It was the founder of the modern Olympic movement Baron Pierre de Coubertin who first appreciated how the phrase translated as “swifter, higher, stronger” most succinctly paraphrased the ideals and ambitions of athletes. 2008 is an Olympic year and, following on from Rugby World Cup success and preceding FIFA 2010, provides an ideal opportunity for introspection by the sports medicine fraternity. Indeed internationally, as Sports and Exercise Medicine (SEM) seeks to establish a niche as an emerging and recognized specialty, questions as to the definition and scope of the field, qualifications required to practice SEM and appropriate training programmes and facilities are currently quite topical.
SEM, by not being confined by an organ or body system, requires a broad range of knowledge and skills incorporating musculoskeletal and orthopaedic medicine, rheumatology, internal medicine, emergency medicine, paediatrics, neurology, public health medicine, physiology and psychology.
The most concise definition of the field that I have encountered is that of the Royal College of Physicians (UK) which recently recognized SEM as a specialty:
‘‘SEM is the discipline that addresses medical conditions and injuries that occur in those who wish to participate in sport or to exercise in other ways. It also covers the role
of physical activity in the treatment and prevention of illness’’(Br J Sports Med. 2006; 40; 955-970).
Sports medicine often conjures up dramatic images of the on-field management of high profile professional athletes. The Royal College definition emphasizes that, inherent in understanding the scope of sport medicine practice, is an appreciation that apart from the “sexy” side of the profession that deals with elite athletes – Olympians, Springboks and international footballers- the principal focus is on the management of injuries and exercise-related medical conditions across a spectrum of age groups and abilities, from average and talented schoolchildren to geriatric weekend warriors. In addition the sports physician will use exercise prescription as a therapeutic modality in those who are not but should be exercising.
As with any profession in whichever field, there are certain essential elements that define the competent sports medicine practitioner’s career:
- Formal training
- Work experience in the field
- Continuing education
- A code of ethics
In SEM, fulfilling each of these has specific challenges.
The training of sports medicine clinicians is being increasingly formalized. Unfortunately the exposure of undergraduate medical students to the field in a congested curriculum is minimal and may be limited to a module of exercise physiology and small number of orthopaedic patents. Postgraduate programmes in clinical sports medicine have been running since the early 1990’s and currently 5 South African universities offer such courses. The challenge is to establish formal specialist rotations incorporating hospital and field work that will result in standard examination and fellowship registration criteria.
The work experience of SEM practitioners differs widely. This has much to do with the lack of state facilities for sports medicine and clinicians have relied largely on the private sector to enhance there skills. In South Africa we owe much to a small cohort of orthopaedic surgeons who recognized that the sportsperson requires a unique diagnostic and management approach and initiated the practice of “sports medicine” albeit confined to musculoskeletal conditions. Retired orthopaedic surgeon Dr Clive Noble, team doctor to South Africa’s 1992 Olympic team in Barcelona, was a pioneer in this regard. This has been combined with the knowledge and experience imparted by prominent sports scientists such as Professor Tim Noakes working both in the laboratory and the field. My own experience is that working under sports medicine and orthopaedic colleagues abroad and in South Africa has contributed as much to my pool of knowledge as any formal training I received. Incorporating such work experience in structured programmes remains essential.
Continuing education is an integral part of any career and now an accepted part of ongoing medical registration. Sports medicine is an emerging and hence evolving field and advances are exponential. Examples include biological interventions such as platelet injections, the use of extracorporeal shock wave therapy in tendinopathies, surgical (especially arthroscopic) and cartilage regeneration advances, computerized neuropsychological testing and improved imaging modalities. The South African Sports Medicine Association (SASMA) hosts a biennial congress, The University of Cape Town runs regular clinical update workshops and in 2009 the American College of Sports Medicine (ACSM) will host it’s annual International Team Physician Course in Johannesburg. In addition various annual international meetings, most notably the ACSM and International Federation of Sports Medicine (FIMS) meetings are melting pots of sports medicine information.
Sound ethical practice remains a cornerstone of medicine. In sports medicine the ethical challenges facing the clinician are perhaps greater than in most other fields. Many athletes will be managed in a team environment where their status of health and fitness is of relevance to others. Issues of doctor-patient confidentiality are therefore somewhat complicated by knowledge having to be shared with coaches, team mates and administrators. In addition the issue of doping and cheating in sport has, in recent months, emerged from the back streets and dark laboratories onto our television screens and newspapers with many prominent profession athletes implicated. Apart from the traditional values espoused in the Hippocratic Oath, the sports physician must be guided by the stipulations of the World Anti-Doping Agency (WADA) in not only strongly opposing cheating, but also giving careful consideration to whether a particular medical intervention may compromise individual athlete’s health for the sake of success in the sporting arena .
The role of the Sports Physician (in my simple mind at least!) should be uncomplicated. The first priority is to make a diagnosis. Too often musculoskeletal conditions in particular are treated without a specific diagnosis having been made. Secondly, treat the condition - the athlete has approached you for symptomatic relief. Finally, address the causes; failure to do this will almost certainly result in a recurrence as athletes repeatedly expose themselves to similar stresses.
In an ideal world the sports physician would be the gatekeeper to the field of sports medicine. In many respects, including medical, South Africa is far from ideal and the relatively undeveloped nature of the specialty in many areas dictates that most sports medical problems present to general practitioners, physiotherapists and occasionally orthopaedic surgeons. The broad range of skills required to treat athletes referred to at the beginning of this article suggests that a multi-disciplinary approach is therefore best to manage many sports conditions. The emergence of several private and university-associated sports medicine facilities is an acknowledgement of this and, correctly managed, may provide the most efficient setting for dealing with sport and exercise conditions. Referral to such specialist centres should be considered where the athlete is not responding to conventional treatments, the condition appears to be recurrent, or the athlete competes at a high level.
Sports and exercise medicine in South Africa, as in the rest of the world, is going through a process of evolution and formalization. The competencies required to deal with the array of conditions associated with exercise are vast and, in striving for sports medicine excellence, a process of both structured and informal training is necessary as is ongoing exposure to sports medicine cases and new advances, all practiced within demanding ethical parameters. Our aim must be to allow all of our patients to achieve their own Olympian ideal – swifter, higher, faster.
Dr Jon Patricios
MBBCh MMedSci FACSM
Sports Physician, Johannesburg
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