key: cord-0759293-l0shi681 authors: Kunze, Kyle N.; Fabricant, Peter D.; Marx, Robert G.; Nwachukwu, Benedict U. title: Perspectives on the Impact of the COVID-19 Pandemic on the Sports Medicine Surgeon – Implications for Current and Future Care date: 2020-08-22 journal: Clin Sports Med DOI: 10.1016/j.csm.2020.08.014 sha: 9c5bf15fbd767e382793581e91da6a8db68e30ec doc_id: 759293 cord_uid: l0shi681 As the COVID-19 pandemic continues to affect countless lives globally, the current paradigm of medical and surgical treatment continues to rapidly evolve. This is especially true for the sports medicine surgeon, as treatment prior to the pandemic was considered predominantly elective. The purpose of the current perspective is to provide both subjective and objective data on the changes implicated by the COVID-19 pandemic with regards to the interactions and practices of the sports medicine surgeon. This perspective also considers the potential impact on the patients and athletes treated by sports medicine surgeons. It is our hope that this article provides a unique viewpoint on the impact of the COVID-19 pandemic on the field of sports medicine and provides thoughts on how the landscape of the field may continue to change. The impact of the COVID-19 pandemic has been immense and far-reaching. At the time of this writing, almost five months after the effects of COVID-19 began to be recognized in the United States, the number of new cases remain uncontrolled in certain regions. 20 Coinciding with this pandemic have been numerous unforeseen effects, ranging from socioeconomic ramifications to significant changes in the ways in which we routinely evaluate and treat patients. 8, 14, 18 At this point orthopaedic surgeons, though returning to some degree of normalcy with regards to their practices, must be ready to permanently adapt the changes that this pandemic has imposed. The subspecialty of sports medicine in particular has felt a significant impact. With essentially all sports ranging from novice to professional levels being canceled or postponed for the foreseeable future, it is difficult to conjecture what the future of sports participation will entail. 15 Patients with musculoskeletal injuries treated by sports medicine surgeons may have treatment delayed due to preventative measures implicated by health care institutions and prioritization of non-elective cases. From both patient and sports medicine surgeon perspectives, these barriers may also create significant financial crises. For example, restrictions on participation in sports and on performing elective surgeries may leave institutions at financial deficits or on the brink of bankruptcy. 9, 18 Though many remain optimistic that these barriers will be gradually rescinded, it is only speculation as to if and when health care practices will return to normal volumes and routines. The COVID-19 pandemic has raised many questions that remain unanswered; however, the financial, psychosocial, and physical impacts are clear. The purpose of the current article is to highlight from both patient and physician perspectives the impact of the COVID-19 pandemic on the sports medicine surgeon. These perspectives will be reinforced using an evidence-based review of recent literature highlighting the various impacts of the pandemic. It is the primary aim of this article to enlighten both the academic community and general public as to how this pandemic has and continues to influence current sports medicine practice and thought, in addition to how it is poised to change future practice -perhaps permanently. J o u r n a l P r e -p r o o f The current healthcare landscape has transformed orthopaedic sports medicine care. As surgeons, the global pandemic has required us to cater to the musculoskeletal needs of our patients in a way that respects their overall health and mitigates the risk of COVID-19 transmission. The current section will highlight some of the ways that sports medicine surgeons and health care institutions have adapted to this landscape and provide a perspective on how this has affected care delivery. The utilization of telemedicine has been expanded to comprise a large portion of patient visits in order to respect the physical barriers instated by government and state officials such that the risk of COVID-19 transmission be minimized. 6, 12 Specifically, the barriers associated with the provision of virtual musculoskeletal care have been removed in the wake of the COVID-19 global pandemic. Insurers now reimburse for telemedicine and legislature now allows for the provision of virtual care even going as far as to allow the practice of telemedicine across state lines for some encounters in some jurisdictions. A healthcare industry analysis by McKinsey & Co. suggested that in healthcare there had been a rapid adoption of telemedicine with high rates of both patient and provider satisfaction. 2 There are many benefits and challenges for the sports medicine surgeon in engaging in virtual visits with patients. Major limitations to the use of telemedicine include technical difficulties resulting in lag or premature ending or disruption of a visit, concern for the quality of the encounter, and inability to perform a complete physical examination. 16 Though telemedicine continues to expand and the efficiency and technical quality of visits will likely to continue to improve, the in-person physical examination is impossible to replicate, as this is a skill that is cultured and developed throughout training. Tanaka et al. 16 recently proposed a set of checklist items and systematic virtual examination techniques to help address these limitations. Their recommendations for a virtual checklist include (1) ensuring the camera is secured in a steady position, (2) numerous space and positioning guidelines for the knee, hip, shoulder and elbow depending on the extremity that is the chief complaint, (3) lighting recommendations, (4) clothing recommendations depending on the extremity that is the chief complaint, and (5) ensuring that the patient is in a place where they can speak privately. For the systematic virtual exam, the authors propose various maneuvers that the patient can perform in conjunction with provider instruction in