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Sport and exercise medicine discipline

Suicide, sport and medicine: more education and awareness needed for athletes’ mental health

10 Dec, 12 | by Karim Khan

By Dr. Kerry Lang

I was very interested to read Dominic Malcolm and Andrea Scott’s BJSM editorial on suicide, sport and medicine (2012) and agree that more attention should be paid to the psychological welfare of athletes.

I am a doctor, albeit not a psychiatrist, and have also been part of the British triathlon team since 2005. On several occasions I was acutely aware of depression in athletes that has gone apparently undetected. In one particular case, a female athlete was deliberately self-harming in response to her perceived poor performance in training. She had inflicted substantial lacerations to her forearms, which were obviously visible when swimming. I felt a duty of care to report this to her coaches and challenged them on whether or not they had noticed the wounds. The response from the first coach was they had not noticed and from the other coach was that they had noticed but felt inadequately qualified to address the issue.

This is just one example of where education is needed to identify warning signs and hopefully prevent catastrophic consequences. Not only the sports physician, but the whole support team needs to be aware of signs and symptoms for mental health issues.

Treatment for athletes is available. Education in what services are available is the key to providing mental health resources. There are sports psychologists who work closely with teams and individual athletes, general practitioners and team doctors with mental health training may also be useful and in more serious cases tertiary referral to a psychiatrist. Cognitive behavioral therapy and antidepressants are currently used with good effect. There is also an important role for preventative medicine in identifying “at risk” individuals and implementing early intervention.

Screening may be useful. Some simple signs for the performance team to look out for are: changes in appetite and weight, withdrawal from other team members or friends, crying, tiredness, indecision, anxiety, moodiness, loss of enthusiasm, feelings of sadness, lack of concentration and anger.

Formal screening can be done with the Beck Depression Inventory, the Hamilton Rating Scale for Depression (Ham-D), or the Montgomery-Asberg Depression Rating Scale.

A simple tool that, as far as I know, is not widely used but may be helpful in a coach-athlete setting is a self reported “vigor” score. Ask athletes to rate their level of vigor from 1-10 on any particular day. Scores consistently of less than 5 may merit further investigation.

In the case I describe in this blog, a sports psychologist became involved and with counseling the individual went on to perform internationally at a high level. Good mental health will ultimately lead to better athletic performance and is as important as good physical health.

References

1. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (June 1961). “An inventory for measuring depression”. Arch. Gen. Psychiatry 4 (6): 561–71. doi:10.1001/archpsyc.1961.01710120031004. PMID 13688369
2. Hedlund JL, Viewig BW (1979) The Hamilton rating scale for depression: a comprehensive review. Journal of Operational Psychiatry 10:149-165
3. Williams, J. B. W.; Kobak, K. A. (2008). “Development and reliability of a structured interview guide for the Montgomery-Asberg Depression Rating Scale (SIGMA)”. The British Journal of Psychiatry 192 (1): 52–58. doi:10.1192/bjp.bp.106.032532. PMID 18174510

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Kerry Lang MBChB, MRCS (Glas)

Medical students and sports medicine – The desperate need for improved access to mentors

5 Dec, 12 | by Karim Khan

Undergraduate perspective on Sports & Exercise Medicine - a BJSM blog series

By Matthew Gray

You may well have read the recent blog post or listened to the even more recent podcast featuring Cardiff medical student and Sport and Exercise Medicine (SEM) enthusiast Liam West. Although heavily summarising, Liam’s overarching conclusion was that students interested in SEM should be enthusiastic and proactive in gaining exposure in the speciality. Liam also puts forward a number of the many “challenges” that undergraduates face in their struggle for SEM success. These included the topic to which this post relates – the lack of mentors and shadowing experience available to students.

Why does it matter?

It’s pretty clear that in order to attract the very best students, SEM must come across as a speciality that is enthusiastic and inclusive. The part to be played by positive role models for students in achieving this cannot be overstated. It’s interesting that both enthusiasm and approachability have been shown to rank amongst the highest of the characteristics sought by undergraduate students in a role model, albeit in a surgical context [1]. Positive role models also have a significant impact on student decisions regarding future careers [1, 2].

Although there is an impression amongst students of a lack of SEM mentors, the widespread enthusiasm projected by the BJSM community in general potentially suggests the opposite. It seems quite likely that there are many SEM clinicians out there keen to offer their invaluable advice and mentorship to undergraduates; it’s just that at the moment, there is no foolproof way of connecting the two.

Why can’t students take steps to contact clinicians under their own steam?

There is no doubt that students should definitely be using their initiative to get in touch with clinicians, but there are often a number of challenges:

  • Firstly, students showing an interest in gaining initial experiences in SEM will inevitably have a limited idea of what the speciality entails. For example, who exactly comes under the umbrella of the term ‘sports medic’? Guidance in who to approach in this circumstance would be priceless.
  • Secondly, there is a problem that contact details for a given clinician, whether it be postal or e-mail address, are rarely available online. This simple fact alone limits access to SEM mentors for students almost before a student has started looking!
  • Finally, taking this approach is inefficient: there is no guarantee that a single clinician contacted for advice would be willing to offer it. Students are often forced to contact a number of individuals. In the process, this inconveniences those clinicians who do not want to be involved and, in the case of receiving multiple offers of mentorship, puts the student in an awkward position.

