STAYING HEALTHY WHEN PREGNANT WITH TWINS

The fact that you are carrying more than one baby does place you in a special category in the eyes of obstetricians. Many would call a twin pregnancy a high-risk pregnancy, but don’t be scared by this categorization. High risk does not automatically translate into your pregnancy having problems. Rather, high risk can be translated as, “We will need to follow this pregnancy more closely.” Also in the high-risk category are mothers with diabetes, those with a history of preterm labor with prior pregnancies, or those who have other major health issues themselves. The majority of twin pregnancies progress smoothly, and the odds of a healthy pregnancy increase if you take better care of yourself.

The most important step to care for your pregnancy is proper nutrition. Ideally, pregnant mothers should take a prenatal vitamin with folic acid starting from 3 months prior to conception. Folic acid has definitively been proven to reduce the chances of neural tube defects such as spina bifida. If you haven’t started taking the vitamin daily yet, don’t fret about the missed time—but do start now. Take the vitamin with food to reduce nausea, and applaud yourself for taking yet another step to keep your babies as healthy as possible. Moms of twins don’t need 2 prenatal vitamins a day—one is enough.

Eating the proper foods and the right amount of calories is critical in a twin pregnancy. Whereas single-born pregnancies require 300 extra calories a day, most experts agree that twin pregnancies need around 1,000 extra calories a day. Frequent and healthy snacks can help you reach your caloric goals each day. Morning sickness—or in most women’s cases, all-day sickness—can be eased by eating small snacks frequently. Keeping a little something in your stomach at all times can help take the edge off of the nausea. Low-fat yogurt, fruit, smoothies, crackers, and protein shakes are all good snack options.

In addition to the extra calories, it is important to sip on water throughout the day. Keeping well hydrated may drive you crazy in later months when it seems like you’re running to the bathroom every 5 minutes; however, your babies’ extra blood flow and removal of wastes depends on it! It may help to drink more water earlier in the day and then stop after 8:00 pm so that you can sleep longer stretches at night between bathroom breaks.

Proper nutrition and hydration is important for your twin pregnancy, as is listening to your body. Any new pregnancy symptoms you notice must be brought to your obstetrician’s attention; seemingly minor things could be a sign of something more serious.

Because twins have an increased chance of being born early, any symptoms or concerns must be addressed for the safety of your babies. Bleeding or vaginal discharge, contractions that are becoming more frequent, pressure in the pelvis or lower back, or even diarrhea can all be signs of preterm labor. And while early bleeding in the first trimester could be the normal phenomenon of the twins implanting in the uterine wall, you should call your obstetrician if you experience bleeding at any point.

Twin pregnancies can also increase the chances of preeclampsia, a condition in which the mother has increased blood pressure, protein in the urine (detectable by urinalysis), and more swelling than is normal in pregnancy. If you notice rapid weight gain or headaches, alert your obstetrician so you may be examined as soon as possible. Depending on the severity of the situation, treatment may range from bed rest, to hospital-administered medications, to immediate delivery of the babies (the only “cure” for preeclampsia).

An optimistic yet careful attitude during your pregnancy will help your mental state and hence help your babies thrive during pregnancy as long as possible. Take things one day at a time and one week at a time. Eat well and pay attention to what your body and your twins are telling you. Every extra day that your babies spend inside the womb will help them once delivery day arrives. The bigger your belly gets, the bigger your smile should be, since you’re creating 2 miracles!

ENERGY OUT: DAILY PHYSICAL ACTIVITY RECOMMENDATION

Physical activity in children and adolescents improves strength and endurance, builds healthy bones and lean muscles, develops motor skills and coordination, reduces fat, and promotes emotional well-being (reduces feelings of depression and anxiety). Activities should be appropriate for their age and fun, as well as offer variety. Talk to your physical therapist about setting your child up with a movement evaluation to assess body alignment and help your kids learn healthy movement habits! 

The daily recommendation for physical activity for children 6 years and older is at least 60 minutes per day. Active play is the best exercise for younger children.

The types of physical activity should be moderate to vigorous. Vigorous activity is activity that makes you breathe hard and sweat. During vigorous activity, it would be difficult to have a talk with someone. Some activities, such as bicycling, can be of moderate or vigorous intensity, depending upon level of effort. 

