International Performance in Sport ConferenceNewcastle, Sept 2006.
Muscle Responses to Exercise Prof Dave Jones
how optimised muscle performance before (training) and during competition? (i.e. by warm up)
muscle size and strength almost synonymous
technological advances in sports surgrery Mr Lennard Funk shoulder and upper limb surgeon, Manchester, UK.
improvements in surgical skills and ability to teamwork better has asdvanced capabilities - teamwork with coaches, physios and the conditioning coaches
advancements faster than literature
www.shoulderdoc.co.uk www.sportsmedclinic.com
not clearly evidence based
how allow person to recover faster?
aim = return to previous level of sport
National League Player of the month - Paul Rowley, Centurians –
shoulder 1. anthroscopy 2. surface replacement 3. osteochondral lesions 4. rotator cf repair and patches 5. suturtres and anchors 6. hyaluronans 7. acceearted rehab – cryo, tc
knee, sanjiv jari 1. chondrocye transplantation 2. meniscal transplant 3. double bundle ACL
Anthroscopy - ‘ the needle with an eye - no sutres, less pain, day case procedures, quicker rehab, lower morbidity - conditions treated: impingement, AC joint artisritics - overhead athletes shoulder – o internal impingement, dynamic assessment (Burkhart et al, Arthroscopy, 2003) – not just baseball pitchers o anterior plication - contact athletes shoulder o labral lesions o treat all associated pathology o rapid return (Funk et al. Clin J Sports Med, 2006) - Rotator cuff repair and reconstruction o cuff tears o outcomes of RCR • time ti surgery; previous steroid injections, quality of tendon tissue; quality of muscle; smoking and NSAIDs - Collagen patches o reinforcement of repair; provide protection; incr strength of repair replacement; accelerated healing (growth factors) o GraftJacket regenerative tissue matrix - Genetic Engineering o putting stem cells on collagen scaffold - Wheelchair athletes shoulder o acute rotator cuff tear - Osteochondrail lesions of sholder and elbow - Sutres and anchors o extremely strong, semi-biodegradable, controlled release growth factors - Anthroscopic stack - anthroscopic theatre – bridgewater hospital, Manchester - shoulder replacement in young people o surface replacement (bone preserving, minimally invasive, easier revision, long term results (Funk, Copeland and Levy, JBJS 2004) - Post-op advances o anti-implamm • mechanical, biochemical (inhibit phagocystits) o viscoseal hyaluronan (less pain, better function) - Slings and Cuffs (traditional slings, unnatural and no evidence!) o in France: preferred: 15 deg ER Sling – better early ROM - Cryocuf (less pain, less analgesics, faster ecover Singh et al 2001) - Shoulder rehab advances o protect from physiotherapst! o effects of immobilisation o clinical results • old protocol – 20|%s stiff o protect and rehab at same time? o Tendon loading • immobilisation: dec tendon weight, dec stiffness and tensile strength, irregulat collagen fibres, type 3 :> Type 1 collagen; degenerative changes; Exercise: (incr growth factors, tensile strength, incr • EXERCISE RATHER THAN IMMOBILISE - Accelerated Protocol o Day 1-3 weks (0-20% EMG exerciseds; Low activitiy) o 3-6 Weeks (40% + EMG) o 6+ (40% + EMG)
Kneee (Sanjiv Jari) 1. chondrocyye
Autologous Chondrocyye Implanatation (ACI) - cartilege cells harvested and multipled - isolated defects, stable knee reqs,
MACI -
Summary Future: Biological Implants Tissue Engineering
Questions and Answers
question: how does it fit with doping
a: don’t know?
a: growth factor unlikely to enhance
Lee:
Ron: doping do not prevent treatment
Lee: grey area is gene therapy – once therapeutic over, still a permanent enhancement
Michelle Verokken:
Ron: where next big advances?
Funk: not sure ewhether tissue engineering will be taken over by synthetically derived growth factors.
Athletic Injury and Gene Therapy Lee Sweeney
muscle injury in context muscular dystrophy
skeletal muscle
somatic cell gene transfer - delivery of DNA into fully developed tissues (eg lung, liver, heart, skeletal muscles) - technology developed for gene therapy – correction of genetic mistakes that cause disease - hwr same technology for genetic enhancement or improvement of functionality of non-disesase, but injured tissue
Gene delivery into muscle - primary target is post-imtoic (no-dividiing) nuclei of t mature muscle fibres - gene delivery vectors o naked (plasmid) DNA – ineffecitent and transient o Viruses (AAV (Serotypes 6 and 8 are most efficient); Capsule modified lentiviruses o Non-viral DNA conjugates o Adult stem cells (muscle and bone marrow derived)
AAV mediated gene transfer - readily infects skeletal muscle - no drop off of expression over time - limb delivery possible, body delivery still limited - size limitation – some genes don’t fit (duchenne muscular dystrophy) - virus production had been a problem, but new technologies in viral production … amount required to treat will soon not be a problem. - immune response problem –
Questions and Answers
Question: a lot of body builders using systemic IGF-1 from China
question: will treatments be relevant for diff fibre types?
a: wouldn’t redistribute muscle mass.
