NEW ZEALAND

Vol 40 • No 1 • 2013 Official Journal of Sports Medicine New Zealand Inc.

Contents

EditorialS Towards a “Grand Unifying Theory of Sports Medicine” (AKA “Guts Me”) 2 Bruce Hamilton Is the screen clear enough to see the road ahead? 4 Chris Whatman

INTERVIEW Matt Marshall 5 Chris Milne

REFLECTIONS Reflections on the past, the present and a glimpse into the future 7 Chris Milne, David Gerrard, Tony Edwards

Best of British 11 Chris Milne

ORIGINAL RESEARCH: The use of skinfold measurements to predict outcome of open-water 15 swim attempts in Cook Strait Karen Bisley and Michael Marfell-Jones

The use of trunk-mounted GPS/accelerometer system to measure 22 vertical impacts for injury risk factor analysis in Australian Rules footballers: A feasibility study Craig Panther and Chris Bradshaw Comment 1 - Michael McGuigan Comment 2 - Chris Hanna The opinions expressed throughout this journal are the contributors’ own and do Sports medicine practitioners’ assessment and management of 31 not necessarily relfect the view or policy upper respiratory illness in athletes of Sports Medicine New Zealand (SMNZ). Members and readers are advised that Samantha Pomroy, David Pyne, Kieran Fallon and Peter Fricker SMNZ cannot be held responsible for the accuracy of statements made in REVIEW advertisements nor the quality of the Reducing injury in elite sport - Is simply restricting workloads 36 goods or services advertised. All materials copyright. On acceptance of an article really the answer? for publication, copyright passes to the Paul Gamble publisher. No portion(s) of the work(s) may be reproduced without written consent from the publisher. COMMISSIONED ARTICLE Ethics in New Zealand Sports Medicine 39 PUBLISHER Lynley Anderson SPORTS MEDICINE NEW ZEALAND ACSP Code of Ethics PO Box 6398, Dunedin NEW ZEALAND How I TREAT: Tel: +64-3-477-7887 Adhesive Capsulitis 47 Fax: +64-3-477-7882 Email: [email protected] Judith May Web: www.sportsmedicine.co.nz Comment 1 - Chris Hanna Comment 2 - Margie Olds and Graeme White ISSN 0110-6384 (Print) ISSN 1175-6063 (On-Line) REPORTS EDITOR Ride the Wave: AMSSM Annual Meeting, San Diego 51 Dr Bruce Hamilton Bruce Hamilton ASSOCIATE EDITOR IOC Advanced Team Physician Course, Saltsjobaden, Sweden 52 Dr Chris Whatman Nat Anglem Contributors

Reflections on the past, the present The use of skinfold measurements to The use of a trunk-mounted GPS/ and a glimpse into the future predict outcome of open-water swim accelerometer system to measure Chris Milne attempts in Cook Strait vertical impacts for injury risk factor analysis in Australian Rules Chris Milne is a sports physician in private Karen Bisley footballers: A feasibility study practice at Anglesea Sports Medicine in Karen Bisley is a sports physician working Hamilton, NZ. He has been Team Doctor in Canberra at Sports Physicians ACT. She Craig Panther for NZ Olympic and Commonwealth Games graduated through Otago Medical School. Craig Panther is a sports physician based teams from 1990 to the present, and was She is a Fellow of the Australasian College in Auckland. He and his family have in Team Doctor for the Chiefs Super Rugby team of Sports Physicians and Fellow of the Royal recent years spent two-year periods in both from 1997 to 2003. A Past President of the New Zealand College of General Practitioners. London and Melbourne, where he worked as Australasian College of Sports Physicians, Karen is an experienced open water swimmer a club doctor with Fulham FC and Geelong he has also served as National Chairman of having competed in marathon swims both in FC respectively. He has recently completed Sports Medicine NZ. He has been Medical New Zealand and Australia. She successfully a Masters in Medical Science through the Director of Rowing NZ since 2002, and is conquered Cook Strait and has been the University of Auckland, and the Fellowship of currently Chair of the Medical Commission event doctor for a number of open water the Australian College of Sports Physicians. He for Oceania National Olympic Committees. swims. With this experience, she has a good has particular interests in football and sailing He has a longstanding interest in medical understanding of the technical difficulties medicine and is currently the club doctor for writing, and is a previous Editor of the NZ involved. Karen still swims for fitness. Karen Auckland City FC. He currently lives with his Journal of Sports Medicine. also has an interest in gymnastics and dance wife and son on the North Shore of Auckland David Gerrard related medicine. Currently she is the ACT and is based at Unisports Sports Medicine. cycling doctor and has been doctor for the Chris Bradshaw David Gerrard is a sports physician and Canberra Marathon for five years. Associate Professor of Sports Medicine at Chris Bradshaw is a sports physician and the Dunedin School of Medicine, University Michael Marfell-Jones partner at Olympic Park Sports Medicine, leading the medical team at the Geelong of Otago. He is a former Olympic Team Mike Marfell-Jones, sport scientist and campus and is the Medical Director for physician, a New Zealand Chef de Mission, anthropometrist, is currently the Research Geelong Football Club. On returning from an Olympic swimmer and a Commonwealth Manager at the Open Polytechnic of New working in the UK with numerous teams Games gold medallist. His research interests Zealand. He is the International Society for and organisations, he has re-joined the ACSP include children in sport, bioethics and sports the Advancement of Kinanthropometry’s most Board of Censors, having served on the board anti-doping, with over 70 peer-reviewed senior Criterion Anthropometrist and is based from 1997-2000 and also sits on the ACSP publications. He is currently Chair of the in Wellington, New Zealand, from where he Board of Examiners. Chris finished 5th in the WADA TUE Expert Group, Vice-Chair of the travels internationally to teach ISAK courses 1990 Commonwealth Games Decathlon in FINA Sports Medicine Committee, Chair of and re-accreditation workshops. As well as his Auckland. the NZ Drowning Prevention Council and many other publications, he has co-authored former Chair of Drug-Free Sport NZ. all three editions of the ISAK Manual, the Comment 1 Tony Edwards latest being the 2011 edition, and authored the Mike McGuigan Tony Edwards is a sports physician in private ISAK Handbook which is the international Mike McGuigan is a Professor of Strength practice at UniSports Sports Medicine, textbook for all those Level 3 and Level 4 and Conditioning at AUT University and an Auckland, NZ. He has been Team Doctor anthropometrists teaching ISAK courses. Adjunct Professor at Edith Cowan University. for NZ Olympic and Commonwealth Games Comment He is the Associate Editor-in-Chief for the teams from 1990 to 1996, and was Team Kelly Sheerin Journal of Sports Science and Medicine and a Senior Associate Editor for the Journal of Doctor for the Warriors Rugby League team Kelly Sheerin is a physiotherapist and sports Strength and Conditioning Research. He is from 1996-2000. He has been Medical scientist at AUT Millennium Institute. He also currently the Research and Innovation Director of High Performance Sport NZ for is the Manager of the Running and Cycling coordinator for the Silver Ferns. the last 8 years until his resignation earlier Mechanics Clinic, and Deputy Director of this year, and he has been Medical Director the J.E. Lindsay Carter Kinanthropometry Comment 2 of Hockey NZ since 1992. He has also served Clinic. Kelly is currently completing his PhD Chris Hanna as National President of Sports Medicine in gait biomechanics which involves the Chris Hanna is a sports physician working at NZ, and is a member of the FIFA Medical development of a mobile feedback system based UniSports Medicine in Auckland. His interests Committee representing Oceania since 2005. on inertialsensors, aimed at modifying running include hip and groin injuries, and pectoralis mechanics. major ruptures. He is an honorary lecturer for the Postgraduate Diploma in Sports Medicine at the University of Auckland.

Contributors

Sports medicine practitioners’ Peter Fricker Sports Physician’s Code of Ethics. Since then assessment and management of Peter Fricker OAM is a sports physician she has written the NZ Physiotherapy Code upper respiratory illness in athletes currently employed as Chief Sports Medicine of Ethics, and the NZ Sports Physiotherapy Samantha Promroy Advisor with the Aspire Zone Foundation Code of Conduct. Lynley has a number of publications on sports medicine ethics. Samantha Pomroy is currently an intern at the in Qatar. Fricker spent 30 years with the How I Treat: Adhesive capsulitis Canberra Hospital after completing a Bachelor Australian Institute of Sport, as Head of Sports of Medicine/Bachelor of surgery at ANU. Prior Medicine, and then Executive Director from Judith May to this, Sam was a physiotherapist for 10 years, 2005-2011. He was a team doctor to several Judith May is a sports physician who is having a keen interest in sports, working with Australian Olympic and Commonwealth currently working at Grace Sports Medicine in Sydney University Rugby, Sydney University Games teams and travelled extensively Tauranga. Her interests include female issues Flames WNBL, NSW/ACT Under 16/18 AFL with Australian gymnastics and basketball in sport and endurance sports. She is currently and suburban Sydney rugby and AFL teams. teams. His research and industry interests the Medical Director for Triathlon New In the future, Sam is keen for application to are numerous including groin pain, exercise Zealand. She is a Professional Practice fellow the sports medicine program with particular immunology, and anti-doping strategies. He with Otago University teaching the Women in interests in team and Olympic sports, as well was a member of the Australian Sports Drug Sport paper for the postgraduate diploma in as further research involvement. Medical Advisory Committee and the Anti sport and exercise medicine. David Pyne Doping Research Panel from 2000 to 2005. He Comment 1 was President of the Australasian College of Chris Hanna David Pyne is a sports scientist in the Sports Physicians from 1994 to 1996. Department of Physiology at the Australian Chris Hanna is a sports physician working at Institute of Sport (AIS). David has 25 years Reducing injury in elite sport - Is UniSports Medicine in Auckland. His interests experience at the AIS and been involved with simply restricting workloads really include hip and groin injuries, and pectoralis every Australian Olympic Swimming Team the answer? major ruptures. He is an honorary lecturer for from Seoul, 1988 to London, 2012. He also has Paul Gamble the Postgraduate Diploma in Sports Medicine extensive experience with court and field-based Paul Gamble is an author and strength and at the University of Auckland. team sports at the AIS and national levels. conditioning specialist. Paul is originally from Comment 2 His work in exercise immunology has focused the UK where he worked in high performance Margie Olds on relationships between exercise, training sports for a decade, beginning his career in Margie is a physiotherapist who specialises in and immune function, epidemiology of illness professional rugby union with London Irish shoulder injuries. She works alongside Graeme in athletes, and nutritional interventions. and latterly serving as National Strength White at Unisports Medicine, has a specialist David has published over 190 peer-reviewed and Conditioning Lead with Scottish Squash shoulder practice in West Auckland, works at papers and holds adjunct appointments at the where he also oversaw sports medicine and AUT on the post-graduate musculoskeletal University of Canberra, James Cook University, sports science provision for players in the programme and has developed a shoulder and Griffith University. He is a member of national programme. Since arriving in New brace to prevent recurrent shoulder instability. Sports Medicine Australia, and a Fellow of the Zealand in late 2011 Paul has continued to American College of Sports Medicine. combine writing and training athletes: in Graeme White Kieran Fallon 2012 he founded the Informed Practitioner Graeme White is a sports and manipulative in Sport website to develop and deliver online physiotherapist with a special interest in Kieran Fallon is Associate Professor in the continuing education courses for practitioners, overhead sports and shoulder injuries. He Faculty of Medicine at the Australian National and is presently engaged with training track is a founding partner at UniSports Sports University where his main responsibility and field athletes. Medicine in Auckland and is a provider to is coordination of teaching of all aspects of High Performance Sport New Zealand. musculoskeletal medicine. He spent 19 years Ethics in New Zealand Sports at the Australian Institute of Sport, the last Medicine IOC Advanced Team Physician Course, Saltsjobaden, Sweden 11 as Head of Sports Medicine and recently Lynley Anderson downshifted to concentrate on medical Nat Anglem, Ngai Tahu Lynley Anderson is a senior lecturer at the education and pursuits that he had neglected Bioethics Centre, University of Otago. She Nat Anglem is a sports physician in for many years. Kieran graduated MBBS teaches ethics and professional issues to Christchurch. His aim is to use models (Hons) from the University of Sydney and holds medical, physiotherapy, and other health of high performance sport to improve the a Master of Sport and Exercise Science degree professional students as well as post-graduate health and well-being of his patients, as well from that university. He gained his MD and students at the University of Otago. Lynley’s as their athletic success. He works for High a Masters degree in Higher Education from PhD explored the ethical issues facing NZ Performance Sport New Zealand within the ANU and holds two medical fellowships. His sports doctors working with elite athletes Wintersport programme. main research interests have been in clinical and teams through interviews with 16 sports haematology and biochemistry in elite athletes, doctors. As a result of this research Lynley was ultramarathon running and mythbusting in invited to write the Australasian College of sport and exercise medicine.

new zealand journal of sports medicine - 1 Editorial bruce hamilton Towards a “Grand Unifying Theory of Sports Medicine” (AKA “Guts Me”)

he latter half of the twentieth century scientific endeavour over this period, has the the speed of light, while scientists sit back was a period of immense social, development of Sports Medicine knowledge and watch what happens. Very cool. The Tcultural and technical development. fared? 2012 discovery of the Higgs Boson, by an It was also the period in which our field of It is perhaps (or hopefully) an interesting organisation founded in 1954 (the year of Sports Medicine was founded and grafted observation that if you were able to add the the 4 minute mile, the publication of the into the specialty that it is today. Fifty years mass of all the individual atoms that you Lord of the Rings, and (unfortunately for on from when our founding members had are composed of, the total would be less my story, but close enough to include) two the foresight to establish the NZ Federation than what you will actually weigh on your years after the formation of our British of Sports Medicine seems a reasonable bathroom scale. This is no mistake of your counterpart BAS(E)M), is considered to be 5 period (despite the fact that 50 years no scales, but, rather confusingly, seems to one of the great scientific breakthroughs. longer seems as long a time period as it once reflect the fact that the sum of the parts is At the time theoretical physicists were did) to reflect on how Sports Medicine has actually greater than the sum of the parts postulating the theory of subatomic particles evolved. Even before the Second World War, - a conundrum that perplexed physicists and experimentalist were taking up the task, the foundations for a future sports medicine from the early 20th century. Remarkably, Sports Medicine internationally was in its specialty were being established in Europe, in an attempt to explain this anomaly and infancy. However, in the last 20 years in Britain and the USA, with physicians and despite no actual evidence for their existence particular, undergraduate and postgraduate therapists recognising the unique challenges (and no way at the time of proving their education in our field has massively of caring for the athletic individual. existence), theoretical physicists in the expanded, presumably enhancing our Subsequently, and despite the post war mid-20th century postulated the existence scientific base and the care of our athletic conditions of the times, the 1950’s saw the of hitherto unknown subatomic particles. patient. Presumably - but how do we really publication of multiple textbooks exploring That is, additional particles that hang around know and what progress we have made? In topics such as injury surveillance, injury and with atoms, over and above the electrons, the 50 years since physicists postulated and illness prevention, and injury management protons and neutrons that we were taught discovered the game-changing, impossible- – topics as relevant today as they were in about at school or university. This theory to-fathom but unifying theory of everything 1,2 the infancy of our field. By the mid-1950’s of an unknown particle, ultimately known Higgs Boson, what progress has Sports national and international sports medicine as the Higgs Boson (after Englishman Peter Medicine made – do we have a Sports organisations were established and Sports Higgs, one of the six theorists to postulate Medicine equivalent of the Higgs Boson? Medicine was already being recognised as a their existence in the form of a mathematical It would be inappropriate to suggest that profession in some eastern block countries. equation) was first proposed in 1964, one the care we provide to Athletes has not The 1960’s saw expansion in both Sports full year after the conception of the NZ improved over the last 50 years, as there Medicine research and the production Sports Medicine Federation. Proving the has undoubtedly been some excellent of referenced textbooks, with the term existence of these unknown particles, research into each of the three traditional “Sports Medicine” appearing in the title of a which ultimately were thought to relate to, cornerstones of Sports Medicine – textbook for the first time in 1962.3 Recently, and unify the theory of everything from prevention, treatment and enhancement. historians comprehensively described the the Big Bang to big surf (and, while not However, I would contend that we lack a development of Sports Medicine in Britain,4 overtly stated in the literature, probably Sports Medicine equivalent of the Higgs in which they recognised three key historical ACL ruptures), became the equivalent of the Boson in terms of either a unified theory for components in the development of sports search for the Holy Grail, for 20th century soft tissue injury causality or management, medicine as being: “prevention”, “treatment” experimental physicists. Almost 50 years of or a robust ability to explore any underlying and “enhancement”. These components were experimentation, international collaboration, theory (should there be one). What we the cornerstones of a fledgling specialty, and controversy, fierce competition and billions do have, are increasingly well-articulated while “enhancement” has evolved into a dirty (and billions) of dollars culminated in the clinical observations, for which we are slowly word, prevention and treatment do remain “discovery” of the Higgs Boson by the Large moving towards an understanding of the real fundamental to Sports Medicine. While the Hadron Collider (LHC) at the European challenges of “prevention” and “treatment”. science supporting the specialty of Sports Council for Nuclear Research (CERN) in For most injuries, our understanding of the Medicine has clearly evolved over the last 50 2012. The LHC, looking remarkably like a patho-aetiological and patho-physiological years, other fields of science have undergone James Bond villains lair, is a 27 kilometre processes involved remains remarkably similar periods of academic evolution. How underground circular tunnel capable of superficial; nor do we yet appear to have the then, in comparison with other areas of smashing particles into each other at almost means to adequately explore these editorial challenges. For example, since the 1930’s, the research, the best line I heard was many other areas of Sports Medicine), there injury surveillance has been both recognised (liberally paraphrased for effect but without seems, unfortunately, only limited progress and instigated in the field of sports injuries, impacting on the accuracy) “…this product in the development of robust underlying and injury prevention as the natural will derive different concentrations of theories, let alone high quality clinical extension of that surveillance was identified platelets for use in different conditions and research. Theory development, such as that as a key function of Sports Medicine locations, as we know different tissues need exemplified by our Australian neighbours from our infancy.6 Without doubt, injury different concentrations for optimal effect… Jill Cook and Craig Purdam considering surveillance, when applied, has become of course…this is still anecdotal, but we tendinopathy,7 or our Norwegian colleagues more structured and sensitive, but despite know this is the way to go”. Listening to on “everything else” should be embraced, this, its application at all levels of sporting subsequent conversations, the impression encouraged and challenged experimentally. activity remains at best inconsistent and one was left with was that the research will It is our remit in sports medicine to a logistical challenge for most sporting show this eventually, so you should start ensure this happens and while we may codes. To be balanced, as I would like to using it now, or your athletes will miss out. not need to split the atom or split into try to appear at least, both prevention and This is without even a clear or consistent theoretical and experimental factions as management have made substantial gains understanding of the pathology we are our physics colleagues have done, we must in some areas, with concussion and ACL treating (for example, what exactly is a support both robust theory development, prevention/management probably standing “muscle strain”?), why this treatment should collaborative investigation and excellence out. However, scratch the surface and there work or how it works, but worse, without in clinical practice. Recycling of inaccurate, remains only a superficial understanding of any attempt to perform quality, quantitative incomplete evidence, driven by vested many of the most fundamental aspects of clinical research to test any non-existent interest and based on a poor theoretical and the aetio-pathological processes underlying (or at best superficially appealing) theories. scientific approach will neither help our the majority of the (common) conditions This approach, which unfortunately patients nor our profession. Let’s not still be we manage. Thus, it remains a challenge appears common within what is still the saying this in 50 years time. after all these years, to understand why one maturing field of Sports Medicine, may be References individual will suffer an injury and another our Achilles’ heel. Often quoted from “the 1 Knight SS. 1952 Fitness and Injury in Sport. not. In the time that the Higgs Bosun was Descent of Man” (1871), Darwin famously Skeffington and Son Ltd. London postulated and hitherto unknown subatomic said “False facts are highly injurious to the 2 Featherstone D. 1957 Sports Injuries. Their particles were identified, we have managed progress of science, for they often endure Prevention and Treatment. John Wright and to describe the complexity of injury in long; but false views, if supported by some Sons Ltd. Bristol athletes, but have made only toddler steps evidence, do little harm, for everyone takes a 3 Williams, J. G. P. 1962 Sports Medicine. The towards a deeper understanding of the salutary pleasure in proving their falseness”. Williams and Wilkins Company. London phenomenon – without which effective While there are a few ways one can interpret 4 Heggie V. 2010 A History of British Sports prevention and treatment will remain this statement, my overwhelming concern Medicine. speculative. This is not however, a diatribe is that through repeated presentation of 5 Sample I. 2013 Massive. The Higgs Boson against our underpaid, underfunded false (or at least unsubstantiated views), and the Greatest Hunt in Science. The researchers who are working hard to we are in danger of creating a specialty of Random House Group Ltd. resolve this situation. Nor is it a shot at the damaging false facts. These self-sustaining 6 Lloyd FS, Deaver GG & Eastwood FR. 1937 clinicians who are working with limited inaccurate beliefs, touted by the modern Safety in Athletics: The Prevention and funds in challenging environments in which “snake oil salesman” will not only delay the Treatment of Athletic Injuries. W B Saunders to perform research. It is however, as I will progression of science and patient care in Co. Philadelphia describe, a shot across the bow for those our chosen field, but potentially destroy the 7 Cook JL, Purdam CR. Is tendon pathology who appear to contrive to delay, potentially profession before we really get going – if a continuum? A pathology model to explain fatally for our field, the process of theory we let it. As the lesser quoted second half the clinical presentation of load-induced development and experimental evaluation. of Darwin’s reference highlights, it is only tendinopathy. Br J Sports Med. 2009 Jun;43(6):409-16 Recently at a large international Sports when the falseness of the beliefs is proven Medicine conference, I was amazed to that the “..path towards error is closed see seven different techniques for blood and the road to truth is … opened”. This manipulation, for use in healing injuries, pathway to unsubstantiated beliefs is one being vocally marketed in the exhibitors that Sports Medicine must avoid if we are to area. Reluctant to engage any of them in survive and progress as a specialty. conversation, I hovered at the back of the Hence, while we may actually have a crowds (literally) of physicians queuing to Higgs Boson-type challenge in trying to hear from these sales gurus. Quite apart develop a grand unifying approach to from the frequent misrepresentation of injury prevention and management (and

new zealand journal of sports medicine - 3 editorial chris whatman Is the screen clear enough to see the road ahead?

n the numbers of items resulting in little useful based on movement pattern screening. Is cover information save for the summary comment this because the screen actually doesn’t of a in the conclusion. I am aware that recently predict injury or are their other factors at Orecent edition there has been a lot of work done on refining play? There are likely many other factors and of the British the screening protocol in HPSNZ and for me a couple were highlighted in the “mission Journal of Sports this has resulted in a far better and hopefully possible” edition of BJSM. One is the role Medicine (BJSM) more useful tool – some more evidence it that genomics play in identifying those at it proclaimed helps identify those at greater risk of injury risk of injury. A podcast with Professor “Sports injury would be nice and hopefully this can be Malcolm Collins from the University of Cape prevention – gathered in time! That said there is plenty of Town (freely available to all on the BJSM mission possible”. anecdotal evidence supporting the concept of website) gave an interesting summary of his This was encouraging as I had recently movement pattern screening and in the view work showing there is increasing evidence started to wonder if this was in fact a mission of many, good theoretical justification.3 genetic profile contributes to an athlete’s even too tough for Tom Cruise! The journal A challenge to the concept of screening susceptibility to tendon and ligament injury reports on the encouraging success of a well- the movement system comes from (genes contributing to the differences in the known Norwegian research team in reducing biomechanists who advocate the value structure of collagen fibres for example). ACL injuries in handball. However while it of increased movement variability. They Most of the research has apparently focused appears there is growing evidence this type have questioned the view that pain and on genetic markers for overuse tendon of injury prevention programme can be dysfunction result from failure to attain a injuries and there are protective as well as successful it seems we are still struggling to specific movement pattern. Several authors harmful genes. There is no doubt a lot of identify the athletes at most risk. We all agree have suggested reduced movement variability work still needing to be done in this area that risk is multi-factorial and one factor may adversely affect joint health by causing including genetic profiles of different ethnic that has received much attention recently is systematic loading on the same areas of populations. Professor Collins was quick movement pattern (functional movement, articular cartilage raising the risk of chondral to correct the misconception that genetic movement competency) screening. damage and osteoarthritis.2 While this is profile will one day predict injury risk but Many authors have for some time promoted an interesting notion my impression is the rather that it could be used alongside other the notion of screening athletes to identify variability they mention is very small in information to aid risk rating or identify how dysfunctional movement patterns before magnitude and while it may be beneficial an athlete will respond to treatment – the pain or functional problems occur. All it’s probably not clinically measurable. environment is still important, movement physiotherapists will be familiar with the Furthermore I doubt the term variability screening still has a place! work of Shirley Sahrmann who advocates means the same to a clinician as it does to Another factor of interest in the same assessment of the movement system, recently a biomechanist – it would be an interesting edition of BJSM was the new tool for better suggesting it should be checked as often as conversation! Perhaps there is an optimal recording of overuse injuries. Ronald Bahr your teeth.4 Movement pattern screening to movement pattern (appropriate relative and his team from Oslo have reported on identify athletes at greater risk for the likes motion between segments in a chain) within a new questionnaire which appears far of ACL injury and other lower extremity which some athletes may have increased superior to traditional injury reporting injuries (especially overuse injuries) is now micro variability and thus these two ideas mechanisms where overuse injuries are widespread and considered a key strategy are not necessarily at odds. My coaching concerned.4 Inappropriate tools for recording in all major sports. Studying the single leg colleagues also speak of the benefits of having overuse injuries may be another factor squat (small knee bend, single limb mini variability in movement patterns during the why past studies have failed to show links squat or whatever your favourite term) as game situation. Again I don’t see this being between movement patterns and injury risk a screening test has been a popular topic at odds with the concept of trying to achieve – particularly risk of overuse injury which is for many research groups. The test seems optimal movement in some fundamental most relevant to movement screening. The reasonably reliable and some have shown it patterns. It does however highlight the need use of this new tool in future studies may to be useful in identifying increased risk of for various disciplines to communicate help and our group certainly has plans to use patellofemoral dysfunction but there is a lack regularly – the multidisciplinary sports it. Tracking exposure suffers from much the of prospective evidence. medicine, science and coaching conferences same problem as injury definition and given I’m sure most involved in screening elite of the past seem a lost opportunity. the environment is still considered key this athletes in this country would agree that the Disappointingly there is little quality needs to be improved in future studies also. initial attempts at screening protocols were prospective evidence available showing we So next time you see an athlete with a less over the top, too complex, with excessive are good at predicting those at greater risk than ideal movement pattern but a clean

4 - new zealand journal of sports medicine editorial injury history – don’t despair! It’s likely this method for the registration of overuse 3 Powers C M. The influence of abnormal hip athlete is blessed with a combination of injuries in sports injury epidemiology: mechanics on knee injury: a biomechanical micro movement variability, good genes and the Oslo Sports Trauma Research Centre perspective. Journal of Orthopaedic & Sports exposure that allows him or her to fly under (OSTRC) Overuse Injury Questionnaire. Physical Therapy, 2010; 40(2), 42-51. British Journal of Sports Medicine, 2013; the radar. Thus when combined with other 4 Sahrmann S A. On “The physical therapy and 47(8), 495. information you may still be able to see the society summit (PASS) meeting...” Kigin CM, 2 Glasgow P, Bleakley C M, & Phillips N. Rodgers MM, Wolf SL; for the PASS steering more likely road many athletes are on by Being able to adapt to variable stimuli: the committee members. Phys Ther. 2010; looking through the movement screen. key driver in injury and illness prevention? 90:1555-1567. Physical Therapy, 2011; 91(3), REFERENCES British Journal of Sports Medicine, 2013; 432-433; author reply 433-435. 1 Clarsen B, Myklebust G, & Bahr R. 47(2), 64. Development and validation of a new

Interview chris milne The Matt Marshall Interview

warning to the unwary - this is and Maori All Blacks were legendary. In no standard interview transcript. addition, he is an honorary member of the AWhat follows is a few thoughts I New Zealand Barbarians Rugby Football have been able to cobble together following Club. an approach to Matt Marshall based on He served New Zealand sport with our association over many years. I had put great distinction internationally, having several questions to Matt and the response been Director of Medical Services for that follows is an admixture of his thoughts Commonwealth Games teams in 1982 and and my own interpretation and reflection. 1986 and our Olympic team in Los Angeles Q1. What got you into sports in 1984. Subsequently he served on the medicine? Oceania National Olympic Committee’s The answer I got from Matt was that Medical Commission from 1984 to 2001. many doctors seemed to treat injuries Matt has had a lifelong interest in sports but gave little thought to prevention or doping matters and was a member of the rehabilitation. From looking at the CV he Hillary Commission Task Force on Drugs Dr Marshall receiving his SMNZ Life sent me, a few things stand out. He arrived in Sport from 1990 to 1991. Subsequently Membership Award, Wellington, 1996. in New Zealand in 1957 and practised as he was appointed to the board of New a GP with an interest in sports medicine Zealand Sports Drugs Agency from 1992 in Whangarei from 1957 to 1995. One to 1999 and has served on the three- Zealand in 1990 and awarded life suspects that he was in some ways a man Therapeutic Use Committee of that membership of Sports Medicine New “Scottish refugee”, seeking release from the organisation from 2002 onwards. Zealand in 1996. summer-less Celtic north to the winterless He is well-recognised for his verbal Outside our organisation he has had north of New Zealand. ability, in particular an ability to reflect on national recognition, being made an Officer Having always been passionate about rugby, experience via many humorous anecdotes of the New Zealand Order of Merit in it is not surprising that by 1959 he had been over the years. It is no surprise that we 2006. He was appointed Patron of Sport appointed honorary doctor to the North have a named lecture, The Matt Marshall Northland in March 2001 and was inducted Auckland Rugby Union. He continued Lecture, at our annual conference which as one of the Legends of Northland Sport in this role until 1995. Longstanding was inaugurated in 1996. Matt served as in 2012. aficionados of our national game will note President of the Northland Branch of Sports Q2. What changes have you witnessed that his period of service incorporated the Medicine from 1982 to 1989 and as National in sports medicine over the course of playing days of the incomparable Going President of Sports Medicine New Zealand your career? brothers (Sid, Ken and Brian) whose from 1983 to 1991. He was appointed a Matt’s career in sports medicine began when deeds for North Auckland, the All Blacks Foundation Fellow of Sports Medicine New I was aged one, so was still in short pants. It

new zealand journal of sports medicine - 5 interview spans some 45 years from that date. some libellous. Easier to tell than commit Statement of Interest [Editors Note: I think Chris is kidding to writing.” How true. Those of us who I should declare that Matt has been both himself here…] have been in the organisation long enough an inspiration and a great supporter of my to share a drink with Matt can testify to career in sports medicine. The same is true From what I can see, the major change the huge store of anecdotes, many of which for several of our other senior clinicians. that has taken place in that time has been stem from a lifetime of service to sport and For young clinicians, if you are unsure of the increasing professionalism within all delivered with an unmistakable Scottish what to do in a given situation, seek advice sport and this has been accompanied by dialect. As he said to me once, “I’m the one as this will invariably provide you with a the need for increased professionalism of who can watch Taggart (Scottish TV show) clearer way forward. sports medicine clinicians. Initially the without an interpreter.” GP or physiotherapist with an interest and skills in sports medicine, who was One of his favourite moments happened largely self-taught, provided care to at the Edinburgh Games. He was standing athletes at all levels. In the 21st century with one of the bowls team, Morgan Moffat, also a Scot. He was an increasing number of First you must hone the clinicians providing dressed in his blazer with a services to our top athletes your skills to be an pocket emblazoned Director are specialist doctors or excellent general of Medical Services. He was approached by a reporter physiotherapists with clinician. Then apply additional qualifications in from the Edinburgh Evening sports medicine. They in those skills to athlete times. “He asked me what I turn have been joined by care. Finally, take did in the team! I managed nutritionists, podiatrists, to keep a straight face and what opportunities psychologists and sport told him that I gave out scientists, who collectively you are offered because medicines and also acted as make up a team of skilled life is a journey of an interpreter for the team, professionals. These along with Mr Moffat. This varied experiences, people collaborate to gem of information appeared provide optimal care for all of which can prove in the Evening Times that night. Needless to say, I was our elite athletes. valuable in the future. fined at the team meeting that On looking through his night. Anyway, my accent is CV, the title “honorary” definitely Glaswegian.” This will mean he crops up repeatedly. In addition to being will be right at home as an interpreter for honorary doctor for the North Auckland the New Zealand team going to Glasgow Rugby Union, he has been honorary doctor in 2014. for Northern Districts and Northland Cricket plus Northland Hockey and Q4. Any advice he may have to offer to a Swimming. For the uninitiated, honorary young clinician contemplating a career in means unpaid. Matt donated copious sports medicine. hours of his own time, often at night and He provided no specific response to this, at weekends, to the service of athletes. The but from my interaction with him over change from “honorary” to “contracted” many years I suspect his response would be is a significant momentum shift in the similar to mine. First you must hone your provision of services at the higher levels of skills to be an excellent general clinician. sport. Nevertheless, there are still a huge Then apply those skills to athlete care. number of members of Sports Medicine Finally, take what opportunities you are New Zealand who provide team care to offered because life is a journey of varied clubs or education sessions on a voluntary experiences, all of which can prove valuable basis. in the future. In later discussion he made the point that it would be a help to any Q3. I asked him to recall a couple of sports physician or other clinician if they memorable moments. study the intricacies and actions involved His response, “Needless to say, plenty has in each particular sport, as this would help happened over my career. Some funny, steer the treatment in the correct direction.

