Challenges in sports medicine

by Brian Sando, 2003 Refshauge Lecturer

Sports medicine has provided many significant advancements in treatment techniques and contributions to community health but there are still a number of challenges to be met.

Those engaged in this area know the satisfaction of an involvement with persons who are, in the main, well motivated to achieve early recovery and to improve their level of fitness or performance.

However there is sometimes a need to resist the suggestion to use the very latest technique, potion or treatment, as these may not have been fully evaluated for their efficacy or safety. Whilst it can be argued that progress is stifled by not trying or developing new initiatives, the responsibility for providing the very best in care or advice makes it imperative for all those involved in sports medicine to observe evidenced-based practice. This is further compounded by an increasing litigious environment.

Contributing to sport
Most of the early arthroscopic surgery, originally applied to the knee joint, was performed on sports people. These athletes, strongly motivated by a desire to get back to their sport in the shortest possible time, were delighted with the less invasive nature of these procedures and the less radical surgery, such as partial rather than total meniscectomies. The outcomes have been a faster return to sport, a lesser risk of complications such as osteoarthritis, which is more likely after a total meniscectomy, etc. These techniques, proven in the sporting community, have been applied with great success in the community at large with the associated cost savings in time lost from work, reduced morbidity and shorter hospital stays.

The various sports medicine disciplines are making great contributions to sports performance. Improved training programs and the monitoring of fitness by physiologists; the biomechanist’s analysis of and improvement in techniques to increase performance and reduce the risk of injury; biochemists and dietitians providing appropriate nutrition advice, other sports scientists, and the treating practitioners in podiatry, psychology, physiotherapy and medicine all contribute.

Injury prevention is a major feature of Sports Medicine Australia (SMA) with Sport Safe Guidelines providing a framework for the reduction of risk for sporting organisations and sports participants. Policy statements on a wide range of issues have been developed. The multidisciplinary nature of SMA, with its many sources of expertise, is the credible body to develop and disseminate such guidelines and policies with, as we know, most of the papers in injury prevention originating from sports scientists.

At the 2002 Australian Conference of Science and Medicine in Sport, it was demonstrated how the management of concussion in sport has progressed with a better understanding and a more scientific approach as to its nature and management. The mandatory ‘miss a week’ now being replaced by a better assessment of severity and recovery through the psychometric and pre-season baseline testing allowing for a better assessment of recovery.

Whilst many treatment techniques have shown great advancement and have proved extremely effective, joint surgery being an example, there are still some areas where advancement will be welcomed.

In the football codes, the hamstring injury is a common cause of missed matches with suggestions for its prevention being made, but not proven, and treatment still not hastening healing or recovery significantly. There are some newer treatments showing promise but still requiring more assessment as to their efficacy.

Osteitis pubis is a condition more common in modern sport, particularly where twisting movements and kicking are combined with running. Studies have delineated the most appropriate investigations to assist in a more accurate diagnosis and in determining the nature of this condition. However, the wide range of treatments applied to it indicate there is not, as yet, a universally successful one. Longer term, it is important, as evidenced by the success of the Pilates programme in the rehabilitation of chronic back problems, that stabilising programmes involving the appropriate abdominal, etc musculature be applied in the management of osteitis pubis to prevent recurrence. Some early treatments that enable players to return in a shorter period of time are showing some promise.

Whilst anterior cruciate repair surgery is providing good results, the lengthy rehabilitation required, behoves us to find better preventive measures. The Australian Football League has funded research into preventive strategies for this particular injury along with a number of other projects.

Contributing to the community
As a community organisation, SMA could be doing more in relation to promoting and developing exercise programmes. Some of the benefits which regular exercise provides to reduce the incidence of illness and conditions such as cardio-vascular disease, which still claims approximately 40% of the deaths in Australia each year, are:
• weight management;
• blood pressure control;
• improved peripheral circulation;
• improved lipid profiles;
• enhanced immune status;
• stress reduction;
• better sleep patterns;
• other psychological benefits;
• greater muscle tone;
• joint protection;
• improved flexibility;
• reduced risk of osteoporosis;
• lessened risk of non insulin dependent diabetes.

