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Travel Considerations for the Athlete and Sports Medical Team
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Craig C. Young; Nicolai Esala
Netter's Sports Medicine, 24, 172-176.e1
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General Principles
Modern transportation systems facilitate easy access to most regions of the world. Although this has allowed for the rapid
growth of international competition, it also creates unique physiologic and psychological challenges for athletes as well as the
sports medicine team.
Jet Lag and Chronobiology
• The American Academy of Sleep Medicine defines jet lag as a syndrome involving insomnia or excessive daytime sleepiness
after travel across at least two time zones. Jet lag is a syndrome of symptoms manifested by physiologic adaptations that occur
when the body is shifted to a new time zone.
• Travel fatigue is a more complex combination of physiologic, psychological, and environmental factors that develop during
travel; it may accumulate over the course of a season and reduce an athlete’s capacity to recover and perform.
• Chronobiology is the field that examines cyclic phenomena in living organisms and their adaptation to solar- and lunar-
related rhythms; these cycles are known as circadian rhythms.
Physiology of Jet Lag
• An average human experiences endogenous cycles of energy, mood, and activity that last approximately 25 hours.
• The primary pacemaker is the suprachiasmatic nuclei of the hypothalamus. When a traveler changes time zones, this
pacemaker must undergo entrainment, which is the process of resynchronization with the new environmental light–dark
cycle. Physiologic mechanisms involved in this process include:
• Melatonin, which is a hormone that is typically secreted at dusk by the pineal gland, helps the body anticipate the daily
onset of darkness.
• Adenosine accumulates when a person is awake and causes progressive sleepiness.
• Adenosine accumulation is blocked by caffeine.
• Direct neural pathway from the retina
• Blue wavelength light, in particular, can interfere with the sleep cycle.
• Arginine vasopressin
• Zeitgebers are environmental cues that help reset the pacemaker; these include light, temperature, exercise, social
interactions, and eating and drinking patterns.
• Disorders of circadian rhythm are most commonly experienced in the setting of a jet lag when a new sleep–wake cycle is
required on entering a new time zone.
• Signs and symptoms of jet lag include changes in mood, headaches, digestive difficulties, and increased susceptibility to
illness. Typically, athletes suffer decreases in cognition, concentration, visual acuity, and memory, which may have
adverse effects on physical and athletic performance.
• The rate of adjustment to a new time zone is typically a day for each time zone crossed.
Prevention of Jet Lag and Travel Fatigue
• A structured athlete travel program that encompasses preflight, inflight, and postflight periods is the first step in establishing
an effective approach to travel fatigue and jet lag.
• Because there is no physiologic adaptation with repetitive time zone transitions, each long-distance journey is unique and
requires its own specific travel strategy based on the direction of travel, duration, and times of arrival/departure.
• By adopting a structured program and fatigue monitoring system, athletes and medical staff can help minimize travel-related
physiologic and psychological issues, limit symptoms, and improve overall performance.
• Preflight component:
• Although it may be difficult because of schedule restrictions, introducing a schedule within 7 days of travel is generally
optimal.
• Consider gradually changing the sleep–wake cycle and meals to the new time zone by shifting an hour a day.
• Consider adjusting training to the destination time zone
• Avoid bright light for 2–3 hours before bedtime
• An emphasis should be placed on getting enough sleep before travel to reduce sleep debt.
• Inflight component:
• If they have not already done so, advise athletes to adjust their schedule to be in sync with the destination time zone as
soon as they board the plane to assist them in preparing for the destination (e.g., watches, meals, and sleep schedules).
• Maintaining appropriate hydration should be a priority.
• Avoid light-projecting devices, such as computers, tablets, and movies.
• Postflight component:
• The postflight period stretches 2–4 days or more beyond arrival. During this time, the activities of an athlete (including
meals, sleep, rest, and recovery) should be strategically planned by the staff to accommodate rapid circadian adjustment.
• The most effective intervention in such situations is a combination of scheduled light therapy, light avoidance, and
melatonin.
• Additional fatigue countermeasures include the judicious use of napping and caffeine, both of which can synergistically
improve alertness and reduce symptoms of fatigue.
Pharmacologic Measures
• Melatonin: Melatonin supplements can aid in managing jet lag symptoms, both preflight and postflight.
• Preflight low doses (0.5–1.5 mg) of melatonin are most effective, whereas higher doses (3–5 mg) are recommended after
flight.
• Pretravel melatonin may be used to gradually shift the feeling of dusk and bedtime to the anticipated time zone.
