MEDICINE Matters

MARCH 2006 – No.12 IN THIS ISSUE

REAPING THE HARVEST

THE STATE OF THE PITCH

CANNABIS AND SPORT

FIT TO MANAGE?

BRUCOSPORT CONGRESS IN BRUGES

PUBLISHED BY UEFA’S FOOTBALL DEVELOPMENT DIVISION EDITORIAL BY DR URS VOGEL FOUR-GONE

It doesn’t feel as though almost four years have passed since we sat down to discuss the aftermath of the FIFA World Cup – and, in the case of some of the pre-tournament favourites, it amounted to something more akin to a post-mortem. Many star players were reported to have under-performed and a high percentage of European failures to live up to expectations were put down to mental and physical fatigue. There was a great deal of talk about excessive workloads.

Four seasons later, we are once to harmonise methodologies is UEFA-HIGUERAS again watching attentively as another step in the right direc- Dr Urs Vogel, Chairman of the UEFA Medical Committee. players prepare for the FIFA tion, as it will permit other stu- World Cup in a year which also dies to be correlated with our includes the African Cup of own. Much of this issue of Medi- Nations. But there have been cine Matters is devoted to mat- changes. UEFA, for example, has ters related to injury studies – lightened the UEFA Champions and we make no apology for that. League burden by removing a group phase. FIFA has insisted Detecting ‘patterns’ in a short that the final whistle be blown time-span is, scientifically, risky. on all domestic competitions in But some interesting talking good time for players to prepare points have already emerged. COVER for the finals in Germany. Overall, the incidence of injury Andriy Shevchenko takes the ball past Greek defender Ioannis Goumas among the clubs involved in our in Ukraine’s 1-0 win in Athens During the same four-year study has fallen in the last four en route to their first-ever FIFA World period, UEFA’s injury studies have years. But is it a coincidence, Cup final, this summer’s tournament to be played in Germany from 9 June gathered momentum and a for example, that the significant to 9 July 2006. From a medical point valuable databank has not only decreases have occurred in the of view, the tournament will also offer an exceptional learning experience. been established but is also be- 2002/03 and 2004/05 seasons? PHOTO: FOTO-NET ing put to good use. The move In other words, after the FIFA

MEDICINE MATTERS/2 The wise use of substitutes has become an important tactic in modern football. GETTY IMAGES CONCLUSIONS

World Cup and the UEFA Euro- But only time – and continued After the tournament in Ger- pean Championship, when one research – will determine whether many, will we express the same would instinctively suspect that we are winning the crusade to concerns as we did in 2002? the incidence of injury would rise. reduce the risk of injury. In a sense, Four years have gone by and we Could the possible explanation the two World Cups will provide may be able to start drawing be that, while we are monitoring interesting points of reference. conclusions. the top stars’ ability to cope with the physical and psychological burdens of major tournaments, the rest of the professional work- force is finally able to benefit from a decent rest?

What’s more, attitudes have changed as a result of injury studies which have undoubtedly increased awareness of the medical issues to be addressed. Reliable data about injury risks during pre-season training have given coaches food for thought. Four years ago, ‘rotation’ was not a frequently used word in the footballing lexicon. But there have now been significant moves in terms of designing and util- ising squads with a view to dis- IMAGES BARON/BONGARTS/GETTY The new UEFA Champions League format has taken some tributing workloads on a more of the pressure off the players. Here, Ze Roberto in Bayern Munich’s equitable basis. UEFA Champions League tie against Club Brugge.

