Editor-in-ChiefDr Peter N. SperrynMB, FRCP, FACSM, DPhysMed

EditorsSurgery: Mr Paul G.StableforthMB, FRCS (Bristol, UK)Science: Dr Ron MaughanPhD (Aberdeen, UK)Physiotherapy: Mr Julius SimBA, MSc, MCSP(Coventry, UK)

Statistical ConsultantsMr F.M. Holliday, MA, DLC, FSS(Loughborough, UK)Mr Simon Day, BSc (London, UK)

Regional Corresponding EditorsBelgium: Prof. M. Ostyn,MD (Leuven)

Brazil: Prof. Eduardo H. DeRose,MD (Porto Allegre)

Bulgaria: Dr Virginia Michaelova,MD (Sofia)

Caribbean: Dr Paul Wright,LMSSA (Kingston, Jamaica)

Cote D'Ivoire: Prof. Constant Roux,MD (Abidjan)

France: Dr Pierre Berteau,MD (Rouen)

Editorial BoardProf. Dieter Bohmer,MD (Frankfurt, Germany)

Dr K.M. Chan,FRCS (Hong Kong)

Dr David A. Cowan,BPharm, PhD, MRPharmS (London, UK)

Dr Wendy N. Dodds,BSc, MRCP (Bradford, UK)

Dr Adrianne Hardman,PhD (Loughborough, UK)

Mr Basil Helal,MCh(Orth), FRCS (London, UK)

Dr G.P.H. Hermans,MD, PhD, (Hilversum, Netherlands)

Prof. Ludovit Komadel,MD (Bratislava, Czechoslovakia)

Prof. W.P. Morgan,EdD, (Madison, Wisconsin, USA)

Prof. Tim D. Noakes,MD, FACSM (Cape Town, South Africa)

Groupement Latine:Dr Francisque Commandre,MD (Nice)

Hungary: Dr Robert Frenkl,MD (Budapest)

India: Dr D.P. Tripathi,MB, BS, MCCP (Patna)

Indonesia: Dr Hario Tilarso,MD Jakarta)

Malaysia: Dr Ronnie Yeo,MB (Kuala Lumpur)

Maroc: Dr Naima Amrani,MD (Rabat)

Prof. Qu Mian-Yu,MD (Beijing, China)

Dr Allan J. Ryan,MD (Edina, Minnesota, USA)

Prof. N.C. Craig Sharp,PhD (Limerick, Eire)

Prof. Roy J. Shephard,MD, PhD (Toronto, Canada)

Prof. Harry Thomason,MSc, PhD (Loughborough, UK)

Prof. K. Tittel,MD (Leipzig, DDR)

Dr Dan S. Tunstall Pedoe,MA, DPhil, FRCP (London, UK)

Prof. Clyde Williams,PhD (Loughborough, UK)

Dr William F. Webb,MB, BS (Sydney, Australia)

New Zealand: Dr Chris Milne,MB, ChB, DipSportsMed (Hamilton)

Pakistan: Dr Nishat Mallick,FPMR, FACSM (Karachi)

Spain: Dr J. J. Gonzalez Iturri,MD (Pamplona)

Thailand: Dr Charoentasn Chintanaseri,MD (Bangkok)

Uganda: Dr James Sekajugo,MB, Dip.SportsMed. (Kampala)

USSR: Dr Sergei Mironov,MD (Moscow)

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Br J Sp Med 1993; 27(2)

FIMS news

International Federation of Sports Medicine

The World Federation of SportsMedicine - some perspectives onits activities

Sports medicine as a science emergedat the end of the 19th century invarious European countries. In 1904 inBerlin, Mallwitz coined the phrase'Sports Physician'. The InternationalHygiene Exposition held in Dresden in1911 was the stimulus for the firstofficial sports physicians congress everheld, and took place in Oberhof,Germany in September 1912. At thesame time the first official federationof sports physicians was founded.Finally FIMS was established in 1928with 11 founder nations. Today FIMShas a total of 90 member nations.The most important tasks of FIMS

are:

1. To uphold the interests of sportsmedicine and to cooperate withother similar international organi-zations such as the World HealthOrganization (WHO), the Inter-national Olympic Committee, theUnited Nations Educational, Scien-tific and Cultural Organization(UNESCO), the International Com-mittee of Sports Sciences and Phy-sical Education.

