SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE SPORTGENEESKUNDE J O U R N A L O F T H E S.A. SP O RT S M E D I C I N E A S S O C IA T IO N T Y D S K R IF VAN D IE S.A. SP O R T G E N EE S K U N D E -V E R E N IG IN G VOLUME 6 NUMBER 3 JUNE/JULY 1991 National Advisory Board Editor in Chief: Clive Noble Associate Editors; P rof TD Noakes Dawie van Velden Advisory Board: Traum atology: Etienne Hugo Physiotherapy: Joyce Morton N utrition: Mieke Faber Biokinetics: Martin Schwellnuss Epidem iology: Derek Yach Radiology: John Straughan Physical Education: Hannes Botha Internal M edicine: Francois R etief International Advisory Board Lyle J Micheli A ssociate Clinical Professor o f Orthopaedic Surgery Chester R Kyle Research D irector, Sports Equipm ent Research Associates P ro f HC Wildor Hollmann President des Deutschen Sportarztebundes Howard J Green Professor, D epartm ent o f K inesiology George A Brooks Professor, D epartm ent o f Physical Education Neil F Gordon D irector, Exercise Physiology Edmund R Burke A ssociate Professor, Biology D epartm ent, U niversity of Colorado Graham N Smith P hysiologist C O N T E N T S Editorial Comment H ealth care in the new South A frica .............. 3 P sy ch o lo g y P sychological dim ensions o f sports injuries .. 4 C ric k e t C ricket injuries - A rev iew .............................. .. 9 N u tr itio n T he effect o f dietary cholesterol on plasm a cholesterol le v e ls .................................................... 14 S A S M A Update SA SM A new s ........................................................... 18 P h y s io th e ra p y T reatm en t o f soft tissue injuries: the facts about f r ic tio n s ................. ... . . . . . 19 T h e C om rades M arathon as seen through the eyes o f a physiotherapist ........... ....... ....... 22 JOURNAL OF THE SOUTH AFRICAN SPORTS MEDICINE ASSOCIATION 269 WEST AVENUE HENNOPSMERE VERWOERDBURG, 0157 SASGV SASMA Photographs courtesy o f The Image Bank T h e Journal o f the SA Sports M edicine A ssociation is p ublished b y M e d p h a rm P ublications, 3rd F lo o r N oodhulpliga C e n tre , 204B H F V erw o erd D riv e, R an d b u rg 2 1 9 4 . PO Box 1004, C ram er- v ie w 2 0 6 0 . T el: (011) 7 8 7 -4 9 8 1 /9 . T h e view s ex p ressed in this pub licatio n are th o se o f th e authors and not necessarily those o f the p ublishers. P rin te d b y T h e N a ta l W u n c « P rin tin g an d P u bfu Jim g C o m p a n y (P r y ) Ltd 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. ) The com p lete one-a-day Multivitamin and Mineral supplem ent Em vit keep s y o n C \o in g i M a d a u s P h a rm a c e u tic a ls (P ty ) L td . P.O. B o x 7 6 2 4 6 , W e n d y w o o d 2 1 4 4 Keep ahead wit-h Reparil-Gel • ■ G2 3 6 7 ' ‘ ------------- 1 0 0 g c o n ta in s : A e s c in 1,0g; A e s c in s o d iu m p o ly s u lp h a te (h e p a rin o id ) 1,0g; D ie th y la m in e s a lic y la te 5 ,0 g Get up cw4 go with Magnesit* f S/24/192 Magnesium - f - aspartate Hcl 1 229,S m g ^ ^ For Magnesium deficie n cy's^- 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. ) e d i t o r i a l H E A L T H C A R E IN T H E N E W SO U T H A F R IC A In the N ew South A frican health care fo r all will becom e the o rd e r o f the day. W ith the unlikelihood o f m uch additional funding being available to achieve this, one must look at the effects this w ill have on sports m edicine. T h e m ajor cost in sports m edicine is the treatm ent o f sports injuries. T hus, if trea t­ m ent can b e avoided by prevention, a great saving can be achieved. Im proved facilities and coaching techniques to all race groups w ould go a long way in this regard. This w ould not form part o f the health budget. At this p o int in tim e, sports m edicine fa­ cilities are part o f South A fric a 's first w orld, i.e. fo r w hites and blacks on m edical aid as well as the richer black soccer clubs that can afford such facilities. M ost o th er injured blacks are treated by w itch-doctors with the tell-tale scratches occurring on the injured part. Seeing that m any sports injuries get b etter w ith tim e alone, in the past this was acceptable "therapy". H ow ever, w ith Aids becom ing a m ajor problem this m ethod o f treatm ent w ill cause Aids to spread unless adequate sterilisation procedures are o b ­ served. A lso, Aids becom es im portant in sports w here bleeding may o ccur such as boxing and o th er collision sports. A dequate precautions such as the use o f ru b b er gloves by the seconds and referee, o r stopping o f a fight once bleeding occurs, may becom e m andatory. T h e answ er to m ost o f the sports m edi­ cine requirem ents is education grass roots level. All coaches and trainers should do a co u rse in first aid w ith a sports m edicine bias. T hey should also have a know ledge o f rehabilitation, know ing w hen an injured play er can return to sport with the least chance o f reinjury. F irst aid should be available at all sporting venues. This can be done w ithout o v er straining the resources o f the first aid groups by, fo r exam ple, at school level having children w ho are unable to play sport b ecause o f ill health o r other reasons jo in the team as first aiders. S im i­ larly at clubs, supporters can b e turned into first aiders. A m inim um standard o f equip­ m ent can be set w ithout overb u rd en in g the club o r schools finances. These sam e school first aiders can, with tim e, im prove th eir know ledge and in rural areas becom e p rim ary health p ersonnel run­ ning clinics w hich can then re fer problem s to peripheral hospitals. T hey may also becom e nurses o r even doctors so vital in the new South A frica. P aram edical education can also be ex­ tended to the third w o rld . S ports m edicine should also form a la rg e r p art o f medical training at o u r universities and colleges, both fo r do cto rs and nurses. S ports m edicine diplom as and d e­ grees should be available at all universities with m edical schools. D epartm ents o f Sports M edicine at all m edical schools should b e m andatory. This w ould ensure b etter healthcare fo r all o u r sportsm en and w om en. A u t o p i a ...... maybe. D r C live N o b le M B B Ch, FC S (SA) E d ito r-in -C h ief ________________________ 3 SPO RTSG ENEESKU ND E VOL. 6 NO. 3 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. ) PSYCHOLOGY PSYCHOLOGICAL DIMENSIONS OF SPORTS INJURIES JR Potgieter T he m any excellent books and jo u rn als p ublished in recent years b ear testim ony to p ro g ­ ress in the field o f sports m edi­ cine d u rin g the p ast decade. Closer inspection o f these texts, h ow ever, reveals a d earth o f literatu re on the psychological dim ensions o f the reh ab ilita­ tion o f injured sportsm en. A lthough this is n ot a healthy state o f affairs, it is, nev erth e­ less, no t surprising. T h e causes o f sports injuries a re p rim arily o f a physical nature. H o w ev er, psychological factors should not b e discounted. S portsm en are p ractical p eo p le and w o rk hard and in a disciplined way on th eir ph y si­ cal conditioning and skills. A lthough they invariably re ­ cognise th e im p o rtan ce o f p sy ­ chological dim ensions in sport, psychological training occupies a relatively m in o r p lace in m ost training regim ens. In addition, in the w orld o f sports th ere is som e resistan ce to utilising the services o f so-called sport psy- JR Potgieter Departm ent o f Human M ovement Studies University o f Stellenbosch chologists to enhance physical p erform ance. T h e p ro cess o f sport socialisation m akes it difficu lt fo r the sportsm an to enlist the services o f a p sy ­ chologist, because such a step is o u t o f line w ith the accepted values o f sports participation such as toughness, d eterm in a­ tion, p ersistence, assertiveness and aggression. T he "old school" approach creates a m i­ lieu that could p erceiv e the consultation o f a psychologist as a sign o f w eakness. R e­ search has verified this as­ sum ption (C arm en e ta l, 1968; Linder et al, 1989; Pierce, 1969; Scanlan et al, 1989). NEED FOR A PSYCHOLOGICAL APPROACH I f it is tru e that the average healthy sportsm an is reluctant to consult a psychologist it is n ot surprising that he is also apprehensive to seek p sycho­ logical assistance when injured. A long with the im proved treat­ m ent o f injured sportsm en it has, how ever, becom e im p o r­ tant to focus on the p sy ch o lo g i­ cal dim ensions o f reh ab ilita­ tion. B ecause the sportsm an can now adays retu rn to an a c ­ tive p ro g ram m e afte r a rela­ tively short p eriod o f tim e, psychological com plications may arise. In m any cases this shortened rehabilitation tim e m ay no t b e long enough fo r the injured sportsm an to adjust p sychologically. H e m ay be p hysically ready fo r re-entry into the sports aren a b u t his m ental ad ju stm en t has no t been com pleted. T h e traum atic rem in d ers o f his injury are still fresh in his m em ory w hile, at the same time, external demands a re placed on him to perfo rm physically. A nxiety and self­ d o u b t as w ell as real fears o f a recu rren ce o f the sam e injury o r an injury to an o th er p a rt o f the body may plag u e him (Ro- tella & H ey m an, 1986). T h e fact that serious com petitors a re highly com m itted and m ake significant investm ents in th eir sport, m akes these fears even m o re significant. R ehabilitation o f the injured sportsm an is th erefo re both a p hysical and psychological p rocess. It follow s that the sportsm an as a w hole should b e treated and no t only the injury. B ecause the em otions are in v o lv ed , sports m edicine pro fessio n als need to attend to the p sychology o f the injured sportsm an (E ld rid g e, 1983). REACTIONS TO INJURY A t the ou tset it m ust b e p ointed o u t that m any sportsm en do not 4 SPORTS MEDICINE VOL. 6 NO. 3 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. ) PSYCHOLOGY need any special psychological treatm ent. S portsm en react to injury in d ifferen t w ays. W ith a sound physical rehabilitation p ro g ram m e and the necessary su p p o rt and en couragem ent m ost sportsm en are ab le to o v erco m e th eir in ju ries suc­ cessfully and w ithout any significant negative effects. Som e m ay even view th eir in ju ries as a fu rth er o p p o rtu ­ nity to display co u rag e, com ­ m itm ent, self-discipline and p ersev eran ce. In contrast, fo r o th ers, injury could p ro v id e a b reak from a taxing training regim en and an escape from the dem ands placed on them (Ro- te lla & H e y m a n , 1986). It p ro ­ vides an excuse fo r below p a r p erfo rm an ces. H o w ev er, fo r o th ers an in ju ry could present a tru e crisis w h ere p sy ch o ­ logical intervention is indicated (L ittle, 1979). STRESS AS A PREDISPOSING FACTOR R esearch findings strongly suggest that th ere is a re la ­ tionship betw een stressful life events o r even o rd in ary daily hassles and a sp o rtsm an ’s p redisposition to injury (Bram - w ell et al, 1975; C oddington & T ro x el, 1980; C ryan & A lles, 1983; P asser & Seese, 1983). A lthough m ost o f the research has been done on contact sports, such as foo tb all, th ere a re indications that this re ­ lationship also holds fo r non- contact sports (K err & M in- den, 1988). It is hypothesised that the p