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Is the abuse of medication the next major concern in sports medicine?

28 Jul, 15 | by BJSM

By Dr Sean Carmody

“Also, be aware of the pills you take. If you take sleeping pills to overcome jet lag, before you know it, you’ll be taking them every night. When your arm is sore and you’re given medication for it, throw that bottle away. Those pills will give you a painful, persistent ulcer. Be aware of what you put in your body.”

Pete Sampras, Letter to My Younger Self, June 29th 2015

americanfootballIn August 2013, sports medicine made headlines around the world as the NFL reached a settlement to contribute $765 million to provide medical help to more than 18,000 former players who may have been affected by concussion. It catapulted the condition into the public conscience, and drove the governing bodies of the world’s most popular sports to enforce policy change to protect the health of their athletes.

With all the scrutiny on concussion over the last few years, the use and sometimes abuse of medications in sport is an issue that has often been overlooked. This could be about to change as eight retired NFL players are suing the league for unethically providing them with pain medications throughout their career. They allege that these medications were taken without prescription or knowledge of side effects, and were used to mask serious injuries. The individuals filing the lawsuit are now believed to suffer from renal failure, dependency and chronic pain among other ailments, as a result of medical mismanagement during their playing careers.

The allegations being made in this lawsuit are supported in the literature. A 2011 paper in the journal Drug and Alcohol Dependence concluded that NFL players who misused opioids during their career were most likely to misuse in later life. Interestingly, misuse of opioids in this population was associated with more chronic pain, undiagnosed concussions and alcohol abuse.

This is not exclusively a problem of American sports. Research published in the British Journal of Sports Medicine highlighted the alarming incidence of medication abuse at major football tournaments, which has not declined despite several preventative campaigns. Nearly half of all players at the 2010 World Cup took some sort of medication and more than one-third of the players were prescribed at least one NSAID before a match, regardless of whether or not they went on to feature in the match. Worryingly, in a similar vein to the NFL players mentioned earlier, a large proportion of the medication prescribed was for players who had not fully recovered from injury or may have received “prophylactic pain-treatment”. This is in spite of the fact that NSAIDs, in particular, may adversely affect the healing of muscular and bone injuries. Furthermore, the players could potentially have consumed over-the-counter medications without the physicians’ knowledge and, hence, the actual intake reported in studies might be underestimated.

The high use of medication is not purely limited to ball-based sports; similar use of medication was reported at the Sydney Olympics in 2000. Moreover, a study in the American Journal of Sports Medicine found that while medication use wasn’t as prevalent in track and field compared to team sports, nearly half of all athletes (44%) studied had taken at least one medication. Cycling has long been plagued by doping scandals, and there is anecdotal evidence to suggest that medication abuse exists within the sport. Significantly, a 2010 study found that using paracetamol increased pain tolerance, and consequently, improved time-trial time in cycling, suggesting that there may be a performance-enhancing effect of taking pain medications too. Nevertheless, long term abuse of medications by athletes is not without its side-effects, as former cyclist Jesus Manzano noted, with particular reference to anti-depressants;

“Prozac cuts the appetite, keeps you in another world, a world where you’re not afraid of what you’re doing… It takes you to a world where you don’t ask any more questions, especially you don’t ask your doctor any questions… Then one day it all stops and you become dramatically depressed. Look at Pantani, Vandenbroucke and all the others we don’t even talk about. There are numerous other cyclists and former cyclists that are addicted to cocaine, heroin and other medications. It’s not just in the world of cycling”

The growing evidence of medication abuse in sport is disconcerting, and its rise is showing no signs of abating. It appears that the long-term health of athletes is being gambled for the sake of the team’s short-term gain. While further longitudinal studies are needed to clarify the long-term effects of medication use in athletes from other sports, there exists enough compelling evidence to act definitively now. It should not take another $765 million pay out for governing bodies to sit up and take notice.

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Dr Sean Carmody is a junior doctor working in the South Thames deanery. He tweets regularly on topics related to sports medicine and performance @seancarmody1.

References

Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med. 1999;28:383-388.

Bailey S, O’Connor PJ. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol 115: 892–899, 2013

Corrigan B, Kazlauskas R. Medication Use in Athletes Selected for Doping Control at the Sydney Olympics (2000). Clin J Sport Med 2003;13:33-40.

Cottler L, Abdallah AB, Cummings SM, Barr J, Banks R, Forchheimer R. Injury, Pain, and Prescription Opioid Use Among Former National Football League (NFL) Players. Drug Alcohol Depend. 2011 Jul 1 ; 116(1-3): 188-194.

Mauger A, Jones AM, Williams CA. Influence of acetaminophen on performance during time trial cycling. J Appl Physiol 108: 98 –104, 2010.