2. To represent FIMS at official nationalsporting events and at sports medi-cine congresses.

3. To develop guidelines for the edu-cation and training of sports physi-cians.

4. To provide a source of informationon sports medicine for nationalorganizations.

5. To assist national sports medicineassociations in their efforts to intro-duce higher qualifications in sports

medicine at universities, and alsowith the legal problems.

6. To publish position statements onaspects of sports medicine, e.g. therole of physical activity in preven-tive health care, the benefits ofexercise, rehabilitation of athletesand medical examination of ath-letes.

Some examples of the work done bythe President of FIMS in 1992 includethe following:

20 March 1992: Inaugural paper andwelcome address of FIMS at the FirstScientific Congress of the Asian Feder-ation of Sports Medicine.7 April 1992: Discussion with theAustrian Minister for Health in Viennaconcerning legislation for preventivemedicine.18 April 1992: FIMS Greeting at theopening ceremony of the First SportsMedicine Centre of WHO in Tokyo,and introductory paper on preventivemedicine and exercise training.24 April 1992: Introductory paper atmeeting of the Belgian Society ofSports Medicine in Brussels.5-10 May 1992: Participation in WorldConsensus Congress on Physical Acti-vity in Toronto, Canada.14 July 1992: Malaga

A practical example of the importanceof FIMS as a worldwide organization isthe recommendation on the topic ofAIDS and Sports. This position state-ment was initiated by FIMS and waspassed after a meeting of FIMS withWHO in Geneva on 16 January 1989.Without FIMS such a recommendationwould not have been drafted. FIMSspeaks as a powerful voice in thesphere of sports medicine, and with-out its presence at international meet-

ings, the significance of the disciplinewould be drastically reduced.

In common with other internationalorganizations such as UNO, UNESCOand WHO, FIMS shares the commonweakness of lack of funding. The feespaid to FIMS by member countries areinadequate to meet our current de-mands, and as a direct consequenceinsufficient information is being distri-buted to members. However, we aretackling this problem, and in futurewill forward more information bulle-tins to national organizations. Distri-bution will be the task of the nationalinstitution. Nevertheless despitefinancial constraints journals such asWorld of FIMS and FIMS Journal weresent to all member nations in the pastfew years.Another problem faced by FIMS is

representation at committee level. TheExecutive Committee is composed of14 nations, with four chairpersons ofthe Standing Commissions. Whenmaking a choice for representation wemust bear in mind that the wholeworld must be represented. It isimpossible to select only internationalscientists without due regard for thenecessity of representing the ThirdWorld. As far as possible we try tomake a fair choice and combine allcultural aspects on our representativebodies.FIMS is well aware of its weakness

and strength. What every membernation should realise is that such auniform world organization exists forits benefit, and actively promote itssupport of FIMS. The power of anyworld organization, including FIMS, isbased on the all out support of eachnational member country.

Wildor HollmannPresident FIMS

76 Br J Sp Med 1993; 27(2)

BASM news

British Association of Sport and Medicine

There are now active regions coveringmost of the UK. Most hold regularmeetings, contact your regionalChairman for detail of events.

Dr Evan Lloyd, Chairman BASMScottish Region72 Belgrave RoadEdinburgh EH12 6NQ UK

Dr R. Jaques, Chairman BASM SouthWest RegionCharity Cottage2 The Row, Cranham GardensGloucestershire GL4 8HP, UK

Dr Colin Crosby, Chairman BASMEastern RegionHighview Hill and Coles FarmLondon RoadFlamstead, Herts AL3 8HA, UK

Dr P. Milroy, Chairman BASM NorthWest RegionBrook House FarmMill LaneKingsley, Warrington WA6 8HH, UK

Dr G. I. Gardener Chairman BASMWest Midlands RegionWhitehornesButtertonNewcastle, Staffs, UKDr I. Adams, Chairman BASMYorkshire RegionDepartment of Accident andEmergencySt James's University HospitalBeckett Street, Leeds LS9 7TF, UK

Dr M. Read, Chairman BASM Londonand South East RegionSport and FitnessLondon Bridge Clinic, London SE27,UKDr K. Kaur, Chairwoman BASM EastMidlands RegionDepartment of General PracticeQueens Medical CentreNottingham NG7 2UH, UK

At present Wales is split between theSouth West and the North Westregions. There is no region coveringthe North East. If anyone is interestedin setting up a new branch in theseareas, please contact the HonorarySecretary at the Department of Ortho-paedics and Trauma, Queens MedicalCentre, Nottingham NG7 2UH.

