8 Aug, 14 | by Karim Khan
Is there a responsibility for professional bodies such as UK Physios in Sport or the BJSM to comment on sportsmedicine / #sportsphysio media?
I don’t know Tiger Woods although I suspect he is probably an avid BJSM follower. So, everything I mention here is in the public domain. 1. Mr Woods has had back symptoms for some time. 2. On May 5, 2014, he blogged in detail about his progress from microdiscectomy surgery (March 31, 2014). 3. He withdrew from the WGC Bridgestone tournament on Sunday 3rd August. 4. He started in the US PGA on Thursday, August 7th.
When Mr Woods reported on his recovery between the Bridgestone withdrawal and his PGA start, the television coverage cited Mr Wood as saying “My sacrum went out, it pinched the nerve and hence the spasms. Once the bone was put back, it was all good. The spasms went away and I started to get some range of motion. I’m not in any pain. That is the good part”
Athletes are entitled to their belief systems; no clinician fixes everything/everybody. Humility has to be a foundation of health care. We would laugh if our colleagues in 1914 had the arrogance to say they knew everything; our colleagues in 2114 would laugh would we claim that. However, the scientific method means that we have current ‘best-practice’ and ‘evidence’.
1. When an athlete says ‘sacrum went out’ should we grin and bear it?
From that perspective, ‘sacrum went out’ is not evidence-based. Mr Woods is not a health professional and does not need to be an expert on health care or back pain. He does not need to read Hodges, Vicenzino or O’Sullivan. No need to define central sensitization. So any comments about ‘sacrum went out’ are not criticisms of Mr Woods, they are just comments for naïve readers who may wonder ‘sacrum goes out?’.
Twitter discussion was quick to point out that the health professional may not have said ‘sacrum goes out’. And no-one suggested a health professional had said that. We have all played Chinese whispers. ‘You may have irritated your annulus fibrosis, your facet joints may have jammed up on a drive, or when you fell in that bunker, you have muscle spasm’ can easily turn into ‘sacrum went out’. [And before the back experts put this on Twitter, I appreciate that one is unlikely to make a ’tissue diagnosis’ here and that management requires a careful history, assessment of movement patterns, special physical examination, some trial treatments and expert explanation etc. – and I am not an expert]. [And of course this clinical scenario will not be solved by an MRI miracle – MR imaging post-surgery is even less helpful than it is pre-surgery]. But those clinical issues are a distraction in this blog. The point is to share issues related to the public discourse when a prominent player shares health opinions that run counter to evidence.
I argue that professional bodies have a responsibility to alert the public that ‘sacrum went out’ is an unlikely diagnosis. No value judgement of the athlete, not impugning the health care provider’s skill. Just facts. “Dear member of the public – if you saw TW’s quote that ‘sacrum went out’…please imagine you didn’t. If you have back pain, we suggest you see someone you trust or one of our specialists.
2. When a health professional explains that sacrum can ‘easily come of place’ should we grimace and bear it?
I’m not going to put the links to a video clip from a TV show because the specifics are not important – it’s not personal. A prominent (i.e., comes up near top on Google) golf television show interviewed a medical doctor (‘affiliations and board certifications’ from the American Medical Association and others) about Tiger Woods’ dramatic recovery between the withdrawal (an inability to bend to take shoes off) at Bridgestone and clearing himself for the PGA 72 hours later. (NB: Not Tiger Woods’ MD – a ‘golf’ MD and ‘specialist sports physician’ (among other attributes))
The MD indicated that he had walked some of the PGA holes with Tiger Woods, observed the 2008 US PGA winner moving freely, bending over fully and swinging freely. The MD had spoken to TW’s coach. Great for television. #Credible. The MD explained (with a lovely anatomical drawing) that the sacrum can ‘easily come out of place’ and that one ‘sees it very often in golfers’. In the same clip, he explained that ‘sacrum out’ (1) has a 20-minute fix, (2) benefits from nonsteroidal anti-inflammatory medications (3) has a benign course (my interpretation of ‘good to go’). The MD expressed full confidence that Tiger Woods was cured – sacrum out, sacrum in. ‘Good to go’.
Really? ‘Good to go’? Go where? On which planet? Many real sports physicians and real sports physios were surprised that TW was ‘good to go’. They committed on Twitter ahead of the PGA starting that TW was likely ‘BAD to go’. Imagine it is a final year medical or physio exam…”You are consulted by a 38-year old former World Number 1 who has not won a tournament since 2008. He has had 4 surgeries included microdiscectomy most recently (March 31st, 2014). On his blog on May 5 (3 months ago) he reported filling in the holes on his private golf course so he doesn’t have to bend.
I’ve worked with [son] Charlie on [baseball] hitting and fielding drills and showing him slowly what to do; I can’t do it quickly. We watch a lot of sports on TV, and we try and copy that. We have a lot of putting contests. I can’t bend down to pick up the ball out of the hole, so we sand-filled all the holes so you can still putt to a hole.
