J O U R N A M O F T H E S A S P O R T S M E D I C I N E A S S O C I A T I O N SI4DICTS MIEDICINIE PQfRTGIENIEIESKUNDIE T Y D S ® IF V A N DI E S A S P O R T G E N EE S K UN D E - V ER E N I GI N G / : - a • physiotherapy Backweek • Back injuries • ultra Man •Soccer injuries V O L 2 N O 3 1987 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Reg. n o ./h r.tV 5 .1/233 [53 ] In sports injury and trauma. DidopM«JC Mdium SC 99 R«9 Ke X/1K2S3 V o lt a re n G T 50 G e ig y didophenac sodium 50 mg (enteric coated tablets) For full p re s c rib in g in fo rm a tio n c o n s u lt MDR o r p a c k a g e in s e r t o r C ib a -G e ig y ( O i l ) 9 2 9 - 9 1 1 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A CONTENTS JOURNAL OF THE S.A. A SPORTS MEDICINE TYDSKRIF VAN DIES A - SPORTGENEESKUNDE- VERENIOINO W M EDITORIAL COMMENT Teaching of Sports Medicine KB FEATURE Back Week D FEATURE Back Injuries in Gymnastics W M PENSEES Sport and the Philosophy of Life W T j ULTRA MAN Ultra Man put to Test E71 SASMA NEWS f£] FEATURE Soccer Injuries [ 3 ABSTRACTS Bodybuilders' Psychosis FE1 FEATURE Memory Jogger FE1 FORUM Rugby Injuries and Tackle NATIONAL SYMPOSIUM Editor inChief DRCNOBLE MB BCh, FCS(SA) Associate Editors PROFTNOAKESMBChB.MD DR DAW IE VAN VELDEN MB ChB (Stell), M Prax Med(Pretoria) Advisory Board MEDICINE: Dr I COHEN MB ChB D Obst, RCOC ORTHOPAEDIC TRAUMATOLOGY: DR P FIRER BSc (Eng) MB BCh (Wits) M Med (OrthoXWits) BRIC E HUGO MB ChB, MMed (Chir) Orthopaedics DR JC USDIN MB BCh, FRCS (Edin) CARDIOLOGY: COL DP MYBURCH SM MB ChB, FACC PHYSICAL EDUCATION: HANNES BOTHA D Phil (Phys Ed) GYNAECOLOGY: DR JACK ADNO MB BCh (Wits) MD (Med) Dip O&G (Wits) Front Coven Transparency courtesy of Image Bank. The Journal o fth e S A Sports Medicine Association is exclusively sponsored by Ciba Geigy (Pty) Ltd. The journal is produced by Bates Hickman and Associates (Pty) Ltd., PO Box 783776, Sandton 2146. The views expressed in this publication are those of the authors and not necessarily those of the sponsors or publishers. AUGUST 1987 VOL 2, NO 3,1987S p o rtb e s e rin g s - en S p o rt in ju ry a n d K a rd io re ha b*)ftasie | C a rd ia c R e h a b ilita tio n P ro g ra m P ro g ra m m e 16 C IB A -G E IG Y 1R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) TEACHING OF SPORTS MEDICINE CLIVE NOBLE MBCHB.FCS (SA) Editor in Chief n recent months I have been touring South Afri­ ca giving lectures on sports injuries. Unfor­ tunately, I have often been appalled at the lack of knowledge of general practitioners as regards sports injuries and sports medicine in general. There are a few enthusiastic souls who have a positive interest but for the re­ mainder of the doctors, the interest has been sadly lacking. The teaching of sports medicine in our universities has been kept to a minimum. There is no university, to my knowledge, that has a course in sports medicine or even a course in sports injuries, despite the fact that in private practice, a consider­ able number of injuries are seen. In many cases the sports injured patient and especially the runner, will seek al­ ternative medicine rather than attend a general practitioner as they feel that the knowledge of the GP. is not suffi­ ciently good and therefore the assess­ ment and handling of the injury has left the runner frustrated and because of the usual advice of 'rest for six weeks' untreated. Surely the time has come for our medical schools to in­ troduce a course, albeit short, in sports medicine, taking in the various fields. Many sporting injuries are not specific to sport but particularly the overuse in­ juries are seen almost exclusively in sport. Bio-mechanics, as a subject, is almost excluded from university curric- ulae I do not think that it should be the task of sports medicine doctors to be teaching CPs basic sports medicine Up­ dating of knowledge should be all that is required. In this Journal we have a stimulating article on soccer injuries written under supervision by two medical students. Why cant there be more like this com­ ing from our Universities? Let us hope that the future will see an emergence of sport medicine from our halls of learning. COMRADES MARATHON Some time ago I queried what would happen if there were a large number of casualities in Comrades. I also sug­ gested that the qualifying time be reduced to reduce the numbers in the race In the media it was reported that more than adequate facilities existed to cope with all emergencies and that there was no need to reduce the quali­ fying times. Well, this year the Com­ rades organisers were put to the test. The sight of runners lying on stretch­ ers on the ground did not give one the impression of "adequate facilities". I am told that the Medics did a sterling job, however, under trying circumstances. The excessive heat was obviously a major factor in creating the problems. In the US.A. many races would be can­ celled with the temperatures ex­ perienced during Comrades. I do not Daily News know the answer because cancelling Comrades would have resulted in a riot the likes of which would have made the worst soccer violence pall into insigni­ ficance. Possibly the doctors involved in Comra­ des treatment should have the power to take obviously ill or injured runners off the road. BACK INJURIES Back injuries in sport cover the whole spectrum of severity from the "nigg- ly" to the catastrophic. They often make diagnosis difficult and treatment even more so. The catastrophic injuries, i.e„ injuries causing paralysis are fortunately rare in controlled sporting situations Diving into empty swimming pools and shal­ low streams with resulting neck injury and quadriplegia can only be prevent­ ed by public education. Neck injuries on the sports fields are largely associated with the high tackle in rugby and the collapsed scrum. Both of these are in the process of being eliminated with the high tackle being outlawed and ex­ perimental changes to the scrumming laws occurring. Some sports place tremendous loading forces on the spine with resultant in­ jury. Gymnastics, squash and wrestling are such sports. Here rule changes will not result in a diminution of these in­ juries so from the medical point of view one has to be sure that the com­ petitors have maximum musculo­ skeletal fitness in order to try and reduce injury possibilities. Another problem facing sports doctors is the aging sportsman whose discs are already degenerating. Here even more carefully controlled exercises may be necessary in order to prevent injury. The old adage for example still applies - one must be fit to play squash and not play squash to get fit!. We wish the physiotherapists the best of luck in their National Back Week in September 1987. AUGUST 1987 VOL 2, NO 3,19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) BACK WEEK HYSIOTHERAPY BACK WEEK 1 - 6 SEPTEMBER 1987. Backache is one of the most common ailments seen by doctors and Phy­ siotherapists It has been estimated that 80% of people suffer from significant backache at least once in their lives Backache affects people's lives in all spheres and is a drain on the country's economy (See statistics) Four years ago, the South African Society of Physiotherapy (SASP) deci­ ded that it was time to start educat­ ing the public on how to prevent and handle backache. National Physiother­ apy Back Week (NPBW) thus became an annual event in September During NPBW, exhibitions at shopping centres educate the public not only on backache, but on the skill of physio­ therapists in dealing with the problem. Physiotherapists have long ceased to function as "technicians" and are now ranked as full professionals in the term. A four year B Sc course is now the standard qualification for physiothera­ pists Many physiotherapists then pro­ ceed to specialist in the treatment of spinal problems. Sponsors have assisted the SASP in producing posters, pamphlets and a nigh quality video on backache (Ciba- Geigyj), all used during NP Back Week. The SABC, & SATV has also given cover­ age as well as many newspapers and magazines throughout the country. Feedback from the public has been ex­ cellent. There appears to be a great nunger for knowledge about backs. e educational skills of the physio­ therapists are, generally perhaps, not appreciated by medical practitioners wno could prescribe it as readily as ui* t prescribe anti-inflammatories, tnout adequate education, no back airJnn1: can Seated effectively, sur- yicany or conservatively. ^ U S T 1987 VOL 2, NO 3,1987 The SASP have not limited themselves to NPBW only in their new venture: on­ going projects have been initiated and are worked on throughout the year, eg. the problem of undesirable exercises being given to schoolchildren. Mem­ bers of the SASP are going out and educating the schools constantly, help­ ing to modify these exercises and teach children to re­ spect their spi nes, from the beginning. Schools also been given puppet shows and been involved in art and po­ ster compe­ titions. The official SASP NPBW poster is in fact based on the winning entry from the Pretoria School for Music Art Ballet & Drama The art departments of UP and the Pretoria Technicons were also involved in de­ veloping a logo for the SASP NPBW is an ambitious project with far reaching ideals The SASP are to be con­ gratulated on being the ones to tackle it and deserve the success it enjoys. Gillian Oosthuizen Curriculum Vitae Dip Physio UOFS Private practice, specialising in spinal re­ habilitation. Read papers on the subject at three international Congresses. Lec­ tures ballet students at the Pretoria Technicon and Pretoria school for Mus­ ic, Art, Ballet & Drama on body condi­ tioning and injuries. Has been a consul­ tant for various fitness organisations over the last five years. Closely involved with NPBW STATISTICS O F BACK PAIN OnanygivendayintheUSA,6.5millionmen and women are in bed with low back trouble Backinjuriesarethe major indus­ trial disabler. 