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Wimbledon! A day in the life of an All England Club SEM Physician – BJSM trainee perspective blog

13 Jul, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr. Ajai Seth

Sports and Exercise Medicine Trainee, MBBS, BSc, MSc, MRCS, MRCGP, MFSEM

Wimbledon 2016 image 2As a life-long avid tennis fan, I was thrilled at the opportunity to spend some time with the medical team at The Championships, Wimbledon. Wimbledon is the oldest, perhaps most prestigious tennis tournament in the world. Held at the All England Lawn Tennis Club (AELTC) since 1877 and currently the only Grand Slam tennis tournament to be played on grass.

Context

Wimbledon is a mass spectator event. Up to 39,000 people can be in the grounds at once. St John’s Ambulance provides medical cover for the crowd and most non-player staff members. For player medical care, the The All England Lawn Tennis & Croquet Club Limited (AELTC) employs a medical team for the duration of the Championships. The medical team at the All England club consists of 3 sports medicine physicians, 1 radiology consultant and a general practitioner who works with the AELTC full time (the Club doctor). In addition to this, there is a strikingly large number of other personnel employed by a variety of tennis organisations. For example, LTA, ATP, WTA and the AELTC. They may include physiotherapy, strength and conditioning, podiatry and massage therapy. Furthermore, top players may have their own entourage of coaching and fitness teams. All this adds up to an extremely busy working environment!

As you may expect, the medical team at Wimbledon hold a wide range of responsibilities. The Wimbledon qualifying event takes place the preceding week at the Bank of England sports ground in Roehampton. A whole host of other housekeeping tasks are associated with this event including: communications, dealings with the press, anti-doping and ensuring adequate medical staffing and equipment.

Pre-competition screenings

A change was made to the tennis calendar in 2015, pushing back The Championships by one week. This allows players more recovery time and transition after The French Open, the second grand slam of the year. Players therefore have an opportunity to use The All England Training club facilities prior to the tournament as well as during. These facilities include the use of 2 separate gyms, 22 practice courts, physiotherapy, massage services and 3 hydrotherapy baths, all at different temperatures. There is also offers a pre-competition opportunity for players to present injuries and seek advice from the medical staff. A sports physician may encounter: flares of chronic musculoskeletal injury, acute musculoskeletal injury and management medical conditions.  The majority of injuries presenting at Wimbledon are pre-existing or recurrent.1 Muscle and ligament injuries are the predominant type of acute injury in professional grass court tennis, with ligament and articular surface injuries being less common.1 Often, the player’s coach/team will attend the consultation and adjustments can be made to their training schedule. Occasionally players will want advice on whether they are fit to play or need to be rested.

Comprehensive AELTC player care

The vast majority of players rely on the medical expertise and diagnostic skills provided at tournaments as much of their year is spent abroad on tour. Therefore when they know good medical services are available, players may seek medical help for more chronic injuries. At the AELTC, they are able to get onsite ultrasound assessment by a sports physician with and offsite MRI assessment, interpreted by an experienced MSK radiologist. All members of the medical team have a vast experience of tennis medicine and years of medical experience at the Championships.

Wimbledon 2016 selfie

Wimbledon 2016 selfie with Professor Mark Batt, Medical Officer at Wimbledon

On the ground at Wimbledon

Perhaps one of the biggest challenges at the AELTC is navigation. Anyone who has been lucky enough to visit Wimbledon as a spectator, will have an appreciation for the complexity of the site layout, which includes 41 courts and a multitude of shops, restaurants and bars. Behind closed doors, there is a vast array of corridors, staircases, walkways and underground connections between the buildings. In order to provide effective medical and emergency treatment for players, it is vital that the medical team are aware of how to respond quickly and efficiently to incidents across the whole site with some courts being relatively difficult to access. It is also important to know how best to evacuate an injured athlete. This may not be as simple as it seems with many obstacles to negotiate. For higher profile matches with more media presence, it is not unusual for the doctor to be courtside, for example Finals Day.

Spending time at the AELTC with the medical team provided fascinating insight into what is involved in supporting athletes in perhaps the highest profile tennis tournament in the world. I would like to thank Professor Mark Batt and Dr. Ian McCurdie for this opportunity.

References

  1. Tennis injury data from The Championships, Wimbledon, from 2003 to 2012. I McCurdie, S Smith, P H Bell and M E Batt. Br J Sports Med January 11, 2016

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Ajai Seth is a Sport and Exercise medicine Registrar and General Practitioner in the West Midlands Deanery. His sporting interests include racket sports, football, athletics and expedition medicine. He is currently Birmingham City Academy and GB para-archery doctor.

Farrah Jawad is a sport and exercise medicine registrar in London and co-ordinates the BJSM Trainee Perspective blog.

The Maria Sharapova drug story: What’s the evidence? Does Meldonium treat heart conditions and diabetes?

17 Apr, 16 | by Karim Khan

By David Nunan @DNunan79

SharapovaMany have commented on the how, who, what and ethical implications following Maria Sharapova’s shock revelation of her failed drugs test. Few have looked in more depth at the why?

The evidence for “why?” in this case falls in to two key areas. First is the evidence that Mildronate (or Meldonium) is indicated for the conditions Maria was taking it for, apparently to “combat a magnesium deficiency, heart problems and because of a family history of diabetes”.

Second, is the question of whether the drug enhances exercise and sporting performance. I will tackle the second issue in my next blog; here I focus on the question:

“What is the evidence for Mildronate/Meldonium to treat heart problems (abnormal ECG), indications for diabetes (familial history) and magnesium deficiency in a 17-year-old athlete?”

Meldonium’s Wikipedia page provides background information on the drug, such as common trade names (“Vazonat”, “Idrinol”, “Msmall”, “Quaterine”, “MET-88”, and “THP”), its chemical name (trimethylhydrasine), one of its Latvian manufacturers, Grindeks, and its widely adopted use throughout Latvia and other Baltic states. It isn’t licensed in the United States or Europe.

