36th AMAA Sports Medicine Symposium at the Boston Marathon[R].

Thirty six years at the Boston Marathon .... and counting. AMAA (then AMJA) or the "running Docs" were true groundbreakers. I've told the story of the birth of running medicine to many runners and they nod with understanding and a thankful gesture to the pioneers of AMJA/AMAA.

What has evolved since 1969 is pretty amazing. If you just started running marathons in the past 10 years, you are accustomed to seeing medical personnel along a marathon course and a full-fledged medical tent at the finish line. Gels, sports drinks, energy bars, space blankets, and mist tents have become common sights at marathons and triathlons. But go back to the 80s and you would have most likely seen medical personnel at the start and finish and not much in between.

Go back even further, to the 70s, and you'd witness the first running boom. Computer timing and barcodes were the rage. Runners were excited to have "technical wear" and cushioned running shoes from new innovative companies like Nike.

When AMAA began in 1969 as the American Medical Joggers Association, there was no such colloquial term as "running medicine." Medical aid stations and finish line medical triage tents did not exist. Water stops were random and manned by local residents using their own cups, tables, and volunteers. When AMJA was formed by Ron Lawrence we saw individuals like Sam Paris, Noel Nequin, Charlie Clark, and our "Energizer Bunny" Judi Babb usher in a new era in running. The gathering of young energetic "running docs" was not only fun but also fostered significant professional exchange. The AMAA Sports Medicine Symposium at the Boston Marathon has now grown into a nationally-recognized and sponsored meeting.

Each year, AMAA members have gathered to listen, question, and debate the latest advances in medicine as they relate to running and endurance sports. And here we are again for the 36th time--and we'll be here every year in the future. I'd like to think that AMAA has had a hand in making endurance running a safer and healthier experience for everyone who toes the line in Hopkinton for that 26.2-mile journey to Boston.

The 2007 symposium presents several topics that have made headlines since last year's race. Malissa Wood, MD, and her research team will present findings and recent outcomes from their two-year cardiac study that involved AMAA members running the Boston Marathon. The New York Times ran a national story on her team's study which raised eyebrows from the running public. Our noted cardiologist runner Paul Thompson, MD, examines the lab we call the Boston Marathon and looks at the impact it's had on science and medicine. Other topics include an update from our noted Hyponatremia Team led by Art Siegel, MD, along with BAA Emergency Services Director Peter Moyer, MD, and GSSI researcher Nina Stachenfeld, PhD. New insights on hyponatremia were revealed at the World Congress of Science and Medicine of the Marathon last October in Chicago; these will be presented at our meeting. We will also look at deaths in marathons through experiences from the Marine Corps Marathon, as presented by AMAA Board Member COL Francis O'Connor, MD, and Marine Corps Marathon Medical Director CAPT Bruce Adams, MD.

AMAA is proud and honored to be part of the stories and history of the Boston Marathon. Ron Lawrence's leadership and vision led to safer marathons and endurance events. His recommendations brought state of the art medical triage and treatment on-site by "bringing the ER to the course." Now the first responders are at the start, along the course, and at the finish line. And the army of AMAA runners showing that they will "run the run" and not just "talk the run" are sending important messages to patients and colleagues. Come join us in Boston for our 36th Annual AMAA Medical Symposium.

Disabled Sports: Using Sports as a Medicine

Robert Harney, MD Orthopedic Surgeon, North Suburban Orthopedic Associates, Malden, MA; Vice President, Disabled Sports USA; Medical Team, International Paralympic Committee; Medical Team, Paralympic Games

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Participation in sport provides cardiovascular fitness, weight control, self esteem, social awareness and the concept of teamwork. This is even more evident in the disabled population whose life expectancy is now approaching that of the able bodied population. This presentation will demonstrate some of the amateur and elite sports opportunities for people with disabilities, as well as some of the technical improvements that are available to this population.

The Boston Marathon as a Research Laboratory: 110 Years and Still Running

Paul D. Thompson, MD Professor of Medicine, University of Connecticut, School of Medicine, Farmington, CT; Director, Division of Cardiology, Hartford Hospital, Preventive Cardiology, Hartford, CT; Associate Editor, Textbook of Cardiovascular Medicine; Editor, Exercise and Sports Cardiology; Past President, American College of Sports Medicine (Co-Researcher, Carmelo Venero, MD, Cardiology Hospitalist)

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The first Boston Marathon on April 19, 1897 was organized by members of the Boston Athletic Association (BAA) who were inspired by the revival of the Olympic Games in Athens and its marathon the year before. The race will be run for the 111th time in April 2007, although the individual race was replaced by a relay during World War I. Since its inception, "Boston" has served as a research laboratory for medical investigators. Indeed, in only its third running (1899), two Tufts professors used Boston to examine urine and hematological changes associated with the event. Such research on Boston marathoners has continued to the present. This presentation will examine the history of medical studies during the Boston Marathon and their contributions to our knowledge of endurance exercise.