Schwenk T, Gorenflo DW, Dopp RR, Hipple E. Depression and pain in retired professional football players. Med Sci Sports Exerc. 2007 Apr;39(4):599-605.

Tscholl P, Feddermann N, Junge A, Dvorak J. The Use and Abuse of Painkillers in International Soccer: Data from 6 FIFA Tournaments for Female and Youth Players. Am J Sports Med February 2009 vol. 37 no. 2 260-265.

Tscholl P, Alonso JM, Dollé G, Junge A, Dvorak J. The Use of Drugs and Nutritional Supplements in Top-Level Track and Field Athletes. Am J Sports Med January 2010 vol. 38 no. 1 133-140.

Tscholl P, Dvorak J. Abuse of medication during international football competition in 2010 – lesson not learned. Br J Sports Med 2012;46:1140–1141.

Tscholl P, Vaso M, Weber A, Dvorak J. High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. Br J Sports Med 2015;49:580–582.

FSEM Supports Concussion Guidelines for the Education Sector

30 Jun, 15 | by BJSM

fsem_v_Variation_1The Faculty of Sport and Exercise Medicine UK (FSEM) is supporting new Concussion Guidelines for the Education Sector, produced by the Forum on Concussion in Sport and Physical Education in conjunction with the Sport and Recreational Alliance.

The guidelines have been created in order to alleviate parental concerns around the safety of school sport and to ensure a consistent and suitable management protocol is available to those working with children in the education sector.

Endorsed by an independent expert panel of Sport and Exercise Medicine, Neurology and Health specialists, the guidelines have a clear message on how to handle a suspected concussion in school aged-children and above, including the dangers of returning to play too soon. Concussion can occur during any physical activity and these simple guidelines will help those working in education to follow the four principles of concussion management:

RECOGNISE – REMOVE – RECOVER – RETURN

Dr Mike England, Fellow of the FSEM, Community Rugby Medical Director of the Rugby Football Union and Facilitator of the guidelines comments: This has been a ground breaking initiative, with sport, education and health coming together to address a very important issue. We hope teachers will find these guidelines useful, as it is imperative that those working in the education sector know how to recognise concussion and take action. If I had to pick out one key message it would be if in doubt sit them out.”

Dr Roderick Jaques, President of the FSEM comments: “We identified the education sector as a priority area through our call for a national consensus on the prevention, assessment and management of concussion. We are now delighted to see the launch of concussion guidelines to help teachers, school staff, coaches, parents and carers to be aware of the danger signs and how a suspected concussion should be managed in the absence of a trained medical professional.”

The FSEM called for a national best practice consensus on concussion, for all sectors where concussion is encountered, last year and has been working with the UK National Sporting Bodies and Medical Royal Colleges. Easy to follow guidelines, like this, could be developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.

View the Concussion Guidelines for the Education Sector at www.sportandrecreation.org.uk/concussion-guidelines

Also see related BJSM material:

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Full text free online. (downloaded >100 k times)

Guest blog by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands

 

 

Scotland’s concussion guidelines highlight the need for a UK wide approach

4 Jun, 15 | by BJSM

News Release – The Faculty of Sport and Exercise Medicine

sealThe Faculty of Sport and Exercise Medicine UK (FSEM) welcomes the launch of Scottish Sport Concussion Guidelines for the general public and for grassroots sports participants, where specialists in Sports and Exercise Medicine are not available to manage concussed players. The FSEM would like to see similar guidelines produced, not just for sport, but to improve recognition, assessment and management of all concussions in the UK.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine UK comments:

Concussion is recognised to be one of the most challenging of injuries to diagnose, assess and manage. Best practice clinical pathways from injury to return to play, work or school for a concussed person, outside of the elite sports setting, are not always easily accessible in the UK.

“The Faculty of Sport and Exercise Medicine fully supports the new Scottish guidelines for the recognition, assessment and management of concussion. We would like to see great initiatives like this developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.”

Sport Scotland, the Scottish National Sporting Bodies, Medical Royal Colleges and the Scottish CMO have produced the guidelines that are intended to provide information on how to recognise sports concussion and on how sports concussion should be managed from the time of injury through to a safe return to play.

The guidelines stress that, at all levels and in all sports, if an athlete is suspected of having a concussion, they must be immediately removed from play.

Any player with a second concussion within 12 months, a history of multiple concussions, player with unusual symptoms or prolonged recovery should be assessed and managed by health care providers (multidisciplinary) with experience in sports-related concussions.

The overriding message is that ALL concussions are serious and if in doubt, sit them out!

The FSEM recognised the need for a national best practice consensus on concussion last year and has been working with a group including UK National Sporting Bodies and Medical Royal Colleges. The group would like to see consistent best practice, recognition, management guidelines and care pathways adopted from ground level up, across all sectors in the UK and by all health and allied professional groups, where concussion is encountered.

