British Association of Sports Exercise Medicine (2006, March, The Belfry)


BASEM, 2006.The Belfry

Alfredson Vacularisation Management

Treatment-Difficult! -    where does the pain come from? -    mid-portion -    insertion -    proximal (patellar Tendon)

Questions and Answers

Question: how much pain warrants injection?

A: pain that interferes with your daily life

Question: cynical about 70% success rate.

Cathy Speed Extracorporeal Shock Wave Therapy (ESWT)

‘if a lot of cures are suggested for a disease, it means that the disease is incurable’ (The Cherry Orchard (1904) Act 1, Chekov)

therapeutic ultrasound

Low Intensity Ultrasound

Standard

Shock Wave -    initially lithotripsy

Non Union

Rotator Cuff!

ESWT

Technical issues Dosage Proposed  mechanism Clinical evidence and interpretation Advers

Does it work? What would it mean to prove to you that it works? People don’t understand economics particularly well, but they value being part of the conversation about the budget. Better and worse systems

The difficult models I presented actually articulate a set of political relationship -    the professions

it is part of your job to do this. Currently, you can take it or leave it, but not for long

stem cells pregnancy magazine

Motto

how evaluate -    eg. Science cafes – their existence proves the need, it is irrelevant whether you can prove people understand

you don’t need to ensure we all undersand the science

pyramid -    controlling information -    promoting healthing

Psychology confounding variables increase with chronicity

PEMT:, miuscle pain and gender difcs Eugene lyskow, nebojsa kalezic -    gender deifferences in pain sensations

lunch

tissue engineering -    mesenchymal stem cells -    in vivo

currently not a clinical tool

using post-natal – adult (haemopoietic) stem cells from bone marrow

(other methods: from fat or tissue (endogenous activation in tissue itself)

are there stem cells in tendon -    tendon-derived cels have poorer differentiation potential than MSCs -    Strassburg et al (Peter Clegg’s work at Uni of Liverpool) -    Explains whyt equine tendone injuiries fail tot repair adequately

Hypothesis -    implanting stem cells wold provide cell source capable of synthesising a matrix more like tendon and less like scar tissue

action? – orchestra -    musician: stem cells -    conductor: orchestrates formation of tendon-like matrix

characs of mscs -    in vitro

differentiation of MSCs -    stem cells implanted systemicall in foeti populated all mesenchymal tissues (Liechty et al, 2000) o    differentiated into target cell popn in each case

stimulus for diffn? – -    mechanical load -    contact with cells -    contact with matrix -    growth factors

put undifferentiated into tendon

Differentiation potential of MSCs cultured on tendon matrix: an in vitro model -    mscs capable of migrating, proliferating, expressing ecm proteins found in tendon

experimental models -    surgical models o    rabbit tendon (young et al, 1998) o    rat patellar tendon (Hankemeier et al, 2005) o

Roger Highfield ‘ have we oversold the stem cell dream? ‘Daily Telegraph, 2005) -    field is high on emotion

‘Cool! Ground breaking stem cell science could reduce… -    newspaper article on stem cell and horses

Sports Injury and HBOT Jules Eden London Diving Chamber

All info on website

Set up online medical company called eMed

Based in St Johns Wood

HBOT has been used to treat: joint, muscle, ligment, tendon injuries

When used with physio time of recovery reduced by 70%

Definition: wher a patient breaths 100% osygen intermittently while the pressure in t treatment chamber is increased to a point higher than sea level ie. >1abs

Various names: hyperbaric, recompression, decompression

Monoplace or multiplace

Not used as much as it should be

UHMS – society for hboc - to use hbo, need

effects -    air/gas embolism -    co poisoning -    crush injury, compartment syndrome and other acute traumatic ischemia -    enhancement of healing in problem wounds

Princoples

Boyle’s Law – bubble crusshing Dalton’s Law – gt thje ppo2 up Henry’s Law

So,

Exposure to 2-3 times normal atmospheric

People believe just binding more o2 to haemoglobin Actualloy, you are pushing it into plama A quantity great enough to sustain life in the total absence of hemoglobin

At point of injury, when you need most o2 to promote repair

Time is the greatest factor athletes -    this is different outside of sport

ME: not sure this holds. Most people will want it asap.

