Review of Peter Brukner and Karim Kahn’s “Clinical Sports Medicine” by Dr Arjun Rao, Sports Physician.

This is primarily a UK written sports medicine book whose primary audience is intended to be at an undergraduate level. With the expansion of the specialty as a whole it is always a difficult task to be comprehensive but the major fundamentals have been covered in a very clear and concise manner. The book is well laid out and presented with a generous number of illustrations.

There is a good balance between musculoskeletal injuries and medical based problems. Basic nutrition and exercise physiology have also been included.

The book has been well researched, as you would expect from the quality of the contributors, and each chapter finishes with a short list of further reference material for those interested. I found the information to be very current and up-to-date. Even an aging Sports Physician such as myself was able to learn an extra thing or too!

I was particularly interested in the sports specific injury section; secretly I was hoping that there may have been a medical explanation or two in there from one of the co-editors as to why Chelsea had a trophyless season – never mind!

Overall this book has very few weaknesses, certainly nothing worth mentioning. I feel it has more than achieved it’s aim of reaching the intended target audience and I can see this material becoming a good source reference book in the years to come, with further revisions, especially when Sports Medicine finally becomes a part of the undergraduate UK medical curriculum. No doubt it will encourage a few undergraduate physiotherapy and medical students to enter a Sports Medicine career path.

Dear Editor,

We were pleased to see the ‘original article’ by Milne and Shaw (2008) offering advice for those traveling to the Beijing Summer Olympics Games in August later this year in a professional or participatory capacity. The authors are to be complimented on their endeavours to accommodate a comprehensive range of environmental aspects that might influence health and performance. Their experiences in China in particular should be of interest to other groups, especially those hitherto unable to make reconnaissance visits to its competitive venues and training camps to experience and monitor the challenges to be faced.

Besides they are in good time to be of use for devising travel strategies and general advice to be circulated to all athletes selected to participate and their support staff.

There is one area that we would wish to comment on, the issue of travel fatigue and jet-lag. These problems will be worse for European, African and American athletes than for those from Australia and New Zealand in view of the difference in time-zone transitions. Furthermore, some of the advice about dealing with jet-lag should not be based on the previous report of Milne and Fuard (2007) in this journal. The interpretation of anecdotal information, on one individual, was flawed. It is easy to beat an opponent who does not exist and the conditions that provoke jet-lag may not have applied in the trip they described.

In the original report, a brief account was given about one subject who traveled between Europe and New Zealand and back within a few days.

The itinerary focused upon constituted a net zero time-zone transition by which time body-clock time and local time were resynchronised. The root cause of jet-lag is the desynchronisation that occurs between the endogenous circadian rhythm and local environmental time. Prior to undertaking the last trip before the critical final game, the athlete would not have been in France long enough to adjust to European time, is unlikely to have experienced anything more severe than mild jet-lag, even if travel fatigue was severe.

The authors made no attempt to measure jet-lag, either subjectively or by means of an appropriate biological marker. Jet-lag is likely to have been minimal by the time of the criterion match since there would have been limited adjustment before the last 12-hour time-zone transition and hence no need of a further re-adjustment. Besides, there was no valid measure of performance used. Evidence consists of an anecdotal comment that the player’s performance was up to its usual high standard (open skills) and that he kicked a conversion and three penalty kicks (closed skills). Finally, the cocktail of soporifics that were advocated are not recommended as a panacea for jet-lag in recent reviews (Waterhouse et al., 2007) or in consensus statements about alleviating jet-lag (Reilly et al., 2007a).

Lastly, the notes about travellers’ diarrhoea and on food are to be welcomed. Whilst the notes are necessarily brief, an appropriate further reference would be that of Reilly et al. (2007b). In this consensus, supported by the International Association of Athletics Federations, more detailed advice on food and nutrition is given, as is an account of other gastrointestinal problems that traveling athletes face.

By:
Reilly, Thomas; Atkinson, Greg; Edwards, Ben; Waterhouse, Jim
Chronobiology Research Group
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University

References

Milne C. Fuard MH. Beating jet lag. Br J Sports Med 2007; 41: 401.

Milne CJ. Shaw MTM. Travelling to China for the Beijing 2008 Olympic Games. Br J Sports Med 2008; 42: 321-326.