Can animals help limit concussions?

7 Feb, 15 | by BJSM

Gregory D. Myer, Director of Research in Sports Medicine at Cincinnati Children’s Hospital Medical Center. Recently wrote a fantastic – and very popular- article for “The Opinion Pages” of the New York Times on the concussion crisis. Below, we highlight a few key paragraphs and link to related BJSM publications. 

CINCINNATI — THE N.F.L. playoffs start tomorrow. During the regular season, the conversation about traumatic brain injuries in sports among doctors, players, league officials, politicians and parents seemed to gain in volume and intensity with each passing week. New revelations from retired N.F.L. players who announced that they had the progressive neurodegenerative brain disease chronic traumatic encephalopathy, or C.T.E., helped fuel these discussions.

The key to beating the concussion crisis lies in dealing with what’s happening inside the skull, not outside of it. Because the brain doesn’t fill the skull, there’s room for it to rattle, be bruised or sheared, not just with every collision but with every sudden stop and even start —a phenomenon sometimes described as “brain slosh.” For athletes in contact sports, brain slosh has long been seen as inherent and unavoidable. But to make progress against concussions, we have to give priority in future research to minimizing brain slosh during game play. This means that we need sports leagues, policy makers and health care providers to emphasize primary prevention instead of damage control…

… Newer helmets don’t seem to make much of a difference, either. Studies appearing in the British Journal of Sports Medicine and the American Academy of Pediatrics found nearly identical rates of sports-related concussions among different helmet brands and models, including older helmets and new. Why? Think about shipping fragile porcelain — do we use steel or titanium containers, or Bubble Wrap? The same principle applies when protecting the brain. Helmets fulfill their primary purpose of preventing skull fractures and lacerations, but they do not reduce concussions. It is the delicate brain within the skull that is damaged because it does not fit snugly. Athletes would benefit from a tighter fit for the brain — a Bubble Wrap effect — during play, but what are the factors within our control that might provide that effect? We have some leads….

Read the full NY Times article HERE.

See related BJSM articles/blogs/podcasts

Clara Karton et al. The evaluation of speed skating helmet performance through peak linear and rotational accelerations. 2014.

Brian W Benson et al. What are the most effective risk-reduction strategies in sport concussion? 2014.

Kimberly G HarmonJonathan A Drezner et al. American Medical Society for Sports Medicine position statement: concussion in sport. 2013.

Shameemah Abrahams et al. Risk factors for sports concussion: an evidence-based systematic review.2014.

BJSM Podcast: Kim Harmon on managing concussion 

BJSM Blog: James Thing – Paediatric concussion…….must try harder!

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Gregory D. Myer is the Director of Research in Sports Medicine at Cincinnati Children’s Hospital Medical Center.

UK Medical and Sporting Organisations Call for Best Practice Consensus on Concussion

24 Sep, 14 | by BJSM

News Release

23 September 2014

The Faculty of Sport and Exercise Medicine (FSEM) UK has hosted a meeting to discuss the need for consensus in the prevention, assessment and management of concussion in the UK. Concussion is common and can have major implications on quality of life if not recognised early.

stock-footage-woman-brain-anatomyKey influencers and brain injury experts attended the meeting, including representatives from the Medical Royal Colleges and National Governing Bodies of sport.

The overwhelming view of delegates present at the meeting was a common desire to progress the development of consensus as to how sport, health and education bodies in the UK can deliver best practice.

Delegates recognised the work currently being done by multiple governments and key agencies in this area, but felt that greater formal collaboration between the Medical Royal Colleges would facilitate the process.

The following work streams were identified as priority areas: 

  • An updated consensus statement on the prevention, assessment and management of concussion in the United Kingdom
  • The development and dissemination of generic concussion guidance for sports and the education sector, in collaboration with groups and agencies currently working in this area
  • The development of dissemination of appropriate guidance and educational resources for the primary care physician and NHS Emergency Department practitioners
  • Input into the planning of care pathways for concussion and mild traumatic brain injury
  • Consideration of a Cochrane review

The group would like to see consistent best practice, recognition, management guidelines and care pathways adopted from ground level up, across all sectors and by all health and allied professional groups, where concussion is encountered. They also recognised the need for a NICE guideline specifically on concussion.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine, comments: Concussion is recognised to be one of the most challenging of injuries to diagnose assess and manage. Care pathways from concussion to return to play, school, work and every day life are not always easily accessible or understood in the UK.

“I am pleased to say that a broad consensus was established between all the participants of the meeting on the key issues of a medically complex area and we are in a position to take forward the development of a much needed consensus on the management of concussion.”