resen ce o f these stressful events decreases the sp o rtsm an 's coping ability (M iller et al, 1990). D aily hassles dem and attention and the resulting division o f atten ­ tion betw een stressful events and the task at hand can be a cause o f injury. T he m ere physical fatigue resulting from a stressful life can be a logical answ er fo r an increase in in ju ­ ries am ong sportsm en w ho are experiencing daily stress. T he o ccu rren ce o f injuries at critical tim es ju s t p rio r to an im portant com petition cannot be explained with certainty. It m ay m erely b e the result o f in ­ tensified training, b ut a p o s­ sible cause could b e attributed to the heightened stress as the day o f an im portant co m p eti­ tion approaches. B ecause avoiding injury p rio r to such com petitions is o f im m ense im portance, it is advisable in som e cases to assist sports­ men psychologically to co u n ter the effects o f daily stress. A ndersen and W illiam s (1988) suggest that it m ay be neces­ sary to assess a sp o rtsm an 's coping behaviours such as sleep p attern s, nutritional habits, tim e m anagem ent, general self-esteem and if the athlete is a student, study skills. T he use o f stress m anagem ent p ro g ram m es, relaxation tech ­ niques, cognitive restructuring, and social support can enhance the coping skills o f the sports­ m an. UNDERSTANDING THE WORLD OF THE INJURED SPORTSMAN Em pathy is a key concept in the rehabilitation o f the injured sportsm an. T h e therapist and coach can enhance this em p a­ thy by understanding the w orld o f the particip an t and w hat it m eans to him . P articipation in re g u la r exercise and sport has the potential to enhance p sy ­ chological w ell-being (Sachs, 1984). T he p articip an t not only derives en joym ent and satis­ faction from sp o rt b u t also d e­ rives feelings o f com petence and con tro l. F u rth e rm o re , p ar­ ticipation in sp o rt and physical ex ercise m ay serve as an im ­ p o rtan t w ay o f red u cin g stress and dealing w ith depression. W hen considering the psycho­ logical and social benefits, it is no t surprising that a sudden term ination o f participation could b e a traum atic experi­ ence fo r the sportsm an. This p ro v id es a p artial explanation o f w hy injured sportsm en, against m edical advice, con­ tinue to p articip ate in activities such as run n in g . It is suggested that these individuals find it m o re acceptable to handle the physical d isco m fo rt and pain associated w ith continued p a r­ ticipation than d ealing w ith the p sy chological tension, anxiety a n d d e p re ssio n asso ciated w ith non-participation (Smith et al, 1990b). It is logical to assum e that the stro n g er the a th le te 's preoccupation w ith health and fitness, the m ore intense these n egative m ani­ festations o f ex ercise d ep riv a­ tion w ill be. A nother phenom enon that m ust b e kept in m ind by the th erap ist, is the tendency o f m any a sportsm an to tie his identity and w orth as a person to his sports p articipation and sports achievem ents (Joseph & R obbins, 1981). A signifi­ cant p a rt o f his d aily interaction w ith o th e r p eo p le is d o n e as a sportsm an. H e sees h im se lf as a sportsm an and o th e r p eo p le, treat him as such. W hen his sports particip atio n is tem po­ rarily o r perm an en tly disco n ­ tinued a loss o f identity can ----------------------------------------------- 5 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) PSYCHOLOGY occur. As a result it is not uncom m on for sportsm en to suffer a loss o f self-esteem w hen injured. E M O T IO N A L R E A C T IO N S T O IN JU R Y T here are suggestions that in ­ j u r e d s p o rts m e n p ro c e e d th ro u g h e m o tio n a l s ta g e s sim ilar to those experienced by the term inally ill. T he limited sports research that has been done on the so-called loss-of- health m odels show s that these could be applied to som e extent to injured sportsm en. O gilvie and H ow e (1986) m aintain that sportsm en w ho are forced to term inate th eir athletic careers proceed through em otional stages sim ilar to those proposed by K iibler-R oss (1969). D enial is the first phase that the injured sportsm an enters. H e may deny the seriousness o f his injury and fail to accept the fact that he will be out o f action for an extended period o f tim e. This is also a com m on p h e­ nom enon am ong sportsm en w ho have to term inate their sporting careers for reasons o ther than injuries, for exam ple if they are no longer able to perform up to standard. A m anifestation o f this denial and unw illingness to accept the fact that they have com e to the end o f their sporting careers is an intensification o f physical training and an even m ore reg i­ mented lifestyle than before. H ow ever, not all sportsm en experience this phase. Smith et al (1990a) observed em o ­ tional reactions am ong injured sportsm en sim ilar to that p ro ­ posed by K iibler-R oss but did not enco u n ter denial as a phase. T hey suggested that sportsm en w ho persist in play­ ing when injured do not deny pain as such, but are motivated to continue participating for m ore com plex reasons. W hen denial is no longer effective in dealing with the effects o f an injury, anger may ch aracterise the next stage. T he unfortunate aspect o f this stage is that anger and rage are often directed at those people w ho are close to the sportsm an, such as his fam ily, team -m ates and coach. This anger is often generalised to include G od, society, and life in general. A nger can also be directed inw ards. The injured sportsm an may becom e exces­ sively self-critical, blam ing him self for his condition. This anger may m anifest in self­ destructive b ehaviour such as alcohol and drug abuse. D uring this second stage the sportsman becomes irritable and difficult to w ork w ith. An o th e rw is e c o a c h a b le and reasonable person can becom e aggressive and negative. This stage could also be ch aracter­ ised by irrational thinking. The injured sportsm an can d isre­ gard im portant aspects o f his injury o r he can oversim plify the situation. A further form o f irrational thinking is o v erg en ­ eralisations and unw arranted conclusions. He may reason that because another person did not recover successfully, he will not succeed either. He may even conclude that the therapist and coach are not in ­ terested in his progress o r are not giving equal attention to his problem s. An understanding coach and therapist should approach such a person with a great deal o f em pathy and pa­ tience. A lthough the reactions o f denial and an g er may be in­ tense they are usually o f a short duration and the sportsm an moves into the next stage o f reactive depression. H e ty p i­ cally w ithdraw s and isolates him self. T his reaction is understandable because the sportsm an is confronted with a m ajor change in lifestyle. H e has invested a great deal o f his life in his sport and shows a type o f g rie f response (P ed­ ersen , 1986; W eiss & T ro x el, 1986). T h e sad aspect o f this reaction is that the athlete iso­ lates h im self from the social support o f im portant other people, w ho he in fact needs to help him on the road to recov­ ery. H e avoids his coach and team -m ates and experiences a feeling o f helplessness and loneliness in this situation that he has created him self. H is life may lose much o f the meaning it had b efo re his injury. If this condition persists o ver an ex ­ tended period o f tim e special counselling may be necessary (O gilvie & H ow e, 1986). A lthough the feeling o f iso­ lation is g enerally the result o f the sp o rtm a n 's own behaviour, som e coaches may contribute to this. C oaches may fail to keep in touch with the injured athlete o r fail to show a co n tin ­ ued and active interest in his progress. T h ere are even c o a c h e s w h o d e lib e r a te ly make the injured athlete feel w orthless in an attem pt to speed up his return to the playing field. It is not uncom m on for in­ ju re d sportsm en to experience feelings o f guilt. T hey may feel that they are letting their team and coach dow n. R uth­ less coaches may exploit the 6 ------------------------------------SPORTS M EDICINE VOL. 6 NO. 3 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. ) PSYCHOLOGY a th le te 's loyalty and co m m it­ ment to get him back on the field as soon as possible. T o counteract these feelings o f loneliness and isolation it is expedient that norm al co n ­ tacts should be resum ed as soon as possible. Social sup­ port is a critical elem ent in enhancing treatm ent adherence (D uda et al, 1989; F isher, 1990). A ndersen and W illiam s (1988) propose that the p re s­ ence o f a supportive social netw ork (w hich includes the physician) may directly protect the sportsm an against injury o r may attenuate the effect o f the stress b rought about by daily hassles and the stressfulness o f com petitive sport. T h e in ju re d s p o rts m a n should rejoin his team as early as possible. A lthough it may be im possible to physically participate in p ractice ses­ sions, he can attend team discussions and scrim m ages. It is fu rth er suggested that he adopts a routined lifestyle sim ilar to that w hich he fol­ lowed p rio r to his injury. A k n o w le d g e o f th e em otional struggles o f the in­ ju red sportsm an can assist the coach and therapist in show ing greater em pathy. It is im p o r­ tant that this em pathy is co m ­ m unicated to the athlete. H e should be told that it is u n d er­ stood and accepted that the injury is inconvenient and that he feels disappointed, frus­ trated, im patient and at tim es angry. On the o th er hand, it should be pointed out to him that it is irrational to punish h im self and others. Open a g ­ g r e s s io n to w a r d o t h e r s , especially those w ho are able to help him is not acceptable. It is also irrational to view his slow progress as a sign o f weakness. The final stage that follows injury is acceptance o f reality w ith the hope that som ehow ev erything will turn o ut for the best. L O C U S O F C O N T R O L Locus o f control can play a s i g n i f i c a n t r o le in th e sp o rtsm an 's perception o f his injury and his rehabilitation. An internal locus o f control refers to the extent an individ­ ual believes that he has control o v er his life. In contrast, an external locus o f control is characterised by a perception that o n e 's life is controlled and d eterm ined by factors outside oneself, such as fate, luck, change and pow erful other people. T he individual with an external locus o f control feels Gatorate T M I H t M u l M C H i n I \ r __________________________ 7 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) PSYCHOLOGY that he is helpless and does not have co n tro l o v er his ow n life. S portsm en gen erally have a strong internal locus o f co n ­ trol. It is th erefo re im portant that this locus o f control be m aintained durin g the reh ab ili­ tation p rocess. S portsm en w ho have em o ­ tional control will function more effectively i f they a re treated in a rational m anner. T hey will exert b etter control o v er th eir p rogress i f they a re provided w ith know ledge about their injury and the rehabilitation process. It has been estab ­ lished that