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12 Years impact to health and sport past – presence - future
Norbert
Bachl
EFSMA-President, Faculty for Sports Science and University Sports,
University Vienna
Since
the European Federation of Sports Medicine was founded in 1997,
EFSMA was developing both in the number of member countries and
also in different wide spread sport medicine activities. EFSMA at
the moment has 41 member countries, has excellent relations to FIMS,
IOC, EOC, ECSS and other international federations and has organized
through its member countries - including the European Congress in
Antalya - up to now 6 successful European Congresses of Sports Medicine.
One very important task is the cooperation with UEMS with the final
goal to have sports medicine recognized as a specialty within the
EU. EFSMA had applied to create e Multidisciplinary Joint Committee
(MJC) of sports medicine within the UEMS and was successful. Then
a curriculum for the education of sports medicine was worked out,
which was recognized by all the sections and the respective board
of UEMS. At the moment EFSMA is active to settle up all the necessary
preconditions for the training centres and trainees. From the European
perspective 20 European countries at the moment have sports medicine
recognized as a specialty and 15 as sub-specialty, within the EU
the numbers are 11 for specialisation and 7 for sub-specialisation.
To be recognized within the EU, we need two fifths of the EU member
countries with the specialty of sports medicine.
Following these achievements, challenges and perspectives for the
future are discussed with regard to the areas research, practical
sports medicine, education and international relations.
Carbohydrate
metabolism and performance
Clyde
Williams and Ian Rollo
School of Sport, Exercise and Health Sciences Loughborough University,
UK
Most
studies on carbohydrate metabolism and performance have used constant
pace exercise. In contrast there are relatively few studies on the
impact of carbohydrate nutrition on performance where the individual
sets the pace e.g. time trials that simulate ‘real life’ competition.
Therefore, we examined the benefits of ingesting carbohydrate-electrolyte
solutions (CHO-E) on self-selected running performance using an
automated treadmill that responds to the runner’s change in speed
without their intervention. In the first study experienced runners
ran as far as possible in 1 h either ingesting a 6.4% CHO-E or the
same volume of a taste and colour matched placebo. In the CHO-E
trial they selected a slightly faster pace and completed a greater
distance than during the placebo trial (Rollo & Williams, 2009).
However, when the study was repeated after the runners had a high
carbohydrate breakfast there was no difference in the self-selected
running speeds between the two trials. It has been suggested that
the brain monitors the glycogen stores of skeletal muscle by an
as yet an unknown signalling mechanism which in turn influences
the selection of exercise intensity (Rauch et al., 2005). To explore
this idea we investigated the influence of simply mouth-rinsing
a CHO-E on self-selected running speed at an exercise intensity
equivalent to a rating of perceived exertion (RPE) of 15 and found
that not only did the runners init select a faster pace but that
they ‘felt better’ (Rollo et al., 2008). Using the 1 h treadmill
running protocol we also showed that mouth-rinsing a 6.4% CHO-E
solution improves the distance covered by fasted runners (Rollo
et al., 2009). Chambers et al. (2009) recently showed, using functional
magnetic resonance imaging (fMRI), that mouth-rinsing a carbohydrate
solution not only improved cycling time trial performance but also
activated the reward centres of the brain. These studies add to
the circumstantial evidence that the brain is actively involved
in monitoring the carbohydrate status of the individual during exercise
and appears to play a role in the self-selection of running pace.
References
Chambers E, Bridge M & Jones D. (2009) J Physiol 578 (8), 1779-1794.
Rauch L, Gibson A, Lambert E & Noakes T. (2005) Brit J Sports
Med 39, 34-38.
Rollo I & Williams C. (2009) Influence of ingesting a carbohydrate-electrolyte
solution before and during a 1 hour running performance. In J Sport
Nutr Exerc Metab in press.
Rollo I, Williams C, Gant N & Nute M. (2008) In J Sport Nutr
Exerc Metab 18, 585-600.
Aviation
medicine
Antonio
Dal Monte
Former Scientific Director of the Sport Science Institute, Rome,
Italy
The
Medicine of Aviation is of physiological origin and, curiously did
born almost one century before the Aviation itself. The father of
the Aviation Medicine is universally recognized the French physiologist
Paul Bert (1870) for his esperiments in balloon on the effects of
barometric low pressure on the human body, but the research of the
high altitude did start about at the end of the 18th century. Jaques
Charles in the 1783, John Jeffries 1784, Robertson 1803, Gay Lussac
1804, Gustav Tissandier 1875 were only few of the many balloonist
that did approch the physiology of the extreme altitude, more than
8000 meters over sea level, and the effects of the very low barometric
pressure on the human body. The researches in Aviation Medicine
did start with the studies on low atmospheric pressure, but about
century later were followed by the other fundamental object of research,
the variation of the “g” force. This very important field of research
is represented by the variation, both in the reduction or in the
increase, in some case very intense, of the gravity force. The experiments
on the multiple of the ground gravity did start not in ballooning
but with the heavier of the air, the aeroplane. The real aspect
of the very severe variation in “g” force did not start for scientific
reasons, but, for the pilots.... by the need of survive. In fact
it was during the first great war 1914-1918, that the aeroplane,
few years after his invention (Wrigth brothers 1903), became a very
effective weapon. With the increase of the sturdiness of the airplanes
did start the aerobatics, very important in the air battles, and
with the aerobatics the high number of “ g force”. One of the relevant
aspect of the Aviation Medicine is devoted to the study on the “g”
force both to the limit of the human structure, as did the American
major Stapp with rocket motorized sledge, or to study and realize
the devices to help the anatomy of the pilots to withstand so high
forces. And, in the same time of the Aviation Medicine, did start
also the Sport Medicine with which there has many points of contact
and objectives. Both the scientific disciplines does not are applied
to sick people but to an healthy population to verify their capacity
to comply with the very specific requirement of both the Sport or
Flying activities. Another point of contact between the two science
is that they uses more or less the same laboratory equipment. An
almost new entry in the field of Aviation Medicine is the Antidoping
control, according to the guidelines of the WADA, the ubiquitary
World Anti Doping Agency. The application of the rules of the Antidoping
Control to the aviation activities not is easy or fully appliable.
Just an example: the oxigen supply in the Sport activities are absolutely
forbidden. In Aviation the prohibition of oxigen condamn to death
some kind of Pilots. This is the case of the gliders pilot that,
if the meteo conditions are favorable, during their competitions,
climbs very frequently at flight levels in wich, without the oxigen
supply and without a pressurized cockpits, they cannot survive.
Bolt´s
and Phelp´s performances – the attempt of a physiological explanation
Ulrich
Hartmann
Institute for Movement and Training Science in Sports, University
of Leipzig, Leipzig, Germany
When
looking through the available literature dealing with this topic,
it is conspicuous that from an energetic point of view there is
no exact knowledge of the stress profile and the energy provision
in the various sport events and disciplines.
Based on those physiological coherences a very good assumption and
a theoretical frame are given to re-calculate the individual performance
of an athlete by computer simulation. The 100m Beijing Olympics
sprint of Usain Bolt as well as the 200m swimming record and the
other competitive races of Michael Phelps are used to calculate
and to remodel the physiological frame of Bolt´s and Phelp´s performance.
– Based on video analysis the number, frequency and length of each
single step for the 100m distance the Phelp´s muscular power output
is calculated by the simulation model written above. Also for Phelps
the speed over the distance, the arm frequency and the propulsion
per stroke was detected; following also for swimming a calculation
was proceeded to explain the individual performance by computer
simulation.
Assuming realistic variations of performance ability, the variability
of the metabolic pattern will be demonstrated. - There is a relatively
favourable result of the special metabolic performance ability at
a relative oxygen uptake (VO2max) or a relatively high glykolytic
performance, depending of the event and discipline.
The differences between the reactions of the top-level athlete´s
organism show that a physiological performance assessment which
is only based on performance, lactate and possibly VO2max is not
very meaningful and can therefore lead to considerable misinterpretations.
A sport specific and the metabolism representing simulation of the
performance will be shown.
Integration
of different technology systems for the development of football
training
V.
Di Salvo 1,2 and M Modonutti M 2
1 Department of Health Science, University of Rome “Foro Italico”,
Italy, 2 Real Madrid TEC, High Performance Centre, Real Madrid CF,
Spain
Over
the last few years, research in the field of Sport Science has incorporated
the use of new technologies in order to advance the levels of specific
knowledge and to find the most appropriate ways to reach the best
performance possible. Within this context, and following the criteria
of integration of new technologies for the development of training
programmes, Real Madrid CF has launched as a top, strategic priority
the development of the world’s leading training and performance
centre. On the principles of this philosophy Real Madrid TEC-Sanitas,
a High Performance Centre focused on innovation in the area of Sport
Science using the latest technology and the collaboration of different
expertises coming from all over the world, has been implemented
with the goal of developing new approaches in the training methodologies
area. This advance will produce a modern concept in the control
of training with individualized programmes that will develop the
performance and the longevity career of all Real Madrid athletes
in order to remain competitive in today’s football and basketball
landscape. The philosophy of TEC is based on the interconnectivity
of different systems and the integration of the results produced
by them. Real Madrid TEC-Sanitas is a multifunctional structure
designed around different operating labs that through cross-platform
activity and interchangeable data analysis optimize performance
in the field by committing to the following:
- Submission of full cycle of functional evaluation monitoring the
physiological characteristics of each athlete;
-Development of individual training programmes following different
aspects (physiological parameters, anthropometric, age, player position,
minutes played etc.);
-Convergence between scientific research and technological on-field
practical application, in order to conduct athlete studies on all
Real Madrid players (professional and youth).
Real Madrid TEC-Sanitas is comprised of the following operating
laboratories: Biomechanics, Functional Evaluation, Neurophysiology,
Image, Vision, Nutrition, Data Analysis Training Methodology and
Research & Development. The Biomechanics Lab is composed by
different systems of high technology fully integrated and synchronized
between that allow a complete analysis of football player movements.
It is composed by 12 cameras monitoring movement along 20 meters,
and two high resolution cameras. In the Functional Evaluation Lab
there are several systems for the evaluation: isocinetic, encoders,
stability board, speed and agility system force platforms, wireless
EMG and foot scan. The Neurophysiology Lab is based on Bio-feedback
and Neuro-feedback systems. The Image Lab use the data collected
from the video match analysis and is developing decision making
systems. In the Vision Lab the visual skill training is the main
priority through the use of different computerized systems. An intelligent
data bases allows the Data Analysis Lab to cross-analyze information
and to test correlations, and assess predictability among all parameters
of performance. The development of cutting-edge instrumentation,
end-user products and training methodologies will become the main
objective of Research & Development Lab.
Patellofemoral
pain: Philosophy behind the problem
M.
N. Doral 1,2, G. Dönmez 2, U. Dilicikik 2, Ö.A Atay 1, A.H. Demirel
2 and D. Kaya 2
1 Hacettepe University Dept. of Orthopaedics and Traumatology, 2
Hacettepe University Dept. of Sports Medicine, Ankara, Turkey
Patellofemoral
(PF) disorders are among the most common problems seen by orthopaedists
and sport physicians. But there is still no consensus in the literature
regarding the terminology for pain in the anterior aspect of the
knee. Thence many terms have been used to describe PF pain disorders
including anterior knee pain, extensor mechanism dysfunction, medial
facet syndrome, lateral facet syndrome, lateral compression syndrome,
patellar malalignment syndrome, patellofemoral pain syndrome, patellofemoral
stress syndrome, intra-articular patellar chondropathy, patellalgia
and chondromalacia patella. Usually the clinical presentation of
anterior knee pain is diagnosed as patellofemoral pain syndrome
(PFPS). PFPS can be defined as anterior knee pain involving the
patella and retinaculum that excludes other intraarticular and peripatellar
pathology. PFPS remains a challenging musculoskeletal entity encountered
by clinicians. The most frequently reported symptom is a diffuse
peripatellar and retropatellar localized pain, typically provoked
by ascending or descending stairs and squatting.
The exact cause and pathophysiology of anterior knee pain is not
well-understood. Fulkerson described six major anatomic structural
sources of PF pain: subchondral bone, synovial lining, retinaculum,
skin, muscle, and nerve. It is accepted that PFPS is multifactorial
in origin and many theories have been proposed. A combination of
variables, including abnormal lower limb biomechanics, soft-tissue
tightness, muscle weakness, and excessive exercise (overactivity
theory) may alter tracking of the patella within the femoral trochlear
notch contributing to increased PF contact pressures that result
in pain and dysfunction.
The patellofemoral joint is considered to be one of the highest
loaded musculo-skeletal components in the human body. Joint reaction
forces that are created within the PF joint in compression and tension
with normal activities of daily living are on the order of multiples
of body weight. Forces on the patella range from between one third
and one half of a person’s body weight during walking to three times
body weight during stair climbing, to 7 times body weight during
squatting, and up to 20 times or more body weight with jumping activities.
Therefore the articular cartilage of the patella is the thickest
in the body and it can reach 7 mm in the central portion of the
patella. However, patellar cartilage is more permeable and more
pliable than other cartilage tissues in the body.
Patellofemoral pain has been attributed to excessive stresses associated
with abnormal PF joint mechanics. Studies of PF joint biomechanics
have focused on force analysis, joint kinematics, and articular
contact forces, areas and stresses. Various biomechanical causes
of PF pain have been suggested including: increased Q angle, genu
valgum, femoral anteversion, external tibial torsion, tenderness
of the lateral retinaculum, abnormalities of the shape of the patella,
femoral groove morphologic features and forefoot pronation.
In addition, generalized ligamentous laxity, vastus medialis weakness
or atrophy and decreased flexibility of the iliotibial band and
quadriceps muscles also have been linked with PF pain. The vastus
medialis obliquus (VMO) has primary importance, because weakness
of the VMO allows the patella to track too far laterally, which
increases PF joint stress and subsequent articular cartilage wear.
Weakness of hip abductors and external rotators are also recommended
to reveal factors contributing to PFPS. These muscles help to maintain
pelvic stability by eccentrically controlling femoral internal rotation
during weight-bearing activities.
Previously, patients with PF pain often were diagnosed with chondromalacia
patellae. Chondromalacia is a degenerative condition of the articular
surface of patella. It is not strongly correlated with patellar
pain. Studies showed that numerous patients with symptoms consistent
with PFPS had no arthroscopic evidence of articular cartilage damage.
Because of the multiple forces affecting the patellofemoral joint,
the clinical evaluation and treatment of this disorder still remain
the greatest enigma for the sport medical physicians and orthopaedic
surgeons. This lecture will address the anatomical and functional
biomechanical causes of PF pain.
Patellar
dislocations in sportsmen
Ugur
Haklar
Acibadem University, Department of Ortohopaedics, Istanbul, Turkey
Etiology of patellar dislocation is multifactorial. Patella alta,
trochlear hypoplasia, lateral patellar tilt, TT-TG distance, generalised
ligamentous laxity, tight lateral retinaculum, pes planus, decreased
femoral anteversion and wide pelvis are among the most common factors.
Hip internal rotation followed by tibial external rotation and knee
valgus is the usual mechanism of injury. Diagnosis is very easy
if patella is still dislocated. But for reducted dislocations anamnesis,
physical examination, direct anteroposterior X-rays but more importantly
MR imaging becomes more important. Location of pain especially on
medial adductor tubercle or inferior lateral wall of lateral femoral
chondyle, presence of hemartrosis, painfull range of motion are
among some alerting findings . Whenever suspected primary care consists
of immobilization, rest, cold application, elevation followed by
removing player from the field. After initial management standart
anteroposterior- lateral and Merchant views should be obtained,
MR imaging should be completed for further evaluation. As Medial
Patellofemoral ligament (MPFL) is primary passive soft tissue restraint
to lateral patellar displacement MRI becomes more important for
MPFL evaluation. Treatment consists of aspiration of hemartrosis
followed by either surgical or conservative treatment. Conservative
treatment has high failure rates because of inappropriate patellofemoral
positioning it causes patellofemoral arthrosis. Still it can be
used for patients with generalised ligamentous laxity. On the other
hand surgical treatment is becoming more popular due to low recurrence
rates. No standard surgical modality is advocated instead treatment
should be individualised according to etiological factor and presence
of osteochondral lesions.
Alteration
in EMG following angioplasty in a patient with peripheral vascular
disease
Yumna
Albertus, Jeroen Swart, Robert P. Lamberts, Michael I. Lambert,
Timothy D Noakes and Wayne E Derman
UCT/MRC Research Unit for Exercise Science and Sports Medicine,
Department of Human Biology, Faculty of Health Sciences, the University
of Cape Town and the Sports Science Institute of South Africa, Cape
Town, South Africa
INTRODUCTION
Peripheral Vascular Disease limits exercise performance due to claudication
pain hypothesised to be caused by ischemia and increased blood lactate
concentrations. However, no research has investigated the influence
of central regulation and more specifically muscle activity on functional
capacity. We report on a patient with a single tight stenosis of
the femoral artery. We investigated changes in muscle activity,
exercise performance and other physiological variables before and
3 days after angioplasty.
METHODS The patient performed maximal voluntary contractions on
prior to walking on the treadmill until exhaustion using the Graded
Treadmill exercise test (GTET) protocol (walking at a constant speed
of 3.2 km•h-1 starting at a 2 % gradient which was increased by
2 % every 2 minutes until exhaustion). Electromyography, heart rate,
brachial blood pressure, rating of perceived exertion, pain score,
oxygen consumption and blood lactate concentrations were measured
during both trials.
RESULTS Most of the patients’ measured physiological variables improved
after angioplasty. Peak force produced during the MVC by the quadriceps
and calf muscles increased by 24 Nm and 19 Nm respectively after
angioplasty in the diseased leg. Blood lactate concentrations from
the 3rd to 5th minute post exercise ranged between 2.00 - 1.75 mmol•l-1
in the Pre - A trial and decreased to the range of 1.75 - 1.50 mmol•.l-1
in the Post - A trial. Muscle activity in the diseased leg was found
to increase after angioplasty and to greater activity extent than
the asymptomatic leg after angioplasty. Muscle activity in the diseased
leg, increased after angioplasty in VL (85 % - 130% max EMG pre
and post angioplasty) and LG (90 % - 180 % max EMG pre and post
angioplasty), whereas MG remained similar over the trials.
CONCLUSIONS The alteration in muscle activity after angioplasty
is a novel finding. It can be assumed that these changes in muscle
activity could be seen as a readjustment of the central drive to
the lower limbs and in the diseased state a possible regulatory
mechanism to protect the body from harm.
Point-of-care
athlete testing, a new approach of sport performance evaluation
Ioan
Stoian
National Institute of Sports Medicine, Bucharest, Romania
Point-of-care
testing is defined as testing performance at or near the sites of
training or competitions, in the precise conditions likely to be
really experienced. In sport science, usually such tests are not
as reliable as laboratory tests, but often have greater validity
because of their greater specificity. This is invariably difficult
to achieve as there are numerous factors experienced in competition
which are near to impossible to replicate in training or testing
environment. A combination of regular field based testing (because
of the practical, easy and immediate nature of the testing) together
with occasional laboratory testing (because of accuracy, reliability
and quality) is a good option for most sports.
From many parameters used to monitor trainings we chose acid-base
status, for the relevance in reflecting in or post-exercise homeostatic
changes. In sport performance, excessive efforts to maintain internal
homeostasis in normal limits may have limiting even negative effects
on performance capacities. It is possible to appreciate sport energetic
requirements (energetic pathways contribution and efficiency in
sustaining exercise), functional status in basal / rest conditions
and exercise, exercise metabolic costs, post-exercise recovery evolution,
using calculated functional indexes. Using an ABL microlab (Radiometer,
Copenhagen) the following acid-base status parameters are determined:
hemog-lobin (Hb), acidity / basicity (pH), partial pressure of carbon
dioxide in blood (pCO2), partial pressure of oxygen in blood (pO2),
oxygen saturation (sO2), bicarbonate (HCO3), actual base excess
(ABE), standard base excess (SBE), standard bicarbonate (SBC), alveolar-arterial
oxygen tension difference (AaDpO2). Blood lactate values are also
determined. Based on specific acid-base disturbances, we can appreciate
performance capacity, reveal the metabolic costs, and also recovery
drive.
The possibility (or ability) of point-of-care testing to be done
in various conditions has demonstrated an significant potential
to change the way of monitoring training and recovery. However,
the lab cannot exactly reproduce the external environmental factors:
run and bike – road conditions, weather, hills, wind resistance;
rowing, canoeing – water conditions, current, weather, wind, boat
friction / water resistance, that athletes experience in training
and playing or training locations (even altitude campus). Based
on these results, valuable coaching decisions could be taken. It
is essential that the coach identifies a reliable, experienced support
team of professionals that can manage the details of competition
based testing leaving the coach free to coach. In trainings, competition
or during rest periods, point-of-care testing can provide the coach
and athlete informations about areas of weakness or limitation,
about developing and improving performance. These kind of testing
respect sport specificity and environmental factors, experience
and training status, age and sex. Based on the testing results,
it is possible to create the athlete’s profile, for training to
performance.
Understanding
the structure and the biological properties of the articular cartilage
Theodora
Papadopoulou
Orthopaedic Department Diana Princess of Wales Hospital, DN332BA
UK
The
structure of mobile interosseal junctions mandatorily includes the
articular cartilage (cartilago articulare). The latter has been
marked off as an obligatory element in the human body descriptions
by anatomists as early as Antiquity and Middle Ages. According to
notions adopted at that time, it was described as avascular, inert
and bradytrophic tissue incapable of recovery after being exposed
to the effect of external factors with ensuing damage. During the
current century, the ever increasing interest in researches into
the articular cartilage is linked first and foremost to practical
medicine – orthopaedics, sports medicine and rheumatology. Over
the last decade, it has been constantly subject of unrelenting attention
by morphologists, molecular biologists, biochemists, specialists
in biomechanics and bionics. Such interest is further stirred up
by the fact that it is a matter of structure fulfilling its functions,
having an essential practical bearing on joint movements, without
being endowed with a number of advantages, characterizing other
tissues: e.g. it lacks innervation, blood vessels and lymphatic
system. Its properties are based not on the peculiarities of individual
cells, but rather on their production; on a complex network of giant
molecules situated around the cells proper and building up the extracellular
matrix, incorporating some of the longest protein chains produced
by cells in nature.
The cartilage covering articular surfaces is mainly, but not exclusively
of hyaline type. Its thickness varies depending on the topography,
and diminishes with aging. In the small joints it measures about
1 - 2 mm, and in large ones – 4 – 7 mm. Articular cartilage is thicker
in the zones of surfaces where the compression forces are strongest,
usually in the central portions. In younger individuals, continuous
movements result in cartilage thickening. It is avascular except
for the deeper layers closer to bones; devoid of nerve branches;
not covered by perichondrium or synovial membrane (except for the
lateral portions). Normally, it never undergoes ossification, and
is built up of cells (chondroblassts) situated within small cavities
of varying size (lacunae), surrounded by intercellular substance
– intercellular matrix. The intercellular matrix determines the
mechanical properties of articular cartilage. During study with
conventional light microscope it is homogeneous in appearance. The
existence of collagen fibers has been definitely confirmed after
the introduction of electron microscopy which contributes to differentiate
two types of fibers – thick (with transverse diameter 600 nm) presenting
transverse striation at periodicity 690 nm, and fine fibrils thick
400nm in diameter.
Current
state of the art and future directions in cartilage injuries
Reha
N. Tandogan
Ortoklinik & Çankaya Orthopeadic Group, Cinnah caddesi 51/4
Çankaya, Ankara, Turkey
Although
cartilage defects smaller than 2.5 cm2 can be treated with conventional
methods such as microfracture or mosaicplasty, larger defects require
a more sophisticated approach. Autologous chondrocyte implantation
and the utilization of mesenchymal stem cells are two avenues of
treatment that have become increasingly popular. Although these
treatment modalities are indicated for traumatic or osteochondiritic
defects in young adults, several centers have used these technologies
in the treatment of early osteoarthritis. First generation autologous
chondrocyte implantation (ACI) entails the transplantation of the
patient’s cultured chondrocytes in a suspension under a periosteal
patch. 15 to 20 year data show a success rate of 73% in isolated
chondral defects, most successful being in the femoral condyles,
followed by the patella and tibia. Ankle, shoulder and elbow joint
applications have been reported. The use of ACI in adolescents and
patients with previously unsuccessful cartilage surgeries has also
produced satisfactory outcomes. Problems of hypertrophy and delamination
of the transplant occur in about 15-42% of the cases and may necessitate
secondary surgeries. Second generation ACI utilizes a 3 dimensional
resorbable matrix seeded with chondrocytes that can be shaped to
fit the chondral defect. Although clinical results are similar,
less secondary surgery, more evenly distributed cells, possibility
of arthroscopic implantation and easier surgical handling are advantages
of second generation ACI. 5-10 year results of second generation
ACI are promising. The most frequently reported techniques have
been MACI, Hyalograft C and CARES with around 85% good clinical
results. Many improvements, mostly experimental, are being made
in ACI to achieve better outcomes. These so called 3rd and 4th generation
ACI techniques include selective culturing of cells, the addition
of growth factors to matrices, use of hydrostatic pressure to improve
cell quality, the use of fetal allogenic chondrocytes or mesenchymal
stem cells in a matrix for a single stage surgery. The use of chondroinductive
matrices to augment microfracture is also promising. The field of
cartilage regeneration is evolving at a breathtaking speed and new
technologies are constantly being introduced. The merits of each
will become clear with increasing clinical follow-up with possible
extension of indications to osteoarthritic joints.
Polypharmacy
in sport
Milica
Sinobad, Nenad Radivojevic, Jelena Suzic and Nenad Dikic
Anti-doping agency of Serbia, Sports Medicine Association of Serbia,
Belgrade, Republic of Serbia
Sport
performance primarily depends on genetic characteristic of the athlete,
but as well as morphological, physiological, psychological and metabolic
sport specific characteristics. Optimal training can improve physical
power, enhance mental strength and make competitive advantage. However
athletes very often use different substances in order to achieve
better physical fitness and sport performance. Implementation of
Anti-doping rules decreases use of prohibited substances, but increases
use of different dietary supplements. If we add irrational usage
of medications, first of all analgetics, we can resume that polypharmacy
is present in sport.