Dr Simon Kemp, Hon. Secretary of the Faculty of Sport and Exercise Medicine and Chief Medical Officer for the RFU, comments; “Individual sporting bodies recognise the work that they need to do on concussion, however we need to move towards a cross-sports consensus on the recognition and management of concussion with consistency across all sporting bodies and in conjunction with education and healthcare systems.”

Dr Christine Haseler, representing the Royal College of General Practitioners (RCGP), comments: “The RCGP is interested in developing a consensus on the recognition and management of concussion with the group. Out of which, we would like to see a concussion education resource for GPs, which can be applied to the general public as well as those participating in sport.”

Dr Clifford Mann, President of the College of Emergency Medicine (CEM), comments: “One emergency department alone can see upwards of a dozen cases of concussion a week, most of whom are adolescents. There currently exists a large number of differing guidelines out there. Common guidelines, which can be applied across both healthcare and education sectors, are much needed. I am pleased to see that there is already consensus on the need for common guidelines from the meeting attendees and, as this gains momentum, we hope that other key organisations will sign-up.”

Dr Anna-Louise Mackinnon, Jockeys Medical Adviser to the Professional Jockeys Association and Injured Jockeys Fund, comments: “In racing we see more episodes of concussion than in most other sports and we would welcome generic concussion guidelines for UK sport to be used alongside the current British Horseracing Authority Concussion Management Protocol. Consistent advice across all sports, both recreational and professional, is vital to the optimal management of concussion. The development of educational resources available to all those working at the grass roots level will be of great benefit.”

Dr Ian Beasley, Chair of the FA’s Medical Committee and Doctor to the England Men’s Senior Football Team, comments: The advice of medical professionals is key when it comes to the recognition and management of concussion. Whilst sporting bodies have developed processes to deal with many types of injury, including concussion, this is an area that is in need of a set of common guidelines which can be applied across a broad range of sports. All managers, leaders, teachers, players and clubs need to understand the risks associated with head injuries and be equipped with the correct knowledge.”

Concussion to groin pain: BJSM editors and authors contribute to a 200-strong clinician education event

17 May, 14 | by BJSM

BJSM editors and authors contributed to a 200-strong clinician education event run by the Faculty of Sport and Exercise Medicine of Ireland on Tuesday April 29.

Andy Franklyn-Miller argued the ‘compartment pressure’ syndrome was a misnomer for pathology that relates to relative overuse. His article can be found HERE  (OPEN ACESS) in BJSM and his podcast on the topic is among the top 5 of all time on BJSM podcasts (LISTEN HERE).

BJSM concussion cover 2014Eanna Falvey addressed the challenges of deciding on return to play in concussion and he challenged what many US newspapers are taking as gospel – that repeated concussion leads to chronic traumatic encephalopathy (CTE). BJSM’s 4th issue of 2014 addressed this question and Paul McCrory is on BJSM podcasts (LISTEN HERE).

Senior Associate Editor Peter Brukner (@PeterBrukner) reviewed the challenges of managing groin pain in sport. He argues that Copenhagen’s Per Holmich’s ‘entities’ approach is a useful one. You can see watch Per Holmich talk about history and clinical examination on YouTube (HERE) and read about the entities (HERE).

To close off the educational event, BJSM Editor in Chief Karim Khan reviewed the pathogenesis of tendinopathy arguing that collagen failure and abnormal tendon cells/matrix needs to be respected even if there are some biochemical changes that have loosely been linked to ‘inflammatory’ pathways. The new BJSM paper ‘Time to revisit inflammation”  (OPEN ACCESS)  is a thought-provoking contribution to tendinopathy management science by UK Professor Jonathan Rees. If you are interested in tendon injuries and their quality management, go to Oxford in September (2014). International Scientific Tendinopathy Symposium.

This event was part of a 10-city educational tour of UK supported by BJSM, McGraw-Hill publishers, and Aspetar Orthopaedic and Sports Medicine Hospital, Qatar.

What do you think? Tweet @BJSM_BMJ or email us (karim.khan@ubc.ca)your thoughts.

IOC World Conference – Prevention of Injury & Illness in Sport: On the ground recap

24 Apr, 14 | by BJSM

By Liam West (@Liam_West)

IOC conference

For 3 years this conference has been firmly on my “SEM Bucket List” and it did not disappoint. Firstly, Monaco in the sun is a sight to behold and secondly to walk into a coffee break to see the “who’s who” of global sports medicine was simply inspirational. The numbers for the event were equally impressive;

  • 24 symposia
  • 5 keynotes
  • 34 workshops
  • 73 free communications
  • 233 poster presentations (unopposed in the time table)

The only downside was that I could not attend all of the sessions, although I guess that speaks volumes of the quality of presentations on offer. Below is a summary of the 3 days and some take home messages from the sessions I attended.

