By Dr Stan Baltsezak

The UK trainee perspective (The BJSM blog features the trainee perspective every two weeks)*

February, March and April are the months when British Universities & Colleges Sport (BUCS) championships take place. Students from all over the UK compete in numerous contact and non-contact sports.

The Championships and Games provide a unique opportunity for budding SEM doctors to learn the rules of the sports, observe elements of coach-athlete interaction and gain experience looking after different sports as an event doctor. All necessary equipment is provided by BUCS so all you need to bring is your skills and a keen interest in sport.

Being a doctor at the pitch side, pool side or ring side allows you to observe the mechanism of injury and assess the injury minutes after it’s happened. It is somewhat different to when we see patients in emergency departments or trauma clinics.

I was a ring side doctor at the Boxing competition in February 2012. A boxing doctor’s job is very hands on and can be divided into two parts:

1) Providing pre-bout medical examination (that may mean performing around 60 examinations before competition starts); within a limited timeframe you need to assess most of the important organ systems to make sure that the boxer is fit to fight

2) Being at the ring side, ready to respond to any knock out (KO) that may happen during the fight.

Knowledge of Amateur Boxing Association (ABA) rules is crucial during pre-fight medicals e.g. boxers cannot wear soft/hard contact lenses during the fight.  I came across 3 students who were going to box with lenses on. Restrictions limit the competition of boxers whose visual acuity falls below 6/12 in their best eye. The question that had to be answered is: can you convert contact lens prescription into visual acuity?

Knowing rules and regulations is also important during bouts since a doctor can and may need to stop the fight on medical grounds.

All junior docs and medical students who want to experience sports medicine will be welcomed to volunteer and/or shadow other doctors during BUCS competitions. Those who are interested to take part in future events should contact BUCS Chief Medical Officer.

Useful web sites:

1. http://www.bucs.org.uk
2. http://www.abae.co.uk

Dr Stan Baltsezak is a Specialty Registrar in Sport and Exercise Medicine. He works with GB men’s water polo squad, Paralympic Archery, and Manchester City FC reserve and academy teams.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” which runs every two weeks.

Leon Creaney, SEM Physician, BUPA

Dear Sir,

I congratulate the IOC Consensus panel on having produced as clear a
summary of the current understanding of the basic and clinical science
relating to PRP as the body of published literature allows. While there
was initially great hope in Sport Medicine circles that PRP would become
the magic bullet for injuries, recent trials such as de Vos1, have failed
to provide that conclusive evidence so desired.

This is not surprising. The more we learn about tissue regeneration,
the more apparent it becomes how complex a process it is. Tissue
regeneration is not a passive phenomenon, instead it is a highly co-
ordinated interplay of multiple cell lines at different stages of
maturation. Different cellular and humoral components play their different
roles.
The process can be likened to the repair of a collapsed building. Consider
muscle injury. The initial cells on scene, due to bleeding, are platelets,
but they appear to be relatively passively involved – alarm bells which
sequester and awaken the major players. Platelets release chemotactic
factors which attract neutrophils to clear the debris2,3. However within
24 hours macrophages4 arrive, akin to the foreman, and it is these cells
that appear to regulate the process from this point onwards. If there is
any ‘brains’ or ‘thinking’ to tissue repair, it would seem to be the
macrophages doing it. Next come the actual builders. Fibroblasts are
activated to produce a collagen infrastructure, and satellite cells, to
form myocytes and finally myotubes, merging to become a single strand of
muscle fibre5.

So where do ‘growth factors’ come into it? These proteins are simply
the communications being sent between the foreman and his workers. The
messages are very simple – move or stay put, divide or don’t divide, live
or die, make collagen etc. In biology we use the terms chemotaxis;
mitosis; quiescence; apoptosis and protein biosynthesis. The point is this
- growth factors are just the messenger molecules used by one cell to send
an instruction to another, they are not the person giving the orders.

Unfortunately the ‘language’ of growth factors is very different to
English. We are used, pretty much, to one word having roughly one meaning.
However growth factor ‘words’ are more like a tonal language, Mandarin. In
these languages the same word can have multiple different meanings
depending on how you pronounce it. In the same manner, growth factors can
produce varying effects depending on their concentration, time of release,
point in cell cycle and recipient cell. Thus trying to pin any one growth
factor down to one particular action can be pointless – TGF-?1 is commonly
associated with fibrosis 3,6,7, but it can stimulate regeneration or
fibrosis, chemoattraction or stasis, depending on its concentration8,
target cell, and sequence within the tissue regeneration process.