Although getting in touch with mentors ‘under your own steam’ is great, it is surely not the best approach. There must be a better way of linking students with SEM mentors. It seems that the root of the problem lies in a lack of established infrastructure to pair mentor and ‘mentee’ – something that could so easily be improved.

What can be done? – A suggestion

The introduction of an SEM mentor network (for the sake of this blog post, let’s call it SEMnet) where willing SEM professionals sign up to offer a point of e-mail contact for interested students in a given geographical area could be the simple solution.

For students, this would serve as a straight-forward but invaluable ‘foot in the SEM door’ allowing questions to be answered and serving as a platform to organise future SEM experiences.

In the UK, for example, SEMnet could be incorporated into the Faculty of Sport and Exercise Medicine (FSEM) as a benefit of (free) student affiliation. In turn, this would protect the privacy of clinician’s details, only allowing access to ratified, affiliated medical students. Promotion of SEMnet by BASEM, BJSM and within medical schools would also be key

in order to spread the message of this opportunity as widely as possible.

Consequences

By not improving access to mentors/SEM experiences to students, there is a real danger that talented students (who may well have become those championing the speciality in the future) may just pass by SEM. Ignorance of this issue is not really an option, especially if we hope to maintain the strength and quality of the speciality into the future.

References

  1. Ravindra P, Fitzgerald JE. Defining surgical role models and their influence on career choice. World J Surg 2011;35(4):704-9.
  1. Wright S, Wong A, Newill C. The impact of role models in medical education. J Gen Intern Med 1997;12:53-6.

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Matthew Gray is a fourth year medical student at Newcastle University, UK, with an avid interest in SEM. He is now a contributor to the BJSM ‘undergraduate perspective on SEM’ blog and amateur but enthusiastic triathlete!

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

Sports Medicine: Inspiring the next generation (Part 2 of 2)

23 Nov, 12 | by Karim Khan

Undergraduate perspective on Sports & Exercise Medicine - a BJSM blog series

 By Liam West (@Liam_West) & Dr. Peter Brukner (@PeterBrukner)

The second of this two part interview series exploring the field of Sport & Exercise Medicine (SEM) is with Dr. Peter Brukner (PB). He is a world renowned name in SEM, co-authors Clinical Sports Medicine (for many the “SEM Bible”), hosts a fantastic SEM website and helped set up the prestigious Olympic Park Sports Medicine Centre in Australia.

LW: Hi Dr. Brukner. Could you start by describing what is involved in sports medicine for the undergraduate readers?

PB: It is a very broad field. The core is musculoskeletal medicine concerning injuries categorised into acute, chronic or acute-on-chronic injuries. As a sports medicine physician you need be able to diagnose these conditions from a comprehensive history, clinical examination and often imaging techniques. Then you must decide the management plan which may be physiotherapy rehabilitation, injections, surgery etc. You should have a good understanding of all these areas, even ones you may not be directly overseeing such as the rehab, as ultimately you will be running the show! At the end of the day, the patient is your responsibility.

LW: A great overview. What other skills do students need to acquire to be successful in sports medicine?

PB: Competency with clinical skills and underlying knowledge of radiological skills, rehabilitation protocols, recovery and available treatments is fundamental to success in sports medicine. Increasing performance, rehabilitation and prevention is at the heart of everything we do. Good research is out there with which we can reduce the risk of certain injuries – you will need a good understanding of this. As well as all these medical factors you must have an understanding of training, sport and biomechanics, nutrition and psychology which are all components of sports medicine.

There are also the challenges of looking after a team on a day to day basis. Screening, travel and its associated issues (jetlag effects etc), doping and dealing with the media can all prove difficult. You must be source of education for players as to the dangers of certain performance enhancing practices. It is much broader than running on to the football pitch with the magic sponge! I think this is what people don’t understand about sports medicine.

LW: If you could only say one thing to a student that is trying to weigh up a potential career in sports medicine with a more traditional medical speciality what would it be?

PB: One of the big differences with sports medicine and other medical specialities is the multi-disciplinary approach. Once students start clinical attachments they will soon realise that consultants often treat their physiotherapists like third rate citizens! We really must work as equals in a team. If you think you know a whole load more than physios, don’t get into sports medicine! Be an orthopaedic surgeon, sounds like you have the right personality for that! I have learnt more sports medicine from physiotherapists than from doctors.

LW: That sounds very appealing. So what jobs can we get into in sports medicine?

PB: A huge range is on offer. You can become a consultant in the NHS or private practise managing musculoskeletal injuries or exercise related problems. You could be working at one of the multi-disciplinary sports medicine centres popping up around the UK. You can get involved with university jobs based in research or teaching. Then there is obviously involvement with team sports or professional sporting organisations. Most do a combination of these.

Sports physicians also have to become the world leaders in exercise prescription and dealing with the effects of exercise on patients with various chronic health problems. Something you have spoken to Dr. Mike Loosemore about.

LW: Any advice for medical students wanting to get involved in sports medicine?

PB: Go and look after your local sports team. Most amateur or semi-professional teams are dying to get people that can come and help them. You obviously need some simple skills and to act under proper guided supervision. Completing sports strapping / taping, first aid or pitch side trauma management courses can make you a valuable member of the medical team. Look to cover sports that guarantee carnage! Rugby, football or hockey are perfect and you will learn lots just from being around acute pathology and their subsequent management.