adjustm ent p ro b ­ lem s in the rehabilitation o f cardiac patients is related to uncertainty about th eir co n d i­ tion (C hristm an, 1988). S im i­ larly, u n certainty could retard the rehabilitation o f the injured sportsm an. A p art from keep­ ing the athlete inform ed about his injury and his p ro g ress, it is suggested that the athlete is involved in the planning o f his rehabilitation. T h e process o f goal setting has relevance here. A lth o u g h th e in j u r e d sportsm an should b e involved in his ow n rehabilitation, F ish er (1990) w arns that the m otivation and adherence to persist w ith a rehabilitation p ro g ram m e is not the sole r e ­ sponsibility o f the person being treated. In fact, the attitude o f the therapist m ay be self-fu l­ filling. T he m o re nonad­ herence the therap ist expects the less he w ill be m otivated to chan g e the b eh av io u r o f the injured sportsm an if he p e r­ ceives the resp o n sib ility as being the p a tie n t's alone. This m otivation can b e reduced by failing (a) to adequately ex ­ plain the injury and proposed treatm ent, (b) to request the sp o rtsm a n 's assistance in the p ro g ram m e, (c) to m onitor p ro g ress, and (d) to m otivate the sportsm an w hen neces­ sary. CONCLUSION W h ile m any sportsm en cope effectively w ith injury there are others w ho need special attention to adjust psychologi­ cally. An understanding o f the em otional reactions that follow an injury could lead to g reater em pathy w ith the sportsm an. Social support, encouragem ent and the m aintenance o f norm al relationships could have a sig­ nificant effect on the reh ab ili­ tation process. K eeping the athlete inform ed about the n ature o f his injury and the p u r­ po se and p rogress o f reh ab ili­ tation could enhance recovery. R E FE R E N C E S 1. Andersen MB and Williams JM. A model o f stress and athletic injury: Prediction and prevention. Journal o f Sport and Exercise Psychology, 1988; 10: 294-306. 2. Bramwell ST, Masuda M, Wagner NN and Holmes TH. Psychological factors in athletic injuries. Journal o f Human Stress, 1975; 2: 6-20. 3. Carmen L, Zerman JL, and Bjgine GB. The use o f the Harvard psychi­ atric service by athletes and non­ athletes. M ental Hygiene, 1968; 52. 4. Christman NJ. Uncertainty, coping and distress. Research in Nursing and Health, 1988; 11, 71-82. 5. C oddingtonR D andT roxelJR . The effects o f emotional factors on foot­ ball injury rates: A pilot study. Journal o f Human Stress, 1980; 7, 3-5. 6. Cryan PD and Alles WF. The rela­ tionship between stress and college football injuries. Journal o f Sports Medicine, 1983; 23, 52-58. 7. D udaJL , Smart AE and Tappe MK. Predictors in adherence in rehabili­ tation o f athletic injuries: An appli­ cation of personal investment theory. Journal o f Sport and Exercise Psy­ chology 1989; 11, 367-381. 8. Eldridge WD. The importance of psychotherapy for athletic-related orthopaedic injuries among adults. International Journal o f Sport Psy­ chology, 1983; 14, 203-211. 9. Fisher CA. Adherence to sports injury rehabilitation programmes. Sports Medicine 1990; 9, 151-158. 10. Joseph P and Robbins JM . Worker o r runner? The impact o f commit­ ment to running and work on self- identification. The psychology o f running, 1981; pp. 131-145. MH Sacks and M Sachs (eds.). Cham­ paign, 1L: Human Kinetics. 11. Kerr G and Minden H. Psychologi­ cal factors related to the occurrence o f athletic injuries. Journal o f Sport and Exercise Psychology. 1988; 10, 167-173. 12. Kiibler-Ross E. (1969). On death and dying. New York: MacMillan. 13. Linder DE, Pillow DR, Reno RR. Shrinking jocks: Derogation o f ath­ letes who consult a sports psycholo­ gist. Journal o f Sport and Exercise Psychology, 1989; 11, 270-280. 14. Little JC. Neurotic illness in fitness fanatics. Psychiatric Annals, 1979; 9, 148-152. 15. Miller TW , Vaugh MP and Miller JM . Clinical issues and treatment strategies in stress-oriented athletes. Sports Medicine, 1990; 9, 370-379. 16. Ogilvie BC and Howe M. The trauma o f termination from athletics. A p­ plied sport psychology. Jean M. Williams (ed.). 1986; pp. 365-382. Palo Alto, CA: Mayfield. 17. Passer MW and Seese MD. Life stress and athletic injury: Examina­ tion of positive versus negative events and three moderator variables. Journal o f Human Stress, 1983; 10, 11-16. 18. Pedersen P. The grief response and injury: A special challenge for ath­ letes and athletic trainers. Athletic Training, 1986; 21, 312-314. 19. Pierce RA. Athletes in psychother­ apy: How many, how come? Jour­ nal o f the American College Health Association, 1969; 17, 244-249. 20. Rotella R and Heyman SR. Stress, injury, and the psychological reha­ bilitation o f athletes. Applied sport psychology. Jean M. Williams (ed.). 1986; pp. 343-364. Palo Alto, CA: Mayfield. 21. Sachs ML. Psychological well-being and vigorous physical activity. Psy­ chological foundations o f sport, 1984; pp. 435-444. JM Silva 111 and RS Weinberg (eds.). Champaign, IL: Human Kinetics. Other references on request. 8 ----------------------------------- SPORTS M EDICINE VOL. 6 NO. 3 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. ) CMUCKET CRICKET INJURIES - A REVIEW Richard Stretch R eview s o f sporting injuries h av e tended to co n cen trate on con tact sports, w ith reports and research on cric k et injuries receiving little attention, mainly being conducted as p a rt o f oth er analysis and being p u b ­ lished in m edical jo u rn als. This has resulted in the m ajority o f cricket ad m in istrato rs, coaches and players n ot bein g aw are o f the nature, incidence, cause and risk factors associated with p laying a gam e that is d em an d ­ ing m o re physical o u tput than p rev io u sly . It w as fo r this reason that a review o f crick et injuries was conducted. T h e B ritish S ports C ouncil estim ated the risk o f injuries to club crick et players to be 2 ,6 p e r 10 000 man hours p la y e d .12 T h ese figures excluded inju­ ries thought to b e triv ial, as w ell as m any ch ro n ic o v eru se injuries. T h e rate o f injury to first class crick eters in A u stra­ lia w as estim ated to b e 1 p e r 30 m an-hours p la y e d .3 South A f­ rican p rovincial and in tern a­ tional crick eters (7 1 ,6 % ) w ere found to b e at a g reater risk o f Richard A Stretch MA D epartm ent o f Human M ovement Studies University o f Fort Hare Private Bag X I 314 Ciskei injury than club cricketers (2 8 ,4 % ) .4 D eaths from crick et date b ack , according to crick et lo re, to the passing o f F red erick L ouis, the P rin ce o f W ales and father o f G eorge III, w ho died hours afte r being struck on the head by a crick et b a ll.2 B lonstein5 suggests that six d eaths p e r y ear o ccu rred in the U nited K ingdom as a result o f playing cricket. However, these figures should b e considered w ith reserv atio n .3 T h e m ajor portion o f serious injuries w ere sustained during m atches (6 9 ,3 % ), with 2 6 ,1 % occurring during practices and 4 ,6 % during both m atches and p ractices.4 T he injuries o ccu r­ red fairly regularly th roughout the season, with a slight in ­ crease durin g the early and latter p a rt o f the season,4 o v e r­ use injuries m ore com m on to ­ w ards the end o f the seaso n .6 T h e incident o f injury to the head, neck and face varied from 9 % in club and provincial p la y e rs,4 20% in provincial players7 and 25 % in club c ric k ­ e te rs.2 C oncussions, co n tu ­ sions, lacerations and nose bleeds w ere the m ost com m on. E ye injuries in crick et w ere reported as long ago as the beginning o f the c e n tu ry ,8 with later cases o f ch ro n ic glaucom a secondary to traum a9 and o cu ­ lar concussion,10 reported. F ive cases o f severe eye injuries, including retina detachm ent and ru p tu re o f the globe, w ere d ocum ented in batsm an and close fie ld e rs .11 This accounted fo r 9 ,0 % o f sport related ey e injuries. A survey o ver 18 m onths carried o u t at the Sussex E y e H osp ital revealed five m inor ey e injuries caused by playing c rick et w hich ac­ counted fo r 5 ,4 % o f all sport­ ing ey e in ju ries re c o rd e d .12 C o ro n eo 13 recom m ended that o cu lar p ro tectiv e devices be w orn when playing indoor crick et after rep o rtin g four cases o f o cu lar inj uries in crick­ eters. T he u pper lim b accounted fo r 25% o f injuries in club cric k e te rs,2 32% in provincial crick eters7 and 34% in pro v in ­ cial and club cric k e te rs.4 T he fingers w ere found to b e the m ost v u ln erab le site fo r inju­ ries. 1-2-4-6'14-15 T h ese injuries consisted prim arily o f fractures, dislocations and contusions w hile batting and fielding. "T h ro w ers shoulder" w hich is caused by degene- ration and inflam m atory changes o r p a r­ tial and co m p lete ru p tu res o f the ro tato r c u f f w as also found to b e a co m m o n crick et in­ j u r y , 16 w hile C lay S h o v eller's fractu re w as recorded as a re ­ sult o f playing c ric k e t.17 B ack and tru n k in ju ries ac­ counted for approxim ately 18% o f the serious and 14% o f the less serious in ju rie s.4,7 T h e c ase o f a splenic ru p tu re as a result o f being struck by a crick et ball w as re p o rte d .18 Y oung fast bo w lers w ere found to b e v ul­ ----------------------------------------------- 9 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) CRICKET nerable to low er back injuries,19 w hile the case o f a young fast b ow ler w ho developed acu te p n eum om ediastinum and b ilat­ eral pneu m o th o races w hile p ractisin g fast bow ling w as re ­ p o rte d .20 M any injuries o ccu r in the lo w er lim bs d u e to im pact from the ball, stress injuries asso ­ ciated w ith rep etitiv e m ove­ m ents and o th e r injuries n o r­ m ally associated w ith field sports. T h e findings varied from 2 5 % ,2 30 % 7 and 3 8 % .4 T h e unusual case o f tw o b ro th ­ ers sustaining serious injuries in the sam e pre-m atch fielding practice session was d o cu ­ m en ted .21 T h e first sustained a m edial m eniscus injury which had to b e excised arth ro - scopically and th e o th er a transverse fractu re o f the m iddle third o f th e fem ur. Bow ling has been found to be the m ajor cau se o f injuries, varying from 38% in young schoolboy p la y e rs ,19 4 2 ,0 % in club and pro v in cial cricketers4 to 65 ,7 % in p rovincial cric k ­ e te rs.7 T h ese w ere found to be p re d o m in a n tly lo w e r b ac k in ju ries,4,7,19,22 m uscle tears, especially o f the hip flex o r, the ad d u cto r longus o f the leg and the rectus fem oris m u s c le s ,6,16 and o v er-u se in ju rie s.4'719,22 S erious in ju ries, m ainly to the low er b ack o f a nu m b er o f elite and ju n io r fast bo w lers, w ere caused by a com bination o f the forces a t fro n t foot im pact and a front-on bow ling a c tio n .19 Spondylolysis w as found to be com m on in A ustralian fast b ow lers p laying first class c ric k e t.6 This in ju ry is d u e to a stress fractu re that occurs to the p arts interarticulans on the side oppo site the bow ling arm as a resu lt o f the rotation and extension o f th e back when b ow ling fast. S tress fractures a re com m on in fast bow lers and-occur prim arily in the meta­ tarsal bones, the fibula and tib ia .6 O ther com m on over-use in ju r ie s in c lu d e a b d o m e n m uscle te ars,6 