Reilly T. Atkinson G. Edwards B. et al. Coping with jet lag: a Position Statement for the European College of Sport Science . Europ J Sport Sci 2007a; 7: 1-7.

Reilly T. Waterhouse J. Burke LM. Alonso JM. Nutrition for travel. J Sports Sci 2007b; 25: S125-134.

Waterhouse J. Reilly T. Atkinson G. Edwards B. Jet lag: trends and coping strategies. The Lancet; 2007; 369: 1117-1129.

Download a program here.

Another excellent patient handout.

Patient Information Sheet 8 - Tennis elbow

Patient Information - Shoulder dislocation

Patient Information - Rotator cuff strain and impingement

The type of activity undertaken, at what time in life and the woman’s body mass index (BMI) will determine how protective the activity is against the disease.

Lean women who play sport or undertake other physically active things in their spare time, especially if they have been through the menopause, have the lowest risk of breast cancer.

The researchers reviewed the literature and analysed 62 studies looking at the impact of physical activity on breast cancer risk. They then examined how breast cancer risk was affected by type of activity, intensity of activity, when in life the activity was performed and other factors.

The most physically active women were least likely to get breast cancer. All types of activity reduced breast cancer risk but recreational activity reduced the risk more than physical activity undertaken as part of a job or looking after the house. Moderate and vigorous activity had equal benefits.

Women who had undertaken a lot of physical activity throughout their life had the lowest risk of breast cancer, and activity performed after the menopause had a greater effect than that performed earlier in life.

Physical activity reduced breast cancer risk in all women except the obese and had the greatest impact in lean women (BMI of less that 22kg/m2).

Women who were mothers, had no family history of breast cancer, were not white also had a reduced risk of breast cancer.

The authors said the way in which physical activity protected against breast cancer was likely to be complex and may involve effects on sex hormones, insulin-related factors, the immune system and other hormone and cellular pathways.

Contact:
Dr Christine M Friedenreich
Division of Population Health and Information,
Alberta Cancer Board.

Malceski returns at a bionic pace

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans - who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks - and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal - though Geelong and Hawthorn might have something to say about that.”

Miracle op to melt down surgeons’ phones
- James Fardoulys, May 10, 2008

IF Nick Malceski survives his first game back from injury next weekend, the phone lines of every knee surgeon in the country will run hot on Monday morning with patients asking for “the Malceski operation”.

Why?

Because Malceski injured his knee on February 17. That makes it a mere 12 weeks since his surgery on February 22, a lightning-fast recovery period compared to the traditional 12-month lay-off.

Malceski underwent a new type of anterior cruciate ligament repair, known as the Ligament Augmentation and Reconstruction System (LARS). Like most “new” technology, the history of this type of surgery goes back a couple of decades.

ACL surgery has been around since the 1950s, but became common from the 1980s.

In the past, attempts to directly repair the ligament have failed because it is difficult to suture and the knee difficult to adequately immobilise, which risks loosening the repair.

Surgeons then started using tendons from other sites as substitutes, or grafts, to make a new ACL. These were structurally stronger than the shredded ACL.

The downside was that new blood vessels and nerves had to grow into the graft, and structural changes occurred within the fibres of the graft, before it resembled the original ACL.

This “remodelling” process takes about a year, which is why traditional ACL graft patients are off sport for that length of time.

In the mid-1980s surgeons tried shortening this time off by removing the damaged ACL and replacing it with grafts made of artificial materials such as Dacron or Gortex. The new graft was at maximum strength from day one. There were additional benefits in avoiding problems such as pain, weakness, scarring or infection at the donor graft site, known as “donor site morbidity”.

Unfortunately the initial good results produced by artificial grafts were short-lived.

A knee moves backwards and forwards through about two million cycles per year. No artificial material lasts forever, and within a year most of these grafts have disintegrated.

Worse still, the ground-up debris often causes severe reactions within the knee joint. Typically these players, such as Footscray’s Rod MacPherson and Zeno Tzatsakis, returned for a handful of games, but didn’t play again after the artificial graft failed. The notable exception was Doug Hawkins, who took a year off, then played on for another decade.

In Canada a group tried a slightly different approach. They used an artificial graft stitched inside a hamstring (biological) graft. This was known as the Kennedy Ligament Augmentation Device (LAD).

