Sport Health Volume 38 Issue 4 - The Olympic and Paralympic Games by Sports Medicine Australia

Sport

health VOLUME 38 ISSUE 4 2021

The Olympic and Paralympic Games

FEATURING

• The Olympics During a Pandemic • Challenges Experienced by Athletes • Heat Illness and Hydration • Nutrition for Olympic Athletes

Contents 16

REGULARS

Injuries are associated with less chance of having a medal during international championships

02 From the Chair

Professor Pascal Edouard shares the factors that can affect an athlete’s performance at the Olympic Games.

SMA Chair Professor Gregory Kolt talks about the future of SMA and how far Australia has come in the last twelve months.

03 From the CEO SMA CEO Jamie Crain discusses the importance of connecting with likeminded people ahead of the 2021 SMA Conference in October.

09 Heat acclimation and re-acclimation prior to competing in the heat Associate Professor Julien Périard examines appropriate methods of preparations for competing in extreme heat.

12 Pandemics and Olympics: how bad is this mix? In this feature, our authors talk about the unique challenges facing the Tokyo Olympics and the dangers that exist. Dr. Mandeep Singh Dhillon, Dr Sidak Dhillon, Himmat Dhillon.

NEWS

Reach for the stars – making progress in physical activity through mass sporting events

The impact of dehydration on performance in the heat and how athletes should drink at the Tokyo Olympics

Professor Adrian Bauman discusses the importance of promoting physical activity throughout mass sporting events.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

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Associate Professor Julien Périard talks all things hydration and how athletes can prepare ahead of competing.

Publisher Sports Medicine Australia Sports House, 375 Albert Rd Albert Park VIC 3206 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028

Copy Editor Kristen Butterworth Manager – Marketing and Communications Cohen McElroy Design/Typesetting Perry Watson Design Cover Photography Gettyimages/wavebreakmedia Content Photography Author supplied; www.gettyimages.com.au

Volume 38 • Issue 4 • 2021

Facing the double burden of coronavirus and heat stroke at the 2020 Tokyo Olympic and Paralympic games Public health researchers discuss the obstacles of holding an event like the Olympic Games in a pandemic. Professor Stuart Gilmour, Global Public Health Scientist Kazuki Shimizu, Public Health Researcher Phuong Mai Le.

People who shaped SMA – Professor Peter Terry Professor Peter Terry shares his career highlights including memorable moments at the Olympic Games.

33 Nutrition and the Tokyo Olympics Lead Dietitian for the Australian Olympic team Sally Walker shares the evolving landscape of the Tokyo Olympics and the importance of proper nutrition.

36 Tokyo and the Paralympic Games Chief Executive Officer of Disability Sports Australia Murray Elbourn highlights the unique nature of the upcoming Tokyo Olympics.

48 Sports Medicine Around the World: Spain

28 Challenges and stresses leading up to the Paralympic Games Dr. Nima Dehghansai discusses the challenges that Paralympians face leading up to the Paralympic Games.

38 SMA Community News

INTERVIEWS

Sports Trainer Spotlight: Marty Fry

Marty Fry looks back on his time as an SMA Sports Trainer and where it has taken him.

5 Minutes With – Dr Adam Castricum Dr Adam Castricum reflects on his career, involvement at the Olympic Games and his journey with SMA.

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FROM THE CHAIR

Looking into the future

elcome to the latest edition of Sport Health!

As we head into the second half of 2021, we look ahead to an important six months for Australia, with a more COVID normal country, with the vaccine rollout in full effect, and appropriate procedures for when breakouts do occur. It is fantastic to see how far we have come in such a short amount of time. In Sports Medicine Australia news, plans for the SMA 2021 Conference on 6-9 October at the Melbourne Cricket Ground are well underway with Dr David Hughes announced as this year’s Sir William Refshauge Lecturer. The highly distinguished Dr Hughes accepted the invitation on behalf of the Australian Sports Medicine Federation (ASMF) Order of Fellows and the conference committee are delighted to welcome him shortly after

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As we head into the second half of 2021, we look ahead to an important six months for Australia.

he returns from the Tokyo Olympics in August this year. We look forward to Dr Hughes sharing his experiences from this prestigious major multi-sport event during the time of a global pandemic.

This month’s edition of Sport Health focuses on the Olympic Games, where we hear from SMA members Dr Adam Castricum and Professor Peter Terry as they look back on their experiences at past Olympic Games and their sports medicine careers to date alongside SMA Sports Trainer Marty Fry. Other features include hydration and nutrition, heat re-acclimation, the Paralympic Games, and hosting a mass sporting event during the pandemic. I hope that you enjoy it. I would like to thank all of those who have contributed to this issue of Sport Health and for those who are preparing for this year’s Tokyo Olympics, in whatever way that may be, I wish you the best of experiences. Professor Gregory Kolt Chair

FROM THE CEO

Rolling into the new normal AFTER THE YEAR THAT WAS 2020, THE TEAM HERE AT SMA IS LOOKING FORWARD TO MAKING UP FOR LOST TIME AS THEY BUSILY PREPARE FOR THIS YEAR’S 2021 SMA CONFERENCE.

s Melbourne is on the back end of what we hope is the final lockdown, we are excited to press forward with early bird registrations now open and a Trade and Exhibitors Prospectus that is brimming with opportunities for businesses. We are thrilled to have secured the Melbourne Cricket Ground as our venue for this year’s conference and we hope that you are able join us. For many of you, the annual conference is a time each year to come together and connect with likeminded sports medicine professionals, engage in ideas and inspire one another with emerging knowledge and new science. Along with the SMA team and the Conference Committee, we are delighted to be able to deliver this to you in 2021. This edition of Sport Health is focused on the Olympic Games. This time last year, we weren’t sure when we would next see the Olympic Games. We have come an incredibly long way in the last twelve months and thanks to the vaccine and COVID safe travel procedures, we can now see Australia’s

The Olympic Games are an enduring symbol of hope, as nations come together in unity after an incredibly difficult year and a half.

best athletes on our television screens in just one month’s time. With cities coming in and out of lockdowns, it is common to feel isolation and uncertainty. The Olympic Games are an enduring symbol of hope, as nations come together in unity after an incredibly difficult year and a half. They are all driven by one higher purpose – to celebrate our greatest sporting talent and see what people can achieve. Features in this edition will dive deeply into the intricacies of the Tokyo

Olympics, covering the challenges athletes face in the lead up to mass sporting events, the promotion of physical activity, appropriate hydration and nutrition, and hosting an event like the Olympics in the time of a global pandemic. We hope that you enjoy this edition of Sport Health. Regards, Jamie Crain CEO

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FEATURE: PHYSICAL ACTIVIT Y AND MASS SPORTING EVENTS

Reach for the stars

– making progress in physical activity through mass sporting events ADRIAN BAUMAN EMERITUS PROFESSOR OF PUBLIC HEALTH, SYDNEY UNIVERSITY ADRIAN.BAUMAN@SYDNEY.EDU.AU VOLUME 38 • ISSUE 4 2021

FEATURE: PHYSICAL ACTIVIT Y AND MASS SPORTING EVENTS

Reach for the stars – making progress in physical activity through mass sporting events

Many exercise scientists, public health professionals and healthcare providers are interested in reducing physical inactivity in Australia. The World Health Organisation has recommended that countries reduce physical inactivity levels by 15% by the year 2030, as part of WHO targets for chronic disease prevention. In Australia, as evidenced by trend data from the ABS National Health Surveys, levels of physical activity have remained fairly static for over 20 years. Note that these are slightly different to the state-based surveillance systems using the Active Australia questions, that have noted a slight increase in walking over that period, but limited change in moderate to vigorous forms of aerobic exercise. Although we know what to do to increase physical activity at the population level, it is quite difficult to implement strategies at both national and state level that are consistent, co-operative, and synergistic. The International Society for Physical Activity and Health (ISPAH) has developed the eight best investments for promoting physical activity. We should all contribute to the implementation of school physical activity policies, primary-care promotion, worksite physical activity promotion and building “active living” environments and transport systems. But these structural and policy changes often take years to implement, and so we often wonder what innovative things we could do to support “getting Australians more active?”. One underutilised strategy is to capitalise on mass sporting events, sporting competitions and Olympic and Commonwealth Games where the community gets interested in watching and supporting elite sport. During these competitions there is often a festive spirit and a nationalistic sense of achievement in the successes of our athletes and 6

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sports people. But imagine if we could use these events to build people’s interest in being active, by planning to incorporate exercise and physical activity promotion before, during and after the mass sporting event. We know from an evaluation of the Sydney 2000 Olympics that men increased their intention to be more active immediately following the Games. How to do this? If public health agencies, sport and exercise professionals combined with the organisers of these mass events to develop promotional and social marketing campaigns, to promote infrastructure and facilities and programs around and during the event, it may motivate people to get off the couch and consider being active. They could think about “achieving their own personal Olympic dream”, even if that was taking up social netball again, playing table tennis or

walking the dog, with reframing these prosaic activities by linking them to participation in the Olympic spirit. There is some uncertainty about the 2020 Olympics in Tokyo, given the resurgence of COVID-19 in Japan, so the 2020 Olympics will not be typical in terms of the energy of supporting crowds, and may lack some of the festive spirit inside the Olympic Village and environment. Nonetheless we will still watch with interest to cheer on Australian athletes, but nothing will motivate us to leave the couch to do anything ourselves. Despite the rhetoric of promoting exercise in Olympic bids and in the bids for the Commonwealth Games, neither Melbourne 2006 nor the Gold Coast 2018 Commonwealth games invested effort in parallel work promoting community sport and exercise. How might this have happened? It would have needed cross-government

FEATURE: PHYSICAL ACTIVIT Y AND MASS SPORTING EVENTS

for people with special needs, and a myriad other programs and resources that could contribute broadly to physical activity participation.

Imagine if we could use these events to build people’s interest in being active, by planning to incorporate exercise and physical activity promotion before, during and after the mass sporting event partnerships starting several years before the Games, with a promotional media campaign, supported by exercise and sport professionals and primary health care workers, and the marketing of community sport facilities and programs. This sounds straightforward, and may indeed not be overly expensive, because it is mostly marketing existing infrastructure and programs, and trying to get more people to access exercise classes, existing walking trails and current sport opportunities. However, it seems that governments become so single-minded and obsessed with delivering the Games as a central focus that they lack additional capacity to work across agencies to build this kind of collaborative approach. If they did, it may assist people who are inactive to think about becoming active, and motivating them to try community walking programs, community swimming classes, sport

Olympics and Commonwealth Games are not the only initiatives that use this kind of approach. Why not utilise the Rugby League State of Origin matches, the Australian Open tennis, the AFL finals campaign, and other contests that attract huge community interest? A variant of this approach is the FFIT (“football fans in training”) programs in Europe, where elite football (soccer) teams and their celebrity players have a program directed at middle-aged inactive males, who are their main “fans”. Lateral and creative approaches are needed to make progress towards the WHO physical activity targets for 2030. Taking the opportunity of heighted community interest during mass sporting events remains an under-realised opportunity for getting Australians more active.

Author Bio Adrian Bauman (Emeritus Professor of Public Health, Sydney University, Australia) has 30 years’ experience in non-communicable disease prevention and physical activity research. He codirects the WHO Collaborating Centre on Physical Activity, Nutrition and Obesity. Current research interests include systems approaches to physical activity and implementation science methods for prevention. He is well-published in the scientific literature and was named 2014-2020 Thompson Reuter (Clarivate) lists of highly cited researchers.