Medical Mantra Medical treatment is the balance of benefits for the symptoms versus the side effects to the rest of the body

Does hboc have any side effects? Yes, but rare -    middle ear barotraumas (must pop your ears) -    claustrophobia – people have impression they are about to go into a coffin -    oxygen toxicity – you get this if you breath pure o2 at 3x, for a couple of hours. Not with this! -    Boredom -    NO (problem with) DOPING

Scottish Study – with Celtic

Who cant go in -    untreated pneumothorax

relative contraindication

www.londondivingchamber.co.uk www.uhms.org www.hboevidence.com

Lance Armstrong used to recover

Questions and Answers

Evidence of enhanced performance?

No trials to suggest this

Mesotherapy

Discovery of mesotherapy Dr pistor – discovered

Polyvalent therapy

Anti-doping control -    used lidokane, was prohibited some years ago, not allowed intravenously -    when controlled, could not conclude whether intra or local -    nothing in urine after 4hrs

Brian English Arsenal chief medical officer

Nuscle Injury

‘the only predictive factor for a hamstrong injury is a previous hamstring injury’ Karim Khan

(Is there a genetic predisposition?)

8 days back to playing field, rather than 16 is a big deal

coach can influ number of soft tissue injuries

some athletes just seem more susceptible – thus, genetic?

‘anything extra that may help, I’m pretty inclined to use it’ -    providing nothing banned within it

WADA – if stimulates natural growth factor should be banned substance – but I continue to use it.

Tour de France -    actovegin use, become a little addiction -    WADA said intravenous actovegan will look into it, banned for now. Now, cant have without medical justification ‘massive loop hole’

Not accelerate repair, but prevent the delay

Perhaps employers in the future will expect return from injury quicker

As medical practitioner, you are allowed to inject substances of your choice.

Actovegin banned intravenously during pre-competition, but not banned outright

Everything geared to recovery

Questions and Answers

Do you treat elite as non-elite?

A: yes.

Question: French diff from English. Would there be a role of these treatments in uk

Brian: we are cautious than some of European doctors. Some think we are needle phobic.

Chair: if have 3 kids and 3 weeks off work, then v serious; perhaps more than the elite athlete who loses £60,000 for three weeks, so sure should be entitled.

Cathy: most common question I hear is there anything in it that could dope positive? It has many things in it

Brian: Maximuscle …. Is pharmaceutically produced, so what is says on it, it has, nothing more.

Cathy: side effect of actovegin

Brian: hypertensive when intravenously.

Autologous Blood Injection for the Treatment of Tendinopathy David Connell Consultant Musculoskeletal Radiologist Royal National Orthopaedic Hospital London

www.devilsfun.nl

angiofibrolastic degeneration

tendon healing

3 phases - brief period of acute inflammation – but not cause of pain

after 6 weeks, remodelling – cell to fibre

physio very important

over a year, fibrous to scar-like tendon over 1 year

treatment

while steroids relieve, no evidence that promote healing

steroids act on the pain fibres -    only on a delta fibres

Cryriax, J, J  Bone Joint Surg 1936

Surgery most effective, but considerable postop downtime

Dry Needling

Bathe in local anaesthetic -    dry-needle x2 -    3 weeks apart -    rehab/physio

nothing in lit stating efficacy, but perhaps 65%

autologous blood injections

treatment for refractory tendinopathy -    fail to respond to rest/physio/ cellular and humoral mediators -    stimulate -    pgdf/egf/fgf refractory tennis elbow -    28 patients o    blind solitary injections o    22 pain free

objective to report findigs in a group of patients

david.connell@rnoh.nhs.uk -    trial for test

blood spinning injection of platelets we did try that , centrifuging blood and taking the surface platelets – which is where best is located but haven’t needed to do this. Just use whole blood.

Prolotherapy = ligament schlerosant injections John Tanner

World anti-doping agency Brian English -    wada have said blood spinning is definitely doping

Are WADA?

Richard Budgett: They are not concerned about autologous blood But if treat blood to concentrate, then it would be injected growth factors, so break rules, but no way they could find that out. So if you do this, you need a TUE.

A: we have had standard TUE and had them approved, but not for spinning or intravenous. Also tried serum.

Cryochamber

Tendinopathy: NSAIDs, GTN, RF, others and, why not, surgery! Nicola Maffulli Keele University

Most athletes do not want to become healthy, just to be well [fit]

As doctors, want to promote repair, but patient only wants to return to competition