Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

By Dr Stan Baltsezak

Preface: BJSM readers can access the ‘Online First’ article relating to wicketkeeper Marc Boucher’s serious eye injury here; he was struck by the bails and suffered irreparable visual loss. This paper will be one of 4 relating to cricket injuries in the upcoming July BJSM.

You are providing sideline care, your player gets poked in the eye and your are confronted by blood and a player panicked by loss of vision in that eye. Are you ready?

In North America, basketball, baseball, and racket sports were the highest risk sports for ocular injuries among amateur players (1,2). In Scotland, 48% of patients admitted with sports related ocular trauma were from racket sports. Football was responsible for 33% of admissions (3). In boxing, serious injuries include hyphaema, angle recession, posterior subcapsular cataract, retinal detachment and orbital fracture (1).

How to examine the eye after trauma

Initial eye examination after blunt trauma must be done immediately at the sport venue. Eyelids are assessed for bruising and laceration. Visual acuity should be recorded for both eyes (Ability to perceive light, movement, finger count at 1 metre, and, if Snellen’s chart is unavailable, a distance from the available readable text should be recorded). Gross visual field assessment should be performed to evaluate injury to posterior structures of the eye.

A simple torch is used to evaluate anterior structures of the eye (look for hyphaema). Difference in the depth of anterior chamber may suggest a leaking wound (e.g. corneal laceration). An Irregular pupil is often seen after contusion. It may indicate injury to the iris, ciliary body, or vitreous prolapse. Corneal abrasion can be detected under blue light after fluorescein staining.

Direct and consensual response to light is checked. In cases where there is significant damage to the optic nerve, a relative afferent pupillary defect will be observed.

Eye movements are checked for presence of diplopia which may indicate orbital fracture (e.g. orbital floor fracture leading to restricted ipsilateral upgaze and less often downgaze) as well as injury to ocular muscles and nerves. Orbital floor fracture also leads to infraorbital nerve anaesthesia.

An ophthalmoscope can be used to assess red reflex (injury to the lens, cornea, vitreous haemorrhage, and retinal detachment will affect it). Fundoscopy is performed to evaluate for presence of vitreous haemorrhage, vitreous detachment, and retinal tears. The optic disc is examined for swelling and haemorrhage.

Important!

A methodical eye examination after trauma will help to ensure rapid recognition of severe injury, enabling appropriate management. If in any doubt, immediate ophthalmologist referral is absolutely essential.

Although some eye trauma assessment can be learned during emergency medicine placement, we recommend a short attachment at the local eye injury department for all SEM trainees.

Tip: There is now a range of ophthalmological Apps designed to assist the “out-of-office” clinician.  Easy to use, Snellen chart apps facilitate rapid and effective eye assessment in the prehospital environment.

References:

1. MacCumber MW. Management of ocular injuries and emergencies. Lippincot-Raven, 1998.

2. Jones, NP. One year of severe eye injuries in sport. Eye 1988;2:484-487.

3. Barr A, Baines P, Desai et al. Ocular sports injuries: the current picture. Br J Sports Med. 2000 December; 34(6): 456–458

Dr Stan Baltsezak is a Specialty Registrar year 6 in Sports and Exercise Medicine. He is currently working at the Kellgren Centre for Rheumatology, Manchester Royal Infirmary.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

By  Dr. Natasha Beach

Photo credit: The Daily Mail, UK.

The fast-growing sport of triathlon (1) comes in a variety of forms. The most commonly used short distance, known as the super sprint has a 400m swim, 10km cycle and 2.5km run.  Sprint distance (the next level up), refers to a 750m swim, 20km cycle and 5km run.  The Olympic distance event is a 1500km swim, 40km cycle and a 10km run (2). The Olympic distance triathlon used to be the pinnacle of an amateur triathlete’s career but there is now an increasing trend to surpass this by competing in the more gruelling half or full iron-man events.

Due to the variety of components and extremes of distances possible, sports medicine teams have to be experienced in dealing with a range of conditions, with a varied and appropriate skill set within the team.

The swim is the highest risk component; cardiac arrests occur.  The underlying causes include hyperthermia and previously undetected cardiac abnormalities. It is essential to have ALS trained staff present and prudent to have an on-site anaesthetist. Other common presentations include hypothermia, particularly in longer distance events with cooler water temperatures, ill-fitting wetsuits with consequent water accumulation and excess drag, or difficulty in breathing due to wetsuit compression. Recently we have noted a rise in eye pain and reduced visual acuity secondary to the use of goggle spray or homemade alternatives.  Frequently, participants are extracted from the water secondary to anxiety.  This is most commonly observed in those new to open water swimming.