A number of clinical trials are cited, unfortunately the links to each of these are dead but they all appear to be conference proceedings.

Grindeks’ own website highlights pre-published results from a 2010 Russian/Latvian/Lithuanian/Ukrainian collaborative phase III RCT. Mildronate proved safe and effective for treatment of angina. The drug’s creator wrote:

“As the author of this medication I have always been sure about the therapeutic effectiveness of Mildronate®…” and “[R]esults of the just-finished multinational clinical trial once more approve effectiveness and the high safety of Mildronate® in the treatment of angina in combination with the standard therapy.”

The webpage does not provide enough detail to ascertain if the study was published in a peer-reviewed journal nor if the protocol was pre-registered.

However, a bit of digging around the website reveals a publication for this study in Seminars in Cardiovascular Medicine.

A double-blind, placebo-controlled trial in 371 chronic CHD patients with stable angina aged between 24 and 82 yrs of age (mean ~61 yrs) was performed to assess the effect of 12 months treatment with mildronate on exercise capacity as primary outcome (so not angina onset). In the 278 that completed the study (no details given for drop outs), patients randomized to mildronate improved performance on a cycling ergometer test by an average of 55 seconds.

My comparison of the study against the CONSORT statement suggests several limitations. I couldn’t find methods for (i) the sequence generation of the random numbers needed for randomisation, (ii) allocation concealment or (iii) blinding of investigators. Again, diverging from CONSORT, there is no statistical analysis section. Therefore, I respectfully posit that the findings from this paper would be classed as having risk of bias for internal validity. This would be considered a limitation were a group like the FDA (Federal Drug Agency) asked to approve the drug for clinical practice.

There appears no pre-registered protocol although reporting bias based on methods described in the paper appears low. Adverse effects were not considered as an outcome nor any reported. No information on funding is given and no conflicts of interest are stated. The study lead author and one of its principle investigators are Editors for the journal in which it was published.

But I’ve just committed one of the sins of a none-EBM approach – cherry-picking (2nd definition in link). Perhaps you want a more systematic approach?

A search of PubMed for “Mildronate” OR “Meldonium” gives 217 returns, 108 of which are in Russian. Filtering for systematic reviews in humans – which would give the highest level of evidence for the efficacy and effectiveness as a treatment for these conditions – gives zero returns.

Filtering for the next level of evidence (RCTs) and only for Mildronate/Meldonium or its drug class gives 22 hits (Figure 1); 11 of which are RCTs (9 in Russian), 4 pharmacokinetic studies (all in English) and 7 studies (all in Russian) where study design/methods are unclear.

Fig1BLog

Studies were published between 1989 and 2015. The study already looked at in detail on the manufacturer website was not picked up in the search.

First thing of note is that there are a number of RCTs assessing the efficacy of Mildronate/Meldonium but no systematic review.

Ascertaining details from each of the 11 RCTs is limited by language restrictions. It appears the largest included 512 patients and the smallest only 35. Clinical conditions assessed in each trial are listed in Box.

 

Patient populations included in 11 RCTs of Mildronate/Meldonium

Coronary heart disease (CHD) [2 studies]
Post MI heart failure with [2 studies] or without [1 study] type 2 diabetes (T2DM)
Ischaemic stroke [1 study]
Post MI [1 study] and after PCI [1 study]
CVD [2 studies]
T2DM with neuropathy [1 study]

I note that I cannot read the Russian papers so my comments are restricted to English language papers. It may be that the Russian studies are high quality and cover off the limitations I see in the English language publications. Only one of the English language studies was pre-registered. However, this was done after the trial had started. (On a separate note, I have many reservations about current processes for trial registration — more on this issue here).

None of the English language studies assessed patients with ECG abnormalities specifically (although these will be indicated in a number of the patient groups), nor pre-diabetes or magnesium deficiency, nor in adolescents!

Focusing on English language evidence of the drug for treating ECG abnormalities, the abstract from one study reports a trial of 1000mg/day intravenous Mildronate for 10-14 days in 30 patients aged 45 to 75 years with CHD led to “a decrease in the number of arrhythmia episodes.”

A second English language trial abstract (with only 2 authors) reported that 12 weeks Mildronate (no information on delivery or dose) “decreased the number of epinventricular extrasystoles (p = 0.002) and the number of paroxysmal rhythm disturbances (p = 0.001)” in 67 myocardial infarction survivors aged 40 to 70 years of age.

It’s not possible to assess the risk of bias, the source of funding or conflicts of interest for these English language trials. Neither trial was pre-registered. Taking a leap of faith, let’s assume these trials are at low risk of bias/no conflict of interest etc., they suggest that short-term (intravenous) use of Mildronate may reduce the frequency of ECG abnormalities in people aged 40 to 75 years of age and suffering from CHD or having survived a myocardial infarction.

But these English language studies are too small to be conclusive. A lack of information on delivery mode in one trial impacts on external validity as it is sold to be taken either orally or intravenously.

So what about treating ‘indicators for diabetes’?

Tne trial reports “a statistically significant improvement in renal functioning: GFR [glomerular filtration rate] increased by 20% vs 2% (p < 0.05); proportion of patients with exhausted FRR [function renal reserve] decreased (p < 0.05)” and “A hypoglycemizing ability of Mildronate was noted” in 30 patients aged 43 to 70 with heart failure and T2DM randomised to 1 g/day Mildronate (no information on delivery mode) for 16 weeks.

A second open label trial by the same group found “Mildronate administration improved clinical condition of the study group vs controls by neuropathy and symptoms count scales.” in 70 patients with T2DM & neuropathy randomised to 1 g/day for 12 weeks.

Again, it’s not possible to assess bias and potential conflicts of interest. External validity would appear poor given the patient population and no data on glycaemic control!

Evidence for Mildronate/Meldonium in magnesium deficiency is easy! However, cardiac arrhythmia may be a symptom of a magnesium abnormality (too much or too little) that provides a (albeit poor) mechanistic link for Mildronate/Meldonium use.