We analyzed data collected from athletes from competitions as well
as from out-competition testing from 2005 to 2008. Among 912 athletes
(age 23.9±6 years, 72 % male), 1.5% (14) of them (64.3% male (9)
and 35.7% female (5) have used ten or more supplements and/or drugs.
These 14 athletes used between 10 to 17 products or 162 different
products. Of that number 76.5% (124) were supplements and 23.5%
(38) were drugs. In average 8.9 supplements and 2.7 drugs were used.
Between 12 -59 single substances have been in products taken by
athletes, in average 33.4 per athlete. Vitamins are the most presented
substances, in some cases in dosage about 250 times greater than
recommended. Most of these athletes took vitamins in 2 or more different
products. Minerals, aminoacids and other substances were taken in
dosages less then recommended.
Overuse of vitamins and suboptimal dosages of other supplements
without clear indications and recommendation show us ignorance of
athletes, coaches and medical stuff involved in sport. Education,
in first place of doctors, then coaches and athletes is a primary
goal. But first step should be cooperation of medicine, pharmacy
and sport science in order to make strategy and recommendations
for use of supplements and drugs in sport.
Nutritional
supplements and medications in sport
Nenad
Dikic, Jelena Suzic, Nenad Radivojevic, Jelena Oblakovic Babic,
Sanja Mazic, Marija Andjelkovic and Milica Sinobad
Anti-doping agency of Serbia (ADAS), Sports Medicine Association
of Serbia (SMAS), Republic of Serbia
Australian
Institute of Sport (AIS) categorized nutritional supplements (NS)
in four groups: group A - approved NS, group B - NS under consideration,
group C - no clear proof of beneficial effects and group D - banned
NS. There are many studies with aim to describe qualitatively and
quantitatively NS and medications used by elite athletes. Our group
did it in several big competitions, like FIBA Europe, University
games, as well as in main international competitions in three years
period. In that largest study we have analyzed data collected from
athletes (n = 912; age 23,9 ± 6 yrs; 72% male) from national, international
competitions and out-of-competition done by ADAS from 2005 - 2008.
Among 2535 reported substances 69,7% (1767) were NS and 28,9% (734)
medications. NS have taken by 74,6% (3,17 per athlete) and medications
by 40,6% of athletes (1.98 per athlete). Almost 21,2 % of all users
reported use of 6 or more different products and one athlete took
17 different products at the same time. In group A of AIS classification
was 56,3% and from group B, C and D, 14,4%, 32,7%, 2,2%, respectively.
Majority of athletes who reported use of medication used NSAID (n
= 225, 66%; 24,7% of all examined athletes). More than one NSAID
was taken by 22% (50) users. In addition, more frequent use of NS
among younger athletes was observed (p <0.05). Our studies confirmed
overuse of supplements and drugs by elite athletes. Fact that large
number of athletes used supplements with no evident performance
or health benefits, demonstrated the need for specific educational
initiatives. Amount, quantity and combination of reported products
raised concern about risk of potential side events.
Submaximal
muscle activity at exhaustion during incremental cycling
Y.
Albertus, R. Tucker, W. Derman, T. D. Noakes and M. Lambert
UCT/MRC Research Unit for Exercise Science and Sports Medicine,
Department of Human Biology, Faculty of Health Sciences, the University
of Cape Town and the Sports Science Institute of South Africa, Cape
Town, South Africa
INTRODUCTION
It is often assumed that all available motor units in exercising
muscle are active at exhaustion, regardless of nature and duration
of exercise activity. The aim of this study was to measure skeletal
muscle activity during progressive cycling to exhaustion in 15 male
trained cyclists during a peak power output (PPO) test.
METHODS Muscle activity was compared to that performed during ‘maximum’
sprint cycling. A further aim of this study was to determine if
muscle activity at the point of exhaustion is repeatable.
RESULTS Skeletal muscle activity at exhaustion was submaximal as
compared to EMG activity during a maximal sprint cycle. All six
muscles measured in the study achieved peak activation of between
44 % - 65 % of that achieved during a 10 second all-out sprint (all
P<0.05), Vastus Medialis (VM; 59 % - 65%), Vastus Lateralis (VL;
54 % - 60%), Rectus Femoris (RF; 44 % - 51%), Biceps Femoris (BF;
42 % - 45%), Medial Gastroc (MC; 40 % - 46%) and Lateral Gastroc
(36 % - 44%). The intra-subject variability showed that only a few
muscles had coefficient of variation (CV) values less than 12 %
at exhaustion. Out of 15 subjects the number of subjects displaying
CV <12 %; VM showed only 6 subjects, VL and MG only 5 subjects,
RF, BF and LG only 4 subjects. This is an indication that muscle
activity at exhaustion varies from day-to-day.
CONCLUSÝONS These data suggest that muscle activity at exhaustion
has a significant day-to-day variation. Furthermore, skeletal muscle
activity is sub-maximal at exhaustion during PPO cycling. The findings
support the hypothesis of a central regulation of maximal exercise
and confirm that only a certain percentage of the limb muscle mass
is active during maximal exercise. These findings are not compatible
with the peripheral model of fatigue, as this model assumes that
the total muscle mass is active at exhaustion.
Low
back pain in athletes
Tolga
Saka
Erciyes University Medical School, Department of Sports Medicine,
Kayseri, Turkey
Low
back pain has been reported to affect approximately 85-90% of the
population at least once during their lifetime. The incidence in
the athletic population has been reported to be 1-30% and is one
of the most common reasons for missed playing time in professional
sports. Unfortunately, the specific etiology of the athlete’s back
pain often remains elusive. Muscle strain is the most common etiology
of low back pain in adolescent, collegiate, and adult athletes.
It is also the most common diagnosis in both acute and chronic low
back pain.
Many conditions may lead to low back pain. Causes of low back pain
include lomber strains, sciatica, non-mechanical back and/or leg
pain, mechanical back and/or leg pain, lumbar spine fractures, abnormalities
of the hip joint, damage of nociceptive (pain generating) structures
(nucleus pulposus,annulus fibrosus, facet joints, ligaments, muscles,
nerve, synovium), intervertebral disk injuries, stres fracture of
the pars interarticularis, sacroiliac joint injury/inflammation,
lumbar instability, mainly. Malignancy, severe osteoporosis, gynecological
and genitourinary conditions should not be missed.
The basic mechanism of injury causing low back pain produces a combined
vector of force that may be difficult to analyze in a force diagram.
The three basic mechanisms of injury to consider are (1) compression
or weight loading to the spine; (2) torque or rotation, which may
result in various shear forces in a more horizontal plane; (3) tensile
stress produced through excessive motion of the spine.The compressive
type of stress is more common in sports that require high body weight
and massive strengthening such as football and weight lifting. Torsional
stresses occur in throwing athletes such as baseball players and
golfers. Motion sports that put tremendous tensile stresses on the
spine include gymnastics, ballet, dance, pole vault, and high jump.
The lumbar spine is a highly vulnerable area for injury in a number
of different sports. The reported incidence varies from 7% to 27%.
Lumbar pain is a big part of many sports, but an organized diagnostic
and therapeutic plan can prevent permanent injury and allow full
function and maximum performance. With reference to lumbar spine
injuries, gymnastics is probably the most commonly mentioned sport.
We mostly face lumbar injuries in sports like ballet, water sports,
pole vaulting, weight lifting, football, running. In addition, there
is a high risk of spine injuries in rotational and torsional sports
like golf, tennis and baseball.
Back pain is a common symptomatic complaint in the active and athletic
population. An understanding of differential diagnosis, careful
history and physical examination is obligatory to pinpoint the back
problem. Prevention is very important. Applying this knowledge and
experience to a preventative setting such as preparticipation evaluations
may allow the clinician to positively impact the development of
these often debilitating injuries through prevention.
Sport
and male sexual function
Luigi
Di Luigi
Unit of Endocrinology - Department of Health Sciences - University
of Rome “Foro Italico” / Italian Federation of Sport Medicine (FMSI),
Rome, Italy
The
possible links between male sexual function and physical training
or sport have mainly been evaluated in terms of exercise-related
modifications of the hypothalamus-pituitary-gonadal (HPG) axis and
in terms of the possible effects of life style on sexuality.
In fact, the main relationships between exercise training, sport
and male sexual function that should be discussed are:
- the role of sexual hormones in the adaptation to exercise-related
stress;
- the effects of physical training or sport on HPG axis;
- the effects of physical training or sport on sexual health;
- the effects of sexual intercourse on sport performance;
- the effects of prohibited substances (i.e. doping) on sexual health;
- the sport eligibility in male athletes with andrological diseases
(e.g. hypogonadism, etc);
- the sport participation and gender modifications;
- the sexually transmitted diseases in athletes;
- the role of sport medicine in the prevention of male sexual disorders
in athletes.
It is known that the endocrine system is highly involved in the
physiological adaptation to exercise-related stress. Depending on
the characteristics of performed exercise and on individual responsiveness,
many hormones mediate the adaptive response to exercise-stress (e.g.
CRH, ACTH, cortisol, catecholamines, GH, PRL, ß-endorphins, and
so forth). Many of these also influence the HPG axis.
Whereas it is still not clear if a sexual intercourse can influence
sport performance in male athletes, it has been fully established
that a moderate training is useful in the prevention and treatment
of sexual disorders in general population. Furthermore, increasing
evidence points to high intensity endurance training (e.g. running)
or specific sports (e.g. cycling) as having detrimental effects
on the HPG axis and on male sexual function (e.g. reduced sexual
desire, erectile dysfunction). Males chronically exposed to exercise-related
stress may exhibit reduced serum testosterone, due to increased
peripheral catabolism and/or to decreased production. Such an “exercise-hypogonadal
male condition” is characterized by stable, reduced, serum free
and total testosterone without concurrent LH elevation, and is reported
as being detrimental to both health and performance. The reduced
serum testosterone levels (e.g. male hypogonadism) can be associated
to sexual and not-sexual symptoms in athletes (e.g. reduced sexual
desire, erectile dysfunction, anaemia, osteoporosis fractures, depression,
and so forth).
Apart from being a symptom of hypogonadism, an inhibited sexual
behavior (e.g decreased libido, loss of erection) in eugonadal athletes
could be also considered as a physiological mechanism of adaptation
to exercise-related stress and might represent one of the biological
effects of stress hormone mediators involved in the endocrine response
to training-related stress. Besides the exercise-stress related
“physiological inhibition” of sexual arousal, the neuro-endocrine
and metabolic modifications induced by intense exercise training,
the effects of the type of sport on male reproductive axis (e.g.
cycling on genitalia) and many prohibited substances (e.g. androgenic
anabolic steroids, amphetamines , diuretics, beta-blockers, and
so forth) can induce male sexual disorders in athletes (e.g. altered
sexual desire, erectile dysfunction).
Tendon
plasticity
S.
Tolga Aydog
Anadolu Medical Center, Atasehir Outpatient Clinic, Istanbul, Turkey
Tendons
that provide movement by transferring the contraction force that
have been emerged by muscle contractions, are consist of a systematic
packed organization of connective tissue primarily by collagens
type I foremost, type III and IV and extracellular matrix protein.
While tendon is completely different from the muscle in terms of
physiological and histological, it can not be considered as independent
from the muscle and when it is evaluated they are assessed together
with musculo-tendinous unite.
From the past to the current date, intensive studies were performed
upon the physiology of the muscle and introduced how the muscle
changes depend on mechanical loading, disuse and ageing. However,
the data accumulation regarding tendon was extremely limited until
the last 10-20 years and their results were in contradiction with
each other intensively. The reasons that have been placed under
this issue are, the studies were made usually in vitro and structural,
mechanical and chemical features of tendon were evaluated one by
one.
As a matter of fact, while very fast and specific responses exist
in the muscle, which is the part of musculo-tendinous unite, to
mechanical loading and unloading; it is impossible that tendon can
stay without responding against this situation. Tendons do not have
an inflexible structure like steel, and thanks to the included elastin
they can stretch in specific measurements. Recently, evaluations,
which were performed by ultrasonography (USG) and magnetic resonance
imaging (MRI) as in vivo, introduce that some changes existed in
tendons, similar to the muscles as response to the physiological
changing.
Tendon morphology and compatibility have been studied as in vivo
techniques (USG, MRI), recent years. These studies have increased
in parallel to the development of space technology, and thanks to
these studies it has been introduced that tendons are not stabile
against exercise and zero gravity environment, and on the contrary
they react. Although tendons react against these situations by changing
their interior structure, especially suffering to exercise especially
during the growth era, introduced that they could display hypertrophy.
Under the lights of these studies, we have been realized;
1. Mechanic features, stiffness and Young modulus of tendon decrease
by the affect of ageing, in other words tendon becomes more compliant,
2. These changes that have been caused by ageing are prevented partially
by performing exercises (up to 70%),
3. Disuse and spinal cord injuries cause reducing of the mechanical
features of tendon,
4. Right after performing of acute exercise, synthesis of tendon
collagen speed and collapsing increase. While this increasing is
characteristic in males, it is limited in females.
5. Estrogen hormone in females is the most important factor that
pressurizes production speed increasing depends on exercise. Increasing
of tendon diameter after menopause and decreasing of collagen production
speed in females taking birth control pills, are the important indicators
that support this situation.
6. While tendon diameters are larger in males that perform regular
exercise in comparison with the males, who do not perform regular
exercise, the same situation can not be discussed in females.
Immunological
responses to exercise
Maria
João Cascais
Sports Medicine Doctor, Clinical Pathologist, Portugal
The
evidence of the changes in immune system with exercise is generally
derived from two sources: laboratory based investigations and epidemiological
studies.
For some years there is considerable evidence that exercise of high
intensity and long duration is associated with adverse effects in
immune function, and low intensity exercise appears to be beneficial
for immune system.
Those observations were based in the results of laboratory evaluation
of the number and qualities of the cells of the immune system, that
appear to be enhanced by the exercise. That is to say, that the
number of natural killer cells and circulating lymphocytes are augmented
in low intensity exercise, and the high intensity exercise makes
a decrease in circulating immune cells.
For a long time we have tried to explain the changes with other
another view keeping in investigation the plasma glutamine and cytokines
considering the exercise as a kind of inflammation, without all
the deleterious effects of this particular aspect of our metabolic
pathways.
The other face of exercise has to deal with mind and emotional changes
we can see in our athletes through the seasons of training and competition
and along the years as they grow, and somewhat, grow older too.
This makes us understand that sports are much more than muscles,
bones it takes a lot from brain also.
Molecular
basis of muscle hypertrophy and repair
Geoffrey
Goldspink
Departments of Surgery, Anatomy and Developmental Biology, University
College Medical School, Royal Free Campus, University of London.
UK.
It
has been appreciated for some time that skeletal muscle is a very
adaptable tissue and that exercise training can be designed to produce
greater muscle mass and strength and/or fatigue resistance. With
the emergence of molecular biology methods it has been possible
investigate the genes responsible for physiological changes when
muscles are subjected to different types of activities. Shortly
after the start of resistance type exercise the IGF-I gene is spliced
to MGF (IGF-IEc in the human) and this involves a “reading frame
shift” which results in a different C terminal peptide to other
types of IGF-I but all have the main globular part of IGF-I. This
unique MGF peptide acts as a separate growth factor which initially
activates the muscle satellite (stem) cells to replicate. These
are important because after embryological development there is no
further increase in nuclei by mitotic division once the muscle fibres
have formed. The extra nuclei required for muscle growth, adaptation
and repair comes from the fusion of activated muscle satellite (stem/progenitor)
cells with the muscle fibres. Following the initial splicing to
MGF the IGF-I gene is later switched to IGF-IEa which is the main
anabolic agent and initiates this fusion and the expression of myogenic
genes. As well as replenishing the muscle stem cell pool the unique
C terminal peptide of MGF has also been found have a role in limiting
tissue damage including protective against oxygen free radical damage
in non muscle tissues including the CNS. Unfortunately, as we grow
older we become less able to produce MGF. Also in diseases such
as muscular dystrophy and ALS there is impairment that results in
the ability to produce MGF and to replenish the muscle satellite
(stem cell) pool and maintain muscle and motor neurons. From a physiological
point of view this is interesting as the initiation of the activation
of the IGF-I gene and the switch in splicing to produce MGF must
involve a mechano transduction system. The detection of mechanical
strain is thought to involve focal adhesion kinases (FAKs). It seems
that as we grow older that this system becomes less sensitive because
of the decreased compliance of the tissue due to cross-linking in
the connective tissues. In some animal experiments we showed that
regular exercise improved muscle compliance during ageing but it
was still not as good as in young mouse muscles. However there are
good prospects for its use as a therapeutic compound for treating
age-related muscle loss muscle as well as muscle cachexia in a range
of diseases. Unfortunately, there seems to be more interest in its
use as a doping agent as it is available over the internet and it
is now being produced using recombinant E coli methods and therefore
it will become relatively inexpensive.
Entrainment
with bio-informative time patterns to optimize tissue regeneration
and performance
Ulrich
G. Randoll
Matrix-Center-München; Lortzingstrasse 26; D-81241 München, Germany
In
the field of life sciences, the interaction of time and space pattern
in living cells and its rhythmic order from macro scale to nano
scale are in the focus since years. Inspired even by Albert Einstein
“Life without rhythm does not exist.” we asked from the clinical
side:
1. How far tissue function is in general and especially tissue regeneration
and performance dependent from the organisation of biological, body
intrinsic time patterns (brain rhythms, breathing rhythms, heart-rhythm
muscle rhythms, cell rhythms etc.)?
2. Are there specific rhythms in the body ordering and organising
these 50 trillion cells of a human organism the whole life span.
3. Is it possible to entrain time pattern from outside the body
for therapeutic reasons?
Regarding body rhythms as a result of coherent single cell function,
we analyzed especially those of the skeletal muscle because it is
with 45% mass the hugest organ of the body. Oscillating in the range
of 8 -12 Hz (alpha-rhythm of the brain) the whole life span, we
studied the physiological and pathophysiological meaning of pulsations
and rhythms for muscle function down to the level of the environment
of the cells, the Extracellular Matrix. [1, 2, 3, 4]
We found, that symptoms are correlated to a loss of order in time
(rhythm) and space (morphological structure) pattern and can be
seen as mismanagement of the “logistic processes” on the level of
cells.
In consequence the idea was born, to construct an apparatus, to
synchronize and to readapt harmonically the cellular processes to
its normal from outside the body, similar to starter of a cars engine.
How tissue regeneration even in worst surgical cases as well as
performance in sports increases by using this entrainment-method
will be presented.
References
1. Randoll UG. 1997. Matrix-Rhythm-Therapy of Dynamic Illnesses.
In Extracellular Matrix and Groundregulation System in Health and
Disease, ed. H Heine, M Rimpler. Stuttgart, Jena, New York: G. Fischer
2. Petenyi A. 1998.: Oszillation der Quergestreiften Skelettmuskulatur
während isometrischer Kontraktion. Abhängigkeit der Oszillationsqualität
von der Größe der Kraftentwicklung, Alter, Krankheit, Trainingszustand
und weiteren Individualfaktoren. Inaugural-Dissertation zur Erlangung
der Doktorwürde der Medizinischen Fakultät der Friedrich-Alexander-Universität
Erlangen-Nürnberg. Abteilung für Unfall¬chirurgie 1998
3. Rohracher H. 1959. Ständige Muskelaktivität (»Mikrovibration«),
Tonus und Konstanz der Körpertemperatur. Wien: Schriftenreihe Univ.
4. Winfree AT. 1987. The timing of biological docks New York, NY:
Scientific American Books
5. Haken H. 1979. Pattern Formation and Pattern Recognition. Berlin:
Springer Verlag
6. Jäger A. 2006. Der Effekt der tiefenwirksamen, rhythmischen Mikro-Extensionstechnik
(Matrix-Rhythmus-Therapie) in der Bewegungstherapie. Inaugural-Dissertation
zur Erlangung der Doktorwürde der Fakultät für Geistes- und Sozialwissenschaften.
Hannover
7. Albert L. 2006. Wirksamkeitsnachweis der Kosten-Relation des
Einsatzes der Matrix-Rhythmus- Therapie in der Automobilindustrie
am Beilspiel der Daimler Chrysler AG am Standort Sindelfingen. Diplomarbeit
zum Erlangen des Grades Diplom-Betriebswirt (FH). DIPLOMA-Fachhochschule
Plauen / Vogtland
Fatique
during exercise: Possible mechanisms and recovery strategies
Mitat
Koz
Ankara University, School of Physical Education and Sports, Tandoðan,
Ankara, Turkey
Training
in its simplest form represents acute challenges to the body intended
to optimize chronic improvements in physiological capabilities.
Today athletes in many sports carried out intense training 2-3 times
per day. These trainings lead to fatique and stress. Limited time
for recovery between games and training can have a negative effect
on performance. The repetitive and intense trainings, the hassle
and stress of travel increase the risk of ‘‘over-reaching’’ or ‘‘burn-out’’,
whereby athletes lose ‘‘form’’ and enter an underperformance spiral.
Although athletes spend a much greater proportion of their time
recovering than they do in training, recovery is one of the least
understood and most underresearched constituents of exercise-adaptation
cycle. Strategies that optimize recovery after physically intense
competitions and trainings are essential to enhance, or at least
maintain, performance in subsequent sporting events (training and
competition). Different recovery strategies such as hydrotherapy,
compression garments, exercise, massage, diet and ergogenics, and
combined methods are investigated and now routinely implemented
by teams and athletes after competition and training. Restoring
of body fluids, minerals and energy sources via diet and ergogenics
can aid recovery. Some relief from muscle soreness may be achieved
by means of a warm-down or exercise. But there are studies that
active and passive recovery yielded similar effects on performance
too. Massage, cryotherapy and alternative therapies have not been
shown to be consistently effective, but the potential psychological
benefit of massage on recovery should not be discounted. Contrast
water immersion has become one of the most common recovery modalities
among elite athletes. Thus hydrotherapy regimens can replace conventional
physical training in the days after competition or training.
Although recovery from training is one of the most important aspects
of improving athletic performance effective training recovery strategies
have not been fully elucidated, and may prove to be spesific to
the individual athlete and to the point in the competitive season.
It can be concluded that optimizing recovery post-exercise depends
on a combination of factors that incorporate consideration of individual
differences and lifestyle factors.
Vibration
and performance
Ayse
Kin-Isler
Baskent University, Department of Sport Sciences, Ankara, Turkey
In
this paper the effects of vibration as an exercise and training
method on human body will be evaluated. For this purpose responses
of muscle spindles and motor units to vibration, effects of acute
and chronic application of local and whole-body vibration on neuromuscular
performance, flexibility and balance will be examined.
Vibrations are mechanical oscillations that is produced either by
regular or irregular periodic movements of a body about its resting
position. The extent of the oscillation determines the amplitude
of the vibration which is the peak-to-peak displacement in millimeters
(mm) and the repetition rate of the cycles of oscillation determines
the frequency of the vibration in Hertz (Hz). Vibration applied
to a muscle belly or tendon elicits a reflex muscle contraction
named as the Tonic Vibration Reflex (TVR). When muscles are exposed
to vibration, they exhibit TVR in the form of a gradually increasing
involuntary contraction. A few seconds after the application of
vibration, the involuntary contraction begins, increases gradually
and stays at a relatively constant level until the vibration ends.
TVR results mainly from the vibration induced activity of the muscle
spindle Ia fibers.
There are two methods of applying vibration to the human body during
exercises. In the first method which is called local vibration,
vibration is applied directly to the muscle belly or tendon or the
muscle being trained by a vibration unit. In the second method which
is called whole-body vibration (WBV), vibration is applied indirectly
to the muscle being trained. That is vibration is transmitted from
a vibrating source away from the target muscle through part of the
body to the target muscle. This method usually requires vibrating
platforms for the transmission of the vibration.
In recent years, vibration has attracted a great deal of interest
in the field of sport and exercise science as a special method of
exercise or training. Some studies in the literature indicate that
vibration exercise or training resulted in improved neuromuscular
performance while others found no effect. The reasons for discrepancies
between studies will be discussed with respect to different methods
of vibration application (local vs WBV), vibration characteristics
(amplitude and frequency) and duration of vibration (short vs long;
acute vs chronic) within this presentation.
Biochemical
parameters in performance testing: Validity and limitations
S.
Oguz Karamizrak
Prof Dr, Ege University Medical Faculty, Dept of Sports Medicine,
Bornova, 35100, Ýzmir, Türkiye
Most
research in sports medicine involves the analysis of biochemical
parameters in a laboratory or field test setting. No consensus exists
regarding the standardization of such tests. To further complicate
the outcome, the variation in biochemical analyses is appreciable.
Systematic causes of error will be discussed in this short presentation,
with emphasis being given to lactate testing, overtraining assessment,
and measurement of main metabolic parameters. A review of genetic
markers is beyond the scope of the present analysis.
In general, the analytical processes are influenced at the biological
material collection, storage, transport, and preparation stages.
The sport biochemist should be aware of pitfalls in this phase,
for parameters used in following training, diet, and performances
of athletes, to avoid data misinterpretation. The right choice of
anticoagulants, the preparation of specimens for hormone testing,
and for labile molecules such as cardiac markers, lactate, cytokines,
micronutrients and antioxidants is crucial. Influence of physical
exercise, biological rhythm, overtraining and infection on biochemical
parameters should be taken into account.
Plasma volume changes during and after exposure to severe exercise
and environmental conditions might result in haemodilution or haemoconcentration.
Thus, it becomes important to consider the level of these changes
in assessing plasma constituents’ levels as indicators of training
adaptation. Acute long distance running, bicycle ergometry, and
swimming exercises are known to cause haemoconcentration at the
end. Endurance training has been shown to cause long term expansion
of plasma volume. To further confound the issue, plasma volume changes
are associated with heat acclimatisation, hydration state and physical
training changes. It appears sensible to monitor blood haemoglobin,
haematocrit, and plasma protein levels.
VO2max, LT, OBLA and VT correlate with endurance performance, and
are used to prescribe training loads, and monitor adaptation. Tests
differ in terms of starting and subsequent work rates, increments
and duration of each stage. LT concepts are integrated within the
‘aerobic-anaerobic transition’ framework. They fall into three categories:
use of a fixed BLa, detecting the first rise in BLa above baseline,
and threshold concepts detecting either the MLSS or a clear change
in the BLa curve. The analysis of BLa response to incremental exercise
may vary due to the nature of blood sample and the treatment of
data graphs. Peak power output is reduced in longer staged tests,
whereas VT or LT occur at higher absolute work rates with shorter
staged tests. Sports scientists should consider these factors, and
use protocols mimicking the actual competition.