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FEATURE: HEAT ACCLIMATION

Heat acclimation and re-acclimation

prior to competing in the heat JULIEN D. PÉRIARD RESEARCH INSTITUTE FOR SPORT AND EXERCISE, UNIVERSITY OF CANBERRA, CANBERRA, ACT, AUSTRALIA

he 2020 Tokyo Olympics are expected to be the hottest in modern history. Heat acclimation, the acquisition of adaptations related to heat exposure, is suggested to be the most important countermeasure an athlete can adopt ahead of competition to protect their health and maintain performance. Exercise-heat acclimation develops during repeated training bouts in hot conditions in response to marked increases in core and skin temperature,

skin blood flow and sweat rate. It is commonly accepted that daily training in the heat for 60-90 min for two weeks allows for adaptations to occur, including plasma volume expansion and enhanced heat dissipation. These adaptations contribute to lower the cardiovascular response associated with exercising in the heat and thus enhance performance. The time course of these adaptations is relatively rapid with a large fraction occurring during the first week VOLUME 38 • ISSUE 4 2021

FEATURE: HEAT ACCLIMATION

Heat acclimation and re-acclimation prior to competing in the heat of training and the remaining adaptations developing during the second week. It must be acknowledged however, that a large interindividual variability exists in the magnitude and time frame of the adaptive process. Although the principles highlighted above are relatively well understood, a common question from coaching and medical teams is how heat acclimation should be integrated within the training and taper program of elite athletes. Laboratory and field studies have shown that performance is increased after one or two weeks of training in the heat, however, it may be impractical for athletes to dedicate two weeks to training daily in the heat immediately prior to a major competition. Indeed, the thermal and cardiovascular strain necessary to induce the required adaptations may interfere with the workload programmed within particular training sessions, as well as impede recovery during the taper period, or disrupt travel arrangements. Notwithstanding, it should be re-iterated that the daily heat exposures (which can be passive) required to induce heat acclimation are relatively short, which allow athletes the opportunity to train and rest in cool environments. Moreover, while daily heat exposures are optimal for inducing adaptations, these can be separated by two-three days and still provide an adaptive stimulus. Finally, the decay of heat acclimation appears to occur at a slower rate than its induction, which lends

Figure 1. Potential heat acclimation periodisation. Athletes can undergo a heat acclimation regimen several weeks in advance of competition, maintain some of the adaptations through exercise and periodic post-exercise hot water immersion until traveling, and then re-acclimate with two-three sessions after arriving at the competition venue. The bottom panel provides an example of the time frame and magnitude of adaptation in heart rate during exercise in the heat when conducting an initial 10-day heat acclimation camp and a subsequent five or seven days of re-acclimation 12 and 26 days later, respectively. Redraw with permission from Weller, et al. (7) and Racinais and Périard (4).

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FEATURE: HEAT ACCLIMATION

itself to be performed in advanceof competition and supplemented by a short “top-up” prior to competition. The approach of heat acclimating in advance is further supported by the rebound effect of re-acclimation, wherein a second acclimation period within a month of the initial one allows for faster, and in some cases, greater adaptations. For example, Weller, et al. (7 showed that following an initial 10 day acclimation period, two and four days of re-acclimation after 12 and 26 days without heat exposure (i.e. decay), were sufficient to regain a similar acclimation status (Figure 1). A recent meta-analyses also estimated that approximately 35% of the heart rate, 30% of the sweat rate and 36% of the core temperature adaptations are lost in the two weeks following heat acclimation. However, regular exercise-heat exposure during this period decreases the rate of decay. Passive heat exposure may also be used during this period to accommodate travel and/or taper requirements, all the while providing the stimulus to maintain adaptation. A re-acclimation period of two to five days closer to competition would then be sufficient to regain adaptation, with an extended reacclimation period potentially allowing for further adaptations to develop.

In summary, heat acclimation should become an essential component of training prior to competing in the heat to help protect the health of athletes and optimise performance. An athlete preparing for the Tokyo Olympics, or any other competition in hot/humid ambient conditions, may plan an initial heat acclimation camp a few weeks before their event and subsequently minimise the decay in adaptations with regular exercise and/ or passive heat exposure until traveling (e.g. once or twice per week). This would also allow faster re-acclimation during a “top-up” immediately prior to departure for competition.

of Sydney and former Research Scientist (2011-2015) and Head of Research Operations (2015-2017) for the Athlete Health and Performance Research Centre at Aspetar, Qatar. Originally from Canada, he received his PhD from the University of Sydney in 2011. Julien’s integrative research examines the physiological mechanisms that impact on health and performance in adverse environments (heat and altitude), along with strategies to mitigate their influence and harness their adaptive potential. He has worked with both amateur and professional athletes from various disciplines, along with National and International Federations (FIFA, ITF, UCI, World Athletics and World Triathlon). He has authored over 80 research publications in international journals, including an invited review in Physiological Reviews on exercise under heat stress. Julien has also edited a textbook on Heat Stress in Sport and Exercise. He currently serves as Associate Editor for Frontiers in Physiology (2015-Present) and has served as Guest Editor for the British Journal of Sports Medicine (2014) and Scandinavian Journal of Science and Medicine in Sport (2015).

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FEATURE: PANDEMICS AND THE OLYMPICS

Pandemics and how bad is this mix?

ports and health are so intertwined, that issues with one invariably have repercussions on the other. The 2020 Summer Olympics are unusual for many reasons, principal among which are the controversies being raised due to the COVID-19 pandemic. Many publications in 2020 had discussed the problems and the issues arising from this unique mix of events; the 2020 Olympic games were appropriately delayed by one year, and subsequently they are being planned on the same dates in 2021. This is something unprecedented, and never has a disease caused so much disruption in the history of organised sports. The delay unfortunately has not solved the problem; the pandemic rages on, and many countries have been overwhelmed by second waves of the disease, and some have even seen their health care systems crumble. Central to any competitive sport is the elite athlete. Issues unrelated to the sport which have a disruptive effect on the organisation of events, also have a significant effect on the athlete, both in the form of physical and mental conditioning. Many questions are raised; will the levels of competition, of achievement and of course of involvement be the same as in normal times? Will we still get as many broken speed and endurance records in 2021 as with the previous Olympics? The situation we must remember is unusual, and many issues have to be considered; when a high level of athletic participation is expected, in addition to the athletes’ efforts, a large part of the preparation is often dependent on the support staff. They have to be prepared to be able to tackle any unusual situations, many of which are outside the circle of the individual athlete. For elite mega-events

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like this to be successful, there is a role to be played by sports officials, there are local populations to be considered, and of course they are those personnel that manage the logistics and interactions among all of the above. This becomes a very big and complex structure, involving close interactions on a daily basis, most of which are repetitive and would involve close contact. In the time of this pandemic, where social distancing and aerosol related spreads are an issue, this is an area of concern, and could reflect on both the management structure and the athlete. This has reignited the debate in 2021; should the Olympics be held at all? Japan is a small but densely populated country, which nevertheless manages most issues with a high degree of efficiency. However, the COVID-19 pandemic has surpassed all limits of efficiency and technology and has broken through even in the world’s best health systems. The big factor behind the International Olympic Committee (IOC) pushing for the Olympics this year is money; the amounts invested by local organisers are huge and would be wasted, the potential profits for the IOC by broadcasting rights would be immense and be lost, and local populations would lose out on the profits that visiting athletes and tourists bring in. But is this argument enough to push for the “Olympics as usual”? Should the games go on, regardless? Epidemiological experts have discussed this threadbare; a special supplement of Current Tropical Medicine Reports last year focussed on “Massive gathering events and COVID-19”. Unlike the Zika Virus that affected the 2016 Olympics in Rio de Janerio, the SARS COV-2 virus is more transmissible, and can be transmitted

FEATURE: PANDEMICS AND THE OLYMPICS

Olympics

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FEATURE: PANDEMICS AND THE OLYMPICS

Pandemics and Olympics how bad is this mix?

even by asymptomatic people due to its long incubation periods. As more than 20 million people were expected to mix with one another, coming from 204 countries around the world, the Olympic games have the potential to becoming a “superspreader” event and could lead to a resurgence in infections worldwide. This was noted in some megareligious events in India, and in other events worldwide, and thus significant caution and restraint are advocated. Whatever happens, the primary consideration should be the elite athlete; these are sports persons who have trained all their young lives for this event, which potentially would be the pinnacle of their achievements. In a way, depriving them of participating here seems a crime; mental anguish would be significant and focused physical effort would be wasted. The postponement of the Olympics in 2020 has meant that some athletes have retired, and it has become a permanent loss of opportunity for others. Work schedules have been altered, some athletes, coaches and support staff have been infected, some have had family members who developed the disease, and many training sites have had to close due to the pandemic. The pandemic and the uncertainty have already affected the athletes in many ways; physical 14

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timetables have been altered, training schedules remodeled and build up games have been re-arranged. This has been good for some and not so good for others; many qualifying competitions had to be cancelled or scheduled in different parts of the world; many athletes from countries with high virus infection loads were unable to travel and thus missed out on qualification spots. Those who had qualified previously were unable to train due to restrictions and lockdowns, leading to lower levels of physical and mental fitness. This latter aspect is more significant, as mental health is as important as physical readiness, and many physically equal athletes lose out due to unequal mental conditioning. The natural question that needs to be asked is that whether it is fair for the world to expect these athletes to perform at the same level as they would have in normal times? This is a vexing question as repeating postponements of events leads to even more stress and uncertainty, and significantly effect performance. How would the parameters and heights of achievement of the postponed 2020 Olympics compare with the records and achievements of athletes performing in normal times? All these issues sit as a giant cloud over the upcoming games.

The 2020 Summer Olympics are unusual for many reasons, principal among which are the controversies being raised due to the COVID-19 pandemic.

As we write this commentary, we are unsure of what to expect, both from the athletes, and the managers. The best efforts will undoubtedly be put in, but the dangers of infection will persist, and it is hoped that these games are not remembered as a tragedy, rather that the celebration of sport that they are meant to be. Baron LeCoubertin’s latin quote of “Citius, altius, fortius,” for “Faster, higher, stronger,” is still the driving force, but negative factors are still too many and are looming ominously. But the words from a modern cinema classic STAR WARS seem more appropriate, and we say to the participants in our efforts to wish them luck- “Let the Force be with you”.

FEATURE: PANDEMICS AND THE OLYMPICS

About the Authors Himmat Dhillon is an APA Titled Sports Physiotherapist working out of his private practice in Richmond, Melbourne. After doing his Bachelors degree in one of the top Indian Universities, Himmat went to Australia in 2014 and completed his Masters in Advanced Clinical Physiotherapy (Sports) from UniSA and Masters in Clinical Rehabilitation from Flinders University in Adelaide. He relocated to Melbourne and worked as the physiotherapist for NPL and State League Football teams in East Melbourne before starting his own private practice in 2018. He has a special interest in Football injuries and has previously published on cricket injuries, sports related rehabilitation and golf injury epidemiology.

Dr. Mandeep Singh Dhillon, is the current Professor and Chair, Dept. Of Orthopaedic Surgery, Post Graduate Institute of Medical Education & Research at Chandigarh, India and also Heads the Dept. Of Physical Medicine and Rehabilitation. He also runs the Sports Medicine Clinic, PGIMER, Chandigarh He is a former President of the Indian Orthopaedic Association, Indian Arthroplasty Association, Indian Association of Sports Medicine, Indian Foot & Ankle Society and Founder President of the Indian Biologics Orthopaedic Society. He is an Honorary consultant to the Board of Control of Cricket in India, Sports Authority OF INDIA, Indian Hockey Federation, Gymnastic Federation of India, and both Punjab and Chandigarh (UT) Cricket Associations. He has published extensively on sports injury management and epidemiology.

Dr Sidak Dhillon is one of the first few specialised Sports Medicine physicians in India. He completed his M.D. in Sports Medicine in 2019 after which he pursued a Diploma in FIFA Medicine. He has an avid interest in all sports and most of all football. For the last 3 years he has been working in football and currently is the Team Physician for Chennaiyin F.C., which is a football team participating in the Indian Super League (ISL). He has previously published on sports rehabilitation, hamstring regeneration after harvesting, and injuries in cricket.