shoulder inju­ r i e s , 7 ta lo tib ia l ex o sto ses, p atella r tendonitis6 and bruised heels and "shin sp lin ts".4,6,7 Batting accounted for 17,1 % o f the injuries4 with m uscle pulls and im pact injuries being the m ost co m m o n .4,7 T h e m a­ jo rity o f head injuries w ere as a result o f being struck by the ball w hile attem pting to hook, by the ball deflecting o ff the top-edge o f the b at on to the head w hile playing a horizontal-bat stroke, o r as a resu lt o f being struck by the ball rearing o f f the p itc h .7 T h ese injuries w ere sustained w hile the batsm en w ere b at­ ting w ithout a helm et o r w ith a helm et w ith ear-pieces only, respectively and included co n ­ cussions, broken nose and cheek bones and lacerations, req u ir­ ing stitches around the eyes, mouth and chin. Four o f the ey e injuries reported by Jones and T u llo 11 w ere as a result o f the ball deflecting o f f the top ed g e o f the bat w hile hooking and striking the eye on the side o f the dom inant hand. T he d an g er o f a fracture, as a result o f being struck by the ball w hile batting, to the distal third o f the u ln ar, rib fractures and soft tissue in ju ries, especially to the u p p er leg, abdom en and tes­ ticles w ere rep o rte d .6 T h e top- and m iddle-order batsmen w ere found to b e m ore susceptible to im p act injuries to the head, p h ­ alanges, m etacarpals and low er arm injuries than the low er- o rd e r b atsm en ,7 w hile P ay n e3 rep o rts that bo w lers sustained m ost im p act injuries w hile b at­ ting. L o w er lim b injuries w ere m ainly ham string, quadriceps and c a lf m uscle pulls as a result o f running between the w icket.1- 4 ,7 F ield in g and catching re­ sulted in 4 0 ,9 % o f the serious in ju ries w ith 63 ,9 % im pact in ­ ju rie s to the u pper lim b s.4 C o rrig an 6 reported three cases o f rup tu red spleens sustained w hen, attem pting to catch o r field a ball, they landed heavily on th eir left side. "T hrow ers shoulder" can p ro v e to be one o f the m ost troublesom e injury to cric k e te rs.6,22 F iv e, o u t o f n ine shoulder injuries sustained o ccu rred w hile field in g .7 T w en ty -fiv e p ercen t o f the serious injuries resulted in the p lay ers being o u t o f the g am e for m o re than tw enty-one days, w hile 4 7 ,8 % and 2 7 ,2 % w ere n ot ab le to p ractice o r play for betw een o n e and seven days and eig h t and tw enty-one d ay s, resp ectiv ely .4 In ju ries to the u pper and lo w er lim bs w ere the m ost serious in term s o f days m issed with n in e in ju ries to each region prev en tin g the players from playing for twenty- o n e day s o r m o re.4 T h e upper lim b injuries to the club cric k ­ eters resulted in an av erag e o f fiv e days being lost to play, w ith a ran g e o f betw een 0 to fifty-six d ay s, w hile an average o f six days w ere lost to p lay as a resu lt o f in ju ries to the low er lim b s .1 T h e head and facial injuries1,4 and the back and trunk injuries4 gen erally enabled the crick eters to retu rn to the gam e w ithin seven to n ine days o f injury. T h e length o f recovery tim e v aried w ith the level at w hich the p lay ers com peted. M any o f the in ju ries sus­ 10 ---------------------------------- SPORTS MEDICINE VOL. 6 NO. 3 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. ) CRICKET tained w ere eith er re-occurring in ju ries from the p rev io u s sea­ son o r re-o ccu rred again later in the season. T w enty p ercent o f the in ju ries sustained on an international to u r w ere re- a g g r a v a te d in ju r ie s fro m the prev io u s seaso n ,23 w hile 2 3 ,9 % o f the injuries to b e re ­ o ccu rren ce o f old in ju ries and 22 ,7 % o f th e new in ju ries sus­ tain ed w e re re -a g g ra v a te d again durin g that season.4 P ayne3 reported an increase in o v er-u se in ju ries in young ch ild ren , especially in the areas o f stress fractures and grow th cartilag e injuries. T h e p rim ary areas o f concern, p articularly to the fast bow lers, w ere found to be dam age to the grow th cartilag e o f the knee and trac­ tion apophysis, and co m p res­ sive stress to the articu lar surface cartilag e o f the fem ur and talus. T h irty -eig h t percen t o f young fast b o w lers w ere found to have suffered o n e d is­ abling injury durin g a single season, w ith stress fractures o f the lu m b ar an d /o r sacral v e r­ tebrae (11% ), and soft tissue injuries to the back (27 %) cau s­ ing them to m iss at least one m a tc h .19 D u T oit and R ade- m an18 reported the case o f a 1 4 -y ear-o ld b o y re q u irin g splenectom y fo r a ruptured spleen after b lunt trau m a from a crick et ball. T he case o f a y o u n g f a s t b o w le r w h o developed acu te p n eu m o m e­ diastinum and bilateral pneu- m othoraces w hile p ractising fast b ow ling w as reported by C lem ents and H a m ilto n .20 T he y o u n g er p lay ers tended to b e at the greatest risk to injury with 53 ,3 % and 5 1 ,4 % o f th o se in the age gro u p s below 21,1 years and betw een 21,1 and 2 6 ,2 years, respectively, sus­ taining som e form o f serious in ju ry .4 T h e less serious injuries were mainly strains o f the groin, hip, ham string, quadriceps and back m uscles, finger injuries, tw isted ankles, shin splints, blisters, abrasions and bruised feet, heels and fingers. F o rw a rd 24 recorded all the ind o o r cricket injuries that w ere reported at the R oyal P erth H ospital d u ring a six- m onth perio d . H e found that o f the sixty-four patients treated all fell in the 19 - 34 y ear age gro u p , w ith fourteen o f these being w om en. F ield in g (72% ) and batting (17% ) resulted in the m ajor share o f these in ­ ju rie s , w hile no injuries w ere sustained w hile b ow ling. T h e m ost com m on injuries w ere to the fingers and thum b. K nee and ligam entous strains o f the ankle w h ile tw isting to catch o r avoid the ball, as w ell as ey e in ­ ju rie s to w icket-keepers as a result o f being struck by the ball after deflecting o f f the edge o f the bat, w ere fairly co m ­ mon. F ifty p ercen t o f the in ­ ju re d players required tim e o f f w ork, w ith thirty p ercent being o f f w o rk fo r m o re than a w eek and ten percen t being hospital­ ised. F ro m the literatu re re ­ view ed it is evident that the incidence o f crick et injuries, p articu lar o v er-u se injuries and those norm ally associated w ith field sports, is an under- recognised p roblem . A ppro­ p riate injury records and d ata collection need to be introduced. This w ould enable coaches, players and those involved in treatm ent and rehabilitation, to successfully bring about the reduction, p revention, trea t­ m ent and rehabilitation o f these injuries. RE F E R E N C E S 1. Weightman D and Browne RC. In­ juries in eleven selected sports. British Journal o f Sports Medicine, 1971; 2: 27. 2. Temple R. Cricket Injuries: Fast pitches change the gentleman's sport. The Physician and Sports medicine, 1982; 10(6): 186-192. 3. Payne W R , H oy G , Laussen SP and Carlson JS. What research tells the cricket coach. Sports Coach, 1987; 10(4): 17-22. 4. Stretch RA. Somatotype and body composition changes in first-class cricketers. Paper presented at "Inter­ national Congress on Youth, Lei­ sure and Physical Activity and Ki- nanthropometry IV", Brussels, Bel­ gium, 21-25 May 1990. 5. Blonstein JL. Medical aspects o f am ateur boxing. Proc R Soc Med, 1966; 59: 6499. 6. Corrigan AB. Cricket Injuries. Aus­ tralian Family Physician, 1984; 13(8): 558-562. 7. Stretch RA. Injuries to South Afri­ can cricketers playing at first-class level. Sports Medicine, 1989; 4(1): 3-20. 8. OgilvieFM . On one o f the results of concussion injuries o f the eye ("holes" at the macula). Trans Opthalmol Soc UK, 1900; 20: 202-229. 9. D 'O m brain A. Traumatic monocu­ lar chronic glaucoma. Trans Optha- m ol Soc, Australia, 1945; 5: 116- 120. 10. Littlewood KR. Blunt ocular trauma and hyphaema. Australian Journal o f Ophthalmology, 1982; 10: 263- 266. 11. Jones NP and Tullo AB. Severe eye injuries in cricket. British Journal o f Sports Medicine, 1986; 20(4): 178- 179. 12. Gregory PTS. Sussex Eye Hospital sports injuries. British Journal o f Ophthalmology, 1986; 70: 748-750. 13. Coroneo MT. An eye for cricket - ocular injuries in indoor cricketers. The M edical Journal o f Australia, 1985; 142: 469-471. 14. Nel D, Smit PJ and Stoker DJ. Die invloed van sportsbeserings op sportdeelname en werk. South Afri­ can M edical Journal, 1979; 53: 426- 428. 15. Williams JGP. Joint Injuries. In: I Cohen, GR Beaten and D Mitchell (Eds). The South African Textbook o f Sports Medicine, University of Witwatersrand, Johannesburg, 1979. Other references on request. ---------------------------------------------- 11 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) S3] Relifen 500 tablets 500 m g n a b u m e t o n e . R e e n o R / 3 . 1/265 W h en y o u r p a tie n t’s in pain, y o u r first responsibility is to take aw ay th a t pain. Q u ick ly . Effectively. B ut doing so could lead to unacceptable gastro­ intestinal side effects and co m b in atio n th erap y . B ut n o w , ten years o f precisely targeted m o lecular research have p ro d u ced a h ighly effective, no n-acidic an ti-in flam m a to ry . Relifen. Each tablet is m ade o f 500 mg n ab u m eto n e, a n o n -stero id a l an ti-in flam m ato p ro v en in n u m e ro u s d o u b le blind studies to b effective as o th e r b en ch m ark N S A ID s. Yet its ro u te o f action is to tally different. Relifen is a n o n-acidic p ro -d ru g . In the sto m ach , it is relatively inactive. It is absorbed fro m the d u o d e n u m , into the p o rtal b lood suf F inally, in the liver, it is m etabolised into a po in h ib ito r o f p ro stag lan d in synthesis. R efer package in sert f o r full p re s c rib in g in fo rm a tio n . F u r th e r in fo rm a tio n is available fro m o u r M edical D e p a r tm e n t. S m ith K lin e B eecham P h arm a ceu ticals P O Box 347 Be 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. ) Relieving his pain is pretty sporting of you, old chap. But do you have to get him high on acid? T h e active m etab o lite p en etrates th e synovial fluid to reach th e inflam ed site, giving effective relief of sy m p to m s. E x cretio n is by the kid n ey s, so g astro ­ intestinal dam age th ro u g h biliary recircu latio n and reflux is unlikely. F o r effective relief from pain and inflam m ation, with less chance of gastro -in testin al d isco m fo rt, y o u now have an ideal choice. Relifen. R clilen a n d th e SB lo g o a rc tra d e m a rk s . 