6 - new zealand journal of sports medicine Reflections CHRIS MILNE, DAVID GERRARD, TONY EDWARDS Reflections on the past, the present and a glimpse into the future

he year 2013 marks the 50th Sperryn(who is well known to New Zealand complete ruptures of major tendons such as anniversary of the founding of audiences having lectured at our conference the achilles tendon could be treated either the New Zealand Federation in 1983 and 1994). In the USA, Dr Don in an equinus cast or with operative repair, Tof Sports Medicine, the forerunner of O’Donoghue had just published (1962) his but lesser degrees of tendon pathology Sports Medicine New Zealand (11 March landmark textbook entitled “Treatment of in runners were often managed either by 1995SMN). It was February 11, 1963 when Injuries to Athletes” and J Cerney (1963) retirement from running or a complete the first formal meeting of SMNZ was held published the massive 872 page “Athletic change of sport. For example, John Davies, in the Red Lecture Theatre of the Otago Injuries: An Encyclopedia of Causes, Effects the 1500m bronze medallist at the 1964 Medical School, to elect the “Foundation and Treatment”. In Scandinavia, Per-Olaf Tokyo Olympics managed his achilles Officers”. They comprised Dr Norrie Astrand was hard at work on his Textbook tendinitis by switching to cycling for a few Jefferson (President), Dr Jack Kilpatrick of Work Physiology which provided the years, before returning to a lower level of (Hon Secretary), and Dr John Heslop and basis for modern exercise physiology. running as a club athlete. Professor Phillip Smithells completing the So what was the state of the art Heat illnesses were poorly understood and inaugural Executive Committee. back in the early 1960s? remarkably, athletes were actively advised The genesis of this meeting was perhaps At this stage, anterior cruciate ligament against drinking, at the risk of inducing a chance meeting between Dr Mayne injuries were recognised as a significant the symptom euphemistically referred to Smeeton (Auckland) and Dr Jefferson, contributor to knee instability but there as “stitch”. Consequently many athletes both of whom had an interest in sport were no reliable operative procedures from temperate countries succumbed to and medicine, while serving in the Pacific the effects of dehydration for its reconstruction. The pioneering work of during WWII. Subsequently, a meeting Anterior knee pain was and overheating when they was arranged in Auckland in 1961 frequently treated by Dr Philip Wrightson, raced in major competitions between Norrie Jefferson and Sir Arthur patellectomy, reflecting neurosurgeon in Auckland, held in warmer climes. Porritt, while the latter was on a visit to a limited understanding was carried out in the We knew very little about New Zealand at the behest of the British of the mechanics of the concussion in 1963, other Medical Association. Sir Arthur Porritt, patellofemoral joint and 1960s and 70s. His studies than that some boxers were a distinguished Otago Medical Alumnus, the importance of non showed that there was described as being ‘punch had previously represented New Zealand operative rehabilitation. drunk’ and some even definite cognitive decline as an athlete in the 1924 “Chariots of Fire” Stress fractures, originally died after being knocked Olympic Games and as Chef de Mission described as “march after repeated head injuries out. Rugby players of in 1936, where he mentored another fractures” were recognised and paved the way for later the era who owned up Otago Medical student, the legendary Jack in military recruits, and to having concussions work by authors such as Paul Lovelock. At that time Porritt postulated it would be several years were regarded as a ‘bit the formation of a New Zealand association before Michael Devas would McCrory, which have helped soft’. The pioneering work of medical practitioners with an interest in publish his early monograph clarify our understanding of of Dr Philip Wrightson, sport, thereby laying the groundwork for in this topic. neurosurgeon in Auckland, the organisation of which we are members head injuries. Turning to cardiac was carried out in the 1960s today. It is fitting to record that our issues, anyone suffering a and 70s. His studies showed inaugural President, Dr Norrie Jefferson, myocardial infarct in the early 1960s was that there was definite still resides in Dunedin, where he continues routinely prescribed six weeks of complete cognitive decline after repeated head to take an interest in the proceedings of the bed rest with instructions to avoid future injuries and paved the way for later work by sports medicine community. strenuous activity. Early work in the authors such as Paul McCrory, which have These developments in New Zealand were 1950s by Professors Jerry Morris and helped clarify our understanding of head not occurring in isolation. In the UK, Ralph Paffenbarger in the UK and USA injuries. BASEM had been formed in 1953 and Dr respectively recognised that those habitually On the rugby field the All Blacks, led by John Williams, who was a relatively junior active in their workplace had a lower risk of iconic captains Sir Wilson Whineray and orthopaedic surgeon at the time, published cardiac events, yet this knowledge was slow Sir Brian Lochore, were the internationally his first “Textbook of Sports Medicine”, to translate into cardiac rehabilitation. dominant team throughout the 60s and 70s. which was to be the forerunner of a Similarly, tendon injuries were relatively Sir Colin (Pine Tree) Meads, regarded as a later collaborative volume with Dr Peter poorly understood. It was recognised that colossus of the game and All Black of the

new zealand journal of sports medicine - 7 reflections much closer scrutiny, stimulated by the In Australia the kindred organisation is with midsection achilles tendinopathy amphetamine-induced deaths of Danish Sports Medicine Australia (also founded or patellar tendinopathy, providing they cyclist Knut Jensen in the 1960 Olympic in 1963), and under the auspices of the are prepared to comply with Alfredson’s road race and Britain’s Tommy Simpson in Australasian College of Sports Physicians protocol and adhere to a strict regimen of the 1967 Tour de France. It was another (ACSP)there has been the development of 90 repetitions per day. For the few people three decades before the establishment specialist training in sports medicine. New who do not respond to the Alfredson of the independent World Anti Doping Zealanders have played their part in that regime and who have hypervascular Agency (WADA). organisation, with Chris Milne its first New tendon change, a variety of adjunctive Medical appointments to New Zealand Zealand president from 2006 to 2008. In therapies have come along (although most teams were not formalised until 1964 the UK, the British Association of Sport lack critical levels of evidence). High when Dr Renton Grigor, an Auckland GP, and Exercise Medicine is the equivalent of volume local anaesthetic injections, blood was appointed to the Olympic Team for SMNZ and the Faculty of Sport and Exercise injections and platelet rich plasma (PRP) Tokyo. His credentials were a keen interest Medicine is the equivalent body to the injections all have their advocates and only in treating athletes and a strong affiliation AC SP. time will tell which of these ultimately with the Mt Eden Swimming Club and Further afield in the USA the American is established as the gold standard for the famous stable of athletes trained by College of Sports Medicine, founded in adjunctive treatment. Certainly, surgery legendary coach Arthur Lydiard. Renton 1954, has gone from strength to strength has been very much relegated to small print Grigor became New Zealand’s first official and its annual meetings now attract unless there is a complete rupture or a very Olympic Team physician, followed in some 5000 delegates. This is the world’s high-grade partial tear that has not settled 1966 by Dr Mayne Smeeton, an Auckland preeminent sports medicine meeting and if with non-operative means. anaesthetist and former NZ Universities you have never been it is worth a look. In Our understanding of concussion has high jumper, who accompanied the New the early 21st Century, a European College moved ahead in leaps and bounds, Zealand team to the Commonwealth Games of Sports Medicine was founded, and with and a series of international consensus in Kingston, Jamaica. Subsequently, the an annual conference, continues to gain in conferences have been held since 2001. current pathway for medical appointments strength and numbers year by year. These have enabled experts of various craft to Olympic and Commonwealth Games And what of the clinical issues? groups representing different organisations teams resides with the New Zealand around the world to come together and Firstly, anterior cruciate ligament injuries Olympic Committee. hammer out some agreed protocols. are no longer the inevitable career- There has also been the development Pan forward to 2013 shortening or ending injury that they used of standardised methods of clinical Sports Medicine New Zealand now has 600 to be. ACL reconstruction has been a assessment, e.g. the Sport Concussion members representing 10 regional branches, reliable procedure for the last two decades, Assessment Tool and monitoring of concentrated in the major centres. An but the forces involved in rupturing the progress via paper or computerised testing. enviable record of professional leadership ligament still mean that there is a significant and education has been established risk of post-traumatic arthritis in those who Information technology has been the huge over the past 50 years through a single have sustained an ACL rupture. Anterior advance of the last 50 years and the internet pan professional group representing all knee pain is now managed effectively with provides all clinicians with resources at clinicians active in the field. Jenny McConnell’s taping and exercise their desk, laptop or mobile phone that they could not have even dreamed of as Historically, the former Hillary Commission regime plus attention to core stability little as 10 years ago. Most major journals was responsible for distributing exercises, particularly for the gluteus medius have allowed at least some electronic Government funding to sport at the elite muscle, and provision of orthotics in those access and athletes also have access to this level and SMNZ, acknowledged as an with over-pronation. material. Dr Google has become the most important support service, received critical Our knowledge of stress fractures has widely consulted clinician in the world, financial support. Today High Performance improved immeasurably and modern however we clinicians down here in New Sport New Zealand, formerly the New methods of analysis of bone density, e.g. Zealand can offer what the internet cannot Zealand Academy of Sport, has emerged DEXA scanning, give us a good idea as to - a perspective rather than a tidal wave of as the significant funder of elite athletes. who needs to be managed the most actively. unfiltered information. The growth in professionalism within New The role of energy deficit, particularly Zealand sport, beginning with rugby in the in those with eating disorders, has been In the sporting arena, the All Blacks are the 1990s, now allows athletes in major codes increasingly emphasised in the last decade. current holders of the Rugby World Cup and Richie McCaw recently became the first to make a living from their sport. Elite With regard to tendon rehabilitation, All Black to play 100 tests. He is possibly athletes pursuing concurrent academic the Alfredson concentric then eccentric the greatest All Black ever and hopefully his qualifications are further assisted financially strengthening regime is well-established and career has several years to run. In athletics through the Prime Minister’s Scholarships. effectively rehabilitates about 90% of those

8 - new zealand journal of sports medicine reflections the rise of the East Africans has meant that, Organisations such as ours must and provide cost-effective care in the 21st apart from Nick Willis, New Zealand does have an on-going role in organising century. Against rising public expectations not have a world-class middle distance interdisciplinary meetings and promoting and the increasing availability of high- athlete. However, the Polynesian migration clinical collaboration. We must also tech imaging, this could present our most to New Zealand in the last 50 years has preserve a voice as professional leaders pressing challenge. When our medical led to competitors such as Valerie Adams and continue to express our opinion on system becomes high jacked by the attitude making up for this deficit with great matters of on-going importance in sport currently prevailing in America, where success in field events. and exercise medicine. The future holds reckless over-investigation is driven by the Rowing, cycling, yachting, canoeing and an opportunity for extended collaboration fear of legal challenge, we run the risk of equestrian continue to carry the banner for with our Australian colleagues and the New Zealand health system falling into New Zealand in Olympic events. Yachting those further afield through electronic the same fractious state. We must educate deserves a special mention: through the networking. In the future, audio/video patients that clinical justification must application of high technology and Kiwi interfacing will most likely become the always override their perceived desire for a grit, Team New Zealand, under Peter preferred mode of communication. costly investigation such as an MRI. Blake’s inspired leadership, was able to win Looking to the future in injury Finally, on a personal level, we should all the America’s Cup in 1995 and defend it rehabilitation, one wonders about the attempt to maintain our own personal in 2000. Currently they development of techniques health and fitness and stave off the are pioneering a technique For sport medicine such as the LARS ligament. inevitable age-related decline in organ of foiling in catamarans professionals, the Will this be a winner or function. Keep turning up to meetings and hopefully this will challenges are will it go the way of carbon and socialising with your friends and lead to the Cup returning fibre ACL reconstructions remember that, after exercise, they are to New Zealand later this to maintain our of the early 1980s that probably two of the best medicines we can year. Mark Todd continues competence and provide were subsequently take. to set the benchmark for cost-effective care consigned to the scrap equestrian competitors at heap. Bone stimulation the ripe old age of 56, and in the 21st century. has the potential to Bob Charles is a revered Against rising public improve the healing rate golfer, having won the of stress fractures, but expectations and the British Open way back in is limited by cost to its 1963 and gone on to great increasing availability use in professional sport success in recent years on of high-tech imaging, only. While our ability to the senior tour. Today, map the human genome however, it’s Lydia Ko, this could present our rates as the scientific the teenage superstar of most pressing challenge. achievement of the century, amateur golf, who sets the its therapeutic potential is bar for golf in New Zealand. offset by the misuse of gene While society in 2013 is full of therapy to enhance athletic performance, conundrums and a much more diverse On the sporting field New Zealand has the society than in 1963, as evidenced challenge of staying ahead of the pack in last year (2012) in London our elite rugby and maintaining our excellence in athletes continue to excel on the world rowing, canoeing, cycling, yachting and stage.. Paradoxically, the rise in non- equestrian. The seemingly endless supply communicable diseases such as type 2 of elite East African middle and long diabetes and various metabolic illnesses distance athletes of ‘pneumopod’ stature reflects a sedentary lifestyle where we will predictably prove unbeatable. Sadly, are too often transfixed by a television or the Tokyo sight of two New Zealanders computer screen. Cigarette sponsorship medaling in an Olympic 1500 metre race is a thing of the past, yet the promotion again is extremely unlikely. However, as of alcohol remains a significant source of was the case in Atlanta, we might well see income for many sporting codes. two Kiwi equestrians once again mount the And what of the future? same Olympic podium. The next 50 years will present For sport medicine professionals, the both opportunities and challenges. challenges are to maintain our competence

new zealand journal of sports medicine - 9 20 - 23 November 2013 Wellington • New Zealand

Combining the Annual Meetings of Sports Medicine New Zealand and The Australasian College of Sports Physicians

Website: www.sportsmedicine.co.nz/conference • Email: [email protected]

Partners in Performance

10 - new zealand journal of sports medicine best of british chris milne

JULY athletes they can be treated with operatively 1 Whole of school programmes The July issue included an editorial entitled or non-operatively depending on individual 2. Transport priorities and systems that ‘Is lifelong exercise damaging to the heart’. patient characteristics. prioritise walking and cycling and Written by Matthew Wilson, who spoke at Exercise in pregnancy is something that is public transport the SMNZ Conference in November, plus being increasingly recommended. Barakat 3 Urban design regulations and Greg Whyte, cardiologist from the UK, the and co-authors from Madrid found that infrastructure that provide for equitable article notes that regular endurance exercise a moderate physical activity programme and safe access for recreational physical training appears to slow the performed during pregnancy activity progressive improved levels of maternal 4 Physical activity and non- decline in glucose tolerance. communicable disease prevention cardiac function. Whiplash injury to the neck is integrated into primary healthcare However, a frequent problem in clinical systems compared with practice. Does physiotherapy age-matched 5 Public education to raise awareness rehabilitation help in its secondary and change social norms on physical management? Michaleff and controls, a higher inactivity Ferreira, two Sydney-based prevalence of 6 Community-wide programmes in physiotherapists, looked at 21 subclinical cardiac multiple settings and sectors trials but found only 12 studies disease has been involving 1395 participants 7 Sports systems and programmes that reported in some could be included in their promote “sport for all” and encourage veteran athletes. meta-analysis. Active participation across the lifespan The authors have physiotherapy interventions had small, This article provides an excellent summary previously postulated that long repetitive short term effects in reducing pain and of what needs to be encouraged in all bouts of endurance exercise may result in improving range of motion compared with societies. fibrotic replacement of the myocardium in provision of a cervical collar and GP care, Earlier in the same issue Viljoen and susceptible individuals. This, in turn, can but the long term data are minimal. These Patricios describe the implementation of a provide a pathological substrate for the authors advocate high quality research national rugby safety programme in South development of arrhythmias. However, evaluating the effectiveness of these Africa. Entitled BokSmart, it is similar to based on the evidence provided here, there interventions in the longer term. the RugbySmart programme utilised in New is no need to change our recommendations Prohormones, e.g. dehydroepiandrosterone Zealand. Thus far, BokSmart has trained to the average person; they have much more (DHEA), are marketed aggressively as “legal 38,500 coaches and referees on the rugby to gain than to lose from embarking on a alternatives” to testosterone with similar safety course. lifelong exercise regime. anabolic effects. A recent major literature Core stability programmes are frequently Hip arthroscopy is a procedure that review found that such substances do not used to prevent future episodes of chronic has been performed with increasing augment muscle size gains observed from low back pain. A Norwegian group frequency. An Australian group conducted resistance training alone, and their use reported on a prospective study with a one a systematic literature review of 29 studies may predispose people year follow up involving and report reduced pain and functional to serious health risks. 109 patients. They found improvement in 14 studies up to 10 years These products remain improved transversus post-surgery. Adverse effects were minimal banned under anti- abdominus lateral slide and predominantly involved transient doping codes and urine among patients with a neuropraxia. tests can pick up even low baseline slide to be The treatment of proximal 5th metatarsal minute amounts in the associated with clinically fractures is something of interest to all system. important long term pain New Zealanders, particularly since our All reduction. It seems the Black captain Richie McCaw suffered this AUGUST exercises work, but the trick injury in the lead up to the 2011 Rugby is getting people to comply World Cup. This Dutch group included The August issue with them in the longer term. 21 studies and concluded that all non- contains an displaced avulsion fractures can be treated important article non operatively. Jones fracture and stress detailing the seven SEPTEMBER fractures in athletes are preferably treated best investments for The September IOC issue surgically, given the better tendency to physical activity. Based on the Toronto included a 10-page IOC Consensus heal and a quicker return to sport. In non Charter for Physical Activity in 2010, the statement on thermoregulatory and altitude investments include the following:

new zealand journal of sports medicine - 11 best of british challenges for high level athletes. Although was an effective method of increasing hip and knee of the symptomatic leg are very wordy, this statement presents state of lower limb flexibility. This was based on maximally flexed. The examiner then the art advice for athletes faced with these consistent strong evidence from six trials slowly straightens the knee. The modified environmental challenges. It includes 99 and three different muscle groups. bent knee stretch test involves maximal references. Sticking with lower limb muscles, a flexion of the hip and knee and then rapid Altitude training is frequently used to multinational group including Nicola straightening of the knee of the involved increase exercise performance in elite Maffulli studied hamstring exercises for leg. Likelihood ratios for a positive test athletes - but does it work? This Swiss track and field athletes. Eccentric training were 4.2 for the Puranen-Orava test, 6.5 for group found that the widely used live high/ has been consistently shown to be able the bent knee stretch test, and 10.2 for the train low protocol may increase exercise to reduce hamstring injury rates. This modified bent knee stretch test. The authors performance in some but certainly not all article introduces exercise classification recommend that these tests be used in athletes, and that the potential response criteria to guide clinicians in designing conjunction with other objective measures seems to be reduced in athletes with an prevention strengthening programmes such as MRI scanning. In practice, MRI already high red cell volume. Intermittent adapted specifically for track and field. scanning is not routinely used outside the hypoxic training is thought not to be The photographs compliment the text professional sporting environment. effective. description particularly well. The final article in the September issues Travel illness is something that is of concern Shin splints (medial tibial stress syndrome) discusses supplements. Spirulina has been to many New Zealand representative teams, are the bane of many running athletes. long recommended as a dietary supplement. especially as we are a long way from major Newman and co-authors describe two It contains micro-algae belonging to the population centres in Europe and North simple clinical tests for predicting the onset cyanobacteria class. There are precious few America. An article studying Super 14 of this condition. These include the shin controlled trials available, but one involving rugby players from five South African and palpation test, which involves palpation of moderately trained runners who received three New Zealand teams was published the distal two-thirds of the posteromedial 6g/day of spirulina supplementation for in this issue. The authors found a higher lower leg, particularly the posteromedial four weeks showed increased fat utilisation, incidence of illness in athletes following border of the shin. The other test is the reduction in markers of antioxidant stress international travel to a foreign country shin oedema test which involves sustained and increased endurance at high intensity where there was a >5 hour time difference. palpation for more than 5 seconds of the exercise (95% VO2max). This incidence returned to baseline on distal two-thirds of the medial surface of the Sucrose is ubiquitous in the Western diet return to the home country. The authors tibia and is positive when signs of pitting as it is in most households as table sugar. believe that destination factors including oedema are noted. These are both tests that Sucrose ingestion before and during temperature, humidity, altitude, pollution are in widespread use in routine clinical exercise can prevent hypoglycaemia if the and airborne pollens may be the cause of practice and it is good to see some evidence exercise is particularly prolonged. However, the higher incidence of illness. base for their continued use. the frequent consumption of sugary Clinicians are frequently called on to Proximal drinks can increase the risk of tooth provide advice for those who are exercising hamstring decay, so it is not all good news. at moderate altitude. This includes tendinopathy Once again the BJSM delivers a people going trekking in the Himalayas or is a condition wide range of articles of interest to Andes. A review paper by Schommer and that clinicians. Those I have included colleagues from Germany points out that at frequently above are merely a selection that altitudes of <2500 metres, acute mountain becomes I believe hold widespread interest sickness is mild, transient and affects <25% chronic. An for our readers. of the tourist population at risk; the higher Italian group one goes and the older one is, the more risks evaluated OCTOBER are increased. The altitude can exacerbate the validity The October issue was a theme known cardiovascular or pulmonary and reliability issue for the Australasian disease, or lead to a first manifestation of of three pain College of Sports Physicians undiagnosed illness in older people. This modification and featured several articles may be particularly relevant to coaching tests. These of interest. Your editor, Bruce Hamilton, and other support staff for our winter sports included the Puranen-Orava test, which wrote an article entitled Hamstring muscle athletes. involves placing the foot up on a support strain injuries: what can we learn from just above knee height and actively Among other topics, the September issue history. He compared the management stretching the hamstring muscles. The included a systematic review of the effects of strategy for these injuries in the past with second test is the bent knee stretch test, eccentric training on lower limb flexibility. present day management. Early recognition The conclusion was that eccentric training where the patient is lying supine and the

12 - new zealand journal of sports medicine best of british of the importance of warm up and of not Cronulla Sharks in particular have been Combinations of tests provide better pushing things too rapidly gave way to later implicated as a team with problems of drug accuracy but only marginally. He scientific studies on issues such as core abuse amongst their athletes. In general, stresses the importance of providing a stability, which were recognised as early as there seems to be a differentiation between comprehensive clinical examination and 1958. Lloyd in that year recognised that the professional sport and Olympic sport, taking due account of the history. All good risk for all sports injuries may be minimised because money does tend to play a part in sound advice. by what he termed an “alerted posture”. influencing athlete behaviour - surprise, Unrecognised ringside concussive injury Also in the same issue was an article surprise. in amateur boxers is a controversial entitled Pistorius at the Olympics: the saga Bruce Forster and colleagues had an topic. David Darby and colleagues from continues. This dealt with the scientific and excellent pictorial essay on evaluating bone Melbourne studied 96 amateur boxers. ethical dilemma regarding this athlete and marrow oedema patterns in musculoskeletal Of these, 17 failed their first post-bout whether or not he had gained an advantage injury. These can be very useful, computerised cognitive assessment tool and from using his blades. Events have rather particularly when the athlete has a poor 12 of these passed a repeat test. However, overtaken the scientific discussion as he is recall of the exact events of their injury (this of the five remaining boxers there were now facing a charge of murder. Somewhat is the norm for most football players). two not suspected of a concussion after bizarrely, however, he has been permitted The supplement issue included an article their bouts that showed evolving slowing to travel overseas to compete in events, on stacking, defined as the consumption in cognitive performance typical of a pending his trial. of two or more supplements at the concussion. This is disturbing and may also Team doctors same time in an attempt to maximise apply in sports like rugby. Our own prolific have a role results, written by Jeni Pearce, who researcher, Doug King, is looking into this in preventing has recently returned to take up the matter and there was a recent item on a sexual senior nutrition post within High television news show discussing this. Watch harassment and Performance Sport New Zealand. the journals for an update once the article abuse in sport, Combining creatine with beta- becomes available. and an article alanine had an effect on delaying Diagnosing overreaching in team sports by Saul Marks, fatigue, whilst combining creatine player is a controversial area. Sandor Margo Mountjoy with hydroxy-B methylbutyrate Schmikle and colleagues from the and Madalyn produced additive effects on lean Netherlands found that resting growth Marcus provides body mass. hormone levels and ACTH levels after some useful maximal exercise were reduced in players pointers. These that were overreaching. Obviously this data NOVEMBER authors talk about should be used in combination with clinical The November issue celebrated codes of conduct symptoms such as fatigue, irritability and London’s very successful Olympic and for those in positions of power in sport, poor sleep. Paralympic Games earlier in 2012. e.g. coaches and administrators, as well as In the dietary section there was mention Eric Hegedus provided an excellent review clinicians, e.g. doctors and physiotherapists. of tryptophan, which has been prescribed on which physical They include simple measures such as for many years in the examination not sharing a hotel room at an event, not general community to tests provide driving an athlete home after practice and alleviate depression. Two clinicians with not seeing an athlete socially except in a studies have claimed a the most value team setting. beneficial effect of acute when examining Knee joint kinematics can be altered by tryptophan supplementation the shoulder. balance and technique training and an on exercise capacity, but He conducted article by David Lloyd and colleagues these results have not been a systematic examine this issue. The authors recommend borne out by subsequent review of that sidestepping tasks are performed studies. Furthermore, in the 32 articles during biomechanical testing to assess late 1980s there were cases of published the effectiveness of prophylactic training eosinophilia-myalgia syndrome since 2008 and protocols. that were linked to tryptophan commented supplements. I would advise Later in this issue, Peter Harcourt and that the use of athletes to steer clear of them. colleagues wrote about a strategy to reduce any single physical examination illicit drug use in elite Australian football. test to make a pathognomonic diagnosis Cardiology is one of the growth This again is very topical following the cannot be unequivocally recommended. areas within sports and exercise medicine. revelations from a recent report, and the Therefore, it was timely that a supplement of

new zealand journal of sports medicine - 13 best of british

BJSM in November was completely devoted DECEMBER between sport and road traffic trauma. to cardiology issues. Our editor, Bruce The December IOC issue included an They highlight the need to develop a sport Hamilton, contributed an excellent editorial editorial measuring the impacts of the specific pre-hospital evidence base and providing overview of the significant first Winter Youth Olympic Games held then apply that evidence to management of issues. One of the main ones is applying in Innsbruck, Austria in 2012. It covers athletes. standardised criteria to athletes’ ECGs to the medical services on offer at these first The nutritional supplement series continued provide consistent interpretation. This Winter Youth Olympic Games. There is with articles on Vitamins A, C and E. These work was pioneered in Italy and has been also a very good article on course setting were discussed together, as all three have carried on in the USA by Jonathan Dresner and selected biomechanical variables antioxidant properties. Hundreds of studies and colleagues. The article on pages 6-8 related to injury risk in alpine ski racing. on antioxidant vitamin supplementation should be required reading for all those who Setting a course of appropriate difficulty is and exercise have been published but the need to interpret athletes’ ECGs. a significant responsibility. The memory quality of these articles is highly variable; There are significant differences in the way of an athlete dying on the sliding course whether or not athletes need higher cardiac issues are managed in the USA in Whistler in 2010 is etched in our recent dietary antioxidants than their less active versus Europe and a head to head debate, memory. Clearly, less experienced athletes counterparts remains under debate. For including some of the leading lights in the should be offered less demanding courses, those athletes who wish to err on the side of field, was published in this issue. It is also and as their skill level rises so the difficulty caution, food based sources of antioxidant very useful reading. of the course can be progressively increased. vitamins may be preferable to supplement In recent years ethnicity has been shown In the regular December issue there was based sources, in the opinion of these to be a significant risk factor for cardiac an article on ski helmet legislation, is this authors. This is because the possibility of events; in particular, male athletes of Afro- more effective than education. The authors toxicity is lower when foods are utilised. Caribbean descent appear to be more at commented that the impact of parental role My pick for the most valuable article in risk of developing cardiac events. We have modelling on ski helmet use is probably the latter half of 2012 goes collectively to no data on Maori and Pacific athletes and the single most important factor. The the articles in the November supplement this is being gathered by clinicians in New authors recommended non-legislative on cardiology. Sudden cardiac arrest on Zealand at present. In the meantime, the helmet promotion campaigns rather than a the field can be a life or death matter and article beginning on page 22 is worthy of legislative approach. identification of those athletes at increased study. Sudden cardiac arrest on the football field risk is clearly a high priority. Get hold of Atrial fibrillation is the commonest problem is a scary and potentially tragic event. Jiri this issue and read through a few articles in endurance athletes and one that I have a Dvorak, medical director of FIFA, and and you will be much better informed. particular interest in, having watched Rob colleagues provide an excellent, succinct Waddell and other leading athletes deal with summary of the topic. The emphasis is it over the years and assisted where possible. on prompt recognition of sudden cardiac The mechanism is still incompletely arrest and early CPR plus application of the understood but the article on this issue is AED or manual defibrillator as well worth a read. T-wave soon as possible. Once inversion can be a marker the athlete’s condition of serious pathology has stabilised, such as hypertrophic transport to a hospital cardiomyopathy and I facility capable of would recommend a good advanced cardiac life read of that article in this support should be issue of the journal. undertaken as soon as is practicable. Performance enhancing drugs have potential Serious injury on cardiovascular risks and these the sports field is are well covered later on in different to serious the November supplement. It injury in a car is worth pointing out some crash. Jonathan of these risks to athletes who Hanson and Brian believe that they would be better Carlin discuss sport pre-hospital immediate off on performance enhancing drugs. It care as a niche of general pre-hospital care, may not deter them completely, but may using the management of spinal injury influence their decision making. as an illustration of the major differences