Lee: application to dogs – owners would like dogs to be able to keep going for longer.
lunch
biomechanics and sport salo
definition
support issues examples
Conflicts of Interest Panel
mark james, acting head of Salford law school john o’leary mike townley, parters of athletes1
mark Dept of Health recognition of Sport and Exercise medicine as a discrete specialism is releavtn here.
ME: ask question about whether should be charcterised as medicine.
discussions of ‘best practice’ more relevant than legal rules that are tight
ME: we heard earlier that surgical technological developments does not rely on an established evidence base, so can an athlete expect informed consent?
john
what do we mean by implied consent in sport?
mike
need for radical difference in physician’s role in sport performance
ME: Is the patient-doctor model an adequate reflection of the athlete-doctor relationship?
Question: Max Jones (runs Marathons (not the Max Jones of UK Athletics) in what way should aptient-doctor relationship change just because the athlete becomes so good at her hobby. WADA don’t trust doctors. after 1999 lausanne conference,faq was ‘should medical doping be permitted’. answer was no, because only the IOC could control long term effects of doping.
Mike: how should the relationship change? it needs to be less suspicious. doctors must become less suspicious of performance team. athletes must become less suspicious of conseqs off communication of an injury status. in funded sports, not clear that communication leads to de-selection. get beyond idea that favouritism is what counts. british athletes not happy with waiving competition.
ME: 2 athletes, both get injured, one athlete tends to do better with recovery psychologically than another. on this basis, the doctor recommends the former athlete, but on no scientific basis.
Mike: diff between weekend warrior and elite athlete. athletes want to go to limit. amazed at how medical community have reacted.
Rob Dawson: comments outrageous. patient-doctor relationship is sacrosanct. if correct doctor selected for team, they willl have the right values.
Mike: but when accepting claim that nothing breaks patient-doctor relationship
Ross: GMC – doctors role to protect indiv.
James:
Steve Olivier: research ethics. I don’t think the comments are outrageous at all. things can change. why should a rational adult be allowed to waive confidentiality?
Rob:
Mike: great hostility to that waiving of confidentiality. met with resistance before it gets to the athlete.
James: how does one define relationship between doctor and athlete? eg. a power relationship – doctor is older usually, more formal education, perhaps greater level of sophistication. compared with athletes who are youngerk, less experienced in t ways of life, and, perhaps, possessing lesser degree of sophistication. standard I use to make sense is – lookinjg at perspecxtive of aptient – it’s the REASONABLE athlete standard. defining reasonableness is difficult. how achieve informed consent from this perspective? not as an event disclosure – eg. signing a form = consent – I think, compared to gen medicine, sports practictionaer already has special relationship that there is an ongoing comm., that athletes and doctors are working together. sports produce injury. tf, athletes and doctors will have the regular contact. som, there is a special relationship – not legal term. then, issue of informed consent is easier, as ‘process’ or ‘educational’ consent. PROCESS MODEL.
Michelle Verokken: would be fine if informed consent and confidentiality if all athletes over 18. one of my concerns is youngsters brought rhough sports system, where they learn to trust various people. not consent, but only alternative you have to achieve public funding in order to compete. no genuine capacity to consent. implies doctor has nobody behind them, but we know they are.if try to achieve informed consent, must take sport system as a whole.
James: difference between Consent and Assent – if assent, then different from consenting.
Michelle: difficulty in sports is that getting to top, few people who fund themselves without trappings. ie. not sure there is a consensual relationship anymore.
James: objectify athlete
Max: the athlete? the antidoping codes don’t apply to athletes, but to Athletes – defined as International andnational athletes. WADA 2004 best practices code – form at end – ‘I agree and had opp to review IAAF anti-doping code). they don’t need consent. WADA Code not an Agreemnt – if effected by it must sign. when Dick Pound said antidiopng rules are rules that athletes consent to, he said if they don’t like rules, tough!
john: concerned about idea of ‘best interests’ in sport. seems to be a nebulous consent that runs riot.. idea of waiving confidentiality falls in that confidentiality? how does this benefit athlete?
ME: if we are propsing a non-medical model, would this change DoH funding?
john: interests of sport, or interest of athletes.
mE: rights of sport, wrong, but protection of a practice is.
Question: as an athlete, you choose to compete and accept rules. eg. agree that netball is a non-contact sport.
Naomi, UK Sport: project on datsa storing of injury data
Mike: IOC philosophy – ‘exhaulting life…’ that’s not the way it’s viewed.
