On July 5th, a prominent Australian Rules football player suffered an ‘adverse reaction’ to sleeping pills after a game. Drug testing confirmed that the player had not taken any banned drugs and there was no suggestion of that. The media ran stories of players being on a cycle of caffeine ‘uppers’ followed by sleeping pill ‘downers’ as a part of the weekly cycle. TV File footage showed ‘No Doz’ tablet being available to players in the rooms immediately prior to a game. A few former players acknowledged that taking caffeine tablets was part of some players’ routines. Note that Australian Rules football is largely played in one time zone and the player in question was not from a team that regularly travels across time zones.

Australasian College of Sports Physicians President, Andrew Garnham raised important questions on this issue in his weekly newsletter (shared here with permission):

This episode raised many questions. Who should be commenting? What are the boundaries of privacy and confidentiality in such a situation? Could there be any legal implications of comments? Will commenting help to better inform the general public and everyone assocaited with the sport? Does caffeine help performance in AFL football, as it is played in 2010? Are sleeping tablets really necessary after games, especially at night? Do the players fully understand these issues? How much can a club control the medical treatment of an individual? Are the objectives of the performance staff and medical staff at the club correctly aligned? I do think the hot question of whether caffeine tablets should be banned is easily dispensed with.

Feel free to contribute to this discussion by posting a comment below.

This E-letter is in response to Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers. Abstract | Full article

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We read with interest the article from Hasler et al. (2009) “Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers”.

In general, the answer is: ‘yes, there are internal (e.g. gender, age, fitness, skill level, risk taking) and external (equipment, environment) risk factors’ according to comprehensive model for injury causation by Bahr and Krosshaug (1). However, we would like to comment on the presented data and methods used because some results seem contrary to other studies in this research field.

Firstly, Hasler et al. reported that skiers with new equipment have a higher risk of being injured. However, there seems a mistake in the presented data because in the abstract the Odds Ratio (OR) was 59 with a 95% confidence interval of 0.37-0.93 while in Table 1 the OR was 0.59. If the OR of 0.59 was correct, new equipment would decrease injury risk. In addition, what means new equipment? Did the authors compare carving skiers with traditional skiers as done by Burtscher et al. (2) showing a reduced injury rate since the introduction of carving ski? Where is the cut off between new and old equipment? In the discussion section, Hasler et al. stated that the results might be explained by a mismatch between the abilities of the skier and the equipment. Unfortunately, they did not include skill levels in their questionnaire. Several studies showed higher injury rates in less skilled skiers and snowboarders (3, 4) while more skilled skiers had a higher risk to sustain a more severe injury (5).

Secondly, there seem mistakes concerning the presented data about snow conditions. In Figure 3, artificial snow versus old snow and fresh snow versus powder snow show OR <1 while in Table 1 the same OR are presented vice versa (OR 0.21 for old snow vs. artificial snow and OR 0.31 for old snow vs. fresh snow, respectively). It is the same with slush snow versus powder snow which is not a snow condition but a skiing condition in Figure 3 and powder snow vs. slush snow in Table 1, respectively. In addition, old snow seems to be in contrast to fresh snow. Does fresh snow mean powder snow? However, can old snow not be also old artificial snow? Therefore, it is not clear which snow condition actually increases or decreases injury risk.

Thirdly, seasonal checking of skiing equipment showed a trend to decrease injury risk (OR: 0.46, p = 0.056). In our opinion, seasonal checking of skiing equipment includes primarily an adjustment of the bindings. In accordance, Burtscher et al. (2) showed that female carving skiers with a binding adjustment older than 1 year had a twofold knee injury rate compared to those with newly adjusted bindings. The release of a binding is primarily important in preventing injuries to the lower extremity. Therefore, it would be better to define risk factors with regard to the injured body location.

Fourthly, injured skiers showed a higher readiness for risk taking in this study. In contrast, other studies  reported that injured skiers did not take more risk but were less skilled compared to uninjured skiers (6-8). Therefore, it would make sense to include skill level.

Fifthly, Hasler et al. showed a higher injury risk when skiing under bad weather conditions which is well in accordance with the study by Aschauer et al. (9). However, poor snow and weather conditions may be misjudged by injured skiers because they may look for an explanation as to why the injury occurred. In general, self-report to questions might lead to underreport or overreport of health-risk behaviours affected by cognitive and situational factors (10).

Sixthly, gender has not been found to be a significant risk factor in this study. That might be due to the fact that Hasler et al. did not differentiate between injured parts of the body, e.g. females have a higher knee injury risk (2) and males have a higher head injury risk (11) compared to the other gender.