Moving back to the analogy, it requires a great deal of intelligence
to rebuild a collapsed building. The foreman has to send and receive
accurate messages, at the right time, and to the right people, otherwise
the building will end up with structural flaws, and will probably fall
down again. Imagine if he simply threw the blueprints in the air, and
allowed the workers to pick up a piece each and act on what it said -
complete chaos! In the same way macrophages co-ordinate a complex
interplay between themselves and fibroblasts/satellite cells.

This is where PRP has the potential to fall down. PRP has variable
and inconsistent content and concentration.9 There is no consensus on
timing of injection. What does a random bolus injection into an injury
achieve? Are we sending these effector cells a clear and co-ordinated set
of instructions with PRP? Or are they being sent a completely confusing
message? It would seem hopelessly optimistic and na?ve to presume that we
are accurately reproducing biological complexity.

PRP has shown promise in promoting accelerated scar tissue formation
in dental grafts10 and wound healing11, where regeneration of complex
tissue is not a goal. In Sports Medicine however, we require restoration
of functional tissue – contractile muscle or tendon of high tensile
strength – tissue of much greater complexity. The successes in maxillo-
facial applications are perhaps not analogous to these situations.

Whether or not PRP is eventually proven or disproven in Sports
Injuries, it is nevertheless a good start. The Sports Medicine world has
woken to the possibilities of regenerative medicine, and is trying to be
scientific in the development of novel therapies. In the future we will
have improved understanding of how the complex and overlapping processes
of tissue regeneration12 are controlled by co-ordinating cells, stem
cells, effector cells and the messenger molecules that they employ, and
more importantly, how to manipulate these processes for a beneficial
effect.

References

1. de Vos RA, Weir A, van Schie HTM et al. Platelet-Rich Plasma
injection for Chronic Achilles Tendinopathy JAMA 2010;303(2):144-149

2. Anitua E, Andia I, Ardanza B, et al. Autologous platelets as a
source of proteins for healing and tissue regeneration. Thromb Haemost
2004;91:4-15.

3. Toumi H, F’guyer S, Best T. The role of neutrophils in injury and
repair following muscle stretch. J Anat 2006;208:459-470

4. Chazaud B, Brigitte M, Yacoub-Youssef H et al. Dual and beneficial
roles of macrophages during skeletal muscle regeneration. Exerc Sport Sci
Rev 2009;37(1):18-22

5. Jarvinen TAH, Jarvinen TLN, Kaariainen M. Muscle injuries: Biology
and Treatment. AJSM 2005;33:745-764

6. Li Y, Foster W, Deasy BM. Transforming growth factor-?1 induces
the differentiation of myogenic cells into fibrotic cells in injured
skeletal muscle. Am J Path 2004;164(3):1007-1019

7. Shen W, Li Y, Tang Y. NS-398, a Cyclooxygenase-2-specific
inhibitor, delays skeletal muscle healing by decreasing regeneration and
promoting fibrosis. Am J Path 2005;167(4):1105-1117

8. Bischoff R. Chemotaxis of Skeletal muscle satellite cells. Dev Dyn
1997;208:505-515

9. Creaney L, Hamilton B. Growth factor delivery methods in the
management of sports injuries: the state of play. BJSM 2008;42:314-320

10. Marx RE. Platelet-rich plasma: evidence to support its use. J
Oral Maxillofac Surg 2004;62(8):1047-8

11. Lacci KM, Dardik A. Platelet-rich plasma:support for its use in
wound healing. Yale J Biol Med 2010;83(1):1-9

12. Gates CB, Karthikeyan T, Fu F, Huard J. Regenerative Medicine for
the musculoskeletal system based on muscle-derived stem cell. J Am Acad
Orthop Surg 2008;16:68-76

Conflict of Interest:

None declared

This E-lettter is in response to Setting standards for the prevention and management of travellers’ diarrhoea in elite athletes: an audit of one team during the Youth Commonwealth Games in India Abstract | Full Article