“Augmentation” means to support a ligament rather than replace it. The idea was for the synthetic device to give short-term support to the hamstring graft until it became strong enough to carry the stresses and strains.

The key difference in this process is that the synthetic graft isn’t being relied upon to carry the long-term load.

The process worked for the Canadians surgeons. It didn’t seem to have the problems of the artificial ligaments used alone, but the biologic graft still took a year to remodel. With no great advantage, most surgeons simply ignored it and stuck to the standard biologic graft techniques.

Enter the LARS. With this technique the surgeon preserves and repairs the original ACL (which is removed with most of the other operations) and augments it with an artificial polyester graft.

It is closer in concept to the Kennedy LAD than the Gortex and Dacron devices. The LARS ligament is buried within the repaired ACL, supporting it while it heals. Because the preserved ACL already has its blood and nerve supply it heals more quickly than a graft — in about three to four months instead of 12.

French surgeon JP Laboureau, who developed the LARS, also looked at some of the other issues in the construction of artificial ligaments to make them friendlier to human biology.

Several thousand LARS devices have been inserted in Europe, so why is this new to us in Australia?

The answer is geography. The LARS was developed in Europe and most of the published data is in non-English journals.

The Europeans have traditionally been prepared to think outside the box and try new ideas, more so than the litigation-conscious English-speaking countries.

Some of their concepts are now widely used. The French decided to put the ball and socket of shoulder replacements the wrong way around in severe rotator cuff deficiencies — it works brilliantly.

The Germans and Swiss invented ways of fixing fractures which are now standard textbook stuff.

On the other hand, Europe is also home to so much voodoo, quackery, and snake-oil remedies, that English-speaking doctors are always cautious about seemingly wondrous claims, and like to test the merits of new techniques for themselves.

On the surface of it Laboureau seems to have done his homework. He has done extensive basic science work on his ligament design and manufacture, and on his operation technique.

In normal medical practice the patient will discuss with their surgeon the pros and cons of all their options. In the case of the LARS ACL reconstruction, do they want a tried and tested biological graft, for which they need one year off sport? Or do they want a LARS ligament repair, where they may be part of the surgeon’s learning curve, but the recovery is significantly shorter?

What about donor site morbidity versus foreign material? The last 20, or 50, or 200 cases the surgeon performed will influence the discussion. This is how medical decisions are normally made.

In practice this is what will happen:

Nick Malceski will run onto the paddock.

If he goes down in the first five minutes clutching his knee, the LARS ligament people might as well pack up and go on holidays for the next six months, because things are going to go very quiet for them.

If he gets through the game, and especially if he kicks a goal, they can cancel all their plans for the immediate future because they will be busier than the proverbial one-legged fireman stamping out bushfires.

That’s how sports people make decisions. Such is the fickle world of sports medicine.

James Fardoulys is a Brisbane orthopedic surgeon specialising in sports injuries

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans - who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks - and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal - though Geelong and Hawthorn might have something to say about that.”

Authors: Jannique G.Z. van Uffelen, Marijke J.M. Chinapaw, Willem van Mechelen, and Marijke Hopman-Rock
Links to:
ABSTRACT
ARTICLE

Although this study found that exercise improves some aspects of cognitive performance, it also confirmed a recent meta-analysis in concluding that that folic acid supplementation does not significantly benefit cognition. A recent article by our group suggested that much of the relationship between folate levels and cognition may be attributed to exercise because exercise is known to raise folate levels. The current article further reinforces the need for research investigating the interaction of exercise, folate, and cognitive performance.

Balk EM, Raman G, Tatsioni A, Chung M, Lau J, Rosenberg IH. Vitamin B6, B12, and folic acid supplementation and cognitive function: a systematic review of randomized trials. Arch Intern Med 2007; 167(1): 21-30.

Middleton LE, Kirkland SA, Maxwell CJ, Hogan DB, Rockwood K. Exercise: a potential contributing factor to the relationship between folate and dementia. J Am Geriatr Soc 2007; 55(7): 1095-8.

CONSORT, stands for Consolidated Standards of Reporting Trials. The CONSORT Statement is an evidence-based, minimum set of recommendations for reporting RCTs. It helps you prepare your paper for submission. The CONSORT Statement comprises a 22-item checklist and a flow diagram, along with some brief descriptive text. The checklist items focus on reporting how the trial was designed, analyzed, and interpreted; the flow diagram displays the progress of all participants through the trial. The Statement has been translated into several languages.