14 - new zealand journal of sports medicine Original Research KAREN L BISLEY, MICHAEL J MARFELL-JONES The use of skinfold measurements to predict outcome of open-water swim attempts in Cook Strait

Karen L Bisley1 ABSTRACT subcutaneous fat) and triceps skinfold MBChB(Otago), Dip Sports Med(Auckland), Aim measurement greater than 13 mm. MHealSc(Otago), FRNZCGP, FACSP To determine the relationship between Seven swim attempts were unsuccessful. Michael J Marfell-Jones2 skinfold thickness and resistance to In all four unsuccessful swim attempts (by PhD, MSc, DipPE, DipTchng changes in core body temperature and three swimmers), where the sum of eight thus whether skinfold thickness can be a skinfold measurements of the swimmer

1 Sports Physicians ACT, Deakin, ACT, Australia predictor of swim success or failure. was less than 100 mm or a triceps skinfold measurement less than 13 mm, the 2 Faculty Management, The Open Polytechnic of Study Design swimmers were removed from the water New Zealand, Wellington, NZ Prospective observational study. with hypothermia. Three swimmers with Setting a sum of eight skinfolds greater than 100 Cook Strait, a 26 kilometre wide channel Correspondence mm or triceps fold measurement greater between the North and South Island of Karen L Bisley than 13 mm, failed for reasons not related New Zealand. Sports Physicians ACT to hypothermia. Only three swimmers Participants of eight swim attempts where the water Suite 5, 2 King Street Thirteen swimmers, who made 16 attempts temperature was less than 17° C were Deakin, ACT 2600 to swim Cook Strait between January 2005 successful compared to six of eight when AUSTRALIA and May 2007. the water temperature was greater than [email protected] Methods 17° C. Phone +61 2 62815999 Anthropometric measurements of each Conclusion Fax +61 2 62815779 swimmer were recorded before each The sum of eight skinfolds less than attempt. The core body temperature of 100 millimetres is a strong predictor of the swimmers was monitored using an hypothermia vulnerability and resultant ingestible sensor. swim failure in Cook Strait swimmers, INTRODUCTION Results particularly at lower water temperatures. ook Strait is a 26 km (14 nautical Nine of the 16 swim attempts were Key Words miles) channel that separates the successful. These successful swimmers all Swimming, Percentage fat, Subcutaneous North and South Islands of New had a sum of eight skinfolds greater than fat, Core temperature, Hypothermia CZealand. To open water swimmers Cook 100 mm (greater than 15% calculated Strait provides a challenge similar to that of the English Channel. attempting other open water swims around by the body composition and fat thickness The time and distance swum varies the world have died of hypothermia.12, 14 of the individual.21 Fat becomes an effective considerably depending on the speed of the Currently there are no specific criteria to means of body insulation at high heat flow swimmer, tides and the weather conditions be met by individuals who wish to attempt rates - the situation seen in swimmers. on the day. Swimmers are in the water, to swim Cook Strait. Swimmers are not One millimetre of subcutaneous fat during on average, for eight to ten hours. Water required to obtain a medical clearance swimming provides ten times the insulation temperatures range between 14-19º C before, or engage medical support during, of the same amount of fat at rest.19 A over the summer months.2 To be officially the crossing. reciprocal linear relationship between recognised, swimmers who attempt Cook Extrinsic factors that affect the ability of the skinfold thickness and fall in rectal Strait are not allowed to wear a wet suit or a swimmer to maintain their core body temperature in subjects immersed in cold 16 any device that may provide buoyancy or temperature include water temperature water has also been observed. heat protection. and duration of the swim.9 Intrinsic Arms have approximately twice the surface Hypothermia, defined as a core temperature factors include swimming speed, fitness area to volume ratio compared to the lower < 35º C, is one of the reasons cited for and the amount of subcutaneous fat of limbs with consequent greater conductive swimmers being unsuccessful in their the individual.3, 9, 19 The rate an individual and convective loss during exercise.9 It attempts.4,7 No deaths have occurred during cools is not only governed by the difference has been suggested that local upper-limb Cook Strait attempts. However, swimmers between heat generation and loss, but also muscle cooling and subsequent fatigue

new zealand journal of sports medicine - 15 original research may be a main cause of swimming inability included body mass, stretch stature and eight was recorded using a speed and temperature rather than whole body hypothermia.22 skinfold measurements, according to the sensor integrated into a Furuno colour Consequently if the upper limbs are International Society for the Advancement video sounder (Model FCV582, Furuno susceptible to cooling in cold water, an of Kinanthropometry (ISAK) standard Electric Co. Ltd. Nishinomiya, Japan) and air increased amount of subcutaneous fat over protocol, in which the researcher had been temperatures recorded, using a Digital In- the arms may decrease the amount of heat trained.15 Two measurements were recorded Out thermometer TA 20 (ApogeeKits, Texas, loss and reduce arm cooling. A recent report for each location and if these varied more USA), at 30-minute intervals. The core body of accidental exposure scenarios for non- than 10%, a third measure was taken. The temperature of the swimmer was recorded open water trained subjects, suggests triceps average of all readings was used. as the swimmer departed the main launch; skinfold thickness was a better predictor of As per the ISAK protocol, male percentage at 30 minute feed stops, then immediately swimming distance covered before swim fat was calculated from the sum of seven after exit. Following each attempt, core 23 failure than percent fat. skinfolds27 and female percentage fat was temperature recordings were down-loaded This study uses data collected during calculated from the sum of four skinfolds.28 using Microsoft ‘Hyper Terminal’ software, successful and unsuccessful Cook Strait Surface area to mass ratio was also which was then imported into Microsoft swims to evaluate the relevance of calculated.6 ‘Excel’ for analysis. A Pearson’s Correlation coefficient was calculated between sum subcutaneous fat to clinical hypothermia and The percentile ranking of each swimmer was of eight skin fold thickness and outcome. outcome of the swim attempt. calculated for age and gender and compared Outcome was assigned a value of ‘0’ or ‘1’ It is hypothesised that swimmers with a to the New Zealand norms.25, 26 The New for unsuccessful or successful attempts lower sum of eight skin folds would be more Zealand norms for individuals 15 years and respectively. Pearson’s correlation values prone to hypothermia. greater have been calculated for a sum of six were also calculated between sum of eight skinfolds (triceps, subscapular, supraspinale, METHODS skinfolds and the difference between pre and abdominal, front thigh and medial calf). A prospective observational study was post swim core temperatures. conducted on 13 swimmers, who made Individuals less than 15 years have been RESULTS 16 attempts to swim Cook Strait between calculated from the sum of two skin-folds Anthropometric Measurements January 2005 and May 2007. The Human (subscapular and triceps). Consequently Ethics Committee of the University of Otago these skinfold numbers were used to Anthropometric measurements were approved the research project in 2004. It compare the swimmers to the national recorded on 13 swimmers (6 male and 7 was performed in accordance with Ethical norms. female) usually one day before each of their Standards in Sport and Exercise Science Fourteen swim attempts (A-K) were 16 swim attempts (Table 1). Two swims were Research.10 The research was not funded observed by the researcher. Two swimmers not directly observed. One male swimmer and there were no vested interests. The (L and M) had their anthropometric made two attempts and one female attempted research project details were explained and variables taken prior to their attempt and on three occasions. The age range of the informed written consent (or the parents the water temperature through their swims swimmers was between 11 and 52 (mean = of those swimmers under 18 years of age) recorded. However their core temperatures 35, SD = 14) years for males, and between was obtained from the swimmers. They were not measured because the researcher 13 and 46 (mean = 28, SD = 14) years for also completed a medical questionnaire to was not available. Core body temperature females. The percentile ranking for body fat identify any underlying medical problems. was measured before, during and after each for each swimmer was compared to the New Zealand population for age and gender. Only Exclusion criteria related to the Cook Strait attempt using the CorTemp® swimmer B, I and M were observed to be contraindications for use of the ingestible ingestible core body sensor, that was above the eightieth percentile. core body temperature sensor (CorTemp®, swallowed by the swimmer on transit to HQ inc, Florida, USA)11 and no swimmers the starting point, about 20-40 minutes The course and distance each swimmer 24 were excluded for this reason. However two pre-swim. The accuracy of this device is swam varied considerably with different 1 swimmers were excluded because of language reported to be +/- 0.1˚C. starting and finishing points, winds and difficulties and two swimmers were excluded The researcher worked in association with tides. The mean air and water temperatures because the researcher was unavailable. the Cook Strait swim coordinator and his ranged from 14.5- 20.7˚C and 13.4-18.9˚C respectively (Table 2). Each swimmer was coded by an identifying support crew. Support vessels for this study letter from A to M. When a swimmer made included a 42-foot launch and an inflatable Successful Swimmers more than one swim attempt, the swim rubber boat (IRB). The navigator took course Nine of the 16 swim attempts were number was also recorded. readings using a GPS (Global Positioning successful. Where swimmers swam with System, Garmin XL12, Kansas, USA) every a mean water temperature of greater Anthropometric measurements were made 30 minutes and altered the course of the than 17˚C, six of eight swim attempts using Slimguide calipers (Creative Health swimmer to compensate for the wind, tides were successful. When the mean water Products, Michigan, USA) at the first and the swimmer’s speed. Water temperature temperature was less than 17˚C, only three meeting with the swimmer. Measurements

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Table 1: Anthropometric Data of Participants Stretch Sum of eight Surface area to Triceps Percentile ranking Swimmer Gender Age Stature (m) Weight (kg) skinfolds Percent Fat mass ratio skinfold (mm) compared to NZ (mm) (m2/kg) population * A M 44 1.91 96.0 90 12.2 0.023 10 15 B M 11 1.45 43.0 131 19.7 0.030 17 *85 C F 17 1.70 69.0 115 20.7 0.026 15 20 D F 17 1.81 74.0 108 20.5 0.026 14 20 E F 34 1.65 65.0 67 11.1 0.026 8 5 F1 M 25 1.79 80.0 90 12.3 0.025 10 45 F2 M 26 1.80 79.0 98 13.4 0.025 11 50 G F 43 1.62 62.0 122 18.7 0.027 13 10 H1 F 45 1.62 67.0 194 29.0 0.026 25 65 H2 F 46 1.62 65.0 181 28.1 0.026 23 55 H3 F 46 1.62 68.0 187 28.5 0.025 22 55 I M 52 1.92 110.0 214 31.6 0.021 26 90 J F 25 1.59 57.5 140 23.9 0.028 18 65 K F 13 1.67 62.5 166 25.4 0.027 17 *60 L M 45 1.86 97.5 136 20.3 0.023 23 71 M M 43 1.85 95.5 176 25.8 0.023 20 88

*Swimmers (excluding B and K) were ranked compared to the New Zealand norms for age and gender, using the sum of six skinfolds (triceps, subscapular, supraspinale, abdominal, front thigh and medial calf). Swimmers B and K, aged 11 and 13 years respectively were compared to the New Zealand normative data for children of their age and gender using the sum of two skinfolds (subscapular and triceps). M = Male, F= Female

Table 2: Water temperature, pre and post-swim core body temperature and outcome

Water Temp (˚C) Air Temp (˚C) Core Temp Time in Reason for Swimmer Water (hrs: Outcome Failure mins) Mean Standard Mean Standard Pre-Swim Post- Change in Deviation Deviation (˚C) Swim (˚C) Temp (˚C) A 17.3 0.4 19.8 1.4 36.8 31.3 5.6 10:01 Unsuccessful Hypothermia B 17.7 1.3 17.3 2.8 36.8 35.6 1.2 9:09 Successful C 17.1 0.6 17.3 1.3 35.9 37.6 -1.7 5:48 Successful D 17.1 0.6 17.3 1.3 37.2 5:48 Successful E 15.3 0.1 14.5 0.2 37.6 32.6 5.0 2:20 Unsuccessful Hypothermia F1 15.9 0.4 17.1 0.6 34.5 3:10 Unsuccessful Hypothermia F2 16.2 0.3 16.9 0.6 39.6 34.9 4.7 1:47 Unsuccessful Hypothermia G 15.4 0.5 16.6 1.1 37.4 33.6 3.8 8:26 Successful H1 13.4 0.1 16.1 1.7 36.0 36.2 -0.2 6:02 Unsuccessful Failure to Progress H2 15.5 0.8 20.2 1.5 37.2 36.7 0.5 5:01 Unsuccessful Respiratory Problems H3 17.5 0.7 16.1 1.8 37.2 35.6 1.6 8:44 Successful I 17.3 0.7 20.7 2.1 35.6 35.4 0.2 10:27 Successful J 17.4 0.2 18.6 1.2 36.9 35.4 1.6 4:19 Unsuccessful Failure to Progress K 15.4 0.3 14.8 0.6 35.2 8:10 Successful L 18.9 1.0 11:00 Successful M 16.0 0.7 7:11 Successful

new zealand journal of sports medicine - 17 original research of the eight swim attempts were successful swimmers on four attempts (A, E, F1 and F2) swimmers (C and H1) showed a higher core (Figure 1). All successful swimmers had a had a sum of eight skinfolds less than 100 body temperature recording post-swim. sum of eight skinfolds greater than 100 mm, mm (less than 15% calculated subcutaneous Three swimmers suffered from seasickness calculated subcutaneous fat greater than 15% fat) and triceps skinfold thickness less and the sensor pill was not ingested until and a triceps skinfold thickness greater than than 13 mm. They were all removed from just prior to water entry (D and F2) or 13 mm. The Pearson’s correlation coefficient the water because of signs and symptoms after water entry (F1). The high core body between sum of eight skinfold thickness and consistent with hypothermia and a core temperature of swimmer F2 before his outcome was 0.58 (p = 0.04) with swimmer temperature less than 35˚C. swim reflects a hot drink taken soon after H excluded. Swimmer H had both successful Three swim attempts, by two swimmers, the sensor was swallowed. Pre-swim core and unsuccessful outcomes with similar H and J, with a sum of eight skinfolds body temperatures were not recorded before anthropometry and consequently the data greater than100 mm, were unsuccessful. the two other swim attempts (D and F1). does not fit in either group. Swimmer H was a known asthmatic. She Swimmer K did not have her core body The four swimmers under 18 years of age had no respiratory symptoms during her temperature recorded pre-swim due to a had a sum of eight skinfolds greater than 100 first attempt (H1), but was removed because technical problem with the data recorder not mm and were successful in their attempts. of “failure to progress”, as was swimmer J. detecting the ingestible sensor. A Pearson’s correlation coefficient of 0.91 (p Neither swimmer had a core temperature Swimmers with the greatest skinfold < 0.05) was calculated between the sum of below 35˚C. During her second attempt thicknesses had smaller temperature drops eight skinfolds (and calculated percent fat) (H2), Swimmer H was removed because as shown by a linear regression (Figure 2). and triceps thickness. of a respiratory problems, coughing and The Pearson correlation coefficient for the The mean core body temperature of the shortness of breath. difference between the pre- and post-swim successful swimmers was 35.6˚C on boarding Core Body Temperature core body temperatures compared to the sum the launch following the swim. Swimmer G Pre- and post-swim core body temperatures of the eight skinfold thicknesses for the 11 successfully completed the swim with a core of 11 swimmers were recorded (Table 2). swim attempts (by nine swimmers, swimmer temperature of 33.6˚C. Nine swimmers (A, B, E, F2, G, H2, H3, J H making three attempts) was -0.68 (p = Unsuccessful Swimmers and I) showed a decrease in their core body 0.02). Swimmers D, F1 and K were excluded Seven swimmers were unsuccessful. Three temperature from their pre-swim levels. Two because of absent water entry data.

Figure 1: Comparison of sum of eight skinfolds and water temperature to outcome.

250

200

150

Unsuccessful Successful 100 SUM OF EIGHT SKINFOLDS (mm) SKINFOLDS EIGHT OF SUM 50

0 10 12 14 16 18 20 WATER TEMPERATURE (ºC)

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Figure 2: Correlation of core body temperature difference and sum of eight skinfolds.

2

1

0 0 50 100 150 200 250

-1

-2

-3

-4 TEMPERATURE CHANGE (ºC) CHANGE TEMPERATURE

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-6 SUM OF EIGHT SKINFOLDS (mm)

DISCUSSION contrast, swimmer A was able to swim for 10 are so many other factors that impact in a This study looked at the relationship between hours at a mean water temperature of 17.3˚C swimmer’s success or failure. skinfold thickness and resistance to changes before he was removed with hypothermia. Two swimmers (H and J) had skinfolds in core body temperature in 13 swimmers The combination of the swimmer’s low greater than 100 mm and were unsuccessful. over 16 swim attempts, to determine whether skinfold measurements and lower water Neither swimmer had a core temperature skinfold thickness can be a predictor of swim temperatures put them at greater risk of below 35˚C on exit. They were unsuccessful success or failure. losing heat to the cold environment, and because of respiratory symptoms (H2) and Participants with a sum of eight skinfold hypothermia. It is likely that swimmers E “failure to progress” (swim H1 and J). One of measurements greater than 100 mm (greater and F never generated enough heat to offset the swimmers, (H) was a known asthmatic than 15% calculated subcutaneous fat) or losses. Swimmer A was able to generate and her symptoms may have been asthma. triceps skinfold measurement greater than enough heat to offset losses initially, but However anxiety, salt-water aspiration 13mm showed a smaller drop in core body possibly fatigue secondary to prolonged cold syndrome and pulmonary oedema may have temperature than those with a lower skinfold water immersion and exertion prevented him also caused her symptoms.13 generating enough heat in the later part of measurement. This is supported by 9 of 10 Local effects of cold water immersion his swim. swimmers with a sum of eight skinfolds causing impaired muscle function, may have greater than 100 mm being successful. The Subcutaneous body fat is only one potential been a factor in the attempts by swimmer results from this study are consistent with the predictor of open water swim outcome. The J and H1, who were both removed because findings of previous researchers who have fitness of the individual, speed, fatigue, water they did not swim sufficiently far across shown the importance of subcutaneous fat temperature, tides, wind, and length of time Cook Strait before the tide changed. They providing insulation of the swimmer, and immersed in the water and any underlying may have had a day where poor performance consequently a slower rate of heat loss.16, 19 medical conditions potentially influence was idiosyncratic- an “off-day”. However Three swimmers (A, E and F on two swim outcome, but consideration of most of the effect of water temperature must also occasions) were removed with the symptoms these parameters was beyond the scope of be considered. Swim failure and decreased 17, 18, 22 of hypothermia. They all had a sum of eight this study. The Pearson’s correlation of efficiency of swimming has been reported skinfolds less than 100 mm. Swimmers E and 0.58 (a moderate correlation) between sum as water temperature decreases.22 Cooling F were removed from water less than 17˚C, of eight skinfold measurements and outcome of skin and muscles are thought to cause the having swum for less than 3 ½ hours. In is not an unexpected finding because there muscles to become weaker and therefore

new zealand journal of sports medicine - 19 original research decrease the efficiency of swimming. This children, as they were less than 18 years of age. CONCLUSION could ultimately lead to incapacitation and Sources vary as to whether a 17 year old is a Swimmers with a sum of eight skinfold swim failure.19, 22 Swimmer H1 swam in the child or an adult and no consistent definition measurement greater than 100 mm were coldest water (mean 13.4˚C) over the research was found. All four swimmers were successful more likely to be successful in their Cook period. She still maintained a core body on their first attempt and maintained a Strait attempts. temperature of 36.1˚C when she was removed core temperature > 35˚C. Children have a The combination of smaller skinfolds (less after 6 hours. Swimmer J experienced higher surface area to mass ratio compared than 100 mm) and a lower water temperature ‘warmer’ water temperatures, with a mean to adults. This greater surface area to lose predisposed the swimmers to hypothermia, of 17.4˚C. However, her core temperature or gain heat makes them more at-risk from which may lead to swim failure. Swimmers 8 had decreased to 35.5˚C at the time she was environmental extremes of hot and cold. A less than 18 years were at no greater risk of removed from the water, indicating central higher metabolic rate in exercising children hypothermia. The authors concluded that cooling. Central and peripheral cooling may and increased vasoconstriction may also lower skinfold sums are a strong predictor well have affected her swimming ability. explain how young swimmers have been able of hypothermia vulnerability in Cook Strait 8 Tolerance to hypothermia was also observed to tolerate the cold better than adults. As swimmers. children grow, the surface area-to-mass ratio when swimmer (G), completed the swim Practical Implications successfully despite finishing with a core decreases until they attain adult size. Three • It is recommended that all prospective temperature of 33.6˚C. Two swimmers (H1 of the four young swimmers were female and swimmers should have their and C) were observed to have post-swim core had body sizes and surface area-to-mass ratios subcutaneous body fat measurements temperatures greater than their pre-swim comparable to older females in the study. taken. recordings. Temperatures in the normal The fourth swimmer (B) was only 11 years • All prospective swimmers should be range after swimming in cold water have old and weighed only 43 kilograms and was advised of the hazards of attempting such previously been reported.17 Core temperatures a mere 1.45 metres tall. He had the greatest a swim if the sum of their eight skinfold of swimmers on exit, greater than pre-swim surface area to mass ratio (0.03 m2/kg) of all measurement is < 100 mm, or triceps recordings suggests that these swimmers the swimmers. His sum of eight skinfolds was skin measurement is < 13 mm. were able to generate enough heat to offset 112 mm putting him at a percentile ranking losses. However, it cannot be excluded that of 85% for body fatness when compared to Acknowledgements the temperature reading pre-swim may not children in the New Zealand population for Thank you to the swimmers who agreed to have been the true core temperature reading age and gender. All four swimmers had a participate in this study over the 2005-2007 because of the short time the sensor had been sum of eight skinfolds > 100 mm, suggesting seasons. A special thanks to Phillip Rush, ingested. skinfold thickness may be the important the swim coordinator, who allowed me to factor in maintaining heat in children It is acknowledged that the short period of observe the Cook Strait attempts and to participating in open water swims, rather time between pill ingestion and the start of the Captain, Chris McCallum, and the two than the surface area of an individual. This is the swim was a limiting factor in this study. Navigators, Byron Anderson, and Keith in keeping with findings previously observed However the ultimate decision to swim was Murray. Thank you to Dr David Hughes where the cooling rate of children best usually not made until the swimmer was on for helping to prepare the manuscript and correlated with an individual’s subcutaneous the boat heading into Cook Strait. At this Associate Professor David Gerrard for fat thickness, rather than by age or gender, stage some of the swimmers felt or were sick. supervising my Masters Research project. although an improved correlation allowing for Consequently the pill was given when it was REFERENCES differences in surface area to mass ratio has confirmed the swim was on and the swimmer 1 Byrne C, Lim CL. The ingestible telemetry been observed.20 was not obviously sea sick. body core temperature sensor: A review of Women are thought to have a physiological validity and exercise applications. Br J Sports In thirteen of the fourteen attempts observed, advantage in open water swimming due Med. 2007; 41: 126-133. swimmers were seen to apply grease to to their thicker layer of subcutaneous 2 Cook Strait Swim. Available at http://www. their bodies. The effect of the grease was fat. However when men and women are cookstraitswim.org.nz. Accessed 23 May, 2009. not studied as part of the research and compared for fitness and similar body mass no conclusions can be formed regarding 3 Danzl DF, Lloyd EL. Treatment of accidental index little difference is found.5 The small hypothermia. Chapter 16: In: Pozos RS (ed). temperature maintenance or performance numbers in this study prevent any significant Medical aspects of harsh environments. due to grease. There is minimal scientific assessment of the effect of gender on swim Washington: Department of the Army, Office evidence published on this. It is acknowledged outcome. of The Surgeon General, Borden Institute, that grease could be a compounding variable United States of America. 2002. Available The major limitation to this study was the in this research. The effect of grease in open at http://www.bordeninstitute.army.mil/ water swimming is a potential topic for small number of swimmers observed. This published_volumes/harshEnv1/Ch16- further research. reflects the small number of swimmers TreatmentofAccidentalHypothermia.pdf. attempting Cook Strait each year. Accessed 2 March 2012. Four of the swimmers could be classified as

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4 Danzl DF, Pozos RS. Accidental hypothermia. 19 Pugh LGC, Edholm OG, Fox RH, Wolff HS, Comment N Engl J Med. 1994; 331: 1756-1760. Hervey GR, Hammond WH, Tanner JM, Kelly Sheerin Whitehouse RH. A physiological study of 5 Despres JP, Bouchard C, Savard R, Tremblay Physiotherapist and Sport Scientist A, Marcotte M, Theriault G. The effects of channel swimming. Clin. Sci. 1960; 19: 257- AUT Millennium Institute a 20-week endurance training program on 272. adipose-tissue morphology and lipolysis in 20 Sloane RE, Keatinge WR. Cooling rates of pen water swimming is a sport that men and women. Metabolism. 1984; 33(3): young people swimming in cold water. J Appl 235-238. Physiol. 1973; 35(3): 371-375. Ois growing rapidly in New Zealand, with the public participating in an ever 6 DuBois D, DuBois EF: A formula to estimate 21 Tarlochan F, Ramesh S. Heat transfer model increasing number of local swim events, and the approximate surface area if height and for predicting survival time in cold water weight be known. Arch Int Med. 1916; 17: 863- immersion. Biomed Eng Appl Basis Comm. athletes looking for tackling a large array of 871 2005; 17: 159-166. significant challenges such as Cook Straight 7 Explore Te Ara: The Encyclopedia of New 22 Tipton MJ, Eglin C, Gennser M, Golden, and Lake Taupo. Zealand. Open water swimming - a swimmer F. Immersion deaths and deterioration in The authors should be commended for in trouble. Available at http://www.teara.govt. swimming performance in cold water: A tackling a difficult research topic. They have nz/EarthSeaAndSky/RecreationSeaAndSky/ volunteer trial. Lancet. 1999; 354: 626-629. done well to work around the technical and OpenWaterSwimming/1/ENZ-Resources/ 23 Wallingford R. Ducharme MB. Pommier methodological challenges that research such Standard/2/en. Accessed 4 December, 2007. E. Factors limiting cold-water swimming as this entails. This paper offers insight into 8 Falk B. Effects of thermal stress during rest distance while wearing personal floatation a novel topic that I’m sure will appeal to the and exercise in the paediatric population. devices. Eur J Appl Physiol. 2000; 82: 24-29. interest of many readers of this journal. Sports Med. 1998; 25(4): 221-240. 24 White LJ, Jackson F, McMullen J, Lystad 9 Golden FS, Tipton MJ. Human thermal J, Jones JS, Hubers RH. Continuous core responses during leg-only exercise in cold temperature monitoring of search and rescue water. J Physiol 1987; 391: 399-405. divers during extreme conditions. Prehosp 10 Harriss DJ, Atkinson G. Update – Ethical Emerg Care. 1998; 2(4): 280-284. Standards in Sports and Exercise Science 25 Wilson N, Russell D, Wilson B. Size and Research. Int J Sports Med 2011; 32: 819–821 shape of New Zealanders. In: NZ norms for 11 HQ Inc. Ingestible core body temperature anthropometric data. Dunedin: Life in New sensor. Intended use/ contraindications. Zealand Activity and Health Research Unit. Available at http://www.hqinc.net/pages/. 1993a. University of Otago. Accessed 22 November 2007. 26 Wilson N, Russell D, Wilson B. Body 12 King EP S.S.O.-The Accident. Available at composition of New Zealanders. In: Life in http://soloswims.com/accident.htm. Accessed New Zealand Activity and Health Research 4 May 2009. Unit. Dunedin. 1993b. University of Otago. 13 Lehman R. You’re the flight surgeon: salt water aspiration syndrome. Aviat Space Environ 27 Withers RT, Craig NP, Bourdon PC, Norton Med. 2008; 79(11): 1073-1074. KI. Relative body fat and anthropometric prediction of body density of male athletes. 14 Lovesey J. The jolly giant of the sea. Sports Eur J Appl Physiol Occup Physiol 1987a; Illustrated. 1963. Available at http:// 56(2): 191-200. sportsillustrated.cnn.com/vault/article/ magazine/MAG1075301/index.htm. Accessed 28 Withers RT, Norton KI, Craig NP, Norton 26 February 2012. KI. The relative body fat and anthropometric prediction of body density of South Australian 15 Marfell-Jones MJ, Olds T, Stewart AD, Carter females aged 17-35 years. Eur J Appl Physiol L. International standards for anthropometric Occup Physiol. 1987b; 56(2): 181-190. assessment. Potchefstroom, South Africa: International Society for the Advancement of Kinanthropometry (ISAK). 2006. 16 Noakes TD. Exercise and the cold. Ergonomics. 2000; 43(10): 1461-1479 17 Nuckton TJ, Claman DM, Goldreich D, Wendt FC, Nuckton JG. Hypothermia and afterdrop following open water swimming: The Alcatraz/ San Francisco swim study. Am J Emerg Med. 2000; 18(6): 703-707. 18 Pugh LGC. Edholm OG. The physiology of channel swimmers. Lancet. 1955. Special Articles: 761-768.

