Recent Staff Blog PostsMore green in wallets, less green in parksBlazers In FIBA World Cup: France Upsets Spain 65 52 To Advance To SemifinalsIt's Vancouver Brewfest time!Soccer analysis earns blogger some recognitionSay 'No' to the Pasta PassMaking a racket: First week of prep tennisSmelt season to be proposedMcMorris Rodgers, highest ranking woman in GOP and mentor to JHB, accused by staffer of ethics violationsNorthwest football standings and schedule ( Week 2)It's always a bad idea to crash your car into another and drive away, but when the car you hit is driven by an off duty Portland police officer, it's off the charts.Wednesday morning, Maureen Olivier, 43, was at Northeast 112th Avenue and Ninth Street when she made a left turn into the path of a southbound car and hit it, said Sgt. Steve Dobbs with the Vancouver Police Department.Olivier kept going west on Ninth, the officer followed, and she stopped in the 10800 block of Ninth, Dobbs said.The Portland officer called for Vancouver police, who gave Olivier field sobriety tests and took her to jail on suspicion of DUI and hit run driving, Dobbs said. She is a Vancouver resident. Nike Kobe 9 Low EM Home ,Air Jordan 12 Low Black Patent Black Varsity Red Air Jordan 6 Rings Powder Blue Air Jordan 14 Low Light Graphite Nike Kobe 9 Low EM Away Air Jordan Spizike Challenge Red Nike Kobe 9 Low EM XDR White Black Gold Nike Kobe 9 Low EM XDR Prelude Air Jordan 3Lab5 Black Metallic Silver Air Jordan 7 Olympic Gold Medal Pack , nighttime sneakers and exciting footwear can all be chosen for his or her immediate use. Believe fashionable and unique when seeking a pair of footwear. 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Perhaps until 2012 this was a theoretical risk, but as of the publication of these landmark papers 1 3 we can be certain that the increased risk is not zero. There will be much more to come in this field over the next few years and it will dramatically change the landscape of radiology and all medical practice. Pearce and colleagues' study in The Lancet looked at the excess risk of leukaemia and brain tumours for children and young people exposed to CT scans. They found that children exposed to cumulative doses of 50mGy in CT scans may have triple the risk of leukaemia, and doses of 60mGy may have almost triple the risk of brain tumours1. They are clearly cause for concern, as indicated by the fact that 12 other groups from 15 countries are studying the risk of scans on children3. These Lancet findings are more striking when combined with the findings of Pijpe and colleagues' GEN RAD RISK paper published last week in the BMJ2. This study showed that when women who carry a specific mutation associated with breast cancer (BRCA1/2), and who were exposed to diagnostic radiation before the age of 30, had almost twice the risk of breast cancer (with a dose response pattern). 4mGy from a single mammogram or shoulder x ray). Therefore, BRCA1/2 carriers, with an already increased risk of a very common cancer, would be particularly at risk from exposure from radiating scans at a young age. Why does this matter for sports and exercise medicine? Sports and exercise medicine is a field in which most patients have many years of life expectancy remaining; it is also a field in which diagnostic imaging is very common. Imaging is often confined to the limbs but also involves the spine. Importantly, the GEN RAD RISK paper showed, for example, that shoulder X rays in women with the BRCA1/2 mutation can increase the risk of breast cancer. This does not prove that a shoulder X ray is unsafe for the entire female population, but because it is quite plausible, we need to reassess the use of radiating scans. bowel, ovarian) after lumbar spine CT scan, but again we have to presume from the existing knowledge that the increased cancer risk is not zero. In this case, the unknown is the size of the increase in cancer risk (and not whether there actually is one). All tests (and treatments) in medicine need to consider benefits, risks and costs. On the benefit side, the test which gives the best information relevant to management needs to be identified. This can't be done in isolation of the increased cancer risk of radiating scans, particularly in young or middle aged patients. There will still be cases where a test that involves radiation is going to give preferred information to a non radiating one a classic example being in the knee of a 70 year old, where X ray will tell what needs to be known in 95% of cases and MRI scan is generally an excessive use of imaging. CT and bone scan to investigate for suspected pars stress fracture in an adolescent) we may need to quickly change to a recommendation of first line MRI scan to avoid increasing the risk of cancer. Health systems are going to need to change in scenarios where radiating tests are funded but non radiating tests aren't, because clearly it would raise ethical questions for a health system to be funding (offering a financial incentive) to have a test which can increase a patient's risk of cancer when a non risky test is available but unfunded. Up to fifty years ago, some shoe stores used to perform