…(exam question still going….) The player withdrew on the final day of the most recent tournament on August 3rd. He was reported as being unable to pick up balls, take his shoes off. Today is August 5 and you are assessing and providing advice about his management and specifically playing in the US PGA starting on Thursday August 7. (phew, end of background to question!). Question: What is your advice?”
There are many ways to pass but as a UBC Professor (sticking to scope, shocking at golf), I’d say in my course (KIN 461) ‘sacrum out’ as diagnosis, and ‘sacrum in, good to go’ as treatment, would be a fail.
A first year sports physiotherapist is taught about ‘progression’ of exercises and return to play. You have to pass one level to get the text. Example answer might list progressions like this…Putting with kids. Short irons, longer irons. Drivers (easy swing, not too many). More of above…greater volume, greater intensity. 9 holes. 18 holes. Days on, days off of 18 holes. Two days in a row and then an easy day. Three days in a row. Four days in a row, but taking it easy. Later tournament but not hitting for maximum length (many options, just an example). //
Breaking down in Bridgestone is not how you pass the ‘return to tournaments at lower pressure than Majors’ level. That’s why the media was awash with predictions (just one of many snips, below) that TW’s PGA would be the train wreck that it proved to be. No need for Nostradamus.
3. What to do? On the one hand we don’t like to be critical of colleagues.
It’s not easy being interviewed on TV. As a viewer, I don’t have the clinical information about Tiger Woods. On the other hand, the interview can be analysed merely on the facts. Analysis is not personal. NONE of the discussion from commentators related to Tiger Woods’ actual condition.
We were discussing (i) Tiger Woods’ public explanation of his understanding of what is going on and (ii) an MD’s TV (and web clip) explanation. The MD’s website lists ‘Golf Medicine’ under an ‘Expertise’ tag. The MD’s website says he is ‘…sports medicine physician and doctor to some of the top golfers in the world….and a pioneer in the field of golf medicine’. Humbly, he shares that he learns from every patient including from ‘one of my golfers with a major tournament on the line.’ His website includes golfers describing the MD as eminent – ‘the best in the business’.
An MD going on TV with those ‘credentials’ also carries responsibility. A responsibility to fellow MDs, fellow sports physicians and to golf medicine experts. If the TV interview says that the sacrum ‘easily comes out of place‘, this will reflect badly on MDs, real sports physicians and golf medicine experts who base their practice on evidence. If, on surfing the MD’s website one finds claims of ‘4 simple saliva tests’ that allow this MD to quantify the patient’s level of inflammation it raises flags. Immunology expert as well as golf, sports medicine, emergency medicine and surgery…oops I digress… [Editor’s note – take that out]
4. Don’t top players like Tiger Woods have the best clinicians caring for them?
First, I am not commenting on TW’s medical team. That’s way out of my scope. But speaking of elite athletes generally, some make better choices than others. That’s my opinion (level V evidence). Top players, particularly in individual sports, can have a very sheltered life. They might need a GP from time to time. How can they know who the best golf doctor is!
You know how tournament doctors are chosen! Did you see ‘Sportsmedicine Team’ advertised for the US Open in the BJSM, AJSM, JOSPT and other reputable journals? Did you hear that a committee recommended by the AMSSM (@TheAMSSM) reviewed applications? Did you hear PGA organisers commit an appropriate budget for Tournament Physician, Physiotherapist, Massage therapist etc? [How could the PGA possibly pay expert health professionals properly? Its 2009 tax form (#990) revealed the revenue for this non-profit organization was only $973,000,000].* And the players being taken care of by those health professionals share $10 million.
Or do you imagine that a friend of the tournament organizer with an MD degree might have picked up the odd tournament gig? Can you imagine that the price was right? ($0.00? + 3 autographs + one photo). That’s why saying you were the doctor for James Dean, Marlon Brando, Elvis Presley (OK, maybe not a great example) shouldn’t carry weight. #RightPlaceRightTime.
1) Tiger – we all wish you the best. Real sports physicians hate giving advice that a player needs to miss any tournament, let alone a Major. We became sports physicians to allow folks like you to share your talents. And folks like my neighbor, Dr Targett who hacks around. And to promote exercise in 86-year olds like my Mum before she died. Unfortunately Tiger, pathologies exist, rehabilitation can take time. Things may not look good for you at the very top level. Your PGA wins may be done at 14; a writer way more expert at golf than me has suggested.
Sports physiotherapists and sports physicians are big on exercise for rehabilitation. Exercise is a proven therapy. It works via the process of mechanotherapy. But the compression forces alone (not to mention shear etc.) on your lumbar discs from top golf are 6 times bodyweight (see below). That’s a serious Bear you are carrying (!, sorry). Body structures have remarkable capacity to repair with appropriate loading (=rehab exercises and progression) but at the very top you also need high volume practice (not an expert on golf, just guessing).
