Gearing up for the London 2012 Olympiad – Games Makers at the ready

June 4, 2012 by

With less than 8 weeks to go before the opening ceremony of the 2012 Olympiad, London’s preparation for the forthcoming Olympics is moving into the final stages.

There have been a large number of test events so far, two of which I have had the personal privilege of being involved with whilst providing medical cover – namely archery and swimming. The torch relay is well underway, and the media attention in the UK is starting to reach fever pitch.

During the Games, there will be 30 days of competition and around 10 million tickets will be sold. 15,000 athletes will be competing in 46 different sports in a total of 805 events. There will be over 4,000 technical officials, and almost 10,000 team officials on duty.

Of the team delivering the Games, there will be approximately 6,000 staff from the London Organising Committee of the Olympic and Paralympic Games (LOCOG) and more than 125,000 contractors from more than 100 organisations in addition to the volunteer work-force.

A large part of the preparations for the Games is the training of London’s 70,000 or so volunteers, known as the Games Makers. Indeed, volunteers were used for the first time at the Games in 1948 when London was the host City for the second time.

As a member of the medical workforce, I have been required to attend both role-specific training, and venue specific training in order to prepare me for the work ahead as a medical Games Maker volunteer. Role-specific training focuses on some of the generic aspects of the Games Maker role. This includes information about the background to the Games, the venues and the athletes, and offers advice about aspects of the role where Games Makers can make a real difference in delivering a memorable Games to all of our visitors from around the World.

Venue-specific training focuses on the aspects of the individual roles particular to certain venues. Most of the sporting events will take place in the Olympic Park which houses nine venues in total, but there will be other events in different London venues and up and down the Country as well. Competition venues in the Olympic Park include the BMX tract, Water Polo Arena, Velodrome, Copper Box, Riverbank Arena, Basketball Arena, Eton Manor and the Aquatics Centre.

Further afield but still within London, events will take place at Earls Court, Greenwich Park, the Mall, Hampton Court Palace, Horse Guards Parade, Hyde Park, Lord’s Cricket Ground, Wimbledon, the Royal Artillery Barracks, the ExCel Centre, Wembley Arena, North Greenwich Arena, and last but not least Wembley Stadium where I will be assisting in providing medical cover for the football (soccer) events.

Competition venues outside London will include Brands Hatch, Eton Dorney, Hadleigh Farm, Weymouth and Portland, and the Lee Valley White Water Centre.

In addition to the competition areas, there are many other important non-competition venues being used for the Games including Heathrow Airport, St Pancras International Rail Station, the International Broadcast Centre and the Olympic and Paralympic Village that will host 17,000 athletes and team officials during the Olympic Games, and 6,000 athletes and team officials during the Paralympic Games.

Things have largely gone smoothly with the preparations so far, and next weekend I will be collecting my Games Maker uniform and accreditation. There is a real feeling of excitement with the Games just around the corner. Given that the last Games in London was held over 60 years ago, it’s unlikely that I will be able to be involved in a Games taking part in my home City again in my lifetime, and I feel lucky, proud and privileged to be able to make a contribution as a Games Maker in London this time around.

Perhaps of even more importance than my contribution to the Games as a Sport and Exercise Medicine Physician is that of working towards ensuring the success of the Olympic Legacy for health for our Nation. This is the first time that a deliberate and co-ordinated action to attempt to achieve a Legacy for improving the Health of the host Country has been attempted in relation to the Games – this is something that excites me even more than the Games itself. I’ll have more to say about the Olympic Legacy for Health in a future blog post.

Statistics re: 2012 Olympiad taken from the 2012 Games Maker Workbook, pictured

Olympic Torch picture by John Candy at Wikimedia Commons

Olympic Stadium picture at Wikimedia Commons

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Neuropsychological tests in sport-related concussion – are they worthwhile?

May 27, 2012 by 1 Comment

The article by Shrier in the current edition of CJSM revisits the issue of neuropsychological testing in the setting of sport-related concussion, and poses some searching questions in relation to the use of these tools in the diagnosis and management of sport-related concussion. In particular, he asks ‘…do the results of neuropsychological testing change patient management or provide other clinical benefit to the patient?’ and ‘Is there sufficient evidence to mandate it (neuropsychological testing) as standard of medical care?’ (Shrier, 2012).

Whilst it is clear that sport-related concussion is a hot topic in Sports Medicine, with an ever-increasing literature on the subject, and following three expert consensus panellist group meetings since 2001, controversy surrounding the diagnosis, management, and return to play protocols continues to rage amongst academics and clinicians alike.

In his article, Shrier concentrates on the application of neuropsychological tests to the sport-related concussion setting. Whilst it is accepted that neuropsychological tests alone are not adequate to confirm the diagnosis and dictate the ongoing management of concussion, they are currently widely used in the rehabilitation and return-to-play setting as a part of an overall neuropsychological assessment for players in elite sport suffering from a concussion – especially in hockey, and college football.