Seventhly, Hasler et al. calculated that injury risk is higher when warming up. This result contrasts general preventive recommendations (12) and also the findings by Ruedl et al. (13) who demonstrated a twofold injury reduction in a cohort of 36.000 participants of 12 ski schools when warming up.

Eighthly, there seems a mistake concerning the presented data about drug consumption. Figure 3 shows an OR > 1 for abstinence from drugs while inTable 1 drug consumption was presented vice versa. In  addition, in Table 1 an OR of 5.92 was presented while in the discussion the OR was 1.78 for drug consumption.

Since a case control design was used, the amount of exposure to the suggested risk factors was unknown which should be taken into account when interpreting the results (14). In the study by Hasler et al. the controls were interviewed when coming off slopes after skiing. This implies that controls skied probably more than 3 hours although other studies showed that most injuries to the lower extremity occurred within the first 2 or 3 hours of skiing (15, 16). A total of 782 patients were recruited over a period of 5 and a half month and 496 controls were interviewed in six different ski resorts. This means an average of about 83 controls per ski resort and an average of 15 uninjured skiers per month, respectively. However, Hasler et al. (2009) did not specify when controls have been recruited, e.g. every second day. A continuous recruitment of controls seems of utmost importance to compare prospectively potential external risk factors like snow, weather and slope conditions. In general, a prospective study design concerning internal and external risk factors in relation to gender and type of injury should be used. However, at least a case-control-design should be applied matching controls according to gender, age and skill level.

Gerhard Ruedl & Martin Burtscher
Department of Sport Science
University of Innsbruck, Austria

References

1. Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 2005; 39: 324-329.
2. Burtscher M, Gatterer H, Flatz M et al. Effects of modern ski equipment on the overall injury rate and the pattern of injury location in Alpine skiing. Clin J Sport Med 2008; 18:355-357.
3. Langran M, Selvaraj S. Increased injury risk among first-day skiers, snowboarders, and skiboarders. Am J Sports Med 2004;32:96-103.
4. Hagel B. Skiing and snowboarding injuries. Caine DJ, Maffulli (eds.): Epidemiology of Pediatric Sports Injuries. Individual Sports. Med Sport Sci. Basel. Karger,2005;48:74-119.
5. Goulet C, Hagel BE, Hamel D, et al. Self-reported skill level and injury severity in skiers and snowboarders. J Sci Med Sport 2008; doi: 10.1016/j.jsams.10.002
6. Bouter LM, Knipschild PG, Feij JA, et al. Sensation seeking and injury risk in downhill skiing. Person. Individ. Diff. 1988;9:667-73.
7. Cherpitel CJ, Meyers AR, Perrine MW. Alcohol consumption, sensation seeking and ski injury: a case-control study. Journal of Studies on Alcohol 1998;59:216-21.
8. Goulet C, Regnier G, Valois P, et al. Injuries and risk taking in alpine skiing. ASTM STP 1397, Skiing Trauma and Safety: Thirteenth Volume, RJ Johnson, P Zucco, JE Shealy (eds.), ASTM International, West Conshohocken, PA, 2000:139-46.
9. Aschauer E, Ritter E, Resch H et al. Injuries and injury risk in skiing and snowboarding. Unfallchirug 2007; 110: 301 306. (in German)
10. Brenner ND, Billy JOG, Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. J Adolesc Health 2003;33:436-457.
11. Mueller BA, Cummings P, Rivara FP, et al. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology 2008;19:270-76.
12. Koehle MS, Lloyd-Smith R, Taunton JE. Alpine ski injuries and their prevention. Sports Med 2002; 32 (12): 785-793.
13. Ruedl G, Sommersacher R, Woldrich T et al. A structured warm-up program to prevent injury in recreational skiers. Senner V, Fastenbauer V, Boehm H (eds.): Book of Abstracts of the 18th Congress of the International Society for Skiing Safety, Garmisch-Partenkirchen, Germany, April 26 to May 02 2009, 77.
14. Vandenbroucke JP, von Elm E, Altman DG et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Epidemiology 2007;18 (6): 805-835.
15. Ungerholm S, Engkvist O, Gierup J et al. Skiing injuries in children and adults: a comparative study from a 8-year period. Int J Sports 16. Ruedl G, Schranz A, Fink C et al. Are ACL injuries related to perceived fatigue in female skiers? ASTM International 2010; 7 (4), Paper ID JAI102747

Did you know that it costs $US 3 million to catch one football player using anabolic steroids? The total budget for testing for drugs in sport clearly exceeds $US 250 million – it is probably closer to $US 500 million annually. That’s a fair chunk of change. Good idea? Or is there a better way of spending all that money while still deterring drug use in sport. Not easy. Let us know what you think by emailing me via the BJSM Editorial Office: BJSM [at] bmjgroup [dot] com.