• Doses should be taken 30 minutes before bedtime on the night of travel and the initial 2–3 nights after arriving at the
destination. This will mitigate sleep disturbances associated with jet lag while enhancing circadian adaptation.
• Sedatives: Athletes who do not suffer from jet lag or who do not respond to melatonin and experience 1–2 days of insomnia
on arrival will likely benefit from the use of a traditional medium-acting (20–30 minutes) or medium half-life (6 hours)
sedative (e.g., eszopiclone or temazepam). Very-short-acting (<15 minutes) and short half-life (4 hours) sedatives (e.g., zaleplon
or zolpidem) can be useful for sleep during the flight. However, caution must be exercised with inflight use of sedatives
because this may increase the risk of deep vein thrombosis (DVT) and decrease responsiveness in the event of an inflight
emergency. Use of sedatives may be considered illegal in certain sports without a therapeutic use exemption waiver.
• Stimulants: Caffeine and other stimulants (e.g., modafinil) may be useful in combating fatigue. However, use of stimulants
may be illegal for some athletes without a therapeutic use exemption waiver.
• Caffeine: The strategic use of caffeine (e.g., a 50–200-mg pill or beverage) in combination with a 15- to 30-minute nap has
been shown to be effective in improving cognitive function in sleep-deprived states and at the lowest point of the
circadian cycle. Athletes should be cautioned that caffeine above certain levels is often considered illegal by doping codes
and may result in suspension, loss of medals, and vacation of victories.
Nonpharmacologic Measures
Preadaptation and light therapy: Light exposure is the primary cue for circadian rhythms. Exposure to bright light of
adequate intensity and duration can advance or delay circadian rhythms based on the timing of exposure. Bright light
exposure in the morning will help advance the body clock, whereas exposure in the late evening will help delay it. Attempts to
shift circadian rhythms with preflight exposure to bright light before departure have been successful during both eastward
and westward travel. Exposure to natural bright light promotes circadian shifts. Avoidance of bright light, particularly short-
wavelength blue light in the evening, may help with shift for eastward travel. Use of blue blocking glasses, such as amber
safety glasses, may diminish this exposure. Athletes should be cautioned to avoid evening use of tablets, computers,
televisions, and mobile phones to minimize blue light exposure.
Sleep: Sleep can be used to acclimate or adjust an athlete’s circadian rhythm before travel or decrease symptoms of sleepiness
upon arrival. Shifting the sleep schedule 1–2 hours toward the destination time zone in the days preceding departure may
shorten the duration of jet lag. In addition, strategic napping has been discussed as a potential method to mitigate the
symptoms of jet lag. The best time to nap (inflight or postflight) is nighttime in the destination time zone. “Power naps” (20
minutes) do not result in sleep inertia and may decrease daytime sleepiness in individuals experiencing jet lag. However, naps
of >20 minutes may delay sleep adaptation and slow resynchronization.
Deep Vein Thrombosis and Travel
• DVT is a condition wherein a blood clot develops in the deep veins, most commonly in the lower extremities. A part of the
clot has the potential to break off and travel to the lungs, causing a potentially life-threatening pulmonary embolism (PE).
• Prolonged periods of inactivity caused by space limitations may diminish circulation and produce lower extremity
edema. Prolonged sitting with bent knees compresses the popliteal veins, which is another potential risk factor for clot
formation.
• “Economy class syndrome”: Long-distance air travel has been associated with a two- to fourfold increased risk of venous
thromboembolism (VTE), including DVT.
• Environmental factors in flight, such as low oxygen, low humidity, and low cabin pressure, contribute to dehydration,
which concentrates the blood; this effect is worsened when passengers consume alcohol or do not adequately replenish
fluids lost as a result of dehydration. However, there is no evidence that dehydration is directly associated with VTE.
• Reports have suggested that flights of ≥8 hours increase the risk of VTE in the presence of additional risk factors in a
patient.
• Other risk factors include age over 40 years, obesity, and estrogen use.
• Athletes and individuals in general good health are at a lower risk of VTE.
• A DVT most often originates in the calf, with persistent cramping, or “charley horse,” that intensifies over several days. This
pain may be accompanied by leg swelling and discoloration.
• In most cases, travel-related VTE occurs in the first 1–2 weeks after travel. The risk returns to baseline after 8 weeks.