new zealand journal of sports medicine - 21 Original Research CRAIG C PANTHER, CHRIS J BRADSHAW The use of a trunk-mounted GPS/accelerometer system to measure vertical impacts for injury risk factor analysis in Australian Rules footballers: A pilot study

Craig C Panther1 MBChB, MMedSci, PG DipSportsMed ABSTRACT Chris J Bradshaw2 Aims between the difference in vertical load MBBS, FACSP 1 To assess the ability of a trunk-mounted measured at the upper torso vs. the Global Positioning System (GPS)/ sacral levels during a sprint task, and accelerometer system to accurately both injuries and time out of sport. 1 Unisports Sports Medicine, Auckland, New measure vertical impacts at torso and This difference may be due to greater Zealand sacral levels. mediolateral and/or anteroposterior load 2 Geelong FC and Olympic Park Sports Medicine dissipation, and it is postulated that poor 2 To compare and correlate impacts Centre, Victoria, Australia core stability may therefore be a factor measured at each level. in lower limb injury pathogenesis. There 3 To compare impacts recorded during were stronger correlations between sacral Correspondence a pre-season screening session with and torso impacts for jumping tasks Dr Craig C Panther prospectively-gathered injury data in a than for running tasks, but the clinical Unisports Sports Medicine cohort of semi-professional Australian relevance of this is presently unknown. Auckland footballers in order to examine any Players over 23 years of age were more relationships between vertical load and NEW ZEALAND likely to sustain injuries leading to a loss of non-contact lower-limb injuries. training and/or match time. Players were Ph: +64 9 521 9815 Methods more likely to miss training sessions than Fax: +64 9 521 9812 50 semi-professional Australian footballers matches. Email: [email protected] had vertical impacts measured using the Conclusions TM SPI Pro system during a pre-season There is no conclusive relationship training session, during a variety of sport- between vertical load, as measured using specific tasks. Impacts measured at sacral this device, and lower limb, non-contact and torso level were compared. Players injury. Currently, technical issues limit were followed longitudinally throughout the use of this system as a field research regular season play and injuries were tool. Overcoming these issues via changes recorded. Associations between measured in software and harness design may impacts and lower limb non-contact result in more accurate assessments of injuries were examined. accelerations, and associations between Results accelerations and injury risk may A small number of statistically-significant subsequently be demonstrable. The associations – some positive, others addition of a sacrally-mounted device negative - were demonstrated between facilitates comparison of sacral and upper measured impacts and injuries. Overall, torso impacts, but the clinical utility of this measured impacts did not conclusively remains unproven. There may be potential predict injury, possibly due in part in further examining the dissipation of to technical factors and study design. load across the trunk along both vertical Aberrant movement of the unit within and horizontal planes, and its relationship the harness was a potential source of to lower limb injury. inaccuracy and there were further sources Key Words of measurement error inbuilt into the Accelerometer, Global Positioning software package. The most consistent System, Vertical Load, Injury Prevention, result showed a positive association Australian Football

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INTRODUCTION force platforms12 test-retest revention of injuries in sport can reliability,7 and validity in only be beneficial for all stakeholders. measuring centre of mass Apart from individual losses accelerations20 some authors Pto players in terms of time lost to play have challenged the validity or termination of employment, player of impact data gathered from unavailability imposes on clubs significant TAs mounted on the upper treatment costs and deprives them of key torso.17, 19 on-field assets. Finch’s modifications4 to van This study aimed to assess Mechelen’s sports injury prevention model18 the ability of a trunk- advocate assessment of potential injury mounted GPS/accelerometer countermeasures in a field setting prior to system to accurately measure any formal implementation. Accordingly, vertical impacts during research tools and injury prevention a variety of Australian Figure 1: The SPI ProTM device (GPSports.com) methods must be easily accessible to football-related tasks Data Collection and Analysis teams. Technical assessments performed in performed in a pre-season screening session. Data collection was undertaken during a biomechanics laboratories, with force plates Vertical impacts were recorded both at the single pre-season training session. Following and motion capture technology are often torso and the sacral level, close to the body’s enrolment, demographic (playing position, beyond the reach of sporting organisations, centre of mass. Subsequently, impact data age and weight) and impact data were and may not permit analysis of certain were compared with prospectively-collated obtained. Each subject was fitted with two sport-specific tasks. There is a need for injury data across a season to examine any SPI ProTM devices. One unit was mounted in assessment tools which are easily applied relationship between vertical load measured the usual interscapular region of the torso to the team setting and used by existing using this device and lower-limb, non- using the neoprene vest supplied by the personnel. Portable Global Positioning contact injuries. System (GPS)/accelerometer units, currently manufacturer, and an additional unit was METHODS used to track player movements, may meet mounted using rigid strapping tape to the Ethics Approval was granted by the this need. Many teams have already invested level of the lumbosacral junction, located Deakin University Human Research Ethics in the technology, and personnel have been using the sacral dimples. All participants Committee (2010-002). trained in its use. Such systems are easily completed five Australian football-related applied, comfortable for players, and data are Participants tasks, during which impact data were easily downloaded and stored onto existing Five Geelong Football League (GFL) clubs recorded: platforms. accepted an invitation to take part in the 1 Run study. All trained twice weekly, had a team Ground reaction force (GRF) is influenced Subjects were asked to run in a straight physiotherapist willing to commit to weekly by numerous intrinsic and extrinsic factors10 line at a self-estimated 60-70% of maximal contact with the lead author and a nucleus of and specific neuromuscular training has pace, enabling impacts to be measured players meeting the inclusion criteria. Player been shown to reduce vertical ground independent of acceleration, deceleration or inclusion criteria consisted of: male aged 18 reaction force (vGRF) for a given jump- change of direction. or over; intending to play the entire season landing task.8, 14 While opinion is divided as 2 linear Maximal Sprint (i.e. no planned interruptions due to work, to whether a greater vGRF for a given task study or holiday); no low back, pelvic or A “30-30-30” regime was used, whereby confers a greater risk of injury, the weight of lower limb musculoskeletal symptoms (pain, subjects accelerated for 30 metres from a jog opinion is in favour of a link between vGRF swelling, instability, stiffness, weakness) at start, maintained top speed for 30 metres, and lower limb overuse injury.1, 3, 13 The the time of testing and no lower limb injury then decelerated over 30 metres. majority of studies to date have measured or surgery of any kind (excluding dental 3 multidirectional Sprint impacts using a force platform and, in one surgery) in the three month period prior to instance, an accelerometer mounted over Six cones were placed in a zigzag fashion at testing. All participants provided written the proximal tibia.13 While these might 90 degree angles, spaced 10 metres apart. informed consent. be considered industry-standard, they are This provided two changes of direction to certainly not practical in the field setting that Equipment the left and right respectively. Subjects ran is the professional sports club. By contrast, The SPI ProTM device (Figure 1) is designed through the course as quickly as possible. tri-axial accelerometers (TA) mounted to to be worn between the player’s scapulae 4 Vertical Jump the lower trunk are proving increasingly inside a neoprene vest. Within each unit Subjects were instructed to perform a popular as monitoring tools in the sports lie a GPS receiver, a piezoelectronic triaxial maximal jump and simulate the catching of medicine setting, due to their portability accelerometer (sampling frequency 100Hz), a a football above the head, five consecutive and decreasing cost. While they have been magnetometer and a gyroscope. times, with a five metre jog in between. shown to have excellent concordance with

new zealand journal of sports medicine - 23 original research

5 Kicking Table 1: Parameters recorded over the duration of the season. Subjects were instructed to simulate a Games and training sessions completed maximal kick for goal, without the ball, off Significant lower limb non-contact injuries (LLNCIs) their dominant foot, five consecutive times, Games and training sessions missed due to significant LLNCIs with a five metre jog in between. Non-significant LLNCIs Running, linear sprinting and Games and training sessions undertaken with non-significant LLNCIs multidirectional running were classified as Other significant injuries (injuries other than LLNCIs leading to loss of game and/or training time) “running” tasks. Jumping and kicking were Games and training sessions missed due to significant other injuries classified as “jumping” tasks. Injury data were obtained via a weekly report measure. The sacrum vs. torso difference was Impact data were not analysed until the from club physiotherapists. Injury diagnosis investigated using a paired T-test, to assess season had been completed, to avoid any was made by the team physiotherapist and/or the difference of the observed mean values biasing effect on injury data collection. At the lead author. Each team completed a total from zero. In all analyses, a p value of <0.05 season’s end, impact data were imported of 18 regular season matches and 38 training was used to indicate statistical significance. into GPSports’ Team AMSTM software. sessions. The study finished at the end of Pearson’s r was used to correlate sacral and This programme provided a visual readout regular season matches; as not all teams torso impacts. of impacts along 3 axes (x, y, z) as well progressed to post-season play. As the season as a vector summation of all three axes, representing “total bodyload” (T), for each of Table 2: Definitions the five individual tasks. Plots representing Term Definition each individual task were then analysed. Injury A musculoskeletal condition manifesting as localised pain, stiffness or loss Impact values (recorded in units of gravity, of function arising during or following a training session or match. g) were obtained manually from the vertical Lower limb injury An injury arising either from a bone of the lower limb or from a muscle, axis and total bodyload graphs by hovering tendon, ligament or capsular structure with a direct anatomical attachment the cursor over the impact peak, and noting to the lower limb. the value displayed. Each task was analysed Non-contact injury An injury not caused by direct impact from another player or equipment. in the following fashion and mean impacts Significant injury A lower limb non-contact injury directly leading to loss of training and/or recorded for total bodyload (T) and vertical game time. axis (y): Non-significant injury A lower limb injury not leading to loss of training and/or game time, but requiring assessment and/or treatment. • Run: 20 consecutive peaks were Loss of training or Missing, or modification to, a game or training session following the session measured, with the subject at a stable game time in which the injury was sustained. speed. • Linear maximal sprint: 12-20 consecutive peaks were measured over the middle 30 progressed, a timeline was maintained for Results metre section, with the subject running each subject, charting their season in terms of Sixty-one players enrolled in the study. at maximum speed. the following (definitions outlined in table 2): Eleven were subsequently excluded due to: • Multidirectional sprint: The three highest Statistical Analysis 1 Technical difficulties in impact data peaks at each direction change were Poisson regression and Chi-square analyses upload (six players) measured. were used to examine relationships between 2 Transferring to clubs not enrolled in the • Vertical jump: Takeoff and landing peaks individual load measurements and injury study (three players) were measured independently. incidence. The Poisson regression was used 3 Retirement (one player) because the injury data did not approximate • Kicking: Takeoff and landing peaks for 4 Withdrawal due to injury prior to a normal distribution. When assessing each of the five kicks were measured commencement of the season (one injuries, Poisson regressions were performed collectively. player). on the count data with parameters grouped Mean impact values were then divided Of the remaining players, three had into torso total, torso y axis, sacrum total by the athlete’s body weight to give four either sacrum or torso data missing due and sacrum y axis. The association between standardised values per kilogram of to technical issues. This gave a total of 50 each individual load parameter and injury bodyweight for each task (total and vertical subjects, comprising 47 complete and 3 was therefore measured after controlling load for both torso and sacrum). For each partially complete data sets. for the other three load parameters. When value, the difference between sacral and assessing missed sessions, the training Mean sacral impacts were larger than mean torso impact was calculated, this value sessions and games missed were combined torso impacts for all running tasks, and for representing the difference in load between into a single Poisson regression model for most jumping tasks, with the exception of the lumbosacral junction and the upper torso each set of parameters. The type of session, jump-landing and kicking, where there was (refer table 3). match or training was included as a repeated no significant difference between the

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Table 3: Mean impacts and impacts per kg. Table 4. Mean sacral and torso vertical (y) and total (T) loads and mean differences between sites. Task Site Axis Mean Mean Load (g) Load/kg Task Mean Sacral Mean Torso Mean P value § Vertical 3.8304 0.048 Load* Load* Difference# Torso Total 4.2294 0.053 Run T 0.087 0.057 0.027 <0.0001 Run Vertical 5.3466 0.067 Run y 0.062 0.048 0.014 <0.0001 Sacrum Sprint T 0.070 0.053 0.027 <0.0001 Total 5.586 0.070 Running Tasks Sprint y 0.067 0.048 0.019 <0.0001 Vertical 3.8304 0.048 Torso Zigzag T 0.095 0.070 0.025 <0.0001 Total 4.5486 0.057 Sprint Zigzag y 0.080 0.064 0.016 <0.0001 Vertical 4.9476 0.062 Sacrum Takeoff T 0.078 0.066 0.012 <0.0001 Total 6.9426 0.087 Takeoff y 0.065 0.056 0.009 <0.0001 Vertical 5.1072 0.064 Torso Landing T 0.103 0.094 0.009 <0.0001 Total 5.586 0.070 Jumping Zigzag Tasks Landing y 0.088 0.087 0.001 0.8926 Vertical 6.384 0.080 Sacrum Kick T 0.082 0.076 0.006 <0.0001 Total 7.581 0.095 Kick y 0.071 0.072 -0.001 0.6902 Vertical 4.4688 0.056 Torso * Mean for all 50 players, in g/kg Total 5.2668 0.066 Takeoff # A positive value indicates mean sacral impact > mean torso impact Vertical 5.187 0.065 Sacrum § A p value <0.05 indicates a statistically-significant difference between sites Total 6.2244 0.078 Vertical 6.9426 0.087 Table 5: Pearson correlations between impacts Torso recorded at sacrum and torso. Total 7.5012 0.094 Land Parameter r Correlation Vertical 7.0224 0.088 Sacrum Takeoff Total 0.724 Total 8.2194 0.103 Kick Total 0.669 Vertical 5.6658 0.071 Strong Torso Takeoff Y axis 0.642 Total 6.0648 0.076 Kick Zigzag Total 0.509 Vertical 5.6658 0.071 Sacrum Run Total 0.468 Total 6.5436 0.082 Kick Y axis 0.454 Moderate Landing Total 0.408 Table 6. Statistically-significant relationships between impacts and Sprint Total 0.345 injuries and/or missed sessions Sprint Y axis 0.344 IMPACTS Zigzag Y axis 0.268 Task/site/axis Association with Association p value Landing Y axis 0.242 Weak Takeoff torso Total Significant injuries Negative 0.049 Run Y axis 0.153 Landing sacrum Total Significant injuries Negative 0.011 Sprint sacrum Total Non-significant injuries Positive 0.038 two sites (table 4). Stronger correlations Landing torso vertical Non-significant injuries Negative 0.013 were demonstrated between sacral and Jog sacrum Total Non-significant injuries Negative 0.031 torso impacts measured during the takeoff Kick torso vertical Missed sessions Positive 0.027 phase of jumping and when kicking, with Jog torso vertical Missed sessions Positive 0.038 weak correlations demonstrated during Takeoff torso vertical Missed sessions Negative 0.011 jump-landing. (table 5). When examining Sprint torso vertical Missed sessions Negative 0.008 relationships between measured impacts and injures and/or missed sessions, there were a number of statistically-significant associa- Table 7: Statistically-significant relationships between sacrum-torso impact tions spread across tasks and across axes difference and injuries and/or missed sessions. (table 6). Neither axis, site of placement nor SACRUM-TORSO DIFFERENCE task group proved superior in demonstrat- Task/axis Association with Association p value ing associations between variables. Similarly, Sprint vertical Significant injuries Positive 0.005 a small number of statistically-significant Sprint vertical Missed sessions Positive 0.002 associations were demonstrated between Zigzag vertical Significant injuries Negative 0.024 sacrum-torso differences and injuries and/or Landing total Missed sessions Negative 0.038 missed sessions (table 7).

new zealand journal of sports medicine - 25 original research

Demographic and Injury Data vertical load measured using this device and altering these variables on impact values is The 50 players had a mean age of 23.5 ± 3.7 lower-limb, non-contact injuries. A number required. Potential solutions include adding years and a mean weight of 79.8 ± 6.0kg. of sources of potential error appear to limit an adjustable tensioning strap to customise Twenty-nine players suffered a total of 46 the accuracy of impacts, particularly at the current harness to the individual, or significant and 47 non-significant injuries, torso level. In particular, the harness used to using a custom “research vest”, built to outlined in figures 2 and 3. Players above hold the device between the scapulae may minimise aberrant movement of the unit. the mean age were significantly more likely introduce significant error during running Reaching overhead to catch a ball during than players below the mean to report a and jump-landing, calling into question the the jumping task may elevate the harness significant injury (p<0.05) and to miss a validity of comparison of impacts between further and introduce additional error. Other session (either training or match) due to a sites and correlation with injuries. One potential sources of error lie within the Team significant injury (p<0.05). There were 14.7 pattern of association however may suggest AMSTM software, which appears to artificially significant injuries per 1000 player exposure a link between lumbopelvic stability and/or limit the value of impacts recorded on the hours. Players were more likely to miss sprinting gait, and injury. vertical axis to 7.984g. Furthermore, impact training sessions than games due to injury Impact Data peaks were measured manually, by hovering (p<0.05). Based on our data, we are not convinced that the cursor over the peak and recording the this system is able to value. Not only was this time-consuming, measure impacts with but in some cases the impact peak itself was sufficient accuracy difficult to identify from surrounding data. for injury risk factor In a number of cases - particularly on the analysis. Previous vertical axis, on torso-mounted units, and work utilising this when running at higher speeds - there was technology has a double peak (figure 4b) suggesting the questioned the unit had bounced up and down significantly accuracy of impacts in the harness. It was not possible to recorded at torso level differentiate with any certainty the impact by the SPI ProTM; peak from the rebound peak. One might 17, 19 indeed several assume the higher of the two might be the Figure 2: Anatomical distribution of significant injuries. technical issues were impact peak, however given the elastic identified in this properties of neoprene, this assumption study that introduced cannot safely be made. potential sources of Figures 4a, 4b. Vertical (grey, apices upward) error. Our observation and total (black, apices downward) impact of equal or greater plots obtained at torso level during a run mean vertical (a) and linear sprint (b). Note the relatively impacts at torso level well-defined impact peaks during the run for jumping tasks compared to the sprint, where peaks are in particular may less clearly defined and - in some cases - suggest paradoxic duplicate. magnification of A further technical issue is that of sampling impacts between error due to sampling frequency, particularly sacrum and torso when comparing the technology to a force Figure 3: Anatomical distribution of non-significant injuries. level, likely due to platform. The TA in the SPI ProTM unit has the units moving a sampling frequency of 100Hz, whereas Discussion aberrantly within the neoprene harness. force platforms may sample at frequencies of up to 960Hz or more.13 This would not be This study aimed to assess the ability of a Harnesses tend to come in one size fits all, modifiable in the foreseeable future however, trunk-mounted GPS/accelerometer system are used up to six days per week, and are and any sampling error needs to be placed in to accurately measure (at both torso and subject to degradation from hot water, sweat context with the rationale behind the study sacral levels) vertical impacts generated in a and detergents. Any error due to poor fit is – namely to take impact measurement out of pre-season movement analysis screen; and likely to be tolerable for training purposes, the laboratory and into the field. to compare impacts recorded at the torso where conditioning staff require only rough Certain aspects of study design may limit the with their sacral counterparts. Subsequently, estimates of bodyload. For the unit to be applicability of our findings to the clinical these impact data were compared with used for field-based research however, setting. Our subjects were assessed only prospectively-collated injury data across a assessment of various harness types, sizes once during a single pre-season session, season to examine any relationship between and materials to determine the effect of

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Figure 4a: Simultaneous vertical sacral impact plots for the same subject during a linear sprint task.

Figure 4b: Simultaneous vertical torso impact plots for the same subject during a linear sprint tas whereas players assessed multiple times over the ball on the arms and upper torso may between torso and sacral impacts, and the course of a season may demonstrate alter load, particularly in anteroposterior or injuries. Should the validity of torso data changes in load due to ground conditions, mediolateral planes. prove questionable due to artefact, there training periodisation, fatigue and/or Comparison of Sacrum and Torso might be useful data gathered from the injuries themselves. Thus, any relationship Data sacrum that clubs could still use for gait demonstrated using a single pre-season The lumbosacral unit was added as a modification. Due to dissipation of load in GPS/accelerometer measurement may reference point at a site approximating the mediolateral and anteroposterior planes be more accurate for the early part of the body’s centre of gravity. We were interested across the trunk it was anticipated that (i) season than later on. We elected not to have in measuring the relationship between mean vertical impacts would be greater subjects handling an actual ball, as it was felt sacral and torso impacts in light of previous at the sacrum, for all tasks, and (ii) there that having other players deliver the balls literature questioning the validity of torso would be stronger correlations for total would create too much variation in load. It impacts.17, 19 In addition, we wished to bodyload and weaker correlations for vertical is acknowledged however that the use of a investigate any relationship between either load between the two sites. Significantly ball is more realistic, and that the impact of (i) sacral impacts per se or (ii) the difference greater mean vertical impacts were indeed

new zealand journal of sports medicine - 27 original research measured at the sacrum than at the torso for to be a risk factor for injury, particularly sensitive enough to predict injury-prone all running tasks, especially linear sprinting, muscle injury6 with age 23 years an apparent players. While accelerations measured at but not for all jumping tasks. Contrary to watershed for calf and hamstring strains.15 torso level alone did not prove useful in expectation, mean vertical impacts at the These results lend further support to the predicting injuries, impacts measured near torso for jump-landing and kicking were careful management of conditioning and the centre of mass proved no better. Despite not significantly different from those at the training load in older players. Acute ankle strong correlations between the two sites for sacrum. Stronger correlations between sacral sprain was the most common significant some tasks, the areas of strongest correlation and torso impacts were indeed demonstrated injury, followed by hamstring and groin were no more likely to predict injury than for total bodyload than for vertical load injuries respectively, mirroring their the weakest. We infer from these results that alone, and while stronger correlations were frequency seen in previous studies at with this technology in its current form there generally seen for jumping tasks than for community2, 6 and junior16 levels, but not at is no clinical utility in measuring isolated running tasks a notable exception was the elite level however, where ankle injuries rank centre of mass impacts using this technology, jump-landing, which correlated poorly, third in terms of prevalence.15 This difference although the simultaneous measurement of particularly with respect to vertical load. may be due to variations in quality of playing torso and sacral impacts may show promise. These findings again call into question the surface, rehabilitation or availability of Several challenges were present in recording accuracy of impacts derived from the upper preventive taping/bracing. Low back pain injury data across a season. We aimed to torso level, due to paradoxic magnification was the most frequently reported non- limit recall bias by minimising the number of vertical impacts due to the harness significant injury. This was also in line with of athletes per club, with updates from during jump-landing, kicking and running. previous work demonstrating that footballers club physiotherapists on a weekly basis. Paradoxic magnification may not be the across all codes have significantly more Overall, the feeling from the physiotherapists sole explanation for these observations severe and frequent low back pain than non- was that they were happy with the size of however. Player gait and landing technique athletes, and that incidence increases with their assigned group and they felt able to may indeed be relevant. These results may the level of competition.9 Players were more accurately keep track of injury numbers reflect the more vertical nature of taking likely to miss training sessions than games. and session attendance. Reporting bias is off in comparison to a greater horizontal This was in keeping with expectations, as a potential challenge, for two reasons. The dissipation of load on landing. Some players players will frequently modify their training first pertains to the definition of a non- may adopt a more rigid landing style, or loads during the week in order to be available significant injury. While a significant injury indeed accelerate load through their torso for matchday selection. has a relatively unambiguous definition (it upon impact, due to poor lumbopelvic Relationship between Impacts and leads to loss of training and/or match time), stability. A greater mean sacrum-torso Injury the definition of a non-significant injury is difference was observed for vertical impacts Overall, relationships between measured more open to interpretation and it is possible when sprinting, compared to submaximal impacts and injuries were inconsistent, that non-significant injuries went unreported running. In contrast however, the mean although when assessed alongside sacrum- by both players and physiotherapists, even sacrum-torso differences for total bodyload torso difference data, one pattern does when players were asked directly. What were identical. This may reflect the smoother emerge. The difference in mean vertical is an injured calf to one may be perceived nature of sprint running,11 with greater force impacts measured at the torso vs. sacral level as normal post-game soreness by another. dissipation along horizontal planes and was greatest during the sprint task, and this Secondly, players may withhold information potentially less paradoxic movement within difference was associated with an increased due to a desire to not lose their place in the the harness. risk of significant injury and time out of team, and/or to not be perceived as injury- Demographics and Injuries sport. Given the aforementioned concerns prone or “soft” by team-mates or coaches. Player demographic data were consistent regarding accuracy of accelerometer data, The Future with previously published findings in it is possible that these associations are due Although this study was unable to confirm community-level Australian football. 2, 5 to chance, particularly with a relatively any relationship between impacts measured Our finding of 14.7 significant injuries per small injury sample size and only a single using the SPI ProTM and injuries, we believe 1000 player hours is less than previously measurement of load. An alternative there is room for future work in this area. noted at community (27.2/1000)2 and explanation for this finding however is that For this system to be used in research, elite level Australian Rules football (38.2 during sprinting, greater dissipation of force modifications to both hardware and to 43.3/1000).15 Potential reasons for this medio-laterally and/or antero-posteriorly, software appear necessary. A future study include differences in conditioning, injury particularly in the presence of poor comparing torso and sacral TA results in countermeasures, training and match lumbopelvic stability may increase stress on both “standard” and “research” vests to force intensity and sample size. The statistically the low back, pelvic girdle and lower limbs, plate data may provide insight into the role significant age-related increase in both the increasing the risk of injury. Medio-lateral the harness plays in modifying impacts. With number of significant injuries, and sessions and antero-posterior accelerations were respect to software, the limitation of vertical missed due to those injuries, is however not measured in this study, and it may be impacts to 7.984 g will require rectification, consistent with previous work showing age that measuring vertical impact alone is not and it may be possible for the software