Overall, there is some English-language evidence from a few small RCTs that short-term use of Mildronate/Meldomium at 1g/day (intravenously but possibly orally) reduces occurrence of cardiac arrhythmia in high risk (older) patients with CHD. It may also improve renal function in heart failure patients with T2DM and neuropathy symptoms in T2DM.

However, the English-language trials providing this “evidence” are very likely too small and there is high uncertainty about the risk of bias, the quality of the data, conflicts of interest and a lack of data on potential harms.

The question begs “Does the evidence support the decision of the family physician to prescribe Mildronate to a year 17 year old athlete for *treatment* of an abnormal ECG, indicators of diabetes and magnesium deficiency over a 10 year period?”

What would you say if you were on the jury?

In my followup blog (Next week!) I’ll examine whether Mildronate/Meldonium appears to enhance performance.

———————

DavidNunan

David Nunan is a Departmental Lecturer and Senior Researcher at the Nuffield Department of Primary Care Health Sciences, University of Oxford. He is also a senior tutor at the Centre for Evidence-Based Medicine and a member of the Evidence Live 2016 local organising committee.

Follow @dnunan79

 

 

Tennis: Field-based fitness tests – the 7 domains every coach needs to test

2 Sep, 14 | by BJSM

By Dr. Babette Pluim (@DocPluim)

tennis ball and racketAt the start of the indoor tennis season, many fitness trainers and coaches use a set of ‘fitness tests’ to evaluate their junior player. What they really want to know is whether they have a new Federer amongst their pupils (talent identification), what strengths and weaknesses the player has (injury prevention), and their basic fitness level (periodisation).

Which tests do I recommend? There is no simple answer. Test choice depends on availability of facilities, time, finances, and the ultimate purpose of testing.

Do you want to know if your player has a good basic fitness level? Do you want to see how fast and strong they are in comparison to other players? Or is your primary goal just injury prevention?

This video gives an impression of a testing day of the junior players at the Dutch Tennis Federation (KNLTB):

https://www.youtube.com/watch?v=HPdQQP16D7g&feature=youtu.be

In a BJSM open-access overview article, Jaime Fernandez-Fernandez and colleagues describe all the existing physical tests for tennis and discuss their advantages and disadvantages. They also include a summary table of recommended tests. The full article and table are available HERE.

Tennis involves short bursts of intense effort (rallies last 2-10 seconds), followed by breaks of 10-25 s (between rallies) and longer breaks of 60-90s during the change of ends. A typical 3 set match lasts about 1.5 hours, but this varies depending on playing style, level of competition and court surface. A player must cover a mean distance of 3 meters to reach the ball, runs 8-15 m with 3 to 4 directional changes per point, hits the ball 4 to 5 times per rally and covers 2.5-3.5 km per hour of play. During singles matches, the mean heart rate is 70-80% of maximum with peaks of 100% and the mean oxygen uptake 50-60% of VO2 max, peaking at 80%.

Thus, for optimal tennis performance and a rapid recovery, a player needs speed, strength, agility, power and, a good level of basic fitness. Below I discuss the commonly used field tests for a high level, tennis performance program. These are generally cheaper than those used for indoor or laboratory-based testing and are more suitable for large groups of players. If you are interested in laboratory based testing, please refer to the original article.

1. Aerobic endurance

Most tennis federations choose the shuttle run, the Yo-Yo Intermittent Recovery Test or the 30-15 Intermittent Fitness Test. Unfortunately, relatively little normative data is available for young tennis players and the tests are not quite equivalent to the loads in tennis.

Several researchers have tried to develop tests, which mimic the game itself by using the dimensions of a tennis court, and involve tennis strokes in addition to running ability. Weber has developed a test using a ball serving machine in which the ball is hit alternately to the left and right corner of the court and the player must run faster and faster to hit the ball back. However, the quality of the stroke is rapidly lost, you can test only one player at the time, it is not very realistic in tennis terms – and you need a ball machine to perform the test!

There are two other field tests that involve simulated tennis strokes – the Girard test (2006) and the hit-and-run test but I would opt for one of the simple tests (Shuttle run or Yo-Yo IR test). These have the additional advantage that if you measure heart rate, you can monitor progress without having to perform a maximal exercise test.

2. Anaerobic endurance

Anaerobic endurance can be measured relatively easily in the laboratory using a 30 second Wingate test and, in the field, you can use a repeated sprint test. Since there is a high correlation between the speed of a single sprint test (20 meters) and repeated sprint tests (e.g. 10 x 20 m.), a single sprint test is usually sufficient.

3. Strength

Using gym-based equipment, dynamic strength can be measured with a 1 Repetition Maximum (1RM, the maximum weight that can be lifted with one repeat) but this is associated with a high rate of injury so I would recommend using multiple repetitions at the start of the season (e.g. 3RM, 5RM or 10RM).

4. Power

In the field, jumping height measures lower extremity power, and throw distance of the medicine ball measures upper body power. These tests are widely used by tennis nations, so there is plenty of normative data available for these tests.

Radar speed gun measures speed of service and ground-strokes and this has a reasonably good correlation with the tennis ranking.

5. Speed ​​

Electronic interval timing equipment measures speed in the field – a stopwatch is simply not accurate enough. The 20m sprint (with split timing at 5m and 10m) has a high reliability and, because most tennis nations use it, has adequate normative data for the various age groups.

6. Agility

Agility is the ability to change speed or direction quickly and research shows that this is clearly different from pure sprint speed. Agility is usually tested using a noise (acoustic) or light signal as seen in the hexagon test, the spider test, and the Illinois agility test .

7. Musculoskeletal system

A general assessment of the musculoskeletal system is normally included in any screening protocol and a physiotherapist often conducts this. The United States Tennis Association (USTA) have developed a dynamic examination protocol specifically for tennis (High Performance Profile), but unfortunately they do not provide normative data (read more HERE ).

