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Technological Advances in Sports Medicine

Sports Medicine has witnessed a technological revolution in diagnostic, clinical and rehabilitation areas which has taken the treatment in sports medicine to the next level. Sonal Shukla takes a look

Primus is a highly advanced musculoskeletal evaluation and rehabilitation machine

With different sports finally gaining the desired recognition in India and people getting increasingly concerned about their health and fitness quotient, the sports medicine speciality also seem to have dropped the veil of anonymity. The Government of India has also been actively supporting various developments and allocated a budget of Rs 11 billion for the year 2008-09. The 2009 budget increased the allocation for the 2010 Commonwealth Games from Rs 2,112 crore to Rs 3,472 crore. "Yes, sports medicine is a developing market segment in India and is a multidisciplinary vocation," shares Anurag Dubey, Programme Manager, Health IT & Healthcare Delivery Practice - South Asia & Middle East, Frost & Sullivan.

What is more, the segment has witnessed a technological revolution in diagnostic, clinical and rehabilitation areas which has taken the treatment in sports medicine to the next level.

Gait & Motion Analysis, Multi-joint Dynamometer with Sports Simulator, Balance Assessment and Training System (BATS), EMG Biofeedback, Human Performance Evaluation (VO2 max), muscular strength training/testing, advanced arthroscopic interventions are just few of the many examples of latest advancements in sports medicine technology and techniques, which has opened up a plethora of options for the advanced treatments in sports injuries, performance enhancement and fitness.

Says Dr Chandra S Siddaiah, HOD and Consultant, Department of Sports and Exercise Medicine, Manipal Hospital, Bangaluru, "There are plenty of options for the sports doctors to diagnose, treat and rehabilitate athletes with injuries. Now almost all parameters of sports performance can be scientifically assessed like VO2 Max, Lactate threshold tests, Gait analysis, Resting Metabolic Rate, Musculoskeletal strength, power, and endurance. Since a long time, biomechanical assessment of sports specific movements like running, throwing, swimming etc is been done using highly advanced motion analysis systems."

Revolution in Diagnostic and Rehabilitation

Gait & Motion Analysis: An athlete needs efficient movement of flexible joints, strong muscles and balance between different muscle groups. If this is not there, the athlete is prone to many injuries. This is seen in many conditions of the foot and ankle, which maybe bony (leg length difference), muscular imbalances or tendon disorders. Gait and motion analysis has helped the doctors in finding the cause of many of these lower limb problems. Gait and motion analysis is an assessment of the way a sportsman walk and run. This analysis gives in-depth insight about the body biomechanics, weight distribution and relative movement of hips, knees, ankles during running. "Gait analysis is a very powerful tool that the sports doctor has and it can prevent many overuse lower limb and back injuries. It can also find the cause of many injuries and suggest the management of these," says Dr Ravi Kumar Khetrapal, a senior consultant of orthopaedics and HOD sports unit at the Indian Spinal Injuries Centre, New Delhi.

This assessment is preventive and curative for athletes in various conditions like plantar fasciitis, heel spur, flat feet, morton's neuroma, hammer toe, shin splints, knee pain, chronic back pain, calf stiffness etc. "The analysis helps in diagnosing abnormal gait and movement patterns, and in evaluating underlying causes of the biomechanical anomaly, for example, motion analysis is utilised in analysing a bowler's action, or a tennis player serving motion, or a football players kicking motion," says Dr Dinshaw Pardiwala, Consultant- Arthroscopy, Sports Orthopaedics & Shoulder Service Centre for Bone and Joint, Kokilaben Dhirubhai Ambani Hospital, Mumbai.

Highly advanced three dimensional optical motion analysis systems combined with EMG (electromyography) and force platform are generally seen in research labs. These systems can give precise recording, analysis and interpretation of joint angles, movements, segment orientations during any human dynamic movement. This is also used in scientific analysis of posture, balance and coordination. According to experts, very few places in our country have such an assessment centre.

The system consists of simultaneous data acquisition and analysis of four components: six infra red optical cameras capturing human motion in space, 16 channel telemetric EMG representing muscle activity, two force plates measuring joint angles and forces, and two video cameras capturing video in sagittal and coronal plane.

Today, various systems are available for gait and biomechanical analysis. Lesser expensive are the simple video-analysis systems (Dartfish and Silicon Coach).

Further sophisticated systems are very expensive and use infrared markers for analysis, for example, Smart D Motion Capture and Biomechanical Analysis System. By this system, illuminated markers are tracked by an automated multicamera system. There is analysis of motion in all 3 planes (3 D analysis).