Dr. Richard Budgett, IOC Medical Director, reminded all the delegates at the opening ceremony that “It’s all about the athlete” and as a former Olympic gold medalist he knows this more than most! The next day the opening keynote lecture showcased a vigorous debate between Karim Khan (@BJSM_BMJ) and Dominic MacAuley (@DMacA) as to whether sports injury & illness prevention research has delivered. The answer? Yes in certain areas (e.g. ACL prevention), but there is much work to be done (or optimistically to be read as opportunities for research!!).

Using the #IOCprev2014, the interactivity between delegates and speakers both in attendance and across the globe was terrific. Perhaps this was triggered by the excellent symposium about “the power of social media” chaired by @CarolineFinch. Learning points? You can to use social media as a platform to market your message. It is now one of the best ways to signpost readers to scientific content and can improve citation rates although @DrJohnOrchard warned about the perils of engaging in non-academic discussions online. @clairebower explained the three top rules of twitter [slides can be accessed here]. 1) Know your audience, 2) keep it simple & 3) image is everything (use photos). @EvertVerghagen explained that using social media can increase subject recruitment for research and apps may be the future of sports injury prevention – you can find his talk here.

Sudden cardiac death (SCD) was an integral theme at the last IOC conference in 2011 and 2014 was no different – read the open access BJSM issue on Advances on Sports Cardiology here. After the overview by @Prof­_MatWilson, the issue of the optimum screening protocol for SCD was tackled – future efforts lie in detecting subclinical disease in older athletes. No guaranteed protocols were given by the experts but Michael Papadakis provided pro-ECG evidence and then educated delegates to the normal ECG changes associated with age, sex and ethnicity – read the Seattle Criteria here and do the online BMJ ECG interpretation module here. Shanjay Sharma (@SSharmacardio) talked about the importance of maintenance of left ventricular cavity size in the athlete’s heart that is lost in cardiomyopathy and that it isn’t the size of the heart that matters but the function. Screening will never pick up all athletes at risk of SCD – Jonathan Drezner (@AMSSM) preached the importance of sideline preparation and the role of the automated external defibrillator (AED) in preventing SCD. The big take home message – “A seizure or loss of consciousness should be assumed to be sudden cardiac arrest until proven otherwise”

Concussion is the current vogue in SEM and the keynote by Neurologist/Sports Physician & PhD Paul McCrory was well attended. He described that whilst technology has improved enabling us to measure impact & biomechanical forces, these show little correlation to rates and severity of concussion. The most recent Zurich guidelines were emphasized to be just that – guidelines. There are no definite answers so far in concussion and currently we are only looking into neurocognitive athletic function but McCrory explained that concussion is a complex systemic pathology with many components; consider mood, sleep, hormonal disturbances etc. – listen to his 4 recent BJSM podcasts on the topic here – 1,2,3, & 4. It is important to note that Chronic Traumatic Encephalopathy is a separate entity to concussion and as clinicians we must not let the media dictate the course of science – education in this area is key! You can access the BJSM journal dedicated to concussion and the 4th International Conference on Concussion in Sport (Zurich, 2012) here.

The recent IOC Consensus Statement “Beyond the Female Athlete Triad – Relative Energy Deficiency Sydrome (RED-S)” was presented and discussed in a fantastic stream led by @margomountjoy – this work has moved on from the Female Athlete Triad and the journal can be read here. RED-S acknowledges this condition affects both genders and has multisystem involvement with more complex pathophysiology than previously described. It’s all about the energy. RED-S describes the imbalance between training load and recovery as the imbalance between energy availability and expenditure. With low energy availability comes susceptibility to short term risks to illness, infection, fatigue etc and long term risks such as decrease in performance and overall health. The paper proposes a traffic light system to RTP issues for athletes with this condition – useful for clinicians.

Some other short take home messages;

  • The legend of running biomechanics, Benno Nigg, spoke on the evolution of footwear and the prevention of running injuries. He concluded from his years of research that the only thing that actually confers injury protection is the ability of athletes to use a “comfort filter” to choose the shoe/insole that works for them.
  • Injury prevention – @benclarsen presented on the difficulty with recording overuse injuries. He stated that we need to move away from the trend of only measuring time loss injuries and look to include injuries that can lead to overuse pathologies.

I’d like to thank the organisers for putting on such a fantastic event that enabled delegates to meet old friends whilst making new connections that will hopefully last for many years to come. I look forward to seeing many of you at the next IOC Conference in 2017!

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Dr. Liam West BSc (Hons) MBBCh is a junior doctor at the John Radcliffe Hospital, Oxford. He is a founder and current President of USEMS and is also the founder of Cardiff Sports & Exercise Medicine Society (CSEMS). In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series. He has a passion for developing the SEM movement amongst undergraduates and sits on the Council of Sports Medicine for the Royal Society of Medicine as Editorial Representative and on the Educational Advisory Board for the British Association of Sport and Exercise Medicine. His Twitter handle (as above) is @Liam_West and you can find Liam on Facebook as well.