28 - new zealand journal of sports medicine original research authors to enable Team AMSTM to calculate physiotherapists and training staff. accelerations to assess external work and an average impact peak over a desired range The authors wish to express their gratitude to power in able-bodied gait. Gait Posture 2007; of recordings. If this is not possible then the the Geelong Football Club for the loaning of 25: 25-32 inter-rater reliability of the manual method their SPI-ProTM equipment, and in particular 13 Milner CE, Ferber R, Pollard CD, Hamill J, Davis IS. Biomechanical factors associated of impact peak measurement will need to be the time and expertise of Jarrod Wade in with tibial stress fracture in female runners. assessed. This will likely require better quality uploading the data. Med Sci Sports Exerc 2006; 38(2): 323-328 impact data than were observed in this References 14 O’Driscoll J, Kerin F, Delahunt E. Effect of a study. In terms of study design, future work 1 Boling M, Padua DA, Marshall SW, six week dynamic neuromuscular training incorporating the measurement of antero- Guskiewicz K, Pyne S, Beutler A. A programme on ankle joint function: a posterior and medio-lateral loads, together prospective investigation of biomechanical case report. Sports Medicine, Arthroscopy, with the use of video analysis to assess player risk factors for patellofemoral pain syndrome. Rehabilitation, Therapy and Technology 2011; running and landing technique, may assist Am J Sports Med 2009 Nov; 37 (11): 2108-16 3(13) Accessed at: www.smartjournal.com/ 2 Braham R, Finch C, McIntosh A, McCrory in ascertaining whether or not technique, content/3/1/13 P. Community level Australian Football – a lumbopelvic stability and/or kicking style 15 Orchard J, Seward H. Australian Football profile of injuries. J Sci Med Sport 2004; 7(1): League Injury Report, season 2011. are relevant. Further work may also explore 96-105 Melbourne; Australian Football League the value of addressing core stability, lower 3 Ferber RI, McClay-Davis I, Hamill J, Pollard Medical Officers’ Association, 2012 limb muscle balance and gait mechanics CD, McKeown KA. Kinetic variables in 16 Scase E, Magarey ME, Chalmers S. The in reducing injury occurrence. This study subjects with previous lower extremity stress epidemiology of injury for an elite junior did not differentiate on the basis of playing fractures. Med Sci Sports Exerc 2002; 34(5) Australian Football cohort. J Sci Med Sport position or body type, however future work s1-5 2012 May; 15(3): 207-12 with a larger cohort of players could do 4 Finch C. A new framework for research 17 Tran J, Netto K, Aisbett B, Gastin P. Validation so. The small sample size, time frame and leading to sports injury prevention. J Sci Med of accelerometer data for measuring impacts Sport 2006; 9: 3-9 number of injuries may have played a role during jumping and landing tasks. Accessed 5 Gabbe B, Finch C. Injury Countermeasures in in not finding associations. To demonstrate April 28, 2010 at: https://ojs.ub.uni-konstanz. Australian Football. J Sci Med Sport 2000 Jun; de/cpa/article/viewFile/4419/4109 meaningful associations may require a larger 3(2): 31-40 18 van Mechelen W, Hlobil H, Kemper HC. player cohort than this study, and necessitate 6 Gabbe B, Finch C, Wajswelner H, Bennell Incidence, severity, aetiology and prevention the collection of injury data over several K. Australian Football: Injury Profile at the of sports injuries. A review of concepts. Sports seasons to ascertain which particular injuries Community Level. J Sci Med Sport 2002 Jun; Med 1992; 14(2): 82-99 are contributed to by vertical impact load, 5(2): 149-60 19 Visser T, Veenstra BJ, Prinzen J, Zuidema M. and the magnitude of any such contribution. 7 Henriksen M, Lund H, Moe-Nilssen R, Bliddal Quality of ambulant measures of distance, Conclusions H, Danneskiod-Samøe B. Test-retest reliability speed, load and energy consumption during of trunk accelerometric gait analysis. Gait Trunk-mounted GPS/accelerometer military operations. Royal Netherlands Army. Posture 2004 Jun; 19(3): 288-97 Accessed April 2010 at: http://ftp.rta.nato. technology demonstrates potential as a 8 Hewett TE, Stroupe AL, Nance TA, Noyes int/public/PubFullText/RTO/MP/RTO-MP- club-based research tool, but at this point it is FR. Plyometric training in female athletes. HFM-181/MP-HFM-181-P13.doc not possible to make firm recommendations Decreased impact forces and increased 20 Zijlstra W, Hof A. Assessment of spatio- regarding modification of load – based hamstring torques. Am J Sports Med 1996 temporal gait parameters from trunk on measurements acquired via this TA Nov-Dec; 24(6): 765-73 accelerations during human walking. Gait system - in order to prevent injuries. 9 Hoskins W, Pollard H, Daff C, Odell A, Posture 2003 Oct; 18(2): 1-10 Neither is it possible to recommend the Garbutt P, Andrew McHardy, Hardy K, current technology as a screening tool to Dragasevic G. Low back pain status in elite Comment 1 and semi-elite Australian football codes: a predict players at risk of injury. There is Mike McGuigan, PhD cross-sectional survey of football (soccer), scope however for future research into the Professor of Strength and Conditioning Australian rules, rugby league, rugby hardware component of the technology AUT University union and non-athletic controls. BMC used in this study - focusing particularly on Musculoskeletal Disorders 2009; 10: 38 he use of global positioning system the harness – and for modifications by the 10 Hreljac A. Etiology, prevention and early manufacturer to the software package. Once intervention of overuse injuries in runners: a T(GPS) and accelerometry technology is these technical issues have been worked biomechanical perspective. Phys Med Rehabil becoming more widespread in professional through and the technology validated Clin N Am 2005 Aug; 16(3): 651-67 sport. In recent times there have been a large in the field, scope may exist for further 11 Keller TS, Weisberger AM, Ray JL, Hasan number of published papers investigating investigation into associations between SS, Shiavi RG, Spengler DM. Relationship the use of GPS technology, particularly between vertical ground reaction force and impacts and injury using this device. in team sports (e.g. 2, 3, 4). This research speed during walking, slow jogging and Acknowledgements has looked at quantifying the demands of running. Clin Biomech (Bristol, Avon) 1996 sports such as Rugby Union, Rugby League, The authors wish to acknowledge the time Jul; 11(5): 253-259 Soccer and Cricket. It has also attempted to and assistance given by all study participants, 12 Meichtry A, Romkes J, Gobelet C, Brunner assess the training demands of these sports including the subjects, clubs, team R, Müller R. Criterion validity of 3D trunk

new zealand journal of sports medicine - 29 original research in addition to providing more information match performance. However, greater Comment 2 about how to effectively train the physical understanding of the injury prevention Chris Hanna capacities required in these sports. In applications of this information is also Sports Physician this issue, the authors have conducted an required and this is where researchers in UniSports Medicine, Auckland interesting study where they quantified the Sports Medicine have a big role to play. vertical impacts using GPS/accelerometry There has been a rapid uptake of GPS his is a very interesting paper. It has during match play and training with specific technology by team sports and there is Tidentified some very important issues reference to injury risk in Australian Rules now a lot of information on the activity in the use of triaxial accelerometers in field Football players. This type of research has profile of athletes arising from GPS analysis. based research, in particular the ceiling the potential to have a great impact on Sports This includes total distance covered by phenomenon of this particular software Medicine/Sports Science as it will provide players and distance in different velocity package when forces exceed a certain practitioners with greater insight into the ranges.1 However, there is relatively little threshold (7.984g). The stability of harnesses physical demands and potential injury risk of practical information that is gained from may also need to be assessed before further the sports they are working with. simply reporting and comparing measures research can be carried out in this field. In A recent case study is a good example of such as total distance covered. The use of terms of injury prevention, the authors have how GPS can be used to manage players distance per minute of match time may be identified one possible correlation between returning from injury.4 By identifying the more informative. In addition, breaking pre-season screening and the incidence positional requirements of the players and movement into velocity bands in order to of injury in that the difference between measures such as the amount of high speed locate periods of intense activity during trunk and sacral forces during a sprint task running, the authors were able to manage the matches, such as repeated sprint bouts, could correlated with a higher rate of injury and 2 loading and make recommendations based have greater practical application. The greater time out of sport. They postulate, on objective data. This has great potential study reported in this issue goes beyond logically, that this may indicate that poor impact, as it enables practitioners to identify the basic measures such as distance covered core stability might be associated with an objective targets that are specific to match and provides a more in-depth insight to the increased risk of injury. In order to prove play and should help to reduce the risk of actual loads experienced by players, despite this relationship, further research would be re-injury. Another advantage of GPS is some technical limitations as noted by the needed to show that improving an athlete’s that it can be monitored in real-time. This authors. With an increased understanding core stability through intervention reduces is significant as it allows practitioners to of match demands of various sports from the difference between forces recorded at more effectively monitor athletes during the technologies such as GPS and accelerometry, the torso and sacrum, and then they would training sessions. As always with technology, this should allow us to make more informed have to show that this change reduced the the challenge for us is how we can effectively decisions about training athletes, as well as rate of injury in the intervention group. This interpret this information and use it to having implications for injury prevention paper provides useful information for anyone inform our practice. The type of research and managing the rehabilitation programmes planning of further research in this field. conducted by the researchers in this issue of athletes returning from injury. Personally, I believe that monitoring GRFs is a good example of how Sports Medicine References throughout the season is likely to be more can conduct these types of applied studies in 1 Aughey RJ. Applications of GPS technologies useful in injury risk reduction than a one of elite sporting environments to increase our to field sports. Int J Sports Physiol Perform pre-season functional screen. 2011; 6:295-310. knowledge of sports and injury prevention. 2 Boyd LJ, Ball K, Aughey RJ. The reliability In terms of the future application of GPS of minimaxx accelerometers for measuring technology an area of key focus should be physical activity in australian football. Int J greater integration of movement data with Sports Physiol Perform 2011; 6:311-321. fitness, physiological, injury and tactical 3 Mooney M, O’Brien B, Cormack S, Coutts A, data. A recent Australian Football study Berry J, Young W. The relationship between investigated the relationship between Yo-Yo physical capacity and match performance in test (endurance) performance, high intensity elite Australian football. J Sci Med Sport 2011; running distance per minute and total ball 14:447-452. disposals (a key performance indicator) in 4 Reid LC, Cowman JR, Green BS, Coughlan GF. Return to play in elite rugby union: elite players.3 This is an excellent example application of global positioning system of how GPS data can provide an in-match technology in return-to-running programs. J performance measure, and the determinants Sport Rehab 2013; 22:122-129. of that performance can be understood through fitness testing. What is most significant from this work is the connection between physical capacity, fitness and actual

30 - new zealand journal of sports medicine SAMANTHA POMROY, DAVID B PYNE, ORIGINAL RESEARCH KIERAN E FALLON, PETER A FRICKER Sports medicine practitioners’ assessment and management of upper respiratory illness in athletes Samantha Pomroy MBBS BAppSci(Physio) ABSTRACT seldom or rarely conducted. Two-thirds David B Pyne PhD Purpose of respondents reported their treatment and management varies according to Kieran E Fallon MD FACSP To identify the degree of uniformity in the level of the athlete and sport. While Peter A Fricker MBBS FACSP approaches used by sports medicine all respondents reported training of the Affiliations: practitioners’ to assess and manage athlete was modified according to signs upper respiratory illness in athletes, and Medical School, The Australian National and symptoms, only a minority (23%) alignment of contemporary practices with University reported a reduction in performance. current guidelines and recommendations. Sports Medicine, Australian Institute of Sport Twenty percent of respondents reported Methods Correspondence: using the ‘above neck rule’ in training A short 11-item web-based questionnaire modification. The most frequent advice Samantha Pomroy was developed to inquire about the history, included ensuring adequate hydration, 23a Kissing Point Road physical examination, investigations and nutrition, rest, and exercising moderately management of athletes presenting with Turramurra, NSW, 2074 to avoid aggravating symptoms. upper respiratory illness. A total of 24 AUSTRALIA Conclusion sports physicians and six registrars in Tel: +61 4 0188 4313 sport and exercise medicine completed the Substantial variation in approaches Email: [email protected] questionnaire. used for assessing and managing upper respiratory illness in athletes between Results INTRODUCTION sports medicine clinicians was evident. A Substantial variation was evident between pper respiratory illness (URI) standardised and evidence-based approach respondents questioning an athlete for commonly affects athletes, in assessment and management of upper cough at night, inspiratory/expiratory particularly in relation to periods respiratory illness in athletes may assist effort and pain, rash, pleuritic pain and its Uof intensive training and competition.1 Of current practitioners and training of future effect on exercise tolerance, the amount the 184 acute illnesses in athletes recorded sports physicians. of exercise that brought on cough and by sports medicine staff at the 2009 FINA dyspnoea, family history of respiratory Key words Swimming World Championships, about illness and smoking history. Investigations illness, exercise, training, respiratory half involved the upper respiratory tract.2 such as spirometry and peak flow were function, physician The frequency of URI in athletes and the potential effect on performance underlines upper respiratory symptoms1,5 leaving a may be identical no matter the aetiology. the importance of effective assessment and large percentage of unidentifiable infectious To improve diagnostic accuracy, a management.3 or non-infectious causes. Another study comprehensive and reproducible clinical The sports medicine practitioner faces reported substantial differences between history must be undertaken. Respiratory 1,25 a variety of causes of upper respiratory sports physicians’ use of clinical signs and questionnaires such as the WURSS-44 1,12 illness ranging from infection, to asthma symptoms and the results of laboratory and the SF-36 to assess quality of life 6 and allergies. These causes often have findings. Until point-of-care laboratory related to illness are methods of questioning commonality in their symptom presentation tests are routinely available, or higher the general population on symptomatology making it difficult to determine the exact specificity in diagnosis can otherwise be and functional impairment of respiratory cause of illness, especially at the initial achieved, multiple causes of illness have to health. However, a standardised respiratory presentation. The poor correlation of be considered at diagnosis. The importance symptom approach specific for athletes has signs and symptoms with the presence of of correct diagnosis is emphasised by not been reported. a particular pathogen, allergen or other potentially life threatening complications Investigations for athletes who present with 7,8,10,19,20 aetiological agent, and the delay inherent such as myocarditis, exacerbation of upper respiratory symptoms offer great 8,10,19,20 in obtaining results of investigations, can asthma and chronic symptoms such scope for further research. Some studies 11 limit management advice and effective as post viral fatigue syndrome. However have investigated screening strategies using 14,15 14 prescription of medications.4 absolute precision in diagnosis may not salivary IgA and salivary lysosome levels One study of illness in athletes identified be vital in many cases as methods and to monitor risk of infection. This limited pathogens in less than 30% of cases involving medications for relief of common symptoms amount of research is surprising considering

new zealand journal of sports medicine - 31 original research the highly competitive nature of elite sports Table 1: Signs and symptoms of upper respiratory illness in athletes (percentage of and importance of minimising the risk of respondents). illness for individual and team sport athletes. Question, ‘How often do you assess:’ Never Seldom Often Always In view of the high prevalence of upper COUGH respiratory illness in athletes it is important Cough occurrence? 0 3 10 87 to review assessment by sports medicine Cough is productive/dry? 0 7 27 67 practitioners of upper respiratory illness Cough is causing waking at night? 7 30 40 23 in athletes. The purpose of this study How often do you assess the quality of the cough? 3 23 40 33 was to identify the degree of uniformity DYSPNOEA in assessment approaches used by sports medicine practitioners to detect upper How often do you check for dyspnoea? 0 27 27 47 respiratory illness in athletes, and alignment Do you assess the mode of dyspnoea? (i.e. 3 30 33 33 exertion, at rest) of contemporary practices of these Do you assess the severity of dyspnoea? 7 30 40 23 practitioners with current guidelines and INSPIRATORY AND EXPIRATORY EFFORT recommendations. Do you assess if symptoms are worse on 43 10 13 33 METHODS inspiration? Subjects Do you ask if symptoms are worse on expiration? 33 7 17 43 Sports medicine practitioners were initially gender, level of experience approached through the Australasian Table 2. Symptom presentation (percentage of and specialist qualifications. College of Sports Physicians weekly respondents). Section two contained newsletter. Sports Physicians and registrars Question, ‘Do you assess for:’ Yes No questions on signs and on the Australasian College of Sports Myalgia? 100 0 symptoms used to assess Physicians programme, and primary care Arthralgia? 93 7 physicians who had a Masters or Diploma upper respiratory illness in Pleuritic pain? 63 37 of Sports Medicine were also contacted athletes. Section three sought Inspiratory vs. expiratory pain? 47 53 via mail, and in person. A total of 22 male to outline specific elements Pain with cough and location? 80 20 and eight female clinicians completed of history taking including Pharyngeal/laryngeal (sore throat)? 100 0 the questionnaire. There was a broad past medical history, Headache and their characteristics? 97 3 distribution of experience in respondents, six family history, allergies, Sinus discomfort? 100 0 respondents were on the registrar training medications, investigations, programme for the Australasian College of and details of current Earache? 100 0 Sports Physicians, 20 of the respondents had sporting performance. Duration of fever? 93 7 greater than ten years experience as a Sports Section four asked about Hot and Cold Spells? 90 10 Physician. The majority of Sports Physicians management of athletes with Shivering? 93 7 are Fellows of the Australasian College of upper respiratory illness. Night sweats 93 7 Responses were selected from Sports Physicians. This study was approved Allergy symptoms (watery and/or red 87 13 by the Ethics Committee of the Australian a dichotomous scale (yes/no), eyes, runny noses)? Institute of Sport (20091004) and the ordinal scales (always, often, Rash? 43 57 seldom, never) or open- Human Experimentation Committee of the Questioning on whether the cough ended questions. A link was Australian National University (2009/557). caused waking at night was reported by provided to the online questionnaire as well Study Design approximately two-thirds of respondents. as a password and login details to provide Sports Physicians, registrars and physicians Dyspnoea was often or always assessed in protection and ensure the identity of each who had sports medicine qualifications approximately two thirds of respondents respondent was not revealed to the research were invited to participate in a short 11 including its occurrence at rest or on team. item questionnaire. The study was in exertion. Inspiratory and expiratory effort Statistical Analysis the format of a cross-sectional survey. A and their relationship to symptoms showed Descriptive statistics were employed to questionnaire was developed by utilising significant variation in responses with 12,25 report the distribution of responses to each existing respiratory questionnaires, one third never assessing for symptom 8,9,13,17,19,20,22 of the study questions. texts and discussions with a small presentation on inspiration or expiration, RESULTS cohort of experienced respiratory and Sports and another one third always assessing this Physicians. Signs and symptoms of upper respiratory characteristic. Questionnaire illness in athletes Symptoms of pain including myalgia, The questionnaire consisted of four sections. The type of symptoms and whether a cough arthralgia, pain with cough, sore throat, The first section asked demographic was productive or dry was always assessed by headache, sinus discomfort and ear ache information of the participants including the majority of respondents (Table 1). were always inquired about by the majority 32 - new zealand journal of sports medicine original research

Table 3. Exercise tolerance with symptom presentation (percentage of occurring before, during and after training respondents). was assessed by the majority of respondents Question, ‘Do you:’ Yes No (Table 3). The amount of exercise that Measure or assess the amount of exercise that brings on cough and/or dyspnoea? 60 40 brought on cough/dyspnoea was noted by Ask if wheeze occurs during pre-training, during training or post training? 83 17 two thirds of respondents. The effect of symptoms on training intensity, frequency Ask if cough occurs during pre-training, during training or post-training? 83 17 and duration was investigated by the Ask if pleural pain occurs during pre-training, during training or post-training? 43 57 majority. Pleural pain and its effects on Ask if dyspnoea occurs during pre-training, during training or post-training? 87 13 exercise tolerance were asked about by fewer Ask about the effects of training on the symptoms? 97 3 than half of the respondents. Assess whether symptoms have affected training in regards to intensity? 93 7 Athlete’s History and Differential Assess whether symptoms have affected training in regards to duration? 80 20 Diagnosis Assess whether symptoms have affected training in regards to frequency? 73 27 When asked about the patient history the Ask about the overall effect of the illness on the capacity to exercise or train? (e.g. 83 17 majority of respondents indicated they % reduction in training) asked about past respiratory illnesses, asthma, allergies, the level of training and Table 4. Questions asked on the athlete’s history (percentage of respondents). competition schedule, medications used and effectiveness of asthma inhalers in regard Question Never Seldom Often Always to current illness (Table 4). Questioning How often do you ask about past respiratory illnesses to 0 30 47 23 assist in your diagnosis? about smoking history and family history How often do you ask about asthma to assist in your 0 0 33 67 of respiratory illness was split with only diagnosis? half of respondents asking about these How often do you ask about allergies to assist in your 0 17 43 40 details. The majority observed the athletes’ diagnosis? general appearance (Table 5) and checked How often do you ask about the athlete history- level of 0 7 23 70 for dyspnoea at rest. Half of the respondents training or competition schedule to assist in your diagnosis? often or always checked for the presence How often do you ask about smoking history to assist your 3 47 27 23 diagnosis? of watery eyes. Assessment of vital signs, ear, nose and throat and respiratory and How often do you ask about family history of respiratory 3 47 37 13 illness to assist in your diagnosis? cardiovascular examination were often How often do you ask about medications to assist in your 0 7 23 70 or always conducted by the majority of diagnosis (i.e. use of asthma inhalers)? respondents. Investigations (spirometry, How often do you ask about the effectiveness of asthma 0 3 37 60 peak flow, chest x-ray, sputum sample, throat inhalers related to current illness to assist in your diagnosis? swab) were seldom or never conducted by the majority of respondents. of respondents (Table Table 5. Differential Diagnosis/other factors (percentage of Treatment and Management of respondents). 2). Approximately two Athletes with Upper Respiratory thirds of respondents Question, ‘How often do you:’ Never Seldom Often Always Illness always assessed for OBSERVATION Two thirds of respondents said they pleuritic pain, and Observe the athletes general 0 3 10 87 vary their treatment and management appearance? half for inspiratory/ advice according to the level and type of Observe dyspnoea at rest? 0 13 27 60 expiratory pain. The sport. An athlete’s training was generally Observe watery eyes? 3 47 33 17 systemic presentations modified based upon signs and symptoms of fever and duration EXAMINATION and magnitude of decrease in training or of fever were assessed Assess vital signs? 0 17 27 57 competitive performance. Six respondents by the majority of 26 Conduct an ENT exam? 0 20 20 70 used the ‘above neck rule’ (presence of respondents. Allergy above the neck symptoms such as runny Conduct a respiratory exam? 0 7 17 77 symptoms including nose and sore throat without below neck Conduct a cardiovascular 3 20 43 33 runny nose and itchy examination? symptoms such as fever, severe cough or eyes were generally INVESTIGATION gastrointestinal upset allows the athlete assessed, but rash was Conduct spirometry? 23 53 20 3 to train at half intensity for ten minutes. assessed by less than If symptoms worsen training is ceased. Conduct a peak flow test? 13 50 33 3 half of the respondents. If symptoms do not worsen training Order a chest XRAY? 7 93 0 0 Exercise tolerance can continue as tolerated) to determine Obtain a sputum sample? 20 80 0 0 including wheeze, modification of training. In assessing Conduct a throat swab? 27 70 3 0 dyspnoea and cough

new zealand journal of sports medicine - 33 original research when an athlete is able to return to sport, bronchoconstriction19 is important to ensure of uncomplicated upper respiratory tract all respondents indicated a reduction correct diagnosis. Inspiratory/expiratory symptoms does not require them. As might or resolution in signs and symptoms as characteristics should be assessed routinely be expected spirometry, which is generally important determinants. in athletes presenting with respiratory illness only relevant if obstructive or restrictive The advice given to the athlete on how to or problems. airways disease is suspected, was performed return to training ranged from general to Variability in approaches was also seen in infrequently with over two thirds of specific. Sixteen respondents reported a questioning the athlete on the occurrence physicians seldom or never using peak flow graduated programme and nine indicated of pleuritic pain. One third of respondents measurements. If required these tests can be the athlete should progress as able. Eleven did not assess this symptom. Pleuritic pain conducted at the initial presentation and are respondents used the principles of frequency, can be a symptom of pneumonia9,10 and inexpensive in time and cost.20 Diagnostic intensity, duration and specificity to guide although uncommon in athletic populations, testing can give an objective measure of the return to sport. Advice given to the it is appropriate to exclude this complication. whether asthma is associated with, or athlete included decreasing the volume It may also be instructive for physicians to causative of, several of the symptoms which of training if symptoms worsened. Many review chest pain or tightness in the athlete. athletes typically present.10 Peak flow and respondents gave nutrition advice, reminders This symptom can lead the clinician to spirometry are also helpful in cases of acute on hydration and suggestions to ensure check for pneumonia, asthma and cardiac bronchitis as altered flow rates can indicate athletes were getting adequate sleep. abnormalities.1,8,9,10,19,20,25 Both asthma and reduced pulmonary capacity, and thus full Specific medical complications of an upper upper airway obstruction continue to be training loads may not be appropriate.8 As respiratory illness that respondents were under diagnosed and undertreated9 so more some upper respiratory illnesses present with concerned about included viral myocarditis, specific questioning may improve diagnosis. wheeze and cough,1,9,10 use of these tests may non-specified cardiac manifestations, and A low clinical priority was given to the improve the rate of diagnosis of asthma. aggravation of asthma. Post-infection presence of rash as less than half of the Other important considerations for history fatigue, Epstein-Barr virus infection and respondents checked for its occurrence. Rash taking by sports medicine clinicians include splenomegaly in contact sport athletes were can be an important sign of viral illness and the epidemiology of illnesses, particularly also considered. if associated with fever and upper respiratory within the active 12-30 year age bracket. DISCUSSION tract symptoms can indicate meningococcal Epstein-Barr Virus23 and asthma22 should The sports medicine practitioners’ clinical disease.9 A rash can also be associated with always be considered in a differential practices identified in this study were infection by the Epstein Barr Virus.2 Rash diagnosis, together with more serious generally consistent with current guidelines10 could also be a sign of atopy, and an allergic conditions such as meningococcal disease, and recommendations1,8,9,19,20,25 for athlete cause or asthma should be considered. within this age group. presentation with upper respiratory illness. Allergic conjunctivitis, another key feature Many of the respondents included However, there was some variation in of atopy, or viral infection of the upper elements of current contemporary clinical diagnosis, treatment and management of respiratory tract might also be missed as less guidelines8 and recommendations1,9,10,19,20,25 respiratory illness between respondents. than half of respondents seldom or never such as symptom based modification A notable difference was questioning of observed for watery eyes. of training - however none included all the athlete about the presence of a cough Two important aspects of history components of these. Analysis of the at night. This was seldom or never asked taking which lacked consistency were specificity in management advice did not by one third of respondents. This may be questioning the athlete about family history correlate highly with the years of clinical an important question given an athlete’s of respiratory illness and the patient’s experience. Variability between clinicians’ fatigue might be worsened by disrupted smoking history. Current guidelines8 and approaches may relate in part to care for sleep. Cough at night can also be reflective recommendations9,10,1,19,20,25 support both teams as distinct from those competing of asthma1,8,9,19,20,25 or chronic sinusitis, as a lines of questioning. Family history of in individual sports, experience with result of post-nasal drip where secretions respiratory illness was seldom or never asked upper respiratory illness, or simply the track down into the larynx during sleep.9,10 by half of the respondents. This questioning willingness to report on the questionnaire. A second discrepancy was questioning of could assist in identification of asthma and/ For example, some respondents gave symptom severity in relation in to inspiration or allergic rhinitis8 as causes for symptom explicit stages of progression for the athlete or expiration. Failure to ask could mean presentation. Smoking history was asked to resume full training whereas others left stridor from an upper airway obstruction or by half of the respondents. Care needs to it up to the athlete - if the athlete felt well vocal cord dysfunction might be missed.19 be taken to avoid making the assumption then resumption of training could occur. Alteration in respiratory function is not an that athletes do not smoke. Appropriate Specific advice given by the sports medicine uncommon presentation within the athletic questioning may also allow the degree of practitioner can eliminate confusion in the population especially those exercising at exposure to passive smoking to be assessed.25 athlete and coach and limit the problems high intensities. Differentiating inspiratory Ordering of diagnostic tests was limited. of a premature return to sport. The exact stridor from symptoms of exercise-induced This is not surprising as diagnosis and duration of an illness often cannot be management of the majority of constellations determined as individual responses are

34 - new zealand journal of sports medicine original research unpredictable.8 It is therefore not surprising the definitions of upper respiratory illness, 10 Therapeutic Guidelines – Respiratory. Version that practitioners did not identify a specific and on the development of a model for 3. Victoria, Australia, PA: Therapeutic time course for return to full training – a history taking. Consideration should also be Guidelines Australia; 2005. position consistent with previous reports.8,21 given to identifying all potential causes of 11 Maffulli N, Testa V, Capasso G. Post-viral fatigue syndrome. A longitudinal assessment There was a clear distinction between respiratory illness - particularly those with in varsity athletes. J Sports Med Phys Fitness. clinicians with many years of experience cardiac consequences.1,7,8,9,10,25 1993; 33(4):392-9. and those on the registrar program in the A standardised clinical approach for 12 Teul I, Baran S, Zbislawski W. Upper type of physical examination techniques and assessing and managing upper respiratory respiratory tract diseases in self-evaluation tests ordered for upper respiratory illness. illness in athletes, utilising evidence based of health status of Polish students based on More senior clinicians with years of sports guidelines is warranted. The development the SF-36 questionnaire. J Physiol Pharmacol. medicine experience typically ordered fewer of a reliable and reproducible approach 2008; 59 Suppl 6:697-707. tests and conducted an abbreviated physical could be developed in the future to assist in 13 Brenner IK, Shek PN, Shephard RJ. Infection examination. The shortcomings of pathology streamlining all sports medicine clinicians’ in athletes. Sports Med. 1994; 17:86-107. testing in an athletic population have been approaches. An improved treatment and 14. Cunniffe B, Griffiths H, Proctor W, Davies B, Baker JS, Jones KP. Mucosal immunity and noted previously.6 The training of registrars management approach should limit the illness incidence in elite rugby union players should include discussion of this issue. recurrence of symptoms and more serious across a season. Med Sci Sports Exerc. 2011; The management advice reported by two medical complications. 43(3):388-97 thirds of respondents indicated treatment Acknowledgements 15 Neville V, Gleeson M, Folland JP. Salivary IgA and management varied according to the The authors are grateful for the cooperation of as a risk factor for upper respiratory infections level and type of sport. This observation the physicians who participated in this survey. in elite professional athletes. Med Sci Sports aligns with the recommendations of Fricker References Exerc. 2008; 40(7):1228-36. et al.8 However there is growing evidence 1 Spence L, Brown WJ, Pyne DB, Nissen MD, 16 Rundell KW, Speiring BA. Inspiratory stridor of the possibility of adverse effects and Sloots TP, McCormack JG, Locke AS, Fricker in elite athletes. Chest. 2003; 123:468-474. increased bacterial resistance with increased PA. Incidence, etiology, and symptomatology 17 Weidner TG, Sevier TL. Sport, exercise, and the common cold. J Athl Train. 1996; antibiotic usage, particularly given that the of upper respiratory illness in elite athletes. Med Sci Sports Exerc. 2007; 39(4):577-86. 31(2):154-9. majority of upper respiratory infections are 2 Mountjoy M, Junge A, Alonso JM, 18 Centre for Disease Control and Intervention, viral. Sports physicians need to be mindful of Engebretsen L, Dragan I, Gerrard D, Kouidri Epstein - Barr virus and Infectious prescription of antibiotics to limit increases M, Luebs E, Shahpar FM, Dvorak J. Sports Mononucleosis. [CDC website]. Available at: in bacterial resistance and unnecessary side injuries and illnesses in the 2009 FINA World http://www.cdc.gov/ncidod/diseases/ebv.htm. effects. Championships (Aquatics). Br J Sports Med. Accessed September 23, 2010. Clinical approaches to monitoring 2010; 44(7):522-7. 19 Brukner P and Khan K. Clinical Sports of symptoms, dietary management, 3 Pyne DB, Gleeson M, Fricker PA, Batterham Medicine 3rd ed. Sydney Australia, PA: supplements, and recovery post training/ A, Hopkins WG. Characterising the individual McGraw-Hill; 2007 competing also varied. Athlete monitoring performance responses to mild illness in 20 Oxford Handbook of Sports and Exercise Medicine. Oxford, United Kingdom: Oxford for worsening of symptoms, attention to international swimmers. Br J Sports Med 2005; 39:752-756 University Press; 2007 hydration and nutrition and adequate 4 Bloom HR, Zyzanski SJ, Kelley L, Tapolyai A, 21 Fallon KE. Utility of hematological and iron- sleep and rest were commonly reported, Stange KC. Clinical judgment predicts culture related screening in elite athletes. Clin J Sports consistent with the literature.8,9,10 However results in upper respiratory tract infections. J Med. 2004; 14(3):145-52 inconsistencies were evident among Am Board Fam Pract. 2002; 15(2):93-100. 22 Talley N and O’Connor S. Clinical the respondents with a variety of other 5 Bermon S. Airway inflammation and upper examination- A Systematic Guide to Physical suggestions made, many not evidence respiratory tract infection in athletes: is there a Diagnosis 5th Edition 2005; 4:93-121 based. While many suggestions were link? Exerc Immunol Rev. 2007; 13:6-14. 23 Joffe D and Berend N. Assessment and practical and appear warranted they lacked 6 Cox AJ, Gleeson M, Pyne DB, Callister management of dyspnoea. Respirology. 1997; scientific support. Current medical practice R, Hopkins WG, Fricker PA. Clinical and 2(1):33-43. 24 Friman G, Wright JE, Ilback NG, et al. Does must attempt to embrace evidence-based laboratory evaluation of upper respiratory symptoms in elite athletes Clin J Sport Med. fever or myalgia indicate reduced physical management. 2008; 18(5):438-45. performance capacity in viral infections? Acta Limitations of this survey included lack of 7 Brennan FH Jr, Stenzler B, Oriscello R. Med Scand. 1985; 217:353-361 a specific definition of upper respiratory Diagnosis and management of myocarditis in 25 Barrett B, Brown R, Mundt M, Safdar N, Dye illness. This omission may have resulted in athletes. Curr Sports Med Rep. 2003; 2(2):65- L, Maberry R, Alt J. The Wisconsin Upper varied responses. However the responses 71. Respiratory Symptom Survey is responsive, given were true to the clinician’s own 8 Fricker PA and Fields KB eds. Medical reliable, and valid. J Clin Epidemiol. 2005; interpretation of an upper respiratory problems in athletes. Victoria, Australia, 58(6):609-17. illness and what he or she considered when Blackwell Science, 1997. 26 Metz JP. Upper respiratory tract infections: an athlete presented. In our view further 9 Murtagh J, ed. General Practice 3rd ed. NSW, who plays, who sits? Curr Sports Med Rep. 2003; 2(2):84-90 research should address misconceptions on Australia, PA: Mcgraw-Hill; 2003.

new zealand journal of sports medicine - 35 REVIEW PAUL GAMBLE Reducing injury in elite sport - Is simply restricting workloads really the answer?