The Educational programme hasexpanded many fold over the lastyears. Nancy Laurenson our Educa-tion Officer has worked extremelyhard to ensure the smooth running ofcourses, and made them very enjoy-able in addition to being educationallyenlightening. We wish her well as shestarts maternity leave in June. It willbe a struggle to maintain the very highstandards she has set.The highly successful Intermediate

course is planned to run again. Unfor-tunately the sponsorship that we hadlast year has disappeared with the UK

Igovernment's restrictions on non-steroidal gels. The concept behind theIntermediate course is twofold) First, Ihave always felt that insight into thetechniques and training methods of avariety of sport has been a neglectedarea of teaching in sports medicine.We have invited coaches to talk to usabout sports ranging from gymnasticsand dance through to track and field.Second, after organizing the weekendAdvanced injury courses, GrahamHolloway and I realised that moreformal instruction in joint examinationwas required. The Intermediate courseuses the delegates themselves as sub-jects, as opposed to the Advancedcourses where patients with clinicalsigns are brought as teaching aids!

In the March 1993 issue of theJournal there was a flyer for anothercourse to be held at La Santa inLanzarote. This is the resort whichmany of our top sports people use toprepare for their competitive seasons.The centre copes with nearly 40different sports, and has staff on sitecapable of giving instruction. The aimof the course is to provide hands-ontuition for several sports, and educa-tion on injury prevention. The warmweather, excellent facilities and enter-tainment will make for a wonderfulweek. We are aiming to run the coursefrom 7 to 14 October. Sign up! Call theBASM office on 071-253 3244 forfurther information.

East Midlands Region, March 1993

Sports coaches, especially thoseworking with the young, should beadvised that joints must not be over-stretched, particularly when opposingmuscle groups have been unequallyconditioned. So said Professor W. A.Wallace at the inaugural meeting ofthe East Midlands Region of theBritish Association of Sport andMedicine at the City Hospital, Not-tingham on Thursday 18 February.

Professor Wallace of the Departmentof Orthopaedics at Queens MedicalCentre, Nottingham, gave an enter-taining and instructive review ofsporting injuries to the shoulder to anaudience in excess of 120. This turnouton 18 February, demonstrated thegreat interest in sports medicine in the

region and the intention of the regionalcommittee is to have six lectures peryear. The next two will be on 1 Apriland 3 June 1993.

Earlier in the evening Dr FrankNewton from Silverstone enlightenedthe audience as to the stresses experi-enced by the modern racing driver. Hereviewed the history of track racing,showing how the driver had nowbecome almost an integral part of thecar. He demonstrated the unusualdriving position, with the driver sunkdeep into the 'tub' around which thecar is built. The driver works in aconstrained environment and is ex-posed to high g-forces. The stresses onthe internal organs are immense.Typical training programmes werediscussed. The need for training of the

neck muscles became obvious wheng-forces were discussed.The consensus opinion on the even-

ing was that it was a great success, aswas shown by the warm applause atthe end of each presentation.The Chairman of BASM, Mr John

King FRCS, spoke on knee injuries on1 April, with a demonstration by MsJudy Wright MCSP. Future meetingsare planned for 16 September, 28October and 9 December. Topics in-clude Asthma, Running injuries,Watersports injuries and Footballinginjuries. Details later, from: Dr IanMcGibbon, Honorary Treasurer, EastMidlands Region, British Associationof Sport and Medicine, TutburyHealth Centre, Tutbury, Staffs DE139NA, UK.

