THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 6 - JUNE 99

Anabolic Steroids May Help Restore Muscle in HIV Patients

The pairing of anabolic steroids and resistance exercise, a practice used by some athletes but widely condemned by physicians, may gain new respect as a way to reverse muscle wasting in patients who have human immunodeficiency virus (HIV) infection.

Researchers at San Francisco General Hospital (1), as reported recently in The Journal of the American Medical Association (JAMA), conducted a double-blind, randomized, placebo-controlled trial that compared the effects of oxandrolone and progressive resistance exercise with resistance training alone in 22 HIV-infected patients. Before the study, the men had lost about 9% of their body weight.

The 11 patients in the anabolic steroid group received 20 mg of oral oxandrolone each day. The treatment group and the 11 control patients all had normal testosterone levels before the trial and received low-dose testosterone enanthate injections (100 mg per week) to make hormonal status more comparable between the groups by suppressing endogenous testosterone production, ensuring that borderline hypogonadism was not present, and avoiding the possibility of hypothalamic hypogonadism induced by exercise. All patients took part in 8 weeks of resistance training, consisting of three 1-hour sessions per week on nonconsecutive days. Standard isotonic exercise machines were used for training.

At the end of the study, both groups had increases in weight and lean body mass. However, the oxandrolone group had significantly greater gains (body weight, 6.7 kg vs 4.2 kg; lean body mass, 6.9 kg vs 3.8 kg). Both groups had strength gains, but the oxandrolone group's gains were significantly larger.

Benefits vs Cardiac Risks

Leonard Calabrese, DO, section head of clinical immunology in the Department of Rheumatic and Immunologic Disease at The Cleveland Clinic Foundation, says the gains achieved in the study were impressive. Despite the use of protease therapy, muscle wasting is still a clinically significant problem in HIV patients, especially in those who have advanced disease and those who are on highly active antiviral therapy, according to Calabrese. He notes that wasting has several causes: hypercatabolism, malabsorption, and poor nutrition. "Sometimes the wasting is stepwise, and patients will lose 5 or 6 kg after a viral illness or pneumonia and they won't gain the weight back," he says. "It's important to intervene."

Calabrese says some physicians, including himself, are already prescribing anabolic steroids and resistance exercise to reverse muscle wasting in HIV patients. However, he says he is extremely cautious about anabolic steroid use in patients who are on protease inhibitors because both drugs pose cardiovascular risks. Steroids have a negative effect on serum lipids, and Calabrese says protease inhibitors can induce a variety of lipodystrophies as well as glucose intolerance.

"We aggressively assess patients' cardiovascular risk and treat high lipid levels," Calabrese says. For patients who have controlled risk factors and are willing to exercise, he prescribes 10 to 20 mg of oral oxandrolone per day or 100 mg per week of injectable nandrolone. The route of administration often depends on the patients' insurance coverage; Calabrese estimates that the oral drug costs $500 to $1,000 per month and that the injectable form costs $30 to $50 per month.

Study Raises More Questions

The writer of an editorial (2) that accompanied the JAMA article advised caution regarding the possibility of using anabolic steroids in patients with HIV infection. Adrian Sandra Dobs, MD, MHS, associate professor of medicine at The Johns Hopkins University School of Medicine in Baltimore, wrote that before anabolic steroids are adopted into clinical practice, researchers should answer the following questions: (1) Does increasing lean body mass change the prognosis? (2) Is long-term anabolic steroid use safe? (3) Which patients are likely to benefit—those with mild disease or those with advanced infections? (4) Should steroids be use intermittently or continuously? and (5) Which anabolic drug is most effective?

She also suggested that the efficacy of resistance exercise alone should be determined. Assuming that injuries can be avoided, she wrote, exercise "is clearly the safest and least expensive approach to prevent muscle wasting."

Lisa Schnirring
Minneapolis

References

1. Strawford A, Barbieri T, Van Loan M, et al: Resistance exercise and supraphysiologic androgen therapy in eugonadal men with HIV-related weight loss: a randomized controlled trial. JAMA 1999;281(14):1282-1290
2. Dobs AS: Is there a role for androgenic anabolic steroids in medical practice? JAMA 1999;281(14):1326-1327

Lung Injuries in Contact Sports: Diagnosis and Management Tips

Lung injuries in contact sports are rare but can be serious or life-threatening, as in the recent case of pro hockey's Eric Lindros, whose collapsed lung prompted surgery and kept him from the Philadelphia Flyers' playoffs lineup this year.