MEDICINE MATTERS/3 REAPING THE HARVEST

UEFA’s injury studies have been a recurrent theme in Medicine Matters and the state of play is that one of the fundamental aims of the project is now beginning to be achieved. The study was not conceived as an esoteric incidence of injury in domestic compilation of figures. The objective was – and is – competitions. to provide feedback to team doctors which can enhance their efforts to prevent injuries. A case in point is Turkey, where Professor Mehmet Binnet, a mem- ber of UEFA’s Medical Committee, initiated the country’s first injury study along with Dr Onur Polat, Some of the top clubs involved It has never been Medicine Mat- his fellow chairman of the Turkish in UEFA’s project have now been ters’ policy to ‘name names’ but FA’s Medical Committee. monitored over a period of four full the much-publicised case of Michael seasons – which means that the Owen’s fifth metatarsal fracture The pioneering study embraced database has now become a valuable prompted the English media to 406 footballers enrolled in 15 clubs tool and that answers can now be question his presence in this sum- belonging to the Turkcell Premier provided to some of the most fre- mer’s FIFA World Cup. UEFA’s data- League. Data were collected ac- quently asked questions. Clubs and base included details of 19 such cording to UEFA norms over a football organisations often ask, injuries, which allowed a mean ab- period covering 9,190 hours (820 for instance, whether the risk of sence of 76 days to be established. match hours and 8,370 training injury in the top-level game has The evidence also suggested that hours). During this time-span, team increased. There is now enough solid surgery signified a lower risk of doctors recorded and reported evidence to respond that it has not – re-injury. UEFA could therefore 330 injuries at a mean of one injury and that it has even decreased. offer reassuring data to the player, per 27.85 hours. his club and his national association. The ongoing project now features Processing the data revealed signifi- visits by UEFA’s research team to In other words, the seeds sown over cant trends. 142 injuries (43%) oc- the clubs which have participated in the last four years are beginning to curred during the 820 match hours, the study, with a view to establishing produce a harvest. Continued feed- while 188 (57%) corresponded to how to develop the research and back will, we hope, allow physicians injuries sustained during training. what further elements could produc- to advance still further in the cru- When compared with similar stud- tively be incorporated into the moni- sade to prevent injuries, to avoid ies, the salient feature was the toring programme. burn-out syndromes, and to estab- high incidence of injuries during lish viable balances between work training. At the end of each season, there and recovery periods during long is direct feedback to the clubs in the and demanding campaigns. Further analysis uncovered other form of a detailed résumé of their significant trends. ‘Contact injuries’ own results, along with mean figures resulting from tackles or collisions from other teams, enabling compar- RESEARCH = accounted for 30.72%. The remain- isons to be made. Clubs and national VALUABLE EVIDENCE ing 69.28% were non-contact associations are aware that UEFA injuries. The figures suggested to can now provide reliable data and, Harmonising methodologies has the researchers that non-contact for instance, the Italians are keen enabled studies of injury patterns injuries had increased in relation to receive figures related to non- to be effectively interlocked and for to previous seasons and that the contact muscular injuries, while the valid comparisons to be made. At high ratio of non-contact injuries English have expressed more interest the same time, UEFA’s injury study represented a strong indicator of in issues such as groin injuries or has helped to promote individual physical overuse and/or return to the effects of a winter break on the studies within national associations activity before recovery had been incidence of injury. where there is concern about the completed.

MEDICINE MATTERS/4 Several injuries occur during training. EMPICS

The study also grouped figures grammes and a review of entire 495 match hours and 899 training according to geographical areas, training cultures. Clubs were urged hours. Sixteen players sustained providing further food for thought. to check whether specific endurance 17 injuries during the tournament, The teams based in the Marmara re- and elasticity routines were being only two of which were in training gion (broadly speaking, the western implemented and the importance and only three of the match injuries seaboard facing Greece) recorded of adequate warm-up and warm- were due to foul play. that 45.45% of the injuries regis- down procedures was underlined. tered during the season were of the The high ratio of non-contact mus- All but one of the injuries occurred non-contact type. Of the injuries af- cular injuries suggested a need to during the first week of the twelve- fecting teams in the more northerly upgrade preventive measures. day tournament. Only one was Black Sea region, 68.25% were non- classed as ‘major’ while five were contact. And in the central Anato- At the same time, analysis of injury ‘moderate’ (1-4 weeks). lian area, the incidence of non-con- patterns revealed one fact that could tact injuries peaked at no less than be the starting point for debate. Non-contact injuries accounted 94.12%. Muscle injuries are most common for 59% of the total and were con- at football clubs which change their centrated into the final 30 minutes With regard to the nature of the technical staff more than once a of match play. injuries, 50.96% were of low inten- season. Interpretations of this infor- sity, with the player absent from mation can take various channels, training and match play for less than as it could be coherently argued that one week; 40.51% were labelled squad members might be tempted moderate, with the player absent for to overexert themselves on the between one week and one month; training ground to impress a new and 8.12% came into the ‘severe’ coach or, conversely, that the new category and entailed absences in coach is often tempted to launch a excess of a month. The breakdown new regime by working the players by regions revealed that the Anato- harder than his predecessor. lian teams suffered 46.30% in terms of mild injuries; 44.44% moderate; Whatever the answers, the undeni- and 9.26% serious. In the Black Sea able conclusion is that the Turkish region, the figures were 49.23%, injury study provided persuasive 41.54% and 9.23%, while the Mar- evidence in the case for reviewing mara clubs posted the lowest inci- physical training methods with a dence of severe injury (57.35%, view to reducing the high ratio of 36.76% and 5.88%). non-contact injuries.