The bike section can lead to traumatic injuries presenting for medical attention, particularly in wet or windy conditions.  The medical team should identify potential problem areas on the course beforehand, i.e. tight corners or rapid descents, so that prevention can be discussed and resources can be appropriately placed. Having an experienced orthopaedic surgeon in a car or motorbike provides the flexibility to navigate the course promptly, providing appropriate care on the route.  Biking injuries range widely from abrasions and dislocations to ruptured spleens and major head injuries.

Those who complete the swim and bike unscathed generally have little problem during the run. However, exertional hyperthermia can occur on warmer days and in longer distance events. The use of a wet bulb globe thermometer measuring the ambient temperature, humidity, radiant heat and airflow will give an indication of the likelihood of problematic hyperthermia (3).

Asthma, fatigue, dehydration and cardiac related collapse can occur during any of the disciplines; the medical team must be prepared for all eventualities.

Whilst the majority of triathletes complete an event unscathed, there is potential for serious harm.  A well-trained and appropriately skilled medical team can enable the vast majority of competitors to be treated on site with a high probability of returning to triathlon competition in the future.

References

1)     http://www.waylink-english.co.uk/?page=19260

2)     http://www.thelondontriathlon.co.uk/LTRaceDescription.html

3)     http://www.topendsports.com/medicine/wbgt.htm

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Natasha Beach is a Sport and Exercise Medicine registrar in London.  She has an interest in mass participation endurance events and is medical director of a sports events team.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Drs. Moiz Moghal and Natasha Jones

There is rising awareness that physical inactivity is a major health problem. Momentum is gathering at a local level to try to reverse this trend. An exercise prescription or a brief intervention on its own is not enough. The challenge is to integrate an exercise medicine service with proactive partners who can successfully deliver the tools required to change behaviour to an activated community.

In Oxfordshire, the Department of Sport & Exercise Medicine at the Oxford University Hospitals NHS Trust in a unique collaboration with AgeUK Oxfordshire, have been commissioned by the PCT to develop a service to facilitate individualised exercise prescription and signposting for local opportunities to be active. This is targeting people over the age of 50 years and has been achieved through the development of an innovative website called Generation Games which is due to launch next month.

Generation Games is designed to be used by the individual or by the healthcare professional. It will take the user through PAR-Q and GPPAQ before asking about individual barriers to exercise. Following this, the individual will be given a personalised exercise prescription or will be advised to see their GP to ensure that it is safe for them to exercise. Once this has been confirmed, they will be given a detailed list of all opportunities to be active in their local area. The options will be widespread ranging from seated exercise to Nordic Walks to team sports. Working with a well established partner such as AgeUK Oxfordshire will help us to access hard to reach groups, in particular the lonely and isolated. Even a lack of IT access or knowledge is not a barrier as this service can also be accessed via local AgeUK Oxfordshire branches or by phone.

A key part of this project will be to get local healthcare professionals to use the service. We know that practitioners in primary care are best placed to deliver physical activity guidance (1). As such, we hope to visit GP practices across the county to spread the word and to demonstrate the website. The website also provides a useful learning resource regarding the role of physical activity in chronic disease and also references some key papers related to this topic. We hope that this will also provide valuable feedback in order to allow us to continually improve the service. The same will be done using patient focus groups through AgeUK Oxfordshire. We hope to establish firm links with well-established rehabilitation services but also to give access to other specialist departments whose patients we know may benefit, such as cancer and mental health services.

We believe that the message of the benefits of physical activity speaks for itself. In the development of Generation Games we hope that we have made it as easy and as safe as possible for the individual or the healthcare professional in Oxfordshire to access an exercise prescription and to find interesting and fun local activities that will keep them motivated to be active.

Please feel free to access the website on:

www.generationgames.org.uk

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Dr Moiz Moghal is a Specialist Registrar Sport & Exercise Medicine, Oxford Deanery

Dr Natasha Jones is a Consultant in Sport & Exercise Medicine, Oxford University Hospitals NHS Trust

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

REFERENCE:

1.         Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. British Journal of General Practice, 1997, 47, 567-569.