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. ) NUTKTFUQN THE EFFECT OF DIETARY CHOLESTEROL ON PLASMA CHOLESTEROL LEVELS M ieke Faber Eggs, and th erefo re d ietary ch olesterol, play an im portant ro le in the diets o f m any a th ­ letes. E specially w eight train ­ ing athletes are p ro n e to sup­ p lem ent th eir diets w ith eggs in o rd e r to in crease the protein con ten t o f the diet. Since as early as the 1 9 4 0 's the co n tro v ersy on cholesterol intake exists. In the 1 9 4 0 's experim ents w ere d o n e w hich show ed that cholesterol feed­ in g re s u lte d in in c re ased p la sm a c h o le ste ro l le v e ls .29 H o w ev er, a few years later K eys et al (1956) cam e to the conclusion that in adult men the serum cholesterol level is es­ sentially independent o f the cholesterol intake o v er the w hole ran g e o f natural hum an d ie ts.22 T his w as confirm ed by studies that indicated that there w as no co rrelatio n b e­ tw een d ietary cholesterol and plasm a cholesterol le v els.25,40 A lthough no co rrelatio n w as found betw een w h o le egg in­ take and plasm a lipid levels in free living su b jects,19 contro- Mieke Faber Research Institute f o r Nutritional Diseases M edical Research Council versial results h av e been re ­ p orted on the effect o f egg feeding. W h ile no changes in plasm a cholesterol levels w ere observed after the addition o f e g g s to th e h a b i tu a l d ie t17,23,33,36,38 o r an exp erim en ­ tal d ie t15 o f norm al o r uraem ic p atien ts,20 o th er studies re ­ p o rted an in crease in plasm a cholesterol levels after egg fe e d in g o n th e h a b itu a l d ie ts 3-35-39 o r ex p e rim e n ta l diets28 o r on liquid form ula d ie ts .1 T h e increase in plasm a cholesterol levels w as g reater in m iddle aged m en as co m ­ p ared to y ounger m e n .39 V olunteers w ere g rouped in tw o groups. T h e one group show ed significant increases in plasm a cholesterol levels a fte r eating th ree eggs daily for ten w eeks and a significant decrease w ithin tw o w eeks o f cross o v er to eating no eggs. T h e o th er g ro u p show ed a sig­ nificant d ecrease in plasm a cholesterol levels after eating no eggs for 12 w eeks, b ut w hen crossing o v er to three eggs daily, there w as no increase in plasm a cholesterol le v e ls.18 F ifty -six men w ere given a cholesterol free fo rm u la diet. D u rin g this p erio d there w as a d ecrease in plasm a cholesterol levels. A fter the cholesterol free p eriod they w ere divided into fo u r groups w ho received a fo rm u la d iet containing either 0, 106, 212 o r 317 mg ch o l/ 1000 kcal fo r a p erio d o f six w eeks. T h e ingestion o f ch o ­ lestero l resulted in a lin ear in crease in p lasm a cholesterol levels o v er the w h o le ran g e o f cholesterol feeding. Each 100 m g c h o l/1000 kcal o f the diet resu lted in a 12 m g /100 m l in­ crease in serum cholesterol lev els.27 It is expected that fu rth er increases in dietary cholesterol in the ab o v em en ­ tioned study w ould have no fu rth er effect on the plasm a cholesterol levels since it w as show n by C o n n o r et a l10 that the addition o f 475 mg o r 1425 mg cholesterol had the sam e elevating effect on plasm a cholesterol levels. It has also been show n that the plasm a cholesterol levels increased sharply w hen the daily choles­ tero l intake w as betw een 13 mg and 634 m g. T h ere w as no fu rth er in crease in plasm a ch o ­ lesterol levels a fte r the inges­ tion o f 1300 to 4 5 0 0 m g choles­ tero l and th e dose-response cu rv e w as relativ ely fla t.2 A ddition o f tw o eggs had no effect on p lasm a cholesterol levels, b ut w hen the tw o eggs w ere rem oved from the diet th ere w as a significant d ro p in plasm a cholesterol levels afte r 12 w e e k s .16 W hen eggs w ere rem oved from the diets o f 14 ---------------------------------------- SPORTS M EDICINE VOL. 6 NO. 3 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. ) NUTRITION p eo p le w ho h abitually consum e at least o n e egg p e r day, there w as a sm all b u t significant d e­ c rease in p lasm a cholesterol le v els.4’7 EFFECT OF DIETARY CHOLESTEROL ON PLASMA LIPOPROTEINS P lasm a cholesterol is not the only v ariab le to b e looked at. A lthough th ere w as no signifi­ c a n t c h a n g e in p la s m a cholesterol levels w hen one egg w as added to the habitual d iet o f lacto-ovo-vegetarians, th ere w as a significant increase in p lasm a L D L -ch o lestero l.36 W h ile ingesting a liquid fo r­ m ula d iet containing 5000 mg cholesterol in the form o f egg y o lk 1 o r w hen adding choles­ terol to the norm al d iet3 there w as a significant in crease in p la sm a c h o le ste ro l le v els, m ainly d u e to an increase in L D L -ch o lestero l levels. T he rise in L D L -ch o lestero l levels m ay be explained by an in­ crease in L D L -ch o lestero l fo r­ m a tio n .30 T h e consum ption o f a larg e n u m b er o f eggs, w h eth er o r not it leads to an in crease in plasm a cholesterol levels, does alter the p ro p erties in hum an H D L , nam ely it in ­ creases the binding cap a c ity .26 TYPE OF FAT IN THE DIET It has been show n that the e f­ fect o f d ietary cholesterol is dependent on the type o f fat in the diet. In tw o cross o v er studies, healthy students re­ ceived a d iet eith er rich in linoleic acid5 o r p o o r in linoleic a cid 6 w ith tw o levels o f d ietary cholesterol (eith er 200 mg o r 600 m g). T h e high cholesterol diet w as obtained by providing 2 egg yolks p e r day. S upple­ m entation o f the linoleic acid rich d iet w ith th e egg yolk cholesterol caused a signifi­ cant rise in plasm a cholesterol levels o f about 11 m g /100 ml. This rise in plasm a cholesterol w as ho w ev er m uch sm aller than the rise o f 26 m g /100 ml w hich o ccurred w hen the lino­ leic acid p o o r diet w as supple­ m ented w ith the egg y olk cholesterol, indicating th at the effect o f cholesterol is clearly dependent on the type o f fat in the d ie t.5,6 W hen cholesterol w as added to eith er a diet w ith a low o r a high P /S ra tio n , th ere w as an increase in plasm a T C . T h e increase in plasm a ch o les­ terol w as slightly less on the low P /S d iet as com pared to that on the high P /S diet, b u t it should be kept in m ind that the o v e ra ll p la sm a c h o le ste ro l levels (w ith o r w ithout ch o les­ terol) w ere h ig h er on the d iet w ith the low P /S ratio .41 In an o th er cross o v er study, the effect o f changes in dietary cholesterol in tak e as w ell as changes in the type and am o u n t o f fat w as studied. W hen the subjects sw itched from a co n ­ trol d iet (42-45% fat, P /S 0 ,3 -0 ,5 , 2 eggs) to a fat m o d i­ fied d iet (35% fat, P /S 1,0) also containing tw o eggs, the serum cholesterol decreased w ith 29 m g /100 ml. W hen the eggs w ere om itted from th e fat m odified d iet the serum ch o ­ lesterol decreased w ith an additional 7 m g /100 ml. W hen the control d iet w as follow ed up by the m odified fat d iet co n ­ taining no eggs, the d ecrease in serum cholesterol levels w as 41 m g /100 m l. W hen eggs w ere returned to the fat m odified d iet, th e serum cholesterol levels increased by 2 0 m g/100 m l. T h e results o f this ex peri­ m ent suggest that sm aller p ercen tag e changes in the type and am o u n t o f d ietary fat have a sim ilar o r g reater effect on serum cholesterol than a re la­ tively g reater change in dietary ch o lestero l.8 T h is is in contrast w ith earlier studies. In one o f these studies it w as shown that the effect o f changes in d ietary fat com position w as sm aller than th e effect caused by changes in d ietary choles­ te ro l.12 P lasm a cholesterol level increased w hen subjects con-sum ed a cholesterol rich fo rm u la diet. W hen th e satu­ rated fat co n ten t o f this d iet w as decreased, there w as no ch an g e in the p lasm a choles­ tero l levels d u e to cholesterol feeding.11 Although no changes in H D L -C w ere found in the study d o n e by C h en o w eth ,8 it w as found that the increase in plasm a cholesterol w hich o c­ cu rred a fte r a sim ultaneous increase in d ietary cholesterol and fat, w hile the P /S ratio o f th e d iet rem ained the sam e, w as du e to an in crease in LD L- C as w ell as H D L -C .9 E ith er 750 mg (3 eggs) o r 1500 mg cholesterol (6 eggs) w as added to diets w ith a P /S ratio th at ranged betw een 0 ,2 5 and 2 ,5 . W hen the P /S ratio w as eith er 0 ,2 5 o r 0 ,4 , addition o f 3 eggs to th e d iet caused increases in b o th p lasm a cho­ lestero l and L D L -C levels. T h e se in c re a se s w ere in ­ creased fu rth er w hen 6 eggs w ere added to the diet. W hen the P /S ratio o f the d iet w as 0 ,8 , addition o f 3 eggs to the d iet had no effect on plasm a cholesterol o r L D L -C levels, b u t these levels increased after addition o f 6 eggs to the _______________________________ 15 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) NUTRITION diet. A ddition o f eith er 3 eggs o r 6 eggs had no effect on the p lasm a cholesterol and L D L -C levels w hen the P /S ratio o f the d iet w as 2 ,5 . T his study indicated that both th e choles­ terol con ten t and the P /S ratio o f the d iet are im p o rtan t in de­ term ining p lasm a cholesterol and L D L -C lev els.37 F a t p lays and im p o rtan t ro le in determ ining the effect o f dietary cholesterol on plasm a cholesterol levels and has been dem onstrated by the fact that subjects w ho have previously b een cla ssifie d as h y p e r­ responders show ed no re ­ sponse to a m oderate choles­ terol intake w hile they co n ­ sum ed a low fat, high fib re diet w ith a relatively high P /S ratio (1 ,1 :1 ,5 ). T h e effect o f eating nine, zero and nine eggs p e r w eek o v er a p erio d o f three c o n s e c u t iv e m o n th s w a s studied in subjects w ho had previously been classified as hy per-responders to choles­ terol intake. D u rin g the study they consum ed a high fibre, low fat diet w ith a relatively high P /S ratio. T h ere w ere no s ig n ific a n t d iffe re n c e s b e ­ tw een the d ifferen t dietary periods indicating that h y p er­ response to m o d erate choles­ terol in tak e is no t app aren t in peo p le eating a low fat, high fib re d ie t.13 ENERGY AND CHOLESTEROL FEEDING It seem s as i f n o t only the type and am o u n t o f fat in the diet have an effect on the plasm a cholesterol response on c h o ­ lesterol feeding, b u t energy intake also seem s to b e im p o r­ tant. T h e influence o f a low - energy d iet w hen associated w ith a high cholesterol intake w as investigated in a cross o v e r study. W hen tw o w hole eggs and tw o egg yolks w ere added to the habitual d iet o f seventeen norm al men during the first phase o f the study, no changes in p lasm a cholesterol o ccurred. W hen these sam e men w ere p u t on a low -energy d iet during the second p h ase o f the study there w as only a sm all b u t insignificant de­ crease in p lasm a cholesterol levels due to adaptation to a high cholesterol intake. H o w ­ ever, w hen the consum ption o f fo u r eggs p e r day w as associated w ith a low energy intake during p hase 1, there w as an increase in plasm a cholesterol levels w hich n or­ m alized in the second p a rt o f the study w hen they returned to th e ir habitual energy in ­ ta k e .24 EXERCISE AND CHOLESTEROL FEEDING It seem s as if ex ercise also in­ fluences the effect o f choles­ terol feeding on plasm a ch o ­ lesterol levels. It has been shown that aerobic co ndition­ ing in men m ight p rev en t a significant increase in plasm a T C levels at m oderate and high cholesterol in tak es.34 Body b u ild ers are a g roup o f w eight training athletes w ho supple­ m ent th eir diets w ith eggs. O ver a range o f from 0 to 12 eggs p e r day, th ere w as no correlation betw een egg intake and plasm a cholesterol levels. D espite th eir v ery high choles­ terol intake they did not have elevated plasm a cholesterol le v e ls.14 HYPO- AND HYPER­ RESPONDERS T h ere w as a co nsiderable in d i­ vidual variation in the response o f plasm a cholesterol levels to changes in dietary choles- terol.8’15'18’23,31’41 From this wide v ariation it is clear that people can b e categorized into h y p er­ r e s p o n d e r s a n d h y p o -re - sponders. W hat the classifi­ cation o f a hyper- and a hypo- resp o n d er is, is n ot q uite clear. In the study done by O h and M ill e r 31 h y p e r - r e s p o n d e r s w ere defined as those subjects w h o se p la sm a ch o le ste ro l levels increased by m o re than 8% on cholesterol feeding, w h ile hyp o -resp o n d ers w ere defined as th o se subjects w ho show ed no change o r an in ­ crease o f less than 5 % in plasm a cholesterol levels on choles­ terol feeding. H y p er-resp o n d ­ ers can also be classified as those subjects w hose plasm a cholesterol levels a re in the u p p er q u artile on cholesterol feeding w h ile hypo-respon­ ders are those w hose plasm a T C levels fall in the low er q u artile on cholesterol feed­ in g .21 A lthough it seem s as if ex ercise has a p ro tectiv e effect against egg fee d in g ,14,34 too little ev idence is available to ju stify the high egg consum p­ tion o f athletes. It is reco m ­ m ended that athletes follow the sam e recom m endations as the g eneral po p u latio n . It is th erefo re recom m ended that the daily cholesterol intake should not exceed 300 mg p e r d a y .32 R E FE R E N C E S 1. Applebaum-Bowden A, Hazzard WR, Cain J, Cheung M C, Kushwaha RA, 16 ______________________ SPORTS M EDICINE VOL. 6 NO. 3 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. ) M J T M T E O N Albers JJ. Short term egg yolk feeding in humans. Atherosclerosis, 1979; 33: 385-396. 