Over-trained athletes usually present an impaired anaerobic lactacid
performance and a reduced time-to-exhaustion in high-intensity endurance
exercise testing. Lactate levels are slightly lowered during submaximal
performance, resulting in an increased AnT. Although measurements
of resting blood urea, uric acid, ammonia, CK, and serum free testosterone
to cortisol ratio may serve to reveal circumstances which impair
exercise performance, they are not useful in the diagnosis of established
overtraining. Chronic myocyte alterations may cause plasma myoglobin,
troponin I and CK increases. Monitoring reactive oxygen species’
activity might be a good tool for skeletal muscle metabolic stress
level evaluation.
Metabolic schemes studied in relation to overtraining are linked
to CHOs, BCAAs, glutamine, polyunsaturated fatty acids (PUFA), leptin,
and proteins. A higher BCAA oxidation might favour free tryptophan’s
entry into the cerebral area, enhancing serotonin synthesis. BCAA
supplementation before and after exercise decreases exercise-induced
muscle damage and promotes protein synthesis. Higher circulating
glutamine oxidation might cause immunosuppression. The amount of
TAG produced is monitored by controlling the composition of fatty
acids via stearoyl-CoA desaturase action, the control of this enzyme
and lipogenesis by the inhibitory effect of dietary PUFA, and the
interaction of PUFAs with specific transcription factors, which
maintain the balance between oxidation and storage of lipids. There
is some evidence that plasma leptin is more sensitive to training
volume changes than specific stress hormones.
Exercise anaemia might also predispose the tired athlete to overtraining
by lower inflammation reactivity of hepatic/muscular proteins. Iron
in the body can be used as a marker of both adaptation to training
and as an indicator of acute inflammatory response to exercise.
Clinical measurements of serum iron, transferrin, ferritin and the
acute inflammatory protein alpha 1-antitrypsin can be used to differentiate
between an inflammatory response to tissue damage and infection.
Do
mouth guards have negative effects on athletic performance of athletes?
Cem
Cetin
Medicine Faculty of Süleyman Demirel University, Department of Sports
Medicine, Isparta, Turkiye
Many
types of sports activities put participants at risk of orofacial
injury and concussion. Epidemiological studies have reported sports
activities as one of the main etiological factors for the dental
trauma. Furthermore, the highest risk of dental trauma appears to
occur to professional athletes. Maxillofacial injuries do not occur
only during competition. Up to 25–30% of these accidents occur during
training sessions.
Mouth guards have been determined to be the most effective way of
preventing dental injuries. Three types of mouth guards are available:
(i) stock mouth guards, which are prefabricated in different sizes;
(ii) boil and bite mouth guards made from a thermoplastic material,
and immersed in hot water and formed in the mouth of the athlete;
(iii) custom made (CM) mouth guards made by dentists on a model
of the patient’s mouth.
The American Dental Association and the International Academy of
Sports Dentistry currently recommends that mouth guards be used
in 29 sport or exercise activities. These include acrobatics, basketball,
bicycling, boxing, equestrian events, extreme sports, field events,
field hockey, football, gymnastics, handball, ice hockey, inline
skating, lacrosse, martial arts, racquetball, rugby, shot putting,
skateboarding, skiing, skydiving, soccer, softball, squash, surfing,
volleyball, water polo, weightlifting and wrestling.
Although mouth guards have been shown to protect against orofacial
injury, many players do not wear them during training and competition.
The major reasons cited by the athletes for this are discomfort
and difficulty in verbal communication and breathing. Another worry
is that mouth guards will interfere with their athletic performance.
From a psychological point of view, any protective device should
not negatively affect maximum exercise capacity, i.e., the athletic
performance. Effects of mouth guards on performance of athletes
measured in various studies included muscle strength, visual reaction
time; sprint and jumping ability, VO2 max and arterial lactate etc...
Most of the current studies about physiological effects of wearing
mouth guards interested in effect of mouth guards to airflow dynamics
and ventilation and oxygen consumption in low and high intensity
exercise.
Published research consistently shows that wearing a CM mouth guard
does not affect the main performance parameters generally associated
with performance of athletes. It can be concluded that athletes
can use CM mouth guards without any negative effects on their strength
and aerobic/anaerobic athletic performance.
Treatment
options of ACL injury at the medical center
M.
N. Doral 1,2 ?, G. Dönmez 2, U. Dilicikik 2, Ö.A Atay 1, A.H. Demirel
2 and D. Kaya 2
1 Hacettepe University Dept. of Orthopaedics and Traumatology, 2
Hacettepe University Dept. of Sports Medicine, Ankara, Turkey
ACL
is an important stabilising structure of the knee, preventing anterior
translation of the tibia in relation to the femur. Rupture of the
ACL is one of the most common sports injuries in active young people.
Besides providing mechanical support, ligaments give dynamic reinforcement
to the joint via their mechanoreceptors. Therefore, ACL injuries
result in not only mechanical deficits, but also proprioceptive
defects. But do not forget; there is no only ACL in the knee as
a functional stabilizer.
Reconstructive ligament surgery is a common treatment method in
the acute and chronic ruptures of the ACL. The major goals is to
restore ligamentous functional stability, decrease the risk of articular
cartilage deterioration, preserve menisci, and return patients to
active lifestyles and sportive activities.
Various types of grafts and fixation methods have been employed
in such surgeries. Current treatment options in ACL reconstruction
include autografts, allografts, and synthetic grafts. Multiple allograft
tissues are available including bone-tendon-bone patella tendon
(BPTB), anterior and posterior tibialis, Achilles tendon, fascia
lata, and hamstring tendons. BPTB graft (allograft or autograft)
is the most frequently used graft for reconstruction of the ACL
and provides bone to bone fixation options with flexibility in tunnel
selection sizing. Studies have shown greater fixation strength,
superior mechanical properties, and good long-term results with
this technique. On the other hand many concerns have arisen with
regard to donor- site pathology. These includ; anterior knee pain,
patellar fracture, patellofemoral pain/crepitus, kneeling pain,
quadriceps weakness, loss of joint motion, and patellar tendonitis,
tendinozis in a long term period or rupture.
Reconstruction using autogenous tissue as a primary reconstruction
has emerged as the most popular method for reconstruction and has
produced good clinical results. The use of allogenic tissues from
cadavers has risen tremendously over the past decade because of
their advantages of less donor-site morbidity, shorter operative
time, availability of larger grafts, lower incidence of postoperative
arthrofibrosis, and potential improvements in physical functioning
and overall health-related quality of life. The disadvantages of
allografts are; graft incorporation and functional ligamentization
are slower for allografts when compared with autografts. However,
several studies have shown that allograft ACL reconstruction is
a sound alternative to autografts with no significant difference
in postoperative symptoms, activity level, functional outcomes,
or physical examination measures. In ACL reconstruction surgery,
it is also important to fix the graft at the most convenient position
with an adequate tension and soundness.
Finally treatment of the ACL injuries should be individualized because
the patient’s age, occupation, sports activities, and some knee-related
and medical factors affect the surgical decision. Because in an
elite competetive athlete torned ACL cannot heal (not demonstrated
yet) with only conservative management. On the other hand, today
there were %20 athletes w/o ACL, make a sports at the moderate level
w/o any surgical treatment. Functional knee braces have been proposed
to improve outcomes after ACL reconstruction especially by decreasing
the strain on the reconstructed ligament and also by enhancing aspects
of neuromuscular control.
Early
inpatient physiotherapy
Inci
Yuksel
Hacettepe University, Faculty of Health Sciences, Department of
Physical Therapy and Rehabilitation, Ankara, Turkey
Rehabilitation
following ACL reconstruction is generally divided into four phases:
• early postoperative , • subacute strengthening, • functional progression,
• return to sports.
Early postoperative rehabilitation after anterior cruciate ligament
(ACL) reconstruction plays an important role in the functional outcome
of the knee. The main goal of immediate postoperative phase is to
alleviate inflammatory reac-tion that takes place following surgical
intervention. The orthopaedic surgeon and physical therapist are
both concerned about controlling acute pain. Another goal of this
early phase is to enhance range of motion (ROM) and progress to
full weight bearing. The exercise program should be tailored according
to the patient’s needs. It is important to control ex-ternal forces
and protect the healing ligament during this stage. However, contolled
motion should be allowed to nour-ish cartilage, decrease fibrosis,
prevent stiffness and, stimulate collagen healing. Controlled loading
may enhance liga-ment and tendon healing, while excessive loading
can be harmful to the healing graft and lead to anterior-posterior
knee laxity.
Rehabilitation of the patient should begin on the day of surgery
. ACL reconstruction can cause severe postopera-tive pain. Improved
control of postoperative pain facilitates more rapid achievement
of functional outcomes. Postoper-tive pain can be contolled by using
multiple techniques of analgesia. However, simultaneous application
of cold and compression is still a valuable tool in postoperative
pain alleviation. An increase in swelling causes a restriction in
mo-tion and exerts more pressure on nerve endings, which leads to
additional pain . Cryotherapy also helps reduce swelling as well
as pain in 48 hours following the surgery.
During the postoperative inflammatory phase, potential loss of function
may result in scar formation which can restrict normal ROM of the
knee joint. The knee should not be immobilized except during ambulation
after the recon-struction. It is especially important to gain full
knee extenson in this stage. Early passive extention is important
after every ACL repair so that the intra-articular notch is not
allowed to fill in with scar tissue, thereby preventing full knee
extension. Continuous passive motion (CPM) machines can restore
mobility, also decrease postoperative hemarthrosis and edema. Besides
CPM, patients should be encouraged to perform active-assisted range
of motion exercises every hour that they are awake. Physiotherapists
especially should on reflex guarding and spasm as well as inhibition
of quad-riceps muscle, because both of them results in the loss
of function.
When using an ipsilateral patellar tendon graft, early patellar
mobilization is necessary to prevent potential patel-lofemoral complaints.
Quadriceps muscle contractions during weight bearing also pull the
patella proximally and stretch the tendon. Quadriceps muscle strengthening
is another important goal of ealy rehabilitation in ACL reconstructions.
To sum up, clinical milestons of early rehabilitation are reduction
in pain and effusion, full knee hyperextension, 110 degrees of knee
flexion, patellar mobility, ability to perform straight leg rises,
partial weight bearing with at least 70% of body weight.
Out-Patient
physiotherapy and returning to sports
Defne
Kaya, Gürhan Dönmez, Hande Güney, Haydar Demirel and Mahmut Nedim
Doral
Hacettepe University, Ankara Tukey
Rehabilitation
after surgery for an ACL tear is a lengthy process. Return to sports
and activities takes months. Twenty years ago, rehabilitation programs
included immobilization of the leg for 6 weeks or longer after an
ACL reconstruction procedure while inflammation diminished and the
graft healed. Biomechanical studies performed on animals have documented
the adverse effects of immobilization of the knee on the articular
cartilage, ligaments, capsular structures, leg musculature, and
periarticular bone. This has led some authors to advocate early-motion
rehabilitation programs that included guarded motion in a knee brace
or continuous passive knee motion immediately after ACL reconstruction.
Other studies revealed that early mobilization of healing ACL grafts,
including immediate full weight-bearing activities such as walking,
is possible without endangering the healing tissues. It is clear
that immobilization after ACL reconstruction results in undesired
effects; however, little is known about how much activity will promote
adequate rehabilitation of an injured knee without permanently elongating
the graft, producing graft failure, or creating damage to articular
cartilage. This lack of knowledge may be explained, at least in
part, by the fact that there is little information that derives
from prospective, randomized, controlled studies of rehabilitation
after ACL reconstruction.
Specific rehabilitation must focus on each individual athlete, and
you must adhere to your own protocol. It is also important to note
that timelines are a guide -- progression depends on completion
of one step, before advancing to the next step.
Late Phases: The knee, and its range of movement, should now be
essentially normal during everyday activities. This should be maintained
during the late stage. Strengthening and proprioception exercises
should be progressed and, once the operated knee has achieved 90%
of the normal leg in these aspects, functional activities can be
undertaken. In a sporting individual, these activities consist of
sport-specific drills and movements, the intensity, frequency and
duration of which should be gradually increased until normal function
is achieved. Early sports activities can be started and patients
can often begin light jogging, cycling outdoors, and pool workouts.
Side-to-side, pivoting sports -- such as basketball, soccer and
football -- must be avoided. Toward the end of this phase, some
athletes can begin shuttle runs, lateral shuttles and jumping rope.
Functional Phases: Emphasis of rehabilitation should be on sport
simulating activities. These will include figure-of-eight drills
and plyometrics, and over time will include sport drills. For example,
a tennis player may start light hitting, a soccer player some controlled
dribbling, etc. The progression to functional activities can begin
once the player can jog without pain and is comfortable doing plyometric
drills. The idea of this stage is to take the player from gentle
exercise to the high intensity activity at which games are played.
All exercises are preceded by a warm up. As each exercise is a progression,
they should be completed at least one day apart.
Return to Sports:
Deciding when to return to unrestricted sports activities depends
on a number of factors:
• Functional Progression
The decision to return to sports must be based on each individual’s
progression through their therapy.
• Graft Type
Surgeons may delay return to sports if the graft used to reconstruct
the ACL came from a donor. Because these grafts are sterilized and
frozen, there is a belief that they take longer to heal well inside
the patient.
Health
benefit of activity of daily living (ADL) in children
Klaus
Voelker
Institute of Sports Medicine, University Hospital Münster, Horstmarer
Landweg 39, 48149 Münster
Physical
activity is essential for a balanced and healthy development in
children. The structured days of children in western civilization
gives only small room for free and spontaneous activities. In the
international literature complains the decline in physical activity
and the decline in physical fitness. The consequences for health
are obvious, there in increase in overweight and obesity in children.
Physical activity is regarded as one mechanism of compensation and
should be promoted especially in schools and sport clubs. Unfortunately
whether the sport activities neither in schools, nor in sport clubs
and even not in leisure time are sufficient to compensate the extent
of inactivity. All day activities have to be taken into account.
New techniques in the registration of activity of daily living for
example accelerometers allow a different inside view in physical
activity in different settings. This allows the analysis of current
status and the detection of strategies to promote physical activity.
The Münster All-day Activity Study (MAAS) Project examined 1325
school children from the 1th to the 11th grade of school in the
area of Münster in Germany. ADL was registered for one week by using
the Step Activity Monitor (SAM).
The total amount of steps per day declined with age. International
Guidelines demand 7500 steps per day or more than 600 steps per
hour to be regarded as good for health. This amount was reached
only in the 1th and 3th grade of school. The activity level in girls
was always below the level of boys. The time in school is structured
very strong. There are only few opportunities to be physically active.
But even on this low level there a decline with age. The activ-ity
level in the 9th and 11th grade of school must be regarded as low
active or even sedentary. If schooldays are divided into small portions
there are some elements to be found which contain a high potential
for improving physical activity. Physical education has to be mentioned
on the first place, but also the breaks between the lessons and
the way to school are important sources of physical activities.
The attractiveness of these opportunities for being physically active
shows no decline even in higher grades of school.
Obesity
in childhood: Therapeutic options
U
Korsten-Reck
Department of Rehabilitative and Preventive Sports Medicine, University
Medical Center, University of Freiburg, Hug-stetter Str. 55, 79106
Freiburg, Germany
Obesity
is a chronic disease involving interaction between genetic and environmental
factors. Considering the limited financial resources of our health
care system, priority should be given to prevention, early identification
and the treat-ment of risk groups (selective prevention), as well
as early disease management in groups known to be particularly at
risk. Considering the increase and degree of overweight and obesity,
as well as the decrease in physical activity of to-day’s children
and adolescents, we must design new methods of treatment for a variety
of risk groups and establish a network of appropriately trained
physicians in clinics and universities. The degrees of overweight
(overweight < 90th. percentile, overweight between the 90th and
the 97th percentile and obesity > the 97 th percentile or adipositas
per-magna > the 99.5 th percentile) correspond to preventive
or therapeutic intervention levels. Patients should be treated according
to the guidelines of the German “Konsensuspapier 2004”. An increase
in central obesity combined with ele-ments of the metabolic syndrome
underline the quality of the disease. A network of outpatient and
inpatient therapy centers should treat the individual needs of obese
children. The Freiburg Intervention Trial for Obese Children (FITOC)
consists of regular physical exercise (three times a week) plus
comprehensive dietary and behavioral education. At four- to six-week
intervals during the eight month program, seven information sessions
with parents and seven with their children were held. At these meetings,
staff members gave parents theoretical and practical information
on obesity and nutrition, answered individual questions and work
in behaviour training. Children were separately given the same basic
information. Questionnaires concerning nutrition (food frequencies)
and behaviour were regularly completed. Anthro-pometrical, biochemical
and fitness data were collected. Measurements of body height and
weight, fasting total-cholesterol, LDL-cholesterol, HDL-cholesterol
and physical performance followed identical, standardized guidelines.
Initial examinations of all 496 children (boys n=229; girls n= 267)
were conducted. At the beginning of the program, boys were 10.6±
1.5 and girls 10.5 ± 1.6 years of age. Follow-up examinations after
the intensive program were carried out 8.5 ± 1.2 months later. Results
of the FITOC therapy programs (www.fitoc.de), which strictly follow
the AGA’s guidelines, have sufficiently demonstrated that those
affected do not recognize obesity as a chronic disease despite a
growing interest in this syndrome in society. A focus on sports
during therapy and the counselling of daily activities appear to
be key to the achievement of success. From the very beginning, one
must obtain a clear statement of commit-ment from all participants
(parents and physicians, as well as directors and teachers in kindergarten,
day care centers and schools). If this strategy is then supported
by public and private health insurance companies, it can successfully
fight the obesity epidemic.
Platelet
rich plasma treatment in sports medicine
L.C.
Vanden Bossche and G.G Vanderstraeten
Dept Physical and Rehabilitation Medicine, Ghent University Hospital,
De Pintelaan 185, 9000 Gent, Belgium
It
is a fundamental fact that every athlete with a muscle, tendon or
ligament injury wants to regain physical fitness as soon as possible.
More and more attempts are being made to replace faster ‘tissue
repair’ by faster ‘tissue regeneration’ to minimize sports disability
and to allow early rehabilitation. The aim is to accelerate the
natural processes without damaging the body. Platelet Rich Plasma
(PRP) is obtained by centrifugation of autologous blood. Platelets
are a source of growth factors, such as transforming growth factor
beta, vascular endothelial growth factor , and platelet-derived
growth factor, which are responsible for tissue repair and regeneration.
Growth factors are biologically active polypep-tide molecules that
interact with specific cell surface receptors, leading to responses
that are dictated by the receptor-mediated signal transduction pathways
of the target cells. Growth factors are unique because they stimulate
the growth or proliferation of these target cells. Chronic or acute
tendinopathies, tendon ruptures, muscle ruptures, ligament rup-tures,
nonunions and stress fractures are the most important indications
for PRP treatment. At our department many pilot studies have been
performed. Importantly no patient was worse after treatment. After
three weeks we observed marked pain relief and less swelling (in
chronic tendinopathies). More controlled research has been planned
and will be started soon.
Local
administration of growth factors and anti-doping aspects
Paolo
Borrione
University of Rome “Foro Italico”, Department of Health Sciences,
Piazza Lauro de Bosis 15, 00194 Rome, Italy
The
repair response of the musculoskeletal tissues generally starts
with the formation of a blood clot and the following degranulation
of platelets, which releases locally growth factors (GFs) and cytokines.
This microenvironment results in chemotaxis of inflammatory cells
as well as the activation and proliferation of local progenitor
cells. Alpha granules are storage units within platelets, which
contain pre-packaged GFs in an inactive form. The main GFs contained
in these granules are: PDGF (Platelet Derived Growth Factor), TGF-ß
(Transforming Growth Factor-beta), FGF (Fibroblast Growth Factor),
IGF (Insulin Like Growth Factor), VEGF (Vascular Endothelial Growth
Factor) and EGF (Epidermic Growth Factor). It is widely accepted
that GFs play a central role in the healing process and tissue regeneration
being able of modulating the recruitment, duplication, activation
and differentiation of cells involved in bone- and soft-tissue healing
and the efficacy of those GFs should be, in theory, directly proportional
to their local concentration. This observation is at the base of
the use of preparation rich in growth factor (PRGF) in several circumstances,
all of them characterized by the need of activating, modulating,
speeding up or ameliorating the process of tissue repair. In this
setting PRGF should be considered as highly safe autologous haemocomponents
for non-transfusional use. With regard to sport medicine, doping
related issues are still matter of debate when considering this
therapeutic approach for the treatment of sport-related injuries,
in particular because of the IGF-1 content in the platelets alpha
granules. Indeed, the recent version of the World Anti-Doping Agency
code prohibits all use of growth factor therapies in elite sport.
Theoretically, there are two reasons that eliminate anti-doping
concern from the therapeutic use of PRGF: 1) the PRGF content of
IGF-1 is sub-therapeutic in terms of systemic anabolic actions by
a factor of between 500 and 1000; 2) the availability of most IGF-1
is modulated by the IGFBP3 binding protein. Only 1% of the total
IGF-1 released from the PRGF is unbound, and therefore biologically
available. Additionally, the short half-life (10 minutes) of this
unbound and active IGF-1 makes an alteration in systemic levels
unlikely.
On the contrary, with particular regard to the muscle injection
of platelets derived growth factors several issues still need to
be clarified. Assuming that this technique, as it has been demonstrated
by several studies, is able to ameliorate the muscle tissue repair
processes, it is still unclear if the concentrated amount of growth
factors injected into the skeletal muscles may affect the performances
of the treated tissues.
Actually, in Italy, this technique may be used for the treatment
of elite athletes following the approval of the appropriate therapeutic
use exemption but other countries apply different approaches. Therefore,
the author believe that it is necessary to clarify anti-doping regulatory
guidelines and prohibited lists in order to avoid confusion and
to promote an uniform approach given the awareness of the current
clinical utility of these therapeutic approach.
Visualisation
techniques in athlete’s early recovery after trauma and training
Paula
Drosescu
Universýtatea “Al.I.Cuza” Iasi Romania, Iasi - Romania
The
need for quicker recovery after injuries or the pressure to obtain
ever better results leads to the use of less frequently utilized
methods such as visualization. Visualization is a natural process
that allows a person to see pictures in their mind; the pictures
can represent actual things in a person’s waking life or things
that are not actually present, things that a person would like to
achieve. Most of the sport medicine literature presents the results
in how to use visualization in mental training. However, visualization
can also be used in early recovery after trauma. Visualization can
reduce the recovery period by up to a third, depending on the number
of sessions, their length and the personality type of the athlete.
During the workshop the participants will be introduced to the concept
of visualization, why, when and where it is used, the methods of
building good imagery, the reason why sometimes visualization doesn’t
work, the most frequent mistakes that the author has met in her
practice. The workshop is built in three parts: a very short initial
one – with several theoretical concepts, a second part, with practical
exercises, and a third one reserved for discussions and conclusions.
The theoretical part of the workshop presents the author’s experience
with 48 athletes (male and female) from different sports, of different
ages (from 8 to 49 years old); visualization is used in each case
during early recovery after musculoskeletal trauma. The experience
of other 97 athletes is also presented on whom mental training is
used to prepare a competition. In the practical part, the focus
is on the most successful techniques and methods that give results
in real life. Finally, it is also important to present the limits
of the method and the future possibility for future research: the
type of imagery that can be used, the time when the method can be
applied, and the type of the personalities on which it can be applied.
Achilles
tendinopathy: Diagnostic and treatment algorithm
Nicola
Maffulli
Centre for Sports and Exercise Medicine, Barts and The London School
of Medicine and Dentistry, London, England
Achilles
tendinopathy is characterised by pain, impaired performance, and
swelling in and around the tendon. It can be categorized as insertional
and non insertional, two distinct disorders with different underlying
pathophysiologies and management options. Other terms used as synonymous
of non insertional tendinopathy include tendinopathy of the main
body of the Achilles tendon (AT) and mid-portion achilles tendinopathy.
The terms tendinitis, tendinosis, and paratenonitis, or an association
of them, should be reserved to specific histopathological features
of tendon conditions. We suggested that terms such as ‘partial ruptures
of’ a given tendon not to be used to indicate intratendinous lesions
of the tendon under study. We advocated the term tendinopathy as
a generic descriptor of the clinical conditions in and around tendons
arising from overuse. We challenged the common wisdom, intrinsic
in the suffix -itis, that overuse tendinopathies are due to inflammation.
Although sound epidemiological data are lacking, Achilles tendinopathy
is common in athletes, accounting for 6-17% of all running injuries,
possibly because of the continuous prolonged intense functional
demands imposed on the AT . However, it does presents in middle
aged overweight non-athletic patients without history of increased
physical activity. To date, no data are available to establish the
incidence and prevalence of Achilles tendinopathy in other populations,
even though the conditions has been correlated with seronegative
arthropathies (e.g. ankylosing spondylitis).
The essence of tendinopathy is a failed healing response, with haphazard
proliferation of tenocytes, some evidence of degeneration in tendon
cells and disruption of collagen fibres, and subsequent increase
in non-collagenous matrix. Tendinopathic lesions affect both collagen
matrix and tenocytes. The parallel orientation of collagen fibres
is lost, there is a decrease in collagen fibre diameter and in the
overall density of collagen. Collagen microtears may also occur,
and may be surrounded by erythrocytes, fibrin and fibronectin deposits.
Normally, collagen fibres in tendons are tightly bundled in a parallel
fashion. In tendinopathic samples, there is unequal and irregular
crimping, loosening and increased waviness of collagen fibres, with
an increase in Type III (reparative) collagen.
At electron microscopy, various types of degeneration have been
described, namely (a) hypoxic degeneration, (b) hyaline degeneration,
(c) mucoid or myxoid degeneration, (d) fibrinoid degeneration, (e)
lipoid degeneration, (f) calcification, (g) fibrocartilaginous and
bony metaplasia. All can coexist, depending on the anatomical site
and the nature of their causal insult. Therefore, tendinopathy can
be considered the end result of a number of etiologic processes
with a relatively narrow spectrum of histopathological features.