Get your foot in the door with sports medicine by volunteering. As well as your local sports team, marathons and triathlons are always looking for volunteers to help out with the medical teams. These are great opportunities to gain experience and this is what you need to do as an undergraduate. When I interview people for sports medicine jobs I always ask about their relevant volunteer experience. If they say they have only just come across the field, I immediately think “so you failed your application for orthopaedics then…” The genuine sports medicine enthusiast normally has longstanding interest.

Once you graduate, carefully pick your clinical rotations. Emergency medicine, orthopaedics, rheumatology, cardiology and respiratory medicine are all very helpful for a future sports medicine career. Then you might like to undertake a masters degree to further your interest.

You have got to love sport. You have got to appreciate sportsmen and women. You must understand that your regular Sunday league footballer wants to get back to playing after an injury just as much as Wayne Rooney does. You can’t just tell him to rest for 6 weeks and expect him to listen to you! You may think you are pretty hot stuff as you are a medical student but you quickly need to swallow a big slice of humble pie and not be too proud to learn off any member of the sports medical team. You need to be a sponge.

LW: There are some great take home messages for students in there. Can you finally comment on the role that the media plays in sports medicine?

PB: The public know very little about sports injuries and what we as sports medicine doctors actually do. The media can be used as a very powerful vehicle to educate the public on sports medicine. In Australia, sports injuries are openly discussed in the media and in quite a lot of detail, so the average sports fan is quite knowledgeable on the subject. That doesn’t happen here in the UK. I think we should get out there and talk more to the media and break down this culture of secrecy in sport regarding injuries. The average punter knows what an orthopaedic consultant or cardiologist does but they have no idea what a sports physician does. We need to sell our profession.

A perfect example is the case of Fabrice Muamba. Two club doctors did an absolutely sterling job of keeping this guy alive but the sole media attention was that the cardiologist jumped the fence and played no role in the immediate resuscitation. We need to ensure credit is given where credit is due!

LW: I think we will leave it there with that powerful success story. Thanks for your insights into sports medicine Dr. Brukner.

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Dr Peter Brukner (@PeterBrukner) is an Associate Editor of BJSM and an Australian sports medicine physician, author and media commentator living in Liverpool, UK. Currently working with Sky Sports News and one of the sports physicians working with the Australian cricket team. He runs his own website,www.peterbrukner.com which is a site for provocative and insightful sport & exercise medicine columns.

 

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

Exercise Medicine: Inspiring the next generation, an interview with Dr. Mike Loosemore (Part 1 of 2)

14 Nov, 12 | by Karim Khan

By Liam West (@Liam_West) & Dr. Mike Loosemore

Undergraduate perspective on Sports & Exercise Medicine (a BJSM blog series)

The field of Sport & Exercise Medicine has two distinct areas. Namely, Exercise Medicine and Sports Medicine. To gain insights and get tips for students looking to follow in their footsteps, I interviewed two influential figures pushing the boundaries of each field.

The first of this two part interview series is with Dr. Mike Loosemore (ML) who is leading the “Exercise Is Medicine” initiative in the UK.

LW: Hi Dr. Loosemore. Could you describe to the undergraduate readers what Exercise Medicine entails?

ML: Exercise Medicine, or ‘Exercise Is Medicine’ as it’s promoted by the American College of Sports Medicine (ACSM), is the idea that exercise is important in preventing chronic non-communicable diseases (NCD) such as Type 2 diabetes mellitus, heart disease & cancer. Exercise can also be prescribed as a treatment for a NCD allowing the patient to simultaneously reap the additional benefits of regular moderate activity such as reducing co-morbidities and improving the patient’s sense of well being.

LW: So essentially undergraduates can view exercise as a more powerful treatment than handing out a single pill in many circumstances?

ML: Yes. Medical school essentially teaches students how to poison patients as that’s what you do by giving small doses of drugs; although obviously if you give them too much of the drug you poison them properly! It’s completely different with exercise. Using exercise we re-establish a natural process which allows the body to heal itself, returning it to the homeostatic state & often improving health considerable. Humans are exercising monkeys, we need to be active and if you don’t exercise enough important functions of your body start to degenerate!

LW: Powerful stuff! Would you be able to share with the readers some of the data surrounding exercise as a treatment for various NCDs?

ML: Here are some basic facts and figures for the undergraduates from the ACSM website. Regular physical activity reduces the;

  • Risk of heart disease by 40%
  • Incidence of diabetes by roughly 50%
  • Risk of developing Alzheimer’s disease by 30%
  • Incidence of high blood pressure by nearly 50%
  • Risk of stroke by 27%
  • Recurrence of breast cancer by almost 50%
  • Risk of colon cancer by approximately 60%
  • Depression as effectively as Prozac or Behavioural therapy

A pretty impressive intervention that has no medical equivalent that can do one of those things, never mind all of them! If you consider that medical inflation is going up significantly quicker than normal inflation and the population is ageing, we are reaching the edge of a financial cliff as far as healthcare costs are concerned. Currently the vast proportion of the NHS budget is spent on treating disease. Instead we should concentrate on preventing disease occurring in the first place which is relatively cheap! We cannot continue to be a disease service. It is called the National HEALTH Service not the National Disease Service!!!

LW: Hopefully that is a quote that will stick in the mind of many undergraduates! You have briefly touched upon some of the research, but are there any other resources students could use to find out about exercise medicine?