2. Beverdige JMR, Connell WF, Mayer GA, Haust HL. The response o f man to dietary cholesterol. J Nutro, 1969; 60: 61-65. 3. Beyen AC, Katan MB. E ffectofegg yolk feeding on the concentration and composition o f serum lipopro­ teins in man. Atherosclerosis, 1985; 54: 157-166. 4. Beyen AC, Katan MB. Reproduci­ bility of the variations between humans in the response o f serum cholesterol to cessation o f egg consumption. Atherosclerosis, 1985; 57: 19-31. 5. Bronsgeest-Schoute DC, Hautvast JGAJ, Hermus RJJ. Dependence o f the effects o f dietary cholesterol and experimental conditions on serum lipids in man. I: Effects o f dietary cholesterol in a linoleic acid-rich diet. Am J Clin Nutr, 1979; 32: 2183-2187. 6. Bronsgeest-Schoute DC, Hermus RJJ, Dalinga-Thie GM, Hautvast JGAG. Dependence o f the effects o f dietary cholesterol and experimental condi­ tions on serum lipids in man. II: Effects o f dietary cholesterol in a li­ noleic acid-poor diet. Am J Clin Nutr, 1979; 32: 2188-2192. 7. Bronsgeest-Schoute DC, Hermus RJJ, Dallinga-Thie GM, Hautvast JGAJ. Dependence o f the effects o f dietary - cholesterol and experimental condi­ tions on serum lipids in man. Ill: The effect o f serum cholesterol o f re­ moval o f eggs from the diet o f free living habitually egg-eating people. Am J Clin Nutr, 1979; 32: 2193- 2197. 8. Chenoweth W, Ullmann M, Simpson R, Leveille G. Influence o f dietary cholesterol and fat on serum lipids in men. JN u tr, 1982;111:2069-2080. 9. Cole TG, Patsch W, Kuisk I, Gonen B, Schonfeld G. Increases in dietary cholesterol and fat raise levels o f apoprotein E-containing lipoproteins in the plasma o f man. J Clin Endo- crinalM etab, 1983; 56: 1108-1115. 10. Connor WE, Hodges RE, Bleiler RE. The serum lipids in men receiv­ ing high cholesterol and cholesterol free diets. J Clin Invest, 1961; 40: 894-901. 11. Connor WE, Hodges RE, Bleiler RE. Effect o f dietary cholesterol upon serum lipids in man. J L a b Clin M ed, 1961; 57: 331-342. 12. Connor WE, Stone DB, Hodges RE. The interrelated effects o f dietary cholesterol and fat upon human se­ rum lipid levels. J Clin Invest, 1964; 43: 1691-1696. 13. Eddington JD, Geekie M, Carter R, Benfield L, Ball M, Mann J. Serum lipid response to dietary cholesterol in subjects fed a low-fat, high fibre diet. Am J Clin Nutr, 1989; 50: 58- 62. 14. Faber M, Benade AJS, van Eck M. Dietary intake, anthropometric meas­ urements and blood lipid values in weight training athletes (body build­ ers). Int J Sports Med, 1986; 7: 342- 346. 15. Flaim E, Ferreri LF, Thye FW, Hill JE, Ritchey SJ. Plasma lipid and lipoprotein cholesterol concentrations in adult males consuming normal and high cholesterol diets under controlled conditions. Am J Clin Nutr, 1981; 34: 1103-1108. 16. Flynn MA, Anderson A, Rutledge M, Nolph GH, Krause G, Ellersieck MR. Eggs, serum lipids, emotional stress and blood pressure in medical students. Arch Environmental Health, 1984; 39: 90-95. 17. Flynn MA, Nolph GB, Flynn TC, Kahrs R, Krause G. Effect o f dietary egg on human serum cholesterol and triglycerides. Am J Clin Nutr, 1979; 32: 1051-1057. 18. Flynn MA, Nolph GB, Osio Y, Sun GY, Lanning B, Krause G, Dally JC. Serum lipids and eggs. J Am Diet Assoc, 1986; 86: 1541-1548. 19. Green MS, Jucha E. Association o f serum lipids with coffee, tea, and egg consumption in free-living sub­ jects. J Epidemiol Comm Health, 1986; 40: 324-329. 20. Green EM, Perez GO, Hsia SL, C rary M . Effect o f egg supplement on serum lipids in uraemic patients. J Am Diet Assoc, 1985; 85: 355-357. 21. Katan MB, Beyen AC, de Vries JHM, Nobels A. Existence o f con­ sistent hypo- and hyper-responders to dietary cholesterol in man. Am J Epidemiol, 1986; 123: 221-234. 22. Keys A, Anderson JT, M ickelsenO, Adelson SF, Fidanza F. Diet and serum cholesterol in man: Lack of effect o f dietary cholesterol. J Nutr, 1956; 59: 39-56. 23. Kummerow FA, Kim Y, Hull, Pol­ lard J, Hinov P, Dorossiev DL, Valek J. The influence o f egg consumption on the serum cholesterol level in human subjects. Am J Clin Nutr, 1977; 30: 664-673. 24. Lacombe CR, Corraze GR, Nibbe- link MM, Boulze D, Douste-Blazy P, Camare R. Effects o f low-energy diet associated with egg supplemen­ tation on plasma cholesterol and lipo­ protein levels in normal subjects: results o f a cross over study. Br J Nutr, 1986; 56: 561-575. 25. Liebman M, Bazzarre T. Plasma lipids o f vegetarian and non-vegetar­ ian males: effect of egg consump­ tion. Am J Clin Nutr, 1983; 38: 612- 619. 26. Mahley RW, Innerarity TL, Bersot T P, Lipson A, Margolis S. Altera­ tions in human high density lipopro­ teins, with or without increased plasma cholesterol induced by diets high in eholesterol. Lancet, 1978; 11: 807- 809. 27. Mattson FH, Erckson BA, Kigman A M . Effect o f dietary cholesterol in man. Am J Clin Nutr, 1972; 25:589- 594. 28. M cM urryM P, Connor W E, Lin DS, C erqueiraM T , Connor SL. The ab­ sorption o f cholesterol and the sterol balance in the Tarahumara Indians o f Mexico fed cholesterol-free and high cholesterol diets. Am J Clin Nutr, 1985; 41: 1280-1208. 29. M essinger WJ, Porowska Y, Steele JM. Effect o f feeding egg yolk on serum cholesterol levels. Arc Int Med, 1950; 86: 189-195. 30. Nestel PJ, Billington T. Increased transport o f intermediate density lipoprotein (IDL) with cholesterol loading. Metabolism, 1983;32:320- 322. 31. Oh SY, Miller LT. Effect o f dietary egg on variability o f plasma choles­ terol levels and lipoprotein choles­ terol. Am J Clin Nutr, 1985; 42: 421-431. 32. O p't H of L. Consensus symposium: Dietary recommendations for the prevention o f coronary heart dis­ ease. S A fr M ed J, 1988; 74: 475- 476. 33. Porter MW, Yamanaka W, Carlson SD .FlynnM A . Effect o f dietary egg on serum cholesterol and triglyc­ eride o f human males. Am J Clin Nutr, 1977; 30: 490-495. 34. Quig DW, Thye FW, Richey SJ, Herbert WG, Clevidence BA, Rey­ nolds LK, Smith MC. Effects o f short term aerobic conditioning and high cholesterol feeding on plasma total and lipoprotein levels in seden­ tary young men. Am J Clin Nutr, 1983; 38: 825-834. 35. Roberts SL, McMurry MP, Connor WE. Does egg feeding(i.e. choles­ terol) affect plasma cholesterol lev­ els in humans? The results o f a double-blind study. Am J Clin Nutr, 1981;34:2092-2099. 36. Sacks FM, Salazar J, Miller L, Fos­ ter JM , Sutherland M , Samonds KW, Albers JJ, Kass EH. Ingestion of egg raises plasma low density lipo­ proteins in free-living subjects. Lan­ cet, 1984; 1: 647-649. □ ---------------------------------------------- 17 SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) SASMA UPDATE SASMA NEWS T he 4th South A frican Sports M edicine C ongress heralded a new era for sport in South A frica. All indications are that South A frica will be allow ed to p articipate at international level again after years o f isola­ tion. T his places a big respon­ sibility on sportsm en and coaches and also dem ands p ro p er m edical care fo r o u r athletes to en su re that their preparation and participation are scientifically sound and that adequate care is being taken to prevent, treat and re h a b ilita te sp o rt in ju ries. M edical Schools in South A frica have lagged behind the rest o f the com peting w orld in providing adequate p o st­ g r a d u a te s p o r ts m e d ic in e training to doctors taking care o f athletes. D uring the past four years, the S outh A frican S p o rts M edicine A ssociation played a significant role in education and dissem ination o f know ­ ledge through the four S port M edicine C ongresses held in South A frica durin g the past eight years. N ot only did we create a forum w here young South A frican S ports M edicine Scientists could present their research, but w e also invited leading S ports M edicine P h y ­ sicians from all co m e rs o f the w orld to address us on various im portant aspects o f Sport and M edicine. T he m ost recent S ports M edicine congress in Sun City from 24-27 A pril 1991 w as no exception: w e invited five in­ ternational speakers to address us on various topics. T h e Sec­ retary G eneral o f the In tern a­ tional F ederation o f Sports M edicine (FIM S F ederation Internationale M edico S p o r­ tive) attended o ur congress and announced that South A frica will be accepted as the 83rd m em ber o f this influential Sports M edicine body. In o rd er to stage in ter­ national sports events in ou r country, we need to have an accredited analytic laboratory for doping control. Since South A frica has been active in this field since 1983 under the g uid­ ance o f one o f the w o rld 's best known doping control labora­ tories at K in g 's C ollege in L on­ don, it will only be a form ality to obtain international accred i­ tation for o u r doping control facilities. W e had the good fortune o f having D r David C ow an o f London as one o f o ur distinguished guests to ev alu ­ ate o ur facilities and to advise us accordingly. D r C ow an is head o f the K in g 's C ollege Doping Control and Information C entre in L ondon and will be instrum ental in advising the IOC Medical Commission about the South A frican situation. W e b e lie v e that S outh A frica will be ab le to accept the challenge o f providing ad e­ quate m edical support to ou r athletes. T he South A frican Sports M edicine A ssociation succeeded in bringing together all the disciplines involved in sports m edicine and prom oting c o o p e r a tio n b e tw e e n th is m ulti-disciplinary team by making everybody concerned aw are o f their unique role. But this is not enough: South A frioa needs m ore Sports M edicine training facilities to fulfil the needs o f o u r top sportsm en that will soon be co m p e tin g at in tern atio n al level. If the association suc­ ceeds in m aking South A frica m ore aw are o f o u r needs in this regard, it will be a m ajor achievem ent! □ 18 -----------------------------------SPORTS M EDICINE VOL. 6 NO. 3 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. ) P IIY SIO T IIK K A PV TREATMENT OF SOFT TISSUE INJURIES: THE FACTS ABOUT FRICTIONS C r a ig A S m ith Keywords: Soft tissue injuries, scarring, deep transverse frictions, physiotherapy. A B S T R A C T T he treatm ent o f soft tissue injuries by deep transverse frictions (D T F ) has been looked upon by various medical p ractitioners with a certain deg ree o f circum spect. A lthough m ost physiotherapists and a few physicians stringently advocate its use, there are still those w ho a re ignorant to its benefits. T his p aper attem pts to bring to attention the expediency o f D T F by providing a short overview o f how the technique achieves its curative effect. IN T R O D U C T IO N T h e history o f m assage dates back to the tim es o f ancient B abylonia, C hina and h isto ri­ cal R om an d a y s .1 G reat use for it w as found as an effective m ethod o f treating system ic illnesses and o th er injuries. N ow adays, m assage as we are fam iliar w ith, is used m ore for relaxation purposes and the re lief o f stress w hich stem s Craig A Smith BSc Physiotherapy BSc (Hons) Sports Science 16 Vredenhof Carstens Road Tam boerskloof CAPE TOWN 8001 mostly from the lifestyles people lead. A lthough m as­ sage in this respect is very effective in creating a relaxed and calm ing, alm ost euphoric feeling, it clearly has no role to play in the treatm ent o f soft tissue injuries. T h ere is, how ever, a certain m assage technique with which physiotherapists and a good m ajority o f th eir patients are fam iliar. It proffers certain relief with most soft tissue injuries, providing the patient is able to b ear the excruciating pain which unfortunately goes hand in hand with it. W elcom e to the facts about frictions; Deep Transverse Frictions! M ost medical practitioners, barring those who are athletes and w hose injuries have b en e­ fited from it in som e w ay, view D T F w ith a certain am ount o f scepticism and doubt. H ow can a m assag e tech n iq u e resolve an injury w hen it seems to be doing m ore dam age than good? How can the patient b enefit from such a treatm ent w hich actually causes m ore pain than the injury itself? How can any sensible medical per­ son ev er have co m e to devise such a method which should not even be regarded safe as a to rtu re technique? T h ere is, how ever, an answ er to this rhetoric and it lies with the com m ents o f those patients w ho have endured the pain, yet w itnessed the results when treated in this m anner: It works so I'll bear it. No pain no gain. D T F w as view ed as early as 1948 as the only w orthw hile m anipulative treatm ent which could ex ert a beneficial effect on soft tissue lesions. D r Jam es C y riax 2 has cham pioned its cause for many years and now ---------------------------------------- 19 SPORTGENEESKUNDE VOL. 6 NO. 3 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. ) PHYSIOTHERAPY it is w idely used by p h y sio th er­ apists and recom m ended by o ther p ractitio n ers in the treat­ m ent o f o rthopaedic and sports related in ju rie s.3-4 THE THEORY OF DTF T h e specificity o f D T F is such that w hen it is p erfo rm ed p ro p ­ erly and w ith sufficient vigor, enough to brin g the p atient to tears and g iv e reason to renam e it cru cifix io n s3, it p en etrates deep to affected structures far below the skin surface, w h ere o th er m odali­ ties w ould only ex ert their effect a t a superficial le v e l.1 It follow s that m assage, in this w ay, m ust be confined to tissues th at respond to it, and that it m ust ex ert its effect at the ex act site o f the lesio n .5 T h e aim o f this technique is tw o fold; p rim arily to b reak dow n adhesions o r fibrous scarring w hich develop durin g the bodies natural healing process follow ing an injury, and secondly, to increase the m obility o f those tissues and in so doin g , im p ro v e th eir func­ tional capacity. D T F is thus in ­ dicated in the treatm en t o f m uscle strains and tears, ten ­ don le sio n s (te n o sy n o v itis and tendonitis) and ligam ent sprains. APPLICATION OF DTF D T F is applied only to the area o f injury w ith firm p ressu re across th e g rain o f the tissues, b e it a sm all concentrated spot o r a longitudinal p a rt o f a m u scle.6 T h e effects w hich p ro m o te a healing response are as follow s: • A traum atic hyperaem ia is p roduced follow ing a couple o f m inutes o f D T F . T h e increase in bloody supply affords a deg ree o f analgesia by the d estru c­ tion o f L ew is P substances w hich are responsible for pain being f e lt.1 O nce the session is over, the patient's pain is dim inished and the structure hurts less when it is required to fu n ctio n .5 • D T F are applied a t 90 degrees to the injured fibres causing a transverse m ovem ent o f each fibre across the other. The action serves to b reak dow n the adhesive connections which bind the tissues together and resto re free m ove­ m e n t.1 • T issu e p erfusion is im ­ p ro v e d .1 • D T F stim ulates the m echa- noreceptor cells. T h ere­ fore, im pulses from the m oving p arts take p rece­ dence o ver the afferen t sensory stim uli, thus re ­ lieving p a in .1 TECHNIQUE OF DTF It is m ost im p o rtan t that the p erso n , p referab ly a p h y sio ­ therapist, w ho is giving D T F is fam iliar w ith the co rrect appli­ cation o f the technique. B efore com m encing, an accurate d ia g ­ nosis o f the injury based on the history, the site o f the lesion and the response o f the sym p­ tom s to specific testing p ro c e ­ d u res m ust b e m ade so that the therapist can d eterm ine w h eth er the injury w ill benefit from the technique. T h e struc­ tu re to be treated in this way m ust b e isolated and positioned in the co rre ct m anner. W h eth er the fin g er o r thum b pads o r the elbow are to b e used, the tw o skin surfaces m ust m ove in unison to p rev en t a friction injury to the skin i.e. a blister. T he fingers o r thum b should be in a sem i-rigid, flexed position and sw eep o v er the stru ctu re w ith the action controlled a t the w rist. P atien t co m fo rt and stru ctu re position m ust be m a in ta in e d th ro u g h o u t th e treatm ent. MUSCULAR INJURIES M uscles co n tract (concentri­ cally) by shortening and b ro ad ­ ening. An injury to a m uscle, b e it a strain o r tear, w ill ev en ­ tually resu lt in a fibrous scar form ing am ong the fibres. This reduces m o vem ent and causes pain w hen the m uscle con­ tracts. T h e effect o f D T F in the acu te stage is thus to m obilise the fibres in a tran sv erse d irec­ tion and p rev en t these ad h e­ sions from d eveloping. In the ch ro n ic m uscle tear, D T F act to b reak dow n these adhesions and im p ro v e the m u scle's co n ­ tracting m obility. P assiv e longitudinal stret­ ching plays an integral ro le in the m anagem ent o f m uscle injuries and is considered to be a vital tool in m aintaining or im proving fib re length and flexibility. H o w ev er, there is no clear p ro v en evidence to ind icate w h eth er stretching should be in co rp o rated a t the earliest stage o f treatm en t o r w h eth er it should only be in tro ­ duced in the latter stages w hen the injury show s signs o f heal­ ing. T h e ratio n ale o f an early in tro d u c tio n p ro p o se s that 20 ------------------------- --------SPORTS M EDICINE VOL. 6 NO. 3 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. ) PHYSIOTHERAPY m uscle fib re length needs to b e im p ro v ed and capitalised on the increased m obility w hich D T F bring about, and that early stretching d irectly after D T F is thought to achieve this result. A som ew hat co ntras-ting opinion exists supporting the argum ent that stretching should begin at the end stage o f treatm ent. A lon­ gitudinal stretch on the m uscle lengthens th e fibres and in so doing causes them to com e into clo ser contact w ith each o th e r . T h is c o n tr ib u te s to w a r d s f u r th e r a d h e s iv e b inding o f the fibres and re ­ duces flexibility. T hus, early stretching w ould seem to d e ­ feat the aim s o f D T F , being to b reak dow n the adhesions and transversely m obilise the fibres. A s an altern ativ e to early stretching, activ e iso­ m etric contractions o f the m uscle in the shortened range are advocated to m aintain transverse m o b lity .2 TENDON INJURIES L ogic w ould have it that any ov eru se friction injury should n o t b e treated by the sam e m ethod that caused it. In ten­ don lesions, this m ight seem the case, yet D T F is know n to achieve q u ick and satisfying results. In tenosynovitis, D T F p erfo rm ed in a too and fro m otion serve to sm ooth the surfaces o ff, and although lo n ­ gitudinal friction is the causa­ tive actio n , the cu rativ e fric­ tions are in the tran sv erse p la n e .2 In tendonitis, D T F act in m uch the sam e w ay as fo r m uscle injuries by breaking dow n the adhesions w ithin the tendon. LIGAMENT INJURIES T he action o f D T F in ligam ent injuries is to breaking up ad h e­ sions e ith er in the ligam ent it­ self o r binding it to the bone and so increase m obility. In the acute phase, only one to tw o m inutes o f m ild D T F is neces­ sa ry , w h e re a s in c h ro n ic sprains, up to fifteen m inutes o f treatm ent can be given. It is im p o rtan t w hen giving D T F to ligam ents that the affected ligam ent is positioned in a stretched position. F ailu re to bring ab o u t com plete healing can cause respraining fo r the lig am en t d u e to red u ce d strength and p ro p rio cep tiv e instability. CONTRA-INDICATIONS TO DTF T he follow ing are conditions w here D T F are not indicated and should n ev er be attem pted: • B acterial inflam m ation; • Calcific deposits in muscles o r tendons; • Inflam m atory arthritides; • Bursitis; • N erv e injuries; • T raum atic arthritis o f the elbow ; • T hrom bosis sim ulating a soft tissue injury. CONCLUSION T h e topic o f D T F w ith respect to how and w hy it w orks is by no m eans an open and shut case. E vidence detailing its effectiveness and success as a m anipulative tech n iq u e (and th erefo re ju stify in g its usage in the treatm ent o f soft tissue injuries) has been explained and is o f co u rse open to discus­ sion. M o reo v er, the testim o­ nies am ong users and receivers o f the technique m ostly agree th at it do es w o rk , and v ery well at that. In o rd e r to satisfy the ev er questioning hum an m ind w ith feasible answ ers as to how and w hy it does w o rk , it is u nder­ standable that fu rth er ex­ p erim en tatio n , p erh ap s with p athological o r m agnetic reso­ nan ce im aging investigations, needs to b e p erfo rm ed in o rd er to b e able to d raw firm scien­ tific conclusions. H ow ever, science, w hich is its custom , has only m anaged to fuel the d eb ate on the efficacy o f D T F and is unable to at tim es p ro ­ v id e the m ost suitable answ ers. T h ere fo re , w e as ex p lo rers o f its d om ain should not let ou r m inds insistence fo r p ro o f cloud the reality that, although hum an reasoning m ight dent the efficacy o f D T F , its often astounding clinical results has its ow n w ay w ith G o d 's m ar­ vellous creation. M an can only stand by and w o n d er (in pain) ju s t how and w hy and for w hat reasons the facts about frictions add up. R E FEREN CES 1. K am enetzH L. History o f Massage. In: Manipulation, Traction and M assage, Ed. Basmajian JV. Wil­ liams and Wilkins, Baltimore, 1985. 