On the Horizon: Defining the Future of Sports Medicine and the Role of the Physiatrist

This is an incredibly exciting time for physiatrists who are interested in sports medicine. The science of exercise and sports medicine is novel when compared with that of other medical disciplines. Sports medicine specialists are at the forefront of an exciting wave of new research that will provide a better understanding of the mechanisms and prevention of injury, improve cutting-edge diagnostic and treatment protocols, and aid in the prevention and treatment of chronic disabilities by ensuring wider dissemination of the principles of sports and exercise medicine to the general population. Although many of us have been practicing sports medicine for the past several decades, the advent of physical medicine and rehabilitation (PM&R) subspecialty certification in sports medicine has created opportunities that were never before possible. As the science of sports medicine advances and its scope of practice expands, physiatrists must even more thoroughly understand the origins, evolution, and future of sports medicine specialization. When I decided to pursue sports medicine fellowship training 20 years ago, the options were limited. There were very few Accreditation Council for Graduate Medical Education (ACGME) sports medicine fellowships that would consider accepting PM&R candidates, and all of the fellowships within PM&R were nonaccredited and biased toward spine medicine, with a sprinkling of sports medicine exposure. In 2007, the American Board of PM&R granted a subspecialty in sports medicine that allowed PM&R physicians the opportunity to sit for subspecialty board certification in sports medicine. By 2008, the first PM&R directed sports medicine program had received accreditation, and, by spring 2012, there were 15 such accredited programs with 16 available positions. The National Resident Matching Program (NRMP) results for 2011 showed that 53 PM&R physicians had registered, 45 had entered certified rank lists, and 24 were matched; thus 47% of the candidates were unmatched. Although those numbers are discouraging, I know that a number of the applicants eventually found a position outside the match. In addition, 2 PM&R programs were accredited in 2012 and did not participate in the 2011 NRMP. In 2011, 194 accredited positions were available in primary care sports fellowships (internal medicine, family practice, emergency medicine, pediatrics, and PM&R) in the NRMP, the majority of which were through family practice. If we define strength by numbers, then clearly in PM&R we shall have more power as sports medicine professionals if more ACGME fellowships are available. This will be particularly important in 2013, when an increase in the number of PM&R applicants who apply for sports fellowships is anticipated because after 2013 only those who graduate from an accredited fellowship will be allowed to sit for the subspecialty board examination. However, it is encouraging that some of the other primary care fellowships are now accepting PM&R candidates and are thus increasing the potential number of fellowship positions. Sports medicine is a logical stepping-stone for PM&R physicians whose goal is to synthesize expertise in exercise medicine, rehabilitation, and human performance. Sports medicine, like PM&R, forces the physician to go beyond diagnosis, focus on functional assessment, and understand how the diagnosis impacts the patient's physical and daily activities. The collaborative approach used in the physiatric treatment of patients in rehabilitation units is essential to the effective treatment of an athlete. The joint focused efforts of certified athletic trainers, physical therapists, nutritionists, exercise scientists, and coaches is key to helping injured athletes return safely and effectively to their sport. Sports medicine is a wide-ranging discipline [1] that incorporates aspects of disease and injury prevention. It requires special expertise in diagnosing activity-related medical and orthopedic injuries and ailments, and in prescribing exercise to improve physical fitness and treat disease. The scope of training includes advanced skills in the assessment and management of concussion, sideline emergencies, acute uncomplicated fractures (eg, bracing, splinting, casting techniques) as well as skills in musculoskeletal radiology, nutrition, and exercise physiology. This preparation ensures mastery of the special skill set required for team physicians and large events coverage, including the effects of exercising in extreme conditions and in addressing the pharmacologic and ethical issues of drug use and doping in athletes. Training programs should expose the fellow to a diverse range of patients who vary by age, gender, ethnicity, culture, and socioeconomic status, and to special populations such as the elderly, individuals with a disability, and children. Most PM&R sports fellowships in the United States also teach proficiency in joint and soft-tissue injection techniques, musculoskeletal ultrasonography (US), biomechanical assessment and orthotic prescription, compartment testing, and advanced electromyographic skills. The more academically based programs foster research, teaching, and presentation skills, with the ultimate goal of training the next generation of sports medicine leaders. It is possible that the future development of sports medicine in the United States will be a full medical specialty like surgery, internal medicine, or pediatrics, similar to what currently exists in countries such as Finland and Australia. In Europe, sports medicine is now recognized as a medical specialty in 21 