ML: I suggest they go to the ‘Exercise Is Medicine’ website where they can access lots of relevant resources & facts from evidence based research, read the BJSM blog and attend Sport & Exercise Medicine conferences, such as the Cardiff SEMS Olympic Conference 2012 on 15th December which is aimed primarily at undergraduates.

LW: Finally, if there was only one thing that we could do during our undergraduate career to spread the message of Exercise Medicine what would it be?

ML: Include it in your history paradigm. Every time you take history from a patient, ask about exercise. Two reasons for that;

  1. You will find out their individual activities levels and then can encourage them to do more. Any increase in exercise, no matter how small, will start to reduce the risks of chronic NCDs.
  2. A doctor asking about exercise sends a very powerful message to the patient and they clearly see that exercise is important.

LW: Thanks Dr. Loosemore for your expert opinion on Exercise Medicine and how undergraduate students can get involved.

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Dr. Mike Loosemore MBBS DCH MRCGP MSc FFSEM(UK) is a Consultant in Sport & Exercise Medicine at the Institute of Sport, Exercise and Health, University College London. He is the lead Sports Physician (South of England) for the English Institute of Sport and currently the doctor to British Boxing. He is currently president of the Sports and Exercise Medicine section at the Royal Society of Medicine and leads the ‘Exercise is Medicine’ task force in the UK.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

Undergraduate curricula: An opportunity for progress (requires your help!)

5 Nov, 12 | by Karim Khan

By Dr David White

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

Participate in a new and interesting opportunity to help embed physical activity for health within medical undergraduate training. Drive this initiative forward by taking a few simple steps — outlined at the end of this blog.

At the recent Faculty of Sport and Exercise Medicine (FSEM) Annual Meeting in Edinburgh there were confirmations of progress across the UK in the promotion of physical activity for health. However, one recurring issue throughout the FSEM programme was the pressing need for an update of undergraduate education. Several studies convincingly suggest that current inclusion in undergraduate curricula is inadequate. [1,2]

Our current challenge is how to promptly improve undergraduate medical curricula, to place appropriate emphasis on physical activity for health. One or two medical schools have made progress, owing largely to enthusiastic individuals lobbying for amendments to that curriculum (e.g. Drs. Rhodri Martin, Liam West and John Brooks at Cardiff and King’s College, respectively). Vigour and persistence over prolonged periods were required in each of these cases. We can ill-afford to wait for this approach across each of the UK’s 32 medical schools.

The ultimate responsibility for undergraduate curricula across all medical schools lies with the General Medical Council (GMC). Their document ‘Tomorrow’s Doctors’, published in 2009, regulates what medical schools are expected to teach their students [3]. There is not a single mention of physical activity for health in this key document.
Opportunely, the GMC recently published another paper entitled:

            “The state of medical education and practice in the UK: 2012”. [4]

GMC’s aim in compiling this document is:

“To promote discussion and debate on issues and trends that require attention or further analysis, to improve standards of medical practice.”

Accordingly, the GMC have invited responses to this paper. These can easily be submitted online, and via Twitter, Facebook, or LinkedIn. Herein lies the opportunity to make the GMC sit up and take note of the current shortcomings in undergraduate education.

Here is a link to the report, and a brief feedback form.

Please complete the 4 simple questions, and forward the link to others who may support this cause.

The GMC have committed to log all comments detailing ‘Tomorrow’s Doctors’ for when the document is next revised.

In order to truly promote Good Medical Practice, the GMC must now set appropriate, up-to-date standards for our future medical workforce. Medical training needs to be altered to reflect changing patterns of healthcare and support a disinvestment in costly medications. Inclusion of physical activity across each of the relevant specialties is imperative. I believe this will inevitably happen. Seizing this current opportunity to offer feedback, however, could save many years lobbying individual medical schools and promote the more widespread application of curricula improvement.

References:

[1] Oluwajana F, Rufford C,Morrissey D. Exercise, sports and musculoskeletal medicine in UK medical school curricula: a survey. Br J Sports Med 2011;45:2 e1 doi:10.1136/bjsm.2010.081554.26

[2] Weiler R, Chew S, Coombs N, et al Physical activity education in the undergraduate curricula of all UK medical schools. Are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med doi:10.1136/bjsports-2012-091380

[3] General Medical Council. Tomorrow’s Doctors. 2009. Available online.

[4] General Medical Council. The state of medical education and practice in the UK: 2012. 2012. Available online.

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Dr David White is a Sport and Exercise Medicine Registrar based in Scotland, currently working with the Scottish Government and within the CMO Directorate. He is also a Medical Officer with the Irish Football Association and an IPC Classifier.

Email correspondance: david.white@scotland.gsi.gov.uk

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

Physical inactivity in Nigeria: A short analysis (part 2 of 2)

21 Sep, 12 | by Karim Khan

Guest blog by Damilola Alawode (@DAlawode)

 Read part 1 here

In Nigeria, government policies (e.g., policies that might influence health) can arise at three levels. There is the Federal Government, state governments, and local governments. Local governments tend to follow the policy laid down by state governments. Though there is a national health promotion draft policy, there is no legislation compelling the Federal Government to reduce or combat the scourge of NCDs through promotion of physical activity. Unfortunately, Nigeria does not have a goal of reducing physical inactivity by 10% as the government of Canada did for year 2003 or the Healthy People 2020 policy (a 10-year health agenda released by the US Department of Health and Human services in 2010), which identifies physical activity as a leading health indicator.