2. Cyriax JH. Textbook o f Orthopae­ dic Medicine Vol 2. Bailliere Tindall, London, 1980; 3-36. 3. NoakesTD. Lore o f Running. Oxford University Press, C apeTow n, 1987. 4. Corrigan B and Maitland GD. Prac­ tical Orthopaedic Medicine. Butter- worths, London, 1983; 26. □ SPORTSGENEESKUNDE VOL. 6 NO. 3 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. ) PH Y SIO TH ER A PY U PD A T E THE COMRADES MARATHON AS SEEN THROUGH THE EYES OF A PHYSIOTHERAPIST Joyce Morton F o r the p hysiotherapist, C o m ­ rades M arathon starts many w eeks b efo re the event as v et­ eran runners and novices p o u r into o u r practices with m inor injuries, usually created by incorrect training m ethods. O ne o f o u r m ajor roles during this tim e is to en courage ru n ­ ners to ease back on th eir tra in ­ ing. N ovices especially, seem to think that if they do not run right up to the day b efore the race, they will not be able to run from P ieterm aritzb u rg to D urban. Psychological su p ­ p o rt and counselling about glycogen sto rag e and fluid in ­ take are o f utm ost im portance at this stage. N ine years ago, the Natal Sports Interest G roup o f the South A frican Society o f P hy­ siotherapy volunteered the services o f physiotherapists along the route. Smith and N ephew supplied the strapping and A nti-chafe and the service began. In those early years there w as much opposition from o u r medical colleagues involved with the organisation o f the race, for it was felt that if a ru n n er w as not well enough prepared then he should not run. Also a runner should never stop as he w ould not start ru n ­ ning again. The survival shuffle was the slow est speed he should do. T h e organizing co m m ittee has now accepted that w e p erform a m ajor ser­ v ice on the day o f the race because there will alw ays be ru n n ers undertrained o r o v er­ trained w ho benefit from the service w e offer. T he C om rades C om m ittee consists o f Judy M cK eon, Kay M orely and m yself. O ur v o l­ unteers com e from the 3rd and 4th y ear physiotherapy students o f the U niv ersity o f D urban-W estville and Natal p hysiotherapists. T h ere are 7 "E lastoplast" stations along the route and each station has Sm ith and N ephew staff, a trained nursing sister, reco rd ­ e rs a n d p h y s io th e r a p is ts . Sixty physiotherapy volunteers helped this year. C om rades M arathon day starts in the early hours o f the m orning for som e o f the p h y ­ siotherapists in p rivate practice w ho assist their patients by strapping them before they leave for the race. F o r the rest, the day starts from 5 o 'c lo c k o n ­ w ards depending on how far the station is from hom e. M> rule is to be dressed and ready by 6 o 'c lo c k , to w atch the stan o f the race on TV and then tc head for Inchanga 48 km s frorr D urban. Even at this hour, w ithout a "R efreshm ent" sigr stuck to my w indscreen, I 22 _______________________ SPORTS M EDICINE VOL. 6 NO. 3 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. ) PI IY SI OTI IE RAP Y UPDATE w ould not be allow ed onto the Old M ain Road as the police are already on duty. O ur w orking area has been cornered o f f by P eter H am ­ m ond, the Sm ith and N ephew man. All we have to do is put up banners to alert the runners to the fact that there are phy­ siotherapists ahead o f them . T ables are set up w ith hundreds o f rolls o f elastoplast, A nti­ chafe, cottonw ool, elastozoff, b lister plasters and this year, tubes o f V oltaren donated by C iba-G eigy. Lastly o ur long rail is set up near the road. This rail is about a m eter high. It rem inds me o f the cow boys w ho used to tie their horses on sim ilar rails outside the Old W est Bars. T he runners lean on the rail in o rd er that their legs, backs o r necks m ight be treated w ithout their having to lie dow n. T w o large mats are placed on the ground for runners with blisters, head­ aches, painful feet or ankles as w e cannot treat these ailm ents unless the patient sits o r lies dow n. W e ju s t have tim e to eat a delicious break fast cooked and donated by P eter, when the first runners appear. T o them the Inchanga H ill is no threat and w e clap to co ngratulate them as they run past. H o w ­ ev er, it is not long afterw ards that the first o f the runners stops to ask for help at ou r sta­ tion. W e offer three main ser­ vices; to rub aching m uscles using A nti-chafe; to rub using ice o r to strap using elasto­ plast. T h e ice is by far the most p o p u lar treatm ent. H undreds o f p o lystyrene cups are filled w ith w ater and frozen. This m eans that the physiotherapist does not get a frozen hand as she rubs the ice onto a runner. I am sure that any physiother­ apist reading this will tell me that tw o m inutes o f rubbing w ith ice can have no real effect on a runner. O ur investigations done o v er the years have shown that ice does help and m ore and m ore runners are asking to be treated with it. At the Inchanga station Judy and I alw ays take on the task o f strapping. T ogether this year, o ver a period o f approxim ately one and a h alf hours, w e strapped 160 parts o f T h is y e a r ....... 13 9 8 8 r u n n e r s s ta rte d th e r a c e , 12 081 fin is h e d th e r a c e , 1 0 2 8 ru n n e r s w e r e a d m itte d to te n ts f o r m e d ic a l tr e a tm e n t SPORTSGENEESKUNDE VOL. 6 NO. 3 23 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. ) PH Y SIO TH ER A PY UPDATE the body. M ost o f the p ro b ­ lems are knees caused w e are sure, by o v er training o r in co r­ rect shoes. In o rd er to reach the knees, one has to kneel. No one has ev er done research on the frequency o f patella ten­ d o n itis in p h y sio th e ra p ists kneeling on the road during an ultra marathon! B ecause this y ear was a down run, as expected, many o f the runners com plained o f an Ilio-tibial band friction syn­ d ro m e. O ur advice to these runners w as to w alk dow n the hills backw ards. M ost friction o f the band is at 30 degrees o f flexion and this does not happen when one w alks b ack ­ w ards. It m ust be rem em bered that many o f these runners are trying to beat the 11 hour gun, and they definitely have the tim e to w alk dow n hills. T h e runners stopping at our station increase to an alm ost unm anageable num ber. P hy­ siotherapists are seen to be s tr e tc h in g c ra m p e d h a m ­ strings, m obilizing painful backs, giving advice, kneeling on the road to rub a calf, bend­ ing o v er to reach a painful knee, helping a runner remove a shoe, kneeling on the mat to m obilize a cervical spine, running next to a ru n n er to give him some anti-chafe, rem oving rubbing cream s with E l a s to z o f f so that E lastoplast m ight stick and g enerally m anaging to achieve the im possible. Then suddenly, as fast as they ap ­ pear, they all disappear except for one o r tw o runners who have throw n in the towel and are w aiting for the C om rades bus to take them to D urban. I b attle to rise from the road - obviously age has som ething to do with it - and take a sip o f coke which tastes like nectar. W e w earily tidy up, pack our cars and head for hom e know ­ ing that as we do, so there are thousands o f runners grateful to the physiotherapists who have in som e small way helped them to achieve their goal o f com pleting a C om rades M arathon. O ne feels my story should end here, but it does not. Som e o f us d rive down to K ings P ark and w ork in the Red C ross Tend until 8 pm . O ur main function is to help b reak the excruciating cram ps w hich the over- o r under-hydrated ru n ­ ners get when they stop ru n ­ ning. T o w ork in the Red C ross o r the M edical T ent is an ex ­ perience no m edical person involved in the treating o f marathon runners should miss. It alw ays rem inds me o f a battle station. T he w ork done by the hundreds o f volunteers is h eart­ w arm ing and ju s t reinforces w hat kindness man can do to man ... but th a t's an o th er story to be w ritten som e o th er tim e. T his year, the official fig­ ures are that 13 988 runners started the race, 12 081 fin ­ ished the race, 1 028 runners w ere adm itted to the M edical, Red C ross o r St Johns Tents for medical treatm ent. O ur as yet unconfirm ed figures show that the phy sio ­ therapists in the seven Smith and N ephew stations treated approxim ately 4 000 ailm ents. T h e C om rades H ouse has been inundated with telephone calls from runners all o v er the co u n ­ try, asking that the physio­ therapists be thanked for the w ork they do on C om rades D ay. It really m akes it all w orth w hile. □ (S3] V /3 .1 /6 2 , V /3.1 /2 38 W .F .I. H /34/128 TILC0TIL® C o m p o n e n ts : T E N 0 X IC A M 2 0 m g Indications: S y m p to m a tic tre a tm e n t o f the fo llo w in g p a in fu l in fla m m a to ry and d e g en erative d is o rd e rs o f the m u s c u lo s k e le ta l s ys te m : rh e u m a to id a rth ritis ; o s te o a rth ritis ; a n k y lo s in g s p o n d y litis ; e xtra - a rtic u la r d is o rd e rs , e .g . te n d in itis , b u rs itis , p e ria rth ritis , g o u ty a rth ritis (fo r ta b le ts ). Dosage: 20 m g once d a ily at the sam e tim e each day. The p arenteral fo rm is used fo r one o r tw o d ays. For tre a tm e n t in itia tio n in a cu te g o u ty a rth ritis 40 m g (2 ta b le ts ) once daily fo r tw o days fo llo w e d by 20 mg once d a ily fo r a fu r th e r five days is re c o m m e n d e d . C o n tra-in d icatio n s: K no w n h y p e rs e n s itiv ity to the d ru g . P atie nts in w h o m s a lic y la te s o r o th e r n o n s te ro id a l a n ti­ in fla m m a to ry d ru g s (N S A ID s) in d u ce s y m p to m s o f a s th m a , rh in itis o r u rtic a ria . P atie nts w ho are s u ffe rin g o r have s u ffe re d fro m severe diseases o f the u p p e r g a s tro in te s tin a l tra c t, in c lu d in g g a s tritis , g a s tric and duo de na l u lc e r. B efore anaesthesia o r s u rg e ry , 'T IL C 0 T IL ' s h o u ld n o t be g ive n to p a tie n ts at ris k o f kidn ey fa ilu re , o r to p a tie n ts w ith increa se d ris k o f b le e d in g . C o n c u rre n t tre a tm e n t w ith sa lic y la te s o r o th e r N S A ID s s h o u ld be a vo id e d . P re g n a n c y and la c ta tio n . P recautions: S im u lta n e o u s tre a tm e n t w ith a n tic o a g u la n ts a n d /o r oral a n tid ia b e tic s s h o u ld be a voided u n le ss the p a tie n t can be c lo s e ly m o n ito re d . Renal fu n c tio n (B U N , c re a tin in e , d e v e lo p m e n t of o ed em a , w e ig h t g ain , e tc .) s h o u ld be m o n ito re d , w h e n g iv in g a NSAID to the e ld e rly o r to p a tie n ts w ith c o n d itio n s th a t c o u ld in c re a se th e ir ris k of d e v e lo p in g renal fa ilu re . Packs: T a ble ts 20 m g : 1 0 ’ s, 3 0 's . Vial pack c o n ta in in g 1 vial active s u b s ta n c e and 1 a m p o u le w a te r fo r in je c tio n . 24 ----------------------------------- SPORTS M EDICINE VOL. 6 NO. 3 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. )