Shrier points out that neuropsychological tests are designed to give an objective assessment of brain function, but that ‘the objective in concussion management is to measure brain injury’ and points out that ‘brain injury is only one cause of decreased brain function,’ mentioning that there are several other factors that may affect brain function such as the presence or absence of other injuries or mood disorders (Shrier, 2012). The author does not point out exactly when he means by ‘brain function,’ however, nor discusses in detail any of the other multidimensional tools that may be used to assess this such as EEG and fMRI.

There are clearly limitations in using neuropsychological tests in the setting of sports-related concussion related to the issues Shrier points out in his article. However, it is important to remember that it is the application of these tests in the overall clinical context that perhaps assists the practitioner in making an informed and reasoned judgement as to whether impairment in brain function is likely to be secondary to concussion.

Further on in the article, Shrier goes on to argue that neuropsychological tests have ‘minimal value for an individual athlete and does not support mandating (their) use,’ (Shrier, 2012) and then examines the arguments for using the tests related to asymptomatic athletes at rest, athletes who are asymptomatic at rest but symptomatic on exertion, and athletes who are asymptomatic on exertion.

Whilst there is still academic debate surrounding the clinical usefulness of neuropsychological tests in the setting of sport-related concussions, doubt must also be levelled at their applicability and cost-effectiveness, a point also argued by Shrier in his conclusion. He also mentions that there are not enough neuropsychologists with appropriate expertise available to be able to warrant mandatory neuropsychological testing on a population level for them to be considered as standard of care, which is certainly true.

In his conclusion, Shrier argues that ‘NP testing provides only a small increase in prognostic information and does not change the management of athletes who are symptomatic at rest or with exercise,’ and points out that ‘There is no evidence that abnormal NP testing is associated with increased risk of further injury or delayed recovery in athletes who are asymptomatic at rest and exertion.’ (Shrier, 2012). 

The Concussion in Sport group, however,  in their last consensus statement mentioned that ‘the application of neuropsychological testing in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation.’ (McCrory et al, 2009).

No doubt Shrier’s article will fuel much continuing academic debate on the use of neuropsychological tests in the setting of sport-related concussion.

Are you using these tests as part of your overall concussion management programme?

CJSM would like to hear your thoughts on the debate.

References

1) Shrier i. 2012. Neuropsychological testing and Concussions: A Reasoned Approach. CJSM 22(3): 211-213

2) McCrory  P et al. 2009. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. CJSM 19(3): 185-200

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The Larks and the Owls – chronotypes and desynchronosis. Time for an individual approach with MEQ-SA analysis?

May 20, 2012 by

The practical management article in this month’s edition of the Clinical Journal of Sport Medicine by Charles H Samuels highlights a difficult problem facing athletes and their support staff that is commonly encountered during air travel, that of the issue of jet lag. Samuels makes the point about the difference between travel fatigue and jet lag (desynchronosis), defining the former as a  constellation of physical, psychological and environmental factors that impact over time on an athlete’s capacity to recover and perform, and the latter being defined as a number of symptoms occurring following travel between time zones.

The key to the understanding of these concepts lies within the study of Chronobiology – the field of biological science that examines cyclical phenomena in living organisms and their adaptation to solar and lunar rhythms. Human beings are normally diurnal creatures, usually being active in the day and sleeping at night. However, as many night and shift-pattern workers will attest, many of us are required to adapt to different patterns of activity and sleep as part of our everyday lives. Some of us are able to cope with these pattern shifts better than others, whereas extremes of sleep-activity outside the normal range may cause a person difficulty in participating in normal work, school and social activities.

Flight travel over different time zones presents a challenge for the individual as the body seeks adjusts its circadian rhythms to these different  zones. A number of different modalities may be used in order to prevent athletes developing jet-lag, including the use of melatonin, preflight adjustment to travel, timed light exposure and avoidance, and changes in training schedules. However, it is interesting to observe that some individuals seem to suffer from jet lag more than others, and that there is variability in the efficacy of preventative and treatment strategies for desynchronosis amongst athletes.

Why is it that some of us seem to cope better with time zone changes and shift pattern working? Perhaps the answer lies in an individual’s chronotype.

Sleep researchers refer to ‘Larks’ as individuals who naturally wake up in the morning, contrasting with the ‘Owls’ who wake up and go to sleep late. These groups are also described as being comprised by individuals with ‘morning-ness’ and ‘evening-ness’ tendencies. Most people lie somewhere in between. However, there are some interesting differences between the groups with some researchers going as far as to suggest that disease processes may be directly influenced by morning-ness and evening-ness. This news feature in Nature, published in 2009, discusses some of these concepts in greater detail for those readers who may be interested to know more.