However, the FG through the National Sports Commission (NSC) set up a body known as the Nigeria Academicals Sports Committee (NASCOM) headed by a former Nigerian soccer star to collaborate with both state and local governments in promoting an initiative on physical activities in secondary schools (read more here). The initiative started with soccer, and it has been extended to 4 other sports (tennis, table tennis, basketball and swimming); athletics will start later in the year. The schools are required to train teams that would represent them in inter-school competitions from the local to the states up to the national level, thereby maintaining and promoting a culture of physical activity among the students. This is a good initiative that should be built upon by all levels of government as well as the private sector so as to sustain its impact.

The “Walk and Live” program

A state government in the southwest part of the country (The state of Osun) organizes what they call the “Walk and live” program. It is a once a month city walk similar to what takes place in the city of Mombasa, Kenya. It is an attempt to keep citizens of the state fit. Although this initiative can be improved, it has brought the importance of physical fitness to the forefront of more people. This should be applauded, but the message on the importance of having at least 30 minutes of physical activity everyday should be made known to all through different channels and utilising the best methods of public health education and support. This state has also made it mandatory for physical education to be taught in elementary schools, hoping it would make children enjoy the culture of daily participation in physical activities from an early age. This is a commendable policy which other states should look to implement.

The Medical and Dental Council of Nigeria regulates undergraduate medical education and, regrettably, physical activity does not feature within the undergraduate curriculum (in related news, stay tuned for the new BJSM undergraduate blog series). This is a fundamental flaw which should be rectified as patients deserve evidence based professional practice. However this is hampered in Nigeria due to the lack of training in physical activity promotion and behaviour change unlike countries such as USA, Canada and South Africa where sports and exercise medicine specialists use exercise and tailored physical activity to treat and prevent chronic diseases.

The ideal medical curriculum

This can be remedied if the Medical and Dental Council of Nigeria (MDCN) as the regulating authority for training doctors ensures that:

  1. A review of the medical curricular requirements to include emphasis and guidance for physical activity education.
  2. Refresher courses are offered on the significance and management of NCDs and reduction of physical inactivity

These two recommendations are crucial because a majority of the 32% of private facilities registered with the federal ministry of health are primary health care facilities; if we add this number to the public primary healthcare facilities and we have a very significant pool of healthcare facilities that are the first point of patient contact with probably being staffed by doctors who may not be up to date with managing physical inactivity induced illnesses.

We advocate for setting up a body (like the US National Society for Practitioners of Physical Activity and Public Health and the American College of Sports Medicine) to develop specialists in physical activity and public health. This will ensure that there is a practitioner workforce as well as academic trainers to ensure that in future, the medical curriculum includes physical activity promotion (more info here). This model is presently being used in the United States and may also be put in place in Nigeria. This involves training in competencies areas such as use of data and scientific information; planning and evaluation; intervention; organisational structure; and exercise science in public health.

Graduate training should also be created to guide the next generation of researchers in this field. Global capacity in exercise science, physical education, physical therapy, public health, architecture and planning, and environmental health should be increased. There is an urgent need for integration and comprehensive approaches to public health and physical activity.

Also more research into programmes that will increase physical activity and reduce physical inactivity are needed to help to build evidence base for our national policies and action plans.

Next steps – Olympic Legacy?

In conclusion, following the poor performance of Nigeria’s team at the 2012 London Olympics, the Federal Government has ordered a comprehensive re-organisation of the sports sector. I hope this will also have a positive effect on promotion of physical activity in the country and its people.

It will also be of immense national benefit if the appropriate authorities, private organisations and individuals take steps to implement a “Call to action” message. These key actions, namely reducing inactivity and sedentary behaviour, enabling patients and the public to access regular physical activity and exercise as part of an integral part of their daily lives, are necessary to advance global health through physical activities and is something that Nigeria can deliver.

 

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Damilola  A. Alawode (MBChB ile-ife) is a Public Health resident in the Department of Community Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria, a Msc Student (Sports and Exercise Medicine, University of Bath, United Kingdom), an advocate for the promotion of physical activities and a blog writer on Sports and Exercise medicine for Naijamedics.com.

Twitter: @DAlawode  

Email:  dalawode2002@yahoo.com

Acknowledgements

Ann Gates (www.exercise-works.org); A source of inspiration and motivation; and for sharing her resources.

Dr. Dayo Osholowu (IOC certified Sport Medicine Clinician and Director Sport Medicine Program, Lagoon Hospital Lagos state, Nigeria); for his advice and contribution to the piece.

Dr. Stathi Afroditi (Director of Sudies SEM, University of Bath United Kingdom); for her comments on an earlier draft of this report.