The article by Tillett and Loosemore describes guidelines for the prevention and management of travellers’ diarrhoea (TD) based on their experience with the elite athletes and noncompeting members of Team England during the 2008 Youth Commonwealth Games in India. The authors recommended that all team members receive oral and written advice regarding prevention of TD, that all team members are issued alcohol hand gel and instruction for its use, and that all noncompeting team members receive ciprofloxacin for TD prophylaxis. As ciprofloxacin use in elite athletes is considered controversial because of a possible association with tendon rupture, the authors recommended that elite athletes consider the nonabsorbable antibiotic rifaximin as a prophylactic for TD. However, none of the elite athletes on Team England actually received rifaximin as a prophylactic therapy for TD. Further, the authors stopped short of recommending rifaximin for the treatment of TD, simply recommending treatment with empiric antibiotics per local advice and the results of stool culture.

We report here that, in 2008, some elite athletes from the United States received rifaximin either for the prophylaxis or treatment of TD while in Beijing, China. In this small sample of elite athletes, rifaximin was safe and well tolerated, and no adverse events were reported. Rifaximin has been found safe, well tolerated, and effective for both the prophylaxis and treatment of TD in other populations1-8. Based on our experience and the excellent safety profile of rifaximin for the treatment of TD, the use of rifaximin as an antibiotic therapy for the treatment of TD in elite athletes deserves further consideration.

Bradley Connor and Scott Rodeo

References

1.           DuPont HL, Ericsson CD, de la Cabada FJ, et al. Prevention of travelers’ diarrhea with rifaximin- a phase 3 randomized double-blind placebo-controlled trial in U.S. students in Mexico [abstract]. Am J Gastroenterol. 2006;101(suppl):S197-S198.

2.           DuPont HL, Ericsson CD, Mathewson JJ, et al. Rifaximin: a nonabsorbed antimicrobial in the therapy of travelers’ diarrhea. Digestion. 1998;59(6):708-714.

3.           DuPont HL, Haake R, Taylor DN, et al. Rifaximin treatment of pathogen- negative travelers’ diarrhea. J Travel Med. 2007;14:16-19.

4.           DuPont HL, Jiang ZD, Ericsson CD, et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33(11):1807-1815.

5.           DuPont HL, Jiang Z-D, Belkind-Gerson J, et al. Treatment of travelers’ diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide, and loperamide alone. Clin Gastroenterol Hepatol. 2007;5:451-456.

6.           DuPont HL, Jiang Z-D, Okhuysen PC, et al. A randomized, double-blind,
placebo-controlled trial of rifaximin to prevent travelers’ diarrhea.
Ann
Intern Med. 2005;142(10):805-812.

7.           Steffen R, Sack DA, Riopel L, et al. Therapy of travelers’ diarrhea with rifaximin on various continents. Am J Gastroenterol. 2003;98:1073- 1078.

8.           Taylor DN, Bourgeois AL, Ericsson CD, et al. A randomized, double- blind, multicenter study of rifaximin compared with placebo and with ciprofloxacin in the treatment of travelers’ diarrhea. Am J Trop Med Hyg. 2006;74:1060-1066.

Conflict of Interest

Dr Connor has received grant support from and is a consultant for Salix Pharmaceuticals, Inc.
Dr Rodeo has nothing to disclose.

This E-letter is in response to ECG As A Part of the Pre-Participation Screening Programme: An Old an Still Present International Dilemma (Abstract)

Pre-participation screening in competitive athletes in Portugal has been compulsory for more than 40 years. Yearly ECG was introduced in the screening at about the same time as in Italy, for all athletes evaluated at the Sports Medicine Centres in Portugal. The very rare cases of sudden cardiovascular death that have ocurred in the past 25 years in Portugal were not screened at the Centres or had further cardiovascular evaluation pending, and threfore were not qualified for practice. Several athletes have been disqualified from sports participation for cardiovascular reasons, most of them were further investigated because of rest ECG changes findings. We strongly favour the use of 12 lead ECG in the pre- participation screening process. Presently, we routinely screen about 20.000 athletes per year in the 3 Sports Medicine Centres in Portugal.