Creating a more active Australia is a challenge that the Government is anxious to address, particularly as it can have a great impact in reducing expenditure in the health budget. SMA, with its multi-disciplinary expertise, is well placed to advance the development of exercise programmes for Australians of all ages and involvement has commenced in some areas.

Sports supplements
Every year a new ergogenic product presents which is enthusiastically recommended by a sales person with minimal sports medicine knowledge. On enquiry, the sports medicine practitioner is assured that there has been undeniable proof and confirmation of the value of this preparation. However, all papers and product information provided merely present anecdotal experiences. Interestingly, clinical trials never seem to be forthcoming and the lack of effectiveness of these products is demonstrated by their use rarely being sustained for more than one season.

The dangers associated with the use of supplements have been evidenced in the trial undertaken by the IOC accredited drug testing laboratory in Cologne.

It analysed 630 nutritional supplements. Ninety four of these supplements (or almost 15%) contained substances that would have led to a positive drug test. Of these 94 supplements, 23 contained precursors of both nandrolone and testosterone, 64 contained precursors of testosterone alone and 7 contained precursors of nandrolone alone.

None of the illegal substances was listed on the labels. In addition to these 94 samples, 66 others or 10.4% returned borderline results for various unlabelled substances.

The World Anti-Doping Agency’s (WADA) code of strict liability makes athletes totally responsible for whatever substances are found in their bodies, so that individual athletes are responsible for everything they consume. This same code applies to practitioners, scientists, coaches and other support persons so that disqualification penalties also apply to those who administer, encourage or cover up the use of prohibited substances or prohibited methods to or by athletes.

World Anti-Doping Code
The World Anti-Doping Code globally addresses doping in sport. This code provides uniformity for sports, countries and sports drug organisations for the list of banned drugs and methods, the penalties for their misuse and standardisation of testing. Education of athletes and ongoing research are aspects encouraged in the code. At the Second World Conference on Doping in Sport held in Copenhagen in March 2003, 80 countries were represented. Most of these are already signatories to the code as are all international sports federations affiliated with the International Olympic Committee. The aim is for its full acceptance by Athens 2004.

In most aspects of the code there is universal agreement. One area where there has been some difference of opinion relates to the criteria for inclusion on the prohibited list of drugs and methods. Inclusion on the list is considered if any two of the following three criteria are met:
• the substance or method has the potential to enhance or does enhance sports performance;
• use of the substance or method represents an actual or potential health risk to the athlete;
• the use of the substance or method violates the spirit of sport.

A substance is also included on the list if it has the potential to mask the use of other prohibited substances and prohibited methods.

WADA’s determination of the prohibited substances and methods on the prohibited list is final and shall not be subject to challenge by an athlete or other person based on the argument the substance or method is not a masking agent or did not have the potential to enhance performance, represent a health risk or violate the spirit of sport.

There are some who feel that the first criterion -- the potential to enhance sports performance -- should be mandatory and a substance or method only be included on the list if it contained this and one of the other two criteria. An argument can be mounted for the exclusion of substances on a sports anti-doping list which are not performance enhancing, rather than including social drugs, narcotics and other drugs which have no performance enhancing effect.

A further requirement is for international competitors to provide whereabouts information so that, at all times, out of competition testing can be effectively performed. Failure to provide such information to their international federation or drug testing authority can lead to sanctions. As out of competition testing constitutes the greatest percentage of tests performed in an effective sports anti- doping programme, this is an important requirement.

The anti-doping aspect in sport continues to face challenges. A test for human growth hormone is as yet unavailable, although some recent studies suggest that its anabolic effect is minimal and the health risks it provides great. Gene manipulation is also a developing issue and those who heard the paper on this technology at the Perth Conference in 2001, have some understanding of the challenges it provides.

Dr Sando is Chair of the AOC Medical Commission and Chair of ASDA, Senior Medical Director of the Australian Olympic Team (1988-2000) and Australian Commonwealth Games Team (1994-2002), Medical Officer to the Australian Swimming Team (1991-2003) and Chair of the Commonwealth Games Federation Medical Commission (2002).