John: are you talking about implics of practie, sport, or criminal law? probably committin criminal act to defraud – money involved? prize money
Michelle: informed consent from eam doctor’s perspective be suspicious of.
Rob: who owns the records? if change definition of doctor in sport… when a clinent, not same duty of care.
Bruce Hamilton: if genuine consent athlete won’t do it?
Mike: to get informed consent, are you saying
james: ongoing consent. significant practicality – not enough time.
coffee
visualisation techniques
functional equivalence - motor iagery and motor preparation are related to same represn stem - some differences o outcome o dual pre-motor system
a good experience is good when you do not recall how you did it
bad ones often bad because consciously controlling what is wrong - can recall in fullest detail
Practice makes Permanent
Wednesday
Medical Complicity in doping John Hoberman
historical imeline
1893: philippe Tissie performs a doping experiment 1933: a german pharmacologist condemns doping 1941: androgens for the ‘male climacteric’ 1957: American medical association studies doping 1957: ‘should athletes take ‘pep drugs’?’ (UK) 1957: AMA Denounces Amphetamine Doping 1960: an American sports physician on doping
1969: drugs: a threat to sport (Sports illustrated 1972: physican claims steroids don’t work 1985: west german sports doc condemns ysteria 1988: The Lancet on Physicians an Doping 2005: A South Carolind Doc upplied steroids and GH 006: inteview with Loptha Heinrich (Jan Ullrich) 2005: doc comments on golof and testosterone
1890s, era of high performance sport begins crude exptl period of stressing human physiology cyclists become great subjects for testing human limits Tissier linked with De Coubertin – concerned about stree on body from sport ie. physician concern about welfare of athlete goes back far
two aspects of tissier – - 1890s, naïve and is sending cyclists around track with diff liquids, rum, milk, champagne - performing a dopping expt of hisoown
before concept of doping existed, he was interested in wht to do about fatigue
he described athlete as a sick person
athlete as a pathological case
when does idea of doping emerge
1920s
1933, A German Pharmacologist Conmens Athletic Doping - check Mortal engines for quote
UV rays to boost performance
inter-war period, doping discussion as we know it begins
don’t tell me that steroids spoil everything!
marketing of androgens
1941 – Androgens for the ‘Male Climacteric’ healing of male menopause
testosterone synthesisee in 3 labs in 1935
by 1939 being used wrecklessly by US docs
aphrodisiac property of testosterone - irony, was given to women who were in no condition to be sexually active
the focus on athletic doping is imp, btut not enough need to look at the entire medical landscape
booming anti-ageing market
1957 Four Minute Miles accused of Amphetamine Doping, New York Times, June 6 ‘AMA to Study drugs in Sports: Use in Four-Minute Mile Hinted’ [front page story] - assumption by phywsician was that humans not capable of this without supplementation
this set off a discussion
1957 The New York Chapter fo the AMA Denouncest Doping as a Threat to Youtyh – JAMA, June 13: 1244)
ME: What is the motivation of these doctors?
we are still at this stage of the discussion
1957 Sir Adolphe Abrahams on Amphetamine Doping, The Sunday Times June 16 ‘should athletes take ‘pep’ drugs’?
he did not succumbe to the moralising syndrome of the previous eg
need to understand how naïve some physiscians have been about doping before
a victorian outrage in response of AMA officials
this is also recognisable to use, as their genuione alarm of illegitimate use of drugs, what we get is something that is conflation of moral/ethical argument against drug use and the medical argument
ethics and health underpinned anti-doping
conflation of moral and medical is effortless
for Abrahams and brother who were publishing commentaries at the time, Abrahamas was an indep type. refused to assume drugs were effective. he also said ‘quite apart from the possibility of physical illconsequences, physician cocenr about amphatem…. was about suppressing self-inhibiting;’’’ concrn that would suppress limit recognition ‘as to anything unsporting’… o’one is forced to face debatable’ - ie. he did not take automatic moralising position. he insists on thinking about what constitutes doping. this was a sophisticated posn for his day.
imp to understand that this issue was being given attention 50 yrs ago
what constitutes doping was unsettled
groping for a workablre doping definition
why?;
partly because assaled by claims about drug use and by medical concern
1960 An American Sportw Phyiscian on dopin: Amateur vs Professionals, New York Times, sept 12, ‘use of drugs in sport’ first drug induced Olympic athlete death
letter to NYT where immediate parst president of American Coll of Spots Med says ‘the proesional athlete has a job to do, which may be his sole livelihood’ ‘sounds like prince de merode] so he ‘may use any means to acxhieve’ calculated risk of means are recog part of any professional sport
who could describe subculture of toure de france any better!?
using words likke ‘perversion’
he was saying let them do what they want
1969 Sports Illuswtrated: ‘drugs – a threat to sport’ sports Ill, June 23
HK Duley – physician on US team - offered 4 args on behalf of physican involvement in steroid doping o 1. indespensible in weight sports o 2. physician had no obligatin to dissuade athletes from using drugs ‘I did not give steroids at Taho, but I did not inquire what the boys were doing on their own. I did not want to be forced into a position where I had to report them’ o 3. drugs did not differe in any essential way to other performance enhancing techniques. if I know something that would improve performance, without any serious health risk, I see no reason not to make available to an athlete. o 4. medicasl supervsision was safer than no supervision at all ‘lesser harm’ argument. ‘athletes hear about these things arnd are going to get them one way or anyohter’
have to agree with hum on one point - in 1960s etc were many physicians who did not know about these drugs.