In tendinopathic tendons, tenocytes are abnormally plentiful in
some areas. They have rounded nuclei, and there is ultrastructural
evidence of increased production of proteoglycan and protein which
gives them a chondroid appearance. Other areas may contain fewer
tenocytes than normal with small, pyknotic nuclei, with occasional
infiltration of lymphocytes and macrophage type cells, possibly
part of a healing process associated with proliferation of capillaries
and arterioles. Degeneration of the AT is usually either ‘mucoid’
or ‘lipoid’. Collagen fibres that are thinner than normal, and large
interfibrillar mucoid patches and vacuoles are seen. There is an
increase in the Alcian-blue-staining ground substance. The characteristic
hierarchical structure of collagen arrangement is also lost. Vascularity
is typically increased, and blood vessels are randomly oriented,
sometimes perpendicular to collagen fibres. Inflammatory lesions
and granulation tissue are infrequent, and, when found, are associated
with partial ruptures. Inflammatory cells and acellular necrotic
areas are exceptional, and probably not typical of the tendinopathic
process. On the other hand, mucoid degeneration, fibrosis and vascular
proliferation with an inflammatory infiltrate may be found in the
paratenon. Using common staining techniques, light microscopic degeneration
was not a feature of tendons from healthy, older persons. Type I
collagen is the main collagen in tendons; type III collagen is present
in small amounts.
The diagnosis of Achilles tendinopathy is mainly based on history
and clinical examination. Pain is the pivotal symptom. A common
symptom is morning stiffness or stiffness after a period of inactivity,
and a gradual onset of pain during activity. In athletes it occurs
at the beginning and end of a training session, with a period of
diminished discomfort in between. As the condition progresses, pain
may occur during exercise, and it may interfere with activities
of daily living. In severe cases, pain occurs at rest. In the acute
phase, the tendon is diffusely swollen and edematous, and tenderness
is usually greatest 2 to 6 cm proximal to the tendon insertion.
A tender, nodular swelling is usually present in chronic cases.
Clinical examination is the best diagnostic tool. Both legs are
exposed from above the knees, and the patient examined while standing
and prone. The AT should be palpated for tenderness, heat, thickening,
nodule and crepitation. The “painful arc” sign helps to distinguish
between tendon and paratenon lesions. In paratendinopathy, the area
of maximum thickening and tenderness remains fixed in relation to
the malleoli from full dorsi- to plantar-flexion; lesions within
the tendon move with ankle motion. There is often a discrete nodule,
whose tenderness markedly decreases or disappears when the tendon
is put under tension.
The management of Achilles tendinopathy lacks evidence-based support,
and tendinopathy sufferers are at risk of long-term morbidity with
unpredictable clinical outcome. The appropriate moment to switch
from conservative to operative therapy remains unknown, as no solid
data exist on the natural course of recovery. Non-operative care
should be in general a minimum of three to six months prior to considering
surgery since this condition usually resolves. However, each patient
should be evaluated independently. Surgery is generally recommended
to patients in whom conservative management has proved ineffective
for three to six months.
Many common therapeutic options lack hard scientific background
[64]. Rest, cryotherapy, pharmaceutical agents such as non-steroidal
anti-inflammatory drugs and various peri-tendinous injections, training
modifications, splintage, taping, electrotherapy, shock wave therapy,
hyperthermia are used. Modalities tested using randomised controlled
trials include nonsteroidal anti-inflammatory medication, eccentric
exercise, glyceryl trinitrate patches, electrotherapy (microcurrent
and microwave), sclerosing injections, and shock wave treatment.
In 24 – 45.5% of patients with Achilles tendinopathy, conservative
management is unsuccessful, and surgery is recommended after exhausting
conservative methods of management, often tried for at least six
months. There is a the lack of trials on surgical management of
Achilles tendinopathy, and therefore the high success rate needs
to be interpreted with caution. Surgical options range from simple
percutaneous tenotomy (possibly ultrasound-guided, to minimally
invasive stripping of the tendon, to open procedures.
The classical aim of open surgery is to excise fibrotic adhesions,
remove areas of failed healing and make multiple longitudinal incisions
in the tendon to detect intratendinous lesions and to restore vascularity
and possibly stimulate the remaining viable cells to initiate cell
matrix response and healing. However, there is no level I evidence
that fibrotic adhesions should be removed, and the areas of failed
healing should be excised, at least if the pathology does not involve
the paratenon. Multiple longitudinal tenotomies trigger well ordered
neoangiogenesis of the AT. This would result in improved nutrition
and a more favourable environment for healing.
A more recent approach targets not the tendinous lesion itself,
but the neo-innervation which accompanies the neovessels. New minimally
invasive stripping techniques of neovessels from the Kager’s triangle
of the AT for patients with tendinopathy allow to achieve safe and
secure disruption of neo-vessels and the accompanying nerve supply,
producing a denervation effect. During open procedure, if more than
50% of the tendon is debridement, consideration could be given to
a tendon augmentation or transfer.
In conclusion, Achilles tendinopathy gives rise to significant morbidity,
and, at present, only limited scientifically-proven management modalities
exist. The management of this condition remains a challenge, especially
in athletes, in whom the physician often tries to be innovative.
In many instances, this carries with it an unquantifiable risk.
A better understanding of tendon function and healing will allow
specific management strategies to be developed. Many interesting
techniques are being pioneered. Although these emerging technologies
may develop into substantial clinical management options, their
full impact needs to be evaluated critically in a scientific fashion.
Future trials should use validated functional and clinical outcomes,
adequate methodology, and be sufficiently powered. Clearly, studies
of high levels of evidence, for instance large randomized trials,
should be conducted to help answer many of the unsolved questions
in this field.
Metabolic
definition of the physiological background of high performance middle
distance runners
Ulrich
Hartmann
Institute for Movement and Training Science in Sports, University
of Leipzig, Leipzig, Germany
When
looking through the available literature dealing with this topic,
it is conspicuous that from an energetic point of view there is
no exact knowledge of the running performance profile and the energy
provision. Therefore in the last 50 years basic and applied physiology
have provided substantial knowledge, which allows to establish systems
of equations describing the steady state and dynamic behaviour of
the mentioned basic energy delivering processes for the purpose
of mathematical simulation of the muscular energy metabolism as
a function of power output and time. The differences in the simulation
patterns are due to the difference of 3 components of ATP supplying
reactions in the working muscle mass: 1. The concentration of creatine
phosphate ([PCr]) (~alactic work capacity), 2. the content of mitochondria
which determines the maximum of aerobic ATP production rate (aerobic
power (~VO2max (ml/min*kg))) and 3. the maximal glycolytic ATP-production
rate (lactic power (~VLamax (mmol/s*l))). To apply to the human
body the active muscle mass (25% to 35% of body mass) and the lactate
distribution space (35% to 45% of body volume) have to be considered.
As it is for practical purpose too complicated to re-simulate experimental
results of the individual pattern of test results simplifying of
the mathematical approach is needed, without a loss of accuracy.
This seems to be possible regarding two principles: First: Efficiency
of ATP-production is nearly constant at all levels of intensities
which means 1.0 mmol [ATP] ? [PCr] ? 4.3 ml O2.
That means also that 1.0 mmol LA ? 1.35 mmol [PCr] ? 5.8 ml O2 at
muscular level. This is a typical value for top athletes. As the
lactate oxygen equivalent is constant at the ATP production level
according to principle 1: the resulting oxygen equivalent related
to BW varies according to the relation of active and passive lactate
distribution space between 2.4 up to 3.0 ml O2. - 2: The rise of
oxygen uptake in case of an escalating load is approximately mono
exponential. VO2max in skeletal muscle is direct proportional to
mitochondria content (Mit.Vol.) and 1.0 ml Mit.Vol. can consume
4,3 up to 4,5 ml O2/min. A normal 3% Mit.Vol. results in a VO2max
= 4.5 * 30 = 135ml O2/min*kg muscle. – A sportspecific simulation
will be presented.
Chronobiologic
factors of performance
Bruno
Sesboüé, Clément Bougard, Sébastien Moussay and Damien Davenne
Institut Régional de Médecine du Sport, CHU Côte de Nacre, F-14033
CAEN Cedex
With
pleasure we present you an overview of the work done on chronobiology/circadian
rhythms in the laboratory of the university of Caen. In general
biological rhythms are well known to follow the rhythm initiated
by two internal clocks located in the pineal gland and the suprachiasmatic
nuclei.
Both are subject to the influence of external synchronizer in order
to stay within a 24h period. The physical performances follow also
the pace of these clocks. This explains why alactic anaerobic muscle
performance is always superior at 18h compared to those made at
6 o’clock, regardless isometric, concentric or eccentric contraction.
The same is true for performances realized during the Wingate’s
test. For the anaerobic lactic processus, superior performance is
found (e.g. 11%) at 18h versus 6h for environmental actions.
With regard to forced gestures (repeated contractions), the difference
goes beyond the 40th second. This difference between the two types
of movement is probably related to the principles and mechanisms
underlying muscle mechanics, for example nerve conduction. In other
words, the spontaneous frequency of cycling is higher in the evening
than in the morning. The other parameters (maximal oxygen consumption,
maximal power output) remain the same during the day. However, up
to 85% of maximal aerobic power, ventilation for a given power is
greater at night as compared to morning. The rectangular test at
100% of maximal aerobic power exhibits a higher time limit in the
evening with a gain of 16% during the day. The best performances
are realized late in the day. Therefore the athlete needs to regulate
him or herself and start warming-ups in time if top performances
can be scheduled in the evening. For mental performance, we found
a rhythm for vigilance with two peaks, one around 10 a.m. and another
at 06 p.m. Variations are the same for the first stage of action,
namely the identification. In contrast, no differences were noted
for the decision stage.The third stage, or the programming, implements
and improves executing motor tasks throughout the day. For these
reasons, amongst others, the late morning (good psychomotor performance,
poorer physical performance) should be dedicated to learning strategies
and analyzing competition. Finally, in support of these results,
we showed that the wake-up time and breakfast did not influence
the data acquisition in the morning.
Asthma
and sport: Where did we come from and where are we now?
J.
Cummiskey
Respiratory Physician Suite 35 Blackrock Clinic, Rock Road, Blackrock
Co., Dublin, Ireland
Where
have we come from
• 1999 The 3 IOC, MC premises highlighted
• 2001 WADA aTUE for asthma
• 2002 International panel at an Olympic Games
PFT are now manitory in asthma diagnosis. This clinical syndrome
must have the clinical diagnosis of asthma supplemented with the
addition of Pulmonary Function Tests (to ERS and / or ATS standards).
The percentage changes in PFT are as follows:
• resting pulmonary function tests, (12% bronchodilation above the
predicted or the athletes resting FEV-1)
• non-pharmacological challenge (10% bronchoconstriction) Exercise
or Eucapnic Voluntary Hyperventilation tests
• pharmacological stimulation tests
(20% bronchoconstriction at a Methacholine dose of < 4 mg/ml)
(15% bronchoconstriction to a Mannitol test)
(15% bronchoconstriction to a 4.5% saline challenge)
Where are we going with asthma
2008 Publish in 8.2008 IOC, MC consensus statement American JACI
2008/9 WADA scrapping a TUE
2008/9 WADA insisting on only the athletes on the registered testing
pool of each
IF having a full TUE for asthma
2012 Review the criteriae now in place
2010 Possible GINA consensus of asthma in high performance sport
2014 New advances in our understanding of asthma in 5 years
Imaging
of osteochondral lesions of the talus and anterolateral impingement
J.L.
Gielen, P. Van Dyck, F. Vanhoenacker and C. Venstermans
University of Antwerp, Belgium
Both
anterolateral impingement and osteochondral lesions of the talus
are related to repeated inversion mechanism of ankle sprains. They
are frequently encountered in soccer players. Radiological imaging
has a role in the detection and staging of anterolateral impingement
and osteochondral lesions of the talus especially in a preoperative
phase. Anterolateral impingement is already described in the 1950
by Wolin as a meniscoid lesion of massive hyalinised and vascularised,
connective tissue extending into the joint from the anterior inferior
portion of the talofibular ligament Impingement during dorsiflexion
can occur at the anterior inferior tibiofibular ligament, the lateral
gutter and the anterior talofibular ligament. Four grades of anterolateral
impingment are recognised depending on the association of the meniscoid
tissue with bone and cartilage abnormalities. Both MRI and ultrasound
can be used to detect the meniscoid tissue. Dynamic ultrasound examination
is able to demonstrate the impingment during dorsiflexion of the
talocrural joint. The purpose of this presentation is to illustrate
the findings and grading system on US and MRI examinations. Osteochondral
lesions of the talus are detected and staged by plain CT and or
plain MRI. Four stages are recognised depending on the grade of
detachment of the bone fragment. In all but stage 3 with an in situ
fragment these plain techniques are sufficient. In stage 3 the differentiation
of a loose or atached in situ fragment is only possible by CT-arthrography
or MR-arthrography as the contrast infiltration in between the fragment
and roof of the bony defect is proof of a loose in situ fragment.
Preoperative MR imaging and/or CT-arthrogram can help to determine
whether the lesion is loose or not.
Persistent
pain following lateral ankle sprains
Halit
Pýnar
Dokuz Eylül University Hospital, Department of Orthopaedics and
Traumatology, Ýzmir, Turkey
Persistent
pain following ankle sprain may be due to one or more of the following
conditions: a) Misdiagnosis (importance of differential diagnosis),
b) Lesions developing at or following sprain, c) Chronic instability.
Acute inversion sprain is the most common sports injury (45% in
basketball,31% in football).Differential diagnosis is of great importance:Syndesmosis
injury,rupture or dislocation of the peroneal tendons,fracture of
the lateral malleolus,lateral talar process,anterior calcaneal process
and base of the 5th.metatarsal.Tarsal coalition and osteoid osteoma
should be ruled out in every chronic sprain pain.
Most common lesions developing during or following ankle sprain
are osteochondral lesions,osseous and soft tissue impingement syndromes,sinus
tarsi syndrome and reflex sympathetic distrophy. Lesions due to
insufficient healing are chronic lateral instability (mechanical
or functional), avulsion fractures or symptomatic ossicles,subtalar
instability,and neural injuries.
In summary, a good knowledge of differential diagnosis is the key
to lessen persisting symptoms following acute ankle sprain.Additional
lesions that develop at the time or after the injury are treated
properly.
Cardiac
emergencies in sports
H.
Löllgen
Med.Dept., Remscheid Hospital, Germany
Cardiac
emergencies and sudden death during physical activity remain a challenge
in the general population and in athletes as well. Definition and
epidemiology of sudden death will be given. Cardiac emergencies
are mainly due to acute arrhythmias, myocardial ischemia or syncope.
Causes of sudden death are complex ventricular arrhythmias due to
structural heart disease. Coronary artery disease predominates in
people over 35 years. In younger subjects (below 35 ys), especially
in athletes, “electrical” abnormalities i.e. ion channel diseases
such as Brugada- Syndrom, cardiomyopathy (ARVD,ALVD) , WPW-Syndrom
or long or short QT-syndrom predispose to threatening circulatory
collaps. Diagnosis is based on history, including sports and family
history, clinical examination, resting ECG (consensus recommendation).
It is strongly recommended that expertise from sports medicine and
cardiology as well is need for correctly interpretating resting
ECG in athletes.Stepwise increasing diagnostic procedures include
stress testing, echocardiography and analysis of autonomic function,
MRI and invasive procedures, with MRI as the key diagnostic tool
for analysis of structural heart disease even in myocarditis. Molecular
autopsy is now the standard approach in sudden athlete’s death of
unknown origin. Possible diagnostics and treatments for survivors
include: Cardiac catheterization, electrophysiological testing,
bypass surgery or ballon dilatation (PCI), catheter ablation in
special diseases (HOCM,WPW - Syndrom), drug therapy, and implantable
cardioverter-defibrillator. In athletes, restriction to physical
activity is sometimes recommended depending on the underlying disease
(e.g. myocarditis). Prevention is the best approach using thorough
history and clinical examination and ECG as a pre-participation
screening. Recommendations from the German Society of Sports Medicine
will be presented.
Gray
zone in athlete’s heart
Erdem
Kasikcioglu
Istanbul University, Istanbul Faculty of Medicine, Department of
Sports Medicine, Ýstanbul, Turkey
There
is little doubt that vigorous physical exertion increases the risk
of cardiac events in athletes with cardiovascular abnormalities.
The increased risk of exertion has been documented in athletes in
whom the risk of sudden death. Although hypertrophic cardiomyopathy
is a major complex cardiac disease with a heterogeneous genetic,
morphologic and clinical spectrum and it is the most important cause
of sudden cardiac death among young athletes. The diagnostic criteria
for hypertrophic cardiomyopathy includes a hypertrophic, but not
dilated, left ventricle, in the absence of systemic disease or left
ventricular hypertrophy due to left-sided obstruction. Some athletes
develop substantial excessive left ventricular hypertrophy (13-15
mm) during intense physical training. In this situation, the differentiation
between physiological and pathologic hypertrophy may be difficult,
and this evaluation is important in determining the presence or
absence of cardiac disease in athletes in order to prevent exercise-
related sudden cardiac death.
At present, routine genetic testing is not a practicalmethod for
differentiating physiologic from pathologic left ventricular hypertrophy.
Several echocardiographic and electrocardiographic features can
help to distinguish between hypertrophic cardiomyopathy and physiologic
left ventricular hypertrophy in athletes, but, inevitably, a small
number of individuals fall into a gray zone where differentiation
between the two entities, athlete heart and hypertrophic cardiomyopathy.
Although the presence of septal thickness more than the ranges suggests
the diagnosis of hypertrophic cardiomyopathy, some patients with
the disease have mild hypertrophy within the same range as that
observed in highly trained athletes. Approximately, 2% of elite
athletes have a septal thickness of 13-15 mm. A number of clinical,
electrocardiographic, echocardiographic and new imaging methods
can assist in the identification of hypertrophic cardiomyopathy
in an athlete in these circumstances. Hypertrophic cardiomyopathy
is more likely in the presence of a positive family history of hypertrophic
cardiomyopathy in a first degree relative, echocardiographic demonstration
of a small left ventricular cavity dimension, large left atrial
diameter, abnormal diastolic filling patterns and the presence of
abnormalities on the electrocardiography. Echocardiography is a
valuable non-invasive and frequently using method for differentiating
cardiac pathologies than athlete’s heart; however, it is accepted
that the method is not cost-effective for screening. Although there
are several limitations of echocardiography, it helps for the accurate
diagnosis of hypertrophic cardiomyopathy and facilitates risk stratification.
Furthermore, some scanning and imagine methods may facilitate for
differentiating of two entities, hypertrophic cardiomyopathy and
athlete’s heart.
Preparticipation
medical screening of athletes: The Italian experience
Fabio
Pigozzi
Professor of Internal Medicine, Department of Health Sciences -
University of Rome “Foro Italico”, Rome, Italy
Sudden
cardiac death in athletes is an event that dramatically occurs more
and more often. Up to 90% of these deaths are due to cardiovascular
diseases, therefore referred to sudden cardiac death (SDC). The
causes of athletic-field SCD are strongly related to the athlete’s
age. In young athletes (<35 years) the main causes are represented
by congenital cardiac diseases, particularly hypertrophic cardiomyopathy,
arrhythmogenic right ventricular cardiomyopathy and coronary artery
anomalies. Conversely, in older athletes (>35 years) the high
percentage of deaths is due to coronary artery disease.
Death is a natural and ineluctable event. However, when it occurs
suddenly and unexpectedly in a trained athlete who represents in
our minds the image of health, strength and invulnerability, is
difficult to accept. Indeed, the sudden death of an athlete, while
training or competing, is an infrequent but devastating event to
all involved (patient, family, friends, team, and staff). The great
interest of the mass media for this tragic event, especially when
young or well-known athletes are involved, contributes to increase
their shocking impact on the public.
Over the past two decades ample medical literature on the causes
and the mechanisms of sport-related sudden death as well as on the
screening strategies and disqualification criteria for competitive
athletes, has been collected. Nevertheless, such catastrophes continue
to occur. Sudden death is defined as a witnessed or un-witnessed
natural death occurring unexpectedly within 6 hours of a previously
normal state of health.
Though non-traumatic athletic-field deaths may recognize non-cardiac
causes - cerebral aneurysm, heat-stroke, sickle cell trait, bronchial
asthma, drug abuse -, more than 90% of these events occur in subjects
with pre-existing, and usually clinically silent, cardiac abnormalities.
For this reason, sport-related sudden death should be distinguished
in sudden cardiac death (SCD) and death due to non-cardiac causes.
A primary goal for prevention should be to identify cardiac pathology
through PPS . Recently, interest has been focused on the strategies
and results of PPS in athletes as a valuable instrument of investigation
for:
a) early identification of structural cardiac disease associated
with sudden death
b) reduction of the risk of disease progression associated with
athletic training and competition.
Recommendations regarding eligibility to sport should be on precise
guidelines, such as the ones set by the Bethesda Conference or the
Italian Guidelines (COCIS).
Update
on strategic plan on IOC scientific activities
Strategies in Sports Medicine - Contribution from IOC Medical and
Science Department. An ounce of prevention?
Lars
Engebretsen
International Olympic Committee, Oslo Sports Trauma Research Center,
Department of Sports Medicine, Norwegian University of Sport &
Physical Education, and 2Orthopaedic Center, Ullevaal University
Hospital, Oslo, Norway
At
a time when there is of an abundance of medical meetings, journals
and papers, some might argue that the last thing we need is yet
another field of research. What would justify such an emphasis on
a new and developing research field in medicine such as prevention
of injuries and diseases in high level athletes (1)? First, it must
ask important questions not answered by others. Second, the new
research field should have the potential to create truly new knowledge,
lead to new ways of thinking and lay the foundation for improved
health for our patients. Third, research results from the new field
should be publishable in respected journals, recognized and cited
by peers, presentable at high quality meetings and fundable on competitive
grant review.
Challenges and opportunities: First, is injury prevention important?
Epidemiological studies show that of injuries seen by a physician
in Scandinavia, every sixth is sustained during sporting activity(2).
Among children, every third hospital-treated injury is the result
of sports participation. A research group within the English Football
Association found that the overall risk to professional athletes
is unacceptably high—approximately 1,000 times higher among professional
football players than for high-risk industrial occupations (3).
The second issue relates to the potential for new ideas and improved
health. When we started the Oslo Sports Trauma Research Center in
May 2000, a PubMed search revealed that out of 10,691 papers on
athletic injury, there were only 6 randomized controlled trials
on sports injury prevention. However, a similar search of the literature
now reveals that sports injury prevention research is emerging as
a new field in medicine. While the number of papers on athletic
injuries has increased by 26% over the last five years, clinical
studies and RCTs related to sports injury prevention has doubled.
Sports participation is also important from a public health perspective.
There is no longer any doubt that regular physical activity reduces
the risk of premature mortality in general, and of coronary heart
disease, hypertension, colon cancer, obesity, and diabetes mellitus
in particular. The question is whether the health benefits of sports
participation outweigh the risk of injury and long-term disability,
especially in high-level athletes? Sarna et al. (4) have studied
the incidence of chronic disease and life expectancy of former male
world-class athletes from Finland in endurance sports, power sports
and team sports. The overall life expectancy was longer in the high-level
athlete compared to a reference group (75.6 versus 69.9 years).
The same group also showed that the rate of hospitalization was
lower for endurance sports and power sports compared to the reference
group (5,6). This resulted from a lower rate of hospital care for
heart disease, respiratory disease and cancer. However, the athletes
were more likely to have been hospitalized for musculoskeletal disorders.
Thus, the evidence suggests that although sports participation is
beneficial, injuries are a significant side effect. To promote physical
activity effectively, we have to deal professionally with the health
problems of the active patient. This does not only involve providing
effective care for the injured patient, but also developing and
promoting injury prevention measures actively.
Possible solutions: Since 2007 the IOC is developing various programs
for prevention of injuries and diseases in high level and recreational
sports. This development is occurring with the cooperation of IFs
such as FIFA, IHF, IAAF and FINA as well as with renowned research
institutions world wide. The Medical and Science Department of the
IOC is currently developing research in the prevention field with
several major institutions to focus on research, education and implementation
of the new knowledge to all NOCs around the world. Furthermore,
special issues of the British Journal of Sports Medicine under the
IOC leadership will disperse new knowledge to the scientific community
which again will help IFs and NOCs to implement new knowledge to
the practical athlete. The IOC will have yearly Advanced Team Physician
Meetings to educate our colleagues and a major conference every
third year where researchers from around the world will meet to
discuss challenges and new results in the field of prevention of
injuries and diseases. The IOC will continue the extensive publication
of the Olympic Encyclopaedia and the more practical and very popular
Olympic Hand Book in Sports Medicine. Every year at least two consensus
conferences will be held - in 2009 one on Pre Participation Exams
and on Age Determination in young athletes. The results from these
conferences are spread to all NOCs and IFs. Finally, the IOC will
develop an injury and disease surveillance system for the Olympic
Games- the first successfully conducted in Beijing.
Through these initiatives, The International Olympic Committee (IOC)
will increasingly emphasize the protection of the athletes’ health
and the prevention of injuries.
REFERENCES
1 Kahn CR. Picking a research problem. The critical decision. N
Engl J Med 1994;330:1530–3.
2 Bahr R, van Mechelen W, Kannus P. Prevention of sports injuries.
In: Kjær M, Krogsgaard M,
Magnusson P, et al. Textbook of sports medicine. Basic science and
clinical aspects of sports injury
and physical activity. Oxford: Blackwell Science, 2002:299–314.
3 Drawer S, Fuller CW. Evaluating the level of injury in English
professional football using a risk
based assessment process. Br J Sports Med 2002;36:446–51.
4. Sarna S. Sahi T, Koskenvuo M, et al. Increased life expectancy
of world class athletes. Med Sci
Sports Exerc 2000;25:37–44.
5. Kujala UM, Sarna S, Kaprio J, et al. Hospital care in later life
among world class athletes. JAMA
1996;276:216–20.
6 Kujala UM, Kettunen J, Paananen H, et al. Knee osteoarthritis
in former runners, soccer players,
weight lifters, and shooters. Arthritis Rheum 1995;38:539–46.
