Rugby, Rowing, Dancing, Running – PediaCast 318
We are honored to have “Mr Sports Medicine,” Dr Lyle Micheli (from Boston Children’s), in the PediaCast Studio today. He joins Dr Mike and Dr James MacDonald for a conversation on the history of sports medicine, past and future challenges, and some sport-specific injuries (including those encountered in rugby, rowing, ballet dancing, and distance running). Dr Micheli also serves as Finish Line Director of the Boston Marathon and shares his personal experience with the 2013 bombing. Be sure to tune in!
The History of Sports Medicine
2013 Boston Marathon Bombing
History of Rugby Football (Rugby School)
Gridiron Football Field (Syracuse University, 1910)
USA Rugby (National Teams, Clubs, Colleges)
Find a Rugby Club (USA Rugby)
Columbus Coyotes (Rugby Club)
Columbus Castaways (Rugby Club)
The Columbus Rugby Club
Leave No Child Inside – PediaCast 254
Concussions – PediaCast 177
Concussions and Mobile Apps – PediaCast 261
Physical Fitness and Resistance Training – PediaCast 212
Summer Conditioning for Student Athletes – PediaCast 171
Female Athlete Triad – PediaCast 285
New U, Play Strong, Ounce of Prevention – PediaCast 297
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is May 20th, 2015, Episode 318. And we're calling this one "Rugby, Rowing, Dancing, Running."
I want to welcome everyone to the program.
We have an exciting show lined up for you today with a literal pioneer in the field of Sports Medicine, Dr. Lyle Micheli from Boston Children's. And we brought one from our own in as well, Sports Medicine physician, Dr. James MacDonald, who trained with Dr. Micheli or under Dr. Micheli, I should say. And perhaps he could give us a little secret inside information on his mentor, nothing too embarrassing, but something that might tickle our fancy now that I've raised suspicion.
Which means, Dr. MacDonald would have to think fast on his feet because I didn't warn him I'd be asking. I meant to, actually before you…
Dr. James MacDonald: Well, that's fine. I actually think I'm going to borrow then a line I used to introduce Dr. Micheli at Grand Rounds this morning. I was trying to tell the trainees in the audience of the importance of Dr. Micheli to me in my training as a doctor, but I went beyond that. Working with him changed the trajectory of my life.
My daughter is Lucy in "The Lion, The Witch and The Wardrobe" at her school play. It's about to go off in a week. And as she was preparing for her play, all of a sudden, it occurred to me that Dr. Micheli is Aslan. He is The Lion. And if you associate with The Lion good things will happen, but dangerous things could happen to you. Your life could change. So my time with Dr. Micheli definitely changed me, and I now think of him as Aslan.
Dr. Mike Patrick: Great. I love that. That is fantastic. And, you know, I had to think really hard as we're coming up with the show, what do you talk about with the sports medicine legend? Because there's so many things, and yet you got to narrow down so that there's still some depth to it?
Well, the title gives away some of our plan — rugby, rowing, dancing, and in particular, ballet dancing and distance running — these are sports many Bostonians have an affinity for. They don't get quite as much press here in the Midwest. Well, maybe a little. We do have a great ballet company in Columbus in the form of BalletMet, and of course lots of young ballerinas all over town. And I know because I see them at our Urgent Care Centers, and I'm sure you see them in the Sports Medicine Clinic, primarily with ankle injuries, with other injuries as well.
And the Columbus Marathon is one of the most popular marathons for those attempting to qualify for Boston because it's a pretty flat around these parts.
Rowing, I don't know. Outside of Ohio State, maybe I'm wrong about that, but there's not as much rowing around here, but we'll talk about that a little later.
Rugby on the other hand, I do think that sport's popularity is increasing all over the country.
And along with increasing popularity of all of these activities, we do see young athletes participating, and increased participation leads to more injuries. So we'll talk about some sport specific injuries with Drs. Micheli and MacDonald associated with rugby, rowing, dancing and running. And we'll talk about how those injuries are evaluated and managed and prevented.
In terms of rugby, since Dr. Micheli is an expert on that sport and since I really know very little about it, other than its role as a precursor to American Football, and since I've been hearing more about Central Ohio participating in rugby clubs — in fact, a fellow physician jus t the other day was entertaining me with his stories of rugby adventure. It sounded painful to be honest — but I thought I would indulge my own curiosity and ask Dr. Micheli about the sport because he not only treats injured players, he's an accomplished rugby player and coach. So he'll be able to fill us in and clarify some of the mysteries of rugby for all of us.
Dr. Micheli is also attending physician for the Boston Ballet and long time finish line director of the Boston Marathon, including back in 2013 when the bombs exploded. So we'll have some interesting conversation where that's concerned.
So again, great program coming your way this week. We'll also talk about the history of sports medicine, changes in the way sports medicine is viewed and delivered, past and future challenges in the field.
Also, the importance of physical activity and sports participation during childhood and the teenage years. The benefits, because there are lots of them, but also the pitfalls, particularly where over-participation and perhaps, over-competitiveness are concerned.
So lots coming your way today. Before we get started, I do want to remind you it's easy to get in touch with me. If you have a topic you'd like us to talk about or a question, just head over to PediaCast.org and click on the Contact link.
You can also call the voice line at 347-404-KIDS, 347-404-K-I-D-S.
Also, I want to remind you the information presented in our show is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
Let's take a quick break and we'll get Dr. Lyle Micheli settled into the studio and talk about sports medicine right after this.
Dr. Mike Patrick: Dr. Lyle Micheli is director of the Division of Sports Medicine at Boston Children's Hospital, and Clinical Professor of Orthopedic Surgery at Harvard Medical School.
A long time Bostonian, Dr. Micheli received his undergraduate degree from Harvard College in 1962 and his medical degree from Harvard Medical School in 1966. As an undergraduate, he was a keen athlete, competing in rugby, gridiron football, and boxing. His love for rugby continued after medical school, and he subsequently played the position of prop — you'll have to explain what that is — for the Boston Rugby Club, the Cleveland Blues, RFC, and the Washington Rugby Club. He also served as player coach for the Mystic Rugby Club.
OK, so we've established Dr. Micheli's credentials for the sport of rugby, which we'll talk about more in a bit, but what about his sports medicine credentials?
