This article originally appeared in the May/June 2020 issue of the Ontario Medical Review magazine.
Key topics include maltreatment in sport, and transgender athletes within the health care system
This year marked the 49th anniversary of the popular Sport Med Symposium, held annually in Toronto. The two-day event featured plenary sessions, case presentations, scientific research papers, and practical hands-on workshops on a variety of topics related to the assessment, prevention and management of sport-related injuries.
Presented by the OMA Section on Sport and Exercise Medicine, the 2020 program drew more than 160 physicians, including family doctors, orthopedic surgeons, sport medicine physicians and pediatricians, as well as allied health professionals, including physiotherapists, chiropractors, massage therapists, and nurse practitioners.
Topics covered include maltreatment in sport, transgender athletes within the health care system, physical activity for patients with disability, top trends in sport nutrition, and exertional lower limb pain in athletes. Following are highlights from this year’s presentations.
Dr. Gretchen Kerr (PhD), University of Toronto, presented the Dr. Tom Pashby Sport Safety Fund Lecture, entitled Maltreatment in Sport: Results of a National Prevalence Study of Canadian Athletes.
Dr. Kerr opened her presentation with an overview of the study, noting that results were compiled from a survey completed in April 2019 that drew a total of 1,001 participants, made up of 764 current athletes, and 237 retired athletes who had left their sport within the past 10 years.
The study found the most frequently experienced form of maltreatment among respondents was psychological harm, followed by neglect. Sexual and physical harm were experienced to a lesser degree.
Across all categories of harm, among both current and retired athletes, females reported far more harmful behaviours. Retired athletes reported higher percentages of maltreatment than current athletes in all categories.
Dr. Kerr defined maltreatment as “an umbrella term that encompasses all types of physical and/or emotional ill treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results in actual or potential harm to health, survival, development of dignity in the context of a relationship of responsibility, trust, or power.”
She told delegates that this study is important since the last prevalence study in Canada was completed over 20 years ago, adding that “high-profile cases and the Me Too Movement have now raised awareness, and this should provide an avenue for the athlete voice.”
Dr. Kerr also noted that “societal norms have changed, and what was okay in schools, homes, workplaces, and relationships in the past is not necessarily okay now.”
She said that sport must align its practices to be consistent with other domains in which people, including young people, live, work, learn, and develop.
In discussing sexual harm, Dr. Kerr reported that behaviours can be contact or non-contact. Examples include sexual touching, intercourse, rewards for sexual favours, indecent exposure, sexually oriented comments or jokes, intimidating sexual remarks, and sexting. Psychological harm encompasses acts of aggression, such as hitting, throwing objects, and physical intimidation.
As well, repeated verbal behaviours (e.g., name calling, criticism of the person, degrading, belittling and humiliating comments) would fall into this category, along with denial of attention (e.g., ignoring athletes, or expulsion from practice, threats, humiliation), and body shaming (e.g., public weighing, public posting of body weight/body fat, and negative comments about the body).
Dr. Kerr defined physical harm as contact or non-contact behaviour that can cause physical harm to an athlete, such as using exercise as a punishment, stretching to the point of injury, hitting an athlete with sports equipment, allowing return-to-play prematurely, and excessive repetition of skill to the point of injury. Neglect would include acts of omission such as denying adequate hydration, nutrition, medical attention, or sleep. As well, failure to attend to an injury or pain would be an act of neglect.
She told delegates that knowing about abuse and failing to report is also an important issue, adding that fear of reprisal is often a reason why athletes and others do not report incidents. She referred to a quote from an athlete in the study who noted that “asking sport organizations to deal with abuse in their ranks is like asking them to incriminate themselves.”
Key findings from the study include the following:
“There is a dose response with exercise, and even small increases in physical activity are beneficial.”
Dr. Kim Coros, Toronto
“Training with a diet rich in carbohydrates, either routinely or in a periodized fashion, appears to result in more favourable performance outcomes versus low carbohydrate diets in elite endurance athletes.”
Jennifer Sygo, Toronto
“The risk factors in a patient with distal biceps ruptures are steroids, smoking, vascular watershed, and degeneration – there could be a “pop” followed by weakness, pain in supination, ecchymosis, proximal bulge.”
Dr. Darryl Collings, Collingwood
“Societal norms have changed. What was okay in homes, schools, workplaces, and relationships in the past are not necessarily okay now – sport must be held to the same standards, and sport must align its practices to be consistent with other domains in which people, including young people, live, work, learn, and develop.”
Dr. Gretchen Kerr, Toronto
“Trans athletes subject to doping control are encouraged to seek out information in confidence from the Canadian Centre for Ethics in Sport (CCES) whether a TUE – Therapeutic Use Exemption – is required, and if so, work with the physicians to complete the necessary documentation and submit to the CCES.”
Jennifer Birch-Jones, Ottawa
Stephanie Shostak, Edmonton
“It is important to suspect vascular issues in any athlete who presents with pain, paresthesias, early fatigue, limb swelling, limb discolouration, or skin changes.”
Dr. Taryn Taylor, Ottawa
A plenary session on Inclusion in Sport featured a lecture entitled Uncharted Waters: Trans Athletes Within the Health Care System, presented by Stephanie Shostak, President and CEO of Edmonton-based Prism Consulting Services Ltd., and sport activist and educator Jennifer Birch-Jones of Ottawa.
The presenters told delegates that some of the personal barriers for transgender individuals navigating the health care system include feelings of mistrust, lack of knowledge and/or health literacy, cost, lack of social support and/or isolation.