Assessment
of balance: From theoretical background to practical applications
Dusan
Hamar and Erika Zemkova
Faculty of Physical Education and Sport, Comenius University, Bratislava,
Slovakia
Unlike
a solid object in stable balance position, the human body maintains
a dynamic balance by oscillating center of mass (COM) in all horizontal
directions around a virtual central verticular line. In order to
prevent toppling, vertical projection of COM, representing center
of gravity (COG) must remain within the base of support. This is
achieved by perpetual shifting of the body in horizontal direction
by muscle contraction in the ankle and hip area. Such corrective
movements, controlled by the central nervous system, are based on
sensory feedback information from the muscle proprioceptors, vestibular
apparatus, visual organ, and to some extent also from the skin receptor
in the plantar area. Tightness of this feedback control reflects
the quality of balance. Generally, poor balance is characterised
by rather large excursions of COM and vice versa. The analysis of
COM horizontal movements is utilised for the assessment of balance.
COM projection on the supporting ground is defined as center of
gravity (COG). Recording of its movements is usually based on the
distribution of the gravitational force among the sensors in the
corners of the force platform sampled at the rate of 100 Hz. Such
an approach, in fact, does not display COG exactly. As it does not
take into account only simple projection of COM on the horizontal
plane of the platform, but also momentum forces resulting from corrective
horizontal movements, parameter calculated is in fact center of
pressure (COP). However, as the differences between COP and GOG
are rather minor, COP is utilised for the assessment of balance.
The methods of analysis of COP movements under various conditions,
their reliability and practical application will complement the
presentation.
Genetic
risk factors for musculoskeletal soft tissue injuries
Malcolm
Collins
MRC/UCT Research Unit for Exercise Science and Sports Medicine,
South African Medical Research Council (MRC) and the Department
of Human Biology, University of Cape Town (UCT), Cape Town, South
Africa.
Acute
and overuse tendon and ligament injuries are common as a result
of participating in specific physical or workplace activities. Although
the exact causes of these injuries are unknown, various intrinsic
and extrinsic risk factors, including genetic factors, have been
identified. Common musculoskeletal soft tissue injuries for which
a genetic contribution has been proposed include the Achilles and
rotator cuff tendons, as well as, the cruciate ligaments. Sequence
variants within genes that encode for several collagens (COL1A1,
COL5A1 and COL12A1) and glycoproteins (TNC), which are structural
components of the basic building block of tendons and ligaments
– the collagen fibril, have been shown to be associated with specific
acute and chronic musculoskeletal soft tissues injuries. Recently
variants within the enzymes (MMP3) that degrade the fibril have
also been shown to be associated with chronic Achilles tendinopathy.
Whether these variants are directly involved in the development
of these musculoskeletal soft tissue abnormalities or linked with
the actual disease causing variants remains to be established. The
results of these initial case-control genetic association studies
suggest that these injuries, like other more extensively investigated
complex disorders, such as obesity, and type 2 diabetes, are caused
by a complex interaction of multiple genetic and environmental factors.
Developments in the identification of genetic risk factors for tendon
and ligament injuries will be reviewed. It is proposed that eventually
these and other specific genetic risk factors could be included
in multifactorial models that will identify ‘high-risk’ athletes.
It is conceivable that these models could in the future also be
used by clinicians to develop personalised training programmes to
reduce the risk of injury, as well as, personalised treatment and
rehabilitation regimens for injured athletes. The ethical framework
however in which this is done is not straightforward, need to be
discussed and guidelines developed.
Genes and performance
N.
Bachl, B. Wessner and H. Tschan
Faculty for Sports Science and University Sports, University Vienna,
Austria
Human
physical performance is determined by a variety of environmental
and also genetic factors. Several studies have revealed, that heritability
is a strong component of endurance and strength phenotypes, but
it is important to note, that beside the athletic performance capacity
a lot of genes in the same way are responsible for the normal functioning
of metabolic pathways and processes which are necessary for a healthy
state of an organism. With regard to athletic performance, today
more than 200 gene entries and quantitative trait loci have shown
some associations of linkages with exercise related phenotypes.
Some of these associations seem to be rather weak or need to be
improved in larger populations, on the other hand, the impact of
the R577X-single-nucleotid-polymorphism of the ?-actinin 3 (ACTN3)
gene on elite performance has been confirmed in a series of studies.
Similar results were found for the polymorphism of the Angiotensin
converting enzyme (ACE), the Myostatin (GDF-8) and the Peroxisome
proliferator activated receptor-? coactivator 1, ? (PPARGC1A) and
other genes. However, it is very likely, that more than one genetic
variant will be responsible for a complex trait such as athletic
performance as well as for its components endurance capacity and
strength, which also per se are polygenic. Therefore it seems to
be necessary to look after optimum or favourable polygenic profiles,
but taking into account that other polymorphisms yet are undiscovered
as well as several other environmental factors may explain, why
some individuals reach or don’t reach the upper end of special performance
capacity.
Genetic
variability and training responses
Barbara
Wessner, Harald Tschan and Norbert Bachl
Centre of Sports Sciences and University Sports, Department Sports
and Exercise Physiology, University of Vienna, Auf der Schmelz 6,
1150 Vienna, Austria
The
HERITAGE (HEalth, RIsk factors, exercise Training And GEnetics)
family study documents the role of the genotype in cardiovascular,
metabolic, and hormonal responses to a tightly controlled 20 weeks
aerobic exercise training program. One of the most interesting findings
was that the training-induced changes in the outcome measures such
as the maximal oxygen consumption varied widely, dividing the study
participants in non-responders, medium-responders and high-responders
(Skinner et al., 2001). Of course environmental factors such as
age, gender and diet might have had an impact on the outcome variables.
However, the variability within families was lower than the overall
variability suggesting a genetic influence. At the latest since
then numerous case-control, association or linkage studies tried
to relate the individuals’ genetic make-up with the adaptation to
endurance or resistance training programs (Bray et al., 2009). When
looking on muscle mass or strength genetic variants in the a-actinin
3 (ACTN3), myostatin (GDF-8), ciliary neurotrophic factor (CNTF)
genes seem to influence the response to resistance training (Gordon
et al., 2005). The ability to enhance endurance capacity is modulated
by polymorphisms in the angiotensin convering enzyme (ACE), peroxisome
proliferator-activated receptor alpha (PPARA) and nitric oxide synthetase
3 (NOS3) genes. Even though this list is highly incomplete it seems
to be clear that more than one polymorphism contribute to a complex
phenotype such as the training response making it necessary to develop
a polygenic profile rather than single associations (Ruiz et al.,
2009). Although we are just at the beginning of understanding the
impact of genetic variability future research on this topic should
help us to develop personalized training programs by identifying
personal strengths and weaknesses and therefore finding the “optimal”
exercise.
References
Bray, M.S., Hagberg, J.M., Pérusse, L., Rankinen, T., Roth, S.M.,
Wolfarth, B., Bouchard, C. (2009) The human gene map for performance
and health-related fitness phenotypes: the 2006-2007 update. Medicine
and Science in Sports and Exercise 4, 35-73.
Gordon, E.S., Gordish Dressman, H.A., Hoffman, E.P. (2005) The genetics
of muscle atrophy and growth: the impact and implications of polymorphisms
in animals and humans. The International Journal of Biochemistry
& Cell Biology 37, 2064-2074.
Ruiz, J.R., Gómez-Gallego, F., Santiago, C., González-Freire, M.,
Verde, Z., Foster, C., Lucia, A. Is there an optimum endurance polygenic
profile? Journal of Physiology 587, 1527-1534.
Skinner, J.S., Jaskólski, A., Jaskólska, A., Krasnoff, J., Gagnon,
J., Leon, A.S., Rao, D.C., Wilmore, J.H., Bouchard, C. (2001) Age,
sex, race, initial fitness, and response to training: the HERITAGE
Family Study. Journal of Applied Physiology 90, 1770-1776.
Meniscal
preservation: Current state of the art and future directions
Reha
N. Tandogan
Ortoklinik & Çankaya Orthopeadic Group, Cinnah caddesi 51/4
Çankaya, Ankara, Turkey
The
menisci have important functions of load bearing and load sharing
in the human knee joint. They also contribute to joint lubrication
and act as secondary stabilizers in the event of ACL insufficiency.
Loss of menisci leads to significant biomechanical and biochemical
changes that ultimately lead to loss of cartilage and early onset
osteoarthritis. Preservation of meniscal functions is an important
goal in knee injuries especially in adolescents and young adults.
As arthroscopic techniques have evolved, rim preserving partial
meniscectomy has become the gold standard for irreparable meniscal
tears. However, osteoarthitic changes still occur after partial
meniscectomy depending on the amount of meniscal tissue removed
and the disruption of circumferential collagen fibers. Meniscal
repair is indicated for vertical longitudinal tears in the vascular
1/3 of the meniscus. These are usually acute tears in conjunction
with an ACL injury and have the greatest chance of healing. Isolated
tears have about 75% healing rate in stable knees. Recently the
indications for meniscal repair have been extended to radial tears,
tears in the avascular zone and more complex tears especially for
the lateral meniscus. Enhancement of healing with a variety of techniques
such as the fibrin clot, synovial abrasion, vascular access channels
and microfracturing the notch may improve healing rates. Two options
are available for younger patients with total meniscal loss; meniscal
allografting and meniscal substitution with a scaffold. Meniscal
allografts have shown pain relief and preservation of function in
about 70-80% of the patients at 5-10 year follow-up. It is not clear
whether the allografts can halt the progression of osteoarthritis
at long term follow-up. Problems with sizing, logistics and the
risk of disease transmission have prevented the widespread use of
this technique. A variety of natural and synthetic materials have
been tried to replace the meniscus. Most of them have been unsuccessful
or have not reached clinical phase. A collagen meniscus implant
acting as a scaffold has been used in a small number of patients
with moderate success; however this implant is indicated for segmental
meniscal defects and not total loss of meniscus. In conclusion,
meniscal repair seems the best way to preserve meniscal function.
Although suture techniques offer the strongest fixation, recent
meniscal fixators offer the chance of an easier surgical technique.
Prevention of meniscal injury and early treatment of ACL injuries
before meniscal tearing, especially in adolescents are also important.
Sport
therapy in patents with COPD
Klaus
Voelker
Institute of Sports Medicine, University Hospital Münster, Horstmarer
Landweg 39, 48149 Münster
OBJECTIVE
The incidence of COPD in Germany is estimated between 8-15%. Improvement
in pharmacologi-cal therapy as well as in non pharmacological therapies
has lead to an augmentation in quality of life. One of the non pharmacological
tasks is sports-therapy. Question arise can physical excises in
a ambulatory group improve physical capacity in the amount of activity
of daily living (ADL).
In a prospective controlled longitudinal study we included 29 COPD
patients – 14 patients in a excercise group mean age 67 ±7 FEV 1
40-60%; 15 patients in a training group mean age 61 ± 8 age FEV
1 > 60%. The patients where compared to 17 healthy controls mean
age 63 ± 9. Before and after a six months trainings period spiroergometrie
on a bicycle ergometer, 6-minute-walking-test, postural balance
testing, sit-to-stand-test and dynamic valance test where performed.
All this activities where measured by step watch activity monitor
(SAM) for seven days. Quality of life was measured with special
questionnaires.
METHODS VO2max was 18 ± 3 ml/kg in the excise group and 20 ± 4 ml/kg
in the training group. There was no difference between pre- and
post-test. The distance in the 6-minute walking-test in patients
of the exercise group was 439 ± 9 m and 491 ± 26 m in training group.
This was 67% respectively 75% of the distance in controls. In the
pos-test the level was augmented between three to five percent in
both groups. After the training program there was a slide augmentation
in force- and balance test to be found. The ADL level of the controls
was 6500 steps per day and must be regarded as low active. The training
group was 400 steps per day and the excise group 1000 steps per
day below the level of the controls. The training program improved
ADL level of excise group to the level of the controls and the level
of the excise group was augmented 2000 steps and reached a level
above that of controls. The quality of life was improved in all
interven-tion groups.
CONCLUSION COPD patients, and especially the patients with low capacity,
seem to achieve bene-fit from intervention in ambulatory COPD training
groups.
Biomechanical
modelling in sports medicine
Serdar
Arýtan
Biomechanics Research Group, School of Sports Science & Technology,
Hacettepe University, 06800, Beytepe, Ankara, Turkey
OBJECTIVE
Sports biomechanics suffers from one very serious limitation; in
general it is impossible to measure forces inside the human body
for technical and ethical reasons. In order to measure the force
inside a human body requires an operation to implement a force transducer.
In addition to technical complications and calibration problems
of force transducer, the subject would also be at risk of surgical
infections. Therefore, modelling in biomechanics works as an interface
between the body and measurement settings.
In recent years biomechanical modelling has become very popular
in the area of sports medicine. Recent developments in software
and hardware in the computer technology can be the key explanation
of this popularity. Developing a biomechanical model itself improves
the understanding of the mechanical system’s dynamics and the structure.
On the other hand, most of the real-world biomechanical systems
are so complicated that a satisfying modelling seems extremely difficult.
One standard consequence is that the complexity can be reduced by
cutting down the some part of the system to be modelled. A well
prepared model is simple but also adequately detailed to precisely
represent the system.
Considering the system components (i.e. limbs of the human body)
as a rigid body, rather than deformable body is also helps to reduce
the complexity of the model. Although, in reality, there is no body
is absolutely rigid, deformation of limbs in sports movement can
be ignored, when compared to the gross motion of the system.
METHODS Basically, there are two types of approaches in biomechanical
modelling. The first one is inverse dynamics and the second one
is forward dynamics or direct dynamics. Inverse dynamics calculation
is used to determine joint forces and torques based on the physical
properties of the system being modelled and a time history of displacements
from experimental kinematic data, including velocities and accelerations.
Ground reaction forces, mass and inertial characteristics of segments
are also required in this method. In a forward dynamical analysis
the joint torques are the inputs and the body motion is the output.
It is critical to understand what generate this joint torques. Joint
torques are the addition of internal body forces such as ligaments,
joint constraints, and of course, muscle forces. Muscles are the
actuator in this method. Therefore the correct input into the model
is definitely neural input, which drives the muscles.
Whichever approach is used for modelling, first of all, the equation
of motion has to be derived. The dynamics of biomechanical systems
is based on classical mechanics. The simplest element of a multi-body
biomechanical system is a free particle which can be treated by
Newton’s equations. The rigid body that is a key element in the
modelling was introduced in 1775 by Euler. Thus the equations obtained
are known in human-body dynamics as Newton–Euler equations.
CONCLUSION As indicated above the modelling is widely used in all
fields of sports medicine from kinematics to dynamics. In fact,
advanced biomechanical modelling requires sophisticated simulation
tools which can model accurately enough the physical world at sufficient
speed and allow user interaction.
Modeling
of soft tissue mechanical behavior on computer
Ergin
Tönük
Middle East Technical University Department of Mechanical Engineering
Graduate Program of Biomedical Engineering, Ankara, Turkey
INTRODUCTIONNearly
all mechanical interactions of human body with the surrounding take
place through soft tissues. Therefore, experimental determination
of soft tissue mechanical properties and computer simulation of
various mechanical interactions of human body with the environment
received attention in biomechanics. There are different test equipment
and protocols, each having its own advantages and disadvantages,
that have been utilized till now to uncover soft tissue mechanical
behavior for the purpose of constructing a material law that would
model the mechanical behavior of soft tissues.
METHODS Because the aim is to model mechanical interaction with
the surrounding, it is preferred to use in vivo experiments so that
the tissue of interest would be in its natural environment with
proper interaction with the surrounding tissues.
A soft tissue indenter, which is a noninvasive device, is utilized
for the experiments. Although the primary mode of operation of the
indenter is displacement controlled, with a closed loop control
algorithm force control can also be achieved. The indenter tip that
deforms the soft tissue has an ellipsoid shape to detect in-plane
anisotropy. The indenter system collects simultaneous data of tissue
reaction force, tissue displacement and time. With the utilization
of inverse finite element method, this data is converted into stress-strain-time
data which can directly be used to establish the material law (constitutive
equation).
RESULTS Lower arm bulk soft tissues were tested using three different
test protocols: cyclic loading, relaxation and creep. The results
indicate that soft tissue behavior is nonlinear with stiffening
behavior in increasing strain, considerably anisotropic, not fully
elastic with considerable mechanical energy dissipation, relaxation
is observed under constant displacement and creep is observed under
constant load. There is preconditioning in maximum reaction force
and in hysteresis magnitude in the first few loading cycles. It
was further observed that the soft tissue mechanical behavior is
personal, local in the body and even at the same location mechanical
response changes in time.
CONCLUSION The experimental results reveal that unlike many engineering
materials, soft biological tissues exhibit relatively complex mechanical
material behavior. Computer simulation of mechanical interaction
of human body with its surroundings requires the material model
to reach a maturity for success.
Classification
methods in biomechanical analysis
Murat
Cilli
Biomechanics Research Group, School of Sports Science & Technology,
Hacettepe University, 06800, Beytepe, Ankara, Turkey
OBJECTIVE
Classification of human motion plays an important role in many application
areas, such as surveillance, films, biomechanics, biometric person
identification or the analysis of gait abnormalities in medicine.
Most of the existing systems, description of human movement depends
on variables that represent the kinetics and/or kinematics of the
body segments. Increasing amounts of three-dimensional kinetics
and kinematics data are available from commercial motion-capture
systems. However the problem is not technological since recent advances
have made data collection fast and efficient with sufficient resolution
to provide meaningful measurements. A significant barrier to use
of kinetics and kinematics information is the successful reduction
and classification of this large data set.
METHODS Large data sets have orientated the researches to use different
methods. Using multivariate statistical methods has become widely
accepted technique among the many different approaches. Since the
availability of statistical software packages to do the calculations
has developed the use of linear techniques to describe human motion
data has been employed in a number of studies. Principal Component
Analysis (PCA) which is one of these linear techniques has been
used as an evaluation and classification tool for kinematics and
kinetics data of normal vs. pathological movement patterns. This
approach allows one to identify components of low power that may
be removed from the data set without significantly affecting the
data, thus producing a dimensionally reduced form of the original
data.
CONCLUSION Using linear techniques as a classification tool have
become common within the animation and computer vision community.
However there exist only few studies for biomechanical analysis
in sport medicine. PCA can be used to classify the entire temporal
movement pattern and can detect differences due to disease, gender
and age as well as psychological attributes such as personality
traits and emotions.
Gait
analysis in healthy and operated subjects
Gunes
Yavuzer
Erasmus University Erasmus MC, Department of Rehabilitation Medicine,
Rotterdam, The Netherlands
Quantitative
gait analysis is an objective clinical tool to differentiate gait
deviations, to measure and document neuromusculoskeletal functions
in numbers and graphs, and to obtain accurate and precise measurements
of human movement. It serves not only as a useful tool in planning
treatment, but also a measure of treatment outcome. Although observational
gait analysis has been used for many years in our daily practice,
there are multiple reasons why it may not be adequate for the identification
of more complex gait parameters. A more scientific evaluation can
be provided by the use of three-dimensional (3D) quantitative gait
analysis. The advance of 3D quantitative gait analysis, which includes
kinematic, kinetic, and dynamic electromyographic assessment, has
enabled clinicians to differentiate gait deviations objectively
and understand the primary problem behind a complex disorder more
accurately than can be done with observational analysis. A detailed
history and physical examination of the patient combined with the
gait data and the expertise of the team help in clinical decision-making
in terms of antispastic drugs, orthotics and surgery.
A typical 3D quantitative gait analysis session starts with subject
preparation and followed by data recording and data analysis. During
subject preparation anthropometric data including height, weight,
leg length and joint width of the knee and ankle are collected.
After the subjects are instrumented with retroreflective markers,
they walk barefoot or with shoes together with walking aids (if
they need), at a self-selected pace, a number of times, over a 10-meter-long
walkway during which time data collection was completed. Three to
nine cameras record the quantitative spatial location of each marker
as the subject walked. The trial in which all the markers were automatically
and clearly identified by the system is determined the best data.
Some laboratories average the trials they collected. Three components
of the ground reaction force are collected by forceplates as the
subject steps on them. Ground reaction forces (GRF) and kinematic
data were combined with inverse dynamics to predict joint moments
and powers of hip, knee and ankle joints in three dimensions. The
recorded data is then processed for interpretation. The clinically
validated biomechanical model combines the movement, force plate
and EMG data with patient specific measurements to calculate the
joint center locations, segment orientations, three dimensional
joint angles and moments.
Three-dimensional quantitative gait analysis has advanced our understanding
of normal gait, identified and quantified the biomechanical and
motor control abnormalities of pathologic gait, and documented the
usefulness of various therapeutic interventions. Further research
are needed to show how gait analysis can improve patient care, evidences
that 3D quantitative gait analysis studies can aid in the diagnosis
and determination of the pathomechanics of some gait abnormalities.
Skeletal
muscle adaptation to increased activity level
Haydar
A. Demirel
School of Medicine, Dept of Sports Medicine & School of Sports
Science & Technology, Hacettepe University, 06800, Beytepe,
Ankara, Turkey
Skeletal
muscle is a plastic tissue capable of changing the type and the
amount of protein under increased activity level. Increased activity
induced adaptation in skeletal muscle involves a various of signalling
mechanisms resulting in new protein synthesis. Endurance training
especially targets to mitochondrial protein synthesis. On the other
hand resistance training primarily stimulates the rate of myofibrillar
protein synthesis and results in muscle hypertrophy. Hyperplasia
has also been shown in some experimental conditions in animal subjects.
Exercise training induced various metabolic and morpholocigal changes
are specific to the type of exercise. One of the important feature
of the exercise training is transformation of the muscle fiber types.
Although increased activity level results in fast to slow shift
in myosin isoform, training duration, intensity and frequency play
critical role in this transformation.
Exercise-induced
muscle damage and neutrophils
Gülriz
Ersöz
Department of Physiology, Ankara University, Faculty of Medicine,
Ankara, Turkey
Trauma,
mechanical stretch, exercise may cause muscle damage. All forms
of exercise, if carried out vigourously enough, can lead to ultrastructural
damage of muscle fibers but eccentric exercie, leaves stiff and
sore the day afterwards. Muscle damage is characterized by ultrastructural
changes to muscle architecture, damage-increased muscle proteins
and enzymes in the bloodstream, loss of muscular strength and range
of motion and muscle soreness.
The primary sequence of events leading to exercise-induced muscle
damage is believed to involve initial mechanical disruption of sarcomeres,
followed by impaired excitation-contraction coupling, disturbances
in Ca2+ homeostasis. The activation of calcium–sensitive degradation
pathways and inflammatory reactions are the subsequent steps and
responsible for the delayed-onset muscular soreness (DOMS).
Inflammatory reactions within damaged muscle involves leucocyte
infiltration and increase in proinflammatory cytokine production,
systemic release of leucocytes and cytokines. Neutrophyls and macrophages
play dominant role in inflamatory responses. Neutrophyl infiltration
leads greater damage in muscles. Neutrophyl activation cause increase
in oxygen consumption. The “respiratory burst” result in release
of reactive oxygen species (ROS). ROS are suggested to be responsible
subsequent muscle damage. The neutrohyl response to the exercise
is dependent on the intensity and type of exercise, age and gender.
There are limited data about hte effect of antiinflammatory drugs
and antioxidant supplements.
Evaluation
and diagnosis of isolated and combined knee ligament injuries
Reha
N. Tandogan
Ortoklinik & Çankaya Orthopeadic Group, Cinnah caddesi 51/4
Çankaya, Ankara, Turkey
Recent
interest in the anatomy and biomechanics of the knee joint, combined
with the increased incidence of high energy knee injuries has led
to an increased awareness and diagnosis of knee ligament injuries.
Most isolated knee ligament injuries involve the medial collateral
ligament (MCL) and/or the anterior cruciate ligament (ACL). They
usually occur as a non-contact, low energy trauma during sports.
Meniscal and chondral injuries usually accompany the ligamentous
lesions. Diagnosis is usually straightforward with the typical history
of sudden rotational trauma, followed by a pop and hemarthrosis.
Tenderness along the MCL, frequently on the femoral insertion on
the epicondyle, and a positive valgus stress test are the hallmarks
of MCL injury. A positive Lachman test immediately after trauma
is helpful in ACL injuries. As the swelling reduces and pain subsides
a positive pivot-shift test clearly denotes the injury. Partial
ligament injuries may occur. A positive Lachman test without a positive
pivot shift test implies injury to the antero-medial bundle of the
ACL, while the reverse denotes an injury to the postero-lateral
bundle of the ACL.
Isolated injuries to the posterior-cruciate ligament (PCL) or the
postero-lateral corner (PLC) are rare. These ligaments are usually
injured during a high energy, contact trauma such as a motor vehicle
or industrial accident and involve multiple ligaments. Associated
injuries to the popliteal artery, peroneal nerve, impression fractures
of the contra-lateral femoral condyles, tibial rim fractures, meniscal
injuries and rupture of the patellar tendon may occur. Emergency
evaluation of the soft tissue coverage and neuro-vascular status
of the extremity should be carried out. Gentle examination of the
knee reveals the magnitude of ligament injury. The posterior drawer,
external rotation-recurvatum, dial and varus stress tests aid in
the diagnosis. X-rays may reveal frank knee dislocation or avulsion
fractures. MRI is the gold standard in the evaluation and surgical
decision making of these complex injuries. Routine angiography is
not mandatory if careful clinical and ultra-sound evaluation is
available. Since surgery in the first three weeks after injury is
results in the best clinical outcomes, a treatment strategy should
be formed early after injury. Combined ACL + MCL injuries may be
addressed with a conservative treatment of MCL followed by reconstruction
of ACL after adequate healing of MCL has occurred and knee range
of motion has been restored. All other combined ligament injuries
involving more than two ligaments should be treated surgically in
the first 3 weeks following injury. Boney avulsions of ligaments
can be internally fixed. Mid-substance cruciate ligament injuries
are reconstructed with autologous or allogenic grafts. Primary repair
of the collateral ligaments and capsular structures are performed
if the tissues of are good quality. Chronic cases require reconstruction
of all injured ligaments.