30.85% of injuries affected the thigh, 20.18% the ankle, and 12.38% the CONTACT DETAILS groin. 37.61% of injuries were classed as strains, 24.41% as sprains, and UEFA’s injury studies have been ex- 15.24% were evidently attributable tended to final tournaments of other to overuse. competitions – and it is interesting to

note that the highest ratio of non- IMAGES MUHLY/AFP/GETTY P. Important conclusions were drawn contact injuries was registered in the Franck Dja Djedje of France (left) fights from the country’s first injury study, finals of the 2005 European Under-19 for the ball with Matthew Mills of Eng- which clearly indicated a need for Championship played in Northern land during the 2005 European Under-19 correctly designed training pro- Ireland. The study embraced Championship in Northern Ireland.

MEDICINE MATTERS/5 Physician Dr Ulrich Schmieden and physiotherapist Christel Arbini care for the injured German forward Sandra Minnert during the Women’s EURO 2005 final against Norway. SVEN SIMON

One coherent explanation was that SPEAKING THE issues related to data collection and the Under-19 Championship was reporting served as the basis for staged during the last fortnight of SAME LANGUAGE discussions at a two-day meeting in July, when most teams are still in Zurich, leading to the production of a pre-season training. Preparation What is a ‘severe’ injury? What is consensus statement to be published programmes therefore take on even a ‘recurrent’ injury? Is the Achilles in leading sports-medicine journals greater significance and it could be tendon ‘ankle’ or ‘lower leg’? You in Europe and North America. important for the Under-19 interna- might have clear answers to all three tionals to dedicate time to fitness questions. But will a physician at UEFA’s injury studies fully comply exercises during the ‘close season’. the other end of Europe come up with the agreement and it means with the same responses? that other studies conducted by, The European Women’s Champi- for instance, individual national asso- onship final round, played in Eng- It is no secret that variations in defini- ciations – such as the Turkish project land during the month of June, reg- tions and methodologies can gener- outlined in this issue – can be inter- istered a lower ratio of non-contact ate significant differences in the re- polated with our data. Clubs who injuries. Yet the percentage (36%), sults and conclusions obtained from adhere to the newly agreed format coupled with the 41% recorded injury studies, making it difficult to for recording injuries will, in conse- by the men at EURO 2004, highlights compare like with like. Even though quence, be able to hold their data the frequency of muscle injuries in medical journals have developed against other studies in order to today’s football. strategies such as the Consort state- determine whether injury ratios are ment in response to this problem, above the norm in certain categories. Contusions accounted for 44% of fundamental differences have per- the injuries at the women’s tourna- sisted in published studies of football In answer to the questions posed in ment – exactly double the percent- injuries. This represents a key issue the opening paragraph, the severity age registered at EURO 2004. How- for UEFA when it comes to collating of injuries is gauged by the number ever, the men’s finals in Portugal studies on a pan-European basis, of days that elapse between the day yielded four fractures (9% of all in- so it is good news that a consensus the injury is sustained and the date juries), whereas none were recorded agreement has now been reached, of the player’s return to full partici- in England – arguably a reflection laying the foundations for a harmoni- pation with the rest of the squad of physical intensity and body mass. sation in methodologies and termi- in training and availability for team Once again, the risk of injury was nologies. It signifies a great step for- selection. much greater during match play ward and, as far as we know, football (36.0 per 1,000 hours) than in train- is the first sport to have drawn up It is now clarified that the injury oc- ing (2.5). In this respect, the women’s such a consensus statement. curs on ‘day zero’ (rather than ‘day parameters were similar to the men’s 1’) and that, consequently, a player (32.2 per 1,000 hours of match play The move started with informal dis- who withdraws from training but at EURO 2004 / 2.9 in training). cussions during the 1st World Con- is available for full participation the gress on Sports Injury Prevention in following day should be reported as One of the interesting observations Oslo in June 2005. FIFA’s Medical As- having suffered a time-loss injury to emerge as a common denomina- sessment & Research Centre (F-MARC) with a severity of ‘0 days’. This will tor at all three tournaments (the then agreed to act as hosts for a be classed as a ‘slight’ injury, with two EUROs and the Under-19s) was consensus group formed by experts ‘minimal’ being the term adopted for that the incidence of injury was (from three continents) involved in an injury that entails absence for 1-3 very significantly greater during the study of football injuries – among days, ‘mild’ for the 4-7 day bracket, the initial group matches than in them a member of UEFA’s Medical ‘moderate’ for 8-28 days, and ‘severe’ the subsequent fixtures played on Committee, Prof. Jan Ekstrand. A where absence exceeds that time- a knock-out basis. working document identifying key span. The category that none of us