Well, since 1974, Dr. Micheli has been the finish line director of the Boston Marathon including two years ago, when bombs exploded and tragedy struck. He's been the attending physician of the Boston Ballet since 1977. In 1984, he was appointed to the Board of Directors of the United States Rugby Football Foundation, and he remains an active member of a variety of local, national and international initiatives dedicated to the advancement of sports medicine, sports science, and sports injury prevention.
Dr. Micheli is past president of the American College of Sports Medicine. He has participated in the selection process of the Sport Science Award of the International Olympic Committee President. And he traveled to IOC Headquarters in Switzerland to co-chair and assist in the writing of the International Olympic Committee consensus statement on the health and fitness of young people through physical activity and sport.
Closer to home, Dr. Micheli served for over a decade as Chairperson of the Massachusetts Governor's Committee on Physical Fitness and Sports, and he was recognized for his lifetime commitment and advancement of sports medicine with the 2011 Robert E. Leach Mr. Sports Medicine award at the annual meeting of the American Orthopedic Society for Sports Medicine in San Diego, California.
But what about research? Well you probably guessed he has contributed much, and he has — authoring over 300 scientific articles and reviews related to sports injuries, particularly in children including scoliosis, and other disorders of the spine and the various medical problems encountered by dancers, rowers, distance runners and of course, rugby players. His current research focuses on the prevention of sports injuries in children including assessment of risk factors in injury occurrence, as well as the assessment of shoulder dysfunctions in children and young adults.
Most recently, Dr. Micheli founded The Micheli Center for Sports Injury Prevention in April 2013. The center is dedicated to pursuing evidence-based research which focuses on the prevention of sports injuries and the effect of exercise on health and wellness.
We are honored to have a true pioneer in the field of Sports Medicine with us in the studio today. So let's give a warm PediaCast welcome to Dr. Lyle Micheli.
Thanks for joining us today. I really appreciate it.
Dr. Lyle Micheli: Happy to be here. Thank you.
Dr. Mike Patrick: And Dr. James MacDonald also joins us today.
He's an attending physician with the division of Sports Medicine here at Nationwide Children's and an Assistant Professor of Pediatrics and Family Medicine at The Ohio State University College of Medicine.
Dr. MacDonald attended Harvard Medical School, completed a Family Practice residency at Maine-Dartmouth and a Sports Medicine Fellowship at Boston Children's where he trained under Dr. Micheli's tutelage.
Dr. MacDonald is a member of the USA Swimming Medical Task Force and an Associate Director of the Clinical Journal of Sports Medicine.
He is no stranger to PediaCast, having joined us for two episodes in the past, including PediaCast 212 — when we talked about physical fitness and resistance training, along with the distinguished Dr. Avery Faigenbaum of the College of New Jersey — and PediaCast 254 when he brought along outdoor activist and song writer Jenny Morgan for a discussion on the “Leave No Child Inside Movement.”
It's always a pleasure having Dr. MacDonald on the program, so a warm welcome back to you as well.
Dr. James MacDonald: It's always great coming to studio, Mike.
Dr. Mike Patrick: Really appreciate it.
So Dr. Micheli, how did you become interested in the sport of rugby?
Dr. Lyle Micheli: I was playing football at Harvard at the time, and we did not at that time have spring football, so we're encouraged to play either lacrosse or rugby by the coaching staff. I started playing rugby in the spring and football in the fall. And I kept playing rugby in medical school and through my residency which was partly at Cleveland. And so I got into the sport, and it's a kind of sport you could continue to play.
Dr. Mike Patrick: How did you like it compared to football?
Dr. Lyle Micheli: I preferred it because in football, I played guard and I touched the ball once, I think. My junior in high school, I touched the ball, recovered a foam ball. But by and large, in rugby, once a ball opens up and the play starts, anyone can receive a kick pass, anyone can then turn and pass it, kick and so forth, and so on. So, although there's still specialization within rugby, it's all 15 people participating at the same time.
Dr. Mike Patrick: Well, what is a prop?
Dr. Lyle Micheli: Prop is someone who plays in the very front of the scrum. The scrum is a reverse triangle. The two scrums face each other, and as the line of scrummage became the line of scrimmage…
Dr. Mike Patrick: Oh, I got you. OK, yeah, I was wondering at that.
Dr. Lyle Micheli: You put the ball in the middle, and then you both push against each other and try to get over the ball so you can retrieve it.
Dr. Mike Patrick: Yeah. In what other ways does rugby differ from traditional football?
Dr. Lyle Micheli: There's no blocking in rugby. In fact, it's a foul. You can advance the ball at anytime with a kick running down the field. And he's coming up to tackle you, kick the ball ahead of them, and then you can retrieve it again on the second bounce if you're very, very skilled.
Dr. Mike Patrick: Yeah, I know what you're doing. I really, actually, did more research on rugby for this show than I thought I was going to because you do start to kind of digging in to it and get a little more interested, and more interested in the history of it.
It was developed at the Rugby School in England in 1820. And I'm going to put some links in the Show Notes, so for listeners out there just more interested in the history of rugby.
And then, it gets a little confusing because there's rugby league versus rugby union and some different rules. And then we've got rugby sevens, and so. Then, I started to get a little confused.
Dr. Lyle Micheli: The original game was rugby union, and rugby sevens is like a tournament game. It started, actually, in the late 19th century. It's been around for awhile. Rugby league is a professional game when rugby union was still an amateur game. It's played with 13 men rather than 15, and there's a different principle of driving ahead. It was rugby league. But the game that will be played in the Olympics forthcoming is rugby sevens.
Dr. Mike Patrick: And that's exciting. I think then, people that are really involved with the sport are happy to see it return because it was in the Olympics before.
Dr. Lyle Micheli: Yeah, United States of America is the defending champion in 1924.
Dr. Mike Patrick: Wow.
Dr. Lyle Micheli: We beat the French for the gold medal.
Dr. Mike Patrick: Why was it removed?
Dr. Lyle Micheli: As far as I understand, it was rugby that removed itself because it wanted to go its own way with its own development, with its own structure and so forth. It was very strong at that time, but they claimed now that it's the second most commonly played team sport in the world — soccer being first, rugby second, basketball, probably, third.
Dr. Mike Patrick: Wow. And the gridiron then, originally instead of just lines on the field, they put lines both vertically and horizontally so the field kind of look like a grid.
