Sports Medicine; Current Trends In India

1. Sports Medicine in India Opportunities:

Sports medicine is a super specialty in Medicine; but it has already been decentralized and broken in to many specialized areas with specialists such as sports physicians, sports physiologists, sports traumotologists, sports nutritionists, sports physiotherapists and sports psychologists in other countries. East Germans did lot of original research in sports medicine, however, in India situation is different. Our athlete or a patient cannot afford to meet so many specialists every time; we need more sports physicians and they should work with all other departments in a judicious manner.

Currently there are, no comprehensive sports medicine courses offered in India at MD level. National Institute of Sports (NIS) a government body offers a PG diploma in sports medicine for MBBS doctors and this course is more focused at injury management. Some physical education institutions also offer postgraduate degrees in sports sciences but they lack medical component. At paramedical level, many institutions in India and abroad offer Master Degree in Sports Physiotherapy (MPT). Some of these trained professionals declare themselves as sports medicine experts unfortunately. Sports traumotologists and orthopedicians need special training in understanding exercise physiology, physical training, bio-mechanics and experience in sports related subjects before they declare themselves as sports medicine specialists. By treating couple of elite sports persons or attending some tournaments does not entitle them to act like sports medicine experts.

Many athletes of elite class often obtain advice from untrained and inexperienced people are at great loss and to the country. During medical practice, senior cardiologists, orthopedicians, neurosurgeons leave their patients entirely on physiotherapists and other paramedical staff. It is very important that all the doctors must improve their knowledge related to preventive strategies of rehabilitation principles to render better medical care to people. Now JNTU Kakinada’s initiative to incorporate MS Sports Sciences and Technology in other sense, MS Sports medicine, it will be an opportunity for many in the future. I also wish undergraduate medical courses should include a subject “Introduction to Sports Medicine” in their curriculum. Sports medicine is a medical science, which handles many important aspects of modern human life such as exercise, diet, prevention and rehabilitation to all age groups.

2. Role of Sports Medicine in Sports Performance:

Sports medicine practice has begun 3 decades ago in India, yet the benefits of practice of sports medicine not been enjoyed by sportspersons. Getting an Olympic medal is tougher than becoming an IAS officer. On an average, 15 years of hard work in the form of physical training, skill acquisition, sacrifice of education and coping of competition stress are needed. In this process, the key person is the coach (trainer) who is the first contact to sports persons and who is a link between sports, knowledge and the athlete, his is also a link between sports medicine doctor and sports person. In my personnel experience with many national and international teams, I feel these links are not fully established.

Sports doctors do not understand the coach’s language and he is not able to deliver the goods, coach has no confidence in him; athlete is the looser. In a second situation, coach is ignorant and egoistic not willing to learn, hence he feels threatened by the sports medicine doctor leading to no communication to athlete. Again athlete is the looser. Another common situation where coach comes from the other country (depriving the Indian coach from getting trained in abroad), after the assignment he goes away. Sports officials, managers suddenly come up from nowhere replacing the actual working people on ground to represent in major tournaments like Asian games and Olympics.

Sports persons who are talented come in to lime light on their own. We only either facilitate them or burn them out. It is yet to note that our talent scouting technology identified somebody and trained him to get an Olympic medal. Majority of sports persons come from a rural background with low socio-economic status and many a time some are the sole breadwinners of their family. These talented, motivated players need financial assistance, technical assistance and facilities in the vicinity, during these early growing years. But all these are available only after winning an international medal. This is why we have fewer medals in a huge population.

We need to change the whole system and government policies; more player-friendly legislations are needed to achieve sports excellence for the country. There is an urgent need for a good teamwork from talent spotting to Olympics preparation; the good rapport and confidence makes the athlete perform in excellence.

3. Nutrition Issues:

Nutrition for performance: There is a strong myth among sports persons, coaches and youth trying to build super muscles. They believe the proteins are chiefly responsible for building big muscles. Fair understanding of human boi-chemistry and exercise physiology makes it clear that carbohydrates (sugars) are solely responsible for high performance exercise; in a nutshell, carbohydrates are the fuel for exercise. For your understanding, a short distance runner’s muscles utilize muscle glycogen in the presence of oxygen to provide tremendous energy within the shortest time of 10 seconds.

Similarly, a marathon runner depends on carbohydrates and fats for energy in the presence of oxygen. There is an adequate scientific evidence to substantiate the carbohydrate is responsible for physical performance. Sufficient quantities of proteins, fats, micronutrients, dietary fibre and water are essential for physical performance and health.

Proteins and nutrition supplements: Dietary proteins have same amount of calories as in carbohydrates (1 gram = 4 Kilocalories). All over the world, sports persons believe in consuming nutrition supplements mostly proteins from different sources. About 15% of calories derived from proteins & protein is not a fuel for exercise. Protein supplements offer a big business but increase demands of protein can be met with normal diet easily. Excess protein intake increases load on kidneys and have detrimental effects on health.