X rays on the spot to show whether a kid's shoe was fitting well4 this practice is now considered archaic. Sensibly there is now an attitude in medicine that a pregnant woman should not receive an X ray or CT scan if the information could be obtained in any other fashion. We are probably heading into an era where the same attitude needs to apply to all children and young people, for CT scan and even X ray. Modalities such as MRI and ultrasound (and good old fashioned clinical examination) will need to become more prominent in sports and exercise medicine, at the expense of radiating examinations. These studies highlighted in the blog will generate a demand for consensus meetings involving sports physicians, radiologists, radiation physicists, and epidemiologists among others to provide guidance for clinicians, professional bodies and patients. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. Her views in blogs are also personal and not necessarily representative of her affiliated organisations. Making the decision of when an athlete should return to play after an injury is one of the most challenging parts of a sports clinician's role. This is especially so when working with professional sporting teams, where the pressures can be immense. Ideally, a clear decision making process should be combined with reliable clinical objective markers to reduce the potential for the 'personality bias' of the clinician leading to error in these decisions. Being aware of personality bias Rehabilitators working with elite athletes may have their own 'personality bias' that can expose them to the risk of two opposing yet equally significant errors. On the one hand, the clinician may tend to be overly aggressive. This could be an internal compulsion (the 'Gambler' clinician) or may be the result of external pressures leading them to rush a player back in to competition before it is reasonably safe for them to do so (the 'Weak' clinician). Premature return to competition can lead to athletes breaking down with re injury or simply performing below expectations. If however, an injury does recur in the early stages of a return to competition, then it (perhaps reasonably) exposes that clinician to direct blame for a poor outcome. Any poor performance related to physical deficits may also negatively affect the clinician's relationship with the player and or their coach / manager. Both of these outcomes may in fact put that clinician's career at a club in jeopardy, and this is a fact of which most clinicians are well aware. On the other hand, the clinician may tend towards to being overly conservative. This may also be due to internal compulsion (the 'Conservative' clinician) or because of fear of the consequences described above (the 'Cynical' clinician). If athletes are kept out for longer than necessary to reduce the risk they might break down or perform below expectations on their return, it will mean they miss valuable competition time. This second type of error is not as immediately obvious to the coach / athlete and therefore it is less likely to bring direct blame to the clinician. Naturally if there is a pattern of consistently delayed recovery over a long period of time then it may reflect poorly on those involved. However, it is much more difficult to blame them directly, as it is never really clear as to when any individual athlete could have returned from a particular injury. Perhaps contrary to expectations then, it is likely many clinicians default to the position of being overly conservative. Unfortunately this means some will make a conscious choice to be overly conservative, not in the best interests of the player or the team, but rather in the hope of reducing any risk of being held liable for the more 'obvious' poor result (re injury or poor performance). What is the cost of 'delayed' return to play? To highlight the true cost of unnecessary conservatism from the cynical clinician to a club, consider the following example. If a football team that plays once a week was to have 30 injuries over the course of a season and all those injuries were given just one extra week of rehabilitation more than was really necessary, that would cost the club a total of an extra 30 missed games. Consider then if all those players actually came back 1 week earlier as perhaps many of them could, but this caused 5 players (17% of injuries) to re injure the same area. In the case of each of those 5 re injuries, if the athlete missed a further 4 weeks, the club would lose players for an extra 20 games. This means that despite those recurrences, the club would have cut their total number of games lost to injury by 30% (from 30 to 20 games lost). From his analysis at the time he concluded 'at this stage it may be a sensible strategy to allow earlier return to play in team sports and accept a low moderate re injury rate' after having seen such a pattern in the reported data. In reality, of course, there any many modifying factors that would need to be considered in each individual case. For example, is there extra risk of recurrence with an earlier return for that particular injury, and how long recovery likely will take