Paul Gamble PhD CSCS HPSA from repetitive, cumulative microtrauma open question whether these policies have in occurring during training and competition. fact had any positive impact upon the number Affiliations Implicit in these efforts, and the policies that or severity of injuries sustained by players in Owner/Director of Informed Practitioner have stemmed from them, is the notion that these sports. It is also noteworthy that sports in Sport website and e-learning resources limiting the volume and stresses of training medicine authorities have perhaps been less and thereby the level of residual fatigue that attentive to the possible risk of inadequate www.informedinsport.net athletes are operating under will render frequency and volumes of workloads with them less prone to injury; likewise, reducing respect to injury incidence. Sports Performance Research Institute New the exposure and level of physical strain Investigators in this area have also noted Zealand, AUT University, AUT-Millennium experienced during matches will similarly that there may be negative consequences of Institute of Sport and Health, Antares Place, reduce the number and perhaps severity of limiting workload in terms of performance: Auckland 0632, New Zealand injuries sustained. higher training loads are associated From the data published to date, the with superior performance. By reducing Key Words contention from some authorities is that a workloads in matches and training the Player Management, Workloads, theoretical U-shaped curve exists between level of conditioning of players and in turn 5 Monitoring, Injury Prevention, Team Sports workload and injury risk. According to this their performance may be compromised. Furthermore, from an injury Introduction viewpoint it has n elite team sports particularly, there been identified is a growing emphasis on ‘player that there is a management’, largely based upon lower threshold Imeasures of ‘workload’ derived from training in terms of and competition. These magic numbers are workloads, frequently used to guide the prescription of whereby training. Moreover, it is becoming increasing injury rates are increased with common for decisions on selection to be insufficient based on these parameters – for example, volume and many teams employ a rotation policy whereby Figure 1: Hypothetical U-shaped relationship between workloads frequency of it is predetermined that a player will get and injury risk. exposure to rested for certain fixtures in the schedule. workload.5 One of the central tenets of these policies model, both high and low workloads will Equally, level of conditioning is a major risk is that controlling player’s competition predispose the athlete to a greater risk of factor for injury in team sports.10 Inadequate workloads and exposure to the stresses and injury. conditioning is implicated in the higher conditions of fatigue involved in match play In the case of high workloads, this is rates of injury observed in team sports that will reduce their risk of injury. Hence, the attributed to excessive cumulative stress that occur early in the playing season and during overwhelms the athlete’s capacity to recover the latter stages of playing periods in many rationale for restricting the player’s overall and ultimately exceeds the tolerance of the studies. workload is to limit training-related stresses tissues. The increased risk associated with low An Example from the Sport of Cricket and residual fatigue, thereby reducing the workloads is less apparent, but the insufficient An illustrative and high profile example comes number of injuries sustained in both training conditioning stimulus provided by less from cricket in Australia. As an organisation and competition. This commentary critically frequent exposure and/or lower volumes of Cricket Australia has led the implementation examines the evidence for these practices. work is a probable factor. By extension, it is of ‘informed player management’ policies and The Theoretical Relationship implied that there is both an upper and lower measures of workloads are routinely employed between Workload and Injury Risk threshold in terms of workloads that will serve as part of the criteria for decisions on whether as a protective effect The theoretical underpinning of player to rest players, including for international This theoretical relationship between management policies and the practices of fixtures. Unfortunately, the Australian cricket workload and injury, and the notion of monitoring and restricting workloads is based team continues to experience a notably ‘threshold’ workloads are intuitively appealing. largely on a small number of studies reporting high occurrence of injury, particularly to Certainly the concept of monitoring and a statistical relationship between gross fast bowlers – the main group that these limiting workloads in order to avoid measures of ‘workload’ and injury rates during policies are intended to protect. Moreover, exceeding the theoretical upper threshold training and matches.4,5,6,7 Research efforts these policies remain controversial among has been adopted enthusiastically by sports have been steered towards the reduction of supporters and in the media given the medicine authorities, particularly those non-contact overuse-type injuries resulting perception that resting apparently fit players involved in elite sport. Unfortunately, it is an

36 - new zealand journal of sports medicine review has cost the team in important matches. One of the original and most frequently cited recommended that the volume of sprinting Regardless of these debates, the practice of studies of workloads and injury featured a performed by players in a training session monitoring and restricting workloads for case study of a sub-elite rugby league.6 This should be restricted – presumably to less than bowlers particularly has been adopted widely study reported that reductions in overall 9 metres in total. For a high performance at the elite level, not only in Australia but also training loads in successive years over a three- coach working in elite sport such a suggestion by other major test playing countries. For year period, mediated by modifying training would appear challenging. example, in professional cricket in England duration in year two and intensity in year One of the seminal studies with respect to leading county cricket teams have employed three, coincided with reduced rates of injuries workloads and injury in the sport of cricket what is known as the ‘7-4-2 system’, which sustained by players during training sessions was published by Dennis and colleagues stipulates that bowlers cannot exceed 4 days in the preseason period, in comparison to (2003)5, as part of a wider initiative supported of bowling within a 7-day period, and are year one. Among numerous methodological by Cricket Australia to investigate the also not permitted to bowl for more than 2 issues, most notably the lack of randomised relationship between bowling workloads and consecutive days at any time. counterbalanced study design, it should injury in a cohort of fast bowlers who were Despite the widespread application of be noted that only training injuries were monitored over two seasons. There were two such player management practices, some reported, and this concerned the preseason major trends from the data gathered: practitioners working in elite cricket have period only. 1 bowlers who had less than 2 days between begun to publicly question in the media A similar study of professional rugby union bowling sessions, or more than 5 days whether the limits imposed upon players, in the United Kingdom reported that gross between sessions, appeared to suffer more particularly at development level, may have measures of weekly training volume (number injuries than bowlers who had 3-4 days served the opposite effect and in fact increased of hours per week), based on questionnaires between bowling their overall risk of injury in the longer term. completed by the staff at each respective 2 bowlers who averaged less than 123 Specifically, restricting workloads and thereby club, showed no statistical relationship with balls bowled per week, or more than 188 reducing the stimulus for adaptation and the number of injuries sustained by players deliveries per week, appeared to be at perhaps also the opportunity for technical during training or matches.4 Despite the lack greater risk of injury than the group of development may have paradoxically of apparent association with rate of injury bowlers who averaged between 123-188 reduced players’ level of preparedness and based on the data presented, the authors deliveries per week compromised their resilience to the rigours of nevertheless recommended modifying Another more recent study of cricket in competition when these players progress to the overall volume and content of training Australia from Orchard and colleagues elite senior level. (specifically reducing the hours spent in (2009)15 presented data from fast bowlers Similarly, other authors have raised the activities associated with relatively higher gathered over 10 seasons. The major finding question of whether the practice of imposing injury rates, such as contact training), in order reported was that the relative injury rate per enforced rest creates a sporadic pattern of to reduce the severity of injuries. 1000 overs bowled was only higher for the loading that may be poorly tolerated by More recent studies have attempted to group who bowled the very highest number of players, once more serving to increase injury differentiate between different types of overs in a match (more than 50 overs bowled). risk rather than reducing it.13 The suggestion training load. For example, one investigation The authors did however also suggest that is that athletes respond much better to a of professional rugby league reported training there might be a delayed effect of acute match relatively consistent level of loading, and so load values for different forms of training – i.e. workload in terms of injury risk, as the relative the large fluctuations in daily and weekly field training versus strength/power training risk of injury in the group who bowled over workloads that occur with enforced rest and performed in the gym.8 Once more overall 50 overs in a match appeared to peak between player rotation may be an indirect cause of combined training load was reported to 14 and 28 days following the match.15 Such the injuries observed. There is some data to correlate to injuries sustained during training conclusions however remain speculative in the support this contention, including a recent sessions. The authors found an apparent absence of prospective studies to verify this study from elite Australian Rules football association between strength/power training ‘delayed effect’ hypothesis. which found that marked week-to-week loads and number of injuries sustained during Do Measures of Workload Employed fluctuations in workloads were related to an field-based training sessions.8 This finding was Provide a Valid Indicator of Stress/ increase in the number of injuries observed.16 attributed to the effects of residual fatigue. Recovery of Individual Athletes? Re-examining the Evidence Relating Another study, once more in elite professional Whilst a comprehensive discussion of to Workload and Injury in Team rugby league, subdivided running training methods to assess training stress is somewhat Sports loads by using GPS data gathered during beyond the scope of the present article, it 9 The statistical analyses employed in the running-based training sessions. The should also be noted that there is currently a studies that are often cited in support of categories of running activity employed were: lack of evidence to validate the efficacy and player management practices have typically very low; low; moderate; high; and very-high sensitivity of measures of workload typically comprised simple correlation between intensity with accelerations classified as ‘mild’, employed in elite sport. In the majority of exposure and injury rates, but this has ‘moderate’, or ‘maximum’. None of the running cases both in the literature and in the field subsequently been interpreted as evidence of variables employed were associated with only very gross measures of volume are 9 a causal relationship. The lack of prospective training injuries resulting in missed matches. employed. For example, the ‘volume’ of studies to support this contention is a concern It was noted that there appeared to be more work undertaken in training or matches is given that it is often presented as scientific injuries when players recorded more than 9 typically recorded in terms of duration only, fact by those advocating player management metres of very high-intensity running in a or alternatively workload is calculated as policies. session. Based upon this finding the authors the product of session or match duration

new zealand journal of sports medicine - 37 review multiplied by a measure of ‘intensity’, in most the sport of cricket, a recent study identified professional rugby union and its impact on cases comprising rating of perceived exertion that whilst all the bowlers examined showed the incidence, severity, and nature of match (RPE) for the session as a whole.6 asymmetry in cross-sectional area of and training injuries. Journal of Sports Sciences Due to technological advances in some cases different muscles of the spine, it was only 2008; 26(8):863-873 more sophisticated tools for quantifying those players who demonstrated reduced 5 Dennis R, Farhart R, Goumas C, Orchard J. workload are employed in elite sport, motor control of local stabiliser muscles who Bowling workload and the risk of injury in such as global positioning system (GPS) reported symptoms of back pain.11 elite cricket fast bowlers. Journal of Science and devices and heart rate (or a combination). Similarly, movement errors are likely to Medicine in Sport 2003; 6(3): 359-367 Unfortunately methodological issues remain contribute to a number of the non-contact 6 Gabbett TJ. Reductions in pre-season training with accurately evaluating the intensity injuries seen in team sport. For example, loads reduce training injury rates in rugby of intermittent activity that occurs during many of the injuries that occur in training league players. British Journal of Sports sports using such technologies.1 Moreover, and competition are sustained during Medicine 2004a; 38: 743-749 there is once more a lack of empirical running activity. There is a growing body 7 Gabbett TJ. Influence of training and match evidence to elucidate the relationship of evidence that running injuries can be intensity on injuries in rugby league. Journal of between the derived measures of workload reduced by a combination of gait retraining Sports Sciences 2004b; 22: 409-417 and injury risk.9 For example, a recent alongside other corrective training 8 Gabbett TJ, Jenkins DG. Relationship between study investigated a range of laboratory, interventions. Therefore, assessing players’ training load and injury in professional rugby psychometric and performance parameters movement capabilities, including assessing league players. Journal of Science and Medicine to assess whether any of these markers would running mechanics, with appropriate follow in Sport 2011; 204-209 be sensitive to physical strain and overload up and intervention should be a focus 9 Gabbett, TJ and Ullah S. Relationship between experienced by elite soccer players during a for injury prevention rather than solely running loads and soft-tissue injury in elite 3-week period.14 Laboratory testing included focussing on the volume of running and team sport athletes. Journal of Strength & blood counts and other markers including other activity performed by players. Conditioning Research. 26(4): 953-960, 2012 creatine kinase, psychometric evaluation Conclusions 10 Gamble P. Training for injury prevention: comprised a recovery-stress questionnaire, From these discussions it is apparant that the identifying risk factors. In: Strength and and performance assessments included relationship between workload and injury Conditioning for Team Sports – Sport-Specific vertical jump and maximum velocity scores. risk is far from straight-forward and as such, Physical Preparation for High Performance, None of the parameters studied were able it is crucial to avoid oversimplification. 2nd Edition; Routledge, United Kingdom 2012, to discriminate between the period of high There is currently no solid evidence to pp. 153-180 exertion (>270 minutes total match time) support the concept that enforcing arbitrary 11 Hides J, Stanton W, Freke M, Wilson S, 14 versus low exertion (<270 minutes). restrictions upon workloads will help to McMahon S, Richardson C. MRI study of Fundamentally, the degree of stress, or prevent injury during competition. Clearly the size, symmetry and function of the trunk ‘internal load’, experienced by an athlete is more data is required to elucidate the muscles among elite cricketers with and also highly individual. This was highlighted complex relationship between workloads without low back pain. British Journal of Sports by a study of soccer players by Impellizerri and injury rates before any evidence-based Medicine 2008; 42: 809-813 and colleagues (2007) who reported that guidelines can be implemented in elite 12 Impellizzeri FM, Rampinini E, Marcora SM. in a squad setting, despite a fixed external sport. Moreover, this relationship is likely to Physiological Assessment of Aerobic Training training load being employed for all players, differ according to the sport, and as such it in Soccer. Journal of Sports Sciences 2005; 23(6): the specific ‘internal load’ in terms of acute is probably unsafe to generalise the findings 583-592 responses recorded from each individual from one sport to another, or from one 13 Inness, M, Aughey R. Cricket Australia 12 player varied markedly. Furthermore, the playing squad to another within the same rotation policy could be causing injuries. The timeframe for recovery and adaption to a sport or competition. Finally, the tolerance Conversation http://theconversation.com/ given stressor is likewise highly individual, to workload is likely to vary according to the cricket-australias-rotation-policy-could-be- as it is likely determined by factors such individual player, so any guidelines should be causing-injuries-11759 2,3 as genotype. It is therefore probable that viewed as just that – such information must 14 Meister S, Faude O, Ammann T, Schnittker R, the individual stress/recovery response and be interpreted in the context of the situation Meyer T. Indicators for high physical strain and overall tolerance to load will vary widely and individual. Injury prevention is about overload in elite football players. Scandinavian even between apparently well-matched more than just reducing load. Journal of Sports Medicine 2013; 23: 156-163 15 Orchard JW, James T, Portus M, Kountouris players within a squad. References The workload or volume of activity A and R. Dennis, Fast Bowlers in Cricket 1 Aughey R. Application of GPS Technologies performed is also only part of the picture Demonstrate Up to 3- to 4-Week Delay to Field Sports. International Journal of Sports with respect to overuse injury. By definition, Between High Workloads and Increased Risk Physiology and Performance 2011; 6: 295-310 injuries of this type are the cumulative result of Injury, American Journal of Sports Medicine, 2 Beunen G, Thomis M. Gene driven power of biomechanical overload to the tissues. 37(6): 1186-1192, 2009 athletes? Genetic variation in muscular strength Rather than accepting the notion that 16 Rogalski, B, Dawson, B, Heasman, J, Gabbett, and power, British Journal of Sports Medicine activities undertaken by players in sports TJ. Training and game loads and injury risk in 2006; 40: 822-823 are inherently injurious and so exposure elite Australian footballers. Journal of Science 3 Bouchard C. Genomic predictors of trainability, should be limited, it must be considered and Medicine in Sport 2013; In Press. Experimental Physiology 2012; 97(3): 347-352 that dysfunction is likely to be a factor in 4 Brooks JHM, Fuller CW, Kemp SPT, Reddin many cases. Taking another example from DB. An assessment of training volume in

38 - new zealand journal of sports medicine Commissioned Article lynley anderson Ethics in New Zealand Sports Medicine doctors, and with the exception of a group of approach to two aspects of medical Lynley Anderson PhD researchers in the UK,2,3,4,5 most articles on practice: Bioethics Centre the topic were reflections by doctors looking • Maintaining patient confidentiality University of Otago, Dunedin back over their careers.6,7,8,9,10 No research • Risk taking into the ethical concerns of sports doctors 4 Sports doctors had limited ethical Introduction had been carried out within Australasia. guidance and support ne of the most high profile medical The findings from the Anderson & Gerrard The Sports Environment roles must surely be that of a sports study gave tantalising glimpses of the ethical It was apparent that the very environment of doctor. During televised sports considerations of sports doctors, and so sport at the top level can place a great deal Oevents the sports doctor can often be seen further research using in-depth interviews of pressure on sports doctors. One source of running onto the field of play to attend to was planned to explore these concerns more pressure arises from the commercial nature an injured athlete. Even when not part of fully. This paper summarises some of the of sport at this level where the health and the immediate action, the sports doctor is key finding from the subsequent research wellbeing of the individual athlete may be frequently identifiable in the background. as well as some interesting accounts from secondary to financial priorities (this aspect For the public, it might appear that the work participants. has been discussed in Anderson & Jackson, of the sports doctor is just like any other Brief Methodology 2012).13 For example, one doctor reported doctor – the only difference being the setting. Sixteen sports doctors working with elite that where games are televised live and back- From my research, the practice of medicine athletes and teams in New Zealand were to-back, time is limited for injury assessment in sport and the ethical challenges that arise comprehensively interviewed. Each interview of athletes, and a decision about whether in this area are complex. was recorded, transcribed, and returned to return an athlete to play has to be made What sparked my interest in the ethical to the participant for checking. Grounded quickly. This doctor felt pressured to return issues facing sports doctors arose from theory was the method used for data injured athletes more quickly than they reading an advertisement for Warriors tickets analysis. Media interest in the activities of would otherwise feel comfortable with and in the back of a New Zealand SKY television elite sports people runs high and therefore this included situations where head injuries magazine in 1999. The advertisement every effort was taken to ensure that personal may be present.13 The restrictions on time glamorised the resilience of the then information about doctors and their patients may assist broadcasters but may compromise Warrior’s coach implying that he would was safeguarded. good care. Some sports doctors raised expect the same level of toughness from team Participants in this study were all highly concerns that competitions were sometimes members. Among the extensive injuries experienced clinicians because they worked planned for a time of the day that suited the listed in the advertisement, it stated that he at the pinnacle of sport in New Zealand. The broadcasters schedule rather than the welfare had ‘broken [his] wrist. He used to take it participants had worked in the area of sports of players including the hottest part of the out of the cast, inject it with painkillers, play, medicine for between 6-26 years. Seven day. then put it back in the cast.’ While we could participants were Fellows of the Australasian Sponsorship of teams is also an issue. dismiss this claim as typical advertising College of Sports Physicians (ACSP). Teams want to attract sponsors in order hyperbole, clearly the athlete couldn’t do Key Findings to improve funding, but sponsors expect a this for himself; he required someone with Four key findings emerged from the return on their investment. One participant medical skills.i Immediately questions arose; research. These findings have been discussed described how sponsors might influence would this be acceptable in other areas of in previous publications but are summarised which players are selected to play, so that health care, and if not, what makes sports here. players considered ‘more marketable’ are care so different. 1 The environment in which sports visible to the public. As team doctor this Later that year a group of sports medicine is practiced has the potential to participant felt pressure to ensure these physiotherapists raised concerns that some limit a doctor’s ability to provide quality athletes were visible.13 Sports doctors face physiotherapists were being pushed or care and compromise patient welfare. ethical challenges arising from footwear were actively taking on activities that were 2 Doctors working in sports medicine sponsorship. Teams will often enter into a ethically problematic; they wanted research may have multiple obligations including sponsorship deal with a footwear company carried out into this issue. Following further both patients and employers. At times where the sponsor provides footwear and discussion this research was extended to these responsibilities conflict leading team members must wear their product. include sports doctors.1 At that time very to divided loyalties, where meeting one Some athletes will find the supplied footwear little empirical research had been carried out obligation will result in neglecting others. unsuitable and doctors were often involved into the ethical issues experienced by sports 3 Participants differed markedly in their in assisting an athlete to find appropriate

i Mark Graham played for different teams in a number of countries, so no suggestion is made that this action (whether real or imagined) might have been carried out by a NZ health care provider.

new zealand journal of sports medicine - 39 commissioned article footwear from an alternate company. To arising out of the environment with the environment, and I know it’s different to get around the sponsorship demands some health needs of the athletes. Sports doctors others, but there is absolutely no coach doctors got involved in either blacking out are aware of the pressures pressure whatsoever to the alternate company’s logo on the footwear involved and had I was involved with a have somebody play who or altering it to match that of the team developed some effective shouldn’t otherwise be sponsor. One participant felt ‘told off’ for strategies for working in team in which a key playing. such actions: this environment. player was recovering Some participants would Doctor: We try and actually blacken Conflicting obligations/ from a stress fracture. challenge the coach if the boots out completely. But we get told divided loyalties they felt that athletes off for that. Some divided loyalties The stress fracture was were being pushed into Interviewer: Who from, the sponsor? experienced by doctors regarded as ‘high risk’ returning to play too early. Doctor: The sponsor. Yeah, they pay in sports medicine arise and required a long But challenging the coach people to watch the games to check from the expectations could raise concerns about people are wearing the right stuff. of employers and of the slow rehabilitation. On ongoing and re-employment Interviewer: I didn’t realise that. coach and manager; numerous occasions if they did not comply with Doctor: Yeah, there’s big money. There’s however medical coach demands. the coach ignored millions of dollars involved, so they do – obligations to the patient Putting guys on to the yeah, we get phone calls after the game, remain. Balancing advice from the team field … at the start of the so-and-so wasn’t wearing the right coach demands and physiotherapist, and me. game [with] an injury. boots – [we] get in trouble. So we’re a commitment to the Yes, that has been tried monitored.13 welfare of the patient on a few times and I Some doctors did inform the sponsor in an often creates a dilemma, and where dispute basically say ‘look you do that over my attempt to obtain suitable footwear, however arises it can make it difficult to promote dead body, this is my area that you are many felt it necessary to resort to deceptive player welfare. One doctor describes a tampering with, I don’t come and tell actions in an attempt to act in the best situation where medical advice was routinely you how to coach the team, and I am interest of their patients. ignored: telling you how this is going to be.’ And Dealing with the media poses problems I was involved with a team in which it has probably cost me, if I had of [re] for sports doctors. Sports doctors were a key player was recovering from a applied for this job I might not have commonly asked for information about stress fracture. The stress fracture was got it. athletes. Two participants described being regarded as ‘high risk’ and required a Fear of not gaining re-employment was told by reporters ‘if you don’t tell me, long slow rehabilitation. On numerous discussed by some participants. Some said I’ll make it up’. 13 The threat was clearly occasions the coach ignored advice from these fears were more common when they to encourage doctors to reveal more the team physiotherapist, and me. were less experienced, however as they information about athletes. Different Sometimes the conflict between coach gained experience these doctors became approaches to dealing with the media were expectations and consideration for player more confident: described; some repeat facts the journalist welfare is bought into stark relief as in a Ah, yes, that did initially bother me already knows, or talk in generic terms situation described by one participant: when I was still quite wet behind the about injuries. However some doctors are Even me [as the doctor] trying to ears [both laugh]. To be honest with you well aware of the necessary relationship remove someone [an athlete] from the it did concern me a little bit, but now I between the media and sponsorship with one field of play and the coach have not realise that there are a lot of teams … participant explicitly recognising that sports wanted that player removed …and I management styles change and coaches doctor’s wages were paid by sponsorship say, ‘look [this athlete] is struggling, he change and I think that if you didn’t agreements generated by media coverage. feels unable to go on, he’s got this injury compromise, people will eventually see This raises questions about the implications I think we have got to get him off’ and I the good in it. And to be honest with for patient confidentiality?13 was told in no uncertain terms, that he you, I think there are many teams. If Sponsors, media and broadcasting demands is a wimp and he has to stay on and die you don’t get a job here, you can get a coalesce to create an environment that for the cause. 13 job somewhere else. For me it’s an issue contains subtle and not so subtle pressures. However, it should be noted that not of enjoying the job rather than feeling Not unexpectedly these pressures can be all coaches disregarded the views of guilty and trying to work around issues transferred to the medical team as one of the the doctor. One participant’s described like that. 13 people relied on keep athletes fit and able to how it was in their team: Many talked about the need to retain their be part of the machinery of top level sport. The medical team’s word is final, and professional integrity rather than to stay These pressures add to the ethical complexity there’s no correspondence entered in a job where they felt their values were as doctors attempt to balance the demands into … I’ve only ever known that compromised. One of them put it in a

