Should Olympic imaging services include therapeutic injection?

Editorial Board member Bruce Forster shared an interesting issue for debate. As head of imaging for the 2010 Winter Olympic Games, he is responsible for deciding whether the service should include injecting tendons/joints at the Games or not. In Torino 2006, the imaging services were diagnostic only.

We invite BJSM blog readers to engage in the debate as to whether the sports medicine service should offer full therapeutic capacity or not. Where does one draw the line? Would the imaging physicians be legally liable if the athlete had a complication on return to play?

A comment from Editorial Board Member Chris Milne, New Zealand Olympic Sports Physician:

I’ll kick off. In my view, the imaging services at the games should offer as close as possible to a world class service, since they are dealing with world class athletes. The clinician looking after the athlete should have the ultimate responsibility as to what care is offered to that athlete.

In Sydney 2000, there was a superb imaging service that included CT guided nerve root sleeve injections, and the NZ team made use of this for 3 of our athletes. Issues of return to play are best dealt with by the clinican[s] who are managing that athlete, with consultation/liaison with the coaching staff once a treatment plan has been formulated.

Another comment from Dr Lynley Anderson, Senior Lecturer, Bioethics Centre, Medical and Surgical Science, Dunedin School of Medicine.

I would agree with Chris, if there are sound clinical reasons for something then it probably needs to be supplied.

Am I right to imagine that the underlying question you are getting to is would the image guiding system be used appropriately or inappropriately? That is, is such a service being used to return people to competition when such competition is dangerous to their health?

Here I think we would want to explore issues about the level of consent the patient has given, is the patient being coerced or manipulated by the coach or others, and has such a decision been freely made? Are they fully aware of the consequences of such action? Although high levels of risk taking is not uncommon among athletes, it could be argued that patient awareness and free choice might mitigate this to some extent.

Also I might want to explore the level of independence of the doctor, is he/she acting in the best interests of the patient? Or, is he or she acting outside acceptable medical practice in sport for whatever reason. We might also want to explore whether provision of the service gives the coach or team management another outlet for further pressure on doctors and/or athletes.

So back to Chris’ comments if a service is required for good clinical reasons, I don’t think we should let the fact that it could be abused put us off supplying that service. But it could be an issue if it encourages greater risk taking behaviour and raises expectations and pressure on the doctor.

I think this is an interesting area of debate and discussion.

Dr Paul McCory, BJSM editor at large, adds this comment:

That needs to be balanced by team docs who may not be as knowledgeable or discerning. In Sydney 2000 games (soccer) we had certain team docs who insisted on doing plain xrays on all athletes in their teams at the conclusion of each match. Under the Olympic ‘agreement’ we (as polyclinic volunteer docs) were obliged to facilitate their request in spite of the fact that we felt it unethical and potentially dangerous. We were firmly told by the Olympic organisation to but out when we raised this issue. I have serious concerns with imaging being anything other than diagnostic unless their is some level of certification of
team physician skills (which is of course unrealistic).

Comment from Dave Gerrard, BJSM editorial board member.

I’m in Manchester at present attending a FINA Medical Congress. I am of a mind to say that if injecting in the manner suggested is in accordance with accepted therapeutic practice it should first be done in accordance with WADA TUE (Therapeutic Usage Exemption) requirements.

If it is to simply accelerate a return to sport then the WADA requirements are not met and WADA rules would indicate that TUE should be declined. I believe that imaging services ought to be available to confirm diagnostic suspicions rather than to facilitate return to play.

Dr Paul McCory, BJSM editor at large, adds another comment:

I agree with your sentiment but the host city actually signs an agreement that allows team doctors unrestricted medical rights to treating their teams and that the host city doctors are obliged under that agreement to support those team doctors desires !!

Chris Milne, BJSM editor and New Zealand Olympic Sports Physician replies:

Perhaps with the upcoming European initiative of trying to establish a world curriculum in SEM, we can then follow up with some form of credentialling that would enable Fellows [or their equivalent] to order interventional procedures. Certainly the scenario you describe in Sydney is scary, and there must be a place for the venue/IOC Med Commission people to step in and say that x investigation or procedure is so out of touch with world best/evidence based practice, that it cannot be permitted at a major games…. I realise this is a potential hornet’s nest, but I personally would not shrink from such a proposal, as the ultimate beneficiaries will be the athletes, who will be getting a consistent high standard of care. I’d be interested in the views of others, although I have only 6 months to run in my Presidency, and a fairly short list of what I believe to be achievable goals in that timeframe. This is an item for the long term.

I didn’t realise it was so presciptive, and here’s me being compliant for all these years. Actually, we’ve had great support everywhere from venue docs. However, it’s good to know that background in the event of things getting sticky up in Beijing later this year.

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