References

  1. Abubakari AR et al, Systemic review of the prevalence of diabetes, overweight/obesity and physical inactivity in Ghanaians and Nigerians. Public Health Journal, 2008 Feb;122(2):173-182 http://www.ncbi.nim.nih.gov/pubmed/18035383
  2. Adegoke BO et al, Physical Inactivity in Nigerian young adults; Prevalence and socio-demographic correlates. Journal of Physical Activity and Health, 2011 Nov;8(8);11 35-42 http://www.ncbi.nim.nih.gov/pubmed/22039132
  3. Canadian Fitness and Lifestyle Research Institute (CFLRI) reports 2001 https://www.phecanada.ca/economic-costs-inactivity
  4. California Centre for Physical Activity (CCPA), California department of Health services; The economic costs of physical inactivity, overweight and obesity in Californian adults, 2005 report https://www.phecanada.ca/economic-costs-inactivity
  5. Cost of physical Inactivity, 2008 a publication of Physical and Health Education Canada https://www.phecanada.ca/economic-costs-inactivity
  6. Federal Ministry of Health, Nigeria Report 2010 Health promotion draft policy.   www.scribd.com/doc/43538097/Nigeria
  7. Lancet Physical Activity series: Physical Activity 5; The pandemic of physical inactivity; global action for public health. Lancet 2012, 380: 294-305 Published online July 18, 2012 http://dx.doi.org/10.1016/S0140-6736(12)60898-8
  8. National Society for Physical Activity Practitioners in Public Health. http://www.nspapph.org/new-acsm-nspapph-physical-activity-inpublic-health-specialist-paphs-certification (accessed Jan 19, 2012)
  9. Nigeria demographic and Health Survey 2008 by National Population Commission, Federal Republic of Nigeria and DHSmeasure,2009 http://www.measuredhs.com/../FR222pdf
  10. Odegbami Segun, Mission to Addis Ababa, Segun Odegbami’s Official blog, 2012 Apr 30 http://mathematical7.com/mission-to-addis-ababa/
  11. Odunaiya NA et al, Physical activity levels of Senior Secondary School Students in Ibadan, Western Nigeria. West Indian Medical Journal 2010 Oct;59(5):529-534 http://www.ncbi.nim.nih.gov/m/pubmed/21473401/
  12. Osun State Goverment report June 2012, Walk and Live. http://osunstate.gov.ng/index.php?option=com_content&view=article&id=204&catid=7&Itemid=199
  13.  Business day Newspaper August 15 2012, Poor Olympics outing: FG orders re-organization of sport sector.   www.businessdayonline.com/NG/lndex….
  14. Sallis RE, Exercise is medicine and physicians need to prescribe it. Br J Sports Med 2009 43: 3-4  bjsm.bmj.com/content/43/1.toc

 

  1. WHO Non-Communicable Diseases report, 2004   www.who.int/../ncd_report_chapter1.pdf
  2. WHO, A framework to monitor and evaluate the implementation: Global Strategy on Diet, Physical Activity and Health, 2008. http://www.who.int/dietphysicalactivity/DPASindicators/en/index.html (accessed Jan 19,2012)

CT scans and X-rays increase risk of cancer – changing the goal posts in sports medicine

19 Sep, 12 | by Karim Khan

By John Orchard and Jessica Orchard

Two jaw-dropping papers from The Lancet 1 and BMJ 2 published in the past month should have a major effect on the practice of sports medicine.  They have clearly demonstrated that radiating scans in young people actually do lead to an increased risk of cancer later in life. Perhaps until 2012 this was a theoretical risk, but as of the publication of these landmark papers 1-3 we can be certain that the increased risk is not zero. There will be much more to come in this field over the next few years and it will dramatically change the landscape of radiology and all medical practice.

Pearce and colleagues’ study in The Lancet looked at the excess risk of leukaemia and brain tumours for children and young people exposed to CT scans. They found that children exposed to cumulative doses of 50mGy in CT scans may have triple the risk of leukaemia, and doses of 60mGy may have almost triple the risk of brain tumours1. Though this appears to be a massive increase in risk, the authors point out that these cancers are still relatively rare, causing an estimated one excess case of leukaemia and one excess brain tumour per 10,000 head CT scans. They are clearly cause for concern, as indicated by the fact that 12 other groups from 15 countries are studying the risk of scans on children3.

These Lancet findings are more striking when combined with the findings of Pijpe and colleagues’ GEN-RAD-RISK paper published last week in the BMJ2. This study showed that when women who carry a specific mutation associated with breast cancer (BRCA1/2), and who  were exposed to diagnostic radiation before the age of 30, had almost twice the risk of breast cancer (with a dose-response pattern). This study involved lower doses which we have previously considered fairly ‘safe’ (e.g. 4mGy from a single mammogram or shoulder x-ray). Therefore, BRCA1/2 carriers, with an already increased risk of a very common cancer, would be particularly at risk from exposure from radiating scans at a young age.

Why does this matter for sports and exercise medicine?

Sports and exercise medicine is a field in which most patients have many years of life expectancy remaining; it is also a field in which diagnostic imaging is very common. Imaging is often confined to the limbs but also involves the spine.  Importantly,  the GEN-RAD-RISK paper showed, for example, that shoulder X-rays in women with the BRCA1/2 mutation can increase the risk of breast cancer. This does not prove that a shoulder X-ray is unsafe for the entire female population, but because it is quite plausible, we need to reassess the use of radiating scans. The authors of this study have already recommended that women with the BRCA1/2 mutations should not get mammograms and it is hard to see how this recommendation will not soon be extended to all younger women, as mammograms are meant to be preventing deaths from cancer, not causing them.

Studies have not been published to look at, for example, the risk of  cancers in the abdominal cavity (e.g. bowel, ovarian) after lumbar spine CT scan, but again we have to presume from the existing knowledge that the increased cancer risk is not zero. In this case,  the unknown is the size of the increase in cancer risk (and not whether there actually is one). All tests (and treatments) in medicine need to consider benefits, risks and costs. On the benefit side, the test which gives the best information relevant to management needs to be identified. This can’t be done in isolation of the increased cancer risk of radiating scans, particularly in young or middle aged patients.