the comfort of their own home, and provide approximate weights of household items that can be used during strength of provocative tests. As telemedicine is likely to remain commonplace in the examination and evaluation of patients presenting for sports medicine evaluations, development of further examination maneuvers and new technology that will allow for improved examinations will be imperative. Future directions may include standardized video instructions for patients, application of motion capture technology and more reliance on diagnostic aids. Sports medicine surgeons will need to adapt their diagnostic algorithm in the virtual era in order to continue to provide the highest quality of care for their patients. High-volume orthopaedic sports medicine centers have been forced to quickly absorb significant revenue losses which could not have been anticipated. As these institutions were J o u r n a l P r e -p r o o f unprepared for such rapid financial losses, many are on the verge of bankruptcy and for most a large source of income (elective surgery) has been suddenly and dramatically curtailed. 5, 18 As a result of financial pressures, many institutions have instituted pay decreases, furlough policies and even orthopaedic staff downsizing. In order to respond these financial pressures and better align themselves with their institutional plight, hospital employed surgeons may find themselves accepting pay decreases, while private practice surgeons seek out governmental loans to weather the financial storm. The elimination of elective surgery and by proxy income for sports medicine surgeons may have forced some to seek out alternative sources of income including increased call and locum positions. As sports medicine surgeons return to a "new normal" there is likely immense pressure to recoup the missed volume. The reality, however, is that financial losses in the current fiscal year will have to be amortized in upcoming years and may have implications for surgeon decision making and workload. The likely ripple effects of the current financial difficulties associated with COVID-19 are that financial disaster planning will become a part of institutional contingency planning. Specifically, institutions will pay increased attention to their cash flow, cash reserve and maintaining a health account receivable. Additionally, surgeons have become sensitized to the importance of having cash on hand to cover ongoing monthly expenditures in the absence of monthly income. Financial wisdom suggests six months of typical salary as appropriate liquidity. With governmental and institutional focus on resuming patient care and returning to a "new normal," the short and long-term effects of being immersed in a critical care environment may be overlooked. Many physicians were previously required to care for COVID-19 patients or volunteered to do so, which has been demonstrated to be a significant stressor and impose a large psychological burden. 3, 10 A recent worldwide study of the impact of COVID-19 on spine surgeons revealed that family health concerns and anxiety were common and significant stressors, and that loss of income, clinical practice, and extent of surgical management varied widely. It is plausible, and likely, that these trends exist for sports medicine surgeons as well. As COVID-19 disproportionality affects those individuals of an older age, 7, 11, 13 older sports medicine surgeons may be at risk of increased susceptibility and this too may have a psychological impact. As sports medicine surgeons are implicated to be in hospital settings, this anxiety may be unavoidable and frequent. Such studies highlight the challenges experienced by orthopaedic providers and the need for guidelines to be established for (1) psychosocial treatment of these providers and (2) for anticipation of a second COVID-19 wave. There has been a profound increase in research productivity during recent months, which coincides with diminishing clinical responsibilities. Furthermore, there is likely an "academic gold rush" to take advantage of high rate of acceptance for articles pertaining to the COVID-19 pandemic. Gazendam et al. 4 recently described this phenomenon as the "infodemic" of journal publication. This group performed a systematic literature search and found thatover the short 13-week period since the initial documentation of COVID-19, a total of 1,741 articles pertaining to COVID-19 and SARS-CoV-2 were published in scientific journals, representing an exponential increase in academic productivity. This group also noted a rapid time from submission to publication, and a higher proportion of commentaries and opinion papers in journals with high impact factors. Though a similar exploratory study has yet to be performed specifically for orthopaedic research, similar trends are likely present. This trend will have benefits, but also potentially negative consequences, if increased academic output is a function of sacrifices in quality. However, benefits of this trend include both personal and institutional gains in academic productivity and the potential to advance the field at a much more rapid pace. Institutions may seek to institute research infrastructures that give them the propensity to maintain such productivity observed during this era both now and in future years. Though sports medicine surgeons have been greatly impacted by the COVID-19 pandemic, challenges for their patients are also extensive and must be recognized. Such challenges include enduring musculoskeletal pain and dysfunction in order to minimize travel and potential COVID-19 exposure, anxiety in association with traveling to and being in hospital settings, and return to sport. The current section will discuss some of these challenges and the role in which the sports medicine surgeon may contribute to addressing these challenges. Patients have expressed significant concerns in coming into a hospital setting, whether this is for clinical evaluation or a surgical procedure. Though hospitals are prioritizing minimization of the risk of COVID-19 transmission, for those not routinely part of hospital settings, this can be an overwhelming and anxiety provoking experience. 