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

By Dr Justin Yeoh

The flu may be an “un-sexy” aspect of Sports and Exercise Medicine, but it is nonetheless a topic of importance. Especially given that it is exceptionally common this time of year and afflicts athletes worldwide.

The NHS recommends an influenza vaccination for at risk groups to prevent illness (Immunisation against infectious disease – ‘The Green Book’, DoH).  Some professional sports clubs use this principle and administer the vaccine to large player squads. Due to the regular close contact nature of training and competing in a team sport, the players may be deemed at high risk of contracting and becoming unwell with influenza. The illness can result in missed training and/or matches and potentially spread to other members of the squad or staff. Thus, prevention is important to maintain good health of the team during a season.

This preventative measure seems sensible. However, in this current generation of evidence-based medicine, a quick search of Medline and Embase revealed no studies regarding this specific topic.  Treatment within the Sports Medicine setting is already in danger of having a reputation of not necessarily following evidence-based practice with PRP, shockwave therapy and traumeel to name but a few. Although not proven, they still may have a role in management and this may also be true of the preventative influenza vaccinations. However, there is also another theory that administration of the vaccine itself can result in influenza symptoms.

Is this yet another area of research that needs more work to determine if prophylactic influenza vaccinations are effective? For what it is worth, anecdotally I do advocate its use and, at the club I work at, I try to stab as many of the players as possible!

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Dr Justin Yeoh is a Sport and Exercise Medicine Registrar in the London Deanery, General Practitioner in Reading and Team Doctor for Reading Football Club.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Dr Brinda Christopher

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

Keeping up to date with new medical app releases can be time consuming and often unrewarding. This is partly due to poorly organized app stores and over zealous medical app websites written by generalists. For that reason I reviewed several apps from an SEM perspective and present the most notable.

*The views of the author do not necessarily represent the views of BJSM

BEST ANATOMY APP

Muscle Premium 2 by Visible Body

Muscle Premium 2 is a brilliant app with a seamless and intuitive interface. The visually impressive 3D cadaver can be viewed from any angle and dissected with ease. Learning has never been packaged so neatly before. It negates the need to spend hours reading reams of descriptive text. Its only downfall is that it will not run on ipad1, nor is it available for Android devices.

RECOMMENDED MUSCULOSKELETAL MRI / ANATOMY APP

Monster Anatomy Upper Limbs
Monster Anatomy Lower Limbs by Monster Minds Media

Monster Anatomy is a detailed and accurate colour annotated MRI database. It delivers an optimal learning experience through a clean and logical interface. Intuitive touch navigation enables users to scroll through images of joints in 3 planes and limbs in 2, where flashing dots highlight structures. This is an indispensable tool for interpreting MRI of normal anatomy.

ONE TO WATCH

RealWorld Orthopaedics by Hyperexis

RealWorld Orthopaedics is a French-Canadian app where the index appears to have been lost in translation. If you are willing to overlook the initial navigational disarray, I am sure you will enjoy this app with a simple, but great concept of plain x-rays detailing multiple pathologies with colour coded overlays. It is a useful educational app and definitely one to watch for updates.

ANATOMY FOR iPAD1

Pocket Body by Emedia

Pocket Body is visually simple and clearly laid out with 8 preset layers of anatomy on a computer generated cadaver that rotate around a vertical axis. It almost feels like a no frills service, but the reliability of content and the detailed clinical context boxes make up for the lack of additional dynamic graphics. From a musculoskeletal viewpoint it lacks two important features: illustrations grouping muscles based on actions, and an orientation to view the plantar aspect of the foot in all its complexity.

USEFUL, BUT…

Muscle System Pro III
Ankle and Foot Pro III by 3D4Medical.com

Muscle System Pro III on the other hand has a very sophisticated veneer, with a more flexible viewing interface and videos of muscle actions.
There are however a number of flaws that have the potential to distract an unforgiving user: prolonged loading times of a few seconds, odd orientations of structures, omission of contributory muscles when describing muscle actions, and worst of all, some incorrect descriptions.

“Fibularis (Peroneus) Longus – This muscle originates from the middle third of posterior surface of tibia. It inserts into the bases of distal phalanges of 2nd-5th digits”.

These multiple oversights unfortunately challenge the integrity of 3D4Medical apps, despite being highly revered by Apple.