countries, and another 15 countries offer subspecialty programs. Those who attain specialty or fellowship status must meet extremely rigorous requirements, including the successful completion of multiple-choice, written, and oral examinations. Most programs also include training in research and publication. For example, in Canada, a fellow must have obtained a master of science degree and published a clinical or basic science research paper (often generated from his or her thesis) [2]. I anticipate that the following areas will be at the forefront of sports medicine practice in the future. Musculoskeletal US is rapidly revolutionizing the way in which sports medicine is practiced at the point of care. US diagnosis in the clinic setting is becoming increasingly common for sports medicine practices and recently developed portable US machines that are coupled with notebooks now enable sports medicine physicians to evaluate patients in the training room and on the sidelines. Using US as an extension of a physical examination enables the clinician to actually view pathologic conditions; this can be extremely beneficial to both the physician and the patient. I believe that, eventually, US will be to a sports physician what a stethoscope is to a cardiologist. For example, in the Changi Sports Medicine Centre in Singapore, a musculoskeletal US machine is operational at all times in every patient examination room. With that easy accessibility, trainees learn to view US as an extension of a physical examination as they become skilled in sonopalpation, diagnostics, and guided injections. In sports medicine, US is used most often in image-guided treatments. Although additional research is necessary to determine which types of injections are most beneficial when administered via US guidance, there is no question that US is safer than fluoroscopy for injections to peripheral joints. Electrosonodiagnosis, which is a combination of US and an electrodiagnostic technique (nerve conduction studies, electromyography), is often used in electrodiagnostic medicine and has the potential to play an even more important role in sports medicine [3]. In athletes, focal nerve injuries, entrapments, and overuse conditions are more common than peripheral neuropathy or nerve disorders caused by systemic disease [4]. US is particularly useful in helping clinicians visualize anatomic and dynamic pathologic conditions such as a snapping ulnar nerve displaced by a hypertrophied triceps in a baseball pitcher or groin and abdominal pain in an ultraendurance athlete [5]. In the future, it may be possible to use US-guided near-nerve recording techniques at sites such as the radial tunnel or the thoracic outlet, which are deep structures that cannot be easily assessed electrodiagnostically. Despite the wide use of US by a variety of practitioners in sports medicine, it is critically important that the clinician holding the transducer be able to accurately interpret the results of US assessment. To standardize the fellowship curriculum in primary care sports medicine, the American Medical Society for Sports Medicine has suggested guidelines to ensure that fellows obtain adequate musculoskeletal US training during their fellowship and can thus meet the requirements of competency outlined by the American Institute of Ultrasound in Medicine in its 2009 Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination [6]. The curriculum consists of 4 parts: a didactic component, a period of direct supervision, a proctored clinical experience, and recommendations for continuing education. Advanced biologic therapies used to treat musculoskeletal injuries are clearly on the horizon, and who better than sports medicine physicians to offer that aid to patients? Injected biologics have been used to alter the body's in vivo pro- and anti-inflammatory properties since the 1950s, when Hollander [7] first used intra-articular hydrocortisone to treat arthritis. Such therapies, which are used routinely today to treat spinal and musculoskeletal conditions, are based on the supposition that the body's natural healing mechanism involves inflammatory agents. The science of prolotherapy was thus born to induce an in vivo proinflammatory state that promotes healing. The effectiveness of prolotherapy, which is a very nonselective way of inducing a biologic response via the body's natural healing mechanisms, has received mixed reviews in the literature [8], but it is regularly used by some physicians. The latest wave of natural biologics is platelet-rich plasma, in which the patient donates his or her own blood for harvesting of the body's natural healing biologics, which, subsequently, are injected to a targeted area to enhance healing. Although platelet-rich plasma makes intuitive sense and may be a step in the right direction, the literature yields mixed reviews of its efficacy; a finding no doubt affected by the heterogeneous patients studied and the use of varied treatment techniques with inherent differences in their potential deficits and biologic abnormalities [9]. In the future, the focus of biologic therapy in sports medicine will likely shift to stem cell therapy, which has the potential to offer treatments that we can only imagine at this time. Research is beginning to demonstrate that, via an induced pluripotent stem cell technique, mesodermal cells such as chondrocytes may be generated by reprogramming a patient's own dermal fibroblasts, adipose tissue, or bone marrow. Eventually, we may be able to use that technology to treat cartilage defects with chondrocytes derived from a patient's reprogrammed stem cells. Outani et al [10] reported recently on the