You might also be interested in the EQUATOR network website. This website simplifies good reporting of health research. The resources are aimed at authors, reviewers, and developers of reporting guidelines. The website features a collection of reporting guidelines that includes:

• CONSORT Statement (for reporting randomised controlled trials, as above)
• QUOROM, recently renamed PRISMA (for reporting systematic reviews and meta-analyses of randomised trials)
• STROBE Statement (for reporting observational studies)
• STARD Statement (for reporting diagnostic accuracy studies) and many other guidelines identified through extensive literature searches.
]]> http://blogs.bmj.com/bjsm/2008/05/02/submitting-a-randomised-trial-follow-the-consort-checklist/feed/ http://blogs.bmj.com/bjsm/2008/04/28/re-the-injected-agent-with-color-doppler-does-it-matter-in-tennis-elbow-tennis-elbow-impingemen/ http://blogs.bmj.com/bjsm/2008/04/28/re-the-injected-agent-with-color-doppler-does-it-matter-in-tennis-elbow-tennis-elbow-impingemen/#comments Mon, 28 Apr 2008 22:24:18 +0000 Karim Khan http://blogs.bmj.com/bjsm/2008/04/28/re-the-injected-agent-with-color-doppler-does-it-matter-in-tennis-elbow-tennis-elbow-impingemen/

Tennis elbow - impingement at the common extensor origin? Case report

By E Zeisig, M Fahlstrom, L Ohberg, and H Alfredson

Abstract
Full Text

We thank Dr Knobloch and colleagues for raising questions of the influence of elbow position on the area with high blood flow seen in the common extensor origin and outcome measurement in patients with painful tennis elbow. The first question raised is if the grip strength with 900 elbow flexion might change as well as the grip strength with extended elbow changes in response to the intratendinous injection treatment.[1] This question will be answered in an original article in the future.

The other question raised is if the area with high blood flow inside the area of structural changes seen on ultrasound examination is influenced by elbow position. One of the findings on ultrasound examinations of the common extensor origin is “tendon thickening”.[2] We believe that this thickening in some cases is exposed to internal compressive forces. This belief is based on the findings we have made when we have performed ultrasound and colour Doppler examinations during elbow movement. When the elbow is flexed 70-800 there is plenty of space between the head of the radial bone and the lateral epicondyle but during extension of the elbow, the radius makes a movement towards the lateral epicondyle and there will be impingement of the area with structural changes and high blood flow (Figure 1a and 1c). The raised pressure in the thickened tendon due to impingement at the extensor origin will diminish the high blood flow (not detectable), and like on palpation (applying external compressive force), the patient will experience pain. To perform an intratendinous injection targeting the area with high blood flow, the blood flow must be visible on colour Doppler examination which is the case when the elbow is flexed 70- 800, not when the elbow is extended (Figure 1b and 1d). This theory of impingement at the common extensor origin in tennis elbow might be the explanation behind good results in arthroscopic debridement of the area.[3] Other authors have also noted impingement during elbow arthroscopy, Mullet and colleagues classified their findings as degenerative capsular fold.[4] We hope this case rapport is an acceptable answer to the question at the time being. Further studies of the biomechanical prosperities of the elbow and the effect on the soft tissue are highly indicated. Are some individuals more prone to develop recalcitrance painful tennis elbow?

REFERENCES

[1] Zeisig E, Fahlstrom M, Ohberg L, et al. Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study. British journal of sports medicine. 2008 Apr;42(4):267- 71.

[2] Levin D, Nazarian LN, Miller TT, et al. Lateral epicondylitis of the
elbow: US findings. Radiology. 2005 Oct;237(1):230-4.

[3] Cummins CA. Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes. The American journal of sports medicine. 2006 Sep;34(9):1486-91.

[4] Mullett H, Sprague M, Brown G, et al. Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clinical orthopaedics and related research. 2005 Oct;439:123-8.

]]> http://blogs.bmj.com/bjsm/2008/04/28/re-the-injected-agent-with-color-doppler-does-it-matter-in-tennis-elbow-tennis-elbow-impingemen/feed/