600 000 workers are away from their jo b s during each year because they hurt theirbacksatwork. According to one estimate this costs their employers about a billion dollars annually in sick pay and in wages for replacement personnel. Am ong chronic conditions that limit the activities o f Americans at home and at work, bad back rates third—afterarthritis/ rheumatism and heart trouble The reduction o f 40.8% in man hours lost through education and the running o f back schools has been found tobe the best way to handle back trouble. In the UK in 1979, back pain cost British industry 18millionlostworkingdayscom- pared with 9.3 from strikes. It cost 18 000 millionRand inlost productionandcostthe state 180 million Rand. InSouth Africa thestatisticsare very hard to come by. From Sanlam insurance com ­ pany one statistic is 59% o f the claims in 1983in the age g ro u p o fl5 —24 years were from back and neck problems in the male and 70% in the female R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) FEAT UR, BACK INJURIES IN GYMNASTICS he stress placed by gym- T nasties on the muscu­ loskeletal system is well known, and disorders about the upper extrem­ ity - especially of the shoulder - and of the lower extremity - particularly the knee - certainly occur with great frequency. Another area of special concern in the young gymnast, however, is injury to the back and spine in the course of training and competing in this sport. The demands placed on the back, the lower back in particular, for both dra­ matic range of motion and a high lev­ el of strength in performing maneu­ vers and in absorbing shock of dis­ mounts may well exceed that of any sport. In association with such demands, the incidence of disorders of the spine in gymnasts appears to be high.2!J This potential for back injury appears to result not only from single episodes of macrotrauma but also from the repea­ ted microtrauma of hyperflexion, hy­ perextension, or twisting while per­ forming gymnastic maneuvers. Jackson et al. first noted an apparent increased incidence of spondylolysis in young female gymnasts when com­ pared with a control population.5 They hypothesized that this was due to the repeated hyperextension of the spine occurring in gymnastics. Snook reported two cases of spondylolysis among 66 major injuries in compe­ titive female gymnasts.9 More recently, a report by Dzilba and Cervin suggested that high level competitive gymnasts appear to have a disturbingly high incidence of problems inclu­ ding not only spondylolysis but also frank vertebral apophyseal compres­ sion fractures and mechanical back pain.2 They re­ viewed the case histories of five elite Lyle J. Micheli, m .d. ders of the intervertebral discs. Figure 1. A and B: A young gymnast is shown in a zero degree of lordosis, anterior-opening Boston brace for spondylolysis. Figure 2. The hyperextension test, done with each leg, can be diag­ nostic of spondylolysis if pain is elicited with the maneuver. SPONDYLOLYSIS Spondylolysis is certainly of of greatest concern as a cause of low back pain in the gymnast. These athletes will usually pre- esent with complaints plaints of low back pain, although this is sometimes asso­ ciated with radiat­ ing pain into one or both buttocks This pain is often first noted when the gymnast does a back flip or back walk-over and is often insidious in onset. Oc­ casionally, the gymnast indict a single epi­ sode of hyperextension, ora fall, as initiating the pain. Although initially only elicited with gymnas- ic maneuvers, the pain often be­ comes progres­ sively more sev­ ere with activities of daily living, to the point where it may interfere with simply sitting in school or sleeping. It is, however, usually relieved by supine po­ sitioning. Examination Examination often re- AUGUST1987 VOL 2, NO 5, 193*! gymnasts with back evidence of radiographic de­ generative changes on all of their radio­ graphs. Although the increased in­ cidence of spon­ dylolysis in gym­ nasts has received most attention, we have found that back pain in the gymnast may be due to a variety of causes, rang­ ing from simple hyperlordotic back pain through ver­ tebral body frac­ tures and disor- pain and noted R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) veais a child with a hyperlordotic posture Forward bending is often pain­ less but rising to an upright position, particularly against resistance may elicit pain. Even more specific, having the child stand on one leg then the other while hyperextending the back will often elicit pain. In the case of the unilateral pars fracture, pain while hyperextending the back and standing on the ipsilateral leg may prove to be diagnostic (Fig 2). Neurologic examination of the lower extremities is usually unremarkable although there is often some "relative" tightness of the hamstrings It is impor­ tant to emphasize the term "relative," since straight leg raising to 90 degrees from the supine position, while consi­ dered well with­ in the range of normal, may re­ flect a loss of 30 or 40 degrees of motion in a pre­ viously hyper- flexible gym ­ nast. Careful questioning will usually reveal whether the athlete feels that he or she has lost flexibili­ ty, since flexibili­ ty of the back and hamstrings is a carefully monitored qual­ ity in the gymnast. Plain radio­ graphs of the lumbar spine, in­ cluding an­ teroposterior, lateral, and both oblique views are obtained to assess the in­ tegrity of the posterior ele­ ments Both ob­ lique views must be obtained, since only a sin­ gle pars interar- ticularis may be f r a c t u r e d . Although a Grade I spondy­ lolisthesis may be evident on the lateral radiograph, particularly if a standing view is obtaining, it is ex­ tremely rare to encounter a higher Qrade slip in these patients If the plain radiographs are interpreted as being normal but a high index of suspicion jor spondylolysis persists, based on the nistory and clinical findings, a 1®cnnetium-99 radionuclear bone scan of the lumbar spine should be ob­ tained (Fig 4). We have had several pa­ tients with initially "normal" plain radi­ ographs who, on subsequent evalua­ tion, showed clear-cut evidence of pars defects on additional radiographs. If this study shows increased uptake of radionucleotide, we treat the child for a presumptive diagnosis of spondylo­ lysis. Unfortunately, not even a normal plain radiograph and a negative bone scan will absolutely rule out spondylolysis as a cause of low back pain. In addition, the presence of an active bone scan should not be used as an absolute criterion for whether to institute treat­ ment in a child with spondylolysis. We have had a number of cases of children with low back pain, suggestive plain radiographs, and "normal" bone scans who have gone on to demonstrate fur­ ther symptoms and, in one case, to progress to a first degree slip. Figure 1. A and B, A young gymnast is shown in a zero degree of lordosis, anterior-opening Boston brace for spondylolysis. Management The management of symptomatic spondylolysis in the young gymnast re­ mains controversial. Some physicians are content to manage the patient symptomatically with limitation of ac­ tivity, including no further gymnastics. Occasionally, a soft elastic garment, or corset, and flexion exercises are added to the regimen. It is my opinion that this lesion should be treated as a fracture of the pars in- terarticularis - albeit a stress fracture, the result of repetitive microtrauma - and every attempt should be made to reduce the fracture and protect the spine in order to maximize the potential for healing. For this purpose we have used a rigid polypropy­ lene lum ­ bosacral brace which is con­ structed with 0 degrees of lum­ bar flexion, in an attempt to flat­ ten the low back and increase the chance for heal­ ing by opposing the fractured pars elements (Fig. 1). Once satisfacto­ ry fitting of the brace is at­ tained, the child wears the brace 23 hours per day, with one hour out of the brace for bath­ ing and exer­ cises, which in­ clude abdominal strengthening, pelvic tilts, and antilordotic and lower extremity flexibility exer­ cises. Brace treatment lasts for six months or until the bone scan, if i n i t i a l l y positive, becomes negative. Most children become asymptomatic within three weeks after brace treat­ ment is initiated, and we allow activi­ ties thereafter, including sports activi­ ties, so long as the child remains asymptomatic. For the gymnast, limit­ ed bar work and tumbling are possible but vaulting and most balance beam ^•CUST1987 VOL 2, NO 3,1987 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) work are not possible. The results of brace treatment are promising. Our most recent review of the results of bracing in symptomatic spondylolysis demonstrated that 32 per cent of patients attained bony healing with this program and that 88 per cent of the 75 patients became pain free and were able to resume pain- free sports activity even if bony heal­ ing could not be demonstrated by plain radiographs.8 It is important to em­ phasize that athletically incurred spon­ dylolysis is a stable lesion. We have not encountered a significant slip in any of our patients, despite continued activi­ ty. We therefore believe that the child and parents may be counseled that this lesion does not result in spinal in­ stability but, rather, in potentially activity-limiting back pain in the young athlete or adult. As such, every effort should be made to heal the lesion. However, if a lesion does not heal but remains asymptomatic, we believe that the child may still safely participate in vigorous sports activities. Although the presence of a positive bone scan at the site of fracture is in­ dicative that the body is still trying to heal the lesion, and may reflect an en­ hanced potential for healing, the presence of a cold bone scan in a radi­ ographic lesion should not be taken as a contraindication to brace treatment. We have attained bony healing in five patients with initially cold bone scans. Although we are pleased that 88 per cent of our spondylolysis patients treated with braces became asympto­ matic and resumed full sports activi­ ties, we are still experimenting with new brace designs and different treat­ ment regimens. We are attempting to increase the healing rate above 32 per cent, since frank bony healing of the lesion must hold a better long-term prognosis. Vertebral body fracture Another cause of back pain in the young gymnast is fracture of the ver­ tebral end plates, particularly at their anterior margins. These fractures ap­ pear to be usually the result of repeti­ tive microtrauma - most probably repeated flexion - which injures the an­ terior portions of the end plates and can result in frank vertebral wedging. In the gymnast, these fractures usual­ ly occur at the thoracolumbar junction and may involve three or more ver­ tebral bodies, although one or two lev­ els of involvement are more common. At times, these lesions may be labeled Scheurmann's disease, or "atypical Scheurmann's disease.''" Classic Scheur­ mann's disease, as characterized by Sorenson, occurs in the thoracic spine and involves at least three or more ver­ tebral bodies, with greater than 10 per cent wedging of each body.10 True Scheurmann's disease, of course, may also be the result, at least in part, of repeated flexion microtrauma of the dorsal spine in a child who has tight lumbar lordosis, with forward flexion occurring in the dorsal spine rather than in the lumbar spine below. Once again, plain radiographs are usual­ ly sufficient to make the diagnosis of this microtraumatic fracture. A bone scan generally shows increased uptake at the lesions but is not necessary for diagnosis. Treatment is directed toward putting the spine at rest in order to facilitate normal bony healing. If signifi­ cant vertebral body deformation has already occurred, additional steps should be taken to unload the front of the spine and maximize the potential for bony reconstitution. In our opinion, this is best accomplished with a semi­ rigid thermoplastic brace. If the lesion is at the thoracolumbar junction, a brace with 15 degress of built-in lordo­ sis is used to immobilize the back and unload the front of the spine. Brace treatment is used, once again, for 23 hours per day and is continued until bony healing and vertebral body recon­ stitution are evident - usually four to six months.7 These children usually become asymp­ tomatic in three or four weeks, and, again, limited gymnastic training is al­ lowed as long as they remain asymp­ tomatic. As with spondylolysis, a high index of suspicion when the athlete first complains of back pain and early initiation of treatment will maximize results. Discogenic back pain The differential diagnosis of back pain in the young gymnast must include dis­ cogenic back pain. This disease in the prepubescent child is rare, but its inci­ dence in the adolescent, particularly in the athletically active adolescent, ap­ pears to be increasing.6 The presentation of this disease in the young athlete may be quite different than that usually encountered in the adult. Back pain, as such, may be a rela­ tively minor complaint. More frequent­ ly, the child, or his or her coach, may notice a loss of hamstring flexibility, sometimes unilateral, or the onset of a sciatic scoliosis. Diagnosis may be difficult to make Physical examination may reveal evi­ dence of sciatic irritation, with positive straight leg raising or a positive La- segue's sign. Loss of reflexes or frank muscle weakness is unusual. Often, however, there will be a loss of the abil­ ity to forward flex the spine or reverse the lumbar spine on forward flexion, and this movement may elicit pain. As with all disc disease, conservative treatment aimed at resting the back in a neutral position and avoiding fur­ ther pain or muscle spasm is the primary mode of treatment. In our ex­ perience, the adolescent with disc dis­ ease will usually respond rapidly to bed rest with decreased pain and muscle spasm, but this response may not last if activities are resumed too early We will generally advise the family that their child will be out of vigorous I sports activities for 6 to 12 months fol­ lowing a frank episode of discogenic CONTINUED ON P C 15. AUGUST 1987 VOL 2, NO 3,190 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SPORT AND THE PHILOSOPHY OF UFE DR DP VAN VELDEN HEAD: DEFT OF FAMILY MEDICINE, FACULTY OF MEDICINE, UNIVERSITY OF STELLENBOSCH. t seems only logical that a Sports Medicine Journal should explore the philo­ sophy of sport and exer­ cise, looking to the very reason why modern man enjoys the experience of human movement. It would be difficult to understand why almost compulsive devotion to some of the simplest forms of physical activity should create such an exhilarating feeling if consider­ ation were not given to the holistic na­ ture of man - uniting his body and soul and mind in an equilibrium of earthly bound, transcendental existence. If we are to persue a complicated philosophi­ cal explanation for the basic phenome­ non of sport, we will fail to come to a clear understanding of what human movement is all about. We must rather become like chil- - . ~ _ _ . . dren again, recog­ nizing the very truth in our exis­ tence, and revel­ ling in the mere gift of Life, admit­ ting that we par­ ticipate in mean­ ingful activities simply for the fun of it! We need to be liberated for so many artificial barriers in our lives if we do not want to fall victim to stress, alcohol and drug abuse, addiction to calo­ ries and nicotine and a host of hy­ pokinetic diseas­ es it is amazing to come to the reali- " S ' L h zation that many ____ __ of the meaning- ' X . ful activities we E * 8 'n could be explained in very r n n i? t e r m s A r e w e n o t all striving to ina happiness in the search of what reaiiy matters - the truth makes life worthwhile? It is in this constant search for meaning through exercise that we are able to lose some of the unneces­ sary burdens western society has im­ posed on us. These burdens have blur­ red our vision so much that we are un­ able to see that happiness and fulfil­ ment are actually within us and cannot be bestowed on us by materialistic means. Love cannot be bought, traded or begged - it has got to be created un­ conditionally through devotion to our conception of the Truth. If sport and exercise bring us closer to this ideal, we do not need to look any further for ex­ planations of why people enjoy sport in the same way as children enjoy their play. Dit is nie 'n vreemde verskynsel dat sportgeneeskundiges hulle soms besig hou met filoso fiese soeke na die redes waarom sport en oefening so 'n belangrike hoeksteen vorm van 'n gesonde leefwyse nie. Ge- bore uit die wete dat die mens 'n g e in t e g r e e r d e wese is waarin lig- gaam, siel en gees in ekwilibrium ver- keer, is dit duidelik dat aantasting van enige van die drie komponente van die menslike bestaan aanlei- ding kan gee tot versteuring van die gesondheid. Dit is deur hierdie holistiese siening dat geneeshere al hoe meer onder die indruk gekom het dat gesond­ heid meer is as net die afwesigheid van siekte of gebreke, en dat insette van ons maatskaplike en sosiale sisteem, die ekologie en geestelike verryking net so AUGUST 1987 VOL 2, NO 3,1987 'n belangrike aspek van gesondheid uitmaak as 'n gesonde liggaam. Indien reg aangewend, kan sport en oefening 'n sterk bondgenoot word op die pad na gesondheid. Sou die posi- tiewe motiveringseienskappe van fiks- heid ten opsigte van gesonde eet-, rook- en drinkgewoontes te wyte wees aan die feit dat betekenisvolle fisieke aktiwiteite 'n optimale geestelike en sielkundige klimaat skep waarin 'n ge­ sonde lewenspatroon gedy? Dit blyk egter nie altyd so simplisties te wees nie! Alleenlik wanneer oefening en sport as 'n genotvolle aktiwiteit of spel uitbundige vreugde verskaf, ontdek die mens homself en die doel van sy aard- se bestaan binne die konteks van die sin in die lewe. Dit is jammer dat so baie mense oefening as 'n marteling ervaar en met geen oorredingsvermoe oortuig kan word dat dit wel 'n bron van plesier kan wees nie. Dit mag wees dat die moderne kompeterende lewe die genot uit die spel gehaal het deur 'n oordrewe wen-motief en prestasie- moraal in sport te bring. Dit het 'n gemeenskap van "verloorders" gekweek - om te verloor bly 'n negatiewe motiveringsfaktor indien die deel- nemer nie daarin kan slaag om sy benadering ten opsigte van oefening aan te pas tot 'n genotvolle geestelike ervaring deur 'n fisieke medium nie. Daarom is dit belangrik dat ons weer sal besin oor die doel en wese van sport en oefening. Indien die strewe na fiksheid gesondheidsbevorderend moet wees, is dit nodig dat die kinder- like vreugde van toegewyde deelname aan sinvolle aktiwiteite weer deel sal vorm van ons lewe Die mens soek gedurig na ingewikkelde oplossings vir sy probleme, terwyl die antwoord dikwels so eenvoudig kan wees - ontdek jouself, jou behoeftes en gebreke, maar ook jou potensiaal deur sport en oefening! Deur te konsentreer op die singewende aspekte van sport en oe­ fening, kom ons nader aan die ervar- ingswereld van die kind wat nog uit- bundig kan lag vir die spel van die lewe? R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) r7 THEWRAPS "i ARE OFF! S m i t h + N e p h e w HEALING M M X R HANDS Smith and Nephew Ltd., 30 Gillitts Road. Pinetown 3610 22̂ HOW ELASTOPLAST POROUS ELASTIC ADHESIVE BANDAGE GIVES CONTROLLED COMPRESSION AND FLEXIBLE SUPPORT W h e n treatm ent dem ands a bandage that gives compression and flexible support, your first choice must . be Elastoplast Porous Elastic Adhesive Bandage. The secret of the effectiveness o f Elastoplast Porous Elastic Adhesive Bandage lies in its exceptional lengthways stretch and regain properties which enable it to be applied with the correct tension to give controlled compression. These same stretch and regain properties give flexible support allow ing patient m obility and full participation in rehabilitation programmes. D eveloped for South A frican conditions, Elastoplast Porous Elastic Adhesive Bandage is ideal for strapping swollen or sprained joints, varicous veins, leg ulcers and for other surgical and orthopaedic purposes. The soft fluffy edges of the bandage help to avoid cutting and m arking