7. The Functional Movement Screen (FMS) is probably the most popular tool internationally and is used by physiotherapists to detect weaknesses and asymmetries of the musculoskeletal system with a view to implementing injury prevention strategies.

If you choose one or two simple tests from every domain, you and your player(s) will have more than enough to work with during the upcoming tennis season.

Useful link:
The test protocol guide of the German Tennis Federation can be found HERE

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Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer, KNLTB,Netherlands). She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

Eat, drink, and win? Diet lessons from Novak Djokovic, the 2014 Wimbledon Champion

7 Jul, 14 | by BJSM

By Dr. Babette Pluim (@DocPluim)

Ever since Novak Djokovic wrote his book “Serve to Win”, a hot debate surrounds tennis players diets. Should they all eat gluten-free foods? Will that bring them instant fame and fortune?

Gluten-free?

In his book, Djokovic describes his diagnosis of a strong intolerance for wheat and dairy, and a mild sensitivity to tomatoes. Cutting out gluten from his diet resolved his gastrointestinal complaints, his asthma symptoms (possibly the so called “baker’s asthma”?) and restored his energy levels. While reviewing literature to write this blog, I was actually surprised to read that sensitivity to wheat in the general population (assessed by IgE) is around 1% (Fasano 2003). This percentage is much higher than I remembered from my textbooks (0.01%). So if a player has vague gastro-intestinal symptoms that you can’t pin down, it may well be useful to test for gluten sensitivity. However, we may assume that the current rush by tennis players to embrace a gluten-free diet is not based on a tidal wave of positive jejunal biopsies!

Djorvak takes a drink webWhole foods and protein?

In his book, Djokovic touches on a number of issues worth copying. They are useful tips for anyone, not just tennis players. If you ignore the more eccentric parts, it is actually good sport science (Rodriguez 2009). He places an emphasis on a good, healthy breakfast with plenty of carbohydrates with a low glycemic index – the ones that take a bit longer to digest. This means that he will not simply eat “empty” carbohydrates, but that his breakfast will include fruits, nuts, seeds, grains and quinoa (full of fibre, vitamins, minerals, and other micronutrients).

He likes a protein drink after play and recommends proteins (white meat and fish) and vegetables in the evenings, to enhance recovery. I would personally recommend that you throw some carbs in there as well, to restore the depleted glycogen stores of the muscles and liver; weight gain will not be an issue if you have another heavy work out scheduled for the next day! Timing the protein intake (during and immediately after exercise and at night) is something that has gained more credibility lately for adequate muscle restoration and buildup.

Sports drinks?

When it comes to drinks, Djokovic does not seem to have a single preference. He recommends water in the morning, energy drinks with fructose and hydration drinks during workouts, and protein drinks after play. Professional tennis players usually drink both water and sports drinks during a match. Other players have their own particular preferences and you can see Rafael Nadal shouting out for his recuperation drink on YouTube (see https://www.youtube.com/watch?v=twL0bz6saqs). Players should always start a match well hydrated, and drink enough during a match to balance fluid losses. The advantage of tennis is that players have ample opportunity to drink during changeovers. This is in contrast to football, for example, where extra drinking opportunities had to be created during the World Cup. Tennis players can take a few sips every time they change ends and simply drink to thirst, without the need to force fluid intake. In addition to water, sports beverages also contain the carbohydrates and electrolytes that are recommended to help maintain blood glucose concentration, provide fuel to the muscles, and decrease the risk of dehydration and hyponatraemia (Périard 2014; Kovacs 2006). However, energy drinks with very high concentrations of sugar and caffeine are generally not recommended during play.

A bite to eat?

Another advantage that tennis has over other sports is that players can graze during change overs – the most popular products being bananas, sport bars, energy gels and sweets. Djokovic admits that he sometimes uses a power gel with 25 mg of caffeine before matches if he really wants to be fired up.

Low carb – high fat (LCHF)?

The LCHF debate does not seem to have hit the tennis scene (yet), so I will stay out of that minefield and reduce the Twitter dialogue from South Africa (https://soundcloud.com/bmjpodcasts/high-fat-for-health) !

Does the 2014 Wimbledon Champion play so well just because he eats well?

No, it’s far more complicated than that – growing up and playing tennis in a war zone, exercising up to 8 hours a day, doing lots of mental exercises, having a fantastic team around him, taking care of his body with stretching, strengthening and massage are just a few of the factors that have moulded a tennis superstar.

On what it takes to be a top level tennis player, the man himself says: “I would say 10% is talent, 85% is hard work and 5% is luck.” Novak simply fails to mention his diet!

References

Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med 2003; 163:286-92.

Rodriguez NR, DiMarco NM, Langley S. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. J Am Diet Assoc 2009; 109:509-27.

Périard JD, Racinais S, Knez WL et al. Coping with heat stress during match-play tennis: does an individualised hydration regimen enhance performance and recovery? Br J Sports Med 2014 (suppl 1); 48:64-70.

Kovacs MS. Carbohydrate intake and tennis: are there benefits? Br J Sports Med 2006; 40:e13.

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Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine. She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

 

Novak Djokovic shares his sportsmedicine secrets for success

28 Jun, 14 | by BJSM

This interview was originally published in 2013 in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital

You can subscribe for free and have the Aspetar Sports Medicine Journal delivered to your door – yes, full colour, hard copy to your door. Google ‘Aspetar Sports Medicine Journal’ and enter your address. Easy. No spam. Just good quality sports medicine content.

DvorskyInterview by Dr Bane Krivokapic

Whether he’s on court or off, Novak Djokovic gives 100% of himself. His fitness and flexibility have helped him climb to the World No. 1 ranking. His humanitarian projects and on-court antics have made him a crowd favourite. Not only can he play and win the longest matches the game has ever seen (remember the 2012 Australian Open Final? Or Wimbledon 2013?), but he can play up to an international audience across dozens of media channels. And then return to do it all again in the next tournament in a different country, on a different surface.