Water Management Explains in Sports Medicine: Gurus and Babas promoted excess drinking of water among sports persons and general population (more than 5 liters a day). Hyponatremic cardio myopathy is a serious disease, which makes the heart muscle weak, and this is due to loss of electrolytes as a result of excess water consumption. No food ingredients are good for health if consumed in excess quantity. Sports nutrition, fitness nutrition and immuno nutrition are the essential parts of sports medicine.

4. Physical Education and sports:

It is sad to note that participation in physical training in schools and colleges has drastically reduced in last two decades. The quality of education and role of a physical education teacher is severed due to various reasons. More than 80% of education institutions do not have PT classes and sports facilities. Corporate education culture successfully prevented parental thinking from their children allocating time for physical exercise and sports than academics. I have several times noticed in physical education conferences where delegates were choosing their presentation topics more from psychology than from exercise and fitness; this is because, it is easy to talk on theoretical topics than sharing actual research data. Physical education teachers themselves need to improve their fitness levels and their turnout to stand as role models to their students. Seniors in the field are seemed to be more involved in achieving personnel excellence than working hard to improve the system as such. Physical education teachers are the most important key personnel and they are the custodians of physical fitness in children and responsible for developing out door habits among students.

5. Fitness in School Children:

When I did my first survey in school children in 1999, which was widely publicized in media but very little response from schools and parents received. The study threw light on decreasing levels of fitness components like endurance, flexibility, strength, increase in body fat and early obesity among large number of students and shifting interest from physical activities to more academics were noted. There were similar studies from different parts of the country suggested decline in student fitness. Primary physician, Pediatrician did not focus on childhood obesity and concentrated only vaccination and disease management. Average sports medical knowledge with little training in body composition and fitness assessment is essential in addressing these problems at grass route level.

6. Occupational Health and Sports Medicine:

Every disease has a certain background developed from occupation itself. Every occupation is associated with certain degree of disease, risk and disability. Diseases associated with defects in ergonomics, work place, working environment, working habits and the posture during work or not properly addressed in conventional medical practice. Sports medicine offers major solutions in these areas of occupational health.

7. Sports Medicine and Rehabilitation Issues:

Prevention and Rehabilitation are the most important components of disease management. Developing countries like India hardly focus on these areas due to lack of experts and infrastructure. The attitude of a common man is not pro-active towards health compare to wealth. Physical therapy, occupational therapy, podiatry, arthotics, implants, protective sports gear are still unavailable to majority. Cardiac rehabilitation is hardly practiced even in affluent hospitals. The awareness of disease process among population is very poor; they are often operated upon for many problems which otherwise could have been conservatively rehabilitated. Sports medicine helps in increasing awareness on issues like ergonomics, biomechanics, and correction of muscle imbalance, posture correction and disease specific rehabilitation. More centers, more trained manpower and help from government will be able to reduce the medical burden and surgical trauma unnecessarily.

8. Conclusion:

It is evident that sports medicine education is very important in current situation in India. More people need training and awareness should reach to rural masses and medical fraternity should not drown in technology alone and follow a holistic approach in a humane sense.

Prof Dr S Bakhtiar Choudhary Maj. (Rtd)

MD, D. Lit, Sports Medicine

Hyderabad Spine Clinics, Hyderabad.

E-mail: sbakhtiar@hotmail.com

Water Needs in Marathon Running

1. Runners and common population influenced by local babas and messiahs, often consume too much of water, which amounts to six litres and above in 24 hrs. It’s known from ages that, less water intake leads to hypo-hydration (less than default level in the body) and sudden losses lead to dehydration. Athletes and coaches always worried about hydration till we get useful scientific information like this. New studies say that too much could be even worse.

2. Body cannot manage anything in excess even water; more water we push inside, more work for kidneys. Recollect your school lessons; water has to go through circulation and minute tubules of kidney where, many good chemicals are re-absorbed in to circulation such as sugar, vitamins and some trace minerals.

3. Five days before the Boston Marathon, the NEJM (New England Journal of Medicine) published a major article showing that 13 percent of runners in the 2002 Boston Marathon, might have suffered from hyponatremia (low sodium in blood) a dangerous condition caused by drinking too much fluid. The figure was surprising because Boston draws the best, fittest, and most experienced runners in the world. If Boston has a 13-percent rate of hyponatremia, what is it at other marathons?. It is Frightening because four runners, all women, have died of exercise-associated hyponatremia in the last 12 years after participating in marathons.

4. This form of hyponatremia, or low sodium, is caused, when over-hydration takes place during exercise, dilutes the sodium level in the body. This possibly results in the most serious cases: Brain swelling that could lead to seizures (fits) and other life-threatening complications. This makes hyponatremia arguably the most important marathon-related health risk. This is also noticed over a period of time among elderly population who or on supposedly cleansing diet prescribed by local quacks.