MEDICINE MATTERS/6 Raul suffered a contact injury which will keep him out of the game for three or four months this season. EMPICS

want to record is the ‘career-ending loss; the other – more time-consum- Much the same would apply to a injury’. ing for the medical staff – on the player who suffers an ankle sprain need for medical attention. In other during a match but plays on, Historically, the description of recur- words, the latter will include a rela- receives medical attention after rent injuries has been diverse. A re- tively large number of incidents the game, continues full training current injury is now described as recorded as ‘severity: zero days’. A for six days using ankle taping, “an injury of the same type and at number of hypothetical cases are but aggravates the injury during the same site as an index injury, contemplated in the consensus state- the next match and requires 15 which occurs after a player’s return ment, such as a player who sustains days of rehabilitation. The more to full participation from the index a groin injury. The team physician detailed ‘medical attention’ injury”. A recurrent injury occurring considers that the injury does not mode would give a fuller picture within two months of a player’s re- warrant immediate treatment and (describing the initial sprain as turn is an ‘early recurrence’, one oc- the player continues to take part a zero-day injury), whereas the curring between two and 12 months in training and matches. However, ‘time-loss’ method only records is a ‘late recurrence’, and a repeat the player elects, two months later, the ultimate 15-day injury. injury suffered more than a year later to undergo surgery and then requires is to be described as a ‘delayed recur- 90 days of rehabilitation. In the For team physicians, the consensus rence’. This entails detailed registra- ‘medical attention’ format, the case statement not only makes inter- tion of the index injury, as a repeat should be recorded as a zero-day esting reading but also lays the of an injury imprecisely marked as injury on the date when the physician foundations for thoroughly reli- ‘knee’ or ‘thigh’ may not be a gen- was consulted and then as a 90-day able interchange of information – uine recurrence. injury as from the date of surgery. which can only be positive in the In ‘time-loss’ mode, only the 90-day crusade to reduce the incidence The consensus statement also de- period would be recorded. of injuries in the game of football. fines ‘match exposure’ as games be- tween teams from different clubs, with matches between teams from the same club classed as training exposure – as is match activity that forms part of a player’s rehabilitation after injury. ‘Training exposure’ re- lates exclusively to sessions where there is physical exertion, meaning that team talks, blackboard tactical work and sessions with psychologists or physios are excluded. On the other hand, warm-up and warm- down routines should be recorded as training exposure.

The classification of injuries is dealt with in great detail in the document, along with baseline norms for the recording of data and a standard EMPICS injury report form. Two alternative Ole Gunnar Solskjær is treated for a foot injury. Later the Manchester methods of recording injuries are United forward suffered a knee injury, followed by surgery which sidelined contemplated: one is based on time him for more than a year.

MEDICINE MATTERS/7 THE STATE OF THE PITCH

UEFA has decided to extend its monitoring of artificial surfaces. The report by Professor Jan Ekstrand published in the previous issue of Medicine Matters suggested no substantial difference in injury risks between artificial turf artificial pitch may seem fine when and natural grass but, since the study was initiated, the it is laid, but the idea is to monitor goalposts have been moved slightly by the introduction of its performance with the passage of new criteria, testing formulae and norms for approval. time and to establish levels of wear and tear on the pitch – and the players…

BY THE WAY… FIFA has now established a ‘star sys- and southern sectors. Three coun- tem’, whereby only two-star artificial tries will be pinpointed within each “This is a medical study and it did surfaces will be acceptable for elite region and the study will monitor not consider the effects of artificial competitions, with one-star surfaces two clubs per country, giving an turf on playing styles or the quality acceptable for lower-level games or overall total of 18. Data collection of football produced on this type in certain developing countries. will be meticulous, with a view to of surface.” That sentence, featured producing homogenous, reliable in the report in the previous issue Under the new regime, UEFA and information embracing a period of of Medicine Matters, has provoked FIFA have agreed to cooperate on several years. In other words, an questions and comment. research and monitoring duties, with the former focusing on the top pro level in Europe and the latter monitoring other continents and the amateur game.

In practical terms, this means that UEFA’s team will spring into action as soon as clubs install two-star sur- faces. And the monitoring will not be restricted to a comparative study of injury incidences. Each club will be visited and feedback from players will be included in UEFA’s database. So will detailed information about the state of the surface, as artificial pitches will be tested on an annual basis so that the condition of the pitch can be correlated with injury data. Clubs will also be obliged to keep a detailed logbook related to pitch maintenance – and this infor- mation will also be included in the UEFA database. SNS GROUP

For the purposes of the study, Europe This jigsaw puzzle was assembled into the artificial pitch at East End Park, will be divided into northern, central Dunfermline in 2003. The SPL had the artificial pitch replaced in 2005.

MEDICINE MATTERS/8 The artificial pitch that is home to Vags Boltfelag (VB), located amid the dramatic coastal landscape of the Faroe Islands. JEMS KRISTIAN VANG

The preliminary study conducted by a panel asked to assess injury risks on the two types of surface suggested that artificial surfaces do not detract from the game in terms of incidence figures. The debating point, however, is whether it de- tracts from the game by removing elements from its rich playing texture.