The 60 minutes does not need to be done all at once. Physical activity can be broken down into shorter blocks of time. For example, 20 minutes walking to and from school, 10 minutes jumping rope, and 30 minutes at the playground all add up to 60 minutes of physical activity. If your child is not active, start from where you are and build from there.

Types of Sports and Activities for Children and Teens (and Parents, Too!) 

Aerobic Exercises 

• Use body's large muscle groups 
• Strengthen the heart and lungs 
• Examples of moderate-intensity aerobic exercises include: 
  • Brisk walking 
  • Bicycle riding 
  • Dancing
  • Hiking 
  • Rollerblading 
  • Skateboarding 
  • Martial arts such as karate or tae kwon do (can be vigorous too) 
• Examples of vigorous-intensity aerobic activities include: 
  • Basketball
  • Bicycle riding 
  • Games such as tag 
  • Ice or field hockey
  • Jumping rope 
  • Martial arts 
  • Running
  • Soccer
  • Swimming
  • Tennis

Muscle-Strengthening (or Resistance) Activities 

• Work major muscle groups of the body (legs, hips, back, abdomen, chest, shoulder, arms) 
• Examples of muscle-strengthening activities include:
  • Games such as tug-of-war 
  • Push-ups or modified push-ups (with knees on the floor) 
  • Resistance exercises using body weight or resistance bands 
  • Rope or tree climbing 
  • Sit-ups (curl-ups or crunches) 
  • Swinging on playground equipment/bars 

Bone-Strengthening (Weight-Bearing) Activities 

• Tone and build muscles and bone mass 
• Can be aerobic exercises and muscle-strengthening activities 
• Examples of bone-strengthening activities include:
  • Basketball 
  • Hopping, skipping, jumping 
  • Gymnastics
  • Jumping rope 
  • Running 
  • Tennis 
  • Volleyball
  • Push-ups 
  • Resistance exercises using body weight or resistance bands

About Strength Training 

Strength training(or resistance training) uses a resistance to increase an individual's ability to exert force. It involves the use of weight machines, free weights, bands or tubing, or the individual's own body weight. This is not the same as Olympic lifting, power lifting, or body building, which are not recommended for children. Check with your child's doctor before starting any strength training exercises.

IT BAND SYNDROME

What is it?
The iliotibial band (“IT band”) is a thick band of fascia (a kind of hard flesh) that extends down the outside of the upper thigh. It begins on the pelvis, crosses the hip and knee, and attaches just below the knee. Pain is a result of friction or rubbing of the iliotibial band against the bone on the outside of the knee, which results in irritation of the band. It is one of the most common knee injuries (second only to patellofemoral pain syndrome) and has been reported in as many as 12 percent of runners. Athletes involved in cycling, weightlifting, football, soccer and tennis may also experience pain from the IT band. 

Symptoms

• Pain on the outer part of the knee with sporting activities
• Popping or rubbing sensation on the outer knee
• Pain after sitting for long periods of time with the knee bent
• Pain typically worsening with activities

Sports Medicine Evaluation and Treatment
A sports medicine physician will ask an athlete questions about potential risk factors for ITBS, including running mileage, change in mileage, uphill and downhill running routines, and track workouts. Running the same direction around a track for a long time may worsen ITBS symptoms. A sports medicine physician will perform a thorough physical exam of the athlete’s knee and leg. The provider may look at muscle imbalances, flexibility, leg length, hip and knee alignment, running gait, foot arches and footwear.

For ITBS, imaging is not usually necessary, unless the physician suspects that other causes within the knee may be causing the pain. Treatment of ITBS includes rest, ice and anti-inflammatory medications. Athletes may also have to alter training routines during the recovery period to avoid activities that cause pain. Stretching is an important component to the treatment of ITBS, as well as identifying and correcting strength imbalances. Other treatment options include steroid injections, foot orthotics and very rarely, surgical referral.

Injury Prevention
Athletes should maintain appropriate flexibility and strength, and ensure a proper warm-up prior to activity. 

Return to Play
Athletes may expect to return to activity once the symptoms have improved. Cross training is often a useful tool to use to aid in recovery. Once symptoms are improved, the athlete can gradually return to activity, generally over a period of about four to six weeks.