Br J Sp Med 1993; 27(2) 77

Br. J. Sp. Med 1993; 27(2)

From the journals

Sports medicine current awareness service

Prepared by Kathryn Walter and Nancy Laurenson at the National Sports Medicine Institute(NSMI) Library

The following summaries are takenfrom a selection of recent journalsindexed in the NSMI database. A fulllisting is published monthly in SportsMedicine Bulletin.

Copies of the complete articles are

available (price 15 pence per sheetsubject to Copyright Law) from theLibrary, NSMI, c/o Medical College ofSt. Bartholomew's Hospital, Charter-house Square, London EC1M 6BQ,UK. (Tel: 071-251 0583).A study on The association of changesin physical-activity level and otherlifestyle characteristics with mortalityamong men has been published byRalph Paffenbarger and colleagues(New England Journal of Medicine 1993;328: 538-45). Harvard College alumniwho were aged 45 to 84 years in 1977and who had completed lifestyle ques-tionnaires in 1962 or 1966 and again in1977 were classified according tochanges between these two dates inphysical activity levels, smoking,blood pressure and body weight andthe relation of these factors to mortal-ity between 1977 and 1985. Beginningmoderately vigorous sports activitieswas associated with a 23% lower riskof death than not taking up mode-rately vigorous sport. Also associatedwith lower mortality was cessation ofcigarette smoking, maintenance oflean body mass and consistently nor-mal blood pressure. Findings on deathfrom coronary heart disease mirroredthose on death from all causes.Advertised claims on the efficacy of

Commercially marketed supplementsfor bodybuilding athletes are re-viewed by Katharine Grunewald andRobert Bailey (Sports Medicine 1993; 15:90-103). Supplements include aminoacids, boron, carnitine, choline, chro-mium, dibencozide, ferulic acid, gam-ma oryzanol, medium chain triglycer-ides, weight gain powders, Smilaxcompounds and yohimbine. Manyperformance claims made for thesupplements are not supported bycurrent research. In some instances,no published research was found to

(© 1993 Butterworth-Heinemann Ltd0306-3674/93/020140-02

validate the claims. In other cases,research findings were extrapolated toinappropriate applications. For exam-

ple, biological functions of some non-

essential compounds (e.g. inosine,carnitine) were interpreted as per-formance claims for the supplements.Claims for others were based on theirability to enhance hormonal release or

activity. The authors recommend thatfurther research is conducted on thisgroup of athletes and their nutritionalneeds. The effectiveness and safety ofsupplements merit further investiga-tion.The use of electricity in promoting

analgesia, resolving oedema, woundhealing, re-education of damagedmuscle, prevention of muscle atrophyand muscle relaxation is described byRobert Windsor and colleagues inElectrical stimulation in clinical prac-tice (Physician and Sportsmedicine 1993;21: 85-93). The electrical modalitiesclinically used in sports injury rehabili-tation differ mainly in the way theycombine the parameters of wave form,frequency, pulse width and ampli-tude. Transcutaneous electrical nervestimulation (TENS), high-voltagepulsed galvanic stimulation (HVPGS)and interferential stimulation effec-tively reduce pain. TENS and HVPGScan be used for acute or chronic pain;interferential stimulation is primarilyindicated in acute or subacute softtissue injuries or myofascial pain.Interferential stimulation is more com-fortable and in addition promotes softtissue healing, muscle relaxation andoedema resolution. Minimal electricalnoninvasive stimulation is a newtreatment concept purported to facili-tate tissue healing.The aetiology, clinical signs and

symptoms and treatment of Nerveentrapment syndromes in athletes aredescribed in a recent paper by MarkoPecina et al. (Clinical Journal of SportMedicine 1993; 3: 36-43). Specific syn-dromes related to individual sports aredetailed - thoracic outlet syndrome isfound in swimmers and throwers;compression of the brachial plexusmay result from prolonged carrying ofheavy backpacks and is sometimesreferred to as 'backpack paralysis';

suprascapular nerve entrapment is anuncommon disorder seen in throwingathletes; radial tunnel syndrome com-

monly affects tennis players but mayalso be seen in rowers and weight-lifters; ulnar nerve entrapment isencountered in throwing athletes suchas baseball pitchers, tennis playersand javelin throwers; ulnar tunnelsyndrome is seen in cyclists andracquetball players; carpal tunnel syn-drome may be seen in sports thatrequire gripping, throwing, cycling or