Dr. Lyle Micheli: Right. In order to get the 10 yards of gain, in which we do not have… Rugby's a continuous flow of game, similar to soccer, whereas football has the downs as we all know.
Dr. Mike Patrick: And that started at Syracuse University at 1910. And again, I've got links in the Show Notes for all the historical stuff because regular listeners of the show know I'm a little bit of a history buff.
I'll also have more information on USA Rugby. You can find a rugby club near you with one of the links, and then some links to the Central Ohio clubs — The Columbus Coyotes, The Columbus Castaways, and The Columbus Rugby Club. So if you're local and interested, we'll have links for you in the Show Notes at PediaCast.org for this Episode 318.
So I guess the next question is, is rugby safe for kids?
Dr. Lyle Micheli: There have been some studies including the one that we co-authored with fellow authors from here — from the Nationwide Children's Hospital — and it is similar to soccer as far as the risk of injury. It took no serious injury because there's no blocking in it, in rugby.
So yes, properly coached, properly played and officiated, it's quite a safe game.
Dr. Mike Patrick: Yeah. But you really have to… I would imagine that the officials — especially if there's kids involved — really have to be proactive in penalty use and..
Dr. Lyle Micheli: Be very careful about things like the scrum and the way they joined up, and careful about safety of tackle. No foul play.
Dr. Mike Patrick: What kind of injuries is most commonly associated with rugby?
Dr. Lyle Micheli: We get a lot of lumps, cuts, and bumps, and so forth because it is a contact sport, needless to say. But we also get shoulder separations sometimes. We got AC separations, similar to hockey, similar to ice hockey. We don't get as many of the knee injuries. We do get the cutting knee injuries in the female rugby players, however , the ACL injuries. You get sprained ankles, those type of thing.
Dr. Mike Patrick: Head injuries? You see some concussions here and there?
Dr. Lyle Micheli: Yes, but that's sometimes related to someone who has played American football who's gotten used to hitting with their head. And then realizing rugby, it's totally illogical to hit with their head.
Dr. Mike Patrick: Yeah, that makes sense. Or if you do fall and you hit your head on the ground because you can get a concussion that way too.
In Episode 177 of PediaCast with Dr. Tom Pommering, we talked about concussions and 261, some mobile apps associated with concussions, if you're interested in those more information.
What's the best way to prevent injuries with rugby? I guess it would be following the rules and proper coaching?
Dr. Lyle Micheli: That certainly goes a long, long way. The coach, he gets essential in a contact sport of any type, but in addition, I think that proper conditioning. We like to see neck strength in the exercises which are sometimes hard to come by. The neck machines have disappeared from most fitness facilities for variety of reasons. And so, we think that strengthening around the shoulders, back strengthening if the kid plays in the scrum, and really a good attention to flexibility because it's a cutting, twisting, and turning sport.
Dr. Mike Patrick: Do you use any protection equipment at all? Because I think of those leather helmets. Or caps, I guess. They're not really helmets.
Dr. Lyle Micheli: Yeah. There's a thing called scrum cap. Usually, that's used by someone who maybe has a recent laceration or something to protect the head from that kind of blow.
Dr. Mike Patrick: Yeah. But in general there's no other really special protective equipment?
Dr. Lyle Micheli: No.
Dr. Mike Patrick: Dr. MacDonald, are you seeing more rugby injuries, do you think, in your clinic?
Dr. James MacDonald: That's an interesting question. We see them, I don't know if I would say more like the incidents were increasing, but yeah, we definitely see them. I think the sport is increasingly popular in Central Ohio in youth.
Dr. Mike Patrick: Yeah. Certainly, if it's not getting more popular, they have better PR people because I think we're hearing about it a lot more.
Do you think, Dr. Micheli, that there are more kids involved? Or do you think it's just more awareness? A little bit of both?
Dr. Lyle Micheli: They're definitely, well, little bit of both because it's getting more television's time now as a prelude to the Olympics, but more kids are now playing. In the Boston area, we now have 39 high school programs played in the spring. And last week, we were officially accepted as a varsity sport for the Massachusetts Intercollegiate Athletic Association.
Schools can now list it as a varsity sport and it will be sanctioned by the Association.
Dr. Mike Patrick: Is there any move in Ohio to look into rugby? Or the clubs, they're not really schools affiliated, are they?
Dr. James MacDonald: Good point. No, I think they're independent. It is all related, but I think another aspect of rugby, both youth and in general, that's really appealing is it's much easier to play — for lack of better phrase — pick up rugby than it would be pick up American football.
I mean, in that way, it kind of resemble soccer, and it can resemble basketball. Kids can play it, and I see it when I bike around back to see sometimes some of the fields. Kids are playing. They're not necessarily 15 on the side. They might be playing five aside, but they're playing with rugby concepts and the tackling that one sees with rugby. So I think the way kids play naturally like on a playground and that continuous flow feeds more to, actually, literally the play that kids do than the structure from American football kind of composes.
Dr. Mike Patrick: I think for a pick-up game, if you're used to playing American football, I guess you're more likely to get hurt than with a pick-up game where you don't have the protective gear. Where if you know the concepts of rugby, maybe that protects you a little bit.
Dr. James MacDonald: I think like a lot of things, one of the things that's really interesting about sports medicine is there's so much we know, and there's still so much we don't know. And some of the things you're asking are really spot on questions that are going to need more research over time.
And even this is the sport of lacrosse, but there's a bit to do with the spring and bringing in a headgear, and girls lacrosse down in Florida, is it going to be productive? Are kids actually going to play more dangerously? It's unclear. Those are the kind of things… There are some things that might seem so evidently obvious, but they need research.
Dr. Mike Patrick: Yeah, yeah. And you got to think about those other things like you say, are they going to play more aggressively? Because they have this full sense of security that the helmet's going to help them when they could still get a concussion even with the helmet on.
Dr. Micheli, in what ways has the field of sports medicine changed since the 1960s?
Dr. Lyle Micheli: Well, in this country, sports medicine in that era was primarily dealing with acute traumatic injuries. The sports doctors were off and dealing with football, the team doctor in football or sometimes basketball and hockey in our area. But the focus was more on diagnose treatment of injuries.