It might be a valid argument, for instance, to claim that lesser traction on an artificial surface could reduce the risk of studs locking into the turf and causing ligament damage. On the other hand, that relative lack of traction sometimes prompts players to complain about greater difficulties in turning quickly.

However, many of the players’ comments focus on the difficulty of chipping the ball on an artificial surface or ‘getting under it’ to hit

a lofted pass. In terms of match SNS GROUP analysis, that could translate into The design of footwear custom made for artificial pitches. significant changes. ‘Ball-to-feet’ passes become more prevalent, to the detriment of traditional wing play culminating in crosses. Europe’s first full-size outdoor Corners have a greater tendency artificial football to be played short, as the taker pitch was sometimes experiences difficulty inaugurated in in getting a boot far enough under November 1971 the ball to deliver a more classical by the first athlete to break the lofted centre. four-minute mile barrier, Roger In other words, the purpose of Bannister, flanked including that sentence in the last by the captains issue was simply to alert the reader of the football team of Highbury to the fact that there’s more to the Grove and artificial turf v. natural grass ques- Holloway school tion than meets the medical eye… EMPICS in London.

MEDICINE MATTERS/9 CANNABIS AND SPORT BY DR MARTIAL SAUGY AND DR LYDIA AVOIS, LAUSANNE ANTI-DOPING LABORATORY

The consumption of substances derived from cannabis, such as hashish (resin) and marijuana (“grass”, “pot”), particularly in the form of “joints”, is reported to be widespread.

There is evidence to support theo- The effect of a high level of THC reduced inhibition and developing ries of an upsurge in the use of this in terms of long-term damage to a certain indifference. type of drug in some countries. The health has not been well docu- problem affects society in general mented, although any activity re- Chronic consumption leads to and sport is not immune to it mak- quiring concentration and energy psychological dependence, a chronic ing it a potential problem that the will be affected by its use. sedative effect and even social footballing world cannot ignore. detachment. This has caused increasing concern The effects of cannabis derivatives and uncertainty among young play- are varied and can have physical Does cannabis have ers, parents, coaches and managers. and psychological repercussions as a doping effect? well as influencing a player’s social Sportspeople who consume can- behaviour. Isolated or infrequent The question often asked in the nabis derivatives generally restrict consumption can lead to: case of a positive result for cannabis themselves to low doses. Consump- 1. mild intoxication is whether it was consciously used tion usually takes place outside 2. a sedative effect on behaviour for doping purposes. The response sports facilities and so is outside the 3. slower reaction times must be that this substance can only control of team coaches and/or 4. memory problems indirectly improve performance: it doctors. This lack of control is accen- 5. a tendency towards drowsiness. can have a euphoric effect, reducing tuated by the fact that testing for anxiety and increasing the sociabil- the substance only occurs during In terms of the effects on the body, ity of a player who may be particu- competitions. although heightened sensory per- larly nervous before an important ception can be expected, THC also match. It can also have a relaxing Statistics gathered from laborato- engenders a certain heaviness, effect after the game. In this way, ries accredited by the World Anti- significant relaxation and excessive cannabis can be considered as a Doping Agency (WADA) show that fatigue of the limbs. As the dose doping product which calms the cannabis is easily the most common increases, the user may experience mind. It has already been shown drug causing positive results, in hallucinations, an alteration of the that the use of cannabis in sporting particular ahead of testosterone perception of reality and a marked environments is basically motivated and nandrolone. Positive results reduction in concentration. Further- by the feeling of relaxation and only relate to competition testing. more, as these products are gener- well-being obtained, allowing the They do not take into account any ally smoked, consumption by in- user to sleep more easily. However, positive doses found in urine sam- halation can only have a negative if consumed regularly, it risks be- ples taken out of competition; these effect on sporting performance coming harmful to performance and are not reported by laboratories. and the player’s health (detrimental motivation. effects on the lungs, oral cavity The main active ingredient of can- and upper respiratory tracts). It is when cannabis is consumed reg- nabis is delta-9-tetrahydrocannabi- ularly that the signs become appar- nol (THC). As cultivation methods As regards psychological and social ent in young athletes. There may have developed, it has become pos- behaviour, cannabis accentuates the be changes in behaviour during sible to grow cannabis plants that mood of the person concerned. So training as well as inconsistent per- have significantly higher levels of a user may become carefree, happy formance, concentration or motiva- THC than before. This high THC and relaxed, but also risks becom- tion. Particular care should be taken level may reinforce and change the ing stressed, depressed or paranoid. when a player is vulnerable, for immediate effects of consumption. Other effects on a user include example if lacking support, during

