Time for a break? Competition over the Christmas and New Year period

December 30, 2011 by

And so we have reached the Christmas and New Year break, with good-will on offer to one and all. For many of us, this is a time to get away from work – to spend quality time with our family and friends, and to take a breather from the every-day grind of the nine-’til-five. Perhaps some of us will be indulging a little more than usual by way of food, drink and merry-making.

This is, however, not the case for many of those involved in Sport including the athletes themselves and their numerous support staff. In fact, this is often one of the busiest times of the year for those involved in Professional sport, and the fixture calendar can be particularly crowded as the National sporting bodies and Leagues cram in the fixtures, perhaps in order to secure large crowds of seasonal fans and lucrative television rights.

Some sports participants enjoy a break at this time of year, whilst others are perhaps not so fortunate. For example, in the German Football Bundersliga, teams enjoy a four-week period during which the players can take a breather. It is true to say that some teams decide to fly overseas to train and compete in non-league tournaments during this period in order to maintain their in-season fitness, and some players also fly off to take part in National tournaments on other continents, but some teams certainly allow their players time off to spend with their friends and families citing the importance of rest and recouperation for both physical and psychological recovery.

There have been almost annual calls for a winter break for teams in the English Football League for the last few decades, with some managers and players stating that the demands of the football season, together with matches played during the summer period in competitions such as the World Cup and the European Championships, effectively mean that some players have very little time in which to recover and that this leads to adverse physical and psychological consequences for those players together with negative effects on the performance of National teams playing in the summer period and club sides.

Requests for winter breaks in football in the UK have been increasing over the last few seasons, and regional officials and organisations have tended to put the blame for the players’ busy schedules firmly at the door of FIFA and UEFA.

The latest calls for time off during the Christmas and New Year period here in the UK come from former England Manager Sven Goran-Eriksson, the new Sunderland Manager, Martin O’Neill, League One Football Manager Gus Poyet at Brighton, and Wolverhampton Wanderers midfielder Stephen Hunt. However, others are not in agreement with this strategy including Arsenal’s German defender Per Mertesacker who seems to prefer playing in the UK whilst his German footballing colleagues are enjoying some time off back in Germany at this time.

Arguments for the Christmas and New Year break include the following:

  • Allow for physical recovery
  • Allow for ‘psychological recovery’ and protect against adverse psychological effects of stress during the season / travel etc
  • Injury prevention (possibly linked to adverse weather conditions and hard grounds)
  • Improve overall performance over the season

There is a paucity of evidence on which to make these arguments, however.

Looking in greater detail at just one of these arguments, injury prevention, the evidence to support this has been somewhat conflicting. Although I could find nothing in the literature on the effect of a winter break on injury incidence, one might wish to extrapolate from research looking at the incidence of injuries occurring at different times of the season.

In a study published in the British Journal of Sports Medicine in 1998 on the effect of seasonal change in rugby league on the incidence of injury, an increased incidence of injury in summer was demonstrated, and in another prospective study published in the American Journal of Sport Medicine of injury incidence amongst players of one rugby league club over a nine season period, injury risk was found to have greatly increased as a result of changing the playing calendar from the winter months to the spring and summer period.

A study published in 2007 in the British Journal of Sports Medicine on the association of ground hardness with injuries in rugby union showed a seasonal change in ground hardness and an early season bias of injuries.

Orchard discussed the relationship between ground and climactic conditions and injuries in different codes of football, including soccer, rugby league rugby union, American football, Australian football and Gaelic football in 2002, and found an early-season bias for injuries to the lower limb. He concluded that variations in playing characteristics were likely to account for the patterns seen.

I could find nothing in the literature specifically relating to research on the proposed positive effects of a winter break on psychological factors such as mood profiles etc

Should we be offering our players and teams a mid-winter break, and if so, on the basis of which argument(s)?

CJSM would like to hear your thoughts.

In the meantime, all of us at CJSM would like to wish our blog readers a very happy Christmas and New Year, and we devote this blog post to all those who are working with teams over the Christmas and New Year period.

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Filed under General Interest, Injury Prevention, Psychology in Sport

Injury risks of artificial turf in soccer

December 16, 2011 by 7 Comments

Ever since Astroturf was first installed at the Houston Astrodome back in the 1960’s, there has been much controversy about the use of artifical grass playing surfaces used in a number of different sports. The main issues relate both to ‘playability’ and the way that the surface properties affect playing dynamics, and to the risk of injuries occuring on artificial surfaces.

Despite this controversy, artificial surfaces have been used in a wide range of different sports and in some famous venues. In American Football, for example, the New England Patriots and the New England Revolution share an artificial playing surface at the Gillette stadium, whilst most field hockey games these days are played on an artificial surface.

In the UK, I vividly remember the early artificial surfaces used in football back in the 1980’s, when many teams dreaded the trip to Queens Park Rangers, Luton Town, Oldham Athletic and Preston North End on account of their ‘plastic pitches.’ At the time, most of the pitches were derided by football fans due a combination of their poor playability and recurrent carpet-burn injuries sustained by the players and they lost favour quickly.

I was therefore somewhat surprised to read on the BBC sport website that there are moves afoot for a return to the use of artificial turf in the Football League, headed by Wycombe Wanderers and Accrington Stanley. My interest was all the more galvanised by the fact that Wycombe play in the same league as the team that I look after, Leyton Orient. From the Clubs’ point of view, the argument for installing an artificial playing surface centres on economics, with artificial pitches being much easier to maintain than grass. In addition, it is easy to host other events at stadia with an artificial surface such as pop concerts and other social events. There are independent advocates both for the use of artificial surfaces in soccer, and against their use.

As a team physician, my immediate thoughts turned to the risks of injury when playing on artificial playing surfaces. There is no doubt that there has been an evolution of the quality of playing surfaces over the years. Astroturf, developed back in the 1960’s, was known for it’s somewhat abrasive properties, and the risk of ‘carpet burn’ injuries was all-too-apparent to anyone who dared to perform a slide tackle or similar manouvre on the surface. These were not the only injuries of concern on early artificial surfaces, and there were plenty of papers in the literature that reported an increased risk of other injuries on artificial playing surfaces (see Ekstrand & Nigg, 1989 ; Girard et al, 2007 ; & Steele & Milburn, 1988).

However, the modern third and fourth generation pitches are very different in construction and often promoted as possessing the same properties and injury-risk profiles as grass. For example, Dragoo and Braun reported that the overall injury rate on the new surfaces is comparable to that seen on natural pitches.

Therefore, it was with interest that I read a new review article by Williams and colleagues published in Sports Medicine in November 2011 of football injuries on third and fourth generation artificial turfs compared with natural turf.

The authors performed a literature search using Cochrane Collaboration review methodology to evaluate injury characteristics and risk factors for injury on artificial turfs compared with natural grass turf over a range of ‘football’ codes including Rugby Union, Soccer and American Football. The outcome measure used to assess each included study was the incidence rate ratio for injuries on natural and artificial turf, calculated using natural turf as the reference.

The authors found an increased incidence of ankle injury playing on artificial turf in 8 cohorts, although injury risk for knee injuries was inconsistent. There seemed to be a trend towards less muscle injuries playing on artificial turf compared with natural turf. There was, however, no data on head injuries and concussion.They concluded that their included studies showed a trivial difference in injury rates between third and fourth generation artificial turf when compared with natural turf. Limitations of the study were accepted, including the need for longitudinal prospective cohort studies including an adequate number of teams, and controlling for confounding factors such as weather and gender etc, and I think that there were indeed a number of important limitations of the study such that it is perhaps difficult to draw conclusions based on the evidence we have.

For me, the jury’s still out on the issue of injury risk with the newer artificial playing surfaces, but the traditionalist in me still thinks that soccer was meant to be played on a natural surface. Even if the risk of injury is, in time, proved to be no greater on an artificial surface, having watched soccer played on 3rd generation pitches and having played on them myself, I can say that from my point of view it never really looks or feels the same.

What do our readers think?

Should we entertain an expansion of artificial playing surfaces? If so, should that be just within specific sports? How do you think that we should assess injury risk on these surfaces and do you think that the effects seen would be different in different sports?

CJSM would like to hear your thoughts.

References :

Ekstrand J, Nigg BM. 1989. Surface-related injuries in soccer. Sport Med 8(1):56-62

Girard O et al. 2007. Effects of playing surface on plantar pressures and potential injuries in tennis. Br. J. Sp. Med. 41(11):733-8

Steele JR & Milburn PD. 1988. Effect of different synthetic sport surfaces on ground reaction forces at landing in netball. J. Sport. Biomech. 4(2):130-45

Dragoo JL & Braun HJ. 2010. The effect of playing surface on injury rate :a review of the current literature. Sport Med. 40(11):981-990

Williams S, Hume PA & Kara S. 2011. A Review of Football Injuries on Third and Fourth Generation Artificial Turfs Compared with Natural Turf. Sports Med. 41(11):903-923

(Images of (1) modern artifical turf diagrammatic, (2) side view of artificial turf, and (3) Aspmyra, Norway taken from Wikimedia)

 

Filed under Evidence-based Medicine in SEM, General Interest, Injury Prevention Tagged with

Repeated heading of the ball in soccer – is there a link to brain injury?

December 11, 2011 by 2 Comments

Another day, another article related to concussion and head injury in sport in the New York Times – this time, concerning a possible link between repeated heading of the ball in soccer and brain damage.

The article, ‘A new worry for soccer parents – heading the ball’ highlighted some new research recently presented at the Conference of the Radiological Society of North America.

Michael Lipton, associate director of the Gruss Magnetic Resonance Research Center at the Albert Einstein College of Medicine and medical director of MRI services at Montefiore Medical Center in New York, together with colleagues used diffusion tensor imaging (DTI) to study the effects of repeated heading of the ball in soccer, and found that players who repeatedly head the ball with a high frequency had brain abnormalities on scanning similar to patients with traumatic brain injury.

DTI was used to examine for areas of fractional anisotropy (FA) in the white matter of the subjects, which is thought to have a relation to healthy brain tissue – healthy white matter having a relatively high FA.

Dr Lipton and colleagues used DTI on 32 amateur soccer players who had played the sport since childhood, and estimated how often each player headed the ball on an annual basis based on a standardised questionnaire. They then ranked players based on estimated heading frequency.

The researchers went on to compare brain images of the players estimated to have executed the most frequent headers with those of the remaining players, and identified areas of the brain where FA values differed significantly in certain ‘regions of interest’ (ROI) in the brain responsible for attention, memory, executive functioning and higher-order visual functions.

Using statistical analysis, Lipton and colleagues found that greater heading frequency was associated with low FA. They concluded that exceeding a threshold for heading frequency (1000-1500) may result in brain abnormalities similar to those seen in TBI, and went on to suggest that ‘the exposure threshold we identify suggests public health interventions to minimize excess exposure and, thereby, the adverse outcomes.’

Critics of the study may wish to point out the possible issues of recall bias, plus possible errors in the estimates of frequency of heading and statistical analysis as weaknesses of the study.

For those who wish to read more, there is a great summary of the study on the Radiological Society of North America website. This includes links to video footage of Dr Lipton himself describing the study and related issues, together with the views of a participant in the study.

There have been other studies of heading in soccer related to brain injury, but most of these have been subject to methodological flaws making it difficult to draw conclusions. In addition, some studies have included subjects from the days before the modern soccer balls were used, when leather balls could weight considerably more and especially when wet.

Zetterberg and colleagues examined biomarkers for neuronal injury collected by lumbar puncture following repeated headings in a training session and found no significant changes in neurofilament light protein, total tau, glial fibrillary acidic protein, and albumin concentrations 7-10 days after the repeated headings, with only a mild elevation of CFS S-100B concentration. They concluded that repeated low-severity head impacts due to heading in soccer are not associated with neurochemical signs of brain injury.

Cognitive deficits have been associated with repeated headings in football by some authors such as Tysvaer, although others such as Janda and colleagues who studied a youth population found no abnormalities in cognitive function other than difficulty in learning new words.

The debate about heading in soccer and its correlation with brain injury seems set to rage on into the future.

In the meantime, what should we tell concerned parents requesting medical advice about the issue? Where do YOU stand on this? CJSM would like to know.

References :

Zimmerman M et al. 2011. Making Soccer safer for the Brain : DTI-defined Exposure Thresholds for White Matter Injury Due to Soccer Heading

Zetterberg H et al. 2007. No neurochemical evidence for brain injury caused by heading in soccer. Br.J.Sp.Med. 41:574-577

Tysvaer A & Lochen E. 1991. Soccer injuries to the brain. A neuropsychological study of former soccer players. Am.J.Sp.Med. 19:56-60

Janda D et al. 2002. An evaluation of the cumulative effect of soccer heading in the youth population. Inj. Control Saf.Promot.9:25-31

(Image – England v Scotland 1872 at The Oval, London at Wikimedia commons)

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National Collegiate Athletic Association targeted for legal action on the issue of concussions amongst student athletes

December 3, 2011 by

There was an interesting article in the New York Times this week highlighting a recent class action lawsuit aimed at the NCAA over alleged negligence in relation to prevention and treatment of brain injuries in athletes.

The action represents the first attempt to target the NCAA rather than individual colleges or schools, as pointed out by Nikki Wilson on the Collegiate and Professional Sports Law Blog. Four plaintiffs, three with a history of participation in College football and one who played soccer, have filed lawsuits alleging a ‘long-established pattern of negligence and inaction with respect to concussions and concussion-related maladies sustained by (the NCAA’s) student athletes.’

There are a wide range of claims made, including allegations that the NCAA has failed to implement :

– A support system for players unable to continue to play or lead a normal life after sustaining concussions

– Legislation addressing treatment and eligibility of players who have sustained multiple concussions

– Guidelines for screening and detection of head injuries

– Return-to-play guidelines for players who have sustained concussions

– Effective ways of addressing or correcting coaching of tackling methods that cause head injuries

One plaintiff, Adrian Arrington, claims to have suffered ‘numerous and repeated concussions’ during his playing time at Eastern Illinois and now is alleged to suffer from memory loss, depression, and near-daily migraines as a result. The lawsuit claims that the NCAA ‘..has failed its student-athletes choosing instead to sacrifice them on an altar of money and profits.’

Perhaps unsurprisingly, Donald Remy, the NCAA General Counsel and Vice President for legal affairs, has called the lawsuit ‘wholly without merit.’

The organisation responded by stating that ‘..the NCAA has been concerned about the safety of all of its student-athletes, including those playing football, throughout its history,’ and claimed that ‘..we have specifically addressed the issue of head injuries through a combination of playing rules, equipment requirements, and medical best practices.’

The NCAA and the CDC have collaborated to create educational resources for coaches, student-athletes, medical staff and college sports supporters. The NCAA Sports Medicine Handbook has 4 pages on concussions including information on symptoms, and has a revised management plan for all athletes with concussion.

The outcome of the legal actions will no doubt be watched closely by all former college athletes who believe that they may be suffering from ongoing symptoms as a result of repeated concussions during play.

For a further discussion on the lawsuit issues, readers can listen to the EDUsports podcast on the subject.

In the meantime, CJSM would like to hear your thoughts.

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Pro-bowl picture by Cpl. Michelle M.Dixon

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