There will still be cases where a test that involves radiation is going to give preferred information to a non-radiating one – a classic example being in the knee of a 70 year old, where X-ray will tell what needs to be known in 95% of cases and MRI scan is generally an excessive use of imaging. However in scenarios where we used to recommend radiating tests (e.g. CT and bone scan to investigate for suspected pars stress fracture in an adolescent) we may need to quickly change to a recommendation of first line MRI scan to avoid increasing the risk of cancer. Health systems are going to need to change in scenarios where radiating tests are funded but non-radiating tests aren’t, because clearly it would raise ethical questions for a health system to be funding (offering a financial incentive) to have a test which can increase a patient’s risk of cancer when a non-risky test is available but unfunded.

Up to fifty years ago, some shoe stores used to perform X-rays on the spot to show whether a kid’s shoe was fitting well4 – this practice is now considered archaic.  Sensibly there is now an attitude in medicine that a pregnant woman should not receive an X-ray or CT scan if the information could be obtained in any other fashion. We are probably heading into an era where the same attitude needs to apply to all children and young people, for CT scan and even X-ray. Modalities such as MRI and ultrasound (and good old-fashioned clinical examination) will need to become more prominent in sports and exercise medicine, at the expense of radiating examinations. These studies highlighted in the blog will generate a demand for consensus meetings involving sports physicians, radiologists, radiation physicists, and epidemiologists among others to provide guidance for clinicians, professional bodies and patients. Depending on the recommendations made at consensus meetings, there should ideally also be a review of government/insurance funding arrangements to remove any financial incentives towards the inappropriate use of radiating scans.

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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.comand/or follow @DrJohnOrchard on Twitter

Jessica Orchard is an Australian lawyer with qualifications in economics and public health, currently employed at the NSW Cancer Council. Her views in blogs are also personal and not necessarily representative of her affiliated organisations.

References

  1. Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505.
  2. Pijpe A at al. Exposure to diagnostic radiation and risk of breast cancer among carriers of BRCA1/2 mutations:  retrospective cohort study (GENE-RAD-RISK).BMJ. 2012 Sep 6;345:e5660.
  3. Einstein AJ. Beyond the bombs: cancer risks of low-dose medical radiation. Lancet. 2012 Aug 4;380(9840):455-7.
  4. Bowden T. Frying one’s gonads for shoes. http://www.abc.net.au/unleashed/37598.html

Return to play decision making – Reducing clinician ‘personality bias’ with a call for objective clinical testing

12 Sep, 12 | by Karim Khan

Guest blog by Phil Coles (@PhilColesPhysio)

Making the decision of when an athlete should return to play after an injury is one of the most challenging parts of a sports clinician’s role. This is especially so when working with professional sporting teams, where the pressures can be immense. Ideally, a clear decision making process should be combined with reliable clinical objective markers to reduce the potential for the ‘personality bias’ of the clinician leading to error in these decisions.

Being aware of personality bias

Rehabilitators working with elite athletes may have their own ‘personality bias’ that can expose them to the risk of two opposing yet equally significant errors.

On the one hand, the clinician may tend to be overly aggressive. This could be an internal compulsion (the ‘Gambler’ clinician) or may be the result of external pressures leading them to rush a player back in to competition before it is reasonably safe for them to do so (the ‘Weak’ clinician).  Premature return to competition can lead to athletes breaking down with re-injury or simply performing below expectations. If however, an injury does recur in the early stages of a return to competition, then it (perhaps reasonably) exposes that clinician to direct blame for a poor outcome. Any poor performance related to physical deficits may also negatively affect the clinician’s relationship with the player and or their coach / manager. Both of these outcomes may in fact put that clinician’s career at a club in jeopardy, and this is a fact of which most clinicians are well aware.

On the other hand, the clinician may tend towards to being overly conservative. This may also be due to internal compulsion (the ‘Conservative’ clinician) or because of fear of the consequences described above (the ‘Cynical’ clinician). If athletes are kept out for longer than necessary to reduce the risk they might break down or perform below expectations on their return, it will mean they miss valuable competition time. This second type of error is not as immediately obvious to the coach / athlete and therefore it is less likely to bring direct blame to the clinician. Naturally if there is a pattern of consistently delayed recovery over a long period of time then it may reflect poorly on those involved. However, it is much more difficult to blame them directly, as it is never really clear as to when any individual athlete could have returned from a particular injury.

Perhaps contrary to expectations then, it is likely many clinicians default to the position of being overly conservative. Unfortunately this means some will make a conscious choice to be overly conservative, not in the best interests of the player or the team, but rather in the hope of reducing any risk of being held liable for the more ‘obvious’ poor result (re-injury or poor performance).

What is the cost of ‘delayed’ return to play?

To highlight the true cost of unnecessary conservatism from the cynical clinician to a club, consider the following example. If a football team that plays once a week was to have 30 injuries over the course of a season and all those injuries were given just one extra week of rehabilitation more than was really necessary, that would cost the club a total of an extra 30 missed games. Consider then if all those players actually came back 1 week earlier as perhaps many of them could, but this caused 5 players (17% of injuries) to re-injure the same area. In the case of each of those 5 re-injuries, if the athlete missed a further 4 weeks, the club would lose players for an extra 20 games. This means that despite those recurrences, the club would have cut their total number of games lost to injury by 30% (from 30 to 20 games lost). Dr John Orchard (@DrJohnOrchard) made this point in his review of injuries and re-injuries in AFL in 2005. From his analysis at the time he concluded ‘at this stage it may be a sensible strategy to allow earlier return to play in team sports and accept a low-moderate re-injury rate’ after having seen such a pattern in the reported data.