Diagnosing a sports-related lung injury can be difficult because physicians can't always depend on hemoptysis and disabling pain as clues. According to media reports, Lindros received and delivered many hard checks during an April 1 game against the Nashville Predators (1,2). One report (3) said he fell on his stick. He played the entire game, talked with reporters in the locker room afterward, and went out for dinner before symptoms (light-headedness, nausea, and shortness of breath) emerged later that night.

Robert Promisloff, MD, a pulmonary critical care specialist at Hahnemann University Hospital in Philadelphia, told the Philadelphia Inquirer that it would be rare for a player to be hit hard enough to sustain a hemothorax and not know it, but a well-conditioned athlete such as Lindros might be able to shrug off the pain.

Here are some management tips from two National Hockey League team physicians who have encountered sports-related lung injuries: Gary Dorshimer, MD, internist for the Flyers and fellow of the Association of Professional Team Physicians, and David C. Reid, MD, professor of orthopedic surgery at the University of Alberta in Edmonton and team physician for the Edmonton Oilers.

Evaluation

Dorshimer:

• Keep in mind that lung injuries can occur even when the impact seems routine, such as when a player is hit while the lungs are fully expanded and the throat is closed.
• When auscultating the lungs, abnormal breath sounds may indicate fluid in the lungs, and absence of lung sounds may indicate a collapsed lung.
• Hemoptysis is uncommon and usually benign and self-limiting, but aggressive workup and treatment are warranted if a player coughs up a lot of blood in a short time or a smaller amount over a longer period. Sometimes lung contusions or bronchitis can produce minor bleeding.

Reid:

• On the sidelines, a sign of possible serious bleeding would be unstable blood pressure, usually accompanied by obvious symptoms. Earlier, more subtle signs of possible blood loss include light-headedness, dizziness, fatigue, diaphoresis, tachycardia (above what's expected for recent exertion) or lack of recovery of normal heart rate at rest, and tachypnea. Significant blood loss or dyspnea signals the need for emergency care.
• When a player sustains a chest injury, palpate the ribs for grating or displacement that would suggest a rib fracture. Referred pain to the shoulder tip can suggest an injury to the spleen, liver, or inferior lung.
• Most instances of traumatic hemoptysis involve trace amounts of blood, but be certain of where the blood came from before returning a player to the game. "One time we had a football player with hemoptysis, and we thought it was from trauma during the game, but with some investigating, we found that it was a lung tumor."
• Chest radiographs are indicated for patients who have suspected rib fractures; they are "cheap, quick, and effective."

Dorshimer:

• Chest films can also identify lung tears. Have the patient exhale, and tears with pneumothorax will stand out more.
• Patients who have nondisplaced rib fractures require a period of watchful waiting, and those who have displaced rib fractures with hemoptysis or other symptoms should be hospitalized for observation. Some tears require surgical repair, and pneumothoraces require lung reexpansion.

Return to Play

Reid:

• When hemoptysis involves trace amounts of blood, it's useful to evaluate a player's response the next day to an interval on an exercise bike. If hemoptysis doesn't recur, the athlete can probably be cleared for play.

Dorshimer:

• There are no hard-and-fast guidelines for return to play; the decision depends on the player's sport, injury, and ability to play wearing protective padding. "Pain is a limiting factor with rib fractures. Players are pretty uncomfortable with twisting and turning." Patients who have pulmonary surgery are typically out for at least several weeks.

Reid:

• who have nondisplaced rib fractures can usually return as comfort allows, but those who have displaced fractures should return wearing protective padding or a flak jacket. Sometimes fitting the flak jacket under the jersey is a problem. "That's usually not a problem for bigger players, but for smaller people an equestrian-style chest protector often works well."

References

1. Panaccio T: A painful ending? Injury imperils Lindros' season. Philadelphia Inquirer 1999;April 1:C1
2. El-Bashir T: Collapsed lung will keep Lindros off the ice for Flyers. New York Times 1999;April 3:B7
3. Burling S: Doctors say Lindros injury slow to heal: specialists say it will likely be several weeks before the Flyer's blood and breathing are normal. Philadelphia Inquirer 1999:April 8:E2

Beginners Should Use Care With Tae Bo and Other Kick-Boxing Workouts

Aerobic kick-boxing classes, often called cardio kick-boxing, provide an intense workout that offers multiple benefits, but beginners need to take precautions to prevent injuries, according to the American Council on Exercise (ACE), which serves as a consumer watchdog on exercise products and programs.