Marcos A. Miranda
Sports Medicine Specialist
Lisbon Sports Medicine Centre

Shaving may be a daily ritual for most men, but for athletes it is much more open to debate. Some athletes shave with a vengeance : cyclists shave their legs by tradition and to make easier cleaning road rash and massages, swimmers may even shave their entire body (particularly before swimming suits were authorized) to minimize friction, and body builders go for a full body shave for aesthetic reasons (1). Conversely, in boxing, rugby and other sports where high power production is required, many athletes prefer to wait till after the competition before shaving. They do that to avoid any negative effect of shaving on explosive strength (2). Although to our knowledge there is no scientific rationale for this commonplace idea, shaving one’s beard just before a physical performance is said to impair the nervous flux involved in force production (2). This assumption may be linked to the fate of Samson in the Old Testament, who was reported to loose his strength after having his hair cut (3). This possible decrease in muscle force following beard shaving has been largely feared for Sebastien “Caveman” Chabal, a popular rugby player during the 2007 Rugby World cup who sported a long mane and a thick beard. The player did not risk the strength loss and kept his hair and his beard for the following sport seasons. Although science provides advances for a better understanding of sport performance, many commonplace ideas endure in athletes population (4,5). The fear of ending up weakened like Samson still remains widespread and has not been investigated scientifically, to our knowledge, which motivated the present study. We focused on peak power which can be determined from the force-velocity relationship and is an important functional property from a physical performance perspective. Twenty university students (23.4 ± years; 177.6 cm and 74.2 kg), all trained athletes, were included during bench press tests. There were studied in two cross-over sessions undertaken in a random order, assessing force, velocity and power peaks. One session was with beard shaving 2 to 3 hours prior to the test, and the other was with no beard shaving in the preceding 36 hours. After several warm-up sets using light weights of their choice, subjects performed five consecutive bench press lifts (load corresponding to 50-70 % of their own one-repetition maximum ) with pushes at the highest possible velocity. Lifts were performed using an Olympic bar and plates equipped with an inertial dynamometer using accelerometry (Myotest S.A., Switzerland) reported as a valid and reliable method to assess maximal force, velocity and power from loads corresponding to 30-70% of the one-repetition maximum (6). Analysis of variance for repeated measurements were used to detect differences between the sessions. Results from bench press tests described an homogeneous group of subjects trained in this particular movement of strength training with unchanged performances between the first and second tests (P=0.43).

Figure 1 : Peaks for force, velocity and power in subjects not shaved (A) and recently shaved (B). Means are in bold black lines, forces are expressed in N, velocity in cm/s, power in W.

The performances in maximal power, velocity and force appeared unchanged by the shaving status (P=0.39). Beard shaving shortly before exercise did not appear to affect muscle force production although our results did not assess a possible influence on nervous flux. Our results suggest that the “Samson negative effect” of beard shaving is truly a myth. However, modifying their routine and beliefs could influence their psychological disposition for optimal performance, and change the image they want to project. Therefore, athletes may not be shaved before competing, but from now on they should invoke a better reason than optimization of force production.

Desgorces FD, Trémion M, Noirez P

Université Paris Descartes, UFR STAPS, Paris, France

References

1 R.L. Sharp, D.L. Costill, Med Sci Sports Exerc 21,576-80 (1989)

2 A. Saouter, Terrain n°25, revue d’ethnologie de l’europe, Eds (French culture ministry and foundation of Paris home of Human sciences, Paris 1995).

3 The Old Testament, Book of Judges 16

4 N. Yang, D.G. MacArthur, J.P. Gulbin, A.G. Hahn, A.H. Beggs, S. Easteal, K. North, Am J Hum Genet 73,627-31 (2003)

5 F.D. Desgorces, G. Berthelot, N. El Helou, V. Thibault, M. Guillaume, M. Tafflet, O. Hermine, J.F. Toussaint, PLoS One 3, e3653 (2008)

6 B. Jidovtseff, J.M. Crielaard, S. Cauchy, J.L. Croisier, Sci Sports 23, 94-97 (2008)

BJSM aims to be relevant to clinicians and to influence practice. It has been pleasing to see BJSM quoted in the New York Times, the Financial Post, and other major international news outlets. Our September issue (PDF), in partnership with the IOC continues to have an impact the world over. This link is to the widely read US News. To read the editorial about sudden cardiac death for athletes in the September issue click here.