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FEATURE: INJURIES AND INTERNATIONAL CHAMPIONSHIPS

Injuries and International Championships

IT IS WELL KNOWN AND RECOGNISED THAT THE PERFORMANCE IN SPORTS IS MULTIFACTORIAL. MANY PARAMETERS INTERACT AND PLAY A ROLE IN THE BUILDING OF THE ATHLETES’ PERFORMANCE, AND THEIR SUCCESS DURING COMPETITION. WHEN THE ATHLETE IS GOING ON THE PODIUM TO RECEIVE THEIR MEDAL, THIS MEANS THAT THEY HAVE REACHED A PERFECT ALIGNMENT OF ALL THESE PARAMETERS.

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ne of the parameters that can lead to failure in an athlete’s performance is the injury. The injury is a damage of the musculoskeletal tissue (e.g. muscle, tendon, ligament, bone, cartilage) that can lead to several consequences at the physical level, such as pain, functional impairment and instability. This can also lead to stop sports practice, and long term physical sequalae. Injury consequences could also be at the psychological and societal level. Given its physical consequences, it seems logical to think that an athlete with an injury will have less chance to perform at best during sport practice and especially during a competition. There is some scientific evidence of this relationship, mainly in team sports. In male professional football, Hägglund et al. (2013) reported higher numbers of injuries per hours of football practice and lower match availability due to

FEATURE: INJURIES AND INTERNATIONAL CHAMPIONSHIPS

Given its physical consequences, it seems logical to think that an athlete with an injury will have less chance to perform at best during sport practice and especially during a competition.

of the season used to prepare competitions was associated with performance failure during major international athletics championships during the competition period. Edouard et al. (2019) reported during eight international championships and over a cohort of 219 different countries with a total of 13,059 registered athletes, that lower number of injuries and illnesses per registered athletes were correlated with a higher number of medals and gold medals per registered athletes when countries were grouped according to team sizes. However, there is a need for more data on this topic to confirm these conclusions with other objective arguments. Such results could be of help to better understand the determinants of the performances in athletics and to improve athletes’ and coaches’ adherence to injury prevention strategies.

injury per team had a significant negative influence on performance of the team in league play and in European cups. In basketball, Podlog et al. (2015) reported that the number of games missed due to an injury or illness have been reported to be associated with lower percentage of wins. In a systematic review of studies analysing this relationship, Drew et al. (2017) concluded that it is now admitted that the less you are injured, the more you can practice or compete and the less your team will fail. But the team performance is an association of individual players, and these conclusions may be not fully extraposed at one athlete in an individual sport. In Track and Field (Athletics), although this relationship seems also logical, there is little scientific evidence reporting objective data. Raysmith and Drew (2016) reported, in 33 athletics athletes from the Australian Institute of Sport (AIS), that reduced participation in training due to injury and/or illness in the period VOLUME 38 • ISSUE 4 2021

FEATURE: INJURIES AND INTERNATIONAL CHAMPIONSHIPS

Injuries and International Championships Combined events are a discipline of athletics during which athletes compete in five to ten different running, jumping, and throwing events over one or two consecutive days. In combined events, dropouts are frequent (13% to 38%) and injuries being the cause in about half of them. Therefore, we chose, in an article published in the Journal of Science and Medicine in Sport published in February 2021 (Edouard et al. 2021), to analyse the potential association between injuries occurring during international combined events competition and performance success

during these international combined events competitions determined by the fact that the athlete wins a medal. We thus analysed the data related to participation, injuries occurred during competition, climatic conditions and medals during the combined events competitions of 18 international championships (including two Olympic Games, 6 World Championships and 10 European Championships). With a population of 286 individual athletes (145 male and 141 female athletes) counting 799 individual starts for a combined events competition, we reported

The less you are injured, the more you can practice or compete and the less your team will fail.

using a stepwise multiple regression analysis that the presence of an injury occurred during the competition was significantly associated with about a 50% lower chance of winning a medal during the respective competition; the analysis was adjusted for individual athletes, age, sex, type of combined events, type of championships, range and average temperature, and precipitation. We also reported higher proportion of injured athletes among those who did not win a medal (18% of injured athletes) than among those who win a medal (8% of injured athletes). This study brings additional objective arguments on

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FEATURE: INJURIES AND INTERNATIONAL CHAMPIONSHIPS

the relationships between injury and performance in sports. Being injured during an international combined events competition was associated with performance failure, i.e. lower chance of winning a medal. Although such result seems logical it is important to provide objective data of this relationship. This supports the fact that athletes’ health protection contributes to sports performance, and this reinforces the place and role of injury risk reduction approach as part of the athletes’ preparation towards performance. As stated by Drew et al. (2017), “performance cannot be researched without consideration of the health status of the athlete both during competition and the period prior”. Therefore, as a practical implication of our present study, we reinforce that injury risk reduction strategies should be included as part of the performance preparation in a performanceprevention win-win strategy.

About the Author Pascal Edouard (MD, PhD) is a University Professor and Hospital Practitioner in Physiology and Sports Medicine at the SaintEtienne University Hospital (CHU) and Jean Monnet University, Saint-Etienne. He is currently responsible for the Sports Medicine Unit in the Department of Clinical Physiology and Exercise at the University-Hospital of Saint-Etienne (CHUSE), in which he works as Sports Medicine Physician. He is responsible of the SPIP team: Sports Performance and Injury Prevention, at the Inter‐University Laboratory of Human Movement Science (LIBM EA 7424) of the Jean Monnet University, University of Lyon, Saint Etienne, France. His main research topic

For more information about this specific study on injury and performance in combined events, please see Edouard P, Navarro L, Pruvost J, Branco P, Junge A. In-competition injuries and performance success in combined events during major international athletics championships. J Sci Med Sport 2021;24(2):152–158.

is injury prevention, especially using the sport model of athletics and hamstring injury.

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FEATURE: HYDRATION AT THE OLYMPICS

The impact of dehydration

on performance in the heat and how athletes should drink at the Tokyo Olympics JULIEN D. PÉRIARD RESEARCH INSTITUTE FOR SPORT AND EXERCISE, UNIVERSITY OF CANBERRA, CANBERRA, ACT, AUSTRALIA

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FEATURE: HYDRATION AT THE OLYMPICS

thletes competing at the 2020 Tokyo Olympics Games can expect hot and humid conditions. Ensuring they are well hydrated prior to an event and minimising dehydration via sweat loss during competition will ensure an optimal physiological state and competitive advantage in endurance events. However, there is debate regarding whether athletes should drink to thirst, or plan to drink during a prolonged event. The debate is centred on the level of dehydration that can be incurred prior to its effects influencing endurance performance. Whole-body sweat rate during exercise typically ranges from 0.5 to 2.0 L.h-1

with some athletes (~2%) sweating over 3.0 L.h-1. Gradual reductions in body mass of 2-5% can occur if body water losses are not replenished, resulting in marked decrements in plasma (³10%) and blood (³6%) volume. Such levels of dehydration lead to a state of hyperosmotic hypovolemia that is proportional to the loss in total body water. Hyperosmolality during exercise reduces sweat rate, and thus evaporative heat loss, for any given core temperature. Given that the evaporation of sweat is the primary avenue of heat loss during exercise in the heat, the rise in core temperature (hyperthermia) experienced during endurance exercise is exacerbated.

Figure 1. Effects of exerciseinduced dehydration and recommendations for optimising endurance performance in the heat. Exercise-induced water loss (>2% body mass) via sweating leads to hyperosmotic hypovolaemia, which triggers the sensation of thirst, but also reduces sweat rate for any given core temperature and increases the cardiovascular response to a given work rate. These adjustments impair endurance performance through exacerbated hyperthermia and reduced blood flow to exercising muscles and the skin. Both exercise-induced dehydration (process of losing body water) and hypohydration (state of body water deficit) induce these responses. The choice of drinking to thirst or adopting a planned hydration strategy should be considered based on exercise intensity, duration and climatic conditions, with the aim to minimise body mass loss within the constraints of the sport (rules and regulations), rather than fully replace the deficit. Reproduced with permission from Périard, et al. (8).

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FEATURE: HYDRATION AT THE OLYMPICS

The impact of dehydration on performance in the heat and how athletes should drink at the Tokyo Olympics

Progressive dehydration and hyperthermia also increase heart rate and compromise the ability to maintain cardiac output, leading to a reduction in blood flow to exercising muscle (i.e. oxygen delivery) and the skin (i.e. heat loss). The impairment in endurance performance during exercise in the heat generally emerges when body mass losses surpass 2-3%, and is characterised by an increase in thermal, cardiovascular and perceptual strain. To optimise performance, it is recommended to drink during exercise to prevent excessive dehydration (>2% body mass) and electrolyte (e.g. sodium) imbalances. A dehydration-induced body mass loss of approximately 2% in a 70 kilogram individual is associated with a 2-3% increase in plasma osmolality, which is the approximate threshold that triggers water conservation in the kidneys and the sensation of thirst. Accordingly, it has also been suggested that athletes need only drink to thirst to maximise performance. However, given that the sensation of thirst may only be perceived when approximately 1.5 litres of body water has been lost, coupled with thirst being alleviated before complete rehydration is achieved, drinking to thirst may lead to involuntary dehydration. Notwithstanding, several circumstances may allow for drinking to thirst, whereas others might require a more calculated approach. For example, drinking to thirst may be sufficient to offset fluid losses during low-to-moderate intensity exercise of less than 60 minutes in cool climates. Conversely, high-intensity exercise eliciting an elevated sweat rate, along with activities lasting over 60 minutes in the heat, should be accompanied with a planned hydration strategy (Figure 1). Of note, it is important to acknowledge that a given level of dehydration after completion of an event does not represent the hydration status experienced throughout that event. For

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example, a 70 kg individual competing at a high intensity for 60 minutes might sweat at a rate of 2 L.h-1, leading to a 2.9% loss in body mass if fluids are not consumed during exercise. In this scenario, a 2% body mass deficit would only be surpassed in the final 20 minutes of exercise. Given that performance is not suddenly and markedly impaired upon reaching a particular level of dehydration, but rather decreases progressively, the impact of such a deficit on performance may be difficult to quantify in a competitive field setting due to various

issues (e.g. motivation, pacing, endspurt). However, podium placements are often determined within the final moments of competition, so having an individualised hydration strategy is likely to optimise high-intensity exercise performance in the heat by reducing the detrimental effects of dehydration in the latter stages of an event. Another aspect worth acknowledging is the rate at which fluids can be absorbed. Gastric emptying rates of 15-20 mL.min-1 can be maintained during exercise when water and/or a dilute carbohydrate solution are

FEATURE: HYDRATION AT THE OLYMPICS

following training may lead to a state of body water deficit (i.e. hypohydration) prior to a subsequent training session or competition. Hypohydration leads to hypovolemia and hyperosmolality, which increase the internal temperature thresholds for thermoregulatory cutaneous vasodilation and sweating during exercise. Initiating exercise in a hypohydrated state will therefore expedite the development of thermal and cardiovascular strain. Prolonged exercise in hot/humid environments should be undertaken in a well hydrated state with sweat losses

Proper hydration between training sessions and events is as important as fluid consumption during competition, if not more essential.

replaced to prevent excessive reductions in total body water, but without over drinking. Hydration regimens should be athlete-specific and consider both sweat rate and composition (e.g. sodium). Ultimately, the choice of drinking to thirst or utilising a hydration plan should be based on exercise intensity and duration, the prevailing ambient conditions, and sport-specific rules and regulations regarding access to fluids. Provided in Figure 1 are recommendations to reduce physiological strain and preserve performance when training and competing in the heat.