Sports-Related Concussion in Youth- Improving the Science, Changing the Culture: Book review by Dr. Michael Turner

9 Apr, 14 | by Karim Khan

Book review by Dr. Michael Turner

Sports-Related Concussion in Youth- Improving the Science, Changing the Culture (336 pages)

sports related concussion cover.phpThis is essentially the 2012 Zurich Concussion Consensus process applied to research in youth sport – a great summary of the topic but not an easy read.

For anyone versed in concussion the themes will be familiar:

  • A very high profile topic
  • Very few good quality articles published in the recent literature relating to concussion in youth sport
  • Epidemiology data non-existent for grass roots sport
  • The culture in youth sport is to play down concussion and avoid letting the team down
  • A single definition of concussion is not universally applied so data gathering is a mess
  • Little research has taken place on the molecular changes that occur in the young brain when a concussion occurs
  • Mixed findings on the long term effects of repetitive concussions and sub-concussive episodes
  • Risk factors for post-concussion syndrome and CTE have not been identified
  • No studies on the pre-high school group have tracked the post-concussion changes found in the following activities – physical, cognitive, emotional or sleep
  • There is no data to establish a threshold for concussion in young athletes
  • The is no equipment that can mitigate or prevent concussion, despite the manufacturers claims to the contrary
  • There is currently inadequate information to establish what combination of tests is best to identify and monitor concussion in youth sport (using hospital based or non-hospital based assessment tools)
  • Despite the consensus agreement that concussion should be treated with physical and cognitive, there is little empirical evidence to establish what is the optimal degree and duration of physical rest and if cognitive rest is necessary

The authors explore these problem areas and offer a detailed review of the published literature:

  • Neuroscience, biomechanics and risks of concussion in the developing brain
  • Concussion recognition, diagnosis and acute management
  • Treatment and management of prolonged symptoms and post-concussion syndrome
  • Consequences of repetitive head impacts and multiple concussions
  • Protection and prevention strategies
  • Conclusions and recommendations

 The authors make 6 recommendations:

  1. Surveillance – establish a national surveillance program for children aged 5-21
  2. Evidence based guidelines for concussion diagnosis and management – should be established and research supported
  3. Short and long term consequences of concussion and repetitive head impact – should be evaluated using a controlled, longitudinal, large scale study
  4. Age appropriate rules and playing standards – should be rigorously evaluated by sports associations, schools and national governing bodies of sport
  5. Biomechanics, protective equipment and safety standards – should be evaluated by research funded by the National Institutes of Health and the Department of Defence
  6. Culture change – the NCAA and other organisations should develop, implement and evaluate the effectiveness of the large scale efforts to increase knowledge about concussion and change the culture surrounding concussion (among elementary school through college-age youth, their parents, coaches, sports officials, educators, athletic trainers and health care professionals)

The book costs just US$64-00; the recommended research will cost a great deal more

Sports-Related Concussion in Youth – Improving the Science, Changing the Culture (336 pages)

Institute of Medicine and National Research Council of the National Academies

ISBN – 13: 978-0-309-28800-2

ISBN – 10: 0-309-28800-2

http://0-www.ncbi.nlm.nih.gov.elis.tmu.edu.tw/books/NBK169016/

http://www.nap.edu/catalog.php?record_id=18377

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Dr. Michael Turner, MB BS, FFSEM is the Chief Medical Adviser for the Lawn Tennis Association, London

Listen HERE to the BJSM podcast interview about his time as chief medical adviser of the Lawn Tennis Association, including the medical scandals that have cropped up and the advances he’s seen in the game’s sports medicine.

 

Coaches and doctors need to recognise when they are vulnerable to “win or else” pressure.

3 Feb, 14 | by BJSM

 By Drs. Lynley Anderson and Brad Partridge 

John Orchard’s recent blog On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinician’s hands’, raises some interesting points for debate. Dr Orchard laments that decisions regarding return to play following concussion were made by a coach who is ‘forced by the nature of the job to think in the short term’. Orchard says that coaches are under “ridiculous pressure to win”, and so cannot be trusted to have the long term welfare of players in mind. Furthermore, he believes that the typically short term nature of a coach’s job (that is, they may be sacked if their team is not successful) compromises their decision-making about issues of player safety – as a result, Orchard believes that coaches should not be involved in decision making about return to play from concussion lest they put players at risk of long term harm.