MEDICINE MATTERS/10 BONGARTS

prolonged or repeated injury, when on the time elapsed since consump- until urine samples return negative isolated from family or if subject tion. The quantity discovered in outcomes can be as much as four to excessive pressure for results on urine depends on various factors: weeks (two weeks on average) the pitch. In these cases it is up to 1. the dosage of the most recent after the most recent consumption. the club coaches and doctors to consumption look out for any symptoms that may 2. the time elapsed between In conclusion, even though the appear and to intervene tactfully, the most recent consumption doping effects of cannabis have not although firmly, when necessary. and taking the urine sample been clearly established, this drug In some cases referral to a psycholo- 3. the manner of consumption is on the list of prohibited products gist will be necessary. (single dose or regular consump- and is the subject of competition tion) testing. Given that the product Analysis and the kinetics 4. the individual’s metabolism. takes a long time to be eliminated of urinary elimination from urine, as well as the general If these factors are taken into negative effects over the long According to the World Anti-Dop- account, it is extremely difficult to term on sporting performance, ing Code, an abnormal result must establish a relationship between players should completely abstain be announced for cannabis if the urinary concentration and the from consuming cannabis in what- main metabolite of THC, carboxy- effects on an individual’s psycho- ever form and under whatever THC, is discovered in a player’s urine motor skills. circumstances. at a level in excess of 15 micro- grams/litre as a result of competi- Despite these considerations, some Doping is not merely a pharma- tion testing. This limit has been scientific studies have shown that cological matter. It is a risky under- established to distinguish between on the occasional consumption of taking that compromises health active consumers and smokers of a normal dose (a “joint”), the user and sporting ethics. In a new cannabis and players who may have will have a positive result for car- definition published in the World been passively exposed to cannabis boxy-THC for three, four or even Anti-Doping Code, cannabis is smoke. The limit also reduces the five days, depending on the smoker’s categorically considered a prohib- risk of a positive urine result after body mass. In this way consuming ited substance and has the the consumption of some commer- marijuana with friends a few days capacity to end a player’s career. cial products which may contain before a match could be disastrous traces of cannabis. The use of hemp for a football player as there would seed and oil in the manufacture of be a significant risk of failing a dop- food products has increased consid- ing test. The pretext of recreational erably in some Western countries use is no longer valid. Even if can- since the mid-1990s. The authorities nabis is taken without the intention have acted to impose limits on THC of improving performance, the out- levels such that the consumption of come will be a positive result if the these commercial products will not urinary level exceeds the authorised bring about positive urine results. threshold.

It should be noted that the elimina- For regular users, smoking cannabis tion of THC metabolites from urine several times a week for example, is a very slow process and depends urine samples would remain posi- on an individual’s physiology. In this tive for a much longer time after way, a simple quantification of the the most recent consumption. Sci- urinary concentration of carboxy- entific research published on this UEFA THC reveals very little information subject has shown that the time Dr Martial Saugy.

MEDICINE MATTERS/11 FIT TO MANAGE?

John Barnwell’s coaching career was truncated by a serious car crash when he was on his way home from a charity dinner arranged with a view to raising funds for cancer research. He was lucky to survive an lems can easily go undetected and impact which left the rear-view mirror embedded be allowed to escalate. in his skull. Trying to analyse the underlying causes of the accident, he put much of it down to the sheer intensity “You’re tempted to think that the of the managerial role at football clubs. club will look after you – and some do. But by no means all. In any case, in 1992, the mean figure for tenancy at a managerial job in the league was two years and seven months. At the moment, the figure has already dropped to one year and seven months. In terms of long-term health care, a manager is, basically, on his own.”

John’s response was to try to implant a system offering preventive health care to managers. As it happened, it was Kevin Keegan who put him on the trail of Dorian Dugmore, a cardiovascular specialist who, after emigrating to Canada, had been repatriated by Adidas to spearhead a project aimed at company execu- tives. Ten league managers visited

POPPERFOTO the Wellness International Medical Centre in Stockport, near Manches- ter, during a pilot scheme. Its success John Barnwell as manager of Wolverhampton Wanderers FC parades led to the birth of the ‘Fit to Man- the League Cup after the 1-0 win against Nottingham Forest FC in 1980. age’ project.