Topographic
and functional anatomy of the knee joint
Konstantinos
Natsis
Orthopaedic Surgeon, Assoc. Professor in Anatomy, Greece
The
knee is the largest joint of human body. It is separated in two
joints, the tibiofemoral and patellofemoral joints. The femoral
condyles (FC) roll and slide on the tibial plateau. During flexion
they slide anteriorly and roll posteriorly, while during extension
they slide posteriorly and roll anteriorly. During lateral rotation,
lateral FC moves anteriorly and medial FC moves posteriorly. During
medial rotation, lateral FC moves posteriorly and medial FC moves
anteriorly.
Concerning the tibial condyles (TC), during flexion they roll posteriorly
and during extension they roll anteriorly. When the knee is rotated
laterally medial TC moves posteriorly and lateral TC moves anteriorly.
When the knee is rotated medially lateral TC moves posteriorly and
medial TC moves anteriorly.
In the patellofemoral joint, as the patella moves vertically, along
the trochlea during flexion. During knee flexion the patella and
FC come closer, while during extension the patella and FC separate.
During medial rotation, the patella moves medially and during lateral
rotation it moves laterally.
The lateral meniscus (LM) covers about 80% of the lateral tibial
plateau, while the medial meniscus (MM) covers about 60% of the
medial tibial plateau. However not all knees are the same. When
the knee is extended the menisci move anteriorly unequally, while
when the knee is flexed they move posteriorly unequally. During
lateral rotation LM moves anteriorly and MM posteriorly, while during
medial rotation MM moves anteriorly and LM posteriorly.
The collateral ligaments of the knee, medial (MCL) and lateral (LCL)
are responsible for the transverse stability of the knee during
extension. According to relatively recent observations the MCL is
divided into superficial and deep MCL, while the LCL sometimes may
consist of two bundles. Both ligaments are taut during extension
and slackened during flexion.
The anterior cruciate ligament (ACL) is divided into two parts,
the anteromedial bundle (AMB) and the posterolateral bundle (PLB),
while other authors have separated the ACL in three functional bundles
(AMB, intermediate band, and PLB). However, the two bundle model
has been generally accepted as the best representation to understand
ACL function. The fascicles of the AMB originate at the most anterior
and proximal aspect of the femoral attachment and insert at the
anteromedial aspect of the tibial attachment. Conversely, the fascicles
of the PLB originate at the posterodistal aspect of the femoral
attachment and insert at the posterolateral aspect of the tibial
attachment. When the knee is extended, the PLB is tight and the
AMB is moderately lax. As the knee is flexed, the femoral attachment
of the ACL becomes more horizontally oriented, causing the AMB to
tighten and the PMB to loosen up.
The posterior cruciate ligament (PCL) can be partially separated
into an anterolateral and posteromedial bundle. A more detailed
subdivision of the PCL bundles separates it in anterior, central,
posterior longitudinal and posterior oblique fibers. The anterolateral
bundle is seen to be curved in the sagittal plane and therefore
is slack in the extended knee. When the knee flexes this bundle
becomes tight and also takes a steeper angle away from the tibial
plateau. In deep knee flexion the anterolateral bundle comes to
rest against the roof of the posterior part of the femoral intercondylar
notch. The posteromedial bundle of the PCL is tight and aligned
in a proximal-distal direction in the extended knee. The posteromedial
fibers slacken as soon as the knee starts to flex. In deep flexion
the posteromedial fibers’ attachment moves anteriorly and also upwards
away from the tibial plateau and as a result the posteromedial fibers
then become tight.
In the PCL’s complex we describe the anterior and posterior meniscofemoral
ligaments (aMFL and pMFL). In brief, the anterior and posterior
meniscofemoral ligaments attach respectively distally and proximally
to the PCL attachment to the femur. These positions mean that the
aMFL is slack in the extended knee and tightens with knee flexion,
when it is well-aligned to withstand tibial posterior draw. Conversely
the pMFL is tight in the extended knee and slackens with knee flexion,
because its femoral attachment moves down towards the tibial plateau.
The major structures of the posterolateral corner (PLC) of the knee
include: the iliotibial tract, the lateral collateral ligament,
the popliteus complex consisting of both dynamic components (the
popliteus muscle-tendon unit) and static components (the popliteofibular
ligament, popliteotibial fascicle, meniscofibular ligament and popliteomeniscal
fascicles), the middle third of the lateral capsular ligament, the
fabellofibular ligament, the posterior horn of the lateral meniscus,
the lateral coronary ligament, the arcuate ligament and the posterolateral
part of the joint capsule. However, this anatomy can be quite variable.
Actually, all the muscles around the knee have a dynamic stabilizing
role in the functional anatomy of the joint. One of the most important
dynamic stabilizers, the popliteus muscle-tendon unit, slackens
during knee flexion and lateral rotation and stretches during knee
extension and medial rotation.
Knowledge of topographic and functional anatomy of the knee is very
useful to explain the mechanism of injury and evaluate mainly the
ligamentous injuries. To make these injuries understandable, the
knee can be divided into sections. According to the traumatic mechanism
(varus, valgus, or both), structures in different sections may be
injured. Additionally, there may be associated injury of the central
pivot. Multiple combinations of injuries can occur.
Structures of the anterolateral portion are the most frequently
injured. These injuries are usually associated with damage to the
anterior cruciate ligament. The injury is caused by varus force
with internal rotation of the tibia. Most commonly, the posterior
fibers of the iliotibial tract are damaged. An avulsion fracture
of the Gerdy tubercle may also occur.
The mechanism of posterolateral injury is either direct varus force
while the tibia is externally rotated or sudden hyperextension of
the knee. Clinical signs may be subtle and might remain masked by
the more extensive symptoms due to cruciate ligament damage. Practically
all tears of the (LCL) are associated with damage to posterolateral
knee structures: capsular tears, detachment fracture of the superior
rim of the tibia (Segond fracture), biceps femoris tendon tears,
popliteus tendon lesions, cruciate ligament tears, and so on. Instead
of a (LCL) tear, an avulsion fracture of the fibular insertion of
the (LCL) and biceps femoris tendon can occur. The majority of popliteus
tears are extraarticular, involving the muscular or myotendinous
portion, although they can be intraarticular at the level of the
popliteal hiatus and at or near the femoral insertion. Such injuries
can also be a mixture of intraarticular and extraarticular. Most
popliteus muscle and tendon injuries are associated with damage
to other knee structures: injury to other elements of the arcuate
ligament complex, cruciate ligament tears, meniscal tears, bone
fractures, and so on. Less than 10% of popliteus tears are isolated.
Concerning the stability of medial side of the knee three principal
structural elements have been described: the superficial medial
collateral ligament (sMCL), the deep MCL (dMCL), and the structures
of the posteromedial complex (PMC). Several fibrous bands that form
thickenings of the PMC have been described. These attach around
the femoral adductor tubercle and pass posterodistally across the
joint line, to insert on the rim of the tibial plateau; a central
band among these has been called the posterior oblique ligament
(POL).
The anterior translation laxity with free tibial rotation does not
change significantly when the 3 medial structures are cut at any
angle of knee flexion. Only at fixed tibial external rotation isolated
cutting of the dMCL causes a small but significant increase in tibial
anterior translation.
Posterior tibial translation does not increase significantly when
the sMCL, dMCL and PMC are cut. At tibial internal rotation cutting
the PMC alone and after cutting the dMCL and PMC, further cutting
the sMCL in the extended knee, increases posterior laxity overall.
Of course in severe trauma, all the stabilizing structures of the
knee may be disrupted. In these serious situations, the common peroneal
nerve and gastrocnemius muscle can also be injured.
The
Event Physician – Emergency Sports Medicine
David
McDonagh
Sports
Medicine may have its origins in, yes, India - when the use of therapeutic
exercises were described in the fourth Veda book Artharvaveda, written
sometime between 900 and 100 B.C.
Due to the popularity of sports and the increase in sports injuries,
physicians were asked to attend sports fixtures to offer treatment
to injured athletes. Later, the rehabilitation of athletes became
a necessary function that has evolved into a large and sophisticated
scientific field. The field of sports and exercise medicine has
grown exponentially and now has practitioners and researchers from
many scientific backgrounds, physiologists, nutritionists, physiotherapists,
athletic trainers and physicians. The Federation of Sports Medicine
(FIMS) was created in 1928 to assist the athletes at the St. Moritz
Olympic Winter Games. Later, sports medical organisations have been
established in almost all countries in the world.
But, despite all this development and research, little focus has
been placed on the role of the Event Physician and the tasks he
or she must confront.
Is it time to go “Back to Basics”.
Dr. McDonagh describes where emergency sports care is today. He
will elaborate on the exciting new projects that are developing
in the education of event physicians, with books, courses and research
programs.
Dr. McDonagh is Chair of the International Bobsleigh Federation
Medical Committee; the representative of the Olympic Winter Federations
on FIMS; was team physician for several Norwegian national teams;
was Deputy Chief Medical Officer at the 1994 Winter Olympic Games;
has been advisor for 5 other Olympic Games; is a member of the Norwegian
Antidoping Tribunal and the ICC (Cricket) Antidoping tribunal. He
is an A + E consultant at the University Hospital, Trondheim and
senior lecturer at the Norwegian University of Science and Technology,
Trondheim, Norway.
Medical
coverage in major sports events
Carlo
Tranquilli 1 and Francesca D’Alfonso 2
1 Institute of Sports Science and Medicine, “A. Venerando” CONI
Roma, 2 Scuola dello Sport ConiServizi Roma, Italy
Planning,
organizing and carrying out medical assistance / emergency care
for a major international sports event means providing adequate
medical services to athletes, judges, referees, media, spectators,
volunteers and all accredited individuals and groups. To that end,
the role of sports medicine is of crucial importance and therefore
must be of high quality for the participating athletes since the
primary aim of the practice of sport is promoting health habits.
More specifically, health care management has the following aims:
1) Placing medical care units at training and competition venues,
lodgings, accreditation and press centers thus providing medical
coverage to athletes, managers, staff, media, volunteers, spectators,
etc. This service will provide first aid care, basic and advanced
cardiopulmonary resuscitation, ambulance transportation, any necessary
complementary diagnostic tests, medical treatment or surgery by
specialists and, if necessary, hospitalization.
2) Provision of appropriate equipment and adequate facilities for
medical and health personnel of the participating teams for the
performance of their duties.
3) Implementation of prevention and control measures of Public Health.
4) Implementation of prevention and control measures for veterinary
care in equestrian competitions.
5) Implementation of preventive measures, emergency services and
medical care for water sports competitions (both offshore and small
lakes).
6) Supervision of diet and nutritional quality of meals for the
participating athletes, taking account of hygiene and health issues
and respecting cultural and religious peculiarities.
7) Managing and carrying out doping controls in accordance with
WADA regulations.
8) Producing manuals for medical health care for athletes and delegations
(Medical Guide, Drug Formulary Guide, Doping Control Guide)
In terms of structures and responsibilities, every international
sports event will be organized into three main areas of health care:
Sports Medicine, Public Health and Doping Controls.
These structures strictly depend on the management of health services
operations: a person responsible for each area will be appointed
to facilitate the work of coordination.
Sports medicine aims to provide responsible medical attention to
athletes in accordance with criteria established. Its main areas
of action are:
- Management and Administration
- Sports Medicine for competition and training venues
- Polyclinic at the Athlete’s Village (outpatient services, trauma
services, laboratory analysis, conventional radiology services,
CAT, MRI, ultrasound, physiotherapy)
- Sports Nutrition
Public Health covers three distinct areas:
- Primary care and ambulance transport service (competition venues,
residential venues, media center, accreditation centers, official
events)
- Intensive care units and emergency care service
- Public Health
Doping controls are carried out through the following ways:
- Doping controls are organized at all competition and training
venues and at the Polyclinic Medical Center.
- Preparation of sites in compliance with WADA regulations
- Determining and training of DCOs and “chaperones”
- Organizing doping controls and chain of custody with the accredited
anti-doping laboratory
At the end of the sports event a report on all health activities
should be prepared in order to document the management of the organizational
arrangements and report on issues regarding health care services.
Yachting
Injuries
Kirill
Micallef-Stafrace 1, Andrew Decelis 1, Nicola Micallef-Stafrace
2 and George Buttigieg 3
1 Institute of Physical Education and Sports (IPES), University
of Malta, Malta, 2 Medik Healthcare Services Ltd, Malta, 3 Department
of Obstetrics and Gynaecology, Mater Dei Hospital, Malta
Historically
sailing medicine has been mainly undertaken by doctors that were
themselves sailors. However, with the increase in popularity of
sailing events such as the America’s Cup, The Volvo Ocean Race and
the Olympics sailing programme, a significant effort is being made
to maximise the potential performance of the sailors. Over the last
few decades millions, if not billions, of Euros have been poured
into the development of the sailing boats , yet little thought had
been spent on ensuring the physical and mental performance of the
sailors themselves. This has now all changed. Sailors have been
recognised as being athletes themselves and ameliorating their performance
will automatically lead to better results. This applies to all levels
of sailors, across all the classes, even the weekend ‘warrior’.
Some little attention can ensure injuries are avoided and when they
do happen that they are sorted out as soon as possible. Another
aspect is how to better ones physical and mental performance, but
that will be tackled in another issue.
As we all know, injuries are far from being a rarity in sailing.
Sailing is one of the few sporting disciplines that the athlete
in question in never in complete control. The elements have a nasty
habit of reminding us of this. The type of injury is often related
to the class of boat and the function of the sailor within the crew.
They can be caused by poor athletic conditioning, overtraining or
improper training and the more obvious direct trauma. In sailing
all of them are a common occurrence, although this might not be
apparent to a non sailor. Sailing involves a series of complex physical
manoeuvres which are often repetitive, yet at the same time can
be sudden. To compound matters they are often undertaken in awkward
positions and on a platform that has the unerring capacity of being
unstable. Repetitive powerful movements such as hiking or main sheet
handling can lead to back, knee or upper body ailments. Muscle imbalances
are often found in sailors due to the often unilateral physical
effort imposed on them and if not identified early can cause or
aggravate musculoskeletal problems.
Hyperthermia
and soccer
Sanlý
Sadi Kurdak
University of Çukurova, Faculty of Medicine, Department of Physiology,
Division of Sports Physiology, Balcalý 01330, Adana, Turkey
Only
about 20-25% of the energy released by muscle metabolism during
exercise is used to do work, with the remaining 75-80% appearing
as heat. An increase in body temperature is therefore a normal response
to exercise. Elevation of body core temperature can be compensated
through the evaporation of sweat from the skin surface, but this
increase in sweating rate may eventually cause dehydration during
prolonged exercise. Therefore, performing physical activities during
a sportive event in a hot and humid environment without proper hydration
can be a significant threat to health and performance.
In Europe the regular soccer season typically begins in August and
in some parts temperature may exceed 30 oC with a relative humidity
of 50% (www.bbc.co.uk/weather). Thus, climatic heat stress can be
a problem for soccer players. Although reports of serious heat illness
are rare and deaths are extremely uncommon in soccer, they do occur.
Thermoregulatory responses during exercise in different environmental
conditions have been studied extensively. However, because of the
unique nature of soccer, the physiological and physical challenges
of a soccer game cannot be replicated in a laboratory, though attempts
have been made to simulate this activity pattern. Therefore, studies
performed during a soccer match played under extreme heat conditions
are extremely important to evaluate the physiological strain of
the soccer players that they have to cope with. In fact in a match
played at 36 °C with a relative humidity of 61% had shown that average
body core temperature reaches to values of 39.5 °C with an heart
rate value over 180 beats/minute. Moreover the average sweating
rate reached nearly to value of 2 liter/hour during the game. The
volume of sweat loss, possible changes of plasma electrolyte balance
and osmolality together with hyperthermia would seriously impair
athletic performance capacity and thermoregulatory mechanisms.
Prophylactic interventions such as acclimatization, different cooling
strategies and hydration before, during, and after the sportive
event are extremely important to prevent athletic performance capacity.
It is also important to remember that together with these interventions,
extensive health screening is important to protect soccer players
from the undesired occasions related with physical activities.
Effects
of a single session of resistance exercise training on specific
cardiac and oxidative stress markers
Tschan
Harald 1, Vidotto Claudia 2, Atamaniuk Johanna 3, Kinzelbauer Markus
1, Wessner Barbara 1 and Bachl Norbert 1
1 Center of Sport Sciences and Univversity Sports – Department Sportphysiology,
University of Vienna, Austria, 2 BKW Laboratory Medicine, Vienna,
Austria, 3 Social Medical Center South – Department of Laboratory
Diagnostics, Vienna, Austria
OBJECTIVE
In the past the fear of damage to the cardiovascular system has
led exercise specialists to urge against high intensity resistive
exercise. Strength training has been associated with an abrupt increase
in blood pressute, wall stress, increased myocardial oxygen demand,
myocardial ischemia, and left ventricle dysfunction. The present
study was designed to investigate wether wheater the stress of a
high intensive strength training session can induce myocardial cell
incury in trained weightlifters as assessed by post exercise plasma
concentrations of cardiac specific and nonspecific biochemical markers.
A futher aim of the study was to examine if this intensive training
session would result in an elevation of cell-free plasma DNA or
an elevation of reactive oxygen intermediates (hypoxanthine, xanthine).
METHODS 12 healthy, national class weightlifters performed 6 sets
of 6 lifting exercises at 5 RM each, including isometric stabilization
and the Valsalva Maneuver. Blood samples were drawn and urine samples
were obtained from each subject 1 hr before the training, as well
as immediately after finishing the exercise test and 2 hrs post-exercise.
For dedection of myocardial and skeletal muscle damage cardiac troponin
I (cTnI), total creatine kinase activity (CK) and myoglobin (Myo)
were measured. Serum concentrations of cTnI and myoglobin were measured
by immunoassays – CK activity by routin photometric assay. For detection
of myocardial overload NT-proBNP was analyzed using electrochemiluminescence
immunoassay. The amount of cell free plasma DNA was measured using
fluorescence signal detection and oxipurine levels were analysed
using HPLC technology. A one-way ANOVA with repeated measures was
used to detect changes over time. The Tukey HSD post-hoc test was
used to determine the location of differences when significant main
effects were detected.
RESULTS Beside cTnI all markers showed significant elevations (p<0.05
to p<0.001) over the time course of the 3 blood draws and urine
measurements respectively. Most laboratory markes were outside the
reference ranges. However the sensitive and specific biochemical
markers for dedecting myocardial damage (cTnI and NT-proBNP) stayed
within the reference ranges and tended to decrease toward baseline
levels already 2 hrs after finishing exercise training again. Markers
of oxidative stress and cell free plasma DNA showed the same tendency
with significant elevations (p<0.01) immediately following strength
training but no significant differences compared to baseline 2 hrs
after finishing the training session.
CONCLUSION From the present study it would appear that heavy resistance
exercise is well tolerated by experianced weightlifters without
showing any evidence that lifting tasks damages the myocardium.
The elevention of non-specific markes (CK and Myo) may reflect a
mild tissue trauma of the skeletal muscles. The transient elevation
of cell free plasma DNA and of the oxipurenes might be caused by
short episodes of ischemia of the skeletal muscles resulting in
an elevation of reactive oxygen intermediates.
Phosphodiesterase’s
inhibitors and physical activity
Luigi
Di Luigi
Unit of Endocrinology – Department of Health Sciences - University
of Rome “Foro Italico” / Italian Federation of Sport Medicine (FMSI),
Rome, Italy
Phosphodiesterases
(PDEs) catalyze the hydrolysis of cyclic adenosine monophosphate
(cAMP) and cyclic guanosine monophosphate (cGMP), to the corresponding
5’ nucleotide monophosphate (19). Currently, eleven different PDEs
families have been found throughout the body, each family containing
sub-families and multiple splice variance; they differ in selectivity
for cyclic nucleotides, sensitivity to inhibitors and activators,
physiological roles, and tissue distribution.
Nowadays, million of individuals of different ages take phosphodiesterase’s
inhibitors (e.g. PDE-5i) daily, not only as therapeutic agent to
treat erectile dysfunction (ED), but also for non-therapeutic purpose
(e.g. recreational use). Interestingly, there are many anecdotal
reports of the use of PDE-5i to increase performance in sports,
both in humans and animals.
Experimental studies have indicated that sildenafil, the firstly
used PDE-5i, positively influences exercise capacity in subjects
affected by cardiopulmonary diseases (e.g. pulmonary hypertension)
and in healthy subjects in hypoxic conditions. Some Authors also
hypothesized that subjects with particular responsiveness to the
exercise-enhancing effect of PDE-5i, in hypoxic condition, exist.
In contrast, other Authors observed that the evaluation of the effects
of sildenafil on exercise capacity at a simulated altitude did not
provide conclusive data.
In healthy male athletes we observed that, compared to placebo,
a single tadalafil (i.e. a long-term PDE-5i) administration significantly
reduced systolic BP before and after exercise, decreased O2/HR at
individual ventilatory threshold (IVT), but did not influence individual
O2 max, IVT, and individual anaerobic threshold. Furthermore, we
observed that, compared to placebo, tadalafil administration was
able to amplify the mean salivary C and T responses to a maximal
physical exercise, with concomitant further decrease of salivary
DHEAS/C and T/C ratios. We hypothesized that in our experimental
conditions, tadalafil could have: a) influenced the CNS sensitivity
threshold to exercise-related stress, and/or, b) maximized, at different
levels, the HPA and HPG response to physical stress, and/or, c)
influenced the cytochrome P450 (CYP) 3A-mediated steroids metabolism.
Athletes taking PDE-5i, and also their physicians, are still unsure
whether PDE-5i in some sports might negatively influence performance
or whether specific health risks, related to the interaction between
intense physical activity and PDEs inhibition, exist.
The observed effects of PDE-5i on exercise performances may be relevant
not only in terms of therapeutic use of PDE-5i for diseases other
than ED, but, if further confirmed, also in terms of their possible
fraudulent utilization to influence exercise performance in sports,
raising the difficult question of whether, particularly in some
circumstances (e.g. high altitude and/or induced hypoxia), the PDE-5i
might be considered as “prohibited substances” (i.e. doping) in
athletes. Moreover, very few investigations are actually available
when the effects of PDE5i on sport performance are concerned. Particularly,
it remains to confirm if a non-therapeutic PDE5i administration
in athletes at higher doses (i.e. non-therapeutic) or a prolonged
use influences sport performances in field conditions.
Studies to verify the effects of different PDE5i treatments on both
athlete’s health and exercise performance, and to explore all the
pathways involved are warranted.
Upper
extremity problems in children (Maladaptation and chronic syndromes
of the shoulder)
Vuslat
Sema Ünal
Ankara Numune Eðitim ve Araþtýrma Hastanesi, Ortopedi ve Travmatoloji
Klinigi, Ankara
Pediatric
participation in sports increases each year. Sports injuries in
children becomes an important topic consequently. A considerable
percent (%32) of serious injuries in children ( 5-17 years) occurs
during sports and/or recreational activities.Girls are effected
less than boys. (%20, %40 respectively).
Chronic Sports injury in a child is caused by chronic submaximal
trauma repeating over the healing capacity of the body (microtrauma,
overuse, misuse) and comes to stage as tendinopathy, stress fracture,
osteochondritis, traction apophysitis, maladaptation (flexibility
and strength). The deforming forces either acute or chronic has
effects on growth plate, apophysis, immature muscle development
may cause permenant damages if not prevented and/or treated.
Shoulder maladaptation and chronic injuries in children are common
in sports with repeating overhead movements. Chronic shoulder injury
in a child can occur because of internal factors like; immature
musculoskeletal system, poor dynamic shoulder stabilization, improper
technique. There may also be external factors as; level of competition,
quality of the sports, improper sportswear and protective equipments,
frequent competitions, and improper training program.
Chronic injury of a child may come to scene as rotator cuff injury
or SLAP lesion which is easier and more effective to prevent than
treat. For prevention we have to be aware of two important concepts
of the body motion.
The first one is ‘anticipating postural adjustments’ (APA). This
can be defined as the position, body takes during kicking, throwing,
and running to provide the balance and keeps on with programmed
muscle activations. The muscle activations generate and control
forces by providing interactive moments and loading the joints.
The other concept is kinetic chain segment activation (KCSA). This
term is the description for core activation for distal force development.
The force is generated at the gravity center of the body (core activation)
and transferred to the related extremity through the joints by muscle
interactions to do the intentional movement (distal force development).
As a matter of fact shoulder motions are not created by the periscapulary
muscles but the whole body. APA and KCSA, provides body stability
proximally while performing the activity distally in maximum strength.
Chronic injuries in children occurs due to technical and structural
deficiencies in APA and KCSA. Kinetic chain segment activation is
different in children. So should be the APA. Therefore to diagnose
and treat the weak ring in the chain will prevent the forthcoming
shoulder injury in pediatric athletes.
Driver’s
physical condition, physical training a WTCC experience
Ignacio
Muro
Sports medicine, SeatSport WTCC team doctor, TMEH Centro Médico
Teknon, Barcelona, Spain
An
explanation of the fundamentals of how a WTCC Racing Team prepares
and maintains its pilot’s physical condition. Includes detailed
explanations of what the driver’s job is, his physical necessities,
how to adapt a personalized training program to improve the driver’s
results and how to structure a recovery or recuperation program
after a race or accident.
Motor Sport competitions vary, from cars to motorbikes, but the
basics of the physical training for drivers are common for all.
A motor sport team needs the contribution of a large number of members
and all the efforts are focused on improving the performance of
the car and the driver. The mechanical parts of the car are looked
after by engineers and technicians, the driver is looked after by
a doctor, a physiotherapist and a physical trainer. Not only does
the driver travel around the world for demanding races and tests,
but he also attends manufacturer’s and press events.
Driving a car is an aerobic activity, although it may become anaerobic,
especially when fighting to win. The driver needs to resist high
temperatures wearing an overall, fireproof underwear, balaclava
and helmet. In addition to the stress of the race, car control requires
a huge muscular effort in an oppressive position which produces
high levels of peripheral and central fatigue.
OBJECTIVE
1. General Endurance; Resilience to long-journey duress. (heat,
cold)
2. Muscular Endurance and Balance: Permanent and complete car control.
3. Body Composition; Ideal balance between body weight, fat percent
and muscular percent.
Basic and Functional training.