We wish to expand upon Orchard’s useful and provocative contributions by making several points for consideration. Firstly, we think that Orchard gives the impression (perhaps unintentionally) that coaches such as Andreas Vilas-Boas can either try to win, or can be concerned about player safety – but are unable to do both. We believe that this describes a false dilemma for coaches. The pressure to win is certainly a factor that places coaches in a potentially vulnerable state when it comes to player safety – there are going to be circumstances where this vulnerability is heightened and, if not managed appropriately, lead to harm. But implying that the “win or else” pressure precludes coaches from having any concern about player health and welfare is perhaps not the most accurate or useful way of viewing things. Giving the impression that it is not within the scope of a coach’s obligations to care about player safety may be even more detrimental to player safety. If coaches are absolved of any obligations to the health and safety of players they may see this as encouragement to push the envelope further in their decision making in the belief that it is simply someone else’s job to tell them when they’ve gone too far.

Secondly, it is not surprising that Orchard thinks return to play decisions should be the domain of the team doctor because they ‘are in a position to think longer term with respect to the player’s health later in life’. Those in charge of football teams (and perhaps even those in charge of entire football leagues) could be accused of wanting to have it both ways when it comes to team doctors. On the one hand they want access to medical expertise when it comes to optimising performance and treating injuries because such expertise may facilitate winning. Furthermore, cynics might consider that the involvement of medical professionals allows coaches and administrators to trot out the well-worn line that “the player’s welfare and safety are paramount” – if nothing else, it makes for good PR to concerned mums and dads. But in the event that those medical professionals provide recommendations that do not facilitate the team achieving its goals (or may hinder their achievement), then some coaches and administrators may be apt to ignore such expertise or seek to circumvent it. This appears to be Orchard’s concern too.

Our point is that, team doctors can’t have it both ways either. Given the obligations and goals of coaches, Orchard says that team doctors need greater scope to say who can and can’t play, and that there is a need to redress “the power imbalance on match day between the coaching and medical staff”. In other words, doctors should be the ones with the final say on return to play, and doctors should be the ones to tell coaches when they’ve gone too far. There may be good reasons for this, but we can’t forget that team doctors (like coaches) have many conflicting pressures too – from their patient, the coach, their employer, and perhaps even their medical colleagues.1,2  Not all of these stakeholders necessarily have aligning interests when it comes to each case of injury. Orchard’s call for allowing team doctors longer assessment times seems like a sensible proposal, but it doesn’t eliminate the potential for the assessor to be swayed by these conflicting pressures – just like coaches. So Orchard’s solution is fairly neat, as long as we assume that team doctors are the only stakeholders who are immune to external pressures on decision making! Player welfare is a stated priority for all stakeholders, but Orchard’s most recent post creates the impression that coaches will always lean towards winning over player safety, but no team doctor ever will. We saw this as curious because we agreed with Orchard’s earlier blog post ‘Concussion, risk assessment, and practical steps to reform’, where he suggested that doctors are indeed at risk of losing their job if they do not toe the party line.

In that post, Orchard calculated the chance of the Tottenham medical team being sacked at 1 in 5 to 1 in 20, noting that the risk is ‘demonstrably lower than the manager but far higher than a colleague working in the NHS’. He goes on to state that:

… this level of risk becomes lower if they all “stick solid” with the manager on the decision to return the player to the field and much more likely if a public statement was made to the media along the lines of “the medical team requested that the player be substituted for safety reasons but the manager over-ruled us.”

The message is that members of the medical team are also vulnerable to losing their job and might tailor their medical advice or decision-making to please those who determine whether or not they retain their job.  Doctors are best placed to medically assess a concussion injury, BUT team doctors may not always feel able to make a call that goes against the wishes of the coach and their decision making may involve a compromise between what is in the athlete’s best interest and what is in their own. This raises doubts about the independence of team doctors and places them in a similar position to coaches – a point that seemed lost in Orchard’s most recent blog post.

Furthermore, in a blog post from March 2012 Orchard relayed how coaching staff at the NRL club he was working for made it clear that they would not refer potentially concussed players to him for assessment if there was a chance he would exclude them from further play. Whether or not this ever occurred is unclear, but it clearly made Orchard uncomfortable. Interestingly, when interviewed in 2012, the chief medical officer of the National Rugby League (NRL) implied that team doctors do not have any conflicts of interest affecting their decision-making about concussion:

“There have been questions about whether club doctors have a conflict of interest because they are being paid by the clubs … their number one priority is the welfare of the player. They will always make the right decision by him.” (quoted in Prichard 2012).

Echoing this sentiment, a co-author of the Australian Football League’s concussion management guidelines also appeared to discount the influence of third parties by claiming that team doctors only ever make clinical decisions with their obligation to the player in mind:

”I may be idealistic, I may be wrong, but my feeling is that the guys are going to follow what they’ve been doing which is making sure players are safe. … You have very experienced doctors working in the AFL … we’re not going to be doing anything that compromises or risks player welfare.” (quoted Lane 2011).