Another change has happened, particularly today, as more and more children and, to some extent, women are participating at organized sports training, and as we're seeing more and more overuse injuries, the result of repetitive training. Repetitive plie in dance, repetitive arabesque or backwalk over in gymnastics and so forth. So that it shifted through– I think in our clinic, we see a lot of kids each week. I think more than half are now overuse injuries, not acute traumatic injuries.
Dr. Mike Patrick: What had been the most meaningful advances do you think from a research standpoint?
Dr. Lyle Micheli: I would say that shifting the focus toward prevention. Whereas ten years ago, everyone played lip service prevention. Very little research was being done about ways of preventing knee injuries, for instance, in female athletes or preventing concussions. And now, you open a medicine journal now, you'll see two or three articles on preventive aspects of different sports.
Dr. Mike Patrick: And what challenges lie ahead?
Dr. Lyle Micheli: I think to implement, if you were to do the ideal sports system, it would to do be a very careful assessment of every kid as they enter into a given sport. Say they were interested in lacrosse — or rugby, or football, whatever — assess them with respect to their body and their strengths, and their flexibility or lack of them. Assess the sport. We know pretty well what are the problems that can occur in that sport. Match off the two and that is a real pre-participation evaluation.
Dr. Mike Patrick: Yeah. And if you really have some data to back you up, and then you can advice better in terms of prevention strategies and also pre-participation guidance for the parents on what kind of injuries to expect, what to look for. So that makes a lot of sense.
We know that physical activity in sports participation is important for our health. Why are some of the reasons that parents really should take this seriously in terms of their kids being physically active?
Dr. Lyle Micheli: Well, I think that in our present day and age, what exercise some kids get will only be in an organized sport setting. Free play has gone by the way for various reasons. I mean, it should be, but it has been. As a result, I think that the quality of adult supervision in these organized sports programs, whether their town-based, school-based is essential for the kids enjoying the sport, getting some psychological benefits from it and, of course, physical benefits.
Dr. Mike Patrick: Getting them hooked early on being active, is there any research to suggest that you stay active?
Dr. Lyle Micheli: Yes there are. There are several long-term studies. One from Canada, which showed kids who became involved in a systematic, organized sport or exercise training as children, tracked into being into active adults in a significant higher level of activity.
Dr. Mike Patrick: Given we hear this is the first generation of kids expected to have shorter life span than their parents, but there's something we can do about that. That's not an automatic, and getting our kids active and involved is one way to do it.
Dr. Lyle Micheli: We think that, for instance, on weight control, nutrition is certainly an important part of it — eating healthy, not eating excessive carbohydrates or fats — but in addition, let's not forget the exercise equation. That should be an extremely important part of any exercise prescription for weight loss.
Dr. Mike Patrick: Now, as with everything, there are advantages and then there are pitfalls as well. What activity-related pitfalls should children and families recognize and avoid?
Dr. Lyle Micheli: Well, I think that one of the most important is first is we all get the kid in the sport that they really want to participate in themselves. It's not a family concern or family desire. And then, get them the best instruction there is and progress slowly. There's not a big rush here. They don't have to make the travel team the first year they play soccer and so forth. Let them grow into the sport, make accommodations for their growth spurts which are sort of increased risk periods for injury, et cetera.
Dr. Mike Patrick: It seems like a lot of parents live vicariously through their children's sport participation. That's a great advice. Really focus it on the kid, not what the family wants. And there's lot of lessons in sports participation, not just winning, right?
Dr. Lyle Micheli: The psychological and sociologic advantages and results of sports or act as sport participation showed in a number of settings. One study of Inner City girls showed that active involvement in organized sports increased their performance in schools, decreased the percentage of unexpected pregnancies and so forth.
Dr. Mike Patrick: Tell us a little bit about this sport of rowing. We don't see much of that in Central Ohio. Do we, other than through Ohio State?
Dr. James MacDonald: Dr. Mike, you're asking a good question. It's interesting. In as far as absolute numbers, we don't see large numbers of rowers. But there is Upper Arlington, for instance, they're pretty strong youth rowing community there. There are some boat houses there, and in the reservoir north of Westerville.
So, I think you're right. For the most part, we're going to see it in our clinics coming from the collegiate athletes. But I, literally, just the other day saw a young man, of all things, concussed while rowing.
Dr. James MacDonald: A goose flying off the water ran into him.
Dr. Mike Patrick: Wow.
Dr. James MacDonald: This is for real.
Dr. Mike Patrick: That is very unfortunate.
Dr. James MacDonald: It is, yeah. So all the parents out there, it's very rare. Rowing is a great sport to transition into if your child may have had too many concussions for contact sports. So that anecdote aside, but I literally just saw that rowing injury not that long ago.
Dr. Mike Patrick: But in New England, we see a lot more rowing or that's just a stereotype?
Dr. Lyle Micheli: Absolutely. We have the proximity to the water. We have the Charles River running right through Boston. There all sorts of rowing clubs and rowing houses there.
We have a program called Community Rowing where hundreds, literally hundreds of kids go there. They row during the winter. They have over a hundred erg machines. And so, that gives me opportunity to teach them how to row properly, so they don't excessively strain their back, to use good rowing technique, and then they progress into often competitive shells, either a four or eight for instance.
But in addition, there are a lot of recreational rowers in Boston. People go down at 5:30 in the morning, take their shell out from the boathouse and go for a row along the Charles and go back. We also have ocean kayaks at ocean shells.
There's a tradition there, of course. The first competitive athletic event in America was between Yale and Harvard rowing.
Dr. Mike Patrick: Yeah. What kind of injuries do you typically see when you have a large population of rowers? Probably not as many of the flying Canadian geese injuries, right?
Dr. Lyle Micheli: That's a bit unusual.
Dr. Mike Patrick: Yes.
Dr. Lyle Micheli: We see problems around the shoulder. The kids will get overuse usually the shoulder, elbow. They got a unique type of stress fracture sometimes in their chest wall where the muscles insert. We will sometimes see knee problems with these kids, but not… If properly done, I sometimes send kids with the previous knee injuries into a rowing program. So with proper instruction on rowing technique, that can be done.
I think I see probably equal numbers of rowing injuries from them doing out-of-the-shell training, like they're going, running around the Charles River and sprain their ankle and sort of like this. Or run stadium steps and have a sore knee cap. The rowing in general is a pretty safe sport.
Dr. Mike Patrick: An in addition to proper technique, just getting the strength training, flexibility, those same things that we talked about with rugby are important with rowing as well.