19 On the contrary, social isolated has been demonstrated to be associated with increased anxiety and stress, 21 and the additional effects of musculoskeletal injuries in combination with this remains unknown. As the balance of patient care, financial incentives, and COVID-19 risk comprise a delicate balance, it will be imperative to appropriately counsel patients regarding this anxiety. We recommend taking advantage of clinical encounters in the telemedicine setting to prime patients to their experience in the hospital and to emphasize the precautions set in place to minimize the risk of COVID-19 transmission and the need to abide by these regulations. This may address anxiety through guiding expectations, pain through conservative or surgical care in the inpatient setting, and ensuring the safety of all in these settings. As amateur sporting events have been classified as low-priority in the sequence of returning to a new normal, it is uncertain as to when, and the extent to which, sports will resume. As athletes compromise a large proportion of patients evaluated and treated by sports medicine surgeons, and as athletes remain "sidelined," this has implications for both patients and providers. There remain many questions for the athlete. Some of these questions include (1) if athletes who have contracted COVID-19 will experience long-term effects that influence their health and subsequently their game performance (and if so, what are those long-term diseases and consequences); (2) for those unaffected but that remain "sidelined," how will potential deconditioning or delayed treatment of a musculoskeletal injury influence their propensity for return to sport and their performance; and (3) what will the future of organized sports look like? At the time of this writing, some professional sports, such as golf and mixed martial arts, have experienced relative success in reinstating regular events as a surge of COVID-19 cases has not been observed. This may be a function of these sports being individual-based. Hockey and basketball are sports with smaller teams, which may make this effort slightly less challenging than large sports teams, especially as these sports were in the post-season. In order to facilitate a safe return to sport, some of these larger team sports organizations have explored the "bubble" concept; however, professional baseball has still experienced early setbacks, and other large spectator sports such as football may as well if COVID-19 transmission cannot be adequately controlled. These complications indicate how difficult it will be for amateur sports, including high school and collegiate athletics, to resume regular schedules prior to the introduction of a widely available vaccine. It is our hope that future protocols can improve safety for these professional athletes and the staffs that surround them. It will be imperative for the sports medicine surgeon to safely guide athletes to returning to sport -regardless of when that is or what it looks like. It will be essential for sports medicine surgeons and those involved in the care of athletes to counsel athletes to safely return to sport. In this way, we may help our athletes to avoid injuries associated with returning to sport, such as ruptures of the Achilles tendon or anterior cruciate ligament. We must pay close attention to fatigue and signs of imminent injury such as pain with activity and guide them accordingly. Though we are passionate about the return of sports and hope that our athletes can soon return to doing what they love, our number one priority must be to facilitate a safe return. Another unique cohort of patients being affected by the COVID-19 pandemic are those whom underwent a surgical procedure in the period prior to the pandemic. Indeed, these patients who necessitated extensive rehabilitation and physical therapy were unable to do so in most cases. Prohibiting this essential aspect of surgical recovery may predispose such patients to suboptimal outcomes when compared to their counterparts who were able to successfully complete physical therapy and rehabilitation. It is also likely that such patients will endeavor a longer recovery than their counterparts accordingly. Sports medicine surgeons and physical therapists will need to be conscientious of this impact and help these patients experience the best clinical and functional outcomes possible. As many individuals continue to seek ways of maintaining fitness and staying healthy during the pandemic, a trend in injuries related to home exercise programs may be observed. These patients may develop overuse tendinopathies of the biceps and rotator cuffs if they are not accustomed to performing these exercises regularly. As such, the sports medicine surgeon is likely to continue to observed an increase in these types of injuries for the extent that gyms and fitness centers remain closed. There are certainly many challenges that we have faced and new issues that we will continue to encounter as sports medicine surgeons caring for our patients and athletes in the midst of the evolving pandemic. Despite these challenges, we will endeavor to continue to provide the highest level of care to our patients and to get them back to what they love to do, whether that is walking along the river or hitting a buzzer beater. We understand that there will continue to be injuries regardless of the infectious burden imparted by COVID-19, and therefore we have an obligation to our patients to find innovative and effective ways to treat them both mentally and physically. The rapidly evolving nature of the pandemic may make this process more challenging, as recommendations and epidemiological data are dynamic; however, it is of the utmost importance to take the lessons learned thus far and continue to apply them today and for the future as we approach a "new normal" that consists of treating patients with injuries previously treated with "traditionally normal" methods. We cannot predict with any reasonable certainty the changes that may become, though we can speculate that our practices will continue to adopt telemedicine as a standard of care and distancing and transmission precautions will remain in place for the foreseeable future. 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