Cardiology Updates: A Review of Boston Medical Studies

Malissa Wood, MD, FACC Co-Director, Massachusetts General Hospital Heart Center Women's Heart Health Program; Instructor in Medicine, Harvard Medical School, Boston, MA

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Multiple studies have individually documented cardiac dysfunction and biochemical evidence of cardiac injury after endurance sports; convincing associations between the two are lacking.

Sixty non-competitive runners were screened with echocardiography and serum biomarkers pre and post the 2004 and 2005 Boston Marathons. Echocardiography included conventional measures as well as tissue Doppler-derived strain and strain rate imaging. Biomarkers included troponin T (cTnT) and N-terminal pro-brain natriuetic peptide (NT-proBNP).

All subjects completed the race. Echocardiographic abnormalities post-race included altered diastolic filling, increased pulmonary pressures, and right ventricular (RV) dimensions and decreased RV systolic function. At baseline, all had unmeasurable cTnT. Post-race, >60% of participants had an increased cTnT to above the 99th percentile of normal (>0.01 ng/ml), while 40% had a cTnT value at or above the decision limit for acute myocardial necrosis ([greater than or equal to]0.03 ng/ml). Post-race, NT-proBNP concentrations increased from 63 pg/ml (interquartile range [IQR]=21-81 pg/ml) to 131 pg/ml (IQR=82-193 pg/ml; P<0.001). The increase in biomarkers correlated with post-race diastolic dysfunction, increased pulmonary pressures and the presence of RV dysfunction (RV mid _, r=-0.70, P<0.001) and inversely with training mileage (r=-0.71, P<0.001). Compared to athletes training [greater than or equal to]45 miles/week, those training [less than or equal to]35 miles/week demonstrated increased pulmonary pressures and RV dysfunction (mid _ 16[+ or -]5 vs. 25[+ or -]4 %, P<0.001), and increased myocyte injury (cTnT=0.09 vs. <0.01 ng/ml, P<0.001) and stress (NT-proBNP=182 vs. 106 pg/ml, P<0.001).

It was concluded that completion of a marathon is associated with correlative biochemical and echocardiographic evidence of cardiac dysfunction and injury and this risk is increased with inadequate preparation. These results will be discussed during the panel session held on Saturday, April 14.

Therapies and Trends in the Management of Plantar Fasciitis

Neha P. Raukar, MD, MS Clinical Assistant Professor, Department of Emergency Medicine, Brown Medical School, Providence, RI; Team Physician, Primary Care Sports Medicine, Brown University

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Plantar fasciitis is a common cause of heel pain in adults. This is an irritation to the tough, fibrous tissue that forms the arch of the foot and patients complain of pain upon waking or with prolonged standing. In general, plantar fasciitis is a self-limited condition; however, symptoms usually resolve more quickly when the interval between the onset of symptoms and the onset of treatment is shorter. Most patients with plantar fasciitis are effectively treated with some simple measures such as anti-inflammatory medications, ice applications, shoe inserts, and stretching exercises. Usually, plantar fasciitis can be treated successfully by tailoring treatment to an individual's risk factors and preferences but in some situations patients do not find relief from their symptoms and require more aggressive treatment. Surgical intervention has been the last resort for patients when other treatments of plantar fasciitis do not work. Unfortunately, the surgical success rate is low and there are potentially complicating adverse effects.

This presentation will examine plantar fasciitis and current treatment options, as well as review the literature regarding the use of ESWT and Platelet-Rich-Plasma to treat this problem.

Hypertonic (3%) Sodium Chloride for Emergent Treatment of Exercise-Associated Hypotonic Encephalopathy 

Arthur J. Siegel, MD Director, Internal Medicine, Harvard's McLean Hospital, Belmont, MA; Assistant Professor of Medicine, Harvard Medical School, Boston, MA

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Exercise-associated hyponatremia (EAH) is an acute-onset imbalance in the tonicity of extracellular fluids during or after endurance exercise which results in a blood sodium concentration ([Na+]) of less than 135 mmol/L. Both avid fluid intake and a concurrent decrease in urine formation contribute to this predominantly dilutional effect, which can result in life-threatening pulmonary and cerebral edema during rapid onset.