The 26-year-old Serbian has taken the art of recovery to a whole new level, but the secret to his success, he says, is his team and family. They are the ones who have helped him become a 6-time Grand Slam Champ. Well, that, and eliminating gluten and sugar from his diet, as he tells us here.

How do you feel after playing a match that lasts for many hours? E.g. Australian Open final against Nadal

If you win the match, then you feel fantastic, no matter the amount of hours spent on court. But if you lose, then you can feel really bad, which is normal – you know you gave it all, you fought to the last drop of strength on court, and you lost. That is not easy to handle every time, especially in Grand Slams. But, this is a sport where you can always get another chance, every week there is a new tournament, new challenge. So, you learn from what happened, and turn to what’s coming.

How much time do you need to recover from such an extreme effort?

Tennis trains your body and mind to recover fast from a very early age. Because the season is so long and we play week after week, we don’t really have time to recover our energy to its fullest. You have to factor in different time zones, different climate, food, courts, balls… So your body is always adjusting to something and recovering from something. Not to mention your mind – you have to be able to resist the temptation to just stay in bed and give in to laziness after a long flight, training or match. You have to resist the urge to give up when you lose a point, a game or a set because in tennis, you always get another chance. If not in this game, then in next one; if not in this set, then in the next one. If not this week, then there is the next one. So we get one or two times per year to fully recover. Everything else is just grinding, and not giving up when going gets tough.

What is your recovery routine?

I have a great team of people around me that do the best they can with their expertise to make me feel physically, mentally and emotionally ready for every match and every challenge, and they then help me to recover later on. We have a standard routine after the matches which I don’t like to talk about, but it’s not a big secret. We do the stretching part, ice-baths, massage and similar things that are common in our sport. The main thing is to find the right balance and to understand the true limits of your body.

You give the impression that you are always physically prepared. What advice can you give to other athletes about fitness?

Every player is different, and there is no unique rule or advice. My team and I, as an example, love to be in nature so most of the things I do, I try to do out of the gym if I can. I bike ride, swim, run, play football, basketball. Every day we focus on different parts of the body. My advantage is my flexibility. My muscles are elastic and I spend a lot of time on stretching because that prevents injuries and keeps my body fresh.

How do you personally maintain your health?

I have to thank my diet for that. Eating healthy food helps me stay energised, healthy, pain free and injury free. I talked a lot about this in my book Serve to Win. We are all different and one rule cannot apply to all of us, but I did give some advice on how to find the right formula for your body that will help you stay healthy and happy.

What motivates you?

Love. Love is what keeps me going every day. Love for life, for this beautiful sport, for my family and fiancé and my team. I enjoy playing tennis and love competing. The fact that I am successful at what I do gives me an incredible opportunity to help others less fortunate than I am. I am never lacking motivation to go out there and give my best.

What is the mental game of tennis like? How do you prepare yourself in terms of psychology?

I have certain techniques that help me such as visualisation, meditation, relaxation or quite simple things like walking through a park which does miracles sometimes, I must say.

You often joke around on court – does this help your mental game?

One of my mottos is to be who I am and not pretend to be somebody else. I think that kind of thinking got me to where I am. Apart from being very serious and business-like when I go out on court to play, at the same time I really enjoy those moments and sometimes I like to show it and share it with the crowd.

Who makes up your medical staff?

I don’t really have a medical staff. I mainly visit doctors who have high expertise in working with professional athletes and I’ve been very fortunate not to need any medical assistance in the past few years.

Who do you travel with? A physiotherapist? A doctor?

I don’t travel with a doctor. We do all the necessary tests several times a year, so there is no need for him to be with me at tournaments. On the other hand, a physiotherapist is a crucial part of my team. I work with Miljan Amanovic, my close friend. We have been working together since 2007, when I was number three in the world. He helps me to recover, to prevent injuries and to get my physical condition in the best possible shape. He knows exactly what I need in every moment, which is not an easy task. But, he does it in a magnificent manner, as you can see. We are together for 9 months of the year, and when Miljan is not able to travel with us because of his family, I work with another physio, Saša Jezdic, a great professional and expert. I also travel with Marijan Vajda, my tennis coach, and Gebhard Phil-Gritsch, a fitness coach. We are a team with a capital T.

Who makes the decisions when it comes to your health, you, your doctor or your coach?

I never try to make decisions on my own because even though it’s an individual sport, it’s a team effort in the end that really counts. So the whole team discusses everything that is affecting my game and career, including health.

How much do you believe in the doctors you see?

I am very fortunate to be surrounded by great people who are excellent at what they do. I am certain that doctors I meet during the tournaments and between tennis events are all professionals, therefore there is no reason for me not to trust them. Thank God I am still healthy and young so I don’t need their assistance that much. But I am definitely not the person who will take ‘a pill for every ill’. I strongly believe that our body is able to heal itself if we give it time, and if we eat the right food. On top of that, I observe my body as a whole and don’t think that a headache is just a headache. I always try to understand and respond to the signals my body is sending to me.

You are obviously very close to your team. How does that contribute to your playing?

Without their support I would never be so successful. They mean the world to me. Each member of my team has its own obligations, but we work best as a team. We talk about everything, listen to what everyone has to say and we respect each other. It is a co-operation based on trust, hard work and professionalism, which is a winning formula in my opinion.

What is your relationship like with your coach?

My coach, Marian Vajda, is like my second father. We are more than a coach and a player. He is a very emotional guy and we have a lot of fun off the court which is very important to me. Marian is a good spirit of the team who brings positive energy.

He has contributed a lot in my career. Since we started working together I have won every singles title with him. We have gone through highs and lows, not just in my tennis career but also in my private life. He is the person I can talk to and he is like a part of my family.

Now that you eat gluten free, how do you keep your energy up without large carbohydrate loads?

Being gluten free today is so much easier than couple of years ago. Everywhere you turn you can find gluten free products so I am not really missing out on carbs. My diet is thoroughly explained in my book, so I definitely encourage you to read it.