Authors: AMSSM Members Raul Raudales, MD, and David Berkoff, MD

ATHLETIC PUBALGIA

What is it?
Athletic pubalgia is defined as pain in the groin area of an athlete. It has been given many names in the past, such as sportsman hernia and hockey groin. It often happens in sports that require running, twisting, or kicking including soccer, hockey, rugby, and football. Many conditions can cause athletic pubalgia, including tendon strains, nerve injuries, joint problems, and true hernias.

Symptoms
The pain is in the groin region, can occasionally radiate up into the stomach or down into the thigh, and is frequently increased with running, kicking, twisting, sit ups, coughing, or sneezing.

Sports Medicine Evaluation
There may be tenderness when the doctor pushes on the painful area, and it may hurt when the hip is twisted. X-rays may show abnormalities in the hip or pubic joint. An MRI or ultrasound may show soft tissue abnormalities such as a muscle or tendon injury. A dynamic ultrasound, which involves looking at the area while the athlete moves or "bears down" can help identify hernias or weaknesses in the muscles or tendons.

Treatment
Initial treatment usually includes avoiding painful activities and specific strength and flexibility exercises. Ice, heat, and occasionally anti-inflammatory medications may improve symptoms. Occasionally, tendon injuries require injections to help the area heal, and hernias and certain hip joint and nerve problems may require surgery.

Injury Prevention
Because there is no single specific known cause of athletic pubalgia, prevention can be difficult. However, strengthening the hip adductors and abductors is important. In addition, core strengthening and not playing through pain is important.

Return to Play
Athletes who require rehabilitation must have adequate hip range of motion, good strength, and be functional in their sport before returning to practice or competition. This may take up to 12 weeks. Athletes who undergo surgery are typically able to return to sports but this can take 4 weeks to 6 months.

References
Caudill P, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008; 42(12):954-64.
Litwin DE, et al. Athletic pubalgia (sports hernia). Clin Sports Med. 2011; 30(2):417-34.

CERVICAL STRAIN/SPRAINS

What is it?
A strain or sprain is an injury to a muscle or ligament.  There are many parts of the neck that can be injured, such as the muscles, ligaments, bones, discs, and nerves.  A cervical strain or sprain is a neck injury that involves the muscles or ligaments of the neck. This type of injury can happen in any sport when there is a collision between two athletes, a fall, or contact with impact to the head.   In some collisions or falls, the neck may not be directly injured, but the force of the injury may cause a whiplash of the neck and cause a sprain or strain.  This can occur in many sports, but more often in football, ice hockey, lacrosse, wrestling, and soccer. 

Symptoms
The athlete may start to feel symptoms immediately after the injury, or may slowly feel worsening pain over the course of a few days.  He or she may feel soreness or stiffness in the neck muscles.  It may be difficult to move the neck in certain directions.  The athlete may also feel a spasm or tightness in the neck muscles.  This type of neck injury does not typically involve the bones, nerves, or discs of the neck.  The athlete should not have any numbness, tingling, or weakness in the arms from a true cervical strain or sprain.

Sports Medicine Evaluation/Treatment
 A sports medicine physician will perform a thorough physical examination in order to rule out a more serious neck injury, such as an injury to the spinal cord.  If there are any worrisome signs at the time of the injury, the athlete may be referred for evaluation at the emergency department.  The physical examination includes evaluation of neck movement, location of the pain, and evaluation for muscle spasm.  The athlete can expect a neurological exam to make sure there is no injury to a nerve in the neck.  Sometimes, an x-ray will be ordered to rule out a more serious neck injury.

The treatment of this condition depends on the severity of the injury.  The healthcare provider may prescribe medications to help with the pain or spasm, such as anti-inflammatory medications or mild muscle relaxers.  If the pain is mild, the athlete may be able to do exercises at home to regain full range of motion of his or her neck.  If the pain is worse, the provider may have the athlete work with the athletic trainer if available, or refer the athlete to a physical therapist.  If the athlete is not improving with these treatments over time, an MRI might be ordered to look for a disc or nerve injury.