So, the combination of forces you create, and volume you need to sustain to be competitive on weekends, may not be compatible with another PGA win. This link provides a useful starting place on the biology. Noteworthy, it includes scientific data – ‘studies’. No financial competing interest for surgery or implants. There’s no way to tell your future precisely, you need to work at rehab progressively. I’m just painting a ‘worst-case’ scenario that I hope you have discussed with your expert team. Understand that microdiscectomy is not a guarantee of return to sport at the previous level (i.e., in your case winning Majors, not just showing up). Your player colleagues also need to know that in randomized trials, outcome of surgery has not bettered outcome of physio rehabilitation. As Adam Meakins @TheSportsPhysio tweeted “The best
#sportsphysios don’t have any miracle fixes”
2) Discussion of Tiger’s public explanation of his problem are just discussions – they are not meant to reflect any insider knowledge. They are like a ‘theoretical case’ or a movie where they say ‘any likeness to real people is accidental’. Because of the media focus on top athletes, authorities need to discuss comments such as ‘sacrum went out’. To help the public and to help athletes who want to be part of the discussion.
3) Collegial responsibility and self-promotion on TV. If you find a website that seems rather ‘self-aggrandising’ it might be worth adding a pinch of salt. I’m not referring to any specific website here – so no-one should take offence. And media doctors are important – consider the excellent educational work of Dr Peter Larkins (@DocLarkins), a fully certified real specialist in sports medicine. His expertise is based on formal external certification (Australasian College of Sports Physicians) (not ‘self-certification’ or ‘cereal packet certification’).
Speaking of real sportsmedicine/#sportsphysio experts, I see that Roald Bahr (@RoaldBahr) doesn’t have a personal website telling the world he’s a pioneer or leader in anything. Neither does Jill Cook (@ProfJillCook). They don’t have a *6-part miracle cure for everything*. Their universities, their hospitals, and the IOC may refer to them but they don’t self-market. Remember that the very best don’t need make self-promoting videos with guarantees and background music of a certain genre. And if a physician’s greatest claim to fame is ‘who I’ve treated’ there is reason to think twice. Medicine can be treated as a business.
4) Players – are you sure you have a quality physician and physiotherapist? How do you tell? Don’t ask other folks in the same industry – there is likely to be ‘group think’ in your sport. Speak with folks from different sports who are experienced and who don’t have a commercial interest in being your doctor. I’m not convinced that a golfer (lumbar compression force = 6 times bodyweight per swing x 72 swings per round x 4 rounds) can compare his loads with that of a Cowboys’ quarterback but that’s an aside.
I can see the challenge though. In the US, the American Medical Society for Sports Medicine (@theAMSSM) is an internationally recognized accrediting body for real sports medicine physicians. Has your doctor done an accredited AMSSM fellowship (specialist training)? Who were your doctor’s mentors? Does your doctor encourage you to get different opinions as needed? Does your doctor work closely with sports physiotherapist or experienced athletic therapist? Does your doctor use the word ‘evidence’ (not watertight but a start!)?
In closing, I offer this blogpost with humility. I know there are flaws in BJSM articles. I am open to correcting them and to highlighting that I have made mistakes. My personal scientific articles have wrongs, please let me know. Not all my patients got better. I made clinical errors.
But our compelling goal as real sports physicians and athletes and active people is to share accurate information. To acknowledge what we don’t know, and to be athlete focused in an evidence-based manner. Marketing voodoo/snakeoil/funky treatments has no place among real sports physicians and real sports physiotherapists who are working hard to master the art.
There has be room to point out, and draw attention to, statements that don’t have evidence.
And Tiger, if you can’t get through the PGA tournament because of your back (as I suspect you won’t) I’d respectfully suggest you listen to Dr Peter O’Sullivan’s podcast (link here). He’s a physiotherapist with specialised training in back assessment and treatment, a ton of experience with ‘difficult backs’. And a PhD. Just like a top golfer will have a range of qualities, those qualities belong to a top back clinician. There are a few like him around the world – just as there are a top 10 in golf. Encourage your sportsmedicine/#sportsphysio team to be honest with you – not to tell you what they think you want to hear. Reward those who have courage – to make it part of your team’s culture.
Which brings me to my last book recommendation – The 5 dysfunctions of a team. Patrick Lencioni emphasises that ‘artificial harmony — fear of conflict is cancer in a team. (A similar theme to the ‘GroupThink’ point above). Disagreement is not disloyalty, it’s evidence of loyalty. Your on-course team, your Tiger Jam team, your golf design project teams – encourage them to be honest. An honest, even remotely qualified, itsy bitsy teeny weenie experienced #sportsphysio would have suggested you were not ready on Thursday. You failed the progression (Bridgestone).
I wish you every success, as I do every player. And every 86-year old who knows what’s best for her.
*Above – PGA donate $130 million to charity (much directly from sponsors).