Myth busters, winter sports, tendinopathy and the law – Saturday at the CASEM-OMA symposium

DMacA_ski_resizeDomhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK, recently returned from attending CASEM-OMA Sports Medicine symposium in Ottawa.

 

Myth busters could be a regular session at any medical conference. But sports medicine seems particularly susceptible to suggestion, quackery or placebo as everyone looks for an easy answer. Jamie Kissick took us on an entertaining trip around the dubious evidence base surrounding interventions such as functional movement prediction of injury; managing muscle soreness; glucosamine and chondroitin; ice baths in recovery and many others. I was delighted to hear praise for my colleague Chris Bleakley’s work. And, indeed, mention of the POLICE acronym.

Should my child play contact sports? It is a question asked by many parents following the discussions about trauma in professional sport. J. Scott Delaney outlined many of the arguments, focusing on the short and long term risks associated with concussion. My view of Delaney's talk is that the evidence is unclear- and it can be difficult, even for you as the doctor, to be objective.

Michael Koehle, of the UBC Environmental Physiology Lab, took us to Nepal and, more specifically, to the Himalaya Rescue Association. Most high altitude research is on mountaineers but his work is inspired by the thousands who make the annual pilgrimage to the Gosaikunda Lake (4380m) - many of whom get acute mountain sickness. This is a landscape very like the Scottish highlands with a surprising absence of snow. Koehle showed us how his interest in high altitude illness has guided his research and how many of his theories proved negative on testing, although he still holds out some hope for pulse oximetry and balance testing. As an editor I smiled when he told us about his research paper on “Patellofemoral pain syndrome in Tibetan Buddhist Monks” (Wilderness and Environmental Medicine), cited once. Probably wouldn't have been one for CMAJ.

Saturday morning’s session was about freestyle snow sports. Jeff Purkis summarised the superb achievements of Canadian freestyle athletes: 83 World championship and 15 Olympic medals. He was followed by Robert Foxford, who listed the equally impressive injury toll. After the Sochi Winter Olympics even the IOC were concerned about injuries in certain events. Foxford  presented data from Canadian medical pre assessments showing the pattern of injury and, in particular, ACL injuries, fractures and concussions. Although it’s difficult to make direct comparisons, freestyle skiing athletes were clearly over represented. And, these data reflected athletes that had made it that far: "survivors", to use the epidemiologically correct if unfortunate term. He had three main concerns, their orthopaedic legacy, long term post-concussion problems, and the cumulative radiation dosage, particularly from CT scans in these young athletes with multiple and recurrent injuries. His concern extended beyond the elite athletes and he worries at the risks of ski terrain parks and their lack of regulation, in for example, the size and dimensions of half pipes.

Deidra Dionne, lawyer and 2002 Olympic medal winner, gave us a different perspective as someone who had experienced a severe neck injury yet returned to compete. Having come within a few mm of paraplegia, she explained the tension between medical opinion and wishes of an informed athlete. She had spent every day working towards a dream and she didn’t want it to end with a bad day. She knew the risks and, on her return, asked herself every day, "do I want to do this another time". Her career later ended due to a completely unrelated medical event. From a legal standpoint, however, she pointed out the potential problem of conflicts of interests if a medical team has contracts and could potentially benefit from team involvement. Similarly, if an organisation is rewarded on team performance or if players (and coaches) are paid by performance, there may be more interest in getting an athlete back to competing than following medical advice. Dionne was also strong on respecting an athlete’s ability to make their own informed decision and made an important point about the importance of combining both psychological and physical rehabilitation.

Margo Mountjoy, spoke about role of doctors in international sport. She reminded us of the importance of cultural sensitivity, the challenges facing the relatively fewer women in sports administration, and the personal and family sacrifices required. And, she sportingly responded to every speakers’ ultimate nightmare when told her slides had not been uploaded. One of her messages was about learning communication skills and engaging an audience- a point not lost on Daphne Anderson, who wowed the audience with her 2minute/2 slide presentation given entirely in rhyme.

There was a full house for the final (and immensely entertaining) session on Saturday afternoon dealing with tendinopathy where individual speakers were asked to make the case for eccentric strengthening, nitropatch, dry needling, cortisone, PRP, and shock wave therapy respectively. The consensus appears to be to start with the least invasive treatment first and then progress. Many patients, however, expect a cortisone injection and there is evidence of benefit in the short term. PRP has its advocates although the evidence from a Cochrane review and the IOC is inconclusive. And, some tips from the experts: ask your patients to demonstrate their exercises- if they cannot show them without consulting their crib sheet after a supposed six week trial, they haven’t been doing them. And, to protect yourself from being sued, ensure you make good notes and ask about other treatments and corticosteroid injections elsewhere.

#casemoma was a cool conference with impressive attendance right to the final session. Mind you, outside it was - 30°C with wind chill and a blizzard – they even had to cancel the "fun" run.

See Domhnall's video blog - a recap of the conference:

 

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