In reality, of course, there any many modifying factors that would need to be considered in each individual case. For example, is there extra risk of recurrence with an earlier return for that particular injury, and how long recovery likely will take after re-injury?  Also, other factors such as the point of the season, the particular game, and the position being played etc. will influence whether or not a risk is worth contemplating for an individual athlete at a particular time.

What happens in real life?

The reality is that clinicians working with high level athletes must recognise that it may be equally as negative to have a bias towards conservatism as it is to have bias towards aggression in rehabilitation. Although most clinicians working in an elite environment would probably deny that they ever knowingly act overly conservatively, in reality most would (if being honest) admit there have been times when they have taken longer to return a player to competition than was perhaps essential because they feared the repercussions of any re-injury. Conversely, most would also accept that there have probably been times when they allowed issues that don’t directly relate to the injury into the thought process that ultimately allowed a player to return prematurely. Sports clinicians must be brave in the sense that they must be able to withstand the outside forces which might encourage a rushed return to play, but they must be equally brave in backing their own ability and judgement in getting a player back when the relative risk is reasonable, rather than waiting for the risk to be nil, which of course it will never actually be.

The judgement of what is a reasonable risk is where the real skill of a sports rehabilitator lies. The ability to make this judgment correctly in a more consistent fashion, relies firstly utilising a clearly defined decision making process. The actual process of that return to play decision making was well outlined by Matheson et al (2011). They described a thorough model for considering all the factors that may affect our clinical judgement when deciding on the return to play of an athlete. The first two steps are to evaluate the athlete and the risk of returning to sport. This involves assessing the health status of the athlete and then considering that against risks particular to that sport and in that athlete. This is where improved objective markers would be particularly useful. Having decided that someone may return based on these principles, they acknowledge that there are still many ‘modifiers’ to your final decision which must be considered, and so ultimately clinical reasoning remains paramount. These modifiers would include consideration of issues such as the timing and season, the stage of an athlete’s career, the importance of athlete to the team, the importance of a particular game to the athlete, any conflicts of interest at play (such as financial reward to the player or therapist), any chance of masking occurring, and risks of litigation etc.

What objective measures are there?

The ability to make return to play decisions objectively will help to decrease the potential of clinician personality bias to lead to error. For this reason I contend that developing improved objective markers that may predict a safe return to play is perhaps the greatest research need for rehabilitators working in high level sport.

Unfortunately there are not yet many proven objective markers for sport specific return to play, but there are certainly some clinical tests that may be considered to reliably assess for known risk factors to injuries. Consider these examples.

(1)The Hamstring active flexibility and apprehension test developed by Asking et al (2010) is a reliable test which is more sensitive to picking up on-going Hamstring deficit than traditional assessment methods. (Click here to listen to a podcast with Carl Askling about hamstring management). Considering that hamstring recurrences are such a problem in the football codes it would be reasonable to suggest a normalisation on that test along with all other traditional clinical signs is essential before endorsing a return to play.

(2) A decrease in adduction power as measured by a squeeze test may predict the onset of groin pain in AFL players (Crow 2010). Perhaps therefore after any groin injury a reasonable objective milestone that must be met during rehabilitation before being allowed to progress to full loading is that an athlete must have reached at least their pre-morbidity levels on that squeeze test. (Per Holmich’s podcast on groin pain is here; his short YouTube video is here).

In summary, to clear an athlete to return to play there needs to be confidence that the rehabilitation has been complete, and that a clear decision making process was followed. You must be aware of the dangers of ‘personality bias’ among clinicians and we should attempt to minimise this through the use of objective clinical testing wherever possible. Perfect judgement is impossible but clinicians and managers should appreciate that being overly conservative can be an equally significant and perhaps more common error as being overly aggressive. They should also accept that using objective markers is the way to minimise this. If the current markers fail us or do not exist in the sport specific detail we would like, it does not mean we should shy away from using objective markers, it means we should dedicate time to developing more accurate ones.

References

Orchard et al. Return to Play following muscle strains. Clin J Sport Med. 2005;15:436–441.

Matheson et al. Return to play decisions- are they the team physician’s responsibility? Clin J Sport Med 2011;21:25–30.

Crow et al. Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players. Journal of Science and Medicine in Sport. 13 2010; 202–204.

Askling et al . A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc. 2010;18:1798803.

Stay tuned for the BJSM podcast on this topic with Liverpool FC’s Darren Burgess 

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For the past 2.5 years Phil Coles has been head of Physical Therapies at Liverpool Football club. Prior to this he was head physiotherapist for the Socceroos including the 2010 World Cup, and an associate lecturer at the University of Sydney. You can follow Phil on twitter @PhilColesPhysio.

 

London 2012, the highs, the lows and……the Legacy: A UK trainee perspective

31 Aug, 12 | by Karim Khan

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 29th 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.

“How does a clinician know what’s in the athlete’s best interest?” An Olympic experience

24 Aug, 12 | by Karim Khan

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.

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