The technology is available in India in various centers (approximately at 6-7 centers in India), but skilled biomechanist who can analyse the data are not available. Further, database of Indian athletes is not available for comparison. "These systems are essential to improve skill and performance. This technology is also being presently used to treat patients with gait abnormalities," states Dr Parag Sancheti, Chairman, SIOR, Pune.

Multi-joint Dynamometer with Sports Simulator

As the name suggests, the system serves two separate functions. The multi-joint dynamometer can measure muscle strength of any major muscle group in three different modes; isokinetic, isotonic and isometric. This assessment helps in making rehabilitation programme and strength training schedule for patients with sports or other injuries, targeting isolated weaker muscle groups specifically. The training can be initiated on the machine using isokinetic mode in the early stage after injury reducing the impact on the joint. Sports simulator can simulate many activities / actions in sports like throwing, bowling, driving etc. This gives objective evidence in performing functional capacity evaluation and disability assessment.

The Primus Rehabilitation System

Use of sophisticated equipment such as VO2 analysers can definitely help in performace enhancement

Today, various systems are available for gait and biomechanical analysis. Lesser expensive are the simple video-analysis systems

Use of Isotonic / Isokinetic Machines having a dynamometer can be used to find inherent weakness in muscles and muscle imbalance

Primus is a highly advanced musculoskeletal evaluation and rehabilitation machine. This machine is designed for assessment of muscle strength, power and endurance of any group of muscles and also rehabilitates any musculoskeletal injuries. This can perform muscle training in various modes such as isometric, isotonic, isokinetic and also improves range of movements of a joint in a controlled graded manner. Sportsmen for example, cricket bowlers can get their shoulder strength, power, and endurance assessed before and after a training regime to know their prognosis. "It allows testing and exercise of patients across an extensive range of conditions. It is almost identical to and serves the same purpose as multi-joint dynamometer with sports simulator," opines Dr Pardiwala.

According to Dr Sancheti, this is good equipment for functional training and testing. It can be used from the sub-acute stage of the injury up to end stage rehabilitation and return to play. Again, the only drawback is the equipment is expensive.

Balance Assessment and Training System (BATS)

This system helps in assessing the balance capabilities of a sportsman and evaluates the underlying cause of impaired balance in patients with sports injuries. "Balance Master is one of its kinds as it helps in both balance assessment as well as training. Balance and proprioception are a key component of sports performance and sometimes all that separates top level sportsmen is their somatosensory, visual, or proprioceptive capability," shares Dr Pardiwala. Balance can be impaired because of somatosensory, visual or vestibular dysfunction.

EMG Biofeedback

EMG stands for electromyography, measures the electrical response of the muscles when contracting. The electrical response is measured with pads placed on the skin and results are displayed visually and/or indicated by a tone sound. By indirectly measuring muscle contraction, this allows the user to see and/or hear their level of muscular tension. EMG biofeedback produces more rapid and significantly greater development of strength when combined with more traditional form of strength training. It is used for muscle reeducation and strengthening in sports rehabilitation following surgery or trauma, selective training of a particular muscle after injury and to remediate neck, scapular and lower back pain.

Human Performance Evaluation (VO2 max)

"Biomechanical assessment of sports specific movements like running is been done using highly advanced motion analysis systems" - Dr Chandra S Siddaiah Consultant Sports & Exercise Medicine Manipal Hospital, Bangaluru

"Gait & Motion analysis helps in diagnosing abnormal gait & movement patterns and in evaluating causes of biomechanical anomaly" - Dr Dinshaw Pardiwala Consultant- Arthroscopy, Sports Orthopaedics KDAH, Mumbai

"Database of Indian athletes & skilled biomechanist are essential to improve skill and performance" - Dr Parag Sancheti Chairman SIOR, Pune

Maximal oxygen uptake (VO2 max) is the maximum capacity of an individual's body to transport and utilise oxygen during graded exercise, which reflects the physical fitness of the individual. It is an important determinant of endurance performance which represents a true parametric measure of cardio-respiratory capacity of an individual at a given degree of fitness and oxygen availability.

It involves a graded exercise test (either on treadmill or cycle ergometer) in which exercise intensity is progressively increased while measuring ventilation and oxygen and carbon dioxide concentration of the inhaled and exhaled air. VO2 max is reached when oxygen consumption reaches a peak and remains at steady state despite achieving maximal or submaximal heart rate of the individual. "Use of sophisticated equipment such as VO2 analysers can definitely help in performance enhancement, to improve the cardio-respiratory endurance depending on the nature of the sport," states Dr Sancheti.