About the Author Dr. Julien Périard is an Associate Professor at the University of Canberra Research Institute for Sport and Exercise (UCRISE). He is also an Adjunct Senior Lecturer at the University of Sydney and former Research Scientist (2011-2015) and Head of Research Operations (2015-2017) for the Athlete Health and Performance Research Centre at Aspetar, Qatar. Originally from Canada, he received his PhD from the University of Sydney in 2011. Julien’s integrative research examines the physiological mechanisms that impact on health and performance in adverse environments (heat and altitude), along with

ingested.(1) At higher exercise intensities (>70% of maximal aerobic capacity) gastric emptying and intestinal water absorption are reduced, which may prevent some hydration regimens from offsetting sweat losses. Consideration should therefore be given to the level of dehydration that will potentially be incurred during competition.

strategies to mitigate their influence and harness their adaptive potential. He has worked with both amateur and professional athletes from various disciplines, along with National and International Federations (FIFA, ITF, UCI, World Athletics and World Triathlon). He has authored over 80 research publications in international journals, including an invited review in Physiological Reviews on exercise under heat stress. Julien has also edited a textbook on Heat Stress in Sport and Exercise. He currently serves as Associate

Proper hydration between training sessions and events is as important as fluid consumption during competition, if not more essential. Inadequate hydration

Editor for Frontiers in Physiology (2015-Present) and has served as Guest Editor for the British Journal of Sports Medicine (2014) and Scandinavian Journal of Science and Medicine in Sport (2015).

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FEATURE: CORONAVIRUS AND HEATSTROKE

Coronavirus and heatstroke at the Tokyo Olympic Games STUART GILMOUR, PHUONG MAI LE, KAZUKI SHIMIZU

n the 12th of June, 2021 Christian Eriksen, midfielder for the Danish national soccer team, collapsed on the pitch during the Finland-Denmark match of Euro 2021. Afterwards, his team confirmed he experienced a cardiac arrest and required a defibrillator on the pitch. Although the exact underlying cause of this shocking event is not clear, it serves as a reminder that even the fittest athletes in the world can experience sudden, unexpected medical emergencies. The risk to athletes in the past year has been exacerbated by the novel coronavirus disease 2019 (COVID-19) pandemic, during which sports bodies and governments have attempted to keep professional sports competitions open, at some risk to players. For example, the start of the Japan Rugby Union competition for 2021, the Top League, was delayed due to multiple COVID-19 outbreaks, and several competitive combat sports events have been modified at the last minute or canceled due to COVID-19 infection among participants. These events are not necessarily safe for spectators, either: the 2020 Cheltenham festival was identified as a potential “superspreader” event, as maybe was a prior international rugby match attended by the UK prime minister. Now, the perfect sporting super-spreader event looms: the 2020 Olympics, rescheduled to start in July 2021 in Tokyo, Japan. But this Olympics carries an additional risk beyond the obvious threat of coronavirus. Heat stroke, and the combination of extreme heat,

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humidity and the special demands of coronavirus prevention, may combine to create unique health risks for athletes and spectators alike at this Olympics. We have been researching the effect of the COVID-19 pandemic in Tokyo, and also working on preparing infectious disease countermeasures for the Tokyo Olympics. In late 2020, as part of this research, we realised that the Tokyo Olympics faces a double burden of risk due to outbreaks of the novel coronavirus during the pandemic and heat stroke in both spectators and athletes. Together these risks offer a unique combination of challenges for the 2020 summer Olympics, and it is not clear if the Olympics organisers are ready to deal with them. Heat illness, its impact on Tokyo health system and the Olympics. A simple fact about Japan that is not widely appreciated outside of the archipelago is the extreme nature of its summer. Although short, the summer period in Japan from midJuly to mid-September is a period of extreme heat and humidity, which most non-Japanese cannot easily imagine. Temperatures in Tokyo in late July and early August routinely reach the mid-30s, with relative humidity in the 80s. Tokyo also has a ferocious heat island effect, which exacerbates the high summer temperatures, and due to its proximity to the ocean the heat does not subside at night. Because of this, public advisories about heatstroke prevention are ubiquitous in the summer months, and very few

sporting events are scheduled in this period. It is the worst time of the year to hold elite competitive sports. In general, the health risks of high temperatures are widely communicated with the public; however, humidity must also be taken into account, as high humidity can reduce heat loss, and negatively impact on the body’s cooling mechanism. This makes it easier for people to develop heat illness. From this standpoint, the Wet Bulb Globe Temperature (WBGT) is commonly used in daily life as a combined measure of humidity and heat, and for considering re-scheduling or cancelling sporting events. The weekly average of daily maximum WBGT has increased dramatically in mid-August in recent years, from above 31°C to a maximum of 33.5°C. There is a direct relationship between high WBGT and emergency transportations for heatstroke, with the number of transportations increasing rapidly for every degree of WBGT over 30°C. This relationship can be seen in figure 1, which shows the cumulative total of emergency hospital admissions through different routes (left axis) and WBGT (right axis) during key weeks of the summer months for the past five years. As a result, emergency medical services face difficulties in timely delivery of patients to appropriate healthcare institutions between late July and late August. The heat index in Tokyo is expected to be much higher than in previous competition venues of the Summer Olympic and Paralympic Games. A study

FEATURE: CORONAVIRUS AND HEATSTROKE

by our colleague Koji Wada showed that the mean WBGT in Tokyo during the period of the games reaches 34°C in the afternoon, with a range from 32 – 36°C, while the peak in Rio de Janeiro and Beijing was just 31°C. Furthermore, this peak is unrelenting: there is no point from midnight to midnight when WBGT falls below 30°C in Tokyo, and it is above 32°C for all sunlight hours. This will mean that Olympic athletes who have not yet adapted to the conditions will not perform properly. Furthermore, many groups with physical disabilities have a higher risk of heat-related illness, but no special health policy has been implemented for Paralympic sports. Given that many Olympic athletes are performing at the peak of human physical achievement, and many will not be used to the kind of temperatures they will experience in Tokyo, there is an increased risk to their health, and the possibility in some of the outdoor events of serious accidents. But our experience of COVID-19 in summer 2020 suggests that coronavirus counter-measures – in particular mask use and the need to ventilate indoor spaces – will worsen these already heightened risks. Our research, published in the International Journal of Environmental Research and Public Health in early 2021, showed that emergency admissions for heat stroke in summer 2020 may have worsened the challenges for emergency services dealing with coronavirus. These hospital admissions typically overwhelm emergency services, and some ambulances are forced to travel for long periods of time to find open emergency beds. We showed that in summer 2020, when Tokyo experienced a small wave of coronavirus infections, there was a peak in these delayed hospital admissions that was not consistent with the number of coronavirus infections, and was likely a consequence of the combination of many hospital beds being taken up with coronavirus patients at the same time as the sudden surge in heat stroke cases. This pattern is shown in Figure 2, which plots the daily case numbers of COVID-19 (left axis) and the number of daily emergency transportations which failed

Figure 1: Average Tokyo WBGT and distribution (right axis) and combined emergency hospital admissions for heat stroke (left axis) during key summer months in Tokyo, 2016 – 2020.

Figure 2: Daily COVID-19 cases (left axis) and emergency transportations that did not find a hospital within a defined time period (right axis) in Tokyo, March – September 2020.

to find a reception hospital within a defined time period (right axis). Although daily cases in Japan at present are not especially high, with Tokyo seeing between 300 and 700 new COVID-19 cases every day, we are currently under a state of emergency that is expected to end

on 20th June, and it is likely that by the start of the Olympics Tokyo will be experiencing a new wave of COVID-19 cases. Moreover, COVID-19 clusters caused by several variants of concern have been reported, and many of their related cases have become untraceable. With the onset of the summer heat this could cause the same sudden VOLUME 38 • ISSUE 4 2021

FEATURE: CORONAVIRUS AND HEATSTROKE

Coronavirus and heatstroke at the Tokyo Olympic Games surge of hospital admissions, blocked beds, delayed emergency admissions and health system pressure that was seen in summer 2020 – only this time it will be exacerbated by the presence of a large number of foreign visitors who are at high risk of heat stroke and do not understand Japan’s summer weather or its health system. COVID-19, its impact on the Tokyo health system and the Olympics. Compared to other high-income countries, Japan has so far mitigated the worst epidemiological impact of COVID-19. Despite the fact the ongoing transmission of COVID-19 in Japan has been classified as “clusters of cases”, around 50% of contacts cannot be traced in Tokyo, suggesting the presence of some untraced community transmission. Furthermore, Japan has lagged in COVID-19 vaccination rates compared to other high-income countries. While the vaccination program first started in mid-February, only 15% of the population (mainly health workers and people aged 65 and over) had been vaccinated by early June. The International Olympic Committee (IOC), International Paralympic Committee (IPC), Tokyo 2020 Organising Committee (Tokyo 2020), the Tokyo Metropolitan Government (TMG) and the Government of Japan have developed a range of measures to enable the Games safely in the context of COVID-19. They also said that 80% of the Village would be vaccinated, and some countries prioritise vaccination of athletes ahead of the Olympic Games Tokyo 2020. Nonetheless, there are multiple risks surrounding the Olympic and Paralympic games, connected to both Tokyo’s unprecedented heat and the unusual coronavirus situation. Although many athletes are very fit and young and unlikely to experience significant ill-effects of coronavirus infection, an outbreak of COVID-19 26

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It is likely that by the start of the Olympics Tokyo will be experiencing a new wave of COVID-19 cases.

among athletes at their accommodation remains a significant risk. This will have particular risk for some athletes who may be clinically overweight (for example, heavyweight fighters and weight lifters), who may be dieting to cut weight (for combat sports or other events with weight classes) or who are older (for example shooters and equestrian athletes) and at greater risk from viral infection. In addition to the risk to the athletes’ health, such outbreaks may also lead to the interruption and/or cancellation of events, and the possibility that the Olympics could become a global super-spreader event as athletes and support staff from over a hundred nations return to their home countries. For many athletes, strict COVID-19 countermeasures will require that they wear masks in public and at sporting venues, while waiting between events and in waiting areas for events. A key component of Japan’s relatively successful countermeasures against COVID-19 has been action against the “three Cs”: closed, crowded and close-contact settings. To be consistent with these counter-measures, event venues will be generally ventilated with free movement of air from outside,

which will reduce the effectiveness of air conditioning and increase interior temperatures, preventing sportspeople from gaining the respite they might need to lower body temperatures. Of course, close environments will be necessary for several competitions like badminton and table tennis, which potentially have higher risks of COVID-19 transmission and could trigger superspreading events. Many athletes in track and field, equestrian, boating, shooting, archery and other semioutdoor and outdoor events may have to spend long periods of time waiting in high-temperature locations wearing masks, possibly in direct sunlight, when daytime WBGT values will lie in the extreme range. This will increase the risk of both minor heatstroke events and major incidents with potentially life-threatening consequences for some athletes. At the same time, a renewed wave of coronavirus infections in the general community will put pressure on the health system, leading to the same delays in emergency response that were observed in Tokyo in 2020, but exacerbated by the sudden demand placed on the system by heat stroke among Olympic participants, support staff and spectators. However, it is also important to discuss whether prioritising vaccination for the Olympic and Paralympic Games participants is truly fair and ethical, as rich countries dominate vaccine supplies and many essential workers, even healthcare workers, in low-and middle-income countries are still facing challenges to be fully vaccinated. The 2021 Olympics presents the spectacle of rich countries hoarding vaccines to protect elite athletes from coronavirus exposure in an event the majority of Japanese citizens think should be cancelled, only to create a super-spreader event that inflicts new waves of the pandemic on countries that are unable to access those same vaccines. This is the perfect example

FEATURE: CORONAVIRUS AND HEATSTROKE

of sport acting as a mirror for global society’s ills, and there is little evidence that the Olympics organisers have any interest in addressing this issue.

About the Authors Stuart Gilmour is professor of biostatistics and bioinformatics at the Graduate School of Public Health, St. Luke’s International University, Japan.