the skin. A n d although adhesive, the bandage is porous, allow ing the skin to breathe and sweat and exudate to escape. It is features like these, coupled, with back-up service and strapping technique training program m es that have made Elastoplast Porous Elastic- A dhesive Bandage your first choice for the past 50 years. N ow the wraps are off, ask for it by name when you need controlled compression and support. ’ RegiMcrctl Trade Mark R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) r "ULTRA MAN PUT TO TEST' multi-disciplinary endur­ ance event such as the ele­ ments which go to make up the Ciba-Ceigy sponso­ red Ultra Man, makes special demands, even on the ultra fit athlete The Institute of Sport Research and Training at the University of Pretoria is paying special attention to the physio- dynamics of the various events invol­ ved. Problems could, for instance arise in an athlete who has successfully com­ pleted the Comrades Marathon on many occasions, when he is challenged to turn his hand, or rather his muscles, to a different ultra distance discipline such as cycling or canoeing. Under the guidance of Hans Daehne, the Sports Institute puts athletes through their paces, quite literally, un­ der controlled laboratory conditions. Leading athletes such as Iron Man Ed­ die King, and Transvaal flyhalf Schalk Naude, subjected themselves to the In­ stitute's battery of tests. These include anthropometric tests, i.e. body type measurements such as mass / height, fat weight ratios and muscle measurements. By specialising in one ultra distance dis­ cipline, muscles are selectively deve­ loped and strengthened. Eddie King with his dominant emphasis on run­ ning and cycling was unable to reach his ankles due to shortening of the hamstrings, whereas Schalk Naude could place his hands flat on the floor. The Cybex Test measures muscle strength and endurance. Under strict conditions of measurement, both the extension and flexion of a limb joint is measured through its total range of motion. While the athlete delivers his maximum output, the Cybex compu­ ter plots the appropriate curve. If any svstem is damaged, the injury wn show up as a deviation on the Cy- tracing. In this way the precise lo­ cation and severity of injuries can be oemonstrated and appropriate physio- nerapy or corrective exercise routines Prescribed. The Institute emphasises the impor­ tance of style in any sport, but particularly in running. Top notch cyclists and canoe­ ists tend to have an awkward running style, and it is in the running events that the most injuries during the Ultra Man sequence are expected. The Institute can however get canoeists of on the right foot, so to speak. Leaflets are avail­ able on running style — the importance of stance, follow- through with the ball of the foot and good arm move­ ment. During the demo peri­ od even Eddie King by making a minor adjustment to style was able to smooth his perfor­ mance. A computerised spirometer is used to measure lung func­ tion and lung capacity. Wired up like an astronaut, the athlete performs against set standards while instruments measure his capacity to trans­ port oxygen through heart and lungs and convert it into energy at muscle level. This complex parameter, the V02 max, a measure of the body's ability to accept and utilise oxygen is also an index of performance on the athlete's path to superfitness. SCHALK NAUDE DEMONSTRATING THE SPIROMETER TEST V o O B n e n /w and trauma. didophenac sodium 50 mg ( entericcoated tablets ) ^ g Ho. K/5.1/253 (Wet/Act 101/1965) S 3 C ib o -G e ig y (Pty) Ltd P.O. B ox 9 2 Isan do 1 6 0 0 F o r full prescribing informotion please refer to the M.D.R. * UCWT1987 VOL 2, NO 3,1987 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) U ltraman will test the best With entries having closed for the Johannes­ burg Stock Exchange Marathon, the first op­ tional event within the Ultra Man competition, I think it ap­ propriate to reflect developments wi­ thin Ultra Man to date Response to the competition has been nothing short of phenomenal if one considers the rather substantial chal­ lenge that entrants are faced with. At the time of going to press 132 en­ trance applications had been received and if the encouragingly numerous queries that are received on a daily ba­ sis are anything to go by, a similar num­ ber of entries yet again can be anticipated. There are an abundance of top competitors who have taken up the challenge including the likes of Dr "Tiffy" King, Graeme Pope-Ellis and George Janos, with unconfirmed rumours having it that Danny Bigg's en­ try is in the pipeline. It seems unlikely that as a former gold medalist in the Iron Man, Hansa Duzi and Comrades, Danny will turn down the opportunity to earn a potential R18000 from a competition that seems tailor made for him. Whatever his decision, the na­ ture of the Ultra Man is such that it would be most difficult to speculate who the winner might be. The tactical element that competitors are faced with in terms of choosing events is bound to add a decisively interesting dimension to the challenge, with a bet­ ter than average competitor who com­ pletes all eight events standing a good chance of being up there with the best of them. A misconception that has developed amongst interested parties is that Ultra Man will have their final points stand­ ing calculated on an average rather than on an aggregate basis. The oppo­ site is in fact the case which means that any event completed will yield a positive addition of points to a compe­ titors total. A maximum of 100 points will be earned by the first Ultra Man home in each event which means that a total of 800 points could be earned in the unlikely event of one athlete win­ ning all eight races. For those people who have not yet en­ tered, I would like to stress that entries will be welcomed up to November 15. The first compulsory event is the Vas- byt Ultra Man Cycle Challenge on November 28, a 165km cycling event which is dominated by a series of rather daunting hills. Entrants for Ultra Man will be mailed information on this event which will include a map of the route. With the "Vasbyt" looming I would like to take this opportunity to wish our competitors the best of luck in this event, the second out of the eight en­ durance tests that lie ahead. Bester takes Ultra Man Lead Comrades marathon specialist Nick Bestertakes 100 Ultra Man bonus points into the 165km Vasbyt cycle ultra mara­ thon on November 28 after finishing ninth in the recent 50km Johannesburg Stock Exchange marathon. TheJSEwasthefirstoptionaleventona gruelling Ultra Manfixture list and Bester who was 25th in the Comrades mara­ thon this yearin 6:12:08, finished ninth af- terthe run from Johannesburg to Voor- trekkerhoogte with a time of 2:59:07. As the top Ultra Man finisher, Bester Fromlefttorightcraemepope-Ellis, Danny Biggs, Dr Eddie King, Nic Bester, Piet Mare. earned an automatic 100 bonus points. Points were awarded to the other Ultra Man contenders according to a special formula and Piet Mare grabbed second place on the log with 92,38 points after clocking 3:12:54 in the JSE. Third is top endurance athlete Danny Biggs, who is having a "full go" at Ultra Man after a disappointing Comrades mara­ thon thisyearin which hefinishedoutof the gold medals in 18th place. Biggs picked up 85,99 points for his 3:24:28in the JSE,justahead of Duzi "king" Graeme Pope-Ellis. “The Pope" clocked 3:25:51 for 85.22 bonus points, while Pierre de Jager is fifth on the Ultra Man log with 84,72 points from a time of 3:26:45. Phillip van Tonder is sixth (84,02 points; JSE time of 3:28:01), followed by Roger Zipp (83,13; 3:29:38); Phillip Demosthe- nous(82,72; 3:30:22), veteran Geoff Mat­ thews (81,77; 3:32:06)and Kenneth Poole (81,71; 3:32:12). Leading the woman in the series spon­ sored by Ciba-Geigy is experienced ultra­ distance athlete Priscilla Carlisle, who earned 68,76 pointsfrom her JSEtimeof 3:55:37. Sally Luckoff has 59,37 from 4:12:44 and . Sandra Niemand 45,45 from 4:37:47 A total of 164 Ultra Man competitors ran the JSEinsearch of bonuspoints. Among them was two-time Leppin Iron Man tri­ athlon champion Eddie King — 17th on the log with 80,02 points from time of 3:35:15. The total number of Ultra Man entrants so far is275,andentrieswill be accepted until October 30. MissingfromtheJSEwascurrentSunday Times/Leppin Iron Man champion Henk Watermeyer. He will, however, be one of the top con­ tenders in the Vasbyt ultra marathon and he still has the opportunity to boost his points tally in the Midmar mile swim in February, Arguscycletourin March and Two Oceans marathon in April. Organised by SpekeCyclingClub,theVas- byt ride starts (6am) and finishes at the CONTINUED ON PA CE 19. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SASHA UPDATE, SASGV NUUS SASMA NEWS Dr. D P van Velden Head: Department o f Family Medicine E a afloop van die sukses- volle Sportgeneeskunde- kongres in Kaapstad, kyk die Sportgeneeskunde vereniging weer indring- end na sy doelstellings om te bepaal tot watter mate die vereniging daarin geslaag het om sekere ideale te verwesenlik. Alhoe- wel daar heelwat verrig is met betrek- king tot die bevordering en dissemina- sie van kennis insake die hantering van top sportlui, publikasies van sportwe- tenskaplike navorsing en die diagnose, behandeling en rehabilitasie van sport- beserings, kan daar nog heelwat meer gedoen word in die veld van die kor- rekte gebruik van sport en oefening vir die voorkoming van siektes en die be­ vordering van gesondheid. Weens die paradoks wat daar bestaan tussen sport en gesondheid as gevolg van die negatiewe aspekte van kompe- terende sport en oefening soos bv. die veelvuldige beserings, hittesteek, ver- minderde weerstand teen virusinfek sies, onoordeelkundige gebruik van sti- mulante ea. middels, en ook die wan- opvatting wat daar bestaan dat fiks- heid sinomiem is met gesondheid, is dit logies dat die mediese professie met reg skepties staan teenoor die rol wat sport kan speel in gesondheidsbevor- dering. Die geneesheer is primer ver- antwoordelik vir sy pasient - die beseer- de sportman - se gesondheid en kom dikwels in konflik met sportadministra- teurs, afrigters en die sportman se eie belange en moet soms moeilike beslui te neem wat groot implikasies kan in- nou vir 'n sportman se toekoms, soos nou ook duidelik blyk uit die geval van Naas Botha en die probleem van sy konkussie. Alhoewel die sportman dus nie altyd die toonbeeld van gesondheid is nie, moet geneeshere kennis dra van die oaie positiewe rol wat sport en oefe­ ning mag speel in die holistiese bena- Qenng tot gesondheid. Oonentoesiastiese sportlui self verklaar onomwonde dat hulle nie 'n dokter no- o p het nie, "ek is my eie dokter ek kan me onthou wanneer laas ek siek was nie, die dokters weet nie waarvan hul­ le praat wanneer dit by gesondheid en fiksheid kom nie" Ons moet ongelukkig erken dat sportlui soms geregtig is om sulke stellings te maak, aangesien ge­ neeshere dikwels geen opleiding kry in gesondheid en vele ander aspekte ra- kende sportgeneeskunde nie. In hierdie opsig het die S A Sportgeneeskunde vereniging 'n groot taak om geneeshe­ re toe te rus met die nodige kennis en tegnieke om sportlui bevredigend te hanteer. Die tyd het waarskynlik ook aangebreek om 'n formele nagraadse sportgeneeskundige kwalifikasie in te stel om te voorsien in die toenemen- de behoefte aan deskundige kennis op die gebied van die mediese aspekte van sport. The South African Sports Medicine Association has recognized its respon­ sibility in this regard, and decided to change the format of the Journal slightly, to accommodate more scien­ tific articles on health promotion through a healthy lifestyle. Exercise, sport and fitness are only small, albeit important integral parts of promoting optimal health. Because the medical profession has a holistic approach to­ wards health and health promotion, and realizes that the human being is highly adaptable and complicated, we have good reason to be reserved in ma­ king certain unqualified statements on health and disease prevention - some­ times to the point of dissatisfaction of the general public and the sports fra­ ternity. Although research done by the medical profession does not supply all the answers, we are in possession of certain sound scientific proof that a healthy lifestyle can do more than cer­ tain of the modern therapeutical mo­ dalities to preserve optimum health - these are the facts that we would like to publish in our journal. The General Practitioner should play a much more active part in health pro­ motion and disease prevention, as he has done in the past In his traditional palliative role as comforter of the sick fsieketrooster") in certain of the self in­ flicted chronic degenerative diseases of the Western society. It has long been recognized that the super specialist cannot cater for the total needs of the sportsman, because sports medicine is a multiprofessional discipline incorpo­ rating aspects of all the traditional me­ dical specialities as well as additional knowledge of the exercise sciences, nu­ trition, psychology and even sports ad­ ministration. The sports physician should be knowledgeable of all these aspects ranging from sleep disturban­ ce in sportsmen, through drug abuse, malaria prophylaxis and the adverse in­ fluence of the ecology on the practi­ sing sportsman. The journal wishes to broaden its readership and address the family physician on all the relevant is­ sues of sport, health and the family that is necessary to promote the health not only of the individual, but also of the community as a whole. In the next few issues we envisage pub­ lishing articles on recreational sports, such as hiking for the entire family, ef­ fective stress management program­ mes in an abnormal society as well as the role of a healthy family and sexual life in the concept of holistic health. We also wish to inform our readers on forthcoming congresses and seminars in sports medicine and health matters both here and abroad. The contribu­ tion of physiotherapy to the manage­ ment of sports injuries is becoming in­ creasingly important, and it would be appropriate to have a regular column on sports physiotherapy. Nutrition is also an area of major concern that can feature very prominently in our jour­ nal. The editorial committee would wel­ come any contribution from our read­ ers. It is very important that we should maintain a high standard of scientific credibility in all our articles to further the interest of Sports Medicine in all spheres of the health professions. ^*JCUST1987 VOL 2, N O 3,1987 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SOCCER INJURIES I. Surve 4th Year Medical Student J. Ranchod 4th Year Medical Student A.N. Kettles Registrar From: The Department o f Community Health, University o f Cape Town, S ummary Soccer is the most wide­ ly played sport in South Africa yet no study of soccer injuries in this country has apparently been published. This survey examines the relationship of injuries to factors, both intrinsic and extrinsic to the player All injuries are classified according to type, site, seve­ rity, recurrence, and manner of sustain­ ing the injury. A relationship between injury and some of these factors is shown, the most important being field condition, protective equipment and division played in. Suggestions are made as to how to reduce these inju­ ries. It is also recommended that a fol­ low up study be done on some of the relationships emerging from this study. 1. Introduction Soccer is the most widely played sport in the world.1 More than 40 million ac­ tive players were registered with the Federation of International Football Association in 1982.2 As in other con­ tact sports, soccer has an inherent injury risk w and soccer is considered to be responsible for 50-60% of all sports injuries in Europe. Epidemiological studies have been performed on soccer injuries 1 but it appears that no such information is yet available on South African soccer, despite the fact that soccer surpassed rugby as the most popular sport in this country in 1984.6 As an initial step towards the prevention of soccer inju­ ries in South Africa, the principal authors determined the distribution and pattern of soccer injuries among amateur soccer players, over a period of 9 weeks, extending midway into the 1985 playing season. 2. Materials and Methods For the purposes of this survey, an in­ jury was defined as one that required the attention of the first-aid staff avail­ able at each match. The following procedure was adopted to identify injuries occurring in matches included in the survey: on the morning of each match — Saturday, the first aid teams allocated to each match were given a detailed explana­ tion of the project and the question­ naire, which also had an explanatory sheet attached. Specific instructions were given to ensure that a question­ naire was completed for each player who received first aid attention during the match. The two allocated first aid­ ers were accompanied by an occupa­ tional therapist or the authors until such time as they were competent to complete the questionnaire on their own. They were then checked at regu­ lar intervals to ensure that a high stan­ dard was maintained. The question­ naires were collected after each match. The questionnaire included data about factors both intrinsic and extrinsic to the players, e.g. age, division, playing position, field, weather condition, injury (type), protective equipment worn by AUGUST 1987 VOL 2, NO 3,19# players, referee, etc. Each field was graded according to the following criteria: surface, evenness, presence of tufts and holes, clarity of markings. The survey population consisted of senior members of the Cape District Football Association — an amateur football body with 22 clubs and a to­ tal membership of ± 10 0 0 players. Senior players were defined as all play­ ers in the under 18, under 21, 2 nd, 1st and Premier Divisions. To assess the opinion of players about factors potentially leading to soccer in­ juries, a random sample of 100 players was chosen, using random number ta­ bles Each player was asked to com plete a questionnaire listing eight possible factors from which they were asked to indicate the three which they consi­ dered were the most important. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 3 Results Number and incidence Rate of injuries A total of 227 games were played by 6 4 teams of 11 players each while game duration varied with division. The total number of playing hours studied was 5 826. A total of 73 injuries were recorded, giving an overall injury inci­ dence of 1 injury per 80 playing hours, or 12,5 per 1 000 hours played. This reflects an average risk of 1 in 68 per game for each player. showed the highest injury incidence per game played i.e. 0,8, while the aver­ age for all divisions was 0,32 injuries per game. Injury by Playing Position Table II shows the relationship between playing position and number of injuries The majority of injuries occurred to midfield players (32%) and the least to goalkeepers (15%). However, there is only one goalkeeper per team, and on average three backs, three forward and Table I: injury distribution over divisions and time. No. of No. of No of NO. Of injuries Total man hours Incidence rate per 1000 man hours Division teams games injuries per game played played U18 14 38 14 0,37 836 16,67 U21 10 40 19 0,48 880 21,74 2nd 22 95 5 0,05 2438 2,23 1st 9 24 11 0,46 792 13,89 Premier 9 30 24 0,80 880 27,0 TOTAL 64 227 73 0.32 5826 12,53 different injuries with regard to divi­ sion or playing position, although lacer­ ations were relatively more common in defence positions and sprains more in attacking positions. Table II: injury Incidence in different playing positions Number Corrected of Percentage Position Injuries of Injuries Goalkeeper 11 (15%) 37,0% Back 19 (26%) 21,3% Midfield 23 (32%) 19,3% Forward 20 (27%) 22,4% 73 (100%) 100% Table ill: Distribution of type of Injury Type of Injury Number of Injuries Sprains Lacerations Strains Contusions Fracture 31 (42%) 23 (32%) 13 (18%) 5 (7%) 1 (1% ) 73 (100%) Site of injury Table IV: Distribution