Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK, and recently in Edinburgh for the British Association of Sport and Exercise Medicine conference 2014
Why are the Jamaicans so dominant in world sprinting? And, it’s not just Jamaicans, but those of Jamaican origin representing other countries such as Canada and the UK. Is there a genetic component? Yannis Pitsiladis, a world expert with access to the world’s largest biobank, found no unique genetic trait. Jamaicans’ believe that this dominance is from the eugenic effects of the slave trade - only the fittest and strongest survived. The real explanation may be the system and cultural importance of sprinting- where you may find 45,000 people at the Jamaican schools sprint championship compared to, at most a few thousand, in other countries. Yannis was not saying that genetics are unimportant but they had yet to identify a gene.
Professional sport creates particular difficulties for team doctors. Ian Beasley, England soccer team doctor, explained one of the hazards was that if a player needs business advice they go to a business expert, for financial advice they go to an accountant but, everyone gives them medical advice. He could not blame agents and players for trying to get the best deal for their players but advised doctors not to do anything that could compromise their medical career.
Phil Batty, previously of Blackburn Rovers, Manchester City FC and currently with the Rugby Football Union, reflected that the clinical load in top sport was straight forward but dealing with multi resource athletes with lots of advisors was not easy. He felt the immense pressure to get players back to competition may lead to over investigation and over diagnosis. Clinical assessment is not enough and they expect a scan or investigation which may compromise best medical practice. It becomes difficult to treat the patient and not the scan, to treat function and not anatomy (that even a surgeon may want to correct), and to handle the psychosocial aspects of any pathology. Sadly, he reflected, conservative management is not respected as much as surgery. He cautioned that a team doctor exists in a very different and sometime isolated environment, you may not have a contract, there is no security, no pension, getting holidays can be difficult and you have no professional colleagues. Governance can be challenging and you work with people who do not understand your obligations to your regulatory body. If you get it wrong, you lose not just your job but could lose your livelihood. Phil also gave some advice on personal behaviour. Remember that you are the doctor and not a player- you cannot talk yourself out of situation you have behaved yourself into.
Andy Massey, of Liverpool FC, had some additional advice. Don’t be a supporter. His personal rule was that, when in the dugout, don’t show emotion whether the team wins or loses- your job is as a doctor. Managers’ decisions can be difficult- they are under immense pressure for results and may want to overrule your medical advice. A useful tip may be to point out that, in the long term, key injuries cost money.
Ethical problems commonly complicate sports medicine and Mike McNamee, a professor of ethics, described conversations with sports medicine trainees who talked up the importance of evidence based practice but justified their actions based on anecdote. He also highlighted the contrast between beliefs forged in clinical practice . “I know it works” and what a scientist means. Mark Batt, described some of the dilemmas: If someone has an injury but wishes to compete, for example, in an endurance event to support a charity in memory of their mother. Or, how to deal with an athlete who wants you to prescribe a small dose of an unnecessary medicine- and, if you don’t do it, someone else will. His, guiding principle was - if it feels wrong, it probably is wrong. He recommended: Be clear on your professional boundaries (an expert knows their limitations not their expertise), Seek the advice of a critical friend ( where appraisal can help); Build networks; Behave consistently and; Reflect on your practice.
Canada can be justifiably proud of a superb presentation by Heather McKay from Vancouver. Translational research is about making it happen and, Action Schools BC was ultimately about creating change in children through school. Medical research is preoccupied with efficacy studies, there are fewer effectiveness studies, and little dissemination evaluation but we need to constantly look at how an intervention works in practice. For Heather, it was much more than original research in the laboratory, it was about making it happen and for it to work, the intervention needs to interest people, those who will implement it need to be trained, and a community must ready to accept it. Remember too that while scientists think about planning a randomised controlled trial over two years, government cannot wait that long (they may no longer be in power).
They first did an efficacy trial- a RCT in 10 school which convinced the government that it could work then they undertook their effectiveness phase 2 trial and finally the implementation and evaluation where they reached out to 1400 schools, training 23000 teachers and 500,000 pupils. Key factors were upstream- political will, engagement across multiple sectors and stakeholder involvement. Downstream the key factors were adequate training and resources, a multi component design, flexibility and adaptability and a comprehensive evaluation.
Neil Armstrong, the doyen of childhood activity research in the UK, had some fascinating insights. Contrary to media reports, he explained, childhood physical fitness has remained constant over 30 years. The apparent deterioration is a function of measurement and results from the 20m shuttle run. But, the 20m shuttle run means moving body mass so, as body fat goes up, even when laboratory measures of oxygen uptake remain constant, test performances deteriorate. He also pointed out that habitual physical activity is unrelated to fitness in children (habitual activity doesn’t normally reach a training level). Although objective fitness may not have deteriorated, habitual activity is still very important and, even if we do not see immediate changes in risk factors, it is the long term effects of habitual inactivity that are important.
Shinty, a unique Scottish field game similar to ice hockey but with no helmet or eye protection, has its own pattern of injury. Jonathan Hanson described his efforts to encourage safety awareness in a challenging macho environment. Changing organisational behaviour is complex and much more than just pointing out the risks but when Ronald Ross, a celebrated shinty player- the “Ronaldo of the glens”- started to wear a helmet, other adult players began to wear them too.
Scotland and Lions team doctor, James Robson was asked about a newspaper report suggesting that few players would play beyond the age of thirty. Reflecting on the changing nature of the game, he agreed, expressing some concern that injuries were occurring earlier, that players were spending more time in the gym, were bigger and stronger and, that there may be too much contact during training. His concern was for the younger players.
And, a final few words of advice from other experts. Niall Elliott's courageous decision to pull a British Snowboarder from the Sochi Olympics after a concussion injury made news headlines at the time. He told us about the process and the pressures- but, in top sport unpopular decisions may have to be taken. At these times, it’s not just about professional training - media training is also vital. Gordon McKay, pioneer of internal brace ligament surgery, had an interesting perspective on surgical recovery from ACL surgery: What keeps people out for a year is the iatrogenic injury- the less surgery- the better for patients. Similarly, for Achilles tendon surgery, don’t tie knots at the site of least vasculature- this may mean bypassing the normal procedure. And, Leon Creaney’s advice for those in sports medicine practice was that being an expert is not enough, you need a unique skill because, for example, while you may say you are an expert in gait analysis, so does every 17 year old working in a running shoe shop.