Olympics from the perspectives of public health systems and services. The peak of emergency transportations due to heat illness overlapped the resurgence of COVID-19 in 2020, and an increase of heat illness patients with rising WBGT has been observed. Without urgent reconsiderations and sufficient countermeasures, the double burden of COVID-19 and heat-related illnesses in Tokyo will overwhelm the healthcare provision system and maintaining essential health services will be challenging during the 2020 summer Olympic and Paralympic Games. Our research provides clear evidence that emergency medical services faced difficulties in delivering patients to appropriate healthcare institutions and early intervention in July and August 2020 in Japan, and there is every risk that the same conditions which caused those health system burdens in 2020 will be repeated or even worse in 2021. This summer’s Olympics are still underprepared for safely organising the games in the context of both COVID-19 and heat policy. Considering the ongoing COVID-19 pandemic and Japan’s overwhelmed public health systems, securing sufficient surge capacity for the games, such as resources for regular COVID-19 screening and isolation facilities in multiple venues where the games are scheduled, will be an imminent challenge. People watching the games at home should remember the extreme heat stroke risk that the athletes are facing, as well as the background risk of coronavirus spread in Tokyo. These games are not popular in Japan, and the callous disregard that the international organisers have shown for both the athletes and the citizens of Tokyo should not be forgotten as the spectacle unfolds.

Stuart was born in New Zealand and raised in Australia by British parents, and has lived in Japan since 2006. He originally studied physics but shifted careers to public health where he began his career researching the health of marginalized populations, especially sex workers and people who inject drugs. Stuart obtained his undergraduate degree in mathematical physics at the University of Adelaide, completed masters in Public Health at the University of Sydney, a Masters in Statistics at the University of New South Wales and his PhD at the University of Tokyo. His research interest is in quantitative health system assessment, the use of statistics to improve our understanding of policies and interventions that can improve population health, especially where it is affected by inequality and exclusion. Kazuki Shimizu A cosmopolitan-minded physician and scientist of global public health. His expertise ranges across critical topics in global health, such as infectious disease epidemiology, health emergency preparedness and response, global health security, health system financing, and public private partnerships. At London School of Economics, he was mainly involved in “The Lockdown” survey, a global initiative to capture the experience of social distancing policy and assess how the measures taken to fight against the COVID-19 pandemic affected the educational process, professional opportunities, and wellbeing. Previously, he was trained as a physician and completed his medical residency at the Medical Support Division, Toyota Motor Corporation. He also completed his externship at University of Florida Health Shands Hospital. He obtained his M.D. at Nagoya University, Japan, and earned M.Sc. from London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, United Kingdom. He is a certified physician in the Japanese Society of Travel and Health and holds a position as adjunct lecturer at Nagoya University Graduate School of Medicine, Japan. Phuong Mai Le is a Vietnamese researcher who has been living in Japan for 3 years. She completed a Masters of International Health in the Netherlands in 2016, and has rich experience in the HIV/AIDS response, with eight years working in the Vietnam Ministry of Health. Le presently works as a research assistant at the Graduate School of Public Health, St. Luke’s International University in Japan. She has published articles related to the healthcare system, HIV/AIDS, and global health issues. Her research interests focus on promoting the health of vulnerable populations, such as ethnic minorities, particularly women and children. VOLUME 38 • ISSUE 4 2021

FEATURE: CHALLENGES AT THE PARALYMPICS

Challenges and stresses leading up to the Paralympic Games WHILE THERE ARE NUMEROUS BENEFITS TO SPORT PARTICIPATION (I.E. DEVELOPMENT OF MOTOR SKILLS, IMPROVED PHYSICAL AND PSYCHOLOGICAL HEALTH), THE STRESSES AND CHALLENGES ASSOCIATED WITH THE HIGH-PERFORMANCE SPORT MAY BUFFER THESE POSITIVE OUTCOMES. WITHIN THIS HIGH-INTENSITY ENVIRONMENT, THERE IS A HIGH EXPECTATION FOR ATHLETES TO PERFORM AT THEIR BEST WITH SEVERE CONSEQUENCES FOR BELOWAVERAGE PERFORMANCES. NOT TO MENTION THE INCREASE IN MEDIA EXPOSURE AND SOCIETAL AWARENESS OF ONE’S PERFORMANCE. THE AMALGAMATION OF THESE FACTORS CAN EXPOSE ATHLETES TO EXHAUSTION AND BURNOUT, INCREASE CHANCES OF PHYSICAL INJURIES, AND IN EXTREME CASES, RESULT IN PSYCHOLOGICAL AND PHYSICAL DISORDERS. 28

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hile there are numerous benefits to sport participation (i.e. development of motor skills, improved physical and psychological health), the stresses and challenges associated with the high-performance sport may buffer these positive outcomes. Within this high-intensity environment, there is a high expectation for athletes to perform at their best with severe consequences for below-average performances. Not to mention the increase in media exposure and societal awareness of one’s performance. The amalgamation of these factors can expose athletes to exhaustion and burnout, increase chances of physical

FEATURE: CHALLENGES AT THE PARALYMPICS

There were a wide range of challenges expressed by athletes and coaches which were categorised into sport-specific, personal, and uncertainties.

Paralympics) can exacerbate these challenges, as often, there is an increase in training intensity, number of qualification tournaments, and training camps. Simultaneously, life outside of sport is usually put on hold while sport demands increase (i.e. media engagements, travel, etc.). Not to mention, the Quadrennial contract that coaches receive is often dictated by the team’s performance at the Paralympic Games while athletes’ performances can dictate future opportunities (i.e. being selected for the team the next quad, public speaking, sponsorship, etc.).

injuries, and in extreme cases, result in psychological and physical disorders. In the high-performance context, athletes are not alone in dealing with high expectations and criticism. Coaches too are prone to dealing with lofty expectations to support athletes’ potential and meet continuous sporting demands including balancing of expectations from a wide range of stakeholders (directors, administration team, support staff, parents, athletes) and increased scrutiny by media and news outlets which can result in exhaustion and burnout. The lead-up to major Games (e.g. World Championships, Olympics/

Therefore, understanding the challenges athletes and coaches face, and how they navigate these circumstances may help develop resources to better support them. In this study, we interviewed fourteen high-performance Australian Paralympic athletes (n=8) and coaches (n=6) to better understand challenges, solutions, and strategies utilised by athletes and coaches in the lead up to the Tokyo 2020 Paralympic Games. Challenges There were a wide range of challenges expressed by athletes and coaches which were categorised into sportspecific, personal, and uncertainties. Sport-specific challenges Sport-specific challenges captured the experience of athletes and coaches directly within the sporting environment. These challenges were either specific to their sport (e.g. budgetary constraints), tied directly to individuals (e.g. moving cities to access coaches), or factors that occurred within the sporting environments (e.g.

training and competition contexts). From a coaches’ perspective, there were budgetary constraints that they had to navigate to meet demands of increased travel costs due to training camps and qualification tournaments. Australia’s geographical location relative to other countries was not contributing to the cause. The constant travel also contributed to increased stress for athletes due to the physical and psychological demands including time zone changes, accommodations away from home, lower quality of sleep, slower recovery, and reduced energy. The geographical makeup of Australia also impacted the experience of athletes and coaches in the decentralised training environments. The lack of frequent in-person training contributed to a slower progression in building trust and developing relationships between athletes and their coaches and teammates. Therefore, coaches utilised training camps as an opportunity to increase comradery and increase team chemistry through team activities (sport and non-sport related). The looming performance expectations at the Games also increased the importance of strategic training to ensure optimal recovery and build-up was implemented so the athletes could be at their peak at the Games. This was especially significant for athletes who had impairments that could impact their physical well-being if the training load was not appropriately managed, increasing the stakes of careful planning. VOLUME 38 • ISSUE 4 2021

FEATURE: CHALLENGES AT THE PARALYMPICS

Challenges and stresses leading up to the Paralympic Games There were numerous sport-specific challenges athletes and coaches dealt with including the need to travel for tournaments and training camps which came at a cost financially, physically, and socially. There was also a clear emphasis on the athlete and coach dynamic to better understand athletes’ impairment, their abilities, and tendencies, and how these factors interact, in order to better structure effective training and maximize athletes’ potential in the lead up into the Games. Personal challenges The decentralised environment and geographical makeup of Australia forced some athletes to relocate cities or countries to work with their coach. The extensive commitment to their sport also prevented athletes from committing to other activities or opportunities (i.e. vocation or education), furthering the importance of performing well at the Games. The limited vocational opportunities also left athletes with limited financial means during the lead-up to the Games, forcing them to be strategic with their spending. Coaches were also compelled to spend extensive time away from their families, attending training camps and qualification tournaments. But coaches highlighted the families had grown accustomed to this type of lifestyle and were understanding the circumstances, which was welcomed by coaches since it reduced stress in one aspect of their already stressful situation. In summary, the increase in training camps and qualification tournaments during the lead-up to the Games increased demands for athletes and coaches’ time, compelling them to sacrifice in other areas of their lives. For coaches, it was mainly time away from family, while for athletes, they perceived this as time away from their social circles and potential education or vocation developments. 30

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Uncertainties One of the main uncertainties concerning athletes’ and coaches’ preparation leading up to the Games was the COVID-19 outbreak and its impact on qualification tournaments. It is important to note that the COVID-19 virus was not declared as a pandemic at the time the study was conducted, and participants were more concerned regarding the possibility of qualification tournaments being postponed or cancelled. Athletes showed little concern regarding the possibility of cancellation of the Games, while coaches had some inclination and potential of the outbreak affecting the Games but felt it would be important to proceed as planned until given reason to alter direction. Other uncertainties included the lack of information pertaining to the

number of accreditations each sport can receive at the Games which prevented coaches from developing strategies and implementing these during training. Therefore, limiting the type of Games-specific strategies that athletes can work on with their coaches. For some athletes who have impairments that fluctuate in severity, there were concerns regarding how they would feel on the day of their competition. Athletes highlighted the importance of consistency in their schedule (sleeping pattern, eating cycle, and nutrition macros) to increasing the likelihood of positive outcomes during the Games. The main uncertainty was related to the development of the novel coronavirusCOVID-19, which impacted training camps, qualification tournaments, and delivery of equipment for Tokyo 2020.

FEATURE: CHALLENGES AT THE PARALYMPICS

Lastly, there were concerns regarding athletes’ physical and mental state on event day, with some athletes concerned regarding how their body would respond and whether there will be any impairment-related complications to deal with on the day of the competition. Strategies Strategies highlighted the range of tools athletes and coaches utilised or plan to implement to combat or prevent some of the challenges. Anticipation and Preparation While there were numerous uncertainties during the lead-up to the Games and how the they may proceed, participants emphasised the importance of anticipating challenges and developing solutions to be prepared for a wide range of outcomes. This involved rehearsing certain aspects of the competition outcome during training and coaches focusing on creating an environment that may facilitate opportunities for athletes to learn and adjust (e.g. introducing unexpected challenges during training to see how athletes cope with the changes).

Similarly, athletes also noted the importance of aiming high but also realising the realistic chance of a ‘less than ideal’ outcome. In addition, there were uncertainties regarding accreditation which created a complex situation for coaches to navigate and prepare for as they attempted to develop a training environment similar to the Games.