of injuries over anatomical sites Number of Site Injuries Ankle 18 (25%) Thigh 12 (16%) Shin 9 (12%) Hand 8 (11%) Knee 5 (7%) Groin 4 (6%) Back 4 (6%) Foot 3 (4%) Calves 3 (4%) Elbow 2 (3%) Face 2 (3%) Neck 1 (1%) Shoulder 1 (1%) Ribs 1 (1%) 73 (100%) Lower limb injuries accounted for 74% of all the injuries (54 out of 73), of which the ankle accounted for a total of 18 (25%). The upper limb injuries comprised 15% of the total (11 out of 73), with the hand accounting for 8 of these Severity of injury About one in three of the injured play­ ers had to leave the field whilst the re­ mainder were able to play on. In the to­ tal of 227 games played, 23 injuries could be considered severe, defined as when a player was forced to leave the field as a result of injury. This gives an incidence rate of 1 severe injury per 10 games played, or a severe injury incidence of 4 per 1000 player hours. The overall number of injuries during each week of the season was not great­ ly different and varied from 6 to 10 per four midfield players. Thus, if the data are corrected accordingly, the inci­ dence of injury is greatest for the L i f e - W-ek, of which 90% were new injuries and 10 % recurrences. [ne proportion of injuries as distribut- nrr?Ver ĥe divisi°ns showed that they most in the P^m ier league “ 7 }•'followed by the "Under 21" (26%) niimK 18’’ category (19%). The t h « u ° f p la y in 9 h o u r s "a t r is k " f o r iese three divisions were approxi- e9 y3 ̂although the number of « mes differed. The premier division ^ )0UST 1987 VOL 2, NO 3,1987 goalkeepers. Types of injury Table III shows the frequency of each type of injury. While there was only one fracture, 75% of the injuries comprise sprains (42,5%) and lacerations (31,5%), while 58% of sprains occurred to the ankle, 19% to the knee and 13% to the hand. There was no significant differ­ ence in the relative proportion of R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Field Conditions All fields on which matches were played were graded according to a checklist with a maximum score of 40. The num­ ber of injuries and of playing hours for each field was determined, and the in­ jury incidence per 1000 hours was cal­ culated. When and how injuries occurred Most injuries occurred in the second half (47, or 64%). The commonest method of injury was a foul (42, or 57%) of which 30 occurred in the se­ cond half. When one combines fouls and fair tackles (53) the majority (40, or 76%) occurred in the second half "The high num ber o f sprains In the forward and m idfield positions could be due to the skilful dribbling involved in these positions, especially since 16 o f the 22 sprains recorded were ankle sprains." influence of individual preparation It was established that 39% of injured players had warmed up before games and practices, and 90% had attended at least two soccer practices per week. In general 90% of injured players con­ sidered themselves fit or very fit. The injured players were virtually equally divided over those wearing screw-in studs (37 or 51%) or multi-studs (36 or 4 9 %) and no relationship could be found between the type of studs worn and the injuries sustained. Shin guards were worn by 47% of players and none of these players suffered shin lacera­ tions. Of the injured players, 47 (64%) participated competitively in another sport. TO B E CONTINUED IN THE FOLLOWING EDITION AUGUST 1987 VOL 2, NO 3,1- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Continued fro m page 6 back pain with sciatica. As with spondylolysis and vertebral apophyseal fractures, we have found brace treatment useful in managing these adolescent athletes with disc dis­ ease. We present this treatment pro gram to the patient and parents as a way of resting the back while allowing the patient to continue being ambula­ tor/ and active, as well as continuing in school. With the patient who has disc disease, the brace that has been best tolerated, particularly early in the treat­ ment regimen, has been the somewhat softer and more flexible polyethylene brace with 15 degrees of lordosis built into the brace. As might be expected, the success rate for disc disease with the brace and rest program has not been as high as that for spondylolysis or vertebral end plate fractures. In our initial series, only ap­ proximately 50 per cent of the young athletes with discogemc low back pain were able to return to full sports activi­ ties without pain.7 It would appear wise, if at all possible, to avoid discectomy in the adolescent with disc disease Although the natur­ al history of adolescents after discec­ tomy has not been well studied, the re­ cent review by De Orio and Bianco sug­ gested that there was a relatively high incidence of continuing back com­ plaints in these patients as adults.1 The recent increased interest in chymopapain injections for discogen- ic low back pain with sciatica may have a particularly useful application in the adolescent or young adult with disco- genic back pain. In such patients, of course, the disc rupture appears to be the primary event and is usually not as­ sociated with degenerative changes in the facet joints or posterior elements. Thus, chymopapain injection to mechanically decompress the bulging disc and the associated nerve irritation might well allow adaptive changes to occur in the associated elements of the spine. The long-term result may be a significantly lower incidence of subse­ quent degenerative changes and back pain in this population. Of course, the child with progressive neurologic symptoms, bladder and bowel complaints, or serious motor loss is a candidate for surgical decompres­ sion, as in the adult. Spondylogenic back pain When the gymnast with back pain has been carefully evaluated and the afore­ mentioned diagnoses of spondylolysis, apophyseal fracture, or disc disease have been ruled out, the presumptive Bgpnosis of spondylogenic back pain may be made This is usually associat­ ed with a hyperlordotic posturing of the lumbar spine, tight hip flexors, and, equently, relatively tight hamstrings and lumbodorsal fascia. Children with spondylogenic back pain in association with sports activities will usually respond to a well supervised ex­ ercise program of abdominal stren- ghtening, lumbodorsal and hamstring stretching, and antilordotic posturing of the lumbar spine. The pelvic tilt per­ formed in both the supine and stand­ ing position is the foundation of this exercise program. Surprisingly, a survey of gymnasts in the Boston area by Dr Michael Goldberg revealed that a num­ ber of these were relatively lacking in abdominal strength.5 In some cases, exercises alone have not been sufficient to reverse the lordotic posturing of the low back and relieve the back pain. In such cases, a 0-degree, anterior opening plastic brace has proved to be very useful to relieve the child's pain and allow restoration of function/ These children usually be­ came asymptomatic in three to four weeks. Bracing is usually continued for three to four months in combination with the exercise program outlined earlier, then the use of the brace is tapered. "Young gymnasts com plaining o f back pain m ust never be passed o ff as having sustained a back strain o r "muscle spasms" and treated symptomatically." Tumor and infection A final, extremely important consider­ ation must always be remembered in the young gymnast complaining of low back pain, even pain that is apparent­ ly associated with traumatic athletic ac­ tivities. Tumors of the axial skeleton and infectious processes of the disc or end plates must always be considered in the differential diagnosis of the young athlete with low back pain. The incidence of osteogenic sarcoma of the axial skeleton is low in any age group, of course, but the adolescent and young adult are particularly suscepti­ ble to this disease process. In addition, discitis, although more common in the somewhat younger child or young adolescent, can also be encountered in the older adolescent involved in sports activities A recent case of ours outlines this point very clearly. This was the case of a 17-year-old elite tennis player who began complaining of back pain and radiation of pain into the buttocks This pain was severe enough to warrant hospital admission and evaluation. A presumptive diagnosis of discogenic back pain with severe sciatica was then obtained. However, further evaluation showed elevation of the sedimentation rate and a positive bone scan at the L1-L2 level. Subsequent radiographs confirmed progressive narrowing of the L1-L2 level, and the diagnosis of disc space infection was made. The patient responded well to a program of rest, brace immobilization, and antibiotic treatment and did not require decom­ pression of the disc. Summary The complaint of low back pain in the adolescent must never be taken light­ ly. A high index of suspicion should be particularly entertained in a child par­ ticipating in gymnastic training or com­ petition. As noted in this article, steps can now be taken, particularly if a specific diagnosis is made early, to in­ stitute specific treatment with a high likelihood of success. Young gymnasts complaining of back pain must never be passed off as having sustained a back strain or "muscle spasms" and treated symptomatically. Persistent back pain beyond two weeks warrants, in our opinion, a complete evaluation, careful history and physical examina­ tion, a four-view radiographic assess­ ment of the spine, and, if necessary, bone scans or other more advanced techniques to make a specific diagno­ sis of the cause of the pain. References 1. De Orio, J. K. and Bianco, AJ.: Lumbar disc exci­ sion in children and adolescents. J. Bone Joint Surg. 64A:991-995, 1982 2. Dzilba, R.B. and Cervin, A.I.: Irreversible spinal deform ity in Olympic gymnasts Annual Meeting. American Orthopaedic Society for Sports Medicine, Anaheim, California, March 1983. 3. Goldberg, M.A.: Gymnastic injuries. Orthop. Clin. North Am, 11:717-724, 1980. 4. Hensinger, R.N.. Back pain and vertebral changes simulating Scheurmann's disease Orthop Trans, 6:1, 1982. 