Experts consider this technology extremely important in India since it reflects the physical fitness and athletic capability of the sportsman, and is also utilised in planning cardiopulmonary and sports rehabilitation programmes. However, this equipment too is expensive and few centers in India have this facility. Also there is very limited Indian database available for comparison.

3 Tesla MRI is used for more accurate imaging studies of joint injuries, especially useful for cartilage injuries and 3 dimensional mapping of articular cartilage defects.

Surge in Surgical techniques

Advanced arthroscopic intervention of not just the knee, but all major joints (hip, ankle, shoulder, elbow, wrist) has been possible because of better endoscopic instrumentation and advances in visualisation systems. This has resulted in all operations on joints (except replacement surgery and major fractures) now being performed arthroscopically (as against open surgery), enabling minimal surgical morbidity and early return to full function and sports.

Better Arthroscopic Fixation Systems

Better arthroscopic fixation systems (for example in knee ligament surgery and shoulder surgery) including bioabsorbable screws and anchors ensure early rehabilitation with no need for subsequent implant removal.

Computer Navigated Knee Ligament Surgery & Osteotomy

This surgical technique is available worldwide since the past few months. This ensures precision surgery especially in complex and revision knee arthroscopy cases and ACL/PCL ligament reconstruction.

Platelet Rich Plasma (PRP) Therapy

A number of orthopaedic and sports conditions remain a major therapeutic challenge to orthopaedic surgeons. Some of these difficult conditions include plantar fasciitis (chronic pain in the sole of the foot), tennis elbow (chronic pain in the elbow), ligament and muscle injuries (around the knee and other joints) and tendo-achelles (heel) injuries. Persistent symptoms, due to these conditions, in young sporty individuals have lead to premature ending of their competitive careers. PRP therapy is now being effectively used to mend ligaments and repair tendon injuries.

Whole blood (about 30 ml) is drawn from the patient, prior to the injection, in the blood bank. The blood is then centrifuged to separate the plasma (buffy coat) from the blood. This concentrate, which contains platelets and growth factors (multiplied several fold), is then mixed with activating agents and is injected back into the patient's own damaged tissue where it begins to initiate the process of repair. The repair response in the injured tissue is kick-started by the formation of a blood clot. This is then followed by the implanted platelets being dissolved, triggering the release of growth factors which in turn leads to the formation of a fibrous scar tissue. Eventually the injured tissue is completely replaced by healthy cells.

"The beauty of PRP therapy is that there is no harm in it. It is the patient`s own blood re-injected after treating with centrifugation. This is the attraction and possibly the reason for it to become popular among the sports physicians so fast," opines Dr Vijay Shetty, Orthopedician & Hip replacement surgeon, Dr LH Hiranandani Hospital, Mumbai.

Advances in cell technology has resulted in clinical applications — autologous chondrocyte transplantation for cartilage defects in sportsmen.

ESWL - Extracorporeal Shock Wave Lithotripsy

Non-invasive modalities such as ESWL or Extracorporeal Shock Wave Lithotripsy are now available for muscle and tendon problems (tennis elbow, golfer's elbow, heel pain, calcific tendonitis of shoulder, Achilles tendinitis) in athletes. This modality has ensured that many sportsmen with severe tendonitis problems can avoid surgery as a means of return to sport.

Indian Scenario

Even though the technology is available worldwide, in India the condition doesn't seem very promising. Experts believe that even though, all the above mentioned equipment are today available, they are at very few centres in India. Moreover, the sports medicine personnel have a limited exposure to all the above equipment. "All the above equipment are very sophisticated and requires experts and specialists to use them efficiently. Our country lacks in the right professionals required for the same," opines Dr Sancheti.

Overseas, in countries such as Australia/ America, access to all these equipment is easily available, thus leading to greater awareness. "We have few centers that provide these services but most of them are limited access every individual in the community. We need to make it accessible to every individual who is or wishes to be active and have a healthy lifestyle," says Dr Siddhah. Scientific evolutions will always lead to more advanced technology, however, unless and until it is made widely accessible, the impact can never be seen extensively. It needs to be seen how long it takes for all this widely appreciated sports medicine technology to find a stronghold on the Indian grounds.

sonal.shukla@expressindia.com