• Treatment: Early detection and anticoagulant drugs (e.g., heparin, low-molecular-weight heparin, warfarin; see Chapter 31:
“Hematologic Problems in the Athlete” for additional details)
• Prevention: Maintaining hydration, exercise, and wearing support stockings may help decrease the overall risk. Periodic
activity, approximately every 2 hours, can include isometric exercises, walks along the aisles, or stretching exercises. Below-
the-knee graduated compression stockings that provide 15–30 mmHg of pressure have been advocated as a preventive
measure. Drugs such as aspirin have antithrombotic properties but are not recommended as a prophylactic measure in
otherwise healthy individuals.
Infectious Diseases
• Infectious diseases are common among travelers. Travel to developing countries results in approximately 8% of travelers
requiring medical treatment. Although preventing athletes from acquiring infections may be challenging, use of
commonsense approaches can minimize the risks. Team physicians should investigate which infectious agents are common
at the destination, educate the athlete on appropriate preventive measures, and have treatment available.
• Transportation issues:
• Airplanes: Because modern commercial aircraft use high-efficiency particulate air (HEPA) filters, the risk of transmission
for respiratory illness is primarily from the time the particulate/virus is exhaled until it is collected for filtering and
recycling or dumped overboard. Therefore, it is primarily the two rows in front of and behind seat that are considered
the higher-risk area for transmission or respiratory illness. Having an infected person wearing a mask substantially
decreases transmission risks. Having an uninfected person wearing a mask slightly decreases transmission risk. Having
both infected and uninfected persons wearing masks leads to maximal decrease in transmission.
• Surfaces in public transportation may be contaminated with pathogens; therefore it is important that travelers use hand
sanitizer or wash their hands frequently and avoid touching their face with their hands.
• Traveler’s diarrhea (TD): Approximately 50% of travelers, even in low-risk industrialized countries, will develop at least one
diarrheal episode per short-term trip ( Fig. 24.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000244#f0010) ). Besides the
discomfort and time lost to bowel movements, fluid and electrolyte imbalances have the potential to adversely affect athletic
performance.
• Preventive dietary measures include avoidance of tap water, ice, unpasteurized dairy products, raw vegetables, salads,
undercooked meat, and seafood.
• In 2012, the British Olympic Medical team was successful in reducing illness by educating athletes regarding hygiene,
including the importance of lowering the toilet seat lid before flushing to minimize risk of aerosolization of fecal
bacteria.
• Bismuth subsalicylate (Two tablets [262 mg each] four times/day) may be used for prophylaxis and decreases the risk of
TD by 50%.
• Prophylactic antibiotics were considered an effective measure in the past but are no longer recommended because of the
developing antimicrobial resistance; nevertheless, short-term use for critical trips or in high-risk patients may be
considered.
• Parasites, not bacteria, are the most common cause of diarrhea in developing countries.
• Antimotility agents, such as loperamide and diphenoxylate–atropine, may be used in cases of nonfebrile, nonbloody
diarrhea.
FIGURE 24.1
Traveler’s diarrhea: Incidence and differential features.
• Mosquito-borne illnesses, including malaria, dengue fever, and chikungunya, are common causes of febrile illness in travelers
and should be considered even if symptoms do not occur until after travelers return home.
• Prevention measures include wearing loose-fitting, long-sleeve shirts and long pants treated with permethrin; use of bed
netting; and limiting evening outdoor activities.
• Sprays to prevent bites include 20%–30% N,N-diethyl-meta-toluamide (DEET), 20% picaridin, or 30% oil of lemon
eucalyptus.
• Parasites are a potential concern, particularly in extreme sport athletes in tropical and subtropical climates, who are at a
particularly high risk of contracting nematode and protozoan infections ( Fig. 24.2 (https://www.clinicalkey.com/#!/content/book/3-s2.0-
B9780323796699000244#f0015) ).
FIGURE 24.2
Parasitic diseases: Necatoriasis and ancylostomiasis.
• Vaccinations: The Centers for Disease Control and Prevention’s online Yellow Book contains recommendations of
vaccinations for most destinations; these should be offered to all athletes well in advance of departure.
Inflight Medical Emergencies
• Occasionally, physicians will find themselves called upon by a flight crew to evaluate a passenger who has developed a medical
issue. A physician may determine that he or she can treat and stabilize that patient or that an emergency landing will be
needed.
• Typical airline first-aid supplies will include stethoscope, blood pressure cuff, oral airways, bag masks, cardiopulmonary
resuscitation (CPR) masks, intravenous (IV) supplies, gloves, needles, syringes, antihistamines (oral and injectable), atropine
injection, albuterol inhaler, aspirin, 50% dextrose injection, epinephrine injection, lidocaine injection, nitroglycerin tablets,
and automated external defibrillator (AED).