They also noted that while the International Olympic Committee (IOC) Consensus Guidelines list no restrictions on male trans athletes, female trans athletes must have declared their gender identity as female, and not change this declaration for sporting purposes for a minimum of four years. Female trans athletes must also have a total testosterone level in serum remain below 10 nmol/L throughout the period of desired eligibility to compete in the female category. Compliance with these conditions may be monitored by testing, and in the event of non-compliance, the athlete’s eligibility for female competition will be suspended for 12 months.
The speakers noted that a growing number of national sport organizations have adopted more progressive, inclusive policies and practices for trans athletes, particularly for women, that are aligned with the recommendations from the Canadian Centre for Ethics in Sport.
Calling for support for trans athletes, the speakers suggested the following recommendations:
Dr. Kim Coros, Bridgepoint Active Healthcare, discussed Physical Activity for Patients with Disability. She noted that:
Dr. Coros told delegates that “there is a dose response with exercise, and even small increases in physical activity are beneficial.” For adults aged 18 to 64 who have multiple sclerosis and mild to moderate disability, she advised at least 30 minutes of moderate-intensity aerobic activity twice a week, and strength training exercises for major muscle groups twice a week.
“Meeting these guidelines will reduce fatigue, improve mobility, and enhance elements of health-related quality of life,” she said.
For patients with spinal cord injury, cardiorespiratory fitness and muscle strength benefits are important. These patients should engage in 20 minutes of moderate to vigorous intensity aerobic exercise two times per week, and also three sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, two times per week.
Dr. Coros listed the following resources that may assist in the area of improved activity for patients with disabilities:
Making Sense of Top Trends in Sport Nutrition
The John Sutton Memorial Lectureship, entitled Making Sense of Top Trends in Sport Nutrition, examined ketogenic and intermittent fasting diets, and the effect on performance. Presented by Jennifer Sygo, sports nutritionist at the Cleveland Clinic Canada, the lecture discussed reasons why we should be prepared to talk about current diet trends.
Ms. Sygo said that discussion is important so that “we can remain current and relevant in the patients’ eyes; trust and confidence can be built for the patient and the practitioner; and, if evidence supports it, potentially to help patients, or protect them from harm.”
Her findings indicate that despite achieving substantial increases in capacity for fat oxidation during intense exercise, chronic adaptation to a low-carb high-fat (LCHF-ketogenic) diet impaired exercise economy, and negated the effects of a three-week intense training protocol in a real-life endurance event in elite athletes.
“Training with a diet rich in carbohydrates, either routinely or in a periodized fashion, appears to result in more favourable performance outcomes versus low-carbohydrate diets in elite endurance athletes,” she said.
Ms. Sygo reported that concerns and side-effects with intermittent fasting (IF) include hunger, hypoglycemia, binging and overeating, decreased workout quality, and non-guaranteed weight loss.
She also noted that LCHF-ketogenic and IF diets have both established and emerging clinical uses, and may be part of a practitioner’s toolkit. However, with all diets, LCHF-ketogenic and IF diets carry associated risks and should not be treated as one-size-fits-all diets.
Ms. Sygo advised that practitioners should be prepared to discuss emerging diets with their patients, and should use careful judgment and discretion when promoting or recommending any diet requiring strict adherence. She also noted that registered dietitians can provide support and guidance to patients considering any novel diet pattern.
Dr. Taryn Taylor, Carleton Sport Medicine Clinic in Ottawa, presented a lecture on Exertional Lower Limb Pain in Athletes. She told delegates that exertional limb pain is a common problem in recreational and competitive athletes, and can be a disabling condition that often represents a diagnostic challenge.
“It is important to suspect vascular issues in any athlete who presents with pain, paresthesias, early fatigue, limb swelling, limb discolouration, or skin changes,” she said, adding that a thorough workup and prompt treatment are important for a successful outcome.
Dr. Taylor advised that any athlete who presents peculiar, unrelenting discomfort during sport, that has been resistant to conventional therapies for musculoskeletal injury, should be screened for vascular pathology. Some of the conditions, and symptoms, that may present include the following:
Dr. Neil Dilworth, University of Toronto, was awarded the J.C. Kennedy Award for Excellence in Sport Medicine Research for his entry, The Rosetta Stone Translation Project for Sports Medicine. The objective of his study was to create a translation guide for improving medical care communication with non-English speaking athletes at sporting events.
Dr. Dilworth’s team worked with affiliates in Toronto, Georgetown, Hamilton, London (Ontario); Dublin, Ireland; Oslo, Norway; and Cambridge, Massachusetts. Six sport medicine physicians were interviewed about terms and phrases that would be helpful to conduct field-side translations with a non-English speaking athlete. These terms and phrases were assembled into a single translation template, and provided to proficient foreign-language speakers for translation.
The terms and phrases were then used to generate a basic template for translation guide by health care professionals with proficiency in French, German, Japanese, Mandarin, Norwegian, Portuguese, Serbian, and Spanish (several additional languages, including Arabic and Korean, are in progress).
Dr. Dilworth told delegates that one of the difficulties with online translation is poor accuracy for translating medical terminology, such as anatomical or condition-related terms. This qualitative study establishes a basic set of terms and phrases that could be used for the future development of quick reference linguistic guides, which can then be used in visual communication, or verbally for a proficient speaker.
Future studies could include testing of the guide in the field, collecting feedback from users, and the development of a smartphone application for field-side translation.
Find more information on the Rosetta Stone Translation Project for Sports Medicine.
Barbara Klich is a Toronto-based writer.