5 Jackson, D.W, VViltse, LL, and Cirincione, R.L Spon­ dylolysis in the female gymnast. Clin. Orthop, 117:68-73, 1976. 6. Micheli, L J : Low back pain in the adolescent- Differential diagnosis. AM. J. Sports Med., 7:362-364, 1979. 7. Micheli. L J, Hall, J.F, and Miller, M.E.. Use o f the modified Boston brace for back injuries in athletes. Am. J Sports Med.. 8:351-356. 1980. 8. Micheli. L. J, and Steiner, E. M.: The use o f a modi­ fied Boston brace to treat symptomatic spondylol­ ysis Orthop. Trans, 7:20, 1983. 9. Snook. GA: Injuries in women's gymnastics. AM. J. Sports Med, 7:242-244, 1979. 10. Sorenson, H.K.: Scheurmann's Juvenile Kyphosis. Copenhagen, Munksgaard, 1974. Division of Sports Medicine Children's Hospital Medical Centre 300 Longwood Avenue Boston, Massachusetts 02115 \ A I AUGUST1987 VOL 2, NO 3,1987 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) BODYBUILDERS' PSYCHOSIS urther warning of the F hazards of misuse of ana­ bolic steroids by athletes is given by Drs Harrison Pope and David Katz of McLean Hospital and Har­ vard Medical School in Massachusetts. They treated two men requiring hospital admission for psy­ chosis apparently related to steroid use One was a 22-year-old construction worker who took two eight-week courses of methandrostenolone for bodybuilding. The second was a 40-year-old man with idiopathic impotence who developed major depression with delusions and hallucinations after being prescribed "After the second course he developed severe depressive sym ptom s which lifted after several m onths b u t were followed by prom inent paranoid and religious delusions." methyltestosterone for two weeks. Neither patient had any serious psy­ chopathology before this episode and no medical or neuroendocrine abnor­ malities were found. Both responded well to neuroleptics and have remained psychiatrically normal for more than two years follow up with no further steroid exposure. Intrigued by these cases, Drs Pope and Katz interviewed 31 other anabolic steroid users recruited through adver­ tisements in gymnasia: three had psy­ chotic symptoms including hallucina­ tions and delusions and at least four others had 'subthreshold' psychosis in­ cluding paranoid jealousy and gran­ diose beliefs. In addition, four met criteria for manic episodes while taking steroids and five had major depres- sion.None of the subjects described comparable behaviour when not using steroids. Such cases show that in ad­ dition to well-described medical effects of anabolic steroids there may be seri­ ous psychiatric effects which have so far been largely unexplored. Lancet, 1987, Apr 11, i,863. Acknowledgement Medical News Tribune Jun 25, 1987 George D. Rovere, MD Low back pain in seasoned athletes is not common, but when present it can limit participation. While direct blows or hyperlordotic positions can cause low back pain in certain sports, the most common cause is overuse and resultant strains or sprains of the paravertebral muscles and ligaments Such injuries cause acute pain and spasm, which sometimes do not ap­ pear for 24 hours or longer. Diagnosis is based on history, ruling out of sys­ temic maladies, physical examination, and, if necessary, supplemental tests such as x-rays, myelograms, and bone scans. Treatment of low back pain due to overuse is, sequentially, bed rest and ice for 24 to 36 hours, heat and mas­ sage, analgesics as needed, and a lum­ bosacral support until flexion and strengthening exercises have returned the damaged part to normal. Reference The Physician and Sportsmedicme Vol 15, No. 1, January 87 AUGUST 1987 VOL 2, NO 3,1! 16R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) B omrades Torture- Track by CAROLYN McCIBBON Research on runners could provide a new way of boosting performances in the Comra­ des Marathon by reducing body tempe­ rature and cutting out some of the gruelling agony of the 87-km race. The research — which is a world first — is still in its infancy, and critics have cal­ led for more comprehensive tests and controls before the results are accep­ ted. But early tests show that cramps, nausea vomiting, diarrhoea and kidney problems — which make the Durban to Pieterm aritzburg route a torture track — are linked to poisons, called endotoxins, relea­ sed into the blood­ stream from the gut after strenuous exercise Tests carried out in the medical tent at last years Comra­ des, showed that more than 80 per­ cent of runners in the survey had very high endotoxin levels Antibodies fight the endotoxins, and research from Natal Medical School shows that hard training is a natural way of increasing the antibodies But runners eager for boosted perfor­ mances may be tempted to inject themselves with antibodies manufactured by the Blood Bank. This could cause ethical problems for Comrades' organisers who are battling to keep the sport clean. Runners are al­ ready subject to tests by the SA Ama- )?!dr Athletics Union, but it would be difficult to prove whether runners are injecting themselves with antibodies. MrDanie Malan, chairman of the SAAAU medical committee, said no road runner yad been tested positively for drugs, and “blood doping" was unknown in South Africa. Professor John Brock-Utne of the Phy- ^ o g v Department at Natal University, wno headed the endotoxin research said: "We have shown that high l n” JPx'ns can cause nausea, vomiting «nd diarrhoea. This may be circumven- " When a runner is exhausted, he needs m ore blood sent to his muscles and so the bloodsupplyis shunted from the gut. As a result, the barrier that stops endotoxins from entering the blood is broken down and the endotoxins com e stream ing o u t." ted by high levels of antibodies and one way of getting these high levels is through training" "It appears that with high antibodies you are protected from all the bad side- effects of high endotoxins People with high antibodies may be able to perform better; he said. He explained: "When a runner is ex­ hausted, he needs more blood sent to his muscles and so the blood supply is shunted from the gut. As a result, the barrier that stops endotoxins from entering the blood is broken down and the endotoxins come streaming outr Endotoxins interfered with the normal functioning of the circulatory system, he said, which then affected the heart, muscles and kidneys. Oxygen in the blood was reduced and body temperature shot up, making the runner more tired. Poor circulation led to cramps and kidney problems, he said. The basic treatment for kidney failure — which killed one Comrades Marathon runner last year — was to give intrave­ nous fluids, which would have the effect of flushing endotoxins out of the sys­ tem, he said. Professor Brock-Utne suggested that in the future runners could be tested if they were unsure whether they would be able to complete the course Their antibody levels could give an indication of how fit they were People with very low antibodies might then be advised not to run, he said. Comrades doctor John Godlonton said he had strong reservations about draw­ ing conclusions from the research, be­ cause there were no controls, and the sample was only drawn from runners who had collapsed in the medical tent. Dr Bosie Bosenberg from Natal Univer­ sity's Anaesthetics Department, who was part of the endotoxin research team, said it was still too early to draw significant implications from this study. "The results indicate a correlation be­ tween high endotoxin levels and nausea, vomiting and diarrhoea But because we had a very small sample of athletes, it is difficult to draw conclusions" The results could be biased, he said because only 89 runners in bad shape had been assessed. Acknowledgement Sunday Tribune 31 May 87 ‘̂ 'i-'UST1987 V° L 2, NO 3,1987 17R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) FEATUREA MEMORY JOGGER Exercises to Prevent and Treat Low Back Pain 1 Pelvic Tilt. Lie on your back with knees bent, feet flat on the floor, and arms at your sides Tighten your stomach muscles and flat­ ten the small of your back against the floor, without pushing down with the legs. Hold for five seconds, then slowly relax. 2. Knee to Shoulder. Starting in the same position as for the pelvic tilt, grasp your right knee and gently pull it toward your right shoul­ der. Return to the starting position and repeat with the left leg Alternate legs 3. Double Knee to Chest, starting in the same position as for the pelvic tilt, use your hands to pull your right leg close to your chest, and then pull the left leg even with the right. Grasp both knees and pull them toward your shoulders. Let the knees return to arm's length and repeat. 4. Partial Slt-up. Do the pelvic tilt, and while holding this position, curl your head and shoul­ ders up and forward. Hold briefly. Return slow­ ly to the starting position 5. H a m strin g S tre tch . From the same start­ ing position as for the pelvic tilt, bring one knee to your chest and then straighten the leg vertically, stretching the heel toward the ceil­ ing. You should feel the stretch behind your knee Bend the knee and return the leg to the starting position. Repeat with the other leg 6. R o tatio nal Slt-up. Do the pelvic tilt and, while keeping your hips flat, rotate your up­ per body so that the weight rests on the left shoulder Then, curl your head and shoulders upward, raising your right shoulder higher than the left Hold briefly before returning to the starting position. Rotate your upper body to the right and repeat the movement, this time raising the left shoulder higher than the right. 7. Cat and Cam el. On your hands and knees, relax your abdomen and let your back sag downward Then tighten your stomach mus­ cles and arch your back Repeat. 8. Trunk Flexio n, Prone. Starting on your hands and knees, tuck in your chin and arch your back upward, and then slowly sit back on your heels while letting your shoulders drop to the floor Relax Return to the starting po­ sition. keeping stomach tight and back arched. Repeat. .......... 