Basic training is focused on general endurance. Even if drivers
enjoy sports training, time limitations require that all the training
sessions be previously scheduled. Physical activity should be fun,
and for drivers this implies “wheels and engines” such as: cycling,
motor bikes, snow and water bikes, skiing, ice hockey, beach volley.
Balanced nutrition guidelines should be established and body composition
monitoring should be effected monthly.
Functional training enhances propioception skills and enables the
driver’s ability to fully control body movements even when the car
is shaking during a crash. Balance training is presented as a challenge,
starting from a basic level the driver increases the difficulty
of the exercises on a weekly basis using fit-balls, bosus, elastic
bands, balls, and bars. The driver’s strength is increased but not
his weight or volume.
Complete recovery after a hard day of racing and testing is just
as important as pre-race training. Drivers are instructed in stretching
and yoga techniques to relax their muscles. They get physiotherapy
treatment to prevent and treat muscular soreness and joint swelling,
particularly the cervical area which is difficult to stretch individually.
Spa bath and sauna sessions are used when available.
Prevention
of dental trauma in contact sports
Ayse
Diljin Kececi
Süleyman Demirel University Faculty of Dentistry, Head of the Department
of Endodontics, Isparta, Turkey
In
contact sports, players physically interact with each other, trying
to prevent the opposing team or person from winning. Contact sports
such as rugby, hockey, boxing, basketball or martial arts belong
to the high-risk sports. A blow or kick from the rival most often
causes injury to one tooth, while a fall or blow from a hard object
often results in injuring more than one tooth. Enamel fracture,
crown fracture with or without pulp exposure, root fracture, luxation
injuries, avulsion and fracture of the alveolar process are types
of dental trauma. Dental damage following these injuries is usually
irreversible and can cause functional, esthetic and psychological
impairment.
Prevention of these injuries must be the prime emphasis of sports
dentistry. With the introduction of mouthguards at about the turn
of the century and their widespread use, there has been a reduction
in sports-related dental injuries. Mouthguards have a significant
role in absorbing and dissipating very important part of the energy
in the impact zone. Its main functions are reduction of the impact
of direct and indirect contacts resulting in the orofacial injuries,
soft tissue lacerations, temporomandibular joint damage, concussion,
and mandible fractures.
It must be kept in mind that various mouthguards have, to some degree,
an injury-preventing effect. Many sports-related dental and orofacial
injuries can still occur regardless of whether a mouthguard is worn
or not. The obvious cause of injury in mouthguard-wearing cases
is when the impact force far exceeds the protective capability of
a mouthguard. However, the ordinal impact power in sports is estimated
to be smaller than that found in traffic accidents and mouthguards
are found to be the most effective way of preventing dental injuries.
It is usually found difficult to wear the stock or boils-and-byte
type of mouthguards, because of oral dryness, nausea, instability,
difficulties in breathing and speaking. New studies report that
such kind of problems and the performance of the athlete are not
negatively affected, when a custom-made type of mouthguard is used.
Over the recent years, there has been an increasing interest in
studies related to the protective properties of mouthguards like
reinforcement by various techniques for better shock absorption,
better adaptation and some other details for athletes’ satisfaction,
which will be focused on in this lecture. Besides the importance
of sports dentistry and the role of sports institutions on increasing
the awareness of mouthguard use will be emphasized.
Stretching:
Effects of strength and injury prevention
Ufuk
Sekir
Medical School of Uludag University, Department of Sports Medicine,
Bursa, Turkey
Many
athletes use some type of pre-participation warm-up routine to prepare
themselves for athletic practice or competition. Traditionally,
these warm-ups have included some form of stretching, and stretching
has been commonplace in a multitude of sports. Many athletes, athletic
trainers and other rehabilitation professionals believe that stretching
promotes better performance and/or reduce the risk of musculoskeletal
injury during strenuous exercise or strength assessment tests by
improving flexibility or pain-free range of motion about a joint.
Athletes and coaches use many different types of stretching that
are usually based only on their personal preference, but no optimal
type or amount of stretching has been identified. There are various
techniques of stretching, including ballistic, proprioceptive neuromuscular
facilitation (PNF), static, and dynamic stretching. Among these,
static stretching is widely used because its application is easy
and safe. Recently, numerous studies have examined the effects of
static or dynamic stretching on maximal isometric, concentric, or
eccentric dynamic muscle strength. Typically, it was shown that
pre-exercise static stretching may temporarily compromise a muscle’s
ability to produce strength either isometrically or isokinetically.
In contrast, some evidence exists indicating that dynamic stretching
exercises may improve muscle strength performance. This has implications
for athletes involved in sports that require high levels of strength
and force production. Some researchers have proposed that static
stretching prior to competition may hinder performance and prompted
recommendations that static stretching be omitted or replaced by
dynamic stretching during warm-ups. On the other hand, stretching
is commonly perceived as an important way to prevent injury by the
public, sports coaches and sports medicine professionals. However,
in the literature, conflicting data have been reported concerning
the relationship between flexibility and athletic injury. The literature
reports opposing findings from different samples. A number of reviews
of the stretching literature exist, in which authors advocate stretching
as an important part of an injury prevention program, although these
conclusions are not based on any clinical evidence. But, at the
same time, other numerous recent systematic reviews on this matter
have shown no evidence that stretching does, in fact, reduce injury
risk. Therefore, no definitive conclusions could be drawn as to
whether stretching reduces the incidence of exercise-related injury
due to the heterogeneity and poor quality of the studies. Consequently,
based on the studies in the literature, there is not sufficient
evidence to endorse or discontinue routine stretching to prevent
injury among competitive or recreational athletes. Better research
is needed to determine the proper role of stretching in sports,
especially as there are increasing numbers of athletes and growing
recognition that all people need to increase their physical activity
to improve their health and quality of life.
Prevention
of football injuries
João
Pereira de Almeida
SLB Medical Doctor, Portugal
A
program of sport injury’s prevention is mandatory in medical support
to sport activities. Working in a club with more than 150.000 affiliated
and with a sport activity more than 2500 a day, we have to plan
a program that can reduce the number of injuries. Twenty years ago
European Council organized a program of Sport injury’s prevention
and in the following years different sport organizations adapted
those recommendations. In our Club, SPORT LISBOA AND BENFICA - SLB,
we organize the program in classic items.
Primary prevention: Characterize the risk factor (intrinsic and
extrinsic)
Secondary prevention: Correction of risk factors
Tertiary prevention: treatments of dysfunctions
The medical department is multidisciplinary; we have sport medicine
doctors and orthopedics and other specialties physiotherapists,
psychologists, nurses, physiologists, nutritionist, homeopaths and
administrative support. Organize a program in different sports is
difficult and we began with soccer and we are now speeding to basketball
futsal, volleyball, handball and roller skating. In the beginning
we have a deep dialog with all the staff (technicians, coaches etc.).
In the material support we have to “built” new gymnasium and to
organize the training camps and in the stadium, new methods of registration
of the mobility of the players. For each player we have a registration
of medical condition, psychological, nutritional conditional capacities
and we evaluate cardiac and biochemistry adaptations every training
and game. Special program of UEFA, surveying of sport injuries is
already available. We asked to be included in that program. After
two years working with the program or sport injuries prevention
we have in season 2008/2009 very good results.
Workshop
ultrasound of the wrist and hand
JL
Gielen
University of Antwerp, Belgium
The
wrist and hand have a very complex anatomy that is well demonstrated
on modern high resolution ultrasound. The first part of this workshop
will refresh relevant anatomy, the second “hands on” part will demonstrate
these anatomic pecularities, where as in the last part the relevance
of this anatomy will be demonstrated in pathological cases. The
regions that are addressed are the dorsal hood and extensor mechanism,
the flexor tendons, the ulnar collateral ligament of the thumb with
special interest in the detection of Steners lesion. The ulnar nerve
and Guyon’s canal. And the extensor compartments with special focus
on the first (De Quervain’s) compartment and the sixth or ECU compartment.
Olympic
performance: beyond genes & genome
Vassilis
Klissouras
Professor of Ergophysiology, University of Athens, Athens, Greece
My
main argument in this presentation is that the traditional dyad
of genes and environment, as a cause of top sport performance, may
require revision to consider epigenetic influences witch play a
crucial role in regulation of genotypic functions of complex human
traits, and hence, we need to go beyond gene and genome to understand
the nature of Olympic performance.
Genetic influences. Heritability estimates for phenotypes related
to sport performance is in the 50-90% range. Findings from twin
studies lead to the conclusion that genetic influence is so ubiquitous
and persuasive in sport performance that we now ask: not what is
heritable, but what is not heritable. During the past decade, Quantitative
Genetics and Molecular Genetics have began to come together to identify
specific genes responsible for substantial heritability of determinants
of sport performance, although so far no definite evidence was found
that DNA sequence variants in a given gene is reliably associated
with performance variation.
Environmental influences. A high heritable attributes does not mean
that it is unaltered, fixed and predetermined and the environment
has no effect. It only indicates that observed individual differences
in the given attribute are due to genetic differences and are highly
predictable. Genetic potential is not a passive possibility, but
an active disposition, actualized through laborious effort and the
sweat of the brow. However, training can exert its profound effect
only with the fixed limits of heredity.
Epigenetic influences. The picture emerging is consistent with the
notion that superior sport performers are endowed with high genetic
potential for their specific sport, actualized through hard, prolonged
and prodigious effort. Yet, there is an increasing body of experimental
evidence suggesting that epigenetic influences may play an important
role in superior performance. The process of epigenesis mediates
variations in gene expression that occur in response to changes
in a person’s internal and external environment. It has been shown
that young identical twin pairs are essentially indistinguishable
in their epigenetic markings, in various tissues including muscle,
whereas older identical twin pairs exhibit remarkable differences
in their overall content and genomic distribution of 5-methylcytosine
DNA and histone acetylation, affecting their gene – expression profile.1
Findings we obtained from identical twin athletes of Olympic level
are consistent with an important role of epigenetic alterations
in both biological and behavioral phenotypes. Apparently such alternation
inevitably mold our DNA, silencing some genes and promoting the
expression of others, thereby facilitating cognitive, emotional
and behavioral changes that empower the athlete to push himself
to his limits.
Reference
1 Fraga MF, Ballestar E, Paz MF, Ropero S, Setien F, Ballestar ML,
Heine-Suner D, et al. Epigenetic differences arise during the lifetime
of monozygotic twins. Proc Natl Acad Sci USA. 2005; 102:10604-10609.
Can
supplements increase performance? Should they be on the list?
Anton
JM Wagenmakers
Professor of Exercise Biochemistry, School of Sport and Exercise
Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
Recent
reports show that between 70 and 100% of all athletes use nutritional
supplements. Total global consumer spending on nutraceuticals (dietary
supplements for sport and health reasons) is estimated at $187 billion
and still rising with 6-7% per annum.
Nutritional supplements among others are used by athletes to enhance
energy supply and performance, to enhance recovery from exercise
and anabolic effects in muscle, to enhance immune system function,
and to enhance performance via effects on the central nervous system.
Properly designed scientific studies for many popular supplements
have failed to confirm the effects claimed by suppliers. This review
lecture will focus on creatine, caffeine, and bicarbonate: 3 supplements
for which hard scientific evidence has been generated that they
have an ergogenic effect using properly designed performance tests
in several laboratories and confirmed by evidence on the underlying
mechanisms. Creatine improves high intensity intermittent exercise
performance in laboratory conditions. This effect is not of particular
practical relevance in athletic events, but is most useful in soccer,
hockey etc, that is in events that depend on outrunning members
of the other team in repeated sprints. As 1-3 kg weight gain is
a side-effect and as there is no effect on endurance performance,
its use is better avoided by endurance athletes. No evidence has
been published for its claimed muscle anabolic effect in humans.
Caffeine improves exercise performance in events lasting > 60
sec, but its effect on sprinting performance is inconclusive. Ingestion
of 5-6 mg/kg bw (3-6 cups of coffee) can improve performance; ingestion
of more does not lead to larger effects. Caffeine has central effects,
but the exact mechanism still is not known. Caffeine potentially
reduces muscle glycogen breakdown, but there are many studies that
have failed to find this effect. Bicarbonate (NaHCO3 300 mg/kg)
ingestion 1-3 h before exercise improves performance in events lasting
0.5 to 7 min, but may lead to nausea, gastro-intestinal discomfort
and diarrhoea. The effect is most likely due to increased efflux
of intracellular lactate and H+, leading to a delay in a critical
decrease in intramuscular pH that impairs metabolic and contractile
function. Finally some critical notes will be made on the excessive
use of sports drinks containing antioxidants as several free radicals
play important roles in exercise induced microvascular recruitment
and training adaptation.
Why
anti-doping? The need for an operational ethics
Hans
Hoppeler 1 and Sigmund Loland 2
1 University of Berne, Switzerland, 2 Norwegian School of Sport
Sciences, Norway
During
the last decades there has been a steady increase in the kinds and
numbers of bio-chemical and bio-technological means for physical
and mental enhancement. International surveys show that attitudes
towards such means seem to change in a liberal direction. The heated
debate over WADA’s whereabouts system may be an indication of more
serious public challenges to anti-doping in the time to come. Anti-doping
needs a clear and operational ethical justification that is easy
to communicate in convincing ways.
In the WADA Code, doping is defined as fundamentally contrary to
‘the spirit of sport’. ‘The spirit of sport’ is explained as ‘…the
celebration of the human spirit, body and mind and is characterized
by the following values: ethics, fair play and honesty; health;
excellence in performance; character and education; fun and joy;
teamwork; dedication and commitment; respect for rules and laws;
respect for self and other participants; courage; community and
solidarity’.
Although these are key values in sport, the references are of a
general kind and hard to apply when it comes to concrete cases.
Some values, such as fairness and health, can also be twisted in
the direction of a more liberal doping policy. By combining a view
of sport as the ‘virtuous development of talent’ (Tom Murray) with
biological insights, an outline will be given of an operational
interpretation of ‘the spirit of sport’. Such an interpretation
holds that the development of talent towards sporting and human
excellence implies utilizing the adaptive responses of the human
organism as developed through evolution, and not overruling such
responses with external means. This view will be elaborated, and
an argument will be given that an operational anti-doping ethics
can be communicated to the public in simple and convincing ways.
The
2010 prohibited list – open questions
L
Horta
Conselho Nacional Antidopagem (CNAD) – Lisbon, Portugal
The
World Anti-Doping Program is composed by three levels of documents.
At the first level we have the most impor-tant document - the World
Anti-Doping Code, describing the major principles of the fight against
doping. At the second level we have five international standards,
describing different practical procedures to be followed by all
anti-doping organizations worldwide. At the third level we have
the model guidelines, that are very pragmatic documents, and not
mandatory as the previous ones.
The Prohibited List is a level two document that defines the prohibited
substances and methods. The Code de-fines the criteria that must
be fulfil to determine the integration of one substance or method
in the List: 1 - Medical or other scientific evidence, pharmacological
effect or experience that the substance or method has the potential
to enhance or enhances sport performance; 2 - Medical or other scientific
evidence, pharmacological effect or experience that the use of substance
or method represents an actual or potential health risk to the athlete;
and 3 – WADA’s determination that the use of the substance or method
violates the spirit of sport described in the introduction to the
Code.
The Prohibited List is revised at least once a year. The annual
revision of the Prohibited List is an elaborate and dynamic process
involving international scientific experts and the solicitation
of input from stakeholders so that changes are founded on expanding
anti-doping knowledge and trends. The development of the Prohibited
List begins with the circulation of a draft to stakeholders. Comments
received are considered by WADA’s List Committee, who then pre-sents
its conclusions to WADA’s Health, Medical and Research Committee.
This Committee submits its final recom-mendations to the Executive
Committee, who discusses the recommendations and makes a final decision
at its Septem-ber meeting. The Prohibited List is published in the
WADA’s website at October 1st, in order to allow the anti-doping
organisations (international federations and national anti-doping
organisations) to inform their affiliates about the new Prohibited
List that will be in force in January 1st.
The construction and the revision of the Prohibited List represents
a very difficult task taking in consideration the huge amount of
prohibited substances and methods and also the complexity of the
scientific methods involved in their detection. To increase even
more the complexity of detection some prohibited substances are
also produced endoge-nously.
The objective of this presentation is to underline some open questions
concerning the Prohibited List and the in-herent detection methods
in the following sections:
S1. Anabolic Agents – the limitations of IRMS analysis and the importance
of endogenous steroid profiling in the endocrinological model of
the Athlete’s Passport;
S2. Peptide hormones, growth factors and related substances - The
use of hypotalamic releasing factors, the de-velopment of new erythropoiesis-stimulating
agents and the enhancement performance properties of different route
of administration of platelet-derived preparations (e.g. Platelet
Rich Plasma, “Blood Spinning”);
S3. ß-2 Agonists – Need to determine a threshold level for the detection
of formoterol and terbutaline;
M1. Enhancement of Oxygen Transfer - Difficulties to detect autologous
blood transfusions and erythropoiesis-stimulating agents with very
narrow windows of detection and the importance of blood profiling
in the blood model of the Athlete’s Passport;
M2. Chemical and Physical Manipulation – The inclusion of proteases
as an example in the prohibited list;
S6. Stimulants – Scientific bases for the reintroduction of pseudoephedrine;
S9. Glucocorticosteroids - Difficulties in establishing the way
of administration of glucocorticosteroids taking in consideration
the detected urinary concentrations and need to define different
threshold levels for detection.
Finally we underline the importance of the WADA’s program for financing
research projects in order to revise the Prohibited List and improve
the methods of detection. WADA committed more than US $ 44 million
to that pro-gram since 2001.
Should
oxygen be on a prohibited list
Nenad
Dikic
Anti-doping agency of Serbia (ADAS), Republic of Serbia
In
the draft of the 2010 prohibited list for the first time is prohibited
the use of hyperoxic conditions, except for medical emergencies
and in those sports where the use of supplemental oxygen is mandated
as a safety requirement (aeronautic, mountaineering). This raised
attention of various groups of experts, as well as athletes. There
are no clear definitions of hyperoxic conditions, but one of the
definitions for hyperoxia is a condition characterized by greater
oxygen content of the tissues and organs than normally exists at
sea level (Merriam Webster dictionary). In reality, we could make
greater oxygen content in our body by breathing pure oxygen from
the bottle, by using hyperbaric therapy or using different kinds
of hypoxic devices, including living in the hypoxic environment.
All methods are providing more oxygen in our tissues. Does it mean
that all those methods are forbidden? For example hypoxic training
is frequently used by competitive athletes to improve sea-level
performance, but benefits are controversial. Hypoxic exercise may
increase the training stimulus, thus magnifying the effects of endurance
training, but conversely, hypoxia limits training intensity, which
in elite athletes may result in relative deconditioning. Even modern
approach of living and training at altitude have not been proven
to be advantageous compared with equivalent training at sea level.
Totally the opposite hyperbaric oxygen (HBO) therapy is defined
as a medical treatment in which the patient breathes 100% oxygen
intermittently while inside a chamber at a pressure greater than
1 atmosphere absolute. The Undersea and Hyperbaric Medical Society
currently approves 13 medical indications for treatment with HBO.
But certain sport experts try to direct professional and college
athletic teams to use HBO to treat sports injuries, to speed recovery
after exercise, and as an ergogenic aid to enhance performance,
but without real proof of the oxygen activity. Finally, bottled
oxygen is the most frequently accessible method by many athletes.
When is acceptable and justifying using that kind of oxygen and
other methods, it is the open question which should be discussed.
There are many guidelines for using the oxygen and only WADA seeks
international harmonization to prohibit it. Oxygen should not be
added to the list, since there is no clear evidence that enhance
performance, has negative health effect and it is against the spirit
of sport, which means that doesn’t fulfil the criteria for doping
substance.
The
role of exercise in osteoporosis management
Kirill
Micallef-Stafrace 1, Andrew Decelis 1, Nicola Micallef-Stafrace
2 and George Buttigieg 3
1 Institute of Physical Education and Sports (IPES), University
of Malta, Malta, 2 Medik Healthcare Services Ltd, Malta, 3 Department
of Obstetrics and Gynaecology, Mater Dei Hospital, Malta
Osteoporosis
is a condition of decreased bone mass which leads to an increased
risk for fractures. It is a predominantly silent disease that has
become a major public health problem in Europe and the rest of the
world, especially amongst the elderly populations. By the year 2050
it is estimated that over one third of the European population will
be over 60 years of age with the concomitant increase in the incidence
of osteoporosis. In fact fractures of the hip are expected to double
over the next 50 years. This will lead not only to a decrease in
the quality of life of our elderly population but also of a significant
increase in health care costs. Physical activity as part of a healthy
lifestyle has an important role to play in the prevention and management
of the osteoporotic patient. Exercise at a young age will help maximize
the bone mineral density and if continued lifelong will continue
to stimulate bone formation, strengthen muscles and improve balance
and coordination. These are all important elements, not only to
aid in the management of osteoporosis but also to reap multiple
other health benefits. The chosen exercise ideally should involve
weight bearing physical activities such as running and jumping.
However, all forms of physical activity can benefit the osteoporotic
patient since they contribute to an avoidance of falls and thereby
decreased fracture incidence.
Hemodynamics
of swimming in health and disease
H.Löllgen
1 and Ruth Löllgen 2
1 Med.Dept., Municipal Remscheid Hospital Germany, 2 Dept. of Pediatric
Disease, Hopital Cantonal, CH- Geneve, Switzerland
Swimming
is a special kind of head out water immersion. Based on own results,
this presentation demonstrates studies of central hemodynamic (heart
rate, stroke volumen, cardiac index, Frank-Starling Diagram) response
during stepwise increasing head out water immersion. In addition,
respiratory function with respiratory mechanics, respiratory gas
exchange and ventilatory control are shown with different depth
of water immersion. These changes also do occur in patients.
Water immersion and training in water has to be critically seen
in patients with high blood pressure, unstable coronary artery disease,
heart failure or pulmonary hypertension. So-called swimming testing
with telemetric ECG transmission is strongly recommended in patients
with cardio-pulmonary diseases.
A some more moderate form of training is the newly developed aqua-riding.
Aquajogging may be prescribed when legs cannot be used after sports
injury but endurance training should be done.
Today, the effect of regular training swimming as an approach to
primary prevention has not been demonstrated by an evidence based
investigation. Prospective cohort studies are required to answer
this question. In osteoporosis, swimming is without effect.
Proprioception:
Definition, clinical importance and evaluation methods
Defne
Kaya, Uður Dilicikik, Hande Güney, Haydar Demirel and Mahmut Nedim
Doral
Hacettepe University, Ankara, Turkey
The
ability that transmit the sensation of body position, perception
and interpretation of this data and giving an conscious or unconscious
reaction resulting in approximate posture and movement is called
proprioception. Proprioception is a specialized variation of the
sense of touch that encompasses the sensations of joint motion (kinesthesia)
and joint position (joint position sense). Mechanoreceptors are
the sensory receptors located in soft tissue articular structures.
Three distinct morphological types of mechanoreceptors are situated
within ligamentous tissue (Ruffini endings, Pacinian corpuscles,
and Ruffini corpuscles), and two types of mechanoreceptors appear
in the musculotendinous tissue that surrounds the joint (muscle
spindles and GTOs). Mechanoreceptors function by transducing some
form mechanical deformation into a frequency modulated neural signal
which is transmitted via afferent and efferent pathways. The disruption
of muscle and joint mechanoreceptors from physical trauma results
in partial deafferentation of the joint and surrounding musculature,
thus resulting in diminished proprioception. The results of current
investigations indicate the need for proprioceptive training during
any rehabilitation program designed to return athletes to preinjury
levels of activity following ligament and muscle injuries. A lot
of measurement methods of proprioception have been defined in the
literature. Based on these measurements, scientists comment the
proprioceptive status in some specific conditions. Has the proprioception
influenced by braces, elastic bandages, surgical or conservative
treatments, has the increased proprioception decreases the incidence
of injury, enhances the sportive performance and the other questions
about the proprioception aimed to be answered by measuring the proprioception
with different methods. However, to measure the proprioception is
difficult and cannot be done directly. Thus, the testing conditions
are not the same with the instant of injury. Patients are usually
in supine position, and their extremity is positioned in a computerized
system for proprioceptive measurements. Non weight-bearing and static
positions are not relevant to the injury position in the real life.
Hence, it is doubtful that the existing measurement techniques and
their results can reflect the real status of proprioceptive level
in injured or uninjured persons. Another important issue on testing
methods of proprioception is that they are not specific to a tissue,
a ligament, capsule or a joint. For example, during a knee joint
evaluation, the test results may be influenced by the pathologies
of hip joint and/or ankle in almost all measurement techniques.
Thus no test method can evaluate the proprioception separately when
accompanying lesions are found in the same joint.
Sports
traumatology, sports medicine and proprioception
Ufuk
Sekir
Medical School of Uludag University, Department of Sports Medicine,
Bursa, Turkey
The
primary function of proprioception is prevention of both traumatic
and overuse related sports injuries. Other tasks of proprioception
include providing the athlete return to sport activities safe again
with reduced, or even without injury risk following injury or surgery
and enhancing the sports performance of the athlete. It has been
shown in a study that the majority of injuries during soccer occurred
in the lower extremities with 81%. The most common injury type within
these injuries was ankle sprains (17.2%). The authors concluded
that the cause for this high ratio may be insufficient ankle joint
stability and/or sensorimotor deficiency. In parallel some authors
suggested that ankle sprains can be prevented by external ankle
supports and proprioceptive/coordination training, especially in
athletes with previous ankle sprains. Training of neuromuscular
and proprioceptive performance as well as improvement of jumping
and landing technique seems to decrease the incidence of severe
knee and ACL injuries. Such prevention programs are likely to be
more effective in groups with an increased risk of injury. A study
regarding this issue exhibited with stretching, strengthening, plyometrics,
proprioception, and sports-specific drills an 88% decrease following
1 year, and 74% reduction following 2 year in ACL injuries. Alike,
it was stated again that using a neuromuscular training program
may have a direct benefit in decreasing the number of ACL injuries.