Dr. Lyle Micheli: Yes.
Dr. James MacDonald: And may I just interject something. You know, this is almost universally true in sports, but I think rowing — because there's a repetitive motion over and over and over again, thousands of times — form becomes really, really important as part of injury prevention. It's universally true law, but I think it applies even more in rowing.
And so, a lot of times the trick is to integrate the medical care with the coach and the person teaching the child how to row because if the form can be proper, that goes a long way toward that because you're not going to have the same kind of impact you would, say, with running. Running form maybe great, but if you run a hundred miles a week it doesn't matter. You're still going to get stress fracture possibly, that sort of thing.
Dr. Mike Patrick: Yeah, absolutely. So much endurance too. How long is a typical row? What's the term?
Dr. James MacDonald: Piece? There's someone talking about piece? Or is it a 2,000 meters, Dr. Micheli. Is that a common?
Dr. Lyle Micheli: Yeah, 1,500 to 2,000, depends on the course itself. There's some variability. Yeah, but that's competitive of eight rowing, usually eight or four. There's also doubles rowing, singles competitions.
We have a competition called The Head of the Charles in the fall. It's an international competition. Rowing teams come from England, etc. That's a point-to-point race. They basically go from point A to point B, and they're racing against time, basically.
Dr. Mike Patrick: Very interesting.
Dr. James MacDonald: You know, one of the unifying things between rugby and rowing, it just occurred to me when you talked about the intensity of rowing, those two sports are exceptional in both demanding high levels of aerobic and anaerobic capacity. You need the endurance of a running athlete, and you need the strength of a wrestler, basic for both. They're quite impressive that way because of that.
Dr. Mike Patrick: Really good all-around kind of sport.
Let's move on to dancing. So how do you become involved with the Boston Ballet?
Dr. Lyle Micheli: They approached us, basically. The dancers approached us. We were the first sports medicine program in Boston. Several dancers came to see us for problems. And that time, for instance, if you sprained your ankles, whenever you sprain your ankles, we put you on a cast for cast for six weeks. Then we take you 12 to 15 or 16 weeks to recover from the cast. And we didn't do that. We started really icings, bracing, rehabilitation, right off the bat physical therapy. And so, it lend itself to the effective return-to-dance for these dancers.
So then, after two years, Boston Ballet approached us and said, "Can we have a more formal relationship?" And it has continued to this day. We have our fellows rotate down there once a week and then see the dancers. We cover all their performances. We have a physician all of their performances, and we've done a lot of interesting research with them.
Dr. Mike Patrick: Very interesting. What kind of injuries do you typically see? I kind of said we see a lot of ankle injuries. Are there other injuries as well? I guess knees, hips?
Dr. Lyle Micheli: Yeah. It depends on the age. The younger kids will have some knee problems. Repetitive plie, repetitive releve and so forth, though they're gone by the time they become more serious or more accomplished in the dance. They can get back injuries from repetitive arabesque and so forth. They get occasional traumatic injuries. They can fall. We get the one or two ACL injuries of the knee a year from coming down from a jump.
It's remarkable how really low the occurrence to that injury is given to what they do to their bodies. But they got very good balance, very good coordination. And even though they're more flexible in general, they don't seem to get the ACL injuries that we would expect.
Dr. Mike Patrick: What about head injuries, concussions? You probably see those occasionally too.
Dr. Lyle Micheli: We do. Well, it depends on the style of dance. We see that more in jazz dancing perhaps and some of the folk type dancing. We published an article on it. It does occur.
Dr. Mike Patrick: I'm going to stir your brains here for a minute. I had a listener right in because her daughter dances, and she says she double-jointed so she's got lots of flexibility. Her question was that her dance teacher told her that she shouldn't be a gymnast. Because she was really had an interest in gymnastics, and so the dance teacher's kind of steering her away from gymnastics.
So my impression was maybe he didn't want to lose her in the dance class. Is there issue with gymnastics and hyperflexibility?
Dr. Lyle Micheli: Well, they're both are positive attributes for a dancer or a gymnast. Perhaps, he was more concerned about possible increased risk of injury with gymnastics, something like that.
Dr. Mike Patrick: Yeah, that's kind of interesting. I thought, "Hey, I got the two of you in the room. I'll get an answer from you, guys."
In terms of preventing injuries in dancers, I would assume that the things we've been talking about with conditioning and flexibility and resistance training, all that still important for dancers as well.
Dr. Lyle Micheli: And pre-screening. Our dancers come from variety of backgrounds. We might hire some two new dancers that come from a certain style of dance. And we have instituted a pre-screening which we find very effective. We can find old injuries that have not been properly rehabilitated. We can find that they have certain propensities, maybe have less range of motion in the left angle than the right, and so forth.
So it gives us a way of instituting preventive measures. Maybe despite the fact they're dancers, their left hamstring is tired than it should be.
Dr. James MacDonald: There's one other thing, we've touched on. I see the two phrases overuse or over-scheduling. It would apply to dance. It would apply to any sport, but kids as a general thumb — and there's actually a good evidence to support it — if you're playing your sport, or in this case dance, more hours per week than you have years, in other words, let's you're 11 years old and you're in the studio, you're at the gym, doing your gymnastics or whatever for 20 hours a week, that is a very very high risk factor for overuse injuries.
Dr. Mike Patrick: Very good to know.
Dr. James MacDonald: So for parents out there, that's a general thumb, and it's a pretty good one.
The other one is over-scheduling. Separate from that overuse, the child who's in this and then in this, and then in this, that's over-scheduling. There's actually a very good study. It's actually another protŽgŽ of Dr. Micheli's, Anthony Luke, in the Clinical Journal of Sport Medicine, studied that an over-scheduling is a risk factor. Usually kind of goes hand in glove with not enough sleep, the sleep that kids need for their general health and also for recovery. But over-scheduling is also something you really want to worry about.
Lots of things are appealing to parents. Get that kid playing violin, piano, playing soccer, karate, start adding them up too much. It's also a set up for…
Dr. Mike Patrick: You know, and then get on your school work that you need to get done. And you really still need some free time just to do something, maybe some creative. Of course, if it's an instrument or something…
But has there been any studies looking at what the basis is for overparticipation? Is that coming from the kids? Is that coming from the parents? I suspect, it's a little bit of a combination, and you can't pigeon hole and say in every family, it's going to b the same. But do you find it more one over the other?