BOTTOM LINE

I am upgrading my tablet for the sole purpose of owning the Visual Body range because it has resuscitated my desire to learn anatomy. With its outstanding clarity of content and smooth navigation, this app sits in a league of its own.

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Dr Brinda Christopher is a Registrar in Sports and Exercise Medicine based in London

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series

I recently had the honour of assisting with cardiac screening in a dance company and an academy football team. I came across many concerned parents and athletes. Some refused to participate in screening tests.  Some even attempted to hide their family history, including a heart attack at a young age.

Saying a prayer: Owen Coyle, Darren Pratley, Dedryck Boyata and Ryo Miyaichi looks on as Fabrice Muamba lies on the floor after collapsing on the pitch. Photo: ACTION IMAGES

One of the parents had suffered a heart attack when he was 27 years old. He asked me when his son, who was 9 years old, would need to start screening. One parent also asked, since Fabrice Muamba underwent cardiac screening and still collapsed, how effective, really, are the screening processes.

If any of the results turned out to be abnormal, would the person be treated or protected from SCD?

Or would the club be informed of the results and the players be disqualified from their sport?

These were valid million-pound questions, which made me wonder.

I recalled my time at Liverpool Heart and Chest Hospital, when I was part of the team performing family screening for rare cardiac diseases. Even after extensive tests, some of the results remained uncertain, leading to psychological disturbances in patients. One of my patients with suspected Brugada syndrome told me that she had stopped doing anything physical because of the worry of sudden death.

As a Sport and Exercise Medicine trainee, managing “Sudden Cardiac Death” was one of the competencies in our training curriculum. I hope to have gained this competency through training, background reading and practical involvement. Notwithstanding, in ‘real world’ scenarios, many uncertainties still exist.

Background literature

Sudden Cardiac Death (SCD) or Sudden Cardiac Arrest (SCA) is defined as an event that is non-traumatic, unexpected, and resulting from sudden cardiac arrest within six hours of previously witnessed normal health without other explanation. (Sharma et al. BJSM 1997)

Common Etiology

The most common cause of SCA in older athletes (>35 years) is unsuspected coronary artery disease but in the younger group inherited or congenital cardiac disorders are more common. (Sharma et al. BJSM 2012)

Causes of SCA can be widely variable.

Inherited/Congenital causes

1. Myocardial diseases (Hypertrophic Obstructive Cardiomyopathy, Arrthymogenic Right Ventricular Cardiomyopathy)
2. Valvular diseases (such as Aortic root dilatation, aortic stenosis etc)
3. Coronary artery pathologies (congenital anomalies, spasm, dissection, vasculitis etc)
4. Conduction system (such as Wolff-Parkinson-White syndrome, long QT)
5. Ion Channelopathies (eg: Brugada)

Acquired conditions (such as infection, myocarditis, drugs, electrolytes imbalance, blunt trauma etc)

Screening

In Italy, cardiac screening has been compulsory since 1982 in all athletes participating in competitive sports. To prevent one SCD, over 500 athletes are disqualified. Many other European countries also offer Cardiac screening but it is not compulsory. In the UK, screening for heart disease is still not fully funded in the NHS and is provided by charities such as Cardiac Risk in the Young (CRY)

FIFA made the pre-competition medical assessment mandatory for all FIFA competitions and recently initiated the establishment of a database for SCA/SCD for all 208 Member Associations to obtain more information. (Weiler et al. BJSM 2012)

SCA is rare but can be highly traumatic. It usually attracts a lot of media attention and may negatively impact the public view on sport and physical activity.

Improving Protocols

There is a need to establish a Central or National data registry on all SCA/SCD across sport and encourage research using this data to develop a robust and practical screening program.

Meanwhile it is essential to ensure the availability of defibrillators at all stadiums, accessibility of appropriately trained medical professionals across sport, and increasing public and athletes awareness and understanding on heart screening.

And finally pray that you never come across SCD/SCA in any sports team or sporting event that you cover throughout your career.