Injury Prevention
In any collision sport such as football, it is important to play with proper form.  This includes keeping the head up for any collisions or tackles, and not leading with the helmet or head.  Athletes should be taught the proper form for tackling at practice by their coaches, and avoid tackling other athletes until proper technique has been demonstrated.

Return to play
For a cervical sprain or strain that does not include any other worrisome signs, the athlete can return to play once the pain is controlled and he/she has regained full range of motion and strength of the neck.

AMSSM Author: Kris Fayock, MD

REDUCING THE SPREAD OF ILLNESS IN CHILDREN

Whenever children are together, there is a chance of spreading infections. This is especially true among infants and toddlers who are likely to use their hands to wipe their noses or rub their eyes and then handle toys or touch other children. These children then touch their noses and rub their eyes so the virus goes from the nose or eyes of one child by way of hands or toys to the next child who then rubs his own eyes or nose. And children get sick a lot in the first several years of life as their bodies are building immunity to infections.

In many child care facilities, the staff simply cannot care for a sick child due to space or staff limitations, although in others, the child can be kept comfortable and allowed to rest as needed in a separate area of the room where they have already exposed the other children. When waiting to be picked up, an ill child who is being excluded should be in a location when no contact occurs with those who have not already been exposed to their infection. Often, it is best for the child not to be moved to another space to prevent their illness from spreading throughout the facility and to maintain good supervision of the child. In some programs, a staff member who knows the child well and who is trained to care for ill children may care for the child to a space set aside for such care and where others will not be exposed. If the child requires minimal care for a condition that doesn't require exclusion, there may a place for the child to lie down while remaining within sight of a staff member when the child needs to rest. In some communities, special sick child care centers have been established for children with mild illnesses who cannot participate or need more care than the staff can provide in the child's usual care setting.

Even with all these prevention measures, it is likely that some infections will be spread in the child care center. For many of these infections, a child is contagious a day or more before he has symptoms. Be sure to wash your and your child's hands frequently. You never know when your child or another child is passing a virus or bacteria. Sometimes your child will become sick while at child care and need to go home. You will need to have a plan so someone can pick him up.

Fortunately, not all illnesses are contagious (e.g., ear infections). In these cases, there's no need to separate your sick child from the other children. Most medications can be scheduled to be given only at home. If your child needs medication during the day, be sure that the facility has clear procedures and staff who have training to give medication. Ask what they do to be sure they have the right child, receiving the right medication, at the right time, by the right route and in the right dose – and document each dose. 

Measures to Promote Good Hygiene in Child Care:

To reduce the risk of disease in child care settings as well as schools, the facility should meet certain criteria that promote good hygiene. For example:

• Are there sinks in every room, and are there separate sinks for preparing food and washing hands? Is food handled in areas separate from the toilets and diaper-changing tables?

• Are the toilets and sinks clean and readily available for the children and staff? Are disposable paper towels used so each child will use only his own towel and not share with others?

• Are toys that infants and toddlers put in their mouths sanitized before others can play with them?

• Are all doors and cabinet handles, drinking fountains, all surfaces in the toileting and diapering areas cleaned and disinfected at the end of every day?

• Are all changing tables and any potty chairs cleaned and disinfected after each use? 

• Are staff and other children fully immunized, especially against the flu?

• Is food brought in from home properly stored?  Is food prepared on site properly handled?

• Is breast milk labeled and stored correctly?

• Are children and their caregivers or teachers instructed to wash their hands throughout the day, including: 

  • When they arrive at the facility 

  • Before and after handling food, feeding a child, or eating 

  • After using the toilet, changing a diaper, or helping a child use the bathroom (Following a diaper change, the caregiver's and child's hands should be washed and the diaper-changing surfaces should be disinfected.) 

  • After helping a child wipe his nose or mouth or tending to a cut or sore 

  • After playing in sandboxes 

  • Before and after playing in water that is used by other children 

  • Before and after staff members give medicine to a child 

  • After handling wastebaskets or garbage 

  • After handling a pet or other animal

• Make sure your own child understands good hygiene and the importance of hand washing after using the toilet and before and after eating.

• Is health consultation available to deal with outbreaks or to review policies?