Dr. Lyle Micheli: Depends on the situation. I think that quite frankly it's often the kid who was given perhaps inappropriate guidance or instruction from the coaching situation. When you're a 10 year old, the coach says actually do X. When you're a college player, you might say, or professional player, "Well, I don't know about that." The coaches are more human. But I think we have to be very careful about how much these kids are doing. I think James' turn with over-scheduling is very important also.
There's a tendency towards exclusivity. And it's returned again now to be have a super specialization in just one sport. And there's some very recent evidence that it increases the risk of injury.
Dr. Mike Patrick: You want kids to be able to participate in sports, but then when it becomes so competitive that there are kids who can't compete at that level, how do you overcome that? I guess get them involved more in club sport or in a community-kind-of sport?
Dr. Lyle Micheli: Yes. I think it's sometimes a somewhat painful process. I've had mothers come in and say, "I don't understand it. She's swimming slower than them. She used to be up with all of her peers, and now, she's swimming slower than them." Well, what can I say about that? She's slower swimmer.
But I think it's up to the kid to decide what level of participation. And we see this all the time. We have a very serious girl soccer player in high school, goes to college, and makes the decision herself that she's going to study nursing, and so, she's going to be a club soccer player. So sometimes, the kids will sort it out themselves, and in fact, very often.
Dr. Mike Patrick: And it really boils down at how much they enjoy it and what is it that they're… You know, where's the motivating factor for them? Is it intrinsic or extrinsic? That kind of thing.
Dr. James MacDonald: I think it's always the classic thing, parents need to discern all the time is how much do I need to require my child to do a certain thing and how much might the child be driven — for a lack of better phrase — do it themselves? My point being is that because of the benefits of sports and physical activity, it' very important for parents, I think to encourage that sort of thing in their child.
On the other hand, at what level they participate, how intense they participate, that really needs to be driven by the child. Children can burn out very easily and lose the joy of sport, and then you've shot yourself from the foot.
Dr. Mike Patrick: Yeah. Yeah. Let's talk about distance running. You need a lot of endurance, right? For distance running especially when we're talking of marathon. For someone who's interested in distance running, how do you work up to that?
Dr. Lyle Micheli: Well, if they want to resume running say after an injury or surgery, we have a formula that we give them. It's called our 10% rule. In general, we let them increase their volume of training 10% a week. So we use to start out with an exposure of what we call our 10-10-10, ten minutes of brisk walk, ten minutes of a slow jog, ten minutes of brisk walk every other day. And we let them increase their running portion two to three minutes a week.
So we go up slowly. We let the body accommodate, and once they're into that three to four weeks, then they can use the 10% rule, which is if they ran 20 minutes at previous week at a time, they can safely run 22 minutes the next week. So we do it by the clock, not by distance.
Dr. Mike Patrick: I would think that's a good plan for someone who's just really starting out in running or like they want to become a runner. You can't just go out and run a couple of miles. You want to work up to it.
Dr. Lyle Micheli: When the women's running movement first started seriously in the late 70s, in the late 80s in this country, we were seeing stress fractures after 10Ks. I mean, 5, 10, 15 of them in the medical tent. Now that women have been properly coached and advised by running people as far as how to slowly workout, let their body accommodate to an additional load or volume of training, we rarely see that.
Dr. Mike Patrick: What injuries do you typically see in distance runners?
Dr. James MacDonald: Stress fractures are big one.
Dr. Mike Patrick: That's a big one.
Dr. James MacDonald: It's really the knees. Patellofemoral Syndrome is really common in the younger kids more likely to be things like Osgood-Schlatter's Disease, truly in the spring like with spring track. In our clinics here at Nationwide Children's Hospital, the number of, for instance, tibial stress fractures probably trebles compared to what it was in the winter.
Dr. Mike Patrick: And a lot of times, you don't pick those up on plain X-rays, correct?
Dr. James MacDonald: That's right.
Dr. Mike Patrick: So you can have a kid who's having a problem. They go an Urgent Care, let's say, to get an X-ray. They say the X-ray is clear, but they continue to have pain and issues. This could be a warning that there's a stress fracture there.
Dr. James MacDonald: True, and it can sometimes be hard to discern that between more benign conditions called Shin Splints. So yes, sometimes you're only going to be really able to get to the bottom of it if you see a doctor and sometimes need to get other pictures too.
Dr. Mike Patrick: Yeah. Like an MRI or CAT scan or those kind of things. I suspect that with distance running, that's something that we do see a lot of here in Central Ohio, right? We have a lot of cross country teams, and you probably don't see as many marathon runners though as Dr. Micheli.
Dr. James McDonald: Your point's well taken. In our clinics, we see people from ages 6 to 21. It's rare, you're right, 12-year old to do a marathon, but when it was Columbus Marathon time back in October, we saw a fair number of people. Actually, we see employee health. We're more than happy to see people like you, Dr. Mike. You're training for that half-marathon?
Dr. Mike Patrick: I don't know. Do you see more of a student athlete gearing toward a marathon because of the Boston Marathon and the publicity and the hype with that?
Dr. Lyle Micheli: Yes, but it's still not certain whether the training aspect, the training for marathon is safe for children who are still growing. And as a result to that, the Boston Marathon is taking a rather conservative stance that there's an age limit of 18. Time will tell. The problem is that some of these injuries have a long-term effect. They won't have the results of that kind of exposure for 10 or 20 or 30 years. So in the mean time, we're erring on the side of caution. Other marathons will let 16-year-olds compete, but for us, the age is 18.
Dr. Mike Patrick: Yeah. And it's kind of hard to do a prospective study when you tell a parent, "Well, we're going to see if this hurt your kid." They're more likely to not want them to do it.
Dr. Lyle Micheli: Exactly, yeah.
Dr. Mike Patrick: Speaking of the Boston Marathon, how did you become involved with that organization? They approached you?
Dr. Lyle Micheli: Not exactly. One of my patients was a physician. I just saw him as a sort of a favor. He's an adult physician. He was involved with the marathon as a matter of his medical coverage. He said, "Why don't you come on down and help out." I said, "Sure." 1975 was the first year I was there, and there were about five or six or seven of us there. And there's about a thousand runners. Runners came across the finish line, "Hey, how are you doing? How are you feeling? OK? Good. Go get a drink or something."