Related BJSM blogs

A South African Perspective on AEDs

Sudden Cardiac Death screening: notes of caution

Call for NHS to review its policy on screening of young people at risk of sudden cardiac death

ECG Summit in Seattle: Successes and Next Steps

References

1. Ghani S, Sharma S: Pre-participation cardiovascular screening in athletes: when and how. Cardiovascular Medicine 2012;15(1):7–13
2. Sharma S, Ghani S, Papadakis M. ESC criteria for ECG interpretation in athletes: improved but not replete. Heart. 2011;97:1540–1
3. Weiler R, Goldstein MA, Beasley I, Drezner J, Dvorak J: What can we do to reduce the number of tragic cardiac events in sport? Br J Sports Med 2012 46: 897-898
4. Thompson PD: Preparticipation Screening of competitive athletes Seeking simple solutions to a complex problem. Circulation. 2009;119:1072-1074

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Dr. Khine Win is a Specialty Registrar in Sport and Exercise Medicine, West Midlands deanery.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Drs James Thing & Thiviyani Maruthappu

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

As the sun finally breaks through the clouds after months of rain across the UK, it is worth reminding ourselves of the importance of sun protection for our athletes.

As a sports doctor I, like many others, regularly attend events over the summer months, weighed down by numerous medicines and medical kit.  On occasion I am lucky enough to have packed my factor 30 sun protection lotion and try to apply at least once a day but what about those athletes roasting under our very noses?

Athletes who spend long hours in the outdoor sun, with little protection from long sleeved clothing are amongst the most susceptible of individuals

Figure 1: Fitzpatrick skin type scale

Excessive UV exposure occurs in sports such as: skiing, mountaineering, cycling, triathlon and other outdoor endurance events [1].  The knowledge of athletes regarding sun damage and protection tends to be good. However, their sun protection behaviours are often poor [2].

Excessive sun exposure is the strongest risk factor for many dermatological malignancies. This includes basal cell carcinoma, squamous cell carcinoma and malignant melanoma [3]

Malignant melanoma is on the increase. The diagnosis is being made three times more often now than in the 1980 s [4].

As well as excessive outdoor sun exposure, there is an increasing trend among young people to use tanning beds/booths.  Athletes often feel under pressure to conform to aesthetic preconceptions.  Many perform their events in minimal clothing and it is therefore important for them to feel confident in their appearance.  A golden glow is often favoured to the pale complexion of an athlete who has suffered the effects of a long dark English winter (and summer!).

There are many daily use sunscreens on the market now that boast sport specific properties in their resistance to both water and sweat.  As doctors responsible for the health of these athletes perhaps we should be pushing sun protection advice more aggressively?

Top 10 sun protection tips for athletes

1) Always use sun protection lotion when out between the 11am – 3pm

2) Ensure that sun protection lotion has both UVA (5*) and UVB cover (30+)

3) Know your skin type – type 1 skin is much more likely to burn than type 6, with “sunburn” increasing the risk of sun damage and subsequently skin cancer.

4) Know your burn time – the Sun Protection Factor (SPF) gives an indication of skin cover.  Burn time (with sun protection lotion) = burn time (without sun lotion) x SPF

5) Consider using waterproof or ‘sport friendly’ sun lotion

6) Consider wearing a hat and long sleeved clothes (not always possible in sport)

7) Take extra care when exercising around water or snow as the reflection results in faster burn times.

8) Get to know your moles; monitor with regular digital photos if concerned.

9) Know your family history; malignant melanoma has a strong genetic component.

10) Avoid sunbeds, if concerned about appearance consider a good fake tan instead!

Resources

The “World UV” app was set up by the British Association of Dermatologists (BAD) and is free to download.  It enables users to see the UV weather forecast and offers advice on how to avoid sun damage:

Useful patient information leaflets on skin type, self-monitoring of moles and sun protection advice are available here.

References

[1] Moehrle M.  Outdoor sports and skin cancer.  Clin Dermatol. 2008 Jan-Feb;26(1):12-5.

[2] Cohen PH, Tsai H, Puffer JC.  Sun-protective behavior among high-school and collegiate athletes in Los Angeles, CA.  Clin J Sport Med. 2006 May;16(3):253-60.

[3] Stenback F. Cellular injury and cell proliferation in skin carcinogenesis by UV light. Oncology 1975;32(2):61-75

[4] Accessed via http://www.cancerresearchuk.org/ on 22/08/2012

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Dr James Thing is a Sport and Exercise Medicine Registrar in London.  His clinical interests include rugby and athletics medicine.

Dr Thiviyani Maruthappu is a Dermatology Registrar in London and is a member of the British Association of Dermatology (BAD). 

By Dr Ritan Mehta

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

We have just witnessed the ‘Greatest Show on Earth’.  Over 10,000 athletes from 204 National Olympic Committees competed in 26 sports in a total of 39 disciplines at the London 2012 Olympic Games.  Whether you are a sport enthusiast or not, there was an attraction to the Olympics that one could simply not resist. If it wasn’t the exhilarating sport on offer, there was also the torch relay and the fascinating opening and closing ceremonies.

The Highs

On a personal note the Olympics were an incredible high in my life. When I first thought about working in Sport and Exercise Medicine (SEM) I would never have dreamt of working at an Olympic Games, never mind at one staged in my home city. It was an amazing experience, witnessing great sporting achievements at first hand.

My role involved being a Field of Play Retrieval Team Member at the Olympic Stadium. I was fortunate to be sitting trackside, looking out for and assisting in the safe and timely retrieval of injured athletes.  Each shift involved working with different individuals from a variety of clinical backgrounds. The ability of teams to bond and work effectively and quickly together was outstanding.  There was also room for some continuing professional development (CPD) consisting of specialist lectures by well renowned experts on topics ranging from hamstring injuries and exercise associated collapse  to concussion and knee assessment .

From a sporting point of view, the Games had countless highs but for me there were a few defining highlights.

1. The three gold medals for Team GB in 46 minutes on the first Saturday night will go down in history as one of the best ever nights of sport in Great Britain.
2. The fastest man in the world, Usain Bolt winning the 100m, 200m and the 4x100m finals.
3. The young, inspirational 15 year old swimmers Ruta Meilutyte and Katie Ledecky winning gold medals, showing their generation what can be achieved through dedication and hard work.
4. The cycling legends, Sir Chris Hoy winning his sixth Gold Medal and Bradley Wiggins becoming the most decorated British Olympian. They, together with the GB cycling team, have inspired the nation to get back on the bike.

The Lows

The Games did not pass without its problems. Sport is about fair play and competing on a level playing field. The Chinese, Indonesian and Korean players expelled from the Olympics for match-fixing surely showed the ugly side of sport.  One hopes that this will not be allowed to happen again. Performance enhancing drugs and sport are never far apart but with only three positive tests during this Olympics, it was one of the cleanest Games. This however does not tell the whole story. The World Anti-doping Agency reported that over 100 athletes were prevented from competing prior to the games because of doping offences. One must also question whether the limited number of positive tests indicates a reduction in athletes using performance enhancing drugs or whether they are simply getting better at hiding it. This is discussed at length in Dr Peter Brukner’s guest blog: Drugs and the London Olympics.

Comparisons have frequently been made between Olympians and Footballers with the criticism for the latter group. I would question why the racism accusations against Luis Suarez and John Terry have made front page news when there were also three Olympic athletes who were censured for racism, including Petras Lescinskas who was fined £2500 for making Nazi Salutes and Monkey noises when the Lithuanian basketball team played Nigeria, which has barely made the news at all. The International Olympic Committee is commended for making an example of these cases and helping the worldwide fight against racism in sport.

The legacy

Legacy has been a key part of the London 2012 Olympics ever since the Games were awarded in 2005. Every individual has their own thoughts as to what the Olympic legacy really means.  I wanted it to inspire people to take up physical activity in an attempt to reduce the growing obesity epidemic. I was also hoping that it would be a catalyst for the development and sustainability of Sport and Exercise Medicine as a medical speciality.

Strategies have been put into place to encourage individuals to take up physical activity, which I believe will help, at least in the short term.  Time will tell whether this will continue in the long term.

What will happen to Sport and Exercise Medicine?

As a trainee in SEM I am worried about the lack of NHS consultant posts being developed and even more troubled by the lack of new trainees coming onto the training scheme. This topic is raised by Liam West in his BJSM podcast [link to come] .There is a lot of work being done behind the scenes and a £30 million capital grant to develop a National Centre for Sport and Exercise Medicine (NCSEM) is a step in the right direction. I am however left wondering whether the funding and drive for SEM will continue once the Olympics and Paralympics have passed.

The Olympics has been a truly memorable experience for all involved. I am fortunately not yet suffering from Post Olympic Depression Syndrome as I eagerly await working at the biggest Paralympic Games the world has seen starting on 29^th August 2012.