EXERCISE - INDUCED BRONCHOCONSTRICTION (Sports Asthma)

What is it?
“Exercise-induced bronchoconstriction” (EIB) occurs when a person’s airway becomes temporarily narrowed, either during, or soon after, exercise. Depending on the population being examined, anywhere from 10-70% of people may be affected by this. Those with asthma are most likely to experience exercise-induced bronchoconstriction. Other factors that increase the risk of this include having seasonal allergies, having a family member with asthma or allergies, smoking, and environmental exposures such as to chlorine in a swimming pool.

Symptoms
Those affected by exercise-induced bronchoconstriction experience excessive shortness of breath with exercise. It is often accompanied by wheezing, coughing, and chest tightness. Some athletes might mistake these symptoms for simply being out of shape. The intensity of EIB varies – some athletes experience shortness of breath with any exercise, while others have symptoms only during or after vigorous exercise.

Sports Medicine Evaluation
A sports medicine physician will use a stethoscope to listen for wheezing in the lungs, although this is only occasionally present during or immediately after exercise. Direct measurement of airflow before and after exercise can be done to confirm the diagnosis. Measurement of airflow before and after giving a patient medicine to open up the airways also helps screen for baseline asthma. Occasionally, a physician may suggest using an inhaler prior to exercise before any testing is done. If this makes the symptoms go away, no additional testing may be required. If a person is experiencing a decline in his or her athletic performance, a sports medicine physician may also assess for other causes in addition to exercise-induced bronchoconstriction.

Treatment and Injury Prevention
If a person has asthma, the first step is to get it under control. Those with known triggers (such as allergens and cold air) should avoid them if possible. Treatment may simply be limited to this. For most people with exercise-induced bronchoconstriction, an inhaler that opens up the airways can be used 15-30 minutes before exercising with good effect.

Return to Play
When symptoms are adequately controlled, there are no restrictions on exercise or athletic competition. Having an inhaler available during practices and competitions is important for athletes with exercise-induced bronchoconstriction.

AMSSM Member Authors
Brett Toresdahl , MD and Chad Carlson, MD

ATHLETES AND PLATELET-RICH PLASMA

What is it?
“Platelet-rich plasma” (“PRP”) is a term used to describe the blood products with an increased concentration of platelets. “Platelets” contain growth factors, and injecting PRP into injured or non-healing tissue is believed to possibly enhance or speed up healing. PRP is becoming more commonly used to treat some sports medicine injuries. Treatment with PRP begins by taking a patient’s blood through a needle stick in the arm. This blood is placed into a machine, then spun down to concentrate the platelets. There are several different types of machines that create slightly different concentrations of platelets and other blood cells. A sports medicine doctor will determine the best contents of the injection based off what is known to possibly help, his/her preference, and the patient’s injury/condition.

Why is it used?
PRP may be used for a variety of conditions. It can be used to possibly help with ongoing pain and dysfunction related to tendon conditions or injuries. Chronic tendon injuries are not due to inflammation, but are instead related to wear and tear. Commonly treated areas include the patellar tendon (“jumper’s knee”), the lateral epicondyle (“tennis elbow”), and the Achilles tendon. PRP may also be used in acute strains or muscle tears, such as at the calf, “quads”, or hamstring. It may also be used at sites of soft tissue rupture, such as the plantar fascia. Many doctors also advocate the use of PRP for arthritis and other degenerative joint conditions.

Does it work?
Because the use of PRP is still relatively new, research studies are still ongoing. At this point, most studies are relatively small, and the overall benefit of this treatment is still being determined. Many insurance companies consider treatment with PRP as experimental, and will not pay for the procedure. If a doctor feels that PRP may be useful to treat a patient’s condition, payment out of pocket may be necessary.

Sports Medicine Evaluation
Evaluation prior to use of PRP will be similar to a usual clinic visit, with a typical history and physical exam. A sports
medicine physician may use ultrasound to aid in the diagnosis. Ultrasound will also typically be used during the procedure to guide the injection. Very rarely, laboratory testing will be required before the procedure to ensure that the patient has normal blood cell counts even before the procedure. Occasionally, some patients may experience a brief flare up of their pain for several days after the injection. It is usually recommended to avoid oral anti-inflammatory medications like ibuprofen or naproxen for a few days before and several weeks after the procedure, but ice and acetaminophen can be used.