As part of this, communication between athletes and coaches was seen as paramount to a successful outcome. Therefore, exploring multiple means of communication including transparency and clarity in information sharing was very important to be effective. For athletes, they supplemented this by utilising visualisation and imagery strategies to cope with the uncertainties and develop alternative contingency plans. This level of preparation was reported to reduce physical and psychological stress both for athletes and coaches. Managing Expectations It was also evident that managing expectations within the team were important to the chemistry and growth of the team. This included

managing athletes’ expectations on the level of support they would receive both in preparation and during the Games. For support staff, it was important for coaches to clearly articulate each person’s role to prevent miscommunication and ensure a smooth transition on competition day. But more importantly, coaches realised through self-reflection that they needed to manage their own expectations and take care of their health, so they can be in the right mind frame to be able to support the athletes when it matters. Managing their own expectations also helped deal with their personal stress levels. Similarly, athletes also noted the importance of aiming high but also realising the realistic chance of a ‘less than ideal’ outcome. Understanding the multiple narratives allowed athletes to better cope with the doubts that crept into their minds during training. Coaches, too, realised the importance of psychological support at the event, in case an athlete had a disappointing race and needed support in coping with the results. Therefore, for both coaches and athletes, the focus was mostly on their preparation and performance at the Games, and less on the outcome (i.e. medaling or podium finish). Post-Tokyo All the participants were focused on their current goal of achieving the best they can at the Tokyo 2020 Games, thus, conversations regarding post-Tokyo were a mere reflection of what the athletes and coaches miss and what things they would be looking to incorporate into their lives with the reduced workload post- Paralympic Games. For athletes and coaches, inevitably, the performance at the Games dictated certain outcomes post-Games. Thus, there was the theme of ‘pressure.’ VOLUME 38 • ISSUE 4 2021

FEATURE: CHALLENGES AT THE PARALYMPICS

Challenges and stresses leading up to the Paralympic Games Pressure Coaches realised that the outcome of the Games may dictate their employment opportunities. However, unanimously, coaches accepted this as part of their job and highlighted the pressure of performing at the Games was not influenced by the lack of uncertainty regarding their employment status post-Games. Athletes were also aware of the potential opportunities (e.g. public speaking, sponsorship) that could be presented after an ideal performance at the Games. Others in the ‘grey area’ in their careers, saw the Games as feedback to whether they would continue to train for Paris 2024 while some athletes saw the 2024 Paralympic Games as an opportunity to ‘redeem’ themselves if they have a bad performance at the 2020 Paralympic Games. In summary, while athletes and coaches understood the repercussions of their performance at the Games, they were solely focused on a good performance, rather than the consequences that may occur because of it.

Takeaway Points The findings from this study highlight the wide range of challenges that athletes and coaches navigate through as they prepare for the Paralympic Games including sportspecific (budgetary constraints, need for meticulous planning and commitment to increased training, increased travel) and personal factors (lack of social, personal, vocational, or educational outlets). Uncertainties including the COVID-19 pandemic, qualification status, and accreditation also contributed to the stress participants dealt with in preparation for the Tokyo 2020 Paralympic Games. However, athletes and coaches demonstrated strategies including anticipation, planning and managing expectations in dealing with some

of these challenges. Contingency plans, effective communication, and understanding of each other’s roles appeared to be paramount in coping with expected and unexpected events both in preparation, leading up to the Games, and performance at the Games. Lastly, while there was little consideration to outcomes postTokyo, participants did look forward to resuming activities in their lives outside of sport and decreasing the level of commitment in their sport for a short time. There was pressure to perform at the Games as it may have consequences post-Games; however, athletes and coaches were laser-focused on their performance at the Games and less worried about the consequences of poor performances.

About the Author Dr. Nima Dehghansai Nima currently works as an Athlete

Personal Participants highlighted that the preparation for the Games has been exhausting, leaving them disconnected from their families and social circles. In addition, extensive training has had a toll on their bodies. Thus, they were looking forward to a mental and physical break while incorporating their social life back into their lives. Some athletes demonstrated excitement to be relocating back to their ideal living conditions while others shared sentiment to revisiting families and friends while others were looking forward to commencing or resuming vocational or educational commitments. For coaches, they were looking forward to some family time to make up for the time lost preparing for the Paralympics. 32

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Development & Talent ID specialist at Paralympics Australia. He utilises researchdriven empirical evidence to inform policies and initiatives that optimise the sporting environment to maximise athletes’ development. By using a mixed method designed research program, Nima aims to continue to expand and further understanding of factors that impact athletes’ experiences in the Paralympic system, from initiation and recruitment to development across their athletic careers. Nima’s holistic approach to developing strategies in sport has resulted in numerous international collaborators including universities in Australia, Canada, Germany, The Netherlands as well as Australian and Canadian national sporting organisations. Nima along with colleagues, Dr. Ross Pinder and Dr. Joe Baker are authoring a book that examines talent identification and development in Paralympic sports.

FEATURE: NUTRITION AND THE TOK YO OLYMPICS

Nutrition and the Tokyo Olympics THE TOKYO 2020 OLYMPIC GAMES, TO BE HELD IN JULY 2021, HAS BEEN A CONSTANTLY EVOLVING LANDSCAPE AND WILL BE AN OLYMPIC EXPERIENCE UNRIVALLED BY ANY OTHER OLYMPICS SO FAR. PEAK PERFORMANCE AND HEALTH FOR ATHLETES AND STAFF HAS NEVER BEEN MORE IMPORTANT, AND THE ROLE APPROPRIATE NUTRITION PLAYS IN SUPPORTING PERFORMANCE AND HEALTH OUTCOMES WILL BE PARAMOUNT.

stablishing a nutrition service for the Australian Olympic Team in Tokyo has involved many layers of consideration and contingency plans to make sure we have optimal nutrition strategies in place for a constantly evolving environment. We have been grounded by a purpose to create an environment which enables athletes to execute their well-practiced performance nutrition plans. Pre COVID-19 we were working with some challenging anticipated circumstances to manage, including extreme heat and humidity, traveling long distances, early starts and long days, food safety, power conversions and limited space. Throw in a global pandemic and detailed COVID-19 safe countermeasures on top and that means quite a few challenges and boundaries to work within. VOLUME 38 • ISSUE 4 2021

FEATURE: NUTRITION AND THE TOK YO OLYMPICS

Nutrition and the Tokyo Olympics The key skill in approaching this has been being comfortable with the unknown and being able to stay focused and patient when you simply don’t know what things might look like or what the outcomes might be before acting. In a profession where we are all very evidence based it is a shift in mindset to delicately balance what you can control with ‘what if’ situations and risk assessment while having performance and the athlete at the forefront of all our decisions. The nutritional needs, tastes, energy demands, schedule, and special dietary requirements of Australian athletes and support staff have been considered to offer a range of services to support their needs at the Games, both in the village and at venues. With high consumption rates and

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a growing range of specific dietary needs, the range and variety of foods required has expanded greatly in order to accommodate nutrition demands and individual needs. A wide range of convenient and non-perishable food selections, targeted supplements and cooling techniques have been shipped to Tokyo to set up the food environment we have envisaged. With a strong foundation in place to cover essential nutrition needs it will invite flexibility to be agile with our daily service delivery and adapt to the environment to support the unique needs of the athletes and ensure they can feel and perform at their best. A big talking point for most Games is the Village dining hall where all of the countries come together to eat. This

year it will take on more of a functional role than a social one, to provide main meals for athletes. Menus and times of congestion will be shared with athletes ahead of attending to better distribute crowds and get people in, eat and out again promptly. As the athletes will be facing a confined and somewhat unfamiliar environment, it’s also important that we support the athletes as humans and acknowledge the role that food plays beyond fuelling. Having familiar and comforting food available can create a positive experience and welcoming environment which will likely be of significant physiological and psychological benefit. In this instance there will be plenty of Weet-Bix, Milo and Vegemite to have some home-town comforts.

FEATURE: NUTRITION AND THE TOK YO OLYMPICS

It’s been such a privilege to be involved with such a hard-working team so dedicated to making these Games the best that they can be. It has been a remarkable experience to be a part of so far and has offered so many learning opportunities. From championing the nutrition non negotiables, working through challenges, to seeing the support and value for nutrition services, and the role we can play in the athlete’s experience and performance at the Games. Learning from the athletes as well, they have shown their resilience and focus with the extended preparation for the Games and their dedication to compete and show how unbeatable they are not just on the world stage but in spirit.

Advanced Sports Dietitians Gary Slater and Sally Walker have established the nutrition services for the Australian Olympic Team as part of AOT headquarters performance support, assisted by AccSD Holly Edstein with on the ground support at the Games.

About the Author Sally Walker Lead Dietitian for the Australian Olympic team, Sally is an Advanced Sports dietitian and APD who is currently the Nutrition Lead at the NSW Institute of Sport where she has developed a Nutrition Delivery Model to support the effective integration of nutrition services into multi-disciplinary performance teams.

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FEATURE: TOK YO AND THE PARALYMPICS

Tokyo and the Par A

fter a challenging year’s delay, the Paralympic Games in Tokyo will begin on August 24th, 2021. No doubt that the games will bring joy and triumph for athletes, coaches, and their countries who have withstood challenges previously unimaginable through COVID-19 worldwide. The road to this year’s Paralympic games, however, has been rough, with the pandemic impacting every aspect of athletes physical and mental health, their ability to train and prepare through their usual competition schedule. Even the games themselves will be a pale shadow of their usual grandeur.

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Athletes training to participate on the world stage tend to base their training on four-year cycles, with the goal of building up to their peak performance during the games. A whole year’s delay of the Paralympics upended these time-tested training strategies. Athletes had to recalibrate their training schedules to peak one year later than originally planned. Changing both short and long-term training goals is not an easy task and must be made in consultation with coaches and medical professionals. All of them could meet only virtually during this critical pre-Olympic year.

For athletes, whose bodies could not take another 12- months of training, the one-year delay has meant retirement and an end to their athletic career but conversely for younger athletes coming through it has given them the vital time needed to impact the world stage. Making this switch even more complicated, athletes had no opportunity to participate in preOlympic lead-in competitions, which were cancelled as the world shut down. These competitions direct athletes’ pre-Olympic training regimens, as they identify strengths and weaknesses in performance. Even

FEATURE: TOK YO AND THE PARALYMPICS

ralympic Games some training camps to be held in Tokyo in the weeks leading directly up to the games have been cancelled, as Japan has faced a resurgence of COVID-19 infections. The early-stage competitions are fundamental to athletes’ understanding of where they rank relative to their competitors, and the pre-game lead in competitions provides an important opportunity to acclimate to local conditions.

As the games involve not just individual competition but representing one’s country in competition, the loss of this ceremony highlights the many casualties of the pandemic year for athletes. Athletes also will not be participating in a closing ceremony, as they are required to fly home as soon as they complete their events, leaving no time to cherish their Paralympic experience.

The mental-health impacts of the COVID-caused delay have also been substantial. Training in isolation, assuming that training could occur when facilities may not have been available, takes extra mental discipline. Athletes find inspiration in competition and the sports community. Even those athletes who found inspiration in the delay, as they figured out how to put the many pieces of the training puzzle together in a new way, were challenged because they could not simply focus on their sport. With all of the various lockdowns and travel restrictions imposed by the government, it became much harder for them to train. Facilities were closed, and substitutes can be hard to find or non-existent. Paralympic athletes also faced the additional challenge of losing their place at certain facilities that favored Olympic athletes.

Another unexpected mental health challenge for these athletes has been the public outcry against the staging of the games even in 2021. Public concern in Japan and around the world regarding an event that will gather together thousands of people before COVID-19 is truly on the wane has led to calls for boycotts of sponsors and calls for the athletes themselves to refuse to participate in the games. Athletes will experience conflict about

the best course of action they can take - compete but risk losing respect from their countrymen or stay home and lose the chance to bring a medal home for those same countrymen? With only 3.1% of Australians vaccinated as of June 15th and worldwide vaccination rates still under 10%, the risk of the Paralympics becoming a super-spreader event are real. These athletes, who are certainly no strangers to overcoming challenges and being resilient, may have only this year’s games to prove themselves to their sport, their country, and the world. By the time the Paralympic games eventually ends we will have witnessed many remarkable feats and likely have seen many records broken and medals won. For this year’s class of Paralympians, just getting to the games may be the most remarkable feat of all.