5. The history of exercise-associated hyponatremia revolves closely around Tim Noakes, M.D., the noted South African sports-medicine physician. During 1970s, Dr. Noakes was a devoted marathoner who ultimately completed the 54-mile Comrades Marathon seven times. At the time, he wrote three articles encouraging his fellow runners to drink more fluids. But a strange thing happened in the early 1980s. Dr. Noakes started getting calls from athletes and emergency-room doctors faced with a condition never seen before at road races: over-hydration. The runners actually seemed to have consumed too much fluid. In 1985, Dr. Noakes published the similar paper in the field, "Water Intoxication: A Possible Complication During Endurance Exercise." In it he wrote that the condition appears to be caused "by voluntary hyper-hydration.

6. But runners and Ironman triathletes kept developing hyponatremia, Noakes and colleagues continued to publish more papers, and other researchers grew interested in the field. By the mid-1990s, a New Zealand physician named Dale Speedy, M.D., was conducting detailed hyponatremia studies at the Ironman Triathlon in Auckland and found that 18 percent of the Ironman finishers were hyponatremic.

7. By late 2001, Dr. Noakes was invited to write an "Advisory Statement on Fluid Replacement During Marathon Running" for the International Marathon Medical Directors Association. In the paper, he recommended that marathoners drink 400 to 800 milliliters/hour (13.5 to 27 fluid ounces). Dr. Noakes's advice touched off a firestorm, as it was basically 50 percent lower than the widely quoted recommendations of the American College of Sports Medicine, the National Association of Athletic Trainers, and other sports medicine groups, which have generally advised endurance athletes to drink 600 to 1200 ml/hour (20 to 40 ounces).

Problems in Boston

8. Dr. Almond' and his colleagues obtained before-race and after-race body weights and blood sodium levels from 488 Boston finishers, 63 of whom were clinically hyponatremic after the race. The researchers also performed a sophisticated "analysis" to identify what actually caused hyponatremia among the afflicted runners, identifying three primary triggers:

1) Weight gain during the marathon from excessive fluid consumption;

2) A finishing time slower than four hours;

3) Very small or very large body size.

9. Of these, the first was the most important. "The strongest single predictor of hyponatremia was considerable weight gain during the race," the study concluded. Another significant finding: A sports drink doesn't protect you from hyponatremia. "In our subjects, we didn't find that consuming sports drinks was any different than consuming water," Dr. Almond said. "Sports drinks are mostly water themselves, and contain only small amounts of sodium."

10. Gender is not a risk factor for hyponatremia, on the other hand, a lot of women are small and might run over four hours, and those are definite risk factors. At the same time runners should not stop drinking fluids during their marathons, but they should simply aim for a safe middle-ground in their hydration strategies.

Talk About Consumption

11. Hilary Bellamy died from hyponatremia after the 2002 Marine Corps Marathon. According to Dr. Verbalis, hyponatremia was caused by two concurrent events: over drinking; and an "inappropriate hormone response" that limits normal urination. This inappropriate response may be genetic, and can be exacerbated by medications including NSAIDs (pain killers), which many marathoners take to relieve pain and inflammation. But it is also triggered by stress and, especially, nausea--like the nausea marathoners often feel when there's too much fluid sloshing around in their stomach. In the future, the most clued-in experts will no longer tell you to drink XYZ ounces per hour. Instead, they'll say: Drink when you're thirsty; or drink only to the point where you are maintaining your body weight, but not gaining weight.

The Finish Line

1) Don't drink obsessively in the several days before a marathon. Drink when you're thirsty; that will get the job done.

2) Don't take NSAIDs such as aspirin, ibuprofen, or naproxen sodium before, during, or immediately after your race.

3) Weigh yourself before the marathon, and write your weight on the back of your race number. If you need help at the finish line, the marathon medical staff will find this pre-race weight very helpful when they attend to you.

4) During the marathon, drink when you're thirsty, understanding that water, sugars, and electrolytes will help you feel and perform your best. But don't force yourself to drink.

5) Be particularly careful if you expect to run over four hours, and if you have an unusually small or large body size. Drink less if you begin to get a queasy, sloshy feeling in your stomach.

6) Drink sports drinks and also rather than water. But don't expect sports drinks to prevent hyponatremia. They won't.

7) Don't gulp fluids immediately after the marathon. This is a time, according to a 2003 London Marathon report, when the risk of hyponatremia can be quite high, as stomach fluids are absorbed into the bloodstream. Nibble on solid foods and sip a variety of drinks slowly until you feel well recovered.

Happily the word is getting out. After the 2002 hyponatremia deaths at Boston and Marine Corps, the 2003 Boston Marathon had only a six-percent incidence of hyponatremia, and race physicians have told this figure continues to come down. The London Marathon docs say that "after an educational campaign warning runners of the dangers of excessive drinking," there was only one hyponatremia case at the 2004 London Marathon versus 14 the year before.

Prof Dr S Bakhtiar Choudhary

Sports medicine consultant