40 - new zealand journal of sports medicine commissioned article nutshell when he said; ‘you’ve got to think Many doctors found practical strategies for contract as they feel that the team needs to about your philosophy about how you want dealing with situations where the athlete be able to field fit players. All sports doctors to practice medicine.’ did not wish to share information. These need to consider the obligations that are set Clearly, doctors working in sports medicine strategies varied from telling coaches limited up by the employment structure and the use are not the only ones who feel pressure at amounts of information, to encouraging the of contracts. the top level; coaches, managers and athletes athlete to share and then calling the coach Risk Taking Behaviour are all under pressure to succeed and secure in the presence of the athlete so that all The second area where there was a difference future employment, or some other perceived could discuss openly. This group felt it was in responses was regarding risk taking and benefit. Coaches have a financial interest in important for the athlete to know what was how willing a doctor was to limit or assist the success of the team as their own future being said. an athlete to return to play with injuries. At career can be dependent on team success. Many doctors who supported upholding one end of the spectrum it was reported by They need to field their best players and this patient confidentiality in this kind of one doctor that he/she would do anything to can bring them in conflict with doctor. scenario identified the importance of trust assist an athlete to compete so long as it was Patient Confidentiality in the doctor-patient relationship and saw not illegal (although this participant did not Employment contracts between doctors and confidentiality as a necessary cornerstone specify which regulations was being referred sports governing bodies, and athletes and of that trust. This group also saw potential to). At the other end of the spectrum in sports governing bodies, frequently express harms arising from not maintaining order to minimise the risk, one doctor has it expectations about sharing an athlete’s health confidentiality, including patients not written into the contract that the doctor has information with coaches and others.11 informing the doctor and potentially putting the final say on whether the athlete plays or Participants were asked to indicate how they themselves or others at risk. For this reason not. would respond if asked by an athlete not to we might be concerned that employers One participant highlighted the difficulty pass on personal health information, and yet expect doctors to abandon traditional that athlete’s can find themselves in when their contract and that signed by the athlete obligations to patient confidentiality. On the they are injured and yet feel they must play clearly indicated such information was to be other hand, we also need to consider that for in order to retain a team spot: passed on. Ten participants said they would a team to field the best athletes those making …people will still want to play…even not pass the information on while five stated those decisions require information about if it means [causing] themselves more they would pass this on (one was unsure). medical evaluations, and this could be part harm. …I think the problem is that if Of note, doctors were happier to retain of an employer’s expectations. We could also they lose their place in the team then it’s confidentiality when the health information ask questions about whether it is realistic to hard to get back in, and they lose their was not related to an athlete’s ability to play. ask athletes to sign a confidentiality waiver job. So from an employment point of Well, it’s very tricky in that situation. at the beginning of a season saying they will view they would be willing to risk their It depends what it is. Most of them share health information when the nature of health to keep their job. know they’ve signed those [contracts], such information is unknown. Fear of losing a place in a team may and if [the injury] affects the team it’s a A further concern surrounds the need encourage an athlete to play injured. One problem.... I’ve had that happen a few for employees to act in good faith with All Black who played despite times and you really have to go over their employer and … I think the problem having had a number of with the person and try and get them doctors therefore recent head injuries stated in a is that if they lose their to divulge it themselves to someone like need to consider newspaper: ‘There’s no option. the coach or the manager of the team. the implications of place in the team then If you don’t play flat out, you And nine times out of ten they will. And signing a contract it’s hard to get back in, won’t be effective, you won’t if they still really don’t want to, and it’s that encourages be picked.’.15 These kinds of affecting their play, then you still can’t a deviation and they lose their job. comments raise concern as divulge the information.11 from traditional So from an employment to whether athlete’s decision obligations, especially One participant justified telling the coach, point of view they would making is always voluntary. stating: when they are aware It was recognised that athletes If they’ve signed into a situation saying they will not uphold be willing to risk their were under pressure to return that I give free access of my information such demands. health to keep their job. quickly, and this might lead to the coaching staff, then I think Doctors differ in them to request the doctor to they understand that I’m part of that their response to the assist them to return. Athletes structure, that I have a responsibility to issue of what to do about personal health might well be happy to trade good health for pass that information on. …if they want information that is related to the athlete’s some other goal or desire they consider to be it to be private then they have to go to ability to play. Some favour maintaining important. another doctor. That’s my feeling about confidentiality and therefore the patient’s I think most patients, most patients, will that.11 trust, while others will favour upholding the take your advice. There will be some

new zealand journal of sports medicine - 41 commissioned article

patients who say, well I’m going to play, doctors and physicians negotiating this Journal of Medical Ethics 2005. can you just help me to do it as safely complex ethical area with limited support. 2 Waddington I. Sport, Health and Drugs. as possible? Even though we believe that As a result of these findings and with the London 2000: E & FN Spon. it’s not safe for them to play. And that’s support of the ACSP I undertook drafting 3 Waddington I, & Roderick M. Methods of appointment and qualifications of club doctors a difficult situation but it is one that we their new Code of Ethics. This code was and physiotherapists in English professional will often say OK, let’s try this sort of formally adopted in April 2008, and utilises football: some problems and issues. British strapping or that sort of strapping to try many of the topic areas and findings from Journal of Sports Medicine, 2001; 35:48-53. to stabilise something that’s not quite this research. 4 Waddington I, & Roderick M. Management of right and not to the point where we Conclusion medical confidentiality in English professional believe they should be playing. The findings from this research indicate football clubs: some ethical problems and Doctor’s perception and approach to that sports doctors work in an area that is issues. British Journal of Sports Medicine, 2002; risk taking is not always shared. Some ethically highly complex. These complexities 36:118-123. 5 Waddington I, Roderick M, & Parker G. participants identified that athletes did arise from the context of practice; including Managing injuries in professional football: not always recognise the harm associated the environment of top-level sport with its A study of the roles of the club doctor and with risk taking, and all doctors thought inbuilt commercial interests that can exert physiotherapist. Leicester 1999: Professional it important to educate athletes about the pressure on others including the sports Footballers Association Centre for Research risks associated with playing with an injury doctor; the employment structure with its into Sport and Society. and took this role seriously. From reports it associated expectations on doctors that 6 Apple D. Team physician - bad ethics, bad appears that doctors spend a great deal of may be at odds with long-standing medical business, or both? Orthopaedics, 2002; time explaining about the risks of returning obligations to the welfare of the athlete or 25(1):16, 26. to sport too early, the pathophysiology of to concepts such as confidentiality of health 7 Dodds R. What does a team expect from its injury and the rehabilitation required. information. A doctor working at this level doctor? British Journal of Sports Medicine, 1989; 23(3):145-146. The need to balance risk taking activities may experience a number of pressures, from 8 MacLeod D. Team Doctor. British Journal of by athletes was an issue for sports doctors. coaches, athletes, sponsors and others, all Sports Medicine, 1989; 23(4):211-212. Athletes may have desires and goals that requiring a level of negotiation to ensure 9 Matheson G. Maintaining Professionalism. are not always consistent with preserving they are able to provide quality care to The Physician and Sportsmedicine, 2001; or maintaining good health, and for this athletes that they feel is professionally 29(2). reason doctors saw it as their role to bring acceptable.13 It has to be acknowledged that 10 Sperryn P. Ethics in sports medicine - the an element of level-headedness to the some experienced sports doctors were more sports physician. British Journal of Sports conversation. confident than others and had developed Medicine, 1980; 14(2 & 3):84-89. Ethical Support and Guidance practical strategies for dealing with some of 11 Anderson L. Contractual obligations and the The last finding related to the level of the pressures identified. sharing of confidential health information in sport. Journal of Medical Ethics, 2008; guidance and support available to New 34(9):e6-e6. Zealand doctors working in sport with The sports environment (especially at the top 12 Anderson L. Doctoring risk: Responding many participants believing that there level) has aims and goals that do not always to risk-taking in athletes. Sports, Ethics and was inadequate guidance available. Many align with the medical goals and aims of the Philosophy, 2007; 1(2), 119-134. mentioned that if they had a particularly sports doctor. While this is not surprising, 13 Anderson L, & Jackson S. Competing loyalties difficult issue to deal with they turned to it does pose some concern that doctors may in sports medicine: Threats to medical their peers for assistance or to some of the not always be able to provide quality care in professionalism in elite, commercial sport. older more experienced clinicians. While such a setting. The lack of formal guidance International Review for the Sociology of some formal ethical guidelines existed for available at the time of this research was Sport, 2012. sports doctors, these guidelines commonly concerning, particularly for those new to 14 Anderson, L. Writing a new code of ethics for sports physicians: principles and challenges. did not cover the areas of concern as the area of sports medicine who may find British Journal of Sports Medicine, 2009; expressed in this research. The only local asserting professional values difficult in the 43(13):1079-1082. guidance that was available when I was face of the pressures inherent in sport at the 15 Channel Publishing Group. ‘Heading for carrying out this research was the ACSP top level. Recovery.’ Healthwise, June/July 2005, 2005; 3. Code of Ethics, but this document was Acknowledgments written for College Fellows and so is not I would like to take this opportunity to directly applicable to doctors who are acknowledge the generosity of the sixteen not associated with the College. Further sports doctors who contributed to this examination of the ACSP code revealed a research. number of significant problems with it which References 14 rendered the guidance unhelpful. The 1 Anderson L, & Gerrard D. Ethical issues lack of comprehensive guidance left sports concerning New Zealand Sports Doctors.

42 - new zealand journal of sports medicine commissioned article

Australasian College of Sports Physicians Code of Ethics and Professional Behaviour (reproduced with the permission of the Australasian College of Sports Physicians)

Preamble sport and exercise medicine, within the constraints of systems and resources. The objective of the Australasian College of Sports Physicians (ACSP) Code of Ethics and iii. Treat all patients according to medical need, without discrimination on the grounds Professional Behaviour is to provide a comprehensive set of guidelines for the professional of age, gender, ethnicity, disability, religion, lifestyle, beliefs, culture or sexual behaviour expected of registrars and Fellows of the College. It is based on longstanding preference. ethical and professional principles of medicine; it considers the many aspects of the sport iv. Insist upon professional autonomy and responsibility for all medical decisions. and exercise medicine physicians’ professional life; and it responds to areas of concern that have been identified in the sports medicine literature over recent years. v. Work within the scope of his or her competence, and refer on to an appropriately qualified practitioner where appropriate. The Code was developed recognising that, in addition to medical knowledge and technical expertise, excellent medical care in the area of sport and exercise may require cooperation vi. Not permit clinical judgement and practice to be affected by economic interest in, with others including sporting management, collaboration with colleagues and commitment to, or benefit from professionally related commercial enterprises of any kind. other health professionals, while maintaining a clear understanding of the primacy of the health, wellbeing and autonomy of the patient. The sport and exercise medicine physician should: vii. Care for patients using the best available evidence. The work of a sport and exercise medicine physician The Code acknowledges the varied work environments of a sport and exercise medicine viii. Work collaboratively with other professionals and organisations in optimizing patient physician. The sport and exercise medicine physician is recognised as a medical specialist care. and is therefore not a primary care practitioner. Sport and exercise medicine physicians ix. Arrange for the patient to be transferred to an appropriate facility in circumstances work in the following ways: where adequate resources are not available on site. • Office or clinic. It is recognised that the majority of work will be referral-based x. Be willing to facilitate a second opinion for the patient when appropriate. consultations carried out in the sport and exercise medicine physician’s own office or xi. Be willing to provide an honest and frank second opinion when it is sought. clinic. A general practitioner will refer most patients in this setting. 1.2 Continuity of care • Sports body employee (e.g. Netball Australia). A sport and exercise medicine The sport and exercise medicine physician must: physician receives referrals from that source. i. In an emergency, be prepared to care for other sport and exercise medicine • Team physician. Here a sport and exercise medicine physician is employed by a physician’s patients if that sport and exercise medicine physician is unavailable. sporting franchise or team to provide sports medical services for team members at games or events. ii. Ensure that arrangements are made for appropriate hand-over when care of patient is transferred. • Military employee. Employed by the military to provide sports medical services to military sports teams. iii. Ensure that arrangements are made with patient’s general practitioner regarding the care of any medical issue still requiring care at discharge or cessation of treatment. Each area of work raises particular ethical concerns for sports doctors. For example sport and exercise medicine physicians employed as team physicians may experience divided The sport and exercise medicine physician should: loyalties between the needs of their patient and the demands of their employer. The code iv. Facilitate good and appropriate post-discharge care. covers ethical concerns for sport and exercise medicine physicians working in all areas. 1.3 Relationships with patients Legal Obligations 1.3.1 Communication and education This code should be read in conjunction with legislation in the country of practice. The sport and exercise medicine physician must: The ACSP Code of Ethics and Professional Behaviour is not intended to vary the legal i. Listen to, and respect the views of patients (including parents/legal guardians where obligations and duties of sport and exercise medicine physicians in Australia and New the patient is a minor) while remembering that the best interests of the patient is the Zealand. Legislation varies from state to state, and between Australia and New Zealand. underlying value that should guide management. It is the responsibility of the physician to identify the particular legal obligations and ii. Discuss with patients (including parents/legal guardians where the patient is a minor) responsibilities applicable in his or her own jurisdiction. the nature of the injury or health problem. This may include the likely aetiology, the Relationships with other codes of ethics projected recovery, implications of the injury for training and competition, and the This code should be read in conjunction with the AMA Code of Ethics and the NZMA short and long term implications from the injury. (adopted by the Medical Council NZ) Code of Ethics. This code does not seek to alter iii. Discuss with patients (including parents/legal guardians where the patient is a minor) these codes, but seeks to supplement, explain and interpret concepts identified in the the available treatment options, including no treatment; outline the relevant risks of AMA and NZMA Codes. treatment and provide the opportunity for questions to be asked. Format and style iv. Communicate with patients with empathy, honesty and respect (including parents/ The term ‘must’ is used to indicate that the associated statement sets a minimum standard legal guardians where the patient is a minor). that all sport and exercise physicians must achieve. The term ‘should’ reflects a standard The sport and exercise medicine physician should: that the ACSP aims to promote and nurture. v. Where practicable, make use of a trained interpreter if language barriers exist to The Australasian College of Sports Physicians acknowledges the Royal Australasian ensure effective communication with patients. College of Physicians Code of Professional Behaviour from which the ACSP Code of vi. Discuss and educate patients about injury prevention strategies, including protective Ethics and Professional Behaviour has been adapted and the World Medical Association gear and clothing. Declaration on 1.3.2 Consent Principles of Health Care for Sports Medicine (1999) and the International Federation of Sports Medicine (FIMS) Code of Ethics (1997). The sport and exercise medicine physician must: THE CODE i. Obtain consent from a patient prior to providing medical care or intervention. SECTION ONE - Good Patient Care ii. Respect patients’ rights to seek all relevant information in order to make an informed decision about their own care. Good patient care requires a range of clinical, interpersonal and management skills. The nature of the physician-patient relationship is critical to quality of care and achieving iii. Be aware of legal, professional and institutional requirements for gaining consent positive outcomes. Sport and exercise medicine physicians must pay attention to all from patients (including minors, or those who may be compromised in their ability aspects of this relationship, and must also be familiar with legislation and guidelines to consent). within their jurisdictions. Sport and exercise medicine physicians must also pay attention iv. Document appropriately all matters relevant to the consent process; to any employment relationship that may affect the ability to provide care. v. Be aware that competent people have the right to refuse treatment. 1.1 Standard of clinical practice The sport and exercise medicine physician should: The sport and exercise medicine physician must: i. Discuss with the patient the problems associated with getting informed consent in i. Understand the special physical and mental demands placed on patients through high pressure situations of competition. their participation in sporting activities. ii. Where a high pressure situation of competition is limiting the ability of a patient to ii. Provide a good standard of clinical care, consistent with the prevailing standards of make an informed decision, negotiate for removing the patient from the setting to

new zealand journal of sports medicine - 43 commissioned article

complete the consent process. situations the patient must be fully informed of the role of the sport and exercise medicine 1.3.3 Other physician and that relevant information will be shared with sports management. (Can be compared to a doctor carrying out a one off insurance assessment.) The sport and exercise medicine physician must: When signing an employment contract i. Respect patient dignity. The sport and exercise medicine physician must: ii. Be aware that he or she is not obliged to provide treatment where it is his or her professional judgement that the treatment would be either of no benefit or would i. Act in good faith with their employer. harm the patient, or is considered unethical. ii. Not sign an employment contract where he or she is aware that obligations will not be iii. Be sensitive to and respect the cultural values of all patients, including Aboriginals, upheld. Torres Strait Islanders, Maori, and Pacific peoples. The sport and exercise medicine physician should: iv. Refrain from unethical relationships with patients (sexual, financial and other). iii. Seek legal advice prior to signing. Commentary: Where a doctor is employed to care for team members, those athletes are to iv. Inform the employer where there are elements of a contract that forces a physician to be considered patients whether they have currently received medical attention or not. breach his or her professional code of ethics. The sport and exercise medicine physician should: When employed in a therapeutic role v. Provide care in an environment that respects the privacy of the patient. The sport and exercise medicine physician must: 1.4 Record keeping i. Recognise his or her duty to the patient as the first concern and contractual and other The sport and exercise medicine physician must: responsibilities are of secondary importance. i. Ensure maintenance of legible and contemporaneous records (preferably signed ii. Act in his or her patient’s interests. and dated), including adequate records of discussions with patients (and parents/ iii. Not be party to an employment contract that forces or encourages him or her to guardians where that patient is a minor). abandon a commitment to the patient. ii. Be aware of legal requirements about collection, storage, and dissemination of iv. Not take on a role within a team context for which he or she is not suitably qualified personal health information about patients. or is outside his or her scope of practice. iii. Not allow access to medical records by third parties except with the consent of the Commentary: Sport and exercise medicine physicians who are not qualified as, or who patient. have no experience as general practitioners, should not take on this kind of work for iv. Ensure appropriate transfer or storage of patients’ records upon cessation of practice. patients. 1.5 Employment structure and relationships When employed in an assessment role Commentary: When a sport and exercise medicine physician is employed by a team The sport and exercise medicine physician must: or sports governing body, sport and exercise medicine physicians may have multiple i. Inform the patient of the sport and exercise medicine physician’s role prior to the responsibilities to others including: individual patients, a team, coaches and team assessment. management, the governing body, the medical profession and the general public. Some ii. Inform the patient that the sport and exercise medicine physician is not working for responsibilities are laid down specifically within an employment contract, while others rely the interests of the patient. on time-honoured understandings and relationships. At times responsibilities may conflict leading to divided loyalties or competing obligations, where to meet one obligation will The sport and exercise medicine physician should: require the neglect of the other. For sport and exercise medicine physicians, the most iii. Consider whether the separation of an assessment role from a therapeutic role is common divided loyalty is that between the employer and the patient. Problems are more appropriate. likely when the potential for conflict is not recognised and one party is not aware that Commentary: Ideally an assessment and therapeutic role should be separated, however it is the sport and exercise medicine physician has other competing obligations. This section recognised that this may be too difficult or impractical in some situations. is designed to assist sport and exercise medicine physicians in situations where the aims 1.6 Confidentiality of the employer place demands on the sport and exercise medicine physician, via the employment contract, that have the potential to undermine the ability to provide effective Commentary: Confidentiality of health information about athletes is an issue for all sport care for patients. and exercise medicine physicians. However, this is likely to be more problematic when a sport and exercise medicine physician is employed by a team or sporting franchise. Here General statement: A sport and exercise medicine physician as an employee should not be the sport and exercise medicine physician is often faced with a divided loyalty dilemma, asked within an employment contract to: that is either share health information in line with contractual obligations (and employer • act outside the law. expectations) but against the wishes of the athlete, or, respecting the wishes of the athlete, • act contrary to a code of ethics of the professional group to which he or she belongs. but breaching contractual obligations (and employer expectations). Sport and exercise medicine physicians employed by teams or sporting bodies are advised to read this section 1.5.1 Trust in the sport and exercise medicine physician-patient relationship in conjunction with section 1.5 Employment structure and relationships. Commentary: The doctor-patient relationship is a structure that lies at the heart of any General statement: Failure to respect confidentiality of personal health information about medical encounter where care is offered. It is through the doctor-patient relationship a patient may result in a patient choosing not to confide in the sport and exercise medicine that the patient receives attention for his or her concerns and the physician is able to physician, resulting in unnecessary risk to the health of the individual patient or others. use professional skills. The patient is vulnerable for a number of reasons including the presence of injury or illness that they themselves are unable to correct. The patient The sport and exercise medicine physician must: commonly reveals extensive health and personal information to the physician in order i. Maintain the patient’s confidentiality, except where legal requirements direct for the sport and exercise medicine physician to diagnose and offer treatment. A patient otherwise, or a strong ethical justification exists and such disclosure is permitted usually has a lesser degree of knowledge about the body and medical concepts. And, under the law. because of the highly technical nature of medicine, patients are generally unable to assess ii. Seek permission from the patient prior to each disclosure of health information to a the adequacy of treatment. Therefore a patient must place a great deal of trust in his or third party. her sport and exercise medicine physician to do the very best for him or her. Sport and Commentary: exercise medicine physicians are obliged to respect that trust and avoid situations or It is recognised that some sports teams or sporting bodies require athletes demands that may undermine it. Anything that undermines trust will inevitably impact to sign a health information release form at the beginning of the season or on joining a negatively on the ability to provide the patient with the care required. team. This may or may not specify who the information is to be released to, however at the point of signing no one can predict the injuries or illnesses that might occur or the 1.5.2 Divided loyalties and contractual obligations implications of this information. A health information release form signed by an athlete at Commentary: Here a distinction is made between a therapeutic role and an assessment- the beginning of the season or on joining a team does not discharge the sport and exercise only role. medicine physician from the responsibility of seeking permission to each disclosure of Therapeutic role health information about the patient to a third party. The sport and exercise medicine physician is employed in a therapeutic role for the patient The sport and exercise medicine physician should: or team, and in this situation a physician-patient relationship exists. i. Where necessary, educate coaches, trainers, team management and sports governing Assessment-only role bodies of the need for confidentiality between a sport and exercise medicine physician and a patient. There are times when a sport and exercise medicine physician is employed solely for one- off assessment purposes of patients and is not involved in care. The most common example ii. Inform patients of the advantages of sharing health information with coaches and of this is when a patient is transferring between clubs and a medical assessment has to team management to effective patient management. be completed, or if a patient has been selected for a tour or event, subject to passing a In situations where a sport and exercise medicine physician is employed for one-off medical/ fitness assessment. Here the relationship between the sport and exercise medicine assessment purposes only, the sport and exercise medicine physician must: physician and the patient is different than a therapeutic relationship. In assessment only

44 - new zealand journal of sports medicine commissioned article iii. Inform the patient that relevant health information gathered during the assessment likelihood of a severe outcome for the patient (loss of life or severe incapacity). will be passed to the employer. This includes providing pain masking injections, medications, or other clinical Commentary: In such situations, the sport and exercise medicine physician must interventions. document the following: ii. Use caution when providing assistance (pain masking injections, medication, or other • That the patient was informed that relevant health information will be passed to a clinical interventions) to return a patient to sport following injury. third party. iii. When providing assistance (pain masking injections, medication, or other clinical • That the patient agreed to the assessment under these conditions. interventions) to return a patient to sport following injury; inform the patient of the risks involved. Note that such discussion should be documented. iv. Limit the disclosure of health information about a patient to those who are entitled to such information. iv. Be aware that he or she is under no obligation to assist a patient to return to sport following an injury if he or she considers the risks are unacceptable. v. Recognise the commercial and media sensitivity of personal health information about athletes. Commentary: When assisting an athlete to return to sport following an injury the sport and exercise medicine physician may feel some degree of responsibility for further injury 1.7 needs of special populations or exacerbation of an injury. The sport and exercise medicine physician must feel able 1.7.1 Caring for children to refuse to assist if he or she feels considers that the potential for injury is unacceptably The sport and exercise medicine physician must: high. Sport and exercise medicine physicians may wish to factor into decision making the risks associated with the patient playing without medical assistance, but should not feel i. Recognise the particular vulnerability of children in sport. pressured into assisting against his or her better judgement. ii. Be aware of the effects of sport on children with health issues. 1.10 The use of performance enhancing drugs in sport iii. Consider the short and long-term health risks (physical and psychological) of The sport and exercise medicine physician must: training regimes and competition on a child. i. Be aware of and work within the regulations regarding the use of banned iv. Obtain informed consent from a legally appropriate adult for any proposed treatment performance enhancing drugs of the governing body of the sport the athlete is of a child. (Be aware that legal requirements may vary between jurisdictions). involved in. v. Involve the child in decisions about treatment and seek informed consent from the ii. Not assist patients to evade authorised drug testing. child to any proposed treatment on a developmentally appropriate basis. The sport and exercise medicine physician should: vi. Where necessary, refer children to an appropriately qualified child health practitioner. iii. Educate patients, teams, coaches, trainers, other health professionals and the general The sport and exercise medicine physician should: public about the risks of performance enhancing drugs. vii. Educate the child/parents/caregivers/coaches of short and long-term health risks SECTION TWO – Sponsorship, industry and media (physical and psychological) of training regimes and competition on children. viii. Take particular care to identify children who are being required to undertake severe 2.1 Sponsorship training regimes and competition (this may require speaking to the child in private). The sport and exercise medicine physician must: ix. Advocate for children who are being required to undertake severe training regimes Not endorse any product that brings the College into disrepute. (Note that product and competition or competition against their wishes. endorsement may be prohibited in some jurisdictions) x. Be aware of the possibility of non-accidental injury or risk of harm to a child and The sport and exercise medicine physician should: report this to the appropriate authority within the legal framework of the jurisdiction i. Ensure that decisions regarding the supply of health products to the patient or team are in which the sport and exercise medicine physician is working (being aware that legal evidence based. requirements vary between jurisdictions). ii. Advocate for the patient (with that patient’s consent) where the sponsors product may xi. Contribute to sports regulations relating to the participation of children. negatively affect the health of the patient. Commentary: For example, setting age limits for participation in a marathon. iii. Advocate for the patient (with that patient’s consent) where the sponsors demands to 1.8 Risk taking compete may negatively affect the health of the patient. The sport and exercise medicine physician must: iv. Avoid sponsorship of the medical team that is in conflict with good health (e.g. alcohol i. Acknowledge that risk taking is necessarily the responsibility of the patient where sponsorship). that patient is competent and the decision is freely made. v. Be cautious when giving personal endorsement of any product. ii. Assess the likelihood and severity of risk to the patient from returning to sport 2.2 Relationship with industry following injury. The sport and exercise medicine physician must: iii. Inform the patient (where possible) of the potential for harms associated with i. Not accept sponsorship to cover the cost of travel, attendance or meals at conferences returning to sport following injury including the likelihood and severity of injury or meetings for family or friends. or further injury, the patho-physiology of injury, and the implications of injury on quality of life and future career; ii. Not obtain benefit from the sale of a medical device to one’s own patients. iv. When advising athletes about return to sport following an injury discourage choices The sport and exercise medicine physician should: to participate in sport where a patient’s condition creates a high likelihood of a severe iii. Not accept a fee or equivalent consideration from representatives of industry for outcome (loss of life or severe incapacity). seeing them in a promotional capacity. Commentary: Where a choice to participate in sport is freely made and the patient is iv. Be cautious when accepting offers of industry sponsorship to attend conferences and competent, then the patient should be informed of the potential consequences of his or scientific meetings. Acceptance usually should be restricted to those in which he or her action and left to exercise their choice. Where a choice to participate in sport is highly she is to make a formal contribution. In such instances a clear and public declaration likely to result in a severe outcome due to the patient’s condition, then this action should of such support should be made. be actively discouraged. This is not an attempt to place doctors in opposition to any v. Ensure the planning, content, speaker selection and subject matter of any conference, particular sporting activity e.g. boxing, motor racing and parachuting where the risks for meeting or educational gathering, is not influenced by the commercial interests of a catastrophic event exist but are unlikely when undertaken with standard precautions by industry sponsors. a well individual. However it could include these sports if some other consideration exists in the individual such as a motor racing driver with untreated epilepsy, or a boxer with a vi. Declare any relationship with industry when presenting at conferences and scientific detached retina. meetings. v. Ensure that a decision to participate in sport when that participation involves high 2.3 Dealing with the Media levels of risk taking is freely made by the patient. The sport and exercise medicine physician must: vi. Advocate for the patient (with the patient’s consent) where it is thought the patient is i. Be aware that he or she has no duty to provide personal health information about being pressured into taking high levels of risk. patients to the media. The sport and exercise medicine physician should: ii. Not provide personal health information about a patient to the media without the vii. Inform the patient (or direct to someone who can) of protective gear that may be consent of the patient. worn to reduce further injury. The sport and exercise medicine physician should: viii. Work with sporting organisations to reduce injury risks to athletes. iii. Only provide information that is truthful to the media. 1.9 facilitating risk taking Commentary: While it is recognised that sporting bodies do occasionally release The sport and exercise medicine physician must: untruthful medical reports for the purpose of misleading the opposition, this is not the domain of a sport and exercise medicine physician. i. Not knowingly facilitate a return to sport following injury where there is a high

new zealand journal of sports medicine - 45 commissioned article

SECTION THREE - Responsibility to society experience and culture. 3.1 Community role ii. Avoid impugning the reputations of other sport and exercise medicine physicians The sport and exercise medicine physician should: with patients, coaches, team management and others. i. Use his or her knowledge of sport and exercise medicine to improve individual and Commentary: Having a high profile sportsperson as a patient can bring standing within public health. the sporting community and raise the profile of a sports health provider. Impugning the ii. Promote public awareness of medical issues that relate to sport and exercise medicine reputation of another medical provider is not an acceptable means of gaining patients. (e.g. management of fractures, concussion etc.). iii. Refrain from criticising colleagues in any untruthful, misleading or deceptive way. iii. Provide emergency medical care for the public at sporting events. If attendance at iv. Not denigrate another sport and exercise medicine physician publicly (unless events is expected to be high, assist in arranging on-site medical services. required by law). iv. Participate, if invited, when new sports regulations are being drawn up. v. ot plagiarise another’s work or research, or use it without appropriate 3.2 The presence of sport and exercise medicine physicians at high-risk events acknowledgement. The sport and exercise medicine physician should: vi. Refrain from harassing or bullying other sport and exercise medicine physicians in any way. v. Feel able to refuse to attend a sports event which he or she considers has an unacceptably high risk of a severe outcome, and/or where he or she considers his or The sport and exercise medicine physician should: her presence is being misused. vii. Work closely with and co-operate with other sport and exercise medicine physicians. SECTION FOUR – Continuing Professional Development viii. Participate in peer review. 4.1 Maintenance of professional standards 5.3 Registrars The sport and exercise medicine physician must: The sport and exercise medicine physician must: i. Comply with the continuing professional development program requirements i. Provide appropriate supervision of registrars to minimise risks to the patient, and specified by the College and be diligent in the documentation of such compliance. accept responsibility for the welfare of the patient. It is noted that such compliance is compulsory in New Zealand. ii. Be honest and fair in all dealings with registrars. ii. Be aware of other recertification requirements within their jurisdictions. iii. Refrain from bullying or harassing registrars. The sport and exercise medicine physician should: The sport and exercise medicine physician should: iii. Take an appropriate leadership role in planning, undertaking and measuring practice iv. Acknowledge a responsibility to encourage and train future sport and exercise improvement activities, including using the principles of evidence based practice and medicine physicians. continuous practice improvement. 5.4 other members of the sports health team iv. Not undertake treatments or procedures beyond his or her current training. The sport and exercise medicine physician must: v. Endeavour to obtain training in new treatments and procedures. i. Work in a spirit of collaboration and co-operation with other health professionals as a 4.2 The sport and exercise medicine physician’s health team member, respecting the contribution of all members of the sports health team to Sport and exercise medicine physicians should maintain good physical, psychological and patient care. emotional health and develop insight and humility in dealing with situations where health 5.5 The College is impaired. The sport and exercise medicine physician must: The sport and exercise medicine physician must: i. Comply with the obligations expressed in this Code of Ethics and Professional i. Refrain from practicing while impaired by alcohol or drugs or when physical or Behaviour at all times. mental disability impairs his or her performance. ii. Respect and co-operate with the College’s disciplinary proceedings. The sport and exercise medicine physician should: SECTION SIX - Conducting research ii. Have his or her own general practitioner 6.1 Research iii. Endeavour to recognise when fatigue, stress, physical or mental illness or another The sport and exercise medicine physician must: condition reduces his or her clinical or procedural skills, and request the assistance of an appropriately qualified colleague. i. Perform all research with approval of an appropriate research ethics committee. iv. Endeavour to recognise when the symptoms of the ageing process may affect ii. Ensure that all research meets the ethical standards that would be applied by an performance and seek and comply with advice. accredited research ethics committee. v. Take appropriate remedial steps to bring his or her performance to an acceptable iii. Declare to research participants and proposed publishers of research results where standard when impairment is recognised. research has been funded by industry. vi. Recognise impaired health in his or her colleagues and take appropriate action The sport and exercise medicine physician should: including support and, if the impaired colleague does not volunteer such a deficiency, iv. Ensure that financial compensation for participating as an investigator in a clinical trial consider whether to report such ill-health to the appropriate authorities, subject to is commensurate with work performed. appropriate legal requirements. Make publicly available all results of research, negative as well as positive, wherever SECTION FIVE - Professional relationships possible. 5.1 General practitioners Commentary: The relationship between a sport and exercise medicine physician and the patient’s general practitioner is centrally important to effective patient care. The general practitioner coordinates the health requirements of the patient; referring the patient to the sport and exercise medicine physician where necessary, and often directing any follow-up care that is necessary. It is therefore important to keep the general practitioner informed of any findings on assessment and care provided. The sport and exercise medicine physician must: i. Maintain good working relationships with a patient’s general practitioner. ii. Inform the referring general practitioner, with the patient’s consent, of the assessment findings, any treatment provided, and any ongoing care that may be necessary. iii. Inform the referring general practitioner if the patient is to be referred to another health care provider or service. iv. When employed as a team physician, liaise with the patient’s general practitioner and provide a discharge summary at the end of the season, and where a patient leaves the team prior to the end of the season. 5.2 other sport and exercise medicine physicians The sport and exercise medicine physician must: i. Respect another sport and exercise medicine physician’s training, knowledge,