Preparing A Medical Plan for Travel
• Determination of contents of a medical kit ( Table 24.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000244#t0010) ) will
depend on numerous factors, including quality and availability of healthcare at the destination, the sport being covered, and
potential injuries. In more remote locations, as well as in developing countries, inclusion of sterile equipment should also be
considered because these may not be readily available. For international travel, physicians should carry the following
documents:
• Letter from the team requesting medical coverage
• List of medical supplies, including medications being transported
• Check with the destination to ensure that all medications are legal (e.g., stimulant medications such as Adderall ,
lisdexamfetamine, and modafinil are illegal in Japan. Possession of this type of medication, even with a valid prescription
from the athlete’s home country, may result in arrest and jail time)
• Larger volumes of medications intended for the team (e.g., stock bottles of ibuprofen or acetaminophen), in addition to
personal medications prescribed for quantities beyond specific amounts (typically 30 days), may need special permission
or customs declarations and forms for international travel
• Medical license and passport
• List of local medical contacts
Table 24.1
Sample Inventory List For Travel Medical Supplies
Documents
• Inventory list
• Medical license
• Hospital ID
• Business cards
• Passport a
• Copy of prescriptions for personal medications a
• Letter describing team responsibilities a
• Medical evacuation contact numbers a
• World Anti-Doping Agency (WADA) prohibited substance list or online access or sports
equivalent b
Medications
• Acetaminophen
• Anti-inflammatory agents
• Antibiotics
• Gastrointestinal medications (for nausea, diarrhea, and heartburn)
• Corticosteroid (topical)
• Antihistamines (e.g., diphenhydramine; plus a nonsedating variety)
• Anesthetic (injectable)
• Albuterol inhaler c
• Glucose tablets
Supplies
• Gloves (examination and sterile)
• Cardiopulmonary resuscitation (CPR) mask
• Thermometer (and covers)
• Stethoscope
• Blood pressure (BP) cuff
• Bandage scissors
• Alcohol prep pads
• Povidone iodine
• Bandages
• Triangular bandage
• Elastic bandages
• Sterile contact solution
• Penlight
• Fluorescein strips
• Tampons
• Cotton applicators
• Laceration kit
• Butterfly bandages/adhesive skin closures
• Scalpel
• Forceps
• Hemostats
• Needles (18G and 25G)
• Syringes
• Sharps container
• Splints
• Mylar blanket
• Plastic zipper storage bags
• Rubber bands
• Pen
• Electric plug converters a
• Voltage converter a
• International (GSM [Global System for Mobiles]-capable) cell phone a
May Be Considered If Athletes Are Not Drug
Tested • Corticosteroids (injectable) c
• Decongestants c
• Jet lag medications c
Note: Do not carry any pain medication. All pain medications should be carried only by the individual for whom it was prescribed: Transportation by any other individual or
as “team supplies” is against US Drug Enforcement Agency (DEA) regulations and may result in loss of DEA certificate, medical license, or prosecution.
• Travel medical insurance coverage: consideration should be given to the following issues:
• 24-hour physician-backed support center
• Network of referral providers
• Guarantee of medical payments abroad
• Direct pay to foreign hospitals and physicians
• Preauthorizations or second-opinion requirements before emergency treatment or surgery
• Coverage of higher-risk activities (e.g., parasailing, mountain climbing, or scuba diving)
• Coverage for preexisting conditions
• Medical evacuation: Medical evacuation is very expensive, particularly if not contracted in advance. For international travels,
planners should strongly consider having both medical and medical evacuation (back to the home country) insurance
coverage for each member of the traveling party.
Medicolegal Concerns
Traveling with a team may create additional issues, particularly if state or national borders are crossed. The passage of the Sports
Medicine Licensure Clarity Act of 2017 allows team physicians to practice medicine when traveling with their teams within the
United States, but it does not specifically allow teams to travel with medications, nor does it cover international sports coverage.
The Good Samaritan Act should not be counted on to cover team physicians because this varies from state to state. In addition,
physicians should check with their malpractice insurers to ensure that their activities are covered while traveling.
Recommended Readings
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3.Byard R.W.: Deep venous thrombosis, pulmonary embolism and long-distance flights . Forensic Sci Med Pathology 2019; 15 (1): pp. 122-124.
4.CDC Health Information for International Travel . https://wwwnc.cdc.gov/travel/yellowbook/2020
(https://wwwnc.cdc.gov/travel/yellowbook/2020%3e).
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