About the Author Murray Elbourn Murray has over 30 years’ experience in the disability sports sector as an athlete, coach, and sports administrator. He previously held

Moreover, the isolation will not end at training but instead will be an integral part of how the Paralympics are conducted. To keep everyone involved in the games safe from COVID-19, the Paralympic athletes must isolate themselves for 6-8 weeks before the games. While in Tokyo, they will need to receive their meals in their rooms rather than in the traditional Olympic village.

the position of Disability Inclusion Manager at Sport NSW, CEO of Blind Sports NSW, and Chair of Goalball Australia. In all three roles, Elbourn lead significant programs for people with a range of disabilities, increasing participation, revenue, and advocacy of the sector. Prior to his roles at Sport NSW and Blind Sports NSW, Elbourn served as National Client Services Manager at Energy Action and Internal Business Manager at E Utility and Konica Minolta in the United States. Murray has most recently also sat on the NSW

Other Paralympic traditions will also be missing this year in Tokyo. There will be no opening ceremony where athletes march out with their team.

Office of Sport Covid-19 sport recovery group as the representative across the disability sports sector.

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COMMUNIT Y NEWS

Sports Medicine @SMA_News sma.org.au • 2021 SMA Conference registration open • Dr David Hughes to present prestigious Sir William Refshauge Lecture at 2021 SMA Conference

@AICE aice.org.au • Communicating to Improve Patient Care Seminar • ACA Conference 2021 • 2021 Sports Chiropractic Symposium • CPD Dinner on Oral Posture and Function

@ACSEP_ acsep.org.au • ACSEP response to SCPCCC report • ASCEP Annual Conference Highlights

@APS_ psychology.org.au • A $2.3 billion shot of adrenaline for the mental health sector • Psychologists applaud Victoria’s historic investment in mental health

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COMMUNIT Y NEWS

Community News @SportsDietAus sportsdietitians.com.au • SDA Conference 2021

@ESSA_News essa.org.au • ESSA launches eBook to encourage Aussie men to look after their health with physical activity • Australia leads pain management sector with the release of new action plan • Exercise is Medicine Australia celebrates 10 year anniversary • ESSA 2021 Annual General Meeting sees appointment of newly Elected Directors • Summary of the Australian 2021-2022 Budget and its impact on the exercise & sports science industry

@APAPhysio australian.physio • Thrive 2021 Physiotherapy Conference • Government must commit to funding ongoing preventative care and rehabilitation in residential aged care • Urgent business assistance a vital lifeline for Victorian private practice physios • Mental Health gets more money in budget but still a long way from achieving collaborative health care that recognises the role of physio • Australian Physiotherapy Association response to 2021-22 Federal Budget • Rural health initiatives welcome but major challenges to workforce and viability of services remain • APA launches ‘With Your Physio’ campaign to help treat chronic health conditions • APA says NDIS Independent Assessments must be scrapped

View the online version of Sport Health to see links. VOLUME 38 • ISSUE 4 2021

5 MINUTES WITH

5 minutes with

Dr Adam Castricum

Tell us a little bit about your background With European parents that migrated here in the 50’s after the Second World War, I was born in the multicultural melting pot of Dandenong. Being from Melbourne, I naturally grew up with a love of all sports, both playing and watching. Weekends in the winter for me were playing football in the mud in the morning and then the “Big League” in the afternoon at the old VFL Park in Waverley. Through school, I also played tennis, basketball and loved athletics, with the pinnacle for me being competing at the old Olympic Park on Swan Street by the Yarra. I also spent many school holidays working at my Dad’s abbatoirs, but realised I did not want to work in the family business pretty quickly. I went on a school trip to Nepal as a 17-year-old and was exposed to poverty and life I had never seen before which changed me forever. I wanted to help people. I was obsessed with the Olympics from Moscow onwards and dreamt of one day getting to the Olympics. When I realised 6.97m for the long jump and 11.3 for the 100m wouldn’t cut it for the Australian team, let alone state all schools, I was walking past the Olympic rings out front of the old Olympic Park Sports Medicine Centre on the way home from a competition and my new dream of being a sports doctor was born! How did you get involved at SMA? After getting through six years of medical school at Monash after a two-year stint in science at Melbourne 40

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University, I wanted to know how to get into Sports Medicine. I had no other passion in medicine. I remember asking at Olympic Park how to do that, and I was put in touch with Dr. Peter Brukner. Peter warmly invited Kylie Shaw (now a Sport and Exercise Physician in Canberra) and myself over for a BBQ at his place and hatched the plan for us to get on the ACSEP training program. In addition to making sure I read the back page of the newspaper, part of that was to join SMA to get more involved in Sports Medicine and the wider community. If I enjoyed it, then sports medicine was

5 MINUTES WITH

for me. If I didn’t, then find another career! SMA opened up my eyes to the many wonderful possibilities and relationships that sports medicine can offer, and who doesn’t love a conference where everyone is on your wavelength! I have spent much time since getting my ACSEP Fellowship as a Sport and Exercise Physician in 2008 repaying that wonderful opportunity, hopefully inspiring the next generation of passionate sport and exercise medicine clinicians, in whatever field. What does a typical day in your life look like? Much different to 12 months ago!

young family for two weeks, after a COVID-19 exposure. Seven months later after a two-week stint in managed isolation in Auckland, we finally got to Queenstown and set up our base for the next few years. I had also stepped off the ACSEP Board after six years and my role as Head of the Olympic Park Sports Medicine Centre Medical Department for the last 10 years, so was frankly burnt out and looking forward to significantly reducing my workload and spending more time with my young family, who like us all had an incredibly disrupted 2020.

So, my day now is super simple. In the warmer months I will ride my bike to work along the picturesque river trails in the fresh mountain air. In the colder winter, as we have one car (four-wheel drive here in the mountains), I get dropped off on the morning school and childcare run to see patients in clinic until after school pick up, four days a week. My clinic here is a different mix to the patient load at OPSMC last year, where we had no sport in Melbourne for most of the year, and lots of inactivity related MSK pain. Given the Queenstown terrain,

My typical day has changed in the last three months, after my family and I decided to take a sabbatical in Queenstown, in Aotearoa/New Zealand at Axis Sports Medicine. A few years ago, my good friend and colleague, Mark Fulcher, who is the new ACSEP President, offered a spot at their fledgling sports medicine offshoot in Queenstown set up by Dr. Sarah Beable, a wonderful young Sport and Exercise Physician, who I had worked with a bit at the Rio Olympics in 2016, and since on various college committees. The decision to move across the ditch was cemented at the start of the second Melbourne lockdown of 2020 whilst I was isolating away from my VOLUME 38 • ISSUE 4 2021

5 MINUTES WITH

5 minutes with

Dr Adam Castricum my patients are generally outdoor adventure types, so lots of injuries and a much more musculoskeletal focus given the ACC have an excellent insurance funding model here that covers all consultations and most treatments for injuries and trauma for free. This ensures much more equitable care for all the community, which Australia could certainly learn from. When I arrived here, Sarah had a six-week waiting list, which we have now reduced to less than a week for the Southland/Otago region. I’ve also brought across an ultrasound machine for MSK interventions, which means patients can get these interventions at the time of their consultation rather than waiting another four to six weeks for this from the local overstretched radiology service. The

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impact it has on this region to get people back to work, school and doing the activities they love is incredibly satisfying and reinforces why I love my chosen specialty so much. It also reinforces why it is important to remain a generalist even when a specialist and not try to sub-specialise too much as this reduces your expertise which is all the more important in a regional setting like Queenstown. Continuing on my COVID-19 routine from Melbourne, most nights I cook for the family and find this incredibly satisfying and meditative at the same time. Then it’s reading the kids bedtime stories and catching up on Netflix, AFL games or various committee work. I have Wednesday off each week to exercise with my wife, Sophie, after

kids drop off, whether it be in the gym, a walk up a nearby hill or around the edge of the Queenstown lake or in the coming winter, ski on the nearby Coronet Peak 15 minutes straight up. I also keep up remote telehealth consultations with my Australian based OPSMC patients as required to help continue their care. I continue to teach ACSEP registrars remotely preparing for their Part Two exams, as have a love of teaching and preparing the next generation. Every weekend I go for a long bike ride which I started at the start of lockdown 1.0 last year and the family go for a hike together. Getting the right balance of work, exercise, family and friends is front and centre for me at this stage of my career and our sabbatical here provides such a wonderful opportunity to reset.

5 MINUTES WITH

I am incredibly proud and fortunate to be part of such a wonderful college and family and feel that is the greatest strength of the Sport and Exercise Medicine community – the sense of team and collegiality.

What has been the highlight of your career so far? It’s incredibly hard to give one highlight as I’ve been incredibly lucky to be a part of so many wonderful teams and moments, whether it was Olympic Golds with Sally Pearson in London, World Championship Gold with Steve Hooker in Berlin or the two premierships with Hawthorn. My most humbling and satisfying highlight though was my three years as President of the Australasian College

of Sport and Exercise Physicians and having the most fantastic opportunity to work with our incredible Board, CEO and management staff to advocate for equitable access for all in Australia to all the benefits that sport and exercise medicine has to offer, regardless of background. Bringing greater diversity to our college and handing over to our first female President, Louise Tulloh, in Queenstown at our Annual Conference is a moment I will cherish for a lifetime. I am incredibly proud and fortunate

to be part of such a wonderful college and family and feel that is the greatest strength of the Sport and Exercise Medicine community – the sense of team and collegiality. For you, what is the biggest benefit of being an SMA member? The biggest benefit of being a SMA member is that you get to be part of a wider SEM community that has just as much comradeship and community. The annual conference is a wonderful event to collaborate and catch up with friends, old and new, as well as keep up to date with the very best SEM research in the world. I’m fortunate enough to be on the Conference Committee, so I get a first-hand look at all the quality SEM papers with a fantastic team. SMA can open so many doors, and you can learn so much, but, like many of the best things in life, you only get out of it what you are prepared to put in. What is the best piece of advice someone has given you? Don’t be afraid to try something new. VOLUME 38 • ISSUE 4 2021

PEOPLE WHO SHAPED SMA: PETER TERRY

People Who Shaped SMA

Peter Terry What made you decide on a career in Sports Medicine? I suppose I was a classic “wannabe” elite athlete who wasn’t quite good enough to reach the heights myself, so decided that helping others who were good enough was the next best thing. I’ve been very privileged to assist some of the very best. Were you an athlete prior to commencing your career? If so, what sports did you play? I was a half-decent all-rounder, playing in representative teams in rugby, football (soccer) and athletics. I was in the same primary school football team as Gerry Francis, who went on to captain England and manage Spurs, and I briefly played at semi-professional level in my late teens. I played rugby for 20 years, captained my university 1st XV, had two years playing varsity rugby in Canada, and bizarrely represented an Ireland team (via my paternal grandfather) in a 5-nations sevens tournament. Early in my sport psychology career, to demonstrate to the GB bobsleigh team that I could “walk the talk”, I also competed in the 1989 national championships. Can you describe your educational background? After attending Chiswick Grammar School in London, I studied Physical Education and

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English at Borough Road College (then part of London University), the oldest teacher training college in the Commonwealth. I then completed an MA at the University of Victoria in British Columbia, before returning to the UK to complete my PhD in Psychology at the University of Kent. How and when did you start working in Sports Medicine? My first assignment as a sport psychologist was assisting an athlete, whom I’d known from my university days, at the 1983 World University Games in Edmonton, Canada. He won gold, which gave me the erroneous impression that success was rather straightforward. Since then, at nine Olympic Games (three winter and six summer) and more than 100 other international events, I’ve learned otherwise. International medals typically involve endless hours of sacrifice, blood, sweat and tears. The efforts of the most talented and dedicated sports medicine professionals usually go unheralded, except through the gratitude of the athletes who benefit from their efforts but don’t necessarily win. How and when did you first join SMA? What was your initial role? I moved my family to Australia in 2000, just prior to the Sydney Olympics, and joined SMA soon afterwards. Having been elected National Chair of the Australian

PEOPLE WHO SHAPED SMA: PETER TERRY

Professor Peter Terry (centre) at his first of nine Olympic Games (Albertville, 1992) chatting with HRH Princess Anne and HRH Prince Albert of Monaco.