Ten years ago, the former player “Coupled with my own experience,” Even though some of the initial reac- (his career included seven years at John Barnwell comments, “it made tions were of the “Why do I need Arsenal FC) was invited to become me realise that health care for man- that if I’m perfectly fit?” variety, over chief executive of the League agers and coaches was necessary. 80 managers have taken advantage Managers’ Association, an organi- Most of us are former players and, of a scheme currently being funded sation established in England in when you’re playing, you get used to by the English Premiership. One 1992. Within six months, he saw looking after yourself and having of the most persuasive arguments in how the Wimbledon manager, Joe a lot of things done for you. When the project’s favour was actually the Kinnear, suffered a heart attack you become a manager, you can case involving a high-profile coach during a league visit to Sheffield easily find yourself 20 years older at a high-profile club who didn’t Wednesday and was fortunate and, instead of looking after your- take advantage of the scheme. Re- that the home club had highly self, you’re concentrating on looking arranged club commitments forced qualified medical staff on hand. after everybody else. Health prob- him to cancel three appointments at

MEDICINE MATTERS/12 Johan Cruyff (second from left) filmed an anti-smoking campaign after undergoing heart surgery while in charge at FC Barcelona. UEFA

the Wellness Centre and, before a European Society of Cardiology’s aneurysm of the aorta during fourth could be made, he required Working Group for Sport Cardiology, a Liverpool game. These are some emergency surgery for a life-threat- Exercise Physiology and Cardiac of the high-profile examples: ening heart condition. Rehabilitation, apart from being a there are many, many more. former player, qualified coach and Dr Dorian Dugmore is also Secretary head coach of the Great Britain team The ‘Fit to Manage’ scheme set up General of the World Council For at the World Student Games. Medi- by the Football League Managers Cardiovascular & Pulmonary Rehabili- cine Matters asked him to describe his Association (LMA) at the behest of tation and a board member of the work on the ‘Fit to Manage’ project… John Barnwell was initially funded by the Professional Footballers As- sociation (PFA) and, more recently, Cardiovascular risk in English football league managers by the English Premiership. It has been specifically designed to ad- A CAUSE FOR CONCERN? dress the lifestyle and cardiovascu- lar health of the football manager. The stresses and pressures associated attacks suffered by Joe Kinnear Cardiovascular screening of ex- with the management of an English and Barry Fry; Graeme Souness, and athletes (nearly all managers being league club have been highlighted Johan Cruyff both receiving coro- former footballers) has shown us recently in the media. Average work- nary artery bypass surgery and that the most common cause of ing weeks range from 80-87 hours, Gérard Houllier suffering a dissected sudden death is due to degenera- with maximum levels reaching 100 hours. Add to this constant TV, radio and newspaper scrutiny at Premier level. Often, just fighting to survive puts managers in the limelight more than ever before.

The lifestyle associated with such pressure often means long hours on the road, eating poorly – often with a ‘fast food’ diet high in saturated fats and low in nutritional value. Add in a lack of planned exercise, the relentless pressure to win coupled with a fear of losing your job if you don’t, and you have a cocktail that is potentially damaging to your health.

The last 20-30 years have yielded clear evidence of cardiovascular risk/events among league managers. Jock Stein’s sudden death from a myocardial infarction following the ANDERSEN/AFP/GETTY IMAGES Scotland v Wales game in 1985; heart Coaches in the English Premier League undergo cardiovascular tests these days.

MEDICINE MATTERS/13 Nevio Scala and his assistant Michael Henke had some nervous moments when BV Borussia Dortmund played away to Eintracht Trier in the German Cup in 1997. WITTERS

tive ischemic heart disease (Thomp- undergoing electrocardiographic/ The previous discussion raises a big son P.D., Exercise and Sports Cardiol- blood pressure ambulatory monitor- question: Who cares for the carers? ogy, 2001). Indeed, significant ather- ing during a game, compared with Should managers – together with osclerotic narrowing of the coronary being pushed to exhaustion on those appointing them and influenc- arteries (> 75% in 2-3 major vessels) the treadmill one week earlier in ing their performance – be strongly has been found in the majority in a clinical setting. encouraged to establish provision sudden deaths in older athletes to look after their health as a stan- (Northcote et al, Sudden Death and Of the first 54 managers (mean age dard clause in future contracts? Such Vigorous Exercise, 1986). of 49) enrolled in the ‘Fit to Manage’ an approach employed across Europe scheme, 24 (44%) recorded diagnosed can only help to influence others A major challenge is emerging: the cardiovascular abnormalities and/or in the game, including recreational need for ex-footballers who become significant risk which included atrial footballers and spectators, to reduce managers and coaches to take better fibrillation, atrial flutter, aortic steno- the burden of illness associated care of their lifestyle and cardiovas- sis, significant ventricular ectopy, (cou- with lifestyle/cardiovascular disease. cular health. This identifies a further plets, triplets, runs), coronary artery The latter is emphasised in the need for such individuals to be disease, angioedema and hypercholes- recent recommendations of the guided towards making the transi- terolemia. These were recorded European Society’s working group tion from sports-related health and despite overall fitness levels being on sport cardiology for competitive fitness as players, to lifestyle-related acceptable for age/sex (mean peak sports participation in athletes with/ health and fitness as managers and VO2 – 43 mls.O2.kg.min). without cardiovascular disease. coaches. This is being currently ad- dressed through the provision of the Warwick Business School’s ‘Certified (Football) Management Diploma’. It focuses on key elements of success- ful football management, especially health/fitness issues.

