in Major League Baseball Stan Conte, PT , DPT , ATC MIT Sloan - - PowerPoint PPT Presentation

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

• ver a large period of time.

 Rules have not changed except for 7-day concussion DL.

Observations 1998 - 2012

300 350 400 450 500 550 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Observations 1998 - 2012

300 350 400 450 500 550 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

“We also noted an increase in injuries after the 2005 season. The cause for this in unclear, but may be influenced by the change to a stricter drug surveillance policy before the 2006 season.” Posner, et al.

Total DL Dollars 1998 - 2012

$0 $100,000,000 $200,000,000 $300,000,000 $400,000,000 $500,000,000 $600,000,000 $700,000,000 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

45% 25% 11% 6% 15% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% <30 31-60 61-90 91-120 >121

DL Days per Time Period

%

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

0% 10% 20% 30% 40% 50% 60% RHS LHS 3B SS OF RHR 2B C 1B LHR

Elbow Injury Rate by Position

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% RHS LHS RHR LHR C SS 3B 2B OF 1B

Shoulder Injury Rate by Position

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% 20.00% 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  Career Injury History  Injuries by body part  Severity of Injury by body part  Surgery History  Type of surgery  Time duration from surgery

• r injury

 MRI/Diagnostic Tests  Physical Exam  GIRD  Range of Motion  Muscle Weakness  Joint Laxity  FMS  Return to Competition  Biomechanics of Throwing

Baseball Performance Metrics

 Velocity changes  Max Velocity vs Avg Velocity  ERA/FIP Changes  % Strikes  K/BB  Foul balls on 2 strike counts  GB/FB ratios  Horzontal Release Points  Vertical Release Points  Horiontal Movement  Vertical Movement  % Strike Zone  Late Inning inconsiency  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

Targeting Side effects Chronicity of disease

Problems with Drug Delivery

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

Production of proteins

Monocyte Adherence

Monocyte adherence plays a critical role in production of proteins (esp. IL-1ra,) in the ACS syringe

Cytokine- Induction in the ACS-Syringe

Inflammation Res., 2003

Parameter T = 0 hrs (pg/ml) T = 0,5 hrs (pg/ml) T=24 hrs (pg/ml) Increase (factor) IL-4 ND 7,8 ± 2,3 17,2 ± 2,8 2,2*** IL-10 ND 4,3 ± 0,4 8,9 ± 1,2 2,1*** IL-13 ND 192 ± 13,0 189 ± 9,6 - IL-1Ra 73 ± 4,8 778 ± 58 10254 ± 165 140*** 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

Definition of the rating Rating categories

Efficacy in a Comparative Metaanalysis

Nutritional therapy Gene/cell therapy (surgical) Oral The- rapy Percutan./ physical therapy Intra-articular therapy NSAR/COX-2 inhibitor Paracetamol Corticosteroids Hyaluronan Weight reductions Muscular strengthening ACS Acupuncture Arthroscopic lavage Arthroscopic debridement TEP

1++ High 0.2 3 No 1++ High 0.32 3 No 1+ Med- ium 0.36 4 Yes 1++ High 0.29– 0.44 Yes 1++ High 0.15 2 Yes 1++ High 0.55 4 1++ Med- ium 0.32 Low 1+ medi um 0.44 Low 1- Med- ium 0.09 1- Med- ium 0.01 3 High

Level of Evidence (LoE) Effektgröße bzgl. Schmerz Anzahl Behandlungen (NNT) Relatives Risiko unerwünschter Ereignisse Effektgröße bzgl. Funktion

0.69 0.36 0.32 0.06 0.00 0.68 0.60

• 0.1

0.09

Transposition

• steotomy

2 High Provability of the effect: 1++ very good to 5 very poor Number of recommendations/ number of mentions Comparison of study results/literature and contrasting of the effectiveness of ACS and other selected therapies under application of statistical analysis methods No change = 0/improvement in case of value increase/deterioration in case of values < 0 (Max. 1.0) Number of treatments mentions for achieving a relief of the symptoms

Therapies (OA)

• No. needed to

treat(NNT) Level of evidence (LoE) Recommendation Effect size reg. pain Effect size reg. function Effect size reg. stiffness Relative risk of undesired events

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 3rd 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: ?

Prevention

Past: ? Present:

– Education – Proper Technique – Legislating Style of Play (Penalties)

Future:

– Improved Technology (Equipment, Measuring Impacts) – No way to completely eliminate

League Changes Related to Concussion

RTP Sideline Eye in the Sky Independent Neurologist

Other Leagues

MLB

– 2011, 7-day DL

NBA – 2011, baseline cognitive/physical NASCAR

– Considering implementing baseline testing in 2014

Protecting Youth Athletes

Concussions in ALL Sports

Guidelines are applicable across all sports Amongst high school and college athletes, girls’ soccer has second highest concussion rate per exposure

– Journal of Athletic Training, 2007

National estimates of the mechanism of concussion by sport for high school athletes, High School Sports-Related Injury Surveillance Study, United States, 2005–2006 school year

Modifications in Youth Sports

Changes at various levels:

– NCAA – National Federation of State High School Associations – State Laws (Lystedt Law)

This is just the beginning…

Thank you