9. Trunk Flexio n, Seated. Sitting near the edge of a chair, spread legs apart and cross arms over your chest Be sure the chair will not slip backward or tip. Tuck your cnin and slowly curl your trunk downward. Relax. Uncurl slow­ ly into an upright position, raising your head last R eference Vol 15, No. 1, January 87. The physician and sports medicine. CONTINUED FROM PACE 10 Bester takes Ultra Man lead Lynnwood drive-in theatre and the clos­ ing date for entries is November 2, All Vasbyters who complete the race within lOhourswillreceiveamedal, track suit badge and certificate. Thenext compulsory eventafterthecy- clechallengeistheHansaDuzi in January, in which Ultra Man entrants can paddle either single or K2 canoes. The other compulsory events are the 160km Sunday Times/Leppin Iron Man triathlon in February and the87km Com­ rades marathon next June. The overall winner will receiveagold me­ dal and R10,000, with a medal and R1.000 for the others in the top 10 and R2.000 and a medal forthewinnerof each com­ pulsory event. In addition, there will be a medal and R1.000 for the first master(over40)and a medal and R2.000 for the top woman. FOR FURTHER INFORMATION CONTACT MICHELLE REIMERS AT SPORTS INTER­ NATIONAL ON (011) 883-3333. ULTRAMAN RESULTS FOR JSE MARATHON- 1 s t 20 POS. NAME TOTAL POINTS 1. Nicolaas Bester 100.00 2. Piet Mare 92.38 5. Danny Biggs 85.99 I 4. Graeme Pope-Ellis 85.22 1 5. Pierre deJager 84.72 6. Phillip van Tonder 84.02 7. RogerZipp 83.13 8. Philip Demosthenous 82.72 9. GeoffMatthews 81.77 1 10. Kenneth Poole 81.77 11. Stephen Rehbock 81.15 12. Norrie Willliamson 81.14 1 13. DidierEntressangle 8090 14. LochiLochner 80.82 15. Richard Marshall 80.13 16. Jako vanHeerden 80.09 17. Eddie King 80.02 18. Roelofdu Toit 79.88 19. Martin Wood 79.13 20. Colin Cooper 78.70 1 WOMEN'S RESULTS 1. Pricilla Carlisle 68.76 2. SallyLuckhoff 59.30 3. Sandra Niemandt 48.22 1 AUGUST 1987 VOL 2. N0 3.1S 18R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ” FORUM i RUGBY INJURIES AND TACKLE people, have it pushed through earlier, even on a local experimental basis. Yours faithfully Dr S Ger PS. The playing time should be divided into 4 sessions with 3 min breaks be­ tween each session. Reply to Dr Ger's letter The Rugby injury Refering to Dr Selwyn Ger's letter regarding rugby injuries, it remains en­ couraging to note that some physicians Forum for our readers This forum invites our readers to air their views on any subject related to sport and sports medicine. We welcome your ideas, criticisms, con­ tribution, etc Address correspondence to: The Managing Editor, Commedica, PO Box 3909, Randburg 2125. The Editor Sports Journal Rugby injuries and Tackle Dear Sir With regard to the above I wish to state, that the incidence can be reduced, pos­ sibly to 0,5% by- 1) Proper coaching techniques with emphasis on basics — how to fall, how to tackle, how to scrum etc. 2) Change the tackle law a) For schools — a TACKLER may only aim for the body area, be­ tween the shoulder (under the axilla) and the hips (on or above circumference bounded by sym­ physis pubis, anterior and posteri­ or superior iliac spines) b) The tackle will not involve throw­ ing the ball carrier to ground. The ball carrier will only have to be held in this position and he must then release, pass or kick the ball. In other words — it would be a modi­ fied form of touch rugby. If, however the ball carrier is thrown to ground, it will not be against the rules. By changing the tackle law as above, I reel that (even for senior rugby) it will:- 1J Speed up the game 2) It will cut down on rucks, Mauls, Pile ups — thereby reducing injuries. 3) Reduce injuries in general and es- pecially knee and ankle injuries. i nave written a similar letter to Dr c an'e Craven who mentioned that such changes may take ages via the In­ ternational Rugby Board, out, why shouldn't we, as Medical sports August ig 87 V0L NQ—igg7 remain concerned about rugby injuries and are willing to make suggestions regarding possible ways of reducing these injuries. It is important that Dr Ger forwards detailed proposals to the Medical Com­ mittee of the S.A. Rugby Board. Possi­ ble law changes will also involve discus­ sions with the particular governing bodies like the SA. Schools Rugby As­ sociation in this case before a well moti­ vated proposal can be presented to the S.A. Rugby Board for fu rth e r consideration. All attempts must be made to in­ troduce law changes without changing the basic spirit and the game itself. Dr Hugo Chairman: Medical Committee Rugby Board SPORTS INJURY REPRINT SERVICE Sports Injuries occur as a result of phys­ ical activities carried out either for general recreational purposes or with more professional goals in mind. They may be caused by accidents or by over­ use, and they do not necessarily differ from injuries sustained in non-sporting activities. Most sports injuries are minor and would not prevent the average athlete from continuing his daily work, but as more and more people become seri­ ously committed to sporting activities continuing daily work is no longer the only consideration. The injury needs to be treated effectively so that leisure activity can also be resumed at the earliest opportunity. Progress in diagnosis and treatment is making rapid strides in the field of sports medicine, and to keep doctors abreast of recent developments Ciba- Geigy have introduced a SPORTS INJU­ RY REPRINT SERVICE. This service searches medical publications for the most recent articles dealing with Sports Medicine and makes them avail­ able to interested doctors. Careful and planned rehabilitation is es­ sential after an injury. Ciba-Geigy, as leaders in the field of antirheumatic and Sports Medicine, awarded a grant to the National Sports Research and Training Institute to promote scientif­ ic sport research and training. Doctors who wish to receive reprints of articles dealing with Sports Medicine on a regular basis, ond/or would like more information on the Ciba-Geigy Sport Injury Rehabilitation Programme should write to: CIBA-GEIGY (PTY) LIMITED PHARMACEUTICAL DIVISION PO BOX 92 ISANDO ^ 1600 19R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) NATIONAL SYMPOSIUM I heme: Drugs & Sport Par- ‘JC|Pa‘ on Da‘ e To be ad W H j h | vised Venue: Sp o rts H mBm Centre — Un versitv of Pretoria As a result of the nega- tive publicity concerning sport participation and the use of drugs as well as the ignorance and health dangers of the incorrect use of illegal drugs, the Institute for Sport Research and Training at the Universi­ ty of Pretoria have decided to hold a national symposium in order to de­ velop sound perspective in this regard. Experts in this field have been invited to present papers covering various top­ ical issues regarding this subject. The programme is as follows: The Techniques of Testing — by Dr P vd. Merwe (UOVS) Medical Aspects of Ergogenics & other Chemical Compounds — by Dr D. v. Vel- den (University of Stellenbosch) Biochemistry of Illegal Drugs — by Professor F. Terblanche (University of Zululand) Ethical Aspects — by Professor Hannes Botha (University of Pretoria) The Use of Anabolic Steroids from a health point of view — by Professor R. van Rooyen (University of Pretoria) Scientific-accepted Training Methods for the Development of Strength — by Dr N de Bruyn (University of Pretoria) Diet and Strength Development — by Ms Mieke Faber (National Medical Coun­ cil — Tygerberg Hospital) Invitations will be sent out to coaches, physiologists, parents, General Praction- ers and members of the pharmaceu­ tical industry. For further information please contact Cert Potgieter or Petra Talijaard at tel. no (012) 342-2150. c m e course in sports Medicine — Durban 1987 The SA. Sports Medical Association is organising a continued Sports Medical Educational Course in Durban from the 7th to 9th of April 1988. This will be held in the Elangeni Hotel. Emphasis will be placed in various medical and physiological aspects in the runner and include training and conditioning as well as methods of treating running injuries. Forms of intent will be sent to all members of the S.A. Sports Medical Association and other interested bodies. Further information will be published in Sports Medicine Journal Vol 2 No 4 in November. However early registra­ tions and queries can be directed to Organising Committee SASMA Hatfield Forum West 2nd Floor 1067 Arcadia Street Hatfield Pretoria 0083 Tel No. 012 - 43-5594/5/6 In Memoriam It is with great regret that we learned of the passing away of Dr Etricia Prins- loo in July this year, just five months after having diagnosed her own illness — a rare form of leukaemia. Etricia was a medical doctor working on a master's degree in sports medicine (biokinetics) at the University of Pretor­ ia. She was the secretary of SASMA since April 1987 and an active member of the association since its inception four years ago She played a major role in improving communication and co-operation be­ tween Physiotherapists and Medical Practitioners involved in sports medi­ cine and has been actively involved in the expansion of sports medicine in South Africa. She will be sorely missed by all SASMA members and we would like to take this opportunity to extend our sincere sym­ pathy to her husband and family. the: Suid-Afrikaanse Sport geneeskunde Vereniging South African Sports M edicine Association APPLICATION FORM AANSOEKVORM Full Member/Volle lid R25 Student Member/Studente-lid R5 Tel No/Tel N r ............... MASA No/MVSA Nr . F u ll M e m b e r ; M e a ic a i p ra c iih o n e r rs w h o a re m e m b e rs o f M A S A V o ile L id : M e d ie s e p r a k iis y h s w a ile d e v a n d ie M V S A is S t u d e n t M e m b e r : M e d ic a l s iu d e m s in c lin ic a l y e a^s S t u d e n t e l e d e : M e d ie s e s tu d e n te in huf k iin te s e ja re A p p lic a tio n s lo r m e m b e r s h ip o l S. A S M A s h o u ld b e s e n it o The S e c re ta ry S A S M A . H a tfie ld F o ru m W e s i 1067 A r c a d ia S ire e l H a tfie ld . P 'e io n a C 0 8 3 C h e q u e s 10 a c c o m p a n y m e m b e r s h ip fo rm AUGUST 1987 VOL 2, NO 3,19£ 20 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )