Head and neck problems in sport are frequently encountered in everyday practice, but rarely discussed. The morning session of the recent 'Sports and Exercise Medicine for London 2012 and Beyond' meeting jointly organised by CSEM and DJO Education tackled maxillo-facial, ear, nose and throat and neck problems, and epilepsy in athletes.
Head & Neck session
|Morning Session:Prof Nicola Maffulli with Mr Paul Wilson, Mr Phil Earl, Mr Peter Grime (Session Chair), Sandeep Konduru, and Dr Christian Moor|
After a brief introduction by Prof Nicola Maffulli, Centre Lead and Professor of Sports and Exercise Medicine at Barts and the London School of Medicine and Dentistry, Mr Peter Grime, Maxillofacial Consultant at the University Hospital of North Staffordshire (UHNS), chaired the morning session. As it has become customary, each of the five speakers produced clear and practical outlines of the issues they were presenting and lively dialogue with the audience ensued.
The immediate management of ENT trauma including nasal airway and fractured larynx was presented by Mr Paul Wilson, Consultant ENT Surgeon and Head of the School of Surgery at University Hospital of North Staffordshire. He examined the impact of ENT problems in athletes, and discussed techniques to achieve improved nasal airways. He also covered latest best practice in the management of rhinitis, treatment timings and returning to sport.
Mr Philip Earl, Consultant Oral and Maxillofacial Surgeon, Worcestershire Acute Hospitals NHS Trust, and a specialist in maxillofacial sports injuries, presented an overview of managing mandibular fractures and returning to sport. He stated that a significant number of mandibular fractures arise from sporting activity, with contact sports such as football, rugby league and union, and hard ball sports such as cricket and hockey major contributors. Boxing, martial arts and equine sports also feature. Pitch side and event management focuses on airway and cervical spine protection with timely transfer to specialist care, and in hospital the gold standard is open reduction and internal fixation at the earliest opportunity. Return to sport guidelines are hampered by scant evidence but a pilot group of 15 professional team players with 16 maxillofacial fractures managed by the presenter strongly suggest that return to competition is possible in three weeks or less from injury or operation.
He was followed by the session's Chair, Mr Peter Grime, whose talk was largely a call to action by the audience. There are no published protocols to follow with regard to “return to sport” following management of dental and facial injuries and a general lack of consensus around what is reasonable or not! He was also concerned that despite awareness of risk there appears to be poor motivation to self-protect against injury among elite as well as non-elite athletes involved in contact/collision sports. He said: “There are evidence-based studies on, for example, the effectiveness and design of protective equipment such as gum-shields and head gear which lower the risk of injury; however despite such evidence a significant number of participants choose not to comply unless the use of such equipment is mandated by the laws of the sport.”
Cervical spine injuries can be the most catastrophic for the athlete. The subject was tackled by Mr Sandeep Konduru, Consultant Orthopaedic Spine Surgeon at the UHNS. “Fortunately the incidence of tetraplegia following injuries in sport has decreased in the last couple of decades because of better understanding of injury mechanisms and, consequently, improved regulation of games such as rugby. The most common mechanism of injury causing permanent neurological damage seems to be axial compression with the neck in a flexed position.” Delegates heard how temporary neurological injuries can be in the form of a transient quadriplegia/paresis or stingers (nerve root/ brachial plexus injury). Mr Konduru pointed out that cervical spine stenosis seems to be a common feature in patients who have sustained any temporary neurological injuries but that a low canal diameter is not predictive of permanent neurological injury according to current literature. He said: “There are no universally accepted criteria for returning to sport after cervical spine injury. Any recommendation has to be done on an individual basis depending on the type of sport, history of previous injuries, any predisposing anatomical characteristics of the neck which make the athlete more susceptible to further injury.”
Active discussion followed on various aspects of cervical spine injuries including the use of protective equipment such as the role of helmets and other protective gear such as self inflatable vests for equestrian sports.
A fascinating presentation on current management and risk assessment in epilepsy by Dr Christian Moor showed how, with the right support and relevant safety precautions, athletes with epilepsy can control their symptoms and compete at the highest level. Dr Moor is Lead of the North Staffordshire Epilepsy Clinic.
Immunology of Exercise session
|Afternoon Session:Dr Neil Walsh, Dr Nicolette Bishop, Prof Mike Gleeson with Prof Nicola Maffulli|
After lunch the theme shifted. High level sports participation requires intense prolonged training, and it is common to see some of the best athletes floored by upper respiratory tract infection just when they should be at their best.The afternoon session, 'Immunology of Exercise', was Chaired by Mike Gleeson, Professor of Exercise Biochemistry at the School of Sport and Exercise Sciences, Loughborough University. The speakers outlined the scientific bases of exercise immunology, the use of supplements in this field and the implication of appropriate nutrition.
Dr Nicolette Bishop, Senior Lecturer in Exercise Physiology, School of Sport, Exercise and Health Sciences at Loughborough University focused on the impact of exercise and lifestyle on immune function and infection risk. She said that the effect of exercise on infection risks, particularly those of the upper respiratory tract, have been modelled as 'J-shaped' whereby a sedentary lifestyle is associated with an 'average' risk of infection, regular amounts of moderate intensity exercise (brisk walking, light jogging) are associated with a reduced risk of respiratory infection and, perhaps paradoxically, high intensity exercise and heavy schedules of training and competition are associated with an above average risk of infection.
Dr Bishop pointed out that in recent years there has been an apparent increased susceptibility to infection in the elite athlete population. She explained: “Athlete behaviours (for example, travelling, lack of sleep, insufficient recovery from previous infections, being in close proximity to others with infections, airway inflammation, and high levels of psychological stress) are all likely to contribute to this effect. In addition, a large scientific body of evidence has shown that most aspects of the immune system are temporarily depressed following acute exercise sessions. The magnitude of this impairment is proportional to exercise intensity and duration. For this reason, athletes are encouraged to allow sufficient recovery between heavy sessions, or to schedule training sessions to take this effect into account.” Intermittent training protocols reduce the impact of exercise on immune function and intervals of greater than three hours and closer to six provide sufficient recovery from more intense, continuous sessions lasting over an hour.
Dr Neil Walsh, Reader in Physiology in the Extremes Research Group at Bangor University, discussed practical strategies to limit illness risk and maintain athlete immune health. He examined training issues and stress management along with the use of appropriate nutritional supplements and ways of preventing infectious diseases. He also highlighted the importance of immunisation for athletes and support staff along with common sense approaches to proper hygiene.
Prof Mike Gleeson ended the day by examining whether biomarkers of infection risk can be monitored in individual athletes. He referred to his recent research that has investigated the impact of exercise, intense training and nutrition on immune function in athletes.
As Katherine Ready, Senior Physiotherapist, Canoeing, at the English Institute of Sport, remarked: “The afternoon on Immunology of Exercise was an informative, evidence-based session which enabled practitioners to take away practical ideas that can be immediately applied within their scope of practice to aid in the management and monitoring of athletes.”
Prof Maffulli said: “The whole day was characterised by much interaction, a permanent feature of these meetings which is appreciated by the participants.” Dr Abosede Ajayi, Consultant in Emergency Medicine & Sports Physician, thought the whole day was well organised and held in a good central location. He said: “The day served as a one-stop-shop delivered by experts in accessible terms for clinicians working in a number of sporting fields. Basic concepts were reviewed before moving on to more complex and cutting edge research ideas and this was balanced with presentation of real-life data from clinical trials, case studies as well as practical tips on handling clinical issues in practice. I thoroughly enjoyed it and am looking forward to the next event.”
Topics for the next two events in this series are Rotator Cuff/SLAP Lesions and Exercise Prescription (17 June 2011) and Women's Football and Women's Sport (21 October 2011). For more information please visit www.DJOGlobal.co.uk/DJOEducation or email firstname.lastname@example.org.