How do you feel now that you’ve given up gluten?

I feel great. I feel more relaxed, more focused and more in control of my life in general. I’ve learned to sync food with my body’s needs, giving it exactly what it wants, when it wants it. It probably sounds strange to say I feel more relaxed and at balance but it’s true. I am at one with my body – I feed it with the right energy and in return I get a healthy and energised body. My mind and body are now more focused on performance than on masking or fighting pain.

Are you strict about any other foods? Have you cut out anything else?

I am strict about being healthy. I don’t enjoy feeding my body with junk food. It’s funny how after a while of eating right, your body immediately detects the wrong food and rejects it. In the past, every time I ate something ‘sinful’ and took something that was not a ‘healthy’ choice, my body reacted immediately and I would regret going that way. So, I cut out gluten from my life and it was the best decision ever! I also cut sugar and dairy to certain extent. The bottom line is that I am not missing anything, I am replacing junk with good and that cannot feel bad to me or my body.

How tough is it to be a high level tennis player?

It is not easy, I can tell you that. It has its ups and downs. You have to sacrifice a lot in life to be on top. High level tennis players are like Spartans, in a way. From early morning till evening we have a strict schedule of things we must do – four to five hours of practice each day, no matter if it’s 50 degrees outside. Fitness work, gym, running, ice-baths and a controlled diet are just a small part of it. Not to mention commitments to sponsors and tournaments. We travel so much, that sometimes we wake up not knowing which city or country we are in. When you are a top player, there is enormous pressure that you must win every single tournament and beat every opponent. But, I guess that’s the case with every job. If you want to be the best at something, you have to work hard; pressure is a privilege that we must earn. I enjoy tennis – it’s my life and it has given me everything. I breathe tennis and I must say it’s the best thing that has happened to me, so far. So all these things I mentioned I accept as a toll on the road and I keep going straight.

To be a high level tennis player, what percent is talent and how much is hard work?

It depends a lot from person to person, but I would say 10% is talent, 85% is hard work and 5% is luck.

The ATP tour is played on many surfaces. As an athlete, is changing surfaces good or bad for you?

It is always a challenge to change surface in a very short period of time. You have to adapt to different conditions, which is not easy, both physically and mentally. But tennis-wise, I guess the game would be quite boring if we constantly play on clay, for example. Different surfaces give opportunities to different players to show what they know, and this variety is always a good thing in sport.

When are we going to see you in Doha?

I play in Abu Dhabi every year in the Mubadala World Tennis Championship. If I find free time, I would be more than happy to visit Qatar, too. I respect all that the Al Thani family is doing for the country, and I have heard great things about Doha and its marvels. I am sure I will visit Qatar much before the FIFA World Cup in 2022.

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.

 

Increase in tennis injuries at the Australian Open – media hype or evidence based

28 Jan, 14 | by Karim Khan

 By tennis physician, Dr Babette Pluim (@DocPluim)

It was an exciting Australian Open this year, with magnificent tennis, thrilling matches and sizzling heat. The end was a bit unexpected, almost an anti-climax, with Stanislaw Wawrinka seizing the title over an injured Nadal – the first man since 2009 to win a Grand Slam outside the ‘big four’ of Federer, Djokovic, Murray and Nadal.

Nadal’s back problems immediately stirred up debate, with some contending that tennis these days has become so physical that injuries are virtually unavoidable. Is this true? Do we see more injuries now than before?

A recent study by Sell et al. can help us answer this question. [1] They looked at injury data from the US Open over a 16-year period, from 1994 to 2009, to see if they could decipher a trend. As the US Open is one of the four Grand Slams and like the Australian Open played on hard court and in hot weather conditions, these data may apply to the Australian Open as well.

Their main findings were that there were significant fluctuations in injuries from year to year, but there was only a minor and not a statistically significant upward trend. The ankle, followed by the wrist, knee, foot/toe and shoulder were the most common injury sites. Acute injuries occurred more often than gradual-onset injuries, and muscle and tendon injuries were the most common type of injuries. 15% of all acute injuries involved the trunk, and the overall incidence of lower back injuries was 2.3 per 1000 match exposures.

So the low back is not the most common type of injury, but as we could see in Nadal, quite debilitating. So what caused it? As we could see in the Wawrinka-Nadal match, Rafael had trouble serving.

The strain on the back during serving has been studied by Campbell et al. [2]. The authors compared players with and without low back pain, and found that the players with low back pain had significantly higher lateral flexion forces on the non-dominant side during the driving phase of the serve and both groups had high vertical forces. These forces are approximately eight times those experienced during running. Interestingly enough, both the flat serve and the kick serve created high lumbar loading, challenging the popular perception that only the kick serve is “bad for the back”. This study shows that repetitive, powerful serving places high stress on the back and may result in injury.

The final question is: what type of injury? We do not know the diagnosis in Nadal’s case, but we know what the typical findings are in a large cohort of tennis players. Alyas et al. [3] studied 33 asymptomatic tennis players (mean age 17.3+/-1.7 yrs) with MRI and found that only 5 (15%) had a normal spine. All the others (85%) had abnormalities in their spine, including pars lesions (9 players), facet arthropathy (23 players) and disc degeneration and bulging (13 players) and synovial cysts (14).

We can look at this two ways: 1) tennis players are at high risk for abnormalities of their lower back and 2) tennis players can be asymptomatic and pain-free, despite abnormalities of their lumbar spine on MRI. Rumour goes that a new study will come out with the findings of 100 asymptomatic tennis players, and I would be really interested to see that study!

As far as Nadal goes I think it is fair to say that it took courage and strength to continue play despite his lower back injury – he fought and lost in style. I wish him a speedy recovery!

 References

  1. Sell K, Hainline B, Yorio M et al. Injury trend analysis from the US Open Tennis Championships between 1994 and 2009. BJSM 2012 Aug 25 [Epub ahead of print].
  2. Campbell A, Straker L, O’Sullivan P et al. Lumbar loading in the elite adolescent tennis serve: link to low back pain. Med Sci Sports Exerc 2013;45:1562-8.
  3. Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med 2007;41:836-41.

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Babette Pluim  is a Sports Physician KNLTB and Deputy Editor BJSM. Tennis, healthy lifestyle, injury prevention, sports medicine education. Follow her on twitter:  @DocPluim

Australian Open – Hot Tennis. To play or not to play? That is the question!

18 Jan, 14 | by Karim Khan

By tennis physician, Dr Babette Pluim (@DocPluim)

RodLaverThe scorching Australian Open has stirred up debate as to how safe it is to play tennis under extreme conditions. Some claim that it is part of the game, just like wind, rain, and playing late at night and that you just have to deal with it. Prepare, and try to beat the heat!

Others find the conditions to be unacceptable and too dangerous for health, and argue that play should be stopped when drinking bottles start melting on the court surface. Their main concern is that the extreme heat may lead to severe heat illness and possibly even the death of an athlete.

Emotions run high in these heated conditions, so let us try to separate fact and fiction by using available science.

Facts:

A number of studies have investigated the thermoregulatory response of tennis players to heat stress.[1-3] These show that core temperature can be maintained at a safe level across a wide range of environmental conditions and is determined mainly by the intensity of the exercise and the resulting metabolic rate. The cooling mechanisms of the body (sweating and cutaneous vasodilatation) work in optima forma under normal environmental conditions and thermal equilibrium is reached and maintained after approximately 40 minutes of tennis match play.

However, in hot ambient conditions, core body temperature (CBT) is determined not only by the metabolic rate, but also by the environmental heat load.[3] The body’s cooling system has to work hard to reduce excessive heat when both the metabolic rate and environment heat load are high, causing extra strain on the heart. Work by Périard et al, who studied male tennis players during tennis match play in cool (~19°C WBGT, 22ºC) and hot weather (~34°C WBGT, 37ºC), showed  mean CBTs of ~38.7ºC under cool and ~39.4ºC under hot conditions, respectively.[3]  In addition, adverse environmental conditions (e.g. high air temperature, high humidity, solar radiation and no wind) will result in a high skin temperature and increased thermal discomfort (irrespective of the actual CBT).

As thermal discomfort increases, players decrease the pace of the match, which results in a drop in metabolic rate: an excellent example of autoregulation.[1,3] Players will generally take additional measures to cool their bodies and may use fans, ventilators, parasols, ice vests, ice towels, and cold water. BJSM’s ‘Online First’ includes a systematic review on the effect of cooling by Professor Christopher Tyler (UK). Currently the heat rules in tennis allow juniors, women and seniors to have a ten-minute break – and 15 minutes for wheelchair tennis players – between the second and third set to allow some extra time for cooling the body when the WBGT hits 30.1°C. This can reduce the CBT by 0.25°C.[4]

When must play stop?

But is there an air temperature or a WBGT when CBT will continue to rise over 40°C up to 42°C, because the environmental heat load is so high and the metabolic heat production so great that equilibrium cannot be reached? When are tennis players at risk of developing hyperthermia and possibly heat stroke and multi-organ failure? When do we need to stop play?

Cooling is easier in tennis than in some sports. American Football is requires players to wear protective clothing and running requires high intensity continuous work. In those sports, heat illness is more common than in tennis.

However, even the tennis player may be at risk if he/she is ill (cytokines raise the temperature set point), is severely dehydrated (less circulating blood to the skin and less cooling), has an underlying heart condition (increased strain on the heart) or has autonomic dysfunction (high spinal cord injury, less sweating). In these situations, great care must be taken to protect the players from potentially life threatening heat illness or heart problems.

This year’s Australian Open has illustrated that there should be an upper limit above which play should be suspended, even for healthy athletes. This upper limit seems to be around an air temperature of 42°C-43°C or a WBGT of 32°C; if not for the players, at least for the long-suffering spectators!

 References

1. Morante SM, Brotherhood JR. Air temperature and physiological responses during competitive singles tennis. Br J Sports Med 2007;41:773-8.

2. Hornery D, Farrow D, Mujika L, et al, An integrated physiological and performance profile of professional tennis. Br J Sports Med 2007; 41:531-536

3. Thermal, physiological and perceptual strain mediate alterations in match-play tennis under heat stress. Périard J, Racinais S, Knez W, Herrera C, Christian R, Girard O. Br J Sports Med 2014  (accepted)

4. Tippet M, Stofan J, Lacambra M, et al, Core temperature and sweat responses in professional women’s tennis players during tournament play in the heat.  J Athletic Training 2011, 46:55-60

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Babette Pluim  is a Sports Physician KNLTB and Deputy Editor BJSM. Tennis, healthy lifestyle, injury prevention, sports medicine education. Follow her on twitter:  @DocPluim

 

 

 

 

Dr. Babette Pluim: Living the Olympic Dream

22 Aug, 12 | by Karim Khan

By Dr. Babette Pluim (@DocPluim)

To work at an Olympic Games is a dream for every sport physician. So, in 2011, I applied to LOCOG as a volunteer. The minimum commitment was ten days, with an option to do both the Olympics and Paralympics. Nothing could hold me back at the interview. Yes, yes, yes, put me down for everything that is going. Needless to say, every day of sunshine is followed by a cloudy day or two. I did not realise that there were possibly going to be a few spots of rain along the way!

Preparation

The fact that I live in the Netherlands is not LOCOG’s fault but I had to fly back and forth from Amsterdam to London for: my orientation training (a 2-hour rah-rah bonding session), the role-specific training (some general pre-hospital care training and role play), the venue-specific training (in my case, a guided tour of the Olympic Stadium with role play), my GMC interview and accreditation, and finally for LOCOG accreditation and uniform collection. None of these could be squeezed into one visit so I had already visited London five times (along with all the other medical volunteers) and the Olympics hadn’t even started yet. But hey, if the athletes can show commitment and determination, so can I! Armed with my stylish purple/pink uniform, I was ready for anything!

