pads leaguewide, ImCAT) – Neurocognitive testing (ImPACT)
Recognition Future – Measuring Impacts (HITS) – Imaging DTI (Diffusion Tensor Imaging) – Biomarkers to detect tau UCLA
DTI
Treatment Past: Darkness, Quiet Present: – Rest initially – Medication, as appropriate – Rehab strategies (vestibular, balance, cognitive) – Gradual return to activity Future: ?
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