A Doctor’s Perspective - CASM Annual Conference Part
Injuries, and other Issues from the Canadian Academy of Sports Medicine Annual
By Dr. Jennifer
Walker, MD CCFP.
While attending the recent annual
conference of the Canadian Academy of Sports Medicine, I realized there were a
number of topics that would be of interest to cycling fans. A number of the
injuries and conditions discussed are either common in cycling or have occurred
recently in prominent riders. Plus there was discussion of ongoing issues such
as doping that affect cycling.
Performance Enhancing Drugs
Unfortunately, use of
performance-enhancing drugs in sport is an issue that has been in the forefront,
particularly in cycling again recently. I found it interesting to attend a
session presented by a staff member of the Canadian Centre for Ethics in Sport (CCES)
– their purpose is “to promote ethical conduct in all aspects of sport in
Canada”. They administer the Canadian Anti-Doping Program,
which is compliant with the World Anti-Doping Program as determined by WADA. At
the session, there was a significant amount of frustration expressed by some of
the doctors who have been to major games or who work for pro teams. This
frustration was regarding areas of potential confusion in the WADA Prohibited
List, as well as lack of standardization between countries and sports
federations regarding Therapeutic Use Exemptions (TUEs).
A substance (or method) can be included
on the WADA Prohibited List if it is deemed to meet two of the following three
criteria: it has performance-enhancing effects, it has potential or actual
health risks, and/or WADA determines that it “violates the spirit of sport”.
The last criteria is thought by some to be quite nebulous, and would include
some “social drugs” as well as the recent suggestion to ban the use of altitude
tents. WADA’s draft Prohibited List for 2007 is currently being reviewed by
stakeholders before being finalized in the fall and coming into effect in
January 2007. A new website, the Global Drug Information Database (http://www.didglobal.com),
allows athletes to look up medications by their Canadian and UK brand-names to
check whether something is permissible or not.
Areas of debate and confusion currently
include beta-2-agonists (used for asthma treatment), glucocorticosteroids (GCS –
have anti-inflammatory effects and different from anabolic steroids), and
stimulants. CCES has apparently been pushing for the exclusion of common
beta-2-agonists plus GCS from the List, or at least to raise the threshold for
these. There is not much evidence that they have any significant
performance-enhancing effect, and they are commonly used for genuine medical
Therefore, there is a high risk of inadvertent positive tests and a
lot of TUEs must be completed by physicians and processed by the national
anti-doping organizations. In 2005, a number of Australian sports federations
(including the AFL) also petitioned that GCS be removed from the List. Many
sports injuries are treated with GCS in the form of cortisone injections, and
these require an abbreviated TUE form to be completed.
Topical GCS including skin, ear, eye, and nasal preparations already are
permitted without a TUE (e.g., the type of skin cream Lance Armstrong was
apparently prescribed that caused a positive test in 1999).
As for stimulants, while quite a number are specifically
listed as prohibited for in-competition usage, there is also the statement, “and
other substances with a similar chemical structure or similar biological effect(s)”, suggesting that all potential stimulants are banned. Yet stimulants
such as caffeine and pseudoephedrine are no longer prohibited but only
monitored. Stefan Schumacher had the situation where he tested positive in 2005
for cathine, listed as prohibited, but also known as norpseudoepinephrine. The
alternate name is not specifically listed, and was the name apparently checked
by his team doctor and the Dutch cycling federation and thought to be allowable.
One would hope that WADA could clear up some of the confusion and concentrate
more on substances/methods known to be significantly performance-enhancing.
Standardization of TUE's
The lack of standardization regarding
TUEs is also a problem. These may be granted if an athlete would experience
significant health problems without taking the prohibited substance/method,
therapeutic usage would not cause performance-enhancing effects, and there is no
reasonable alternative for treatment. There is not always mutual recognition
among various sports federations or national anti-doping organizations, so work
is being done to develop international medical guidelines for the TUE process. An example given was beta-2-agonists (bronchodilators) for asthma – in Canada,
only an abbreviated TUE form need be completed, but if an athlete is competing
internationally, pulmonary function test results may be required as well.
the most common full TUE applications in Canada are the following:
methylphenidate (Ritalin) and Dexedrine for ADD/ADHD.
prednisone for Crohn’s disease.
insulin for diabetes mellitus.
finasteride (Propecia) for alopecia/hair loss.
short-term narcotics for post-operative pain control.
Of interest to me was that although we
commonly think of certain drugs or methods such as blood transfusions as being
“performance-enhancing”, other techniques exist as well. In another session I
learned that “boosting” among spinal-cord injury athletes involves inducing a
pain stimulus below their injury level (e.g., by blocking their urinary
catheter) in order to induce a condition called autonomic dysreflexia. This
causes a potentially dangerous increase in blood pressure and heart rate, and up
to a 10% improvement in performance. So far, the only way to try to detect this
is by doing random blood pressure checks before races. This then is analogous
to the hematocrit testing done in cycling, and is another example of inferring
cheating through “health checks”, even if it can’t be conclusively proven that
an athlete really used a prohibited substance or method.
Dr. Walker's report will be continued in Part 2
References (part 1):
Canadian Centre for Ethics in Sport -
World Anti-Doping Agency -
Masters, Roy. “Ban on cortisone
a giant headache for AOC”, Sydney Morning Herald.
May 20, 2005 (http://www.smh.com.au/news/Sport/Ban-on-cortisone-a-giant-headache-for-AOC/2005/05/19/1116361677991.html)
“Schumacher Waiting for Verdict”,
Cycling News. August 11, 2005 (http://www.cyclingnews.com/news.php?id=news/2005/aug05/aug11news2)