Horne & Ostberg in 1976 presented a self-assessment morningness-eveningness questionnaire and this has been modified by others to produce an MEQ-SA. Those of you who may wish to objectively assess your lark-ish and owl-ish tendencies can find the modified MEQ-SA questionnaire and scoring table here. 

It is unclear which factors contribute to an individual’s chronotype, as there seems to be no clear correlation to gender, ethnicity, or socio-environmental factors. However, perhaps chronotype variation may go some way to explaining why there is such variability in the effect of different preventative strategies for jet-lag between individuals. If so, then the assessment of an individual’s chronotype may form an important part of an overall primary preventative strategy for travelling athletes and support staff, which may be best conducted as part of an individual approach rather than a team approach.

Unfortunately, there is currently a paucity of literature on chronotype analysis in elite athletes in relation to jet-lag prevention representing an opportunity for further research in this area.

Are any readers using chronotype analysis as part of a jet-lag prevention strategy? CJSM would like to know.

References –

Samuels, Charles H. 2012. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High-Performance Support Teams. Clin.J.Sport Med. 22(3): 268-273

Phillips, Melissa Lee. 2009. Of owls, larks and alarm clocks. Nature 458 

Horne JA & Ostberg O.1976. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int. J. Chronobiol. 4(2):97-110 

 

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Exercise-associated hyponatremia; drinking oneself to death….. Guest blog by Dr Jonathan Williams

April 9, 2012 by

A 22 year old male fitness instructor finished the 2007 London Marathon, collapsed, and despite immediate emergency medical care, died. His serum sodium was markedly low, and the cause of death was found to be hyponatremia. Subsequent investigations established that he had been concerned about becoming dehydrated, and had therefore drunk a large volume of fluid en route. Several other athletes have died from hyponatremia due to drinking excessively, and many others have required hospital care. Studies from the 2002 Boston Marathon and 2006 London Marathon found that 13% and 12.5% of finishers, respectively, had asymptomatic hyponatremia. Our paper in this month’s CJSM explored the 2010 London Marathon runners’ knowledge about fluid intake, their drinking strategies and knowledge about exercise-associated hyponatremia (EAH).

City marathons were established around the world in the 1970s and 1980s. Elite marathon runners of the time rarely drank much during races; when Mike Gratton won London Marathon in 1983, he drank nothing. However, in 1975, the American College of Sports Medicine published a position statement advocating regular fluid intake during endurance events, suggesting this would reduce the risk of heat stroke. During the 1980s and 1990s, increasing numbers of endurance athletes experienced EAH.  International EAH Consensus Development Conferences of 2005 and 2007 reviewed the available evidence about EAH, and advocated drinking “to thirst” rather than the higher volumes recommended by ACSM. In 2007, ACSM revised its position statement advising that fluid intake during exercise should not exceed sweat loss.

In our study, a representative sample of 217 runners was questioned. More than 93% of the runners had read or been told about drinking fluid on marathon day. However, 12% planned to drink a volume large enough to put them at higher risk of EAH, and only 25.3% planned to drink according to their thirst. Although 68% had heard of hyponatremia or low sodium, only 35.5% had a basic understanding of its cause and effects. These findings suggest that runners lack knowledge about appropriate fluid intake on race day. Effective education is needed to prevent overdrinking during marathons.

Professor Tim Noakes has researched EAH for almost thirty years. He is due to publish a book in May 2012 called ‘Waterlogged’ in which he explores the influence sports drink manufacturers have on the science of hydration, and on runners’ drinking habits. ‘Waterlogged’ is likely to be thought-provoking, controversial and fascinating.

The cause of EAH is firmly established and it is entirely preventable. It is now the responsibility of race organizers, drinks manufacturers, running publications and us as sports physicians to educate runners effectively about safe drinking strategies.

Dr Jonathan Williams is a Sports Medicine Doctor and General Practitioner, as well as an avid runner.

The photograph is of the author having just completed a London Marathon

References :

1) Williams J et al. 2012. Hydration Strategies of Runners in the London Marathon. Clin J Sport Med 22 (2): 152-156

2) Hew-Butler et al. 2008. Statement of the Second International Exercise-Associated Hyponatremia Consensus Development Conference, New Zealand, 2007. Clin J Sport Med 18(2): 111-121

3) Hew-Butler et al. 2005. Consensus Statement of the First International Exercise-Associated Hyponatremia Consensus Development Conference, Cape Town, South Africa 2005. Clin J Sport Med 15(4): 208-213

4) Sawka MN et al. 2007. ACSM Position stand – Exercise and Fluid Replacement. Med Sci Sports Ex 39 (2): 377-390

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