There was a slight problem with scheduling. Working 7 days in a row is much easier to fit into a busy work schedule than 7 spread over 17 days. One day on duty, followed by three days off, two days working. 1 day off etc meant that I now had to take six weeks unpaid holiday to cover both the Olympics and Paralympics. Not an insurmountable problem, but slightly unexpected, so a gentle request and a flurry of e-mails resulted in a rescheduling of the Paralympics duties (consecutive days to 9), and I was down to only five weeks away from paid employment.

My first shift

For my first shift I was a bit nervous. It was on the 25th July before the Games had started – the day of the rehearsal for the Opening Ceremony. My shift started at 3pm but we had been told to arrive two hours early and to allow one hour for security. Security actually took three minutes and I never had a delay of longer than five minutes at any time during the Olympics – top marks to the military who were fast, friendly and forever courteous.

As a result, we all gathered in the dining area in good time and right at 1pm the LOCOG staff appeared and split us into two groups: first aid for the crowd and field of play recovery teams. I was in the field of play team (16), normally only responsible for athletes and officials, but today we would also be responsible for the 7,500 people participating in the opening ceremony.

We were taken to the venue medical area under the stadium. The 16 of us were split into 4 groups of 4. My group consisted of a sports physician (me), an anaesthetist, an A+E specialist and a paramedic. The arena field of play had 5 major entrance/exits, referred to as VOMs, one at each corner and an extra one under the Olympic flame. We were evenly divided over the 4 VOMs, and every group had to cover his/her quarter of the track.

Working as a team 

For the first two hours, we did pre-hospital care training (role play) as a team, and practiced resuscitation and recovery scenarios. How would you handle: an official who was hit on the head by a discus, or three hurdlers who collided and ended up with one shrieking loudly, one lying silently, flat on his stomach, and one with his lower leg angled in a funny way? We were rapidly drilled into a smooth running team and got to know each other very well.

Why do you need to train a highly skilled group of professionals? All I can tell you is that it worked extremely well. The nervousness disappeared completely and we rapidly became a ‘front line’ unit that could cope with anything that the event had to throw at us. We were all from different backgrounds, and the training ensured that all our skills and competencies were fully utilised. Hence the make up of each ‘quadrimed’ – a sports physician (to evaluating sport injuries), a traumatologist or anaesthetist (to establish good airway access), and front-line emergency support (paramedic, A+E nurse, ambulance technician etc).

Action in the field!

Did we have anything to do? Certainly – but not a lot! During the 400m relay heats, as documented in every daily paper, the American athlete broke his fibula and continued his leg of the race, the South African tripped  and fell onto his shoulder, and a Jamaican third athlete had an upper leg injury – all in the same race series! Our teams were always located on the outside of the running track so the process was simple – check that it was safe to move onto the field of play, despatch a pair to review the injured athlete (one with a radio), assess the athlete, treat if necessary and rapidly remove to the medical facility (in our case by wheelchair). Easy enough you say, but with 80,000 people screaming at the top of the lungs while you are assessing an injured athlete, the adrenaline is in overdrive.

Every day we had a pre-shift briefing and a post (8-12 hour)-shift debriefing. The topic of one of these briefings was: make sure that you are noticeable, and it is noticed when you offer medical assistance to an injured athlete. Hang on, you say, aren’t you meant to be nearly invisible out there and do you job as inconspicuously as possible?

It turned out that one of the commentators doing an overseas broadcast had mentioned, live on TV, that an athlete had not received prompt medical attention. In fact, the hurdler had been offered a wheelchair immediately (within 20 seconds) but had refused assistance and hopped towards the finishing line. After the end of the race, he was helped off the track by two fellow athletes and medical personnel were finally able to take over.

In our briefing the next day, it was suggested that the visibility of the medical teams should be slightly raised – without going to the extreme of offering a wheelchair to every 10,000m runner when they finish and lie down on the track.

Collapse management

Another gem to come out of our training and briefing sessions included a review of collapse. A collapse before the finish line is abnormal and the athlete requires immediate attention. A collapse after the finish line is more common and is generally innocent – athlete bending over, hands on the hips or knees, athlete lying on the ground on their back with the knees bent, athlete kneeling on the ground with the head touching the ground. Abnormal postures that should sound alarm bells are – athletes lying flat on their back with their legs straight or lying flat face down on the stomach.

All equipment and supplies at the Games were standardised and provided by LOCOG. The medical professionals were not even required to bring their own stethoscopes. Every medical volunteer had a small green waistbag that contained gloves, paracetamol, sticky plasters, scissors etc, for the immediate care of small wounds and minor medical problems. The team leader of every quadrimed (group of four) carried injectable morphine and every group had two radios, a scoop stretcher, a basket stretcher, a gurney, a wheelchair, an AED and a big red medical bag with resuscitation equipment.

Most event doctors are used to carrying their own bag of equipment and supplies. So before every shift we each had to familiarise ourselves with the content the LOCOG provided in the Standard Red Bag. In addition, the 2 hour, pre-shift training and role play sessions enabled the teams to practice using the stretchers, gurney and AED.

One of the best weeks of my life!

I will never forget being on the track the evening that Mo Farah won the 10,000m and Usain Bolt, and the Jamaican Team, set the world record in the 100m relay. I have never heard such an incredible noise, or seen 80,000 spectators stand up and encourage one man home like they did that night!

Elite athlete care is just one part of the sports physicians role but it provides a great opportunity to help athletes who have spent many years training to achieve their goals. Their single minded focus, and continual commitment to improve, is inspirational not only for other sportspeople but for all of us who are aiming for excellence in our vocation.

Volunteering is a crucial part of the Olympic Movement and the LOCOG are to be congratulated on delivering the London 2012 Olympic Games superbly. I am now preparing for my role as the LOCOG venue doctor at Eton Manor, the home of wheelchair tennis during the Paralympic Games – bring it on!

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Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine. She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

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