And then, in 1978, the running boom was starting. Interest in running and marathon running was increasing. 13,000 runners, extremely hot day, and we were murdered. They were sending people in ambulances. We didn't have proper set up at the site in order to start IVs.
This has morphed into very well-organized, very sophisticated system now where we triage the runners, and we see if they can drink. If they can't, we get them IVs. As a result, we rarely in a much lower proportion of kids that have to be sent in at the end of the marathon.
Dr. Mike Patrick: Do you have medical tents set up along the route as well?
Dr. Lyle Micheli: We do every two miles. We have the Red Cross tents. There are two big medical tents at the end, and someone who's been picked up along the route by one of the buses will bring them to the main medical tent to be triaged.
Dr. Mike Patrick: OK, I see. So they bring them to you if they have a problem before they get to you in terms of running?
Dr. Lyle Micheli: Minor problems are taken care of by the Red Cross personnel.
Dr. Mike Patrick: So how many IVs are you doing at a time?
Dr. Lyle Micheli: It depends on the temperature. We had a very cold marathon this year. We didn't have too many, but those that we did, we heated them because they were hypothermic.
Dr. Mike Patrick: Wow.
Dr. Lyle Micheli: If you'll walk in the tent, you'll see 30 or 40 IVs hanging.
Dr. Mike Patrick: Wow. That's incredible. Has it always been the same time of the year?
Dr. Lyle Micheli: Yes. It's always the third Monday in April.
Dr. Mike Patrick: It's always. That's tradition, I should probably know that.
Dr. Lyle Micheli: Patriot's Day.
Dr. Mike Patrick: And you would know that from your time there?
Dr. James MacDonald: Yeah. It's a great day in Boston.
Dr. Mike Patrick: So were you around when the bombing occurred in 2013?
Dr. Lyle Micheli: I was.
Dr. Mike Patrick: Yeah, tell us about that.
Dr. Lyle Micheli: Well, I was at the finish line. If we coin the pictures we have, subsequently, I was walking with a woman. I had my back to the bomb site. So I'm looking at some young woman's wrist. She must have fallen or something. And the bomb went off. I thought it was a student prank. I thought some darn college kids are there, pulling off some stunt. And then, almost simultaneously, I smelled the gun powder and the second bomb went off up the street, about a hundred yards up the street. And then we knew it, of course.
We were not hit. The medical personnel, the safety personnel were not hit because there was snow fencing up between us and the spectators. So to get to them, we had to take down the construction racks and pull down the snow fencing and get to the people as they had been injured there, right in front of the first site and then the second, of course.
Dr. Mike Patrick: And then were you involved in the triaging spectators into that point?
Dr. Lyle Micheli: All the casualties are spectators. And basically a lot of people ran away, but the ones that weren't running were lying on the ground, in some cases, pretty badly injured.
There are three people who died instantly. We did not lose another person, even though we had multiple, double amputees. We improvised. We made tourniquets out of running jackets.
The first bomb went off in front of a running store, the Marathon Sports. We ran in there. We got jackets. We made tourniquets out of them. We packed the wounds with running shirts. We had kids there, athletic training students. They're with wheelchairs that get people who'd collapse at the finish line. We mobilized them; put these people on the wheelchairs, wheeled down in the tent and got more sophisticated care down there.
Dr. Mike Patrick: I guess it was fortunate that this occurred at a location where you have a couple of large medical tents.
Dr. Lyle Micheli: It was extremely fortunate.
Dr. Mike Patrick: Yeah.
Dr. Lyle Micheli: It's one of the numbers of things that helped us. It was just good luck. We have a lot of doctors and athletic trainers right there. We didn't have much equipment, but we were there.
Dr. Mike Patrick: You got IVs.
Dr. Lyle Micheli: In the tent.
Dr. Mike Patrick: Oh yeah, yeah. Sure.
Dr. Lyle Micheli: Not much dressing, but we have a triage system already setup. We just triage and right through the tent. It occurred at 2:50 PM, right at the change of shift of the hospitals.
Dr. Mike Patrick: Oh boy, yeah.
Dr. Lyle Micheli: It was like a semi-holiday in Boston, but half of the hospitals did not have elective surgery. The operating rooms were empty.
Dr. Mike Patrick: Boy, very fortunate.
Dr. Lyle Micheli: People drove in when they heard it on the radio. People went in to the hospitals.
Dr. Mike Patrick: Yeah.
Dr. Lyle Micheli: So we quickly… One injured runner, it was 55 minutes between time she was injured at the finish line — not runner, spectator — and she was triaged through the tent, put in an ambulance, driven to Beth Israel Hospital, in the Emergency Room, up the elevator, in the operating room in 55 minutes.
Dr. Mike Patrick: Wow, that's incredible. How has the Boston Marathon changed since that event?
Dr. Lyle Micheli: Much more security. We have many more dressing type tourniquets and sort at the finish line. I throw it in my little pack now, just in case. It's going to be hard to defend a marathon. It's not like a stadium. More dogs coming through more frequently, but in general, just a tighter security system.
Dr. Mike Patrick: Was there a drop, do you think, in participation or spectatorship?
Dr. Lyle Micheli: Not apparently. The area was still filled with spectators. I give them a lot of respect from that.
Dr. Mike Patrick: Yeah.
Dr. James MacDonald: And then some of the athletes, Dr. Micheli, who weren't able to finish 2013, they doubled down, they came in droves in 2014. The marathon had made it like, you still got the ones who had been stopped. Like the marathon's over and they're still power out.
Dr. Lyle Micheli: They diverted people at Kenmore Square, which was about three miles in finish line. And anyone who is still on the course when the bomb went off and didn't finish was allowed to run the next year automatically.
Dr. Mike Patrick: Oh, that's really nice. And did a lot of people take advantage on that?
Dr. Lyle Micheli: Absolutely.
Dr. Mike Patrick: Yeah. Tell us about the Micheli Center for Sports Injury Prevention. You must be pretty proud of that.
Dr. Lyle Micheli: Yeah. This is what we think is our final job to do — is to prevent sports injuries. We diagnose treatment pretty well now in most places in this country, but I think we have to do a lot more research into preventing this occurring in the first place. So that's the whole push there. We get a kid in, we assess them, multiple assessments of their strength, flexibility, body anatomy, their body composition and we match it to the sport. We have enough data now in that sport, special sports risk of a certain sport like rowing or rugby and so forth.