use of induced pluripotent stem cell reprogramming to generate hyaline cartilage from mouse adult dermal fibroblasts, and Medvedev et al [11] successfully differentiated cartilage from human induced pluripotent stem cell cells derived from fetal neural stem cells. In addition, results of preliminary studies by Centeno and Faulkner [12] suggested that mesenchymal stem cells assist with the healing of meniscal tears, tendon repair, and intervertebral disk repair. With the anticipated advancements in the use of biologics, someday we may be able to stimulate the body's natural healing process and prevent the need for more-invasive therapeutic procedures. In working at an academic medicine center with a human performance laboratory, I am fortunate to witness first hand the use of state-of-the-art approaches to optimize performance and screen for risk factors associated with injury and illness. Athletes, trainers, coaches, and physicians now have access to biomechanical gait and running analysis, video motion analysis, maximal oxygen uptake testing, lactate threshold testing, and bone density evaluations. Interdisciplinary research that integrates biomechanics, biomedical engineering, physiology and exercise physiology, orthopedics, and rehabilitation is encouraged. Various projects at our institution include identifying biomechanical and nutritional risk factors that contribute to or cause running injuries; improved understanding of the etiology, treatment, and prevention of anterior cruciate and patellofemoral injuries; dynamic core muscle testing and training protocols; innovative gait retraining for patients with osteoarthritis; and the use of new evaluation tools to identify concussion. These are just examples of the new directions of sports medicine that go beyond the more traditional medical models focused on treating injury, disease, and suffering, and expand into the areas of injury prevention and human performance. Although sports medicine physicians care for all people engaged in physical activities, from recreational athletes to professional competitors, a recent article by international sports medicine professionals recommends the increased use of clinical sports and exercise medicine for the prevention and treatment of chronic diseases [13]. Those professionals emphasize that the goals of sports medicine involve more than just taking care of elite athletes. Sports medicine is also dedicated to improving the health of and medical care for all people who exercise and to promoting well-being and health through an active lifestyle. As PM&R-trained sports physicians, we are in a particularly unique role to assist with that mission, because much of our training is designed to improve the function and activity level of all people with a disability. The Exercise Is Medicine initiative through the American College of Sports Medicine (Indianapolis, IN) is an excellent example of the bridge that is being built from sports medicine to health promotion and disease prevention. The integration of those approaches is exemplified by the pairing of the World Congress for Exercise in Medicine and American College of Sports Medicine meetings. The newly created American College of Sports Medicine Exercise Is Medicine credential will expand the pool of qualified exercise professionals who can help lead this health-based model, focused on patient education and the use of comprehensive interventions to change lifestyle behaviors. The government of Singapore has embraced a commitment to sports as a public health mission and a means of national pride in the Vision 2030: Live Better Through Sports initiative and plans to open a $1.33 billion sports hub in 2014. The Changi Sports Medicine Centre, which is the largest multidisciplinary sports medicine center in Singapore, provides a glimpse of the future of sports medicine. In the main lobby of Changi Hospital, the multidisciplinary center is the cornerstone and a reminder to all patients that physical activity is essential to health. It also reveals the future direction of sports medicine by enabling the collaboration of sports medicine physicians with physical therapists, athletic trainers, podiatrists, sports psychologists, sports nutritionists, and biomechanists. The center houses specialist clinics in orthopedic medicine, sports endocrinology, and bariatric surgery, and it offers, in one location, preparticipation physical health “packages” for the general public; a weight management program; gait analysis; and maximal oxygen uptake, running economy, and lactate threshold evaluations for athletes. The center serves as an example of how, in one setting, we can build connections between exercise medicine, rehabilitation, and human performance, and a vision of what all sports medicine centers can achieve in the years to come. The future sports medicine physiatrist will treat a wide range of musculoskeletal and sports-related conditions with novel and advanced techniques, and will work with athletes and patients of all ages and abilities as they try to achieve their fitness goals. He or she will have mastered a variety of diagnostic and therapeutic skills and will be able to provide care for elite athletes, top national sports teams, Olympians, and recreational athletes, as well as patients with an acute or chronic disability who want to return to an active lifestyle. I thank the following colleagues for their contributions to this article: Cindy Lin and Kelvin Chew (Singapore); Fabio Jennings (Brazil); Herve Collado (France); Shi-Uk Lee (Korea); and Marko Bodor, Chris Centeno, and David Kennedy (United States).

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