In a recent press release, ACE reported that cardio kick-boxing—a hybrid of boxing, martial arts, and aerobic dance—is quickly replacing step aerobics and indoor cycling as the most popular fitness class at gyms. The classes, many of which are inspired by Tae Bo workout videos, provide an intense full-body workout that uses a variety of movements that are designed to boost strength, aerobic fitness, and flexibility, as well as sharpen reflexes and improve coordination and balance. ACE notes that an hour-long kick-boxing workout burns 500 to 800 calories, compared with 300 to 400 calories for a typical hour-long step aerobics class.

Kick-boxing workouts appeal to people who get bored with "linear-type" activities such as jogging and walking, said Richard Cotton, PhD, chief exercise physiologist for ACE, in the press release. "The variety of movements found in martial-arts-based workouts may be enough to pique the interest of the easily bored and keep them working out for the long run."

ACE advises beginners and other participants to keep in mind the following safety tips:

• Achieve a solid fitness foundation before starting cardio kick-boxing exercises. Even basic classes or videos require above-average endurance, flexibility, and strength.
• Master proper technique. Common beginners' mistakes include overextending kicks and locking joints when punching or kicking.
• Progress gradually at your own pace. Because many programs are not based on progression, it's important to resist the peer pressure to kick as high as the instructor or more experienced class members, or to work out a full hour if this is excessive for you.
• Don't wear weights or hold dumbbells when punching.
• Make sure the instructor is properly certified by ACE or another qualified organization before enrolling in a class.

Field Notes

HCM Death Speeds Revision of Indiana PPE Forms
The Indiana High School Athletic Association (IHSAA) revised its preparticipation exam (PPE) forms in April, prompted in part by the death of a high school basketball star.

According to a March 14 article in the Chicago Tribune, John Stewart, a 7-ft senior, collapsed in the third quarter of a regional playoff game. The cause of death listed on the coroner's report was hypertrophic cardiomyopathy.

Ray Craft, associate commissioner of the IHSAA, said the sports medicine committee of the Indiana Medical Association has always worked closely with the IHSAA and regularly recommends changes to the state's PPE procedures and forms. "There was a lot of media attention about the death, and we turned to them to review our forms again," Craft said, adding that the group added four additional cardiac screening questions to make Indiana's PPE forms address all of the PPE cardiac exam recommendations proposed by the American Heart Association (AHA) in 1996.

A 1998 report in The Journal of the American Medical Association (JAMA) found that eight states had no approved PPE forms and of the states that had forms, many omitted some of the AHA's recommended cardiac screening questions.

Thomas L. Sevier, MD, one of the physicians who worked with the IHSAA on the PPE form changes, said that the new form containing all 13 of the AHA's recommended questions probably wouldn't have prevented Stewart's death. "Unfortunately, sudden death was his first symptom," says Sevier, who is medical director of Central Indiana Sports Medicine in Muncie. Some people argue that expensive diagnostic tests should be performed during the PPE, but the tests aren't perfect and produce many false positives, he said. "This form is the best device we currently have to pick up potentially serious cardiac abnormalities," Sevier said. "The key to the success of the PPE is to make sure that these questions are carefully answered by the athlete's parents or guardians."

Young Baseball Player Dies From Baseball Impact
A 14-year-old baseball player in Thomson, Georgia, died on April 23 after he was hit in the chest by a baseball, according to an article that appeared on the Web site of the Augusta (Georgia) Chronicle (http://augustachronicle.com).

The boy, playing in a recreational league tournament, was trying to steal third base when he was hit on the left side of the chest. He stopped breathing seconds after he was hit. Cardiopulmonary resuscitation efforts by bystanders at the scene were unsuccessful, as was defibrillation administered by emergency medical technicians.

Rabies Vaccination Update
Wild animals' bites are the most common source of rabies infection among humans in the United States, and as summer vacation season begins it's useful to review the recently revised rabies immunization recommendations, as published in the January 8 issue of Morbidity and Mortality Weekly Report. The major changes are detailed in an abstract from a presentation at a November 1998 meeting of the Infectious Diseases Society of America.

• Postexposure prophylaxis should be considered when a patient has been exposed to a bat or other rabid animal, even if no bite of scratch occurred, if significant nonbite exposure may have occurred. Possible (though rare) avenues of nonbite exposure include inhalation of aerosolized virus in a bat-infested cave and contamination of open wounds or mucous membranes with saliva or other potentially infectious material such as neural tissue.
• Ferrets should be quarantined and vaccinated according to the protocols used for dogs and cats.
• For postexposure prophylaxis, patients who have been vaccinated previously should receive as much of the full dose of rabies immune globulin as possible at the exposure site, rather than receive half of the dose intramuscularly.