46 - new zealand journal of sports medicine HOW I TREAT judith may Adhesive capsulitis

Judith May BHB, MBChB, FACSP to the spinati and deltoid. There may be the diagnosis can be made clinically, and Sports Physician tenderness to the anterior and posterior further imaging is not necessary. However, Grace Sports Medicine, Tauranga capsule. I would first assess active range of if there is any inconsistency in the clinical motion which is usually globally restricted, findings, further investigation is probably with external rotation and abduction warranted. In this case, an ultrasound may dhesive capsulitis (AC) or “frozen usually the most significantly affected. I show thickening of the coracohumeral shoulder” is a common condition will then attempt further movement with ligament,increased vascularity in the rotator of the glenohumeral joint which passive range of motion which will have a interval, but a lack of other pathology may Ais characterized by a progressive increase 9 firm mechanical endpoint due to capsular help support the diagnosis. An MRI is in pain and global loss of passive and active restriction. It is important to ensure there is rarely indicated but thickening of both the range of motion. Affecting 2 to 5% of the no compensatory scapulothoracic motion coracohumeral ligament and joint capsule in population, it most commonly affects females when assessing range of motion. the rotator interval, and obliteration of the aged between 40 and 60, with an increased 15 An understanding of the pathology of fat triangle may be observed. Due to the incidence in diabetes mellitus, thyroid and adhesive capsulitis is important to help guide incidence of adhesive capsulitis in diabetes autoimmune disease.3,11 Approximately 20% which treatment may be effective in each I would recommend assessing a fasting of both type 1 and 2 diabetics will develop stage. Arthroscopic and histological studies glucose on most patients, particularly if a the condition, and they will often have a have shown that the painful “freezing” patient has co-morbidities or a recaltritrant more severe, protracted clinical course, that phase is characterised by a hypertrophic course. is recalcitrant to treatment.1 The natural hypervascular synovitis, but there is normal history for AC is a self-limiting course that Management capsular tissue. As the condition moves to will resolve spontaneously over 1 to 3 years; My management begins with education on the stiff “frozen” phase the capsule becomes however, a significant number may still the natural history of adhesive capsulitis dense and fibrotic with large numbers of report residual symptoms after 3 years.14 so the patient has a realistic expectation on fibroblasts and myofibroblasts, with the The condition can be primary or idiopathic, the time course their condition. As with synovitis gradually resolving.11 Cytokines with no apparent precipitating factors, any condition in which the pathogenesis is and matrix metalloproteinases (MMPs) have or secondary and triggered by trauma, unclear there are many treatment options recently been implicated in the pathogenesis immobilisation or surgery. available. I base my management decisions of AC7 with cytokines involved in the on the phase of the disease and the associated Adhesive capsulitis is typically described proliferation of fibroblasts and production pathology. If the patient is in the painful as having 3 phases.12 The first stage is the of collagen.7 MMPs are important in tissue phase where synovitis is a component of “freezing” phase where there is progressive remodelling processes and an imbalance the pathology I offer an intra-articular pain with activity. The second “frozen” between MMPs and their inhibitor TIMP-2 corticosteroid injection, which I typically phase is characterised by gradually reducing has been implicated.7 perform using a posterior approach without pain but a progressive loss of range of Studies assessing the role of MMPs in imaging guidance; a Cochrane review glenohumeral motion. In the third “thawing” menstrual bleeding have shown that estrogen has shown that there does not appear to phase there is a gradual improvement in has a significant role in the expression and be any additional benefit by doing the range of motion and function. activation of MMPs and their inhibitors.13 injection under imaging guidance.4 Studies The typical history is of a graduated onset of This may explain the increased frequency have suggested this approach can give pain in the anterior and lateral shoulder that of adhesive capsulitis in postmenopausal improvement in pain levels for approximately can refer into the deltoid region. There is 2 women. Similarly, the role of cytokines in six weeks. I warn the patient that it is frequently a dull ache at rest but a sharp pain the pathogenesis may explain the increased unlikely to improve their range of motion with movement such as reaching, and a night prevalence of AC in sufferers of autoimmune or the long term outcome, however most pain with difficulty sleeping on the affected disease and diabetes. are grateful to get pain relief while they are side. Many will describe minor trauma such It is important to differentiate adhesive going through the most painful phase of the as reaching behind a seat in the car for a capsulitis from other causes of a stiff painful condition. I do not generally recommend handbag prior to the onset of symptoms. If shoulder such as osteoarthritis of the physiotherapy in this phase and any in the freezing phase they will complain of acromioclavicular or glenohumeral joint, stretching of the capsule seems to aggravate increasing stiffness and difficulty with doing calcific tendinopathy, rotator cuff pathology the condition. I recommend regular passive activities of daily living such as brushing hair and neoplasm. This can usually be achieved range of motion and pendulum exercises and or doing up their bra. It is important to get a with a shoulder X-ray in conjunction with encourage returning to daily activity within past medical history especially any history of the history and examination. If the patient pain limits.. diabetes or autoimmune disease. is in the stiff “frozen phase” then usually If the patient is in the frozen phase with On examination there is often wasting a marked reduction in range of motion I

new zealand journal of sports medicine - 47 how I treat consider an ultrasound guided hydrodilation. Comment 1 scapulothoracic abduction is 180 degrees, In this phase the capsule has become fibrotic 120 degrees from the Glenohumeral joint, Chris Hanna though there may still be high pain levels and 60 degrees from the scapulothoracic Sports Physician due to on-going synovitis. The procedure articulation. So the normal range of UniSports Medicine, Auckland involves distending the capsule with 20 ml abduction of the arm with the scapula fixed of saline and glucocorticosteroid under local should be 120 degrees. Less than this may anaesthetic. I have found this to be well hanks for a great overview Judith. be an indicator of restriction. If you bring tolerated, and can give substantial gains in TThat is very much in line with my the arm back to 90 degrees abduction, there range of motion, reduction in pain levels and understanding of this interesting problem. I should be 90 degrees of external rotation improved function. It is most beneficial in would add the following points: and about 80 degrees of internal rotation in the stiff phase of frozen shoulders.5 When taking the history, possibly due to the this position in a normal arm. In adhesive While there is little scientific evidence presence of the ACC system in New Zealand, capsulitis, these measurements of rotation for using physiotherapy as a stand-alone or possibly due to human nature, most of in abduction are the earliest signs of treatment in AC,8 there is some support the patients I see with adhesive capsulitis restriction. If the arm cannot be abducted for its use after hydrodilation.6 After report a minor injury as the trigger. I suspect to 90 degrees, then measure the amount of the procedure I consider physiotherapy that what the patient interprets as being the abduction, and record the range of rotation to supervise a rotator cuff and scapular cause of the pain, is actually pain caused by in the maximal amount of abduction. This stabilising programme to help restore suddenly taking the inflamed joint into an gives you a very easy way to detect and shoulder function, especially if there is a end range position, bringing the problem to document progress over time. The other test pronounced difference between active and the patient’s attention. that I find very useful in adhesive capsulitis passive range of motion. I see a number of patients with adhesive is the Load-Shift test, which is usually used to assess instability. In AC, the opposite is If a patient is reluctant to have corticosteroid capsulitis who report night pain and found, and there is a marked reduction in injection therapy, other options that may numbness into the hand. Neurological accessory movement in the affected shoulder help pain and function are acupuncture and examination is normal, and these symptoms when compared to the normal shoulder. oral non-steroidal anti-inflammatories. are abolished by intra-articular cortisone. I also compare and record the range of I have rarely sent a patient for surgical I do not see a progressive loss of range of motion of internal rotation in the Hawkins intervention, but occasionally there are motion in the frozen phase. My experience is impingement test position between the two patients who are recalcitrant to treatment that in the freezing phase there is increasing shoulders. and who have a severe restriction in range of pain and loss of range of motion. In the My philosophy on investigations is that motion lasting several months. Arthroscopic frozen phase there is a gradual reduction plain films are mandatory in anyone with capsular release is increasingly preferred in pain, much less night pain, and fewer a history of previous malignancy or red over manipulation under anaesthetic as the episodes of sudden movement pain. I flags like weight loss. As strength is usually surgical procedure of choice due to its lower consider the first significant increase of not compromised by adhesive capsulitis, I complication rate and quicker recovery range of motion to be an indicator of the also request ultrasound imaging in patients time.10 end of the freezing phase, and expect not to need further cortisone from that point who are weak. If I am getting blood tests, I I suspect most conservative management on. In the thawing phase there is minimal have previously used random blood glucose is providing analgesia and improvement in pain (although impingement due to capsular and TSH, although labs in Auckland are quality of life while going through the most restriction and the resultant scapulothoracic now using HbA1C as a screen for impaired debilitating phases of the condition, without dysfunction is quite common), and a slow glucose tolerance. I tend to reserve these altering the natural history of the condition. melting away of the capsular restriction. tests for patients with significant restriction I recommend considering which phase Natural history papers report that full range or protracted courses, because patients with of the condition and hence the associated of motion is often not regained, but that the diabetes or autoimmune disease are more pathology when determining treatment restriction in end range is usually similar to likely to have a more severe disease course. options. In the future treatments that address the other shoulder and therefore it probably In younger patients, I also include a screen the pathogenesis targeting cytokines and is normal for age. for inflammatory diseases, as rheumatoid metalloproteinases may be able to influence arthritis and sero-negative oligoarthritides both short and long term outcomes. In the examination of the frozen shoulder, I can present as isolated glenohumeral find that the most sensitive test for assessing capsulitis. restriction of range of motion is to have the patient lying supine, fix the scapular with the ACC and the New Zealand Guidelines Group ipsilateral hand (ie left hand if examining the published guidelines on soft tissue shoulder left shoulder) to prevent scapular movement, injuries. The only condition that they then abduct the arm as far as possible. strongly recommend corticosteroid injection The normal range of Glenohumeral and be considered in the shoulder is adhesive

48 - new zealand journal of sports medicine how I treat capsulitis in the acute inflammatory phase. has a half-life of 2 hours, which is why most treat and making an early/timely diagnosis They concluded that exercise can exacerbate patients wake up with pain 2-4 hours after is an important part of their conservative the pain in the acute phase but is of benefit they get to sleep. I mention that interrupted management.. Our suspicion for AC is once the acute pain has settled. I recommend sleep saps our energy, makes us cranky heightened when passive shoulder range of intra-articular corticosteroid, and use the and can interfere with our interpersonal motion (ROM) is the same as active shoulder same approach as Judith. I use ultrasound relationships and in some cases our business ROM. Pain with external rotation is also a guidance, and consider hydrodilatation in decisions. I point out that cortisone is not a common finding, however it is important patients who do not respond as well as I cure, and that until the process burns itself that a posterior glide of the humeral head expect. It is always important to consider out, symptoms can return, and a further (relocation test) does not relieve the pain felt alternative diagnoses in these patients as injection may be considered; but intra- with external rotation as this may indicate well. Cardiac ischemia, cervical referral, articular cortisone has been proven to reduce anterior shoulder instability. Adhesive and pathology involving the diaphragm or night pain and improve quality of life. capsulitis is more common in females,9 7 11 peridiaphragmatic organs can all refer pain I would add that there is a 10-20% chance diabetics, those with Dupytren’s and those 10 to the shoulder, but do not usually reduce of developing adhesive capsulitis in the aged between 40-65 years. This together range of motion. other shoulder, and I inform patients of that. with a pain pattern that is painful at night There are currently two schools of thought Also, a number of studies have reported a and unrelieved by rest constitutes our about rehabilitation after corticosteroid persisting limitation of range of motion, differential diagnosis. Differential diagnoses injection in adhesive capsulitis. Some despite resolution of symptoms. Vastamaki includes GHJ instability (decreased pain with practitioners see the administration of and Vastamaki in their paper with a 23 posterior glide in external rotation), and cortisone as an opportunity to aggressively year follow-up of patients who underwent osteoarthritis (degeneration/osteophytes 13 push range of motion. There is no MUA make the point that, although visible on plain X-Ray). Classification of evidence that any intervention speeds up range of motion was very good initially, it primary (idiopathic) or secondary AC (due the resolution of this disease. It is also deteriorated between 6 and 16 years after to conditions such as diabetes, cervical disc, 6 possible to create more pain through the manipulation, however they note that or rotator cuff tears) may also be useful. aggressive assisted mobilisation, and even this restriction reached the level of the Pathophysiology self mobilisation in the acute phase. My contralateral shoulder.2 They suggested that The precise aetiology of AC remains unclear approach is to recommend intra-articular this loss of range of motion may be due to although some authors have proposed corticosteroid until such time as there is the natural process of aging. Other studies elevated serum cytokines to be part of the no longer night pain or sudden movement continued to compare the range of motion in process.6 Bunker et al (2000) proposed that pain. I like patients to have a four week the involved shoulder, with the range of the a minor insult could lead to an exaggerated break between the predicted end of the uninvolved shoulder as it was documented at healing response and propagation of type I previous cortisone injections duration of the time of initial consultation. and III collagen. Fibroblasts differentiate into effect, and any subsequent injection. During References myofibroblasts, causing contraction of the this phase of the disease, I prescribe inner 1 NZGG. “The Diagnosis and Management new Type III collagen. range strengthening, but no stretching. of Soft Tissue Shoulder Injuries and Related Although many authors6,10 have described Deep tissue release of trapezii, paraspinals Disorders - Best practice evidence-based 3 stages Wiffen et al (2002) describes AC as and sternomastoid can be of benefit to guidelines”, June 2004. having four stages. In stage 1 there is dull patients who have developed cervical pain 2 Vastamaki H and Vastamaki M. “Motion pain at rest and sharp pain at end of range. and headaches due muscle spasm secondary and Pain Relief Remain 23 Years After There is progressive loss of active ROM to shoulder pain. Once the patient is not Manipulation Under Anesthesia for Frozen but passive ROM remains near normal. Shoulder.” Clinical Orthopaedics and Related requiring cortisone (and this decision can Arthroscopic investigations in this stage Research, 2013; 471:1245-1250. only be made six weeks after their most describe a hypertrophic vascular synovitis recent corticosteroid injection), I am happy coating the capsule lining. This hypertrophic for them to return to range of motion Comment 2 vascular synovitis is also present in Stage 2 work, but they must continue with their although perivascular scar formation now is Margie Olds strengthening. I do not usually see the beginning to appear. The pain persists and patient again after that. there is progressive loss of range. Stage 3 When I am recommending intra-articular Graeme White describes a painful stiffening of the shoulder, cortisone I point out that cortisone is a Sports and Manipulative Physiotherapist and then the symptoms gradually improve synthetic copy of a natural hormone, cortisol, UniSports Medicine, Auckland to a relatively pain free but stiff shoulder. that we make every day. We make it to wake There is loss of the axillary fold in this stage ourselves up, and we make more when we Diagnosis and arthroscopy shows patchy synovial want to exercise or we get stressed. We stop eople with ‘Adhesive capsulitis’ (AC) thickening without the hyper-vascularity. making it when it is time to go to bed, and it Por ‘Frozen shoulder’ are difficult to Biopsies of this stage contain dense, hyper-

new zealand journal of sports medicine - 49 how I treat cellular tissue. Stage 4 describes slow and range for 10 seconds 3-4/day, while patients idiopathic frozen shoulder.” The Israel Medical steady recovery of ROM.12 of moderate/high irritability (>3/10 VAS) for Association Journal: IMAJ 2008; 10(5): 361- 3 364. Management no more than 5 seconds 3 times per day. We 10 Neviaser A S and Neviaser R J. “Adhesive The stage system described above provides emphasise the need for patients to monitor capsulitis of the shoulder.” Journal of the the framework for our conservative their symptoms after exercise – if there is any aggravation of symptoms beyond an hour of American Academy of Orthopaedic Surgeons management. Identification of AC within 2011; 19(9): 536-542. Stage 1 or 2 is important as these people finishing their exercise or the resumption of night pain then exercise intensity must be 11 Smith S P, Devaraj V S, et al. “The association seem to respond well to corticosteroid between frozen shoulder and Dupuytren’s reduced. injection into the joint space. This disease.” Journal Of Shoulder And Elbow steroid is thought to have an effect on the In summary, early identification of this Surgery / American Shoulder And Elbow hypervascular synovitis. There is some condition is essential to optimal clinical Surgeons ... [Et Al.] 2001; 10(2): 149-151. evidence in the literature that corticosteroid management. Treatment includes range 12 Wiffen F. “What Role Does the Sympathetic injections are more effective than of motion stretches and education of the Nervous System Play in the Development or physiotherapy intervention especially in condition in the early stage. In the latter Ongoing Pain of Adhesive Capsulitis.” Journal decreasing pain in the two weeks following stages of AC, mobilisation of the joint of Manual & Manipulative Therapy 2002; an injection,1 although many of these studies capsule and end of range stretches have been 10(1): 17. did not discriminate between the different found to be useful. 13 Wolf E M and Cox W K. “The external stages of AC. We typically refer for an References rotation test in the diagnosis of adhesive capsulitis.” Orthopedics 2010; 33(5): 303-303. injection under ultrasound guidance as there 1 Blanchard V, Barr S, et al. “The effectiveness is some evidence in the literature14 that this of corticosteroid injections compared with 14 Yoon S-H, Lee H Y, et al. “Optimal Dose of will result in better outcomes for the patient.5 physiotherapeutic interventions for adhesive Intra-articular Corticosteroids for Adhesive capsulitis: a systematic review.” Physiotherapy Capsulitis: A Randomized, Triple-Blind, Our treatment in these early stages is around 2010; 96(2): 95-107. Placebo-Controlled Trial.” The American education of the condition and techniques Journal Of Sports Medicine 2013; 41(5): 1133- 2 Bunker T D, Reilly J, et al. “Expression to avoid aggravation. Any mobilisation in 1139. of growth factors, cytokines and matrix this stage needs to be pain-free and passive metalloproteinases in frozen shoulder.” The stretches should focus on restoration of Journal Of Bone And Joint Surgery. British normal range, once again avoiding pain. Volume 2000; 82(5): 768-773. Working into pain will merely aggravate 3 Dempsey A L, Mills T, et al. “Maximizing an irritated capsule. Some authors have Total End Range Time is Safe and Effective proposed that the sympathetic nervous for the Conservative Treatment of Frozen system also plays a role in recalcitrant Shoulder Patients.” American Journal of AC,12 and we have found that thoracic Physical Medicine & Rehabilitation 2011; mobilisation, neural sliders such as long 90(9): 738-745. sitting, or sympathetic slump mobilisations 4 Foster R L and O’Driscoll M. “Current have been helpful in reducing pain. Gentle concepts in the conservative management of closed kinetic chain ROM exercises in the frozen shoulder.” Physical Therapy Reviews four point kneeling (rocking forwards and 2010; 15(5): 399-404. backwards) can also be helpful. 5 Hertel R. “[The frozen shoulder].” Orthopade. 2000; 29(10): 845-851. When the patients are in stage 3 or 4, we typically use stretches in a home exercise 6 Kelley M J, McClure P W, et al. “Frozen programme. Occasionally we will accompany shoulder: evidence and a proposed model guiding rehabilitation.” Journal of Orthopaedic this with mobilisations to the glenohumeral & Sports Physical Therapy 2009; 39(2): 135-148. joint8,4 but only if we see progressive 7 Lequesne M, Dang N, et al. “Increased improvement as a result of the mobilisation. association of diabetes mellitus with capsulitis Otherwise we monitor their stretches on a of the shoulder and shoulder-hand syndrome.” monthly basis, and increase the stretches as Scandinavian Journal Of Rheumatology 1977; appropriate. Favourites include hands on 6(1): 53-56. a bench and hips into 90 degrees flexion, 8 Maricar N, Shacklady C, et al. “Effect of resulting in increased flexion at the shoulder. Maitland mobilization and exercises for the Floor stretches are also a favourite as they treatment of shoulder adhesive capsulitis: a result in more support through the lumbar single-case design.” Physiotherapy Theory & spine. Patients with low irritability (0-3/10) Practice 2009; 25(3): 203-217. are encouraged to hold the stretches at end 9 Milgrom C, Novack V, et al. “Risk factors for

50 - new zealand journal of sports medicine REPORTS BRUCE HAMILTON Ride the Wave: AMSSM Annual Meeting San Diego, 17-21 April 2013

he American Medical Society for Fellows were able to orally present clinical injuries (I went to this one), Ultrasound Sports Medicine (AMSSM) annual cases (a great way to be noticed), from over diagnostics, fracture care and many many meeting has typically played second 250 applications – the quality of both the more. As you may expect, these did vary Tfiddle in terms of international profile, work up, and the presentations, from young in quality, but if you picked the right one, to both the more well-known American clinicians was exceptional. you had the opportunity to pick up the odd College of Sports Medicine (a massive, Given the nature of the participants, it nugget. multi-disciplinary annual meeting and was not surprising that the majority of I admit to carrying some biases on Sports aligned with the Medicine Science in Sport sessions were medically oriented, and of Medicine in the USA from both what I’ve and Exercise journal) and the orthopaedic high quality. Many of the speakers were seen on TV (For example, episode 12, driven American Orthopaedic Society for names that were recognisable from the series one, House; Broken arm = cadmium Sports Medicine (AOSSM – aligned with literature, and it was a pleasure to have the poisoning), and what one reads about the American Journal of Sports Medicine). opportunity to hear them speak directly. the protective practicing (ie. Investigate Established a little over 20 years ago, the Dr Jonathon Drezner was the current everything before seeing the patient), AMSSM caters for non-orthopaedic Sports (outgoing) President of AMSSM, well known based on the litigious nature of the society. Medicine specialists, and has grown in for his excellent work in cardiac screening Pleasingly, I would like to say that the quality that time from a handful of enthusiastic and cardiac management research. As of the people I met at this conference, and participants to over 1400 attendees this year. such it was guaranteed that there would the evidently high level of understanding of The title of the conference, “Ride the Wave! be a heavy emphasis on cardiac issues. sport related medical issues, firmly debunked The Future of Sports Medicine” reflects the The cardiac sessions were characterised many of my pre-formed beliefs. The positive optimism which characterised the by the presentation of new US-based litigious nature of the society was however entire meeting. Other than a dozen or so epidemiological data, overtly challenging highlighted in one case presentation, with international visitors, all participants were some of the aging but remarkably original an ultimate diagnosis of “swimming induced from the United States, predominantly it and timeless work of Dr Barry Maron. The pulmonary oedema”. Paradoxically, while seemed employed in University (College) value of ECG in cardiac screening was the Fellow presenting the case was happy to Sports Medicine clinics, and to a lesser emphasised, reflecting a move (at least provide a medical clearance to his patient extent private institutions, professional codes academically if not practically) towards the to compete in an ironman – in his patient and Olympic sports. Most eye opening European approach to cardiac screening who had experienced multiple attacks of for me was the extent of the “Fellowship” of Athletes. A further key message was pulmonary oedema in open water swims of programme which is the entry point the importance of Automated External 2 km or more, he was unable to get medico- into working in non-orthopaedic Sports Defibrillators (AED’s) in all training facilities legal clearance to perform a controlled Medicine. By far the majority of candidates – a timely reminder for us all. Finally, it is provocative test to confirm the diagnosis, for the Fellowship programmes, driven worth highlighting the “Seattle Project”, a and thereby potentially manage and prevent out of seemingly dozens of Universities multi-national effort to develop a relevant future episodes (if this can actually be done!). and hospitals, come from a strong family ECG education programme for Sports Am I crazy, or is this just a little messed up? medicine background, although a number Practitioners. Driven by Dr Drezner, this A final note on the exhibitors area. If this is of candidates come from other medical programme is now available to us all, free, on any reflection on the direction that Sports sub-specialties – this creates a strong medical the BJSM website! Medicine is taking, then its difficult to know knowledge base within the organisation, A second feature of the conference were the what the future holds. The two exhibit types with the evolution of equally strong Sports excellent sessions dedicated to concussion that were constantly busy and engaged in Medicine sub-specialties. Competition for diagnosis and management. Once again, active marking were ultrasound and Platelet positions on the Fellowship programmes is these sessions were both academically Rich Plasma – each having seven individual seemingly intense, and this conference was stimulating, and practically useful – a great exhibiting companies. The cynic in me is not a recruiters dream, with current Fellows combination for maintaining interest. sure what to make of this. required to present (either verbally or a A particular feature of the conference was the poster) and prospective Fellows desperately My conclusion. An excellent clinical large number of early morning “Instructional trying to meet key leaders. To give an conference. Well worthy of making Course Lectures” which (after you paid example of the desire from Fellows to present the effort to attend, and in 2014, a great additional money), provided hands on a clinical case (other than research), only 22 opportunity to explore New Orleans! clinical training in areas such as Hamstring

new zealand journal of sports medicine - 51 reports nat anglem IOC Advanced Team Physician Course Saltsjobaden, Sweden, May 2013

encountered again and again, and while in some of the specific risks that will likely be one sense the job of a sports physician can encountered with a Russia-hosted Olympic sometimes be seen as achieving a fast return Games. to play, there were many thought provoking The benefits of a conference with such a discussions with reference to the risks to the “rock star” cast as this one are obvious, but athlete, the team and indeed the medical I might also add that I felt the content of team, of early exposure of the athlete to the conference was weighted a bit heavily normal training and competing. Warnings to the mechanical aspects of health. While were made of the presentation of research acknowledging that the artistic aspects of was invited to attend this conference that used return to play as an end point for medicine are much harder to study, and as the Medical Director of the NZ study, and the risk of returning to play but therefore publish, I believe that in a clinical Wintersport Programme, with particular suffering setback or reinjury was highlighted. and performance based context more space Iview to lessons and connections that might Roland Thomee, a Swedish professor of needs to be made for the psychological be valuable, particularly with the upcoming physiotherapy and PhD described an aspects of health and wellbeing. In this Olympic Games in Sochi , 2014. holistic approach to rehabilitation, noting regard, I think the content of the meeting The trip itself was a long one. In fact the that predictors of good outcome from ACL was too light. duration of travel almost exceeded the surgery included: With such a busy programme and such a duration of the conference, and the risk 1 High pre-operative self efficacy scores lot of travel, by the time I returned home I was that the jet lag would limit how much I (the individual has belief in a good felt somewhat exhausted. However, there could actually benefit from the conference. outcome, as opposed to a doomed or is no time to rest! With the end of May However, as the saying goes: “going west is hopeless mindset) approaching the snow has begun to fall and best”, and I perhaps should have worried 2 Good pre-operative strength a New Zealand winter season (and chance more about my return to work after, rather to observe the fruits of our ACL prevention 3 Low pre-operative pain scores than the conference itself! programmes) is upon us! He also described the benefit in assessing The conference was set in Saltsjobaden, near I extend many thanks to the IOC, NZOC overall health status and social status in Stockholm, in the Swedish Archipelago with and to High Performance Sport NZ for regard to the injury, and then a battery of 40,000 islands scattered through the region. the opportunity for me to travel to this knee function tests. He uses 6 tests which are The Director in charge of the Medical and prestigious meeting. The next instalment in a mixture of 3 endurance (for example 90 Scientific department of the IOC, Richard Monaco, April 2014 will be very much worth second lateral hop test) tests and 3 power (for Budgett welcomed us and set the stage for a attending. example maximal distance hop). He stressed meeting that aimed to “Protect the health of the importance of testing that involves a the athlete”. component of fatigue. There followed a very busy programme for This presentation was followed by the well 3 days with almost 60 presentations and published Grethe Myklebust, who noted that case discussions! There were themes of ACL it can be common for orthopaedic surgeons management, sports team management and to focus on markers such as pain, swelling, return to sport criteria among others. range of movement and clinical tests of graft One of the greatest benefits of this course for stability, rather than functional tests to guide me was the contact with other practitioners return to play. She cautioned listeners on the from around the world. While there wasn’t safety of this approach with a raft of data and much time unaccounted for, there was a examples to illustrate the point. chance to meet with other team physicians, These simple but sensible messages were well make contacts and discuss experiences. received as I considered their application in While there were many lessons, and I gained my own practice. many insights during the conference, the Also of personal interest was a presentation greatest overall lesson for me was: by Fredrik Bendiksen of the Norwegian “Beware the risks of returning the athlete Olympic team discussing the Norwegian too quickly to sport”. This theme was team approach to the Sochi Olympics and

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