1972 An American sports physician claims that etoids don’t work: doping is quackery, JAMA, vol221 August 28, 1972 ‘Drugs and the Athlete’ (Donald L Cooper), pp.1007 ‘normal is the best there is’ ‘ drugs are for losers’
this phase cost sports physicians credibility
1985 West German sports doc (Mortal engines, 1992, p.262) condemns hysteroa about therapeutic anabolic steroid use: Heinz Liesen
1976 most prominent german sports physicans testified that steroids were safe and recommended should be used by national athletes
Heinz Liesen (1985) – testosterone less dangerous than female pill ‘why do we make such a drama out of this?’ - this question keeps returning - if we want to get at deep roots of crisis or, more strongly, freefall, mst see how commercial interests in sport, negotiate performance enhancing treaty with war on drugs
West gErman only place I know that had celebrity sports physicians
Lieson has something interesting to say – substitution therapy
therapy vs enhancement problem
1988 The Lancet on Sports Physicians and Doping, Sept 10: 612 two weeks before ben Johnson ‘Sports Medicnie – is there lack of control?’ - ‘although evidence of involvement of med practitioners…is lacking..they are connivers…’
a real problem brewing with doctors involvement
2006-2006 ‘James Shortt’ - ‘an alternative medicine and longevity doctor provides doping drugs to professional football players in Southc Carolina’ ( - he has just been sentenced to prison for prescribing GH - he is a ‘rogue sports physician’ n - not with an official position - from Jan 01 to Jun 04, authorised around 139 GH prescriptions, etc etc, - comparative context imp - market for anabolic steroids has v little to do with elite athletes! (there is a range of clients). - prescribed to athletes, police officers (thisis imp) - mesamorphists.com - cops, soliders, bouncers, security, fireman, all use them - he take recordedhis own incriminating conversations - he says ‘for you guys what I’m looking for is a non-detectable performance enhancement’ - athlete as client – what does a sport physician owe an athlete? - My guess is that Dr Shorrt is looking for stress from a functional standpointm, rather than therapeutic - treated about 14 NFL to help athletes ‘heal’ from athletes - but he just said the opposite! - medical authorities did not look at Shortt as he saw himself. they blamed him – no medical justification for prescriptio - he then collapses and confesses, saying he wrote prescriptions and he says he knows it was ‘federally wrong’ - he failed his social obligation to create role models
mE: I’m inteeresrted in the range of characters you present.
Dr Lothar Heinrich - ‘anti doping work is not my mission’ - focused on health
ME: why does heinrich not see antidoping work as health work?
- when Ullrich and other 57 got wiped out of Tour, tv viewings went down by a third - ‘cycling is not a drug-ridden sport’ - in sport ‘you hope to participate in something of historic significance’
so much for the detacthment of sports physicians
Questions and Answers
Rob: crucial aspect is that is ‘sports entertainment’ industry
ME: comparable to others?
Rob: bottom line is that it is against the rules. and this is the key Partl.l the future?
John: public survey data suggest around 30-40% say they are unconcerned about medically supervised steroid use. we’ve reached a point when have to think about being a conscientious defector from performance culture of sport. Heinrich doesn’t want to take any social responsibility.
Michelle: where is best pase to have debate about medeicl involvement on performance enhancement
lunch
prof. david cowan, UK Sport kings college London
DTI Foresight - ‘analysis of substance that influence performance’ - he was involved with this. - - landmarks in drug analysis
pharmacogenomics microchip technology
post 2010 - inviv in situ analysis - electromagnetic scanning - direct measurement in complex matrizes - isotope signatures
would we have sport where everybody wins? no.
as long as it is the will of sport comptitors to control doping, effective doping control must be continued
bruce
Garnier ‘medscape ortopediat and sports med 2006 ‘in sport with are dealing with a health even a super-healthy population
Medication Use in Athletes Selectf for Doping Control at t Sydney Olympcis 2000 Caorrigan and Kazlauskas CJSM 2003 ‘it is diffi to udst why t med starff has endorsed such under dosing as apriri one a day…
autologous blood injections
blood spinning - spin off from autologous blood injections
jim
baseball need consent of union in order to do doping tests