Return to Play
The return-to-activity timeline can vary depending on the reason why PRP was performed. Large muscle tears may require several weeks to fully heal, regardless of the procedure, while other indications may benefit from early focused therapy after a short period of rest. Chronic tendon injuries will typically take at least 3 – 6 months to heal. Most physicians will recommend some specific period of complete rest − and often immobilization − following the injection. The physician will usually make the decision on return to sports based on repeat exams, and possibly, repeat ultrasounds.

AMSSM Member Authors: Nicholas R. Phillips, M.D. and Kim Harmon, MD

AMSSM'S COACHES CORNER - KEEPING YOUR ATHLETES HYDRATED

It takes more than having water coolers around to keep your athletes safe and performing at optimal levels. Here are some tips to educate your athletes on maintaining proper hydration, especially as we enter the warmer summer months.

• Have weigh-ins before and after exercise if possible. This will help an athlete know how much fluid intake is necessary for them and if they are falling behind or drinking too much.
   
• Educate athletes on urine color. (Lighter is better hydrated)
   
• Modify practice in hot, humid conditions. Adjust practice time, amount or intensity. Allow frequent hydration breaks and consider equipment modification.
   
• Encourage athletes to drink fluids before, during and after exercise. Water is encouraged unless the exercise is greater than 60 minutes. You may consider sports drinks if activity is greater than 60 minutes.
   
• Keeping fluids cold will encourage more hydration by the athletes.
   
• For optimum performance, athletes should continue drinking BEFORE becoming thirsty.

Source: Lopez, R., Casa D. Hydration for Athletes: What coaches can do to keep their athletes healthy and performing their best, 2006.

YOUR CHILD WAS DIAGNOSED WITH OSGOOD-SCHLATTER DISEASE... NOW WHAT?

What is it? 
Osgood-Schlatter disease refers to a condition occurring during adolescence that causes pain, swelling and soreness on an area of the upper shinbone, just below the knee, called the tibial tuberosity. The condition commonly occurs during the period of adolescent growth spurt where the tibial tuberosity is vulnerable to overuse in an active teenager who is involved in a lot of running and jumping activities. The quadriceps’ (muscles of the front of the thigh) tendon attaches to the tibial tuberosity and with repetitive activity can cause traction of this growth center and cause inflammation to the upper shinbone. Osgood-Schlatter disease is caused by repetitive activities in growing teenagers who do not allow enough time in between activities to allow the inflammation that occurs at the tibial tuberosity to heal.

Symptoms
• The main symptom of Osgood-Schlatter disease is pain at the bump below the knee with activity or after a fall.
• There may be swelling and enlargement of this bump on the upper shinbone.
• Forceful contraction of the thigh muscle can also cause pain.
• One or both knees may be affected.
• The bump on the shinbone may be very tender.

Sports Medicine Evaluation and Treatment
The diagnosis of Osgood-Schlatter disease is typically made by history, physical examination and at times, x-rays of the knee, if deemed necessary by the sports medicine physician.

Treatment:
• The primary focus of treatment is to control the pain as well as tension of the thigh muscle tendon where it attaches to the upper shinbone.
• In severe cases, young athletes may need to have a period of rest from their sport.
• Activity modification, ice and non-steroidal anti-inflammatory drugs (NSAIDs) may also help with pain and swelling.
• A strap placed between the bump and the kneecap may help reduce tension of the tendon on the upper shinbone attachment site.
• Improving the flexibility of the thigh and hamstring muscles.

Injury Prevention
• Early recognition of the symptoms of Osgood-Schlatter disease by young athletes, coaches and parents can allow
early intervention to prevent severe inflammation.
• Young athletes should not try to push through this pain should they start experiencing it.
• Referral to a sports medicine physician can offer the best opportunity for education, intervention and monitoring for the young athlete.

Return to Play
• Prior to starting sports-specific activity, the athlete should have a pain-free single leg squat.
• There should be minimal pain with squatting, jumping and then a progression through sports-specific movements
prior to full return to sport.
• If the athlete experiences pain or limping during this sequence, he/she should continue the treatment and attempt a return to sports after a discussion with the sports medicine physician.
 

AMSSM Member Authors: Neeru Jayanthi, MD and Mark Riederer, MD