after re injury? Also, other factors such as the point of the season, the particular game, and the position being played etc. will influence whether or not a risk is worth contemplating for an individual athlete at a particular time. The reality is that clinicians working with high level athletes must recognise that it may be equally as negative to have a bias towards conservatism as it is to have bias towards aggression in rehabilitation. Although most clinicians working in an elite environment would probably deny that they ever knowingly act overly conservatively, in reality most would (if being honest) admit there have been times when they have taken longer to return a player to competition than was perhaps essential because they feared the repercussions of any re injury. Conversely, most would also accept that there have probably been times when they allowed issues that don't directly relate to the injury into the thought process that ultimately allowed a player to return prematurely. Sports clinicians must be brave in the sense that they must be able to withstand the outside forces which might encourage a rushed return to play, but they must be equally brave in backing their own ability and judgement in getting a player back when the relative risk is reasonable, rather than waiting for the risk to be nil, which of course it will never actually be. The judgement of what is a reasonable risk is where the real skill of a sports rehabilitator lies. The ability to make this judgment correctly in a more consistent fashion, relies firstly utilising a clearly defined decision making process. The actual process of that return to play decision making was well outlined by Matheson et al (2011). They described a thorough model for considering all the factors that may affect our clinical judgement when deciding on the return to play of an athlete. The first two steps are to evaluate the athlete and the risk of returning to sport. This involves assessing the health status of the athlete and then considering that against risks particular to that sport and in that athlete. This is where improved objective markers would be particularly useful. Having decided that someone may return based on these principles, they acknowledge that there are still many 'modifiers' to your final decision which must be considered, and so ultimately clinical reasoning remains paramount. These modifiers would include consideration of issues such as the timing and season, the stage of an athlete's career, the importance of athlete to the team, the importance of a particular game to the athlete, any conflicts of interest at play (such as financial reward to the player or therapist), any chance of masking occurring, and risks of litigation etc. What objective measures are there? The ability to make return to play decisions objectively will help to decrease the potential of clinician personality bias to lead to error. For this reason I contend that developing improved objective markers that may predict a safe return to play is perhaps the greatest research need for rehabilitators working in high level sport. Unfortunately there are not yet many proven objective markers for sport specific return to play, but there are certainly some clinical tests that may be considered to reliably assess for known risk factors to injuries. Consider these examples. (1)The Hamstring active flexibility and apprehension test developed by Asking et al (2010) is a reliable test which is more sensitive to picking up on going Hamstring deficit than traditional assessment methods. Considering that hamstring recurrences are such a problem in the football codes it would be reasonable to suggest a normalisation on that test along with all other traditional clinical signs is essential before endorsing a return to play. (2) A decrease in adduction power as measured by a squeeze test may predict the onset of groin pain in AFL players (Crow 2010). Perhaps therefore after any groin injury a reasonable objective milestone that must be met during rehabilitation before being allowed to progress to full loading is that an athlete must have reached at least their pre morbidity levels on that squeeze test. (Per Holmich podcast on groin pain is here; his short YouTube video is here). In summary, to clear an athlete to return to play there needs to be confidence that the rehabilitation has been complete, and that a clear decision making process was followed. You must be aware of the dangers of 'personality bias' among clinicians and we should attempt to minimise this through the use of objective clinical testing wherever possible. Perfect judgement is impossible but clinicians and managers should appreciate that being overly conservative can be an equally significant and perhaps more common error as being overly aggressive. They should also accept that using objective markers is the way to minimise this. If the current markers fail us or do not exist in the sport specific detail we would like, it does not mean we should shy away from using objective markers, it means we should dedicate time to developing more accurate ones.
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