And then we come out with recommendations for the family. The assessment takes about two and a half to three hours. It's pretty comprehensive. We have over 1,500 data points, and from that, we give them an advice. Then, if they want to come back in two to three months, we retest it and see what the intervention has done.
But we have pretty good ideas now. The risk factors, for instance, of the strength of the muscles around the knee. We know that often hamstrings are too weak compared to the quadriceps, a lot of exercise in a lot of our gyms are quadriceps strengthening. Ironically, it's the hamstring which is the friend of the ACL.
So you want more hamstring strengthening. That's an example.
Dr. Mike Patrick: And you're able to measure what their strength is going in, developed an individualized program for them, for the strengthening and then see the results. That's fantastic.
Dr. Lyle Micheli: Yes. Our goal for hamstring to quad ratio is 0.6. And many of the kids who are coming to see us are 0.32, 0.26 on both legs. And so we focus these hamstrings strengthening in that instance.
Dr. Mike Patrick: Do you see mostly high school athletes, middle school, college? Do you see a mix of everyone or is there a particular age range you see more of?
Dr. Lyle Micheli: I say it's a mixed, but I think we're seeing more high school kids because that's when the sports becomes more serious, more intensive and so forth. Individual sports like figure skating, or gymnastics, we're seeing six-year-olds brought in by their family.
Dr. Mike Patrick: There's a lot of Sports Medicine programs out there, is it important for kids and teenagers to be involved in a pediatric sports medicine program? Or like the older teenagers in particular, is adult sports medicine are going to be fine for them?
Dr. Lyle Micheli: I think there's a cutting point somewhere, depends on the kid. I think that the younger kids are probably better served in general to be seen by someone who deals a lot with kids every day of the week. I think once the kids are fully grown, there's a breaking point there, and it depends on the individual expertise or skills of the physician they're talking about.
Dr. Mike Patrick: Yeah, and what they're experience has been with different age groups.
Dr. Lyle Micheli: Yeah.
Dr. Mike Patrick: Sure. Absolutely. Because you might have a guy like Dr. MacDonald, who's with that group and so, but you do want to ask questions and make sure you're getting the best care for your child.
Dr. Lyle Micheli: Absolutely.
Dr. Mike Patrick: And we'll put links to the Micheli Center For Sports Injury Prevention and also Sports Medicine at Boston Children's. We'll put links in the Show Notes, so folks can find out more information about that.
Dr. MacDonald, tell us about Sports Medicine here at Nationwide Children's Hospital. We've got a great program too.
Dr. James MacDonald: Yeah. It's growing all the time. In fact, with Dr. Micheli visiting, I was just basically driving around Columbus, showing him our various facilities, and we only scratched the surface.
I think a couple of things occurred to me. One is we do see range of age. It's basically around 6 to 21. We sometimes see people a little bit older, but our median age is essentially like 14 1/2. The majority that people will see are like 14, 15-year old. Middle schools, high schools are our sweet spot. I think we have nine clinics now with their nine doctors. I think we had 14,000 patient visits last year.
And then we definitely echo what's being done at Boston Children's in terms of the prevention. Our athletics are trying to do a huge amount of that sort of thing. Functional movement screening with the goal of preventing injuries or ACL prevention for instance is a classic one.
Dr. Mike Patrick: And really come up with an individualized conditioning program for that child for their particular sport.
Dr. James MacDonald: Yes.
Dr. Mike Patrick: That's fantastic. And you guys in sports medicine have been great supporters of PediaCast. Just some recent episodes that we've done, we talked about the New U and Play Strong Programs in PediaCast 297. So I'd encourage people to check that one out.
That's kind of a cool program, weight management and returning kids to the activity and kind of start with cancer kids.
Dr. James MacDonald: That's exactly right. Some of our athletic trainers especially a gentleman named Travis Gallagher has been instrumental on that. The hospital as a whole is getting more interested in the concept of exercise as medicine. I've had people reaching out to me from Pulmonology, the Sickle Cell Clinic as well, interested in bringing more structured exercise program to their chronic disease patients.
That's really enjoyable to watch. And I think actually, one of the sort of push-pull thing are supportive PediaCasting. Your support of us is like, we really think there's a huge amount of evidence to support essentially getting out the gospel that exercise medicine, it beats almost any pill out there. It doesn't solve every problem, but it's part of the solution of almost every problem.
Dr. Mike Patrick: Absolutely. And Dr. Stacy Fischer kind of leads your group with a female athlete triad. We talked about that in PediaCast 285, but that's something that's becoming more recognized as an issue.
Dr. James MacDonald: Yes. And I think, it tells back to something that Dr. Micheli alluded to earlier that his career paralleled. The rise of the mass sports move in the 70s was also predicated at least impart on Title IX, right? The huge numbers of young women coming into sports with equivalent interest, equivalent zeal. It's now basically in our patient population, 50-50 boys and girls, which I think probably would have been unheard of in the early 70s.
But, consequently, young women do face different challenges, and female athlete thrive as one, and Stacy's definitely leading the charge in our facility in terms of …
Dr. Mike Patrick: So, you got to feel the body. That's the key message there right?
Dr. James MacDonald: Absolutely.
Dr. Mike Patrick: You got to get to feel in to work.
All right, well, I really appreciate both of you taking time to your day and coming and talking to us here on PediaCast. Thank you so much.
Dr. Lyle Micheli: Thanks, Mike.
Dr. James MacDonald: It was great.
Dr. Mike Patrick: It's an honor to have you.
All right. Let's take a quick break and I'll be back, we'll wrap up the show right after this.
Dr. Mike Patrick: All right, we have just enough time to say thank you. I want to thank all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.
Also, thanks to Dr. Lyle Micheli from Boston Children's Hospital and the Micheli Center for Sports Injury Prevention and Dr. James MacDonald, Sports Medicine here at Nationwide Children's.
That's all the time we have today. PediaCast is a production of Nationwide Children's Hospital. Don't forget, you can find PediaCast in all sorts of places. We're in iTunes and most podcasting apps for iPhone and Android, including the Apple podcast app, Downcast, iCatcher, Pod Bay, Stitcher and TuneIn.
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This one is in the can. And until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.