These include reduced participation in regular exercise; the nutritional balance between calories burned and expended in post-playing days, which often leads to weight gain; and alter- ations in blood lipid levels and other biochemical markers that can affect cardiovascular risk (e.g. increased adrenaline and cortisol levels during games). The need to balance the de- mands of management with personal family life was also among the issues reflected in a recent TV documentary, EMPICS/SMG showing that the clinical/physiologi- Scotland manager Jock Stein and coach Andy Roxburgh move cal costs of managing a top game the goalposts during a training session prior to the EURO’80 qualifier were higher in the two managers against Norway in October 1978.

MEDICINE MATTERS/14 UEFA MEDICAL COMMITTEE

CHAIRMAN Dr Urs Vogel, Switzerland VICE-CHAIRMEN Prof. Jan Ekstrand, Sweden Prof. W. Stewart Hillis, Scotland MEMBERS Prof. Mehmet S. Binnet, Turkey Dr Alan Hodson, England Prof. Wilfried Kindermann, Germany Dr Mogens Kreutzfeldt, Denmark Dr Jacques Liénard, France Dr Pedro Correia Magro, Portugal Dr Alfonso Moreno Gonzalez, Spain Prof. Paolo Zeppilli, Italy DE VOECHT/AFP

Dr Michel D’Hooghe. BRUCOSPORT CONGRESS October 2006 will mark the end of an era in sports medicine. The annual Brucosport congress in Bruges IN BRUGES will be staged for the 25th and last time.

The event has always been close them to exchange information So the final Brucosport will be held to UEFA’s heart – not least because and experiences. It was something on 13 and14 October and, as Michel Brucosport was the brainchild of new and, in all modesty, I think D’Hooghe says “the idea is to, as Dr Michel D’Hooghe, former chair- it helped to bring structures up to we say in French, finir en beauté.” man of our Medical Committee, a higher level.” Helping him to ‘go out on a high current chairman of FIFA’s Medical note’ will be an ‘all-star team’ se- Commission and, in the more politi- Asked to explain the decision to lected from the previous 24 editions. cal arena, a long-standing member lower the flag after the 25th edition, The final word – on ‘Visions for the of the FIFA Executive Committee. Michel D’Hooghe comments “there Future of Sport’ – will be delivered However, there has been more to have been significant advances in by Jacques Rogge, Michel’s compa- Brucosport than personal attach- communication technology which triot who heads the IOC, while the ments to Michel and his team. The prove that Brucosport has fulfilled founder of Brucosport will take a event has played a significant role its purpose. When we started, there bow on a typically positive note in promoting the development of were maybe two or three journals by discussing ‘Visions for the Future sports medicine. of sports medicine. These days, it of Medical Follow-up in Football’. wouldn’t take me long to jot down “There is still a lot of work to be “The medical advances over these a list of 15 or 16. And that was be- done and challenges to be faced in 25 years,” Michel D’Hooghe com- fore the Internet burst onto the orthopaedics, psychology and so ments, “are obvious to everybody scene as an invaluable communica- on. But one thing hasn’t changed who is old enough to remember the tions tool. There are other reasons over the last 25 years. We can help days when a meniscus operation was for bringing down the final curtain. to produce better athletes but we relatively major surgery; when phys- Those of us who organise it are can’t guarantee better footballers!” iotherapy and rehabilitation were 25 years older, for example! And we more about immobilisation than have lost some team members. IMPRESSUM mobilisation; and debates on doping Some participants have been coming focused on the use of anabolic to Bruges for 10 or 15 years and EDITORIAL GROUP steroids rather than growth hor- might prefer to go somewhere else! Andy Roxburgh mones and so on. But, basically, Bru- At the same time, mergers within Graham Turner cosport came into being at a time the pharmaceutical world have Frits Ahlstrøm when sports medicine in general and affected the sponsorship scenario. PRODUCTION soccer medicine in particular was not So we have decided to change André Vieli that well structured. So the event course and, in the future, to organ- Dominique Maurer wasn’t just about its significance as ise specialised events dedicated Atema Communication SA – CH-Gland a conference. It brought specialists to specific areas such as trainers or Printed by Cavin SA – CH-Grandson together in a context that allowed women’s football.”

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