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PEOPLE WHO SHAPED SMA: PETER TERRY

People Who Shaped SMA

Peter Terry

Psychological Society (APS)’s College of Sport & Exercise Psychologists, I took up an ex-officio position on SMA’s Council of Representatives from 2002-2006. I was so impressed with SMA’s inclusive approach to the range of sports medicine disciplines, especially the mutual respect for one another’s expertise, and took great pleasure in helping to organise several sport psychology conference programs at SMA annual conferences. I was also invited to join the editorial board of JSAMS and became an assistant editor from 2004-2009. How did being part of SMA help your career? SMA is the peak body for sport medicine professionals in Australia and the obvious place to collaborate with like-minded individuals. I never

Professor Peter Terry with Olympic gold medalist trap shooter Suzy Balogh (Athens, 2004).

really considered whether it would help my career when I joined, although it probably has via the connections it helped forge. For me, the professional collaborations and personal friendships have been the biggest reward.

What has been your contribution to SMA? I wouldn’t wish to overplay my contribution to SMA, as many others have done far more to advance the cause of sports medicine in this country. I’m just grateful for the opportunity to have been something of a conduit between the SMA, the APS, the world of elite sport, and the sport institutes via my longstanding involvement with the Queensland Academy of Sport. I’ve made regular presentations at SMA conferences and contributed articles in JSAMS, and hopefully I’ve been a decent role model for sports medicine whenever the media came calling. What has been your career highlight? Obviously, it’s hard to go past involvement in multiple Olympic Games, especially when medals have been won. That feels like a tiny contribution to history. Beyond that though, I take great satisfaction in having been regarded by my peers as someone worthy of representing them on committees and in figurehead positions. I’m truly honored to have been made a Fellow of the Australian Sports Medicine Federation and other professional organisations. Also, in the wake of Naomi Osaka’s stand on behalf of

With Australian shooting legend, Michael Diamond, at the 2007 World Championships in Cyprus. 46

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PEOPLE WHO SHAPED SMA: PETER TERRY

athlete mental health, I reflect with great satisfaction on my involvement in the Women’s Tennis Association Age Eligibility Commission more than 20 years ago, which brought about significant change to the path for adolescent girls into professional tennis and produced enduring benefits for player well-being and career longevity. Do you have any career regrets? I think I’m with the great French singer Édith Piaf on this one, when I say “Non, je ne regrette rien”. Perhaps I should have moved to Australia earlier in my career though.

What do you believe is your most important contribution to your industry? I’d say my most enduring contribution to the profession has been in helping to produce the next generation of sport psychology practitioners via my role as Professor at the University of Southern Queensland (USQ). It gave me immense satisfaction to see the likes of Georgia Ridler, Michael Lloyd, and Gene Moyle (all products of the USQ program) become so influential in Australian elite sport. I also take pride in having helped to develop sport psychology throughout the AsianSouth Pacific region during my time on the Managing Council and as President

of the Asian-South Pacific Association of Sport Psychology (ASPASP). What is your advice to those starting out in their sports medicine career? Never pass up an opportunity to get involved and be willing to make contributions to the professional bodies you join. Links: When Naomi Osaka talks, we should listen. Athletes are not commodities, nor are they super human (theconversation.com) https://bjsm.bmj.com/content/ bjsports/40/5/464.full.pdf

With six-time marathon kayak world champion, Anna Hemmings, at the 2005 World Championships in Perth, Australia. VOLUME 38 • ISSUE 4 2021

SPORTS MEDICINE AROUND THE WORLD: SPAIN

Sports Medicine in Spain ALTHOUGH IN MANY COUNTRIES SPORTS MEDICINE IS AN ADDITIONAL COMPETENCE, IN SPAIN IT IS A PARTICULAR TRAINING THAT INCLUDES GENERAL AND SPECIFIC FORMATION WITH ALL FIELDS OF SPORTS MEDICINE (EXERCISE PHYSIOLOGY, ERGOMETRY, ORTHOPEDICS AND TRAUMATOLOGY, BIOMECHANICS, ANTHROPOMETRY, RESPIRATORY CONTROL, CARDIOLOGY, SPORT NUTRITION, PHYSICAL ACTIVITY FOR HEALTH, SPORTS PERFORMANCE, SPORTS PSYCHOLOGY, MOUNTAIN MEDICINE, EMERGENCY MEDICINE, UNDERSEA AND HYPOBARIC MEDICINE AND ANTI-DOPING).

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SPORTS MEDICINE AROUND THE WORLD: SPAIN

fter six years of medical education, similar to rest of EEC, whose training includes a subject on exercise physiology or physical exercise and health (30-60 hours) in most Spanish Universities, specialised training starts, including sports medicine. At this regard, sports medicine started as a regulated training in 1987 and the official program is a three-year university training. In Spain there are four sports medicine schools located in the following universities: Oviedo, Madrid, Barcelona, Granada and Cádiz. The students are admitted in these schools once they pass the state exam (medical internal resident: MIR). The academic program has a theoretical and a practical part, the latter is carried out both in the university and in the regional hospitals. The practical training includes a clinical rotation through the related specialties throughout the three years: Emergency Medicine, Orthopedics & Traumatology, Rehabilitation, Sports Cardiology, Pneumology, Sports Nutrition & Dietetics, Internal Medicine, Pediatrics, General surgery, Primary health care, Obstetrics and Gynecology. In addition, specific practices are

carried out in the facilities of the School of Sports Medicine: General Sports Medicine, Sports Medical Examinations, Kineanthropometry, Exercise Physiology, Orthopedics & Traumatology, Rehabilitation, Toxicology, Exercise Testing, Power Testing, Holter tests, etc. Knowledge assessment is continuous and there is also a final assessment of each subject. Nowadays, in our country, the regulations related to medical specialisation have changed and all medical training must be received in the hospital. This has caused a temporal stoppage in the training of this specialty and the MIR positions are not called for sports medicine Sports medicine is a medical specialty that deals with the prevention, diagnosis and treatment of pathologies related to physical exercise and sports training. sports medicine is actually not only available to top athletes but also to anyone interested in sports and health. The sports medicine physician plays a very important role in the prevention of cardiovascular, metabolic, musculoskeletal,

respiratory, psychiatric and other diseases through the prescription of regular physical exercise. The main focus of these professionals is the promotion of regular physical activity, as a coadjutant method for disease prevention, weight management, reduction of morbidity, better health and well-being of the population. To develop all these functions in a satisfactory way we must have a solid training in the various medical fields related to physical exercise, health and sports performance, among others. By the end of training, the sports medicine specialist should have the knowledge and competencies on how to manage a wide range of exerciserelated functional parameters, advise on the therapeutic use of exercise, and provide medical support to athletes at all levels of participation. The practice of sports medicine in Spain is, basically, private, although there are public institutions at the national, regional and municipal levels that are in charge of the control of federated and elite athletes. Today, many sports

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SPORTS MEDICINE AROUND THE WORLD: SPAIN

medicine physicians work more on the prescription of physical exercise for health than on sports performance. Sports medicine is not only available to top athletes but also to anyone interested in sport and health. Currently in our country there are about 1000 sports medicine physicians and most of them are working in the specialty. The learning of medicine never ends and in particular sports medicine continuous training can be carried out by joining the Spanish Association of Sports Medicine (SEMED) and attending national congresses and annual meetings. Definitely, SEMED watches over the interest of sports medicine in our country. The Spanish Society of Sports Medicine has edited the journal “Archivos de Medicina del Deporte” since 1984, which for a few years has been open, free and published in English (http://archivosdemedicinadeldeporte.com/).

Sports medicine is not only available to top athletes but also to anyone interested in sport and health.

About the Author Miguel del Valle MD, PhD is a University Professor on the Faculty of Medicine of Oviedo University. He is a Sports Medicine Physician (1992), Head of School of Sports Medicine, member of the Spanish Society of Sports

The Spanish Society of Sports Medicine is currently a member of The European Federation of Sports Medicine Associations (EFSMA) and The International Federation of Sports Medicine (FIMS).

Medicine. He has directed 30 doctoral theses (“cum laude” and six have earned the rating of Extraordinary Award). Scientific experience: He has more than 180 publications, of which 68 are included in the Science Citation Index and he is Editor of the Archives Journals of Sports Medicine, Chairman of the

Dr. Miguel del Valle Editor of Archivos de Medicina del Deporte Member Governing Board of SEMED

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Organising Committee of the Second European Congress of Medicine Sport, and Chairman of the Scientific Committee FIMS World Congress of Sports Medicine.

SPORT TRAINER SPOTLIGHT: MART Y FRY

Sports Trainer Spotlight

Marty Fry How did you get involved at SMA? Like so many Sports Trainers, I have come from a sporting background having played Australian Rules Football for many years. During that time, I gained the utmost respect for the Sports Trainers at the clubs I was involved with and became familiar with Sports Medicine Australia. Fast forward a few years and I studied a Diploma of Remedial Massage and started my own clinic. I started to gain a lot of clients who where actively involved in sport and started to become contracted to professional sports teams as a remedial therapist. I decided that adding a Level 1 Sports Trainers qualification would be an ideal complement to my skillset.

What do you love most about being a Sports Trainer? I love the fact that its such a varied role that often has its challenges. I love helping athletes in so many different ways; initial treatment, taping, massaging, warming up, hydrating to cooling down and recovery. The interaction with players, coaches and other health professionals really makes for a great team environment. It’s the varied nature of this role that has also motivated me personally to learn more so I have also added the FIFA Diploma of Football Medicine, ASADA Anti -Doping courses and I am currently completing a Certificate Four in Fitness to my existing qualifications.

How long have you been an SMA Sports Trainer? In 2011 I attended my first Level 1 Sports Trainers Course and since then I have attended many SMA courses and I am now a Level 2 Sports Trainer. In 2017 I became a member of the SMA Tasmania State Council which has been a fantastic opportunity to broaden my network of peers whilst also being able to be involved in the planning of educational opportunities for members and the promotion of SMA. In 2017 I was given the opportunity to become a course presenter and since then have had the privilege to meet so many experienced Sports Trainers and people starting out on their journey as a Sports Trainer.

What has been the highlight of your journey as a Sports Trainer so far? Some highlights so far as a Sports Trainer have included: being a member of the Tasmania State Council, presenting on the topic of Sports Massage at a Sports Trainers Conference and having the opportunity to present courses has definitely been a highlight. Having been a course presenter now for a few years, it has been a great opportunity to not only share knowledge but also learn so much from other Sports Trainers that have attended courses. I believe the network of Sports Trainers out there is such a great bunch of people all wanting to achieve the same outcome for their athletes and teams and I have been fortunate to make some great friendships with likeminded people.

A highlight is also having the opportunity to be a Sports Trainer and Massage Therapist at National events including the Australian Badminton Championships and with professional sports teams, I hope to be able to continue these opportunities in the future. What tips/advice do you have for any new Sports Trainers who are just starting out? Always be accepting to learn more and improve your skills. Find a mentor and never be afraid to ask and learn from others. I was fortunate enough to have a mentor, who is also a course presenter and Sports Trainer with over 30 years of experience. He is a Tassie legend in the Sports Trainers field, and I have been able to learn so much from him and his experiences which is something I will always be grateful for. Always stay current with your accreditation. Being an SMA member is a great way to be involved with such a diverse range of professionals that not only helps your own development as a Sports Trainer but builds a valuable network of professionals that can also assist in your athletes or team’s health, performance and wellbeing.

Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028