For those who can’t make the Paralympics but need a sports medicine fix – remember that the BASEM conference is on November 22 and 23, 2012. Just 100 days to go!

References

Peter Brukner on Drugs and the London Olympics.

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Dr Ritan Mehta is a General Practitioner, Specialist Registrar in Sport and Exercise Medicine and Club Doctor for Watford Football Club.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Dr Amir Pakravan

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

The practice of medicine, by its very nature, is prone to ethical problems and dilemmas. This is even more evident when providing pitch-side or field of play medical care to professional athletes. Whether it is Fencing’s 10 minute or Taekwondo’s 1 minute rule, the medical practitioner is almost invariably pressed for time to assess an athlete in a less than ideal consultation area and make on-the-spot decisions which could potentially end either the athlete’s hopes and dreams of glory or their professional career.

The London Olympic games saw more than 10,000 elite athletes from 204 countries competing across 26 different sports. Considering the current number of UN member states at 193, one can only anticipate an exceptionally diverse population of highly motivated individuals from different cultural backgrounds, all of whom are determined to perform to the best of their ability and beyond.

Cultural differences and their impact on individuals’ perception of and attitude towards injury, pain, suffering, and chivalry can immensely influence athlete’s reactions and expectations. To further complicate matters there is media attention, coaching and support team expectations, potential financial gains, and more often than not, governments’ invested interest in Olympic teams for publicity and propaganda purposes.

Be it repeated injections of local anaesthetic into an injured limb or complacency in providing adequate care, we have all heard of medical team members who for one reason or another, and either by informed choice or through sheer pressure of on the spot snap decision making, have treaded into the grey zone between what is considered ethical and unethical practice.

Such decision making dilemmas became vividly evident to me when, in my role on the Field of Play during the Games, I got involved in assessing and providing medical care to an Olympic gold medal hopeful whose injury meant he would have to leave the competitions without a medal. In addition to an intensely emotional reaction from the athlete and his initial resolve to compete through extreme pain, his medical support team continued to request his return to the competition despite being fully aware of the nature of his injury.

Our team, however, did all that was deemed appropriate at the time and eventually after a factual discussion with the athlete and his coaching team he decided to retire from competition. We further organised investigations and follow up as appropriate and achieved a favourable conclusion, or did we? Well, maybe not from the athlete’s perspective.

On reflection, and after discussion with other senior colleagues, I am convinced our approach was consistent with the best practice in similar presentations to an Emergency Department or outpatients Orthopaedic or Sports Injuries clinic. But we were dealing with completely different circumstances where the athlete, from a different cultural background, and at the peak of his sporting career was under immense pressure to perform. He had a medical support team which he trusted and which encouraged him to continue, with this probably being his only chance of getting an Olympic medal. This clearly was a very stressful situation.

The ethical issues arising from this case are complex considering that:

1) The objectivity of advice offered by an athlete’s own medical team, given their full knowledge of his medical history which they were reluctant to share.

2) The athlete’s ability to give informed consent or make decisions under such immense pressure.

3) The potential ‘conflict of interest’, given our role as an independent but responsible third party.

These are only but a few of the issues for clinicians who work in this setting to consider and discuss.

Suggested Further Reading:

1)  L Anderson. Writing a new code of ethics for sports physicians: principles and challenges. Br J Sports Med. 2009;43:1079-1082

2) Salkeld LR. Ethics and the pitchside physician. J Med Ethics. 2008 Jun;34(6):456-7

3)  Standaert CJ, Schofferman JA, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: conflict of interest. Arch Phys Med Rehabil. 2009 Oct;90(10):1647-51

4) Holm S, McNamee MJ, Pigozzi F. Ethical practice and sports physician protection: a proposal. Br J Sports Med. 2011 Dec;45(15):1170-3 (Free, Editor’s Choice)

5) Holm S, McNamee M. Ethics in sports medicine. BMJ. 2009 Sep 29;339:b3898 (not free)

6) FSEM Professional Code. V.1 – ©1st July 2010 FSEM (UK)

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Dr Amir Pakravan is a Sports and Exercise Medicine Registrar in Cambridge who has worked with different professional and elite team sports.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

 Interchange laws, bleeding and apparently dying players

@DrJohnOrchard

I am very interested to have read the Blog by Drs Fowell and Earl (http://blogs.bmj.com/bjsm/2012/08/17/closing-soft-tissue-wounds-rapidly-at-pitchside-a-role-for-metal-skin-staples-without-anaesthesia/) about the use of staples to close lacerations on the side of the pitch in football matches.