Marathon runners with hypotonic encephalopathy related to EAH, including two cases with fatal cerebral edema, demonstrated non-osmotic secretion of arginine vasopressin (AVP) and fulfilled the essential diagnostic criteria for the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The pathophysiology of SIADH as the proximate cause of EAH accounts for otherwise puzzling clinical observations such as cases occurring after only moderate fluid intake or presenting hours after races.

This formulation provides a framework for enhancing prevention by monitoring weight changes during races to detect positive fluid balance before the onset of mental status changes. Most importantly, SIADH supports a strategy for use of oral and intravenous hypertonic solutions including 3% sodium chloride for the emergent treatment of moderate and life-threatening symptoms of hypotonic encephalopathy. This approach has resulted in improved clinical outcomes at recent races.

During the panel session on Sunday, April 15, we will address the prevention and treatment of EAH, as well as examine optimal hydration for a marathon runner.

What's Running Through Their Minds?: Psychological Assessment and Intervention at the Marathon Finish Line

Jeffrey L. Brown, PsyD, ABPP Clinical Associate, McLean Hospital, Belmont, MA; Instructor, Department of Psychiatry, Harvard Medical School, Boston, MA

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Running a marathon is indeed physically challenging and psychologically demanding. Adding a sport psychologist to the Boston Marathon Medical Team at the finish line in 2002 was a unique and historical decision. Now commonplace on race day, psychologists work alongside physicians, nurses, and other healthcare professionals with the collective goal of comprehensively treating and stabilizing runners who seek medical services. The psychologist's function on the medical team is as diverse as the types of runners who are treated at the finish line.

With a backdrop of cognitive-behavioral theory, this presentation will provide an overview of the psychologist's role and services offered in the medical tent. Included for discussion will be common types of psychiatric cases evaluated at the finish line, brief psychological interventions which can be useful in stabilizing difficult-to-treat athletes, and a review of psychiatric symptoms associated with hyponatremia. Ethical dilemmas facing a sport psychologist treating athletes, as well as a model for integrating a sport psychologist into an existing medical team will be offered. Case examples will be provided to illustrate the clinical material presented.

--Dave Watt, AMAA Executive Director

RELATED ARTICLE: AMERICAN MEDICAL ATHLETIC ASSOCIATION'S 36TH ANNUAL SPORTS MEDICINE SYMPOSIUM AT THE BOSTON MARATHON[R]

April 14-15, 2007

Jointly Sponsored by the American College of Preventive Medicine 

AGENDA

Saturday, April 14th
 7:00-8:00   On-Site Registration and Continental Breakfast
 8:00-8:45   TBA
 8:50-9:35   The Boston Marathon as a Research Laboratory: 110 Years and
             Still Running (Paul D. Thompson, MD)
 9:35-9:50   Break
 9:50-11:10  Cardiology Updates: A Review of Boston Medical Studies
             (Panel Chaired by Paul D. Thompson, MD)
             Malissa Wood, MD
             Kent Lewandrowski, MD
11:15-12:00  Cardiac Screening in Competitive Athletes (Adolph M.
             Hutter, Jr., MD, MACC)
12:00-1:15   Lunch (on your own)
 1:15-2:00   Exercise Associated Collapse: The Marine Corps Marathon
             Experience (COL Francis G. O'Connor, MD, MPH, FACSM)
 2:05-2:50   Marine Corps Marathon Deaths: A Series of Case Studies
             (CAPT W. Bruce Adams, MD)
 2:50-3:05   Break
 3:05-3:50   What's Running Through Their Minds?: Psychological
             Assessment and Intervention at the Marathon Finish Line
             (Jeffrey L. Brown, PsyD, ABPP)
 3:55-4:40   Overtraining (Thomas M. Howard, MD)
 4:45-5:45   Cocktail Reception Outside Ballroom
 6:00-8:00   Dinner Hosted by AMAA

Sunday, April 15th
 7:30-8:30   On-Site Registration and Continental Breakfast
 8:30-9:15   Can We Predict Who Will Hit the Wall? Measuring
             Mitochondrial DNA Content as a Surrogate for Aerobic
             Metabolism (Edward R. Sauter, MD, PhD)
 9:20-10:05  Therapies and Trends in the Management of Plantar Fasciitis
             (Neha P. Raukar, MD, MS)
10:05-10:20  Break
10:20-11:05  Disabled Sports: Using Sports as a Medicine (Robert Harney,
             MD)
11:10-12:30  Hydrating Safely for a Marathon: Strategic Considerations
             (Panel Chaired by Peter Moyer, MD)
             Arthur J. Siegel, MD
             Nina S. Stachenfeld, PhD

Meeting Adjourned