A recent article recommended as the most important initial treatment
approach in patients with ACL injuries improving dynamic single-limb
stance balance and training threshold for detection of passive motion
(kinesthesia) proprioceptive ability. On the basis of, that osteoarthrosis
is associated with decreased proprioception, incorporating a multi-station
proprioceptive exercise program also in patients with bilateral
knee osteoarthrosis exhibited 30-40% improvements in sensorimotor
tests following proprioceptive and balance training. On the other
hand, it was signified that subjective knee function is related
to proprioception. This means, patients with ACL rupture having
symptoms possess more proprioceptive deficits compared to asymptomatic
patients. Besides, abnormal knee joint proprioception was also established
in individuals with patello-femoral pain syndrome (PFPS) and authors
advised here also that proprioceptive rehabilitation techniques
should be incorporated into the treatment of PFPS. Differently,
it was demonstrated that isokinetic exercise in rehabilitation protocols
of patients with PFPS also has a positive effect in improving knee
joint proprioceptive acuity. Regarding the role of proprioception
in sports performance, a recent study emphasized that rhythmic gymnasts
have developed abilities in postural stability, balance, and “transfer”
to bipedal postural sway, especially in medio-lateral displacements
and that these capabilities constitute an important role in their
successful sports career. In conclusion, sensorimotor system is
important in terms of preventing injuries and improving performance.
It is crucial to evaluate, reinforce, and develop the sensorimotor
system for scientists coping with sports injuries and sports performance.
New
challenges for detection of doping in sport
Geoffrey
Goldspink
Departments of Surgery, Anatomy and Developmental Biology, University
College Medical School, Royal Free Campus, University of London.
UK.
The
inevitable use of growth factors for enhancing muscle strength and
athletic performance is a major concern of the World Anti-doping
Association as well as the antidoping agencies in individual countries.
Although this now involves expert scientists with powerful analytical
methods, the so called “counter culture” also includes well trained
scientists, team doctors and coaches who are under pressure to ensure
their sports people succeed. The Olympic Games as well as being
known for what city they were held in have also somewhat cynically
be named after the prevalent type of doping that has been used.
We have had for example, the beta agonist, the EPO, the steroid
games etc. Based on the present interest and the next games retrospectively,
may be called the “growth factor games”. Recently, much effort has
been expended on developing a treatment for muscle wasting associated
with a range of diseases as well as in ageing. Emerging molecular
techniques have made it possible to gain a better understanding
of the growth factor genes involved and how they are activated by
physical activity in young individuals. In addition to hGH and IGF-I
two factors some growth factors such as MGF a type of IGF-I which
is a very positive regulator of muscle hypertrophy and strength
and strategies for reducing the negative effect of myostatin, will
be described. As well as an initial method for screening large numbers
of sports people it is necessary to have at least one confirmatory
test that will stand up in a Court of Law to convince the Judge
that a substance had been taken to alter the individual’s physiology
advantageously. Developments in mass spectrometry combined with
robotics and analysed by powerful computer programmes such as neural
networks allow hundreds of blood and urine samples to be analyses
within a day or so, to detect a changed metabolic profile to be
detected. This is the new branch of chemistry known as “metabolomics”.
In order to establish these methods, collaborative work was carried
out with analytical chemists at Nottingham Trent University and
the race horse testing laboratories at Newmarket UK. This initial
screening approach enables hundreds of blood samples to be analysed
within a day. We used blood from samples from mice and also human
volunteers that had been “doped” using hGH and were used to determine
abnormal patterns of metabolites such as leucine rich glycoprotein
(LRG) which are good indicators of doping. Following this those
suspected of doping are subjected to confirmatory tests which are
more expensive in time and money but which is physiologically based
and could lead to a conviction in a Court of Law. One confirmatory
test that was established in the author’s laboratory will be described.
Results
Management – from a reprimand to a life ban
L
Horta
Conselho Nacional Antidopagem (CNAD) – Lisbon, Portugal
The
revised World Anti-Doping Code that entered in to force last January
1st 2009 introduced more flexibility and proportionality in the
sanctioning system of anti-doping rule violations. The article 2.1
“Presence of a Prohibited Substance or its Metabolites or Markers
in an Athlete’s Sample” and 2.2 “Use or Attempted Use by an Athlete
of a Prohibited Substance or Prohibited Method” defines two of the
more important and frequent anti-doping rule violations. The Prohibited
List defined two types of prohibited substances: the specified and
non specified substances. The specified substances are those substances
that can be used for therapeutic purposes and have low enhancement
performance properties and most times the anti-doping rule violations
concerned with these substances are due to negligence of the athlete
rather than a real doping purpose.
As the general rule for anti-doping rule violations concerned with
non specified substances, the period of ineligibility imposed for
a first anti-doping rule violation shall be in general two years,
unless the conditions for eliminating or reducing the period of
Ineligibility or the conditions for increasing the period of ineligibility
are met. For violations involving specified substances the period
of ineligibility shall be for a first violation at minimum, a reprimand
and no period of ineligibility from future events, and at a maximum,
two years of ineligibility.
For multiple violations the Code defines a very broad spectre of
sanctions, depending on the kind and seriousness of the anti-doping
rule that were committed.
The objective of this presentation is to demonstrate, giving examples,
the importance of the scientific expertise to support an ideal proportionality
in sanctioning anti-doping rule violations:
Case one – a rider that participated in an international event had
two adverse analytical findings for a glucocorticosteroid (betamethasone)
and claimed that the results were covered by an abbreviated therapeutic
use exception (ATUE). The scientific expertise demonstrated that
the concentration profile of the concerned specified substance in
the urine along the event couldn’t be explained by the ATUE;
Case two - a football player had an adverse analytical finding for
a glucocorticosteroid (methylprednisolone). The athlete and team
physycian claimed that the result was cover by an ATUE for Methylprednisolone,
where an intra-articular administration of 20 mg of that compound
was declared 38 days before the in competition test and that the
fact of a previous surgery on that joint could explain the delay
in the urinary excretion. The delay could be explained to a chronic
inflammation of the synovial membrane after surgery. The scientific
expertise demonstrated that the concentration profile of the concerned
specified substance in the urine couldn’t be explained by the ATUE;
Cases tree and four – two athletes, one a football player and the
other a rally pilot, had adverse analytical findings for cannabis
– a specified substance. The first one was sanctioned with a reprimand
ant the obligation to be submitted to tests for detection of social
drugs lasting a minimum of six months and the second one was sanctioned
with two years of ineligibility taking in consideration the risk
of accidents caused by that administration to the pilot itself,
to the co-pilot, to other competitors, officials and public.
Case five – a shooter had an adverse analytical finding for an anabolic
agent (clembuterol), a non specified substance. The athlete and
its defence claimed that the result was originated by an intake
of meat in a “Rodizio” restaurant in Rio de Janeiro. The scientific
expertise demonstrated that the concentrations of the substance
found in the urine couldn’t be explained by the ingestion of such
a meal.
Case six – a rider had an anti-doping rule violation due to the
fact that proteases were found in is urine. The purpose for it to
be found there was to manipulate the detection of EPO. In this case
the athlete used a strategy to deceive the anti-doping laboratory
in the detection of EPO – this fulfils the conditions for increasing
the period of ineligibility.
In conclusion, in the results management of some anti-doping rule
violations, the scientific expertise can be decisive to fulfil the
proportionality of the sanction.
Femoroacetabular
impingement: Anatomy, pathofysiology and radiological imaging
J.
L. Gielen, P. Van Dyck, F.M. Vanhoenacker and C. Venstermans
University of Antwerp, Belgium
Femoroacetabular
impingement has recently been recognised as a cause of early osteoarthritis.
This impingement is particularly frequent in sports activities with
forceful flexion activities at the hip as is the case in soccer
players. Two mechanisms of impingement are recognised. Cam type
is caused by a non-spherical head where as pincer type is caused
by excessive acetabular cover. Both types of bone deformities are
frequently encountered, in the series of Beck et al over 12 % of
individuals were involved, cam type being almost twice more frequent
than pincer type. Both deformities may exist together. These two
types of bone deformities cause different types of articular damage.
In cam impingement the cartilage is sheared off the bone during
flexion, by the non-spherical femoral head while the labrum remaines
untouched. This separation between labrum and cartilage is located
at the anterosuperior acetabular cartilage. In pincer the impingement
is caused by excessive cover of the head of the femur by the acetabulum.
During flexion the labrum is crushed between the acetabular rim
and the femoral neck causing degeneration and ossification of the
labrum. Standing antero posterior plain radiographic examination
of the pelvis is accurate for the detection of femur head and acetabular
bone deformities that are responsible for cam and pincer impingement
respectively. Labral and hyaline cartilage damage is responsible
for the typical C pain at the hip region during the FADDIR (flexion,
adduction and internal rotation of the hip) impingement test. The
cartilage and labral lesions are best demonstrated on MR-arthrographic
examination. De purpose of the presentation is to illustrate the
pathophysiological mechanism of femoroacetabular impingement, to
give diagnostic clues for the radiographic identification of the
responsible bone deformities and to demonstrate the spectrum of
cartilage and labral abnormalities that are encountered on MR-arthrography.
References
Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the
pattern of damage to the acetabular cartilage: femoroacetabular
impingement as a cause of early osteoarthritis of the hip. J Bone
Joint Surg Br. 2005 Jul;87(7):1012-8. PubMed PMID: 15972923.
Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance
arthrography of labral disorders in hips with dysplasia and impingement.
Clin Orthop Relat Res. 2004 Jan;(418):74-80. PubMed PMID: 15043096.
Peeters J, Vanhoenacker FM, Marchal P, Mulkens T, Ghysen D, Myncke
J, Van Dyck P, Gielen JL, Termote JL, Parizel PM. Imaging of femoroacetabular
impingement: pictorial review. JBR-BTR. 2009 Jan-Feb;92(1):35-42.
Review. PubMed PMID: 19358486.
Anderson LA, Peters CL, Park BB, Stoddard GJ, Erickson JA, Crim
JR. Acetabular cartilage delamination in femoroacetabular impingement.
Risk factors and magnetic resonance imaging diagnosis. J Bone Joint
Surg Am. 2009 Feb;91(2):305-13. PubMed PMID: 19181974.
Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes.
Sports Med. 2008;38(10):863-78. Review. PubMed PMID: 18803437.
Arthroscopic treatment of FAI (femora-acetabular impingement)
Sarper
Mehmet Cetinkaya
Acýbadem Bakirköy Hastanesi, Istanbul, Turkey
WHAT
IS FAI? Impingement itself is the premature and improper collision
or impact between the head and/or neck of the femur and the acetabulum
TYPES 1-Cam-type : Excessive bone (bump) over femoral head and neck
causes friction/ impingement.
2-Pincer-type : Overgrowth of the acetabular rim and acetabular
version problem cause friction/ impingement.
3-Combined (Mixed) type: Cam + Pincer
When the extra bone on the femoral head and/or neck hits the rim
of the acetabulum, the cartilage and labrum that line the acetabulum
can be damaged
SYMTOMPS • Groin pain: Sports incluiding repetative hip hyperflexion
and external rotation can cause intra-articular hip problems( soccer,
ice scating,hockey,tennis,golf). Labral and chondral lesions can
be seen in agilitiy sports (runners). • Pain during prolonged hip
flexion and tortions (standing up from sitting position, wearing
socks, puting on shoes , going up & down. • Walking uphill is
also found to be difficult. • The pain can be a consistent dull
ache or a catching and/or sharp, popping sensation. • Pain can also
be felt along the side of the thigh (L3 dermatome) and in the buttocks.
• Byrd – C sign
DIFFERENTIAL DIAGNOSIS • Back pain, • Arthritis, • Apophyseal avulsions,
• Pubalgia, • Avascular necrosis, • Benign Tumors (Osteoid osteoma,
Osteochondroma), • Chondral lesions, • Dysplasi, • FAI, • Gastrointestinal
or genitourinary problems, • Gluteus medius syndrome, • Hernia,
• Hip joint instability, • Ýliopsoas snapping hip, • Ýliotibial
band snapping hip, • Ýntrapelvic disorders, • Labral tears, • Legg-Calve-Perthes
disease, • Ligamentum teres rupture, • Loose body, • Musculotendinous
sprains, • Osteitis pubis, • Osteochondritis dissecans, • Pigmented
villonoduler synovitis, • Piriformis syndrome, • Sacroiliac disorders,
• Siatalgia, • Septic arthritis, • Slipped capital femoral epipyhsis,
• Stress fracture, • Synovial Chondromatosis, • Synovitis, • Throcanteric
bursitis,
DIAGNOSIS • Physical examination : Impingement test (+) : Pain during
flexion+adduction+internal rotation of the hip joint in the intra-articular
problems, • X-Rays: Standard AP and Frogleg (Abduction+external
rotation) x-ray: (Femoral bump, Acetabular rim overgrowth,Calcified
labrum, Acetabular cross-over sing can be seen), • ArthroMRI: MRI
taken after injection of intra-articular solution of 0.2cc Omniscan
+ 20cc SP + 6ccCitanest + 8cc Omnipaque under flouroscopy (Acetabular
labral tear and chondral lesions can be visualized Decrease or loss
of the pain after injection in 4-5 minutes means intra-articular
problems.
CONSERVATIVE TREATMENT • Rest, • Activity modification (restriction
of activities which includes hip flexion over 80 degrees like squating,cycling,leg
press, backward running...etc), • NSAID, • Postural rehabilitation(
to decrease pelvic inclination), • Restoration of pelvic ring reclinination
with abdominal and gluteus maximus muscle strengthening + iliopsoas
and paravertebral muscle stretching which can decrease anterior
coverage of femoral head
SURGICAL TREATMENT • Open Surgery (with safe dislocation): Increased
avascular necrosis risk, Morbidity of Trochanteric osteotomy , Prolonged
rehabilitation period, Cosmetic problems.
ARTHROSCOPIC TREATMENT OF FAI Under general anesthesia with the
traction table and flouroscopy control, hip arthroscopy is started
from anterolateral portal. Then anterior portal is opened. Depending
on surgeon needs, additional portals ( porximal-distal anterolateral
portals) can be placed. With these portals, central compartment
arthroscopic procedures can be done (Acetabular rim (pincer) resection,
labral excision or labral repairs with anchors).After central compartment
arthroscopy, the traction is released and hip flexion up to 45 degrees
and portals are replaced from the same skin insicion to femoral
neck region for peripheral compartment arthroscopy. With these position
and portals, femoral neck bump (cam) resection can be done.
POSTOPERATIVE TREATMENT• 1-2 days hospitalisation, • Mobilisation
with crutches (30-50 % weigth bearing), • Full weigth bearing after
2 weeks, • Leave up cruthes after 3 weeks, • Non-weigth bearing
for 6 weeks after microfracture procedure, • Running after 6-8 weeks,
• Return to sports after 3-4 months, • Studies have shown that 85-90%
of hip arthroscopy patients return to sports and other physical
activities at the level they were at before their onset of hip pain
and impingement
COMPLICATIONS • Numbness on groin region (excessive and prolonged
traction causes temporary nerve paralysis), •Temporary impotance
in males (traction can cause pudental nerve neuropraxia), • Stress
fracture of femoral neck (excessive femoral neck resection), • Decubitus
lesions over scrotum,perineum,labia depending on traction, • Retroperitoneal
fluid extravasation, • Iatrojenic chondral and labral lesions, •
Intra-articular breakage of guide pin/ surgical equipments, • Heterotrofic
ossification, • Avascular necrosis of femoral head, • Infection,
• DVT, • Hip instability( excessive capsular release).
CONCLUSION Hip arthroscopy is indicated when conservative measures
fail to relieve symptoms related to femoro-acetabular impingement,
a condition that has been poorly understood and under-treated in
the past. Advances have made hip arthroscopy a safe and effective
alternative to open surgery of the hip, a tremendous advantage in
treating early hip conditions that ultimately can advance to end-stage
arthritis
EMG
applications in sports medicine
Hayri
Ertan 1, Axel J. Knicker 2 and Serge Ro 3
1 Anadolu University, School of Physical Education and Sports, Eskisehir,
Turkey, 2 Sport University Cologne, Institute for Motor Control
and Movement Technique, Dept. of Motor Control and Neurosciences,
Germany, 3 Boston University, Neuromuscular Research Centre, MA,
USA
Earlier studies have proven that high-level athletes have a different
activation-relaxation and/or co-contraction strategies than that
of middle class or beginners. These findings motivates the researchers
to concentrate on defining certain strategies for given sports branches.
The purpose of the current paper is to share the latest findings
of high-level athletes in archery, female volleyball and soccer.
The findings that will be presented in this session have been gathered
by using basically Electromyography (EMG). So, the current manuscript
tries to define both some certain muscular activation-relaxation
and/or co-contraction strategies in given sports branches and mention
the importance of EMG findings in evaluating high-level performance.
The first findings will be from sport archery and the muscular activation
strategies during the release of the bowstring. Two different muscular
activation strategies have been defined in the literature. In the
first strategy, archer releases the bowstring by actively contacting
the forearm extensor and gradually relaxing the forearm flexor muscles.
The archer releases the bowstring with clear relaxation of forearm
flexors and without active involvement of forearm extensors in the
second strategy. The second strategy is known to decrease the lateral
deflection of the bowstring, which is reputed to increase the score
on the target.
As for the studies related with male soccer, the findings have demonstrated
that high level soccer players show more agonistic activation during
forward swing and ball contact phase and less antagonistic activation
during follow through; whereas middle class soccer players demonstrated
less agonistic activation during forward swing and ball contact
phase and high antagonistic activation during follow through phase
during the kicks to a stationary ball. It has been concluded that
to increase ball speed on target; one should (1) increase the contraction
values of Vastus Lateralis (VL) and Vastus Medialis (VM) during
forward swing and ball contact phase, and (2) decrease contraction
values of Gastrocnemius (GAS) during backswing and follow through
phase.
The results that were related with high-level female volleyball
players have shown that agonist-antagonist contraction ratios and
coordination, landing technique and intramuscular coordination are
the important factors for countermovement jump. Having high GAS
activation values during landing may be explained by landing technique.
VM, VL, GAS, GM and BF muscles are activated before ground contact
in order to stiffen the joint in preparation for touch down. It
can be said that pre-activation is important for the jumping performance.
For the female volleyball players, it has been concluded that high
level volleyball players showed higher muscular activation during
propulsion phase, but lower during landing and post landing phases
compared with control group.
In conclusion, high-level sportsmen have different contraction-relaxation
and/or co-contraction strategies. These strategies may be used for;
1. Selecting talented athlete for given sport branches, 2. Decreasing
the occurrence rate of any type of injury and 3. Monitoring the
athlete’s development.
The
hazards of DXA, BMI and other golden standards
Clarys
Jan Pieter
Provyn Steven and Scafoglieri Aldo (research associates) Experimental
Anatomy, Vrije Universiteit Brussel
Human
Body Composition (BC) is characterized by data acquisition techniques
classified in various models (morphological and chemical). For adiposity
matters, single measures, indexes and prediction formulae have been
validated using a variety of “golden standards”. Hypothetically,
different techniques should provide the same outcome. However, preliminary
work indicates, the opposite.
Different techniques provide exact, identical and reproducible values,
or, are these values simulations, approximations or predictions?
Fact is that all in vivo techniques deliver indirectly obtained
values. Fact is that many of these indirect techniques have been
validated against other indirect techniques. Fact is that some golden
standards never were validated against direct data. Fact is that
for the clinic and public health, accuracy and precision are essential.
Fact is that these issues have become manufacturer-dependent and
not always quality controllable. The borderline between assumptions,
predictions and accurate precision has become too vague and is too
often ignored. The purpose of this work is to verify the value of
3 (indirect) standard BC systems, against direct values. The quality
control of BMI, DXA and hydrodensitometry, respectively, will be
dealt with separately.
I. The Quetelet index (1832-1972) or the BMI (1972-…).
The use of BMI as an indicator of BC is based on its correlation
with indirectly obtained values of adiposity. Direct evidence for
the validity of BMI as an adiposity index is lacking. The relationship
of BMI with total body AT and other BC constituents is explored
in human cadavers (N=29). Correlations between BMI and BC constituents
were calculated and prediction equations with BMI as the dependent
variable and all BC constituents as independent variables were developed.
BMI was moderately related to AT but much stronger to bone mass.
AT, nor its BC constituents improved the prediction. BMI is not
an appropriate adiposity index in particular for elderly persons.
The high proportion of unexplained variance between BMI and direct
adiposity mass limits its use as a BC index. BMI might be an index
for bone mass rather than for adiposity, and is not an indicator
for stress, cancers, cholesterol, diabetes or obesity. The use of
the BMI as measure of adiposity is not justified.
II. DXA, DEXA … Dual Energy X-Ray Absorptiometry.
Reviewing the literature of DXA application, one cannot avoid obtaining
a controversial impression of this method of choice. Some studies
support the DXA technique as convenient for % Fat, Lean Body Mass
(LBM) and Bone Mineral Content (BMC) measures. Other studies suggest
a violation of basic biological assumptions. Twelve porcine carcasses,
viscera included, were measured with DXA and CT before dissection
into its major components. Soft tissue samples allowed for chemical
and hydration analyses and the complete skeleton was ashed for BMC.
Part of the problem results from erroneous terminology. The predictive
character of DXA is good. Significant differences indicate that
clinical precision is at risk.
III. Hydrodensitometry.
Hydrodensitometry combines hydrostatic weighing and the calculation
of (i) the body volume and (ii) density. This density is used to
calculate % Body Fat. Hydrodensitometry was previously a golden
standard, but has been criticized suggesting a violation of basic
assumptions underlying its use. Despite numerous signals of error
hydrodensitometry is used to day in sport medical laboratories still.
Fat prediction anomalies in combination with in vitro information
of bone densities and hydration should reinforce earlier criticism.
In studies of middle-distance, marathon runners and professional
football players 10 had negative AT with 2 subjects estimated at
-12% AT. Biologically, this is impossible. Direct anatomical cadaveric
data confirm a high inter- and intra-individual bone density hydration
variability, re-confirming that the 2-component hydrodensitometry
model is invalid and that it has been an erroneous reference for
many in vivo BC studies in the past.
Methodological
problems in body composition evaluation
C.
Acikada
Hacettepe University School of Sport Sciences and Technology, Beytepe
06800, Ankara, Türkiye
This
paper attemps to give a brief overview of methodological problems
in assessing athletes body composition measurements in field and
laboratory settings. There are number of different methods available
for field and laboratory settings. The available methods are based
on concepts driven from five level, and two, three, four, and multiple
compartment models of analysis of human body. Majority of the body
composition contents are based on some assumptions, comparisons,
calculations, and estimations. As the number of estimated compartments
or contents of body composition increase, the amount of inherited
error of calculation in the mathematical assumptions increase. Therefore,
most of the body composition methods used have some inherited errors,
based and assumptions of measurements and calculations. Using above
mentioned basic concepts, there are number of widely used methods
available in laboratory and field settings. Some of these methods
are named as direct and some as indirect methods. Direct methods
are used on human and animal cadavers with some chemical approaches
in order to determine the amount of different tissues in the body,
and, therefore, they are not used on living bodies. In some cadaver
based studies the number of cadavers from which the mathematical
modeling is driven can be the sourse of error. For example in Brozek
et al, (1963) modelling there were only 3 cadavers on whom the density
equations were driven for fat mass and fat free mass. Despite this
direct methods are considered to have high validity, and are used
to validate indirect methods. Among indirect methods hydrostatic
weighing, anthropometric methods, bioelectric impedance methods,
infrared interactance, and some part or whole body counter methods
such as dual-energy x-ray absorptiometry are used.
The
skinfold: Myth and reality (revisited)
Jan
Pieter Clarys
Experimental Anatomy, Vrije Universiteit Brussel, Belgium
More
than 10,000 studies and over 450 formulae using skinfolds to predict
body fat reflect the extent of its popularity. Basic assumptions
to understand the skinfold measure are tested with dissection data
of 3 different cadaver collections.
Assumption I. A calliper produces a constant skinfold compressibility
at all sites of the body? Skinfold thickness, direct depth measurement
of the subcutaneous adipose tissue (AT) layer and radiographic depth,
skinfold compressibility could be obtained for each site. It was
found that skinfold compressibility is by no means constant.
Assumption II. Skin thickness is a negligible part or a constant
fraction of the skinfold? All skinfold measurements contain a double
layer of skin of unknown thickness. Skin thickness was most marked
at subscapular level, where it accounted for 28.1% of the skinfold
reading (34.0% for males, 23.9% for females). The subscapular and
triceps sites are most commonly used for predicting AT but have
quite different proportions of skin. Skin thickness can lead to
30% error of the AT patterning.
Assumption III. AT patterning is constant (equal) all over the body?
The patterning of subcutaneous AT exhibits large variations between
individuals. To assess the value of various sites within the same
individual, correlations between the calliper and incision thickness
with the dissected subcutaneous adipose tissue mass are needed.
Of the six best sites, all but one were on the lower limb. The triceps,
a highly favoured site for ‘fat’ prediction ranked (a poor) eleventh.
The best predictors were front thigh, medial calf, rear thigh and
supra-spinale. But AT patterning is under no circumstances equally
divided over the body.
Assumption IV. Predicting fat of the human body is conditional to
the fat content within the AT? The assumed constancy of the 2-compartment
model is no longer valid. Reported values range from 5.2 to 94.1%
(generally in the range 60-85%). The fat content of AT increases
with increasing adiposity. ‘Fat’ is ether-extractable, e.g. lipids,
whereas ‘adipose tissue’ is a morphological entity. Confusing the
two has become colloquial and should be avoided. Assumption V. Skinfold
callipers are only able to estimate subcutaneous adiposity? In order
to estimate total body adiposity some assumptions must be made about
the relation between internal and subcutaneous AT. Proportionality
provides a rationale for the use of skinfolds, unless internal AT
should be negligible, again providing justification for the use
of callipers. Data suggest a good correlation between external and
internal mass in both men (r=0.72) and women (r=0.86).
Assumption VI. Having rejected the concept of the prediction of
body fat, we consider instead if total body adiposity can be confidently
predicted from skinfolds? With a strong relationship between subcutaneous
AT and total body adiposity, skinfolds should have the same relation
with subcutaneous and total AT in men and women. A strong significant
correlation between these entities was found in men (r=0.82), but
not in women (r=0.56) , reflecting gender-associated different tissue
masses distribution. This difference in basic relations jeopardises
the use of skinfolds. ‘Skinfolds for men only’ seems somewhat obtuse.
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