Orchard has raised some important concerns for the care of athletes and been refreshingly frank in confronting ethical issues facing team doctors – in this post we have sought to clarify some of these issues. There is a need for good research to elucidate the mechanisms that make coaches and medical support staff more vulnerable to decisions with the potential to compromise the wellbeing of players.  This will help develop strategies for managing these issues.

References

1.              Partridge, B. (2013). Dazed and confused: Sports medicine, conflicts of interest and concussion management. Journal of Bioethical Inquiry. DOI: 10.1007/s11673-013-9491-2

2.              Anderson, L., & Jackson, S. (2013). Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport. International Review for the Sociology of Sport, 48(2), 238-256.

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Dr Lynley Anderson is a Senior Lecturer at the Bioethics Centre, Division of Health Sciences University of Otago

Dr. Brad Partridge is a NHMRC Research Fellow at the UQ Centre for Clinical Research, The University of Queensland

 

 

Paediatric concussion…….must try harder!

31 Dec, 13 | by Karim Khan

By Dr James Thing

paedetric concussionThere has been plenty of discussion lately on the topic of sports concussion and its mismanagement at an elite level. This was most recently and infamously highlighted when Hugo Lloris was allowed to continue playing for Tottenham after a period of clear loss of consciousness following a traumatic collision with an opponent.

In addition to this a recent $765 million out-of-court NFL settlement has prompted other sports to raise their game and introduce new standards of management for players with suspected concussion, however concussion diagnosis and management at a paediatric level in the UK remains worryingly inadequate.

In the UK there are, to my knowledge, no specific referral pathways or specialised clinic services for young individuals who have sustained a sport-related concussive injury.

By comparison the US has widely and wisely invested in concussion management for adolescent athletes, ensuring that young brains are closely monitored and optimally protected.

I recently travelled to the Sport and Exercise Medicine Department at Boston Children’s Hospital where I observed the true scale of attention currently being offered to young concussed athletes.

The clinic was set up in 2007 in response to the growing number of sport-related paediatric concussion presentations.  The clinic is available to local children aged 8 and over and caters for the broader Massachusetts area, covering 1.04 million 5-18 year old’s [2].

The clinic receives over 1000 new referrals per year, and deals with mostly complex or prolonged concussive cases [1].  The clinic integrates successfully with local schools and colleges in the Massachusetts area, enhancing effective communication and facilitating requests for school absences and ‘accommodations’ as required.  The state is enviably designed for concussion management with almost every school or college employing an athletic trainer who is able to undertake baseline computerised neurocognitive testing (most commonly ImPACT) in 95% of educational establishments [1].

This structure offers the clinician a huge advantage as they can easily access baseline test reports and make an informed and evidence based decision regarding return to play for the individual.

The clinic has standardised the management for adolescent athletes with concussion and relies on self-developed clinical protocols to facilitate optimal outcomes, utilising a team of experienced psychologists, neuro-psychologists, athletic trainers, psychiatrists, neuro-radiologists and research coordinators.

Numerous research articles have stemmed from the novel clinic, helping to shape the care of paediatric concussion around the globe.  The clinics provide the perfect environment for research generation, which has recently focused on predictors of symptom duration in paediatric concussion [3], the prevalence of undiagnosed concussion in paediatric athletes [4] and the use of computerized neurocognitive testing in sport-related paediatric concussion [5].

In the UK at present there is no standardisation of management for paediatric athletes suffering from concussion.  Management depends on the individual clinician’s understanding and interest in sports concussion.  Algorithms do not exist and treatment is generally delivered on an ad hoc basis.

It is now time to resolve this issue by establishing specialist services and starting to provide the necessary care that our young athletes deserve.

References

[1] Verbal correspondence with Dr William Meehan, Director, Sports Concussion Clinic, BCH SEM Dept.

[2] US Department of Commerce/US Census Bureau, State and County QuickFacts: Massachusetts.

http://quickfacts.census.gov/qfd/states/25000.html

[3] Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013 Jul;132(1):8-17.

[4] Meehan WP 3rd, Mannix RC, O’Brien MJ, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med. 2013 Sep;23(5):339-42.

[5] Meehan WP 3rd, d’Hemecourt P, Collins CL, Taylor AM, Comstock RD. Computerized neurocognitive testing for the management of sport-related concussions. Pediatrics. 2012 Jan;129(1):38-44.

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Thanks to Drs William Meehan, Michael O’Brien, Pierre d’Hemecourt, Andrea Stracciolini and Michael Beasley at Boston Children’s Hospital.

Dr James Thing is a final year Sport and Exercise Medicine registrar with an interest in paediatric sports medicine and concussion.  He provides match day cover at Harlequins Rugby Club and Cranleigh School.  He was awarded the Bauerfeind travel fellowship, which funded his trip to Boston.

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