I used metal staples like this quite a few times myself in the early 2000s in rugby league and wrote up one of the cases in the BJSM (Orchard JW. Video illustration of staple gun to rapidly repair on-field head laceration.  Br J Sports Med 2004;38(4):e7). Now I still use staples as one of the options for closing wounds in rugby league players, although no longer do I do it on the sidelines. Shortly after the 2003 case (which was subsequently written up) a further case which was far more notorious occurred when I closed an eyebrow laceration on Michael De Vere in a rugby league State of Origin game

This was done on the pitch itself whilst a video refereeing decision was being made, meaning that the player didn’t leave the field – he didn’t miss any playing time at all. The video of the procedure, however, was captured on TV and shown to millions of viewers. The reaction to the vision was that the NRL (National Rugby League) banned the use of the staple gun outside the dressing room, meaning that players have to now leave the field to have a laceration closed.

The issue of management of lacerations is one which not only is of concern to team doctors – who must weigh up both (1) optimal medical treatment of an injury and (2) minimising loss of game time for players – but it now also needs to be a major concern for sporting administrators.

I cover some of the related issues in an Editorial in the August 2012 BJSM (Click here for: Orchard J. More research is needed into the effects on injury of substitute and interchange rules in team sports Br J Sports Med 2012;46:10 694-695). All sporting bodies should engage Medical Directors and medical/injury management concerns must to be prominent when considering existing and proposed new rules. Whether use of staple guns pitchside should be recommended in a sport depends on quite a few factors, including (but not finishing with) whether it will lead to unpleasant images on TV.

Blood management will be influenced by substitution rules

The sports rules for handling blood and the interchange/substitute laws clearly have a major impact on medical management. If the rules allow for “free” interchanges/substitutes for bleeding wounds (as per rugby union), then the player can be treated in the dressing room with minimal time pressure. However, this privilege (‘free’ substitution to respect the bloody player) can also lead to the distortion that it is advantageous for a team to have a player suffer a laceration (as they get an extra interchange in these circumstances). This, of course, is the scenario under which the “Bloodgate” affair arose. If it is disadvantageous for a team to have a player missing from action, then extremely rapid wound closure becomes a valuable priority. The challenge for all sports lies in balancing all of these concerns.

Practical implications of Fowell and Earl’s new data (blog, above)

I suspect that some football team doctors will look at the large case series of Fowell and Earl and decide that under the current FIFA rules (3 substitutes but no interchanges or “blood bins”) it makes sense to use staples on the side of the pitch, without local anaesthetic, for the uncommon scenario (in football) of a head laceration. History is in danger of repeating itself; this practice may be tolerated until children are exposed to it in their living rooms (e.g. by seeing a replay of it being done in an FA Cup final, for example).

More substitutes in football? (soccer)

A benefit of any debate on whether or not to ‘ban’ pitchside stapling in football will be that it should include a consideration about introducing an interchange player to the game itself. If soccer was to allowed 3 substitute players but also 1 roving interchange – the converse of the current ‘bench’ in the AFL (Australian Football League) – then a player could be interchanged off for 5 minutes for stapling/suturing to be done in the dressing room, without penalty to the team. It would also allow the player to be more thoroughly assessed for any co-existing concussion from the same blow to the head. This would fix an uncommon but consistent problem in the sport — how to deal fairly with the bleeding player.

It may also help fix a consistent but far more common problem – the exaggeration of minor injuries. If a player who was tapped on the shins and needed 2-3 minutes to recover was able to be interchanged off the field and temporarily replaced until this recovery, there wouldn’t be as much benefit in “playing dead” to stop the game if the temporary replacement could be made without hurting the team. A hybrid bench of substitute and interchange players (or one with a limited number of interchages rather than substitutes) probably leads to optimal injury management and perhaps even fewer injuries overall.

To close, I contend that the debate about what is best for a sport shouldn’t start with an argument of “this is how it’s always been done” but it should finish with “this is how we will make sure our sport gets the balance right between entertainment, fair play and optimal injury management”.

This Guest Blog relates to the BJSM Blog posted on August 16th – please scroll down.

John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at www.johnorchard.com and/or follow @DrJohnOrchard on Twitter