repetitive wrist flexion-extension;'bowler's thumb' is the most commondigital nerve entrapment; sural nerveentrapment and, rarely, peronealnerve entrapment is seen in runners;and tarsal tunnel syndrome is an

uncommon condition described inrunners, ballet dancers and basketballplayers. Diagnosis relies on a detailedhistory and physical examination. Inmost cases non-operative treatment issufficient and surgery is seldom recom-mended.The use of orthotic shoe inserts has

become a popular adjunct in thetreatment of overuse injuries such aspatellofemoral disorders, shin splints,Achilles tendinitis, plantar fasciitisand stress fractures (Gross ML andNapoli RC Treatment of lower extrem-ity injuries with orthotic shoe inserts:an overview Sports Medicine 1993; 15:66-70). Inserts adjust the biomech-anical variables associated with run-ning injuries and reduce the effect ofhigh stresses produced by runningactivities. Orthotic treatment is basedon an understanding of complex coup-ling of rotation of the lower extremitywith pronation and supination of thesubtalar joint and accurate identifica-tion of the underlying biomechanicaldeficit. Orthotic fabrication is initiatedby determining the neutral position ofthe foot and obtaining an accurate castof this position. Orthotics should beused as one facet in the overalltreatment programme - the use ofproper conditioning and stretching areequally important for injury preven-tion and treatment of specific injuries.Most investigations on the effects of

exercise on the immune system havelargely ignored intense anaerobic exer-

Br J Sp Med 1993; 27(2) 139

cise. However, two recent studieshave examined the effects of a shortbout of maximal effort on immuneparameters. A. B. Gray and co-workerscompared the effects of 1 min ofintense bicycle ergometry on circulat-ing leukocytes in trained and un-trained males (Anaerobic exercisecauses transient changes in leukocytesubsets and 1L-2R expression Medicineand Science in Sports and Exercise 1992;24: 1332-8). Significant changes in theperipheral concentrations and propor-tions of most leukocyte subpopula-tions were observed irrespective oftraining status. Only trained subjectsshowed a significant decrease in thepercentage of CD25+ lymphocytesfollowing mitogen stimulation ofperipheral blood 6 h post exercise,while untrained subjects had a signifi-cantly greater concentration andpercentage of CD8+ lymphocytes im-mediately after exercise. A furtherstudy (Nieman D. C. et al. Effects ofbrief, heavy exertion on circulatinglymphocyte subpopulations and pro-liferative response Medicine and Sciencein Sports and Exercise 1992; 24: 1339-45)examined blood samples before and3 min and 1 h after 30 s of maximaleffort on a cycle ergometer and foundrapid perturbations in circulatinglevels of natural killer cells and Tlymphocytes without a correspondingalteration in lymphocyte function.

Bioelectrical impedance and bodycomposition (Lancet 1992; 340: 1511).Data on the use of this straightfor-ward, non-invasive technique forshort term assessment of body com-position suggests that impedance is asatisfactory and reliable method ofestimating total body water in childrenwho require critical cardiac care. Simi-lar conclusions have also been drawnby researchers who monitor changesin hydration status after cardiacsurgery in adults. Their findings sug-gest that the technique has potentiallywidespread applications to differentpopulations, including patients withchronic renal failure, congestive heartdisease, inflammatory bowel disease,diabetes, growth hormone deficiency,cancer and obesity. The theoreticalunderstanding which supports bio-electrical impedance states that theonly medium that can conduct electri-city within the body is water. Thus,the anhydrous nature of fat restrictsthe flow of electrical current to the leanbody mass. However, bioelectricalimpedance is also used to predict leanbody mass, the underlying assump-tion being that there is a constant andknown level of hydration in leantissue. This assumption could producean uncertain and large error in estima-tion of lean tissue and hence fat tissueas levels of hydration vary within

healthy individuals. Thus one couldask if this method should be used toassess body composition or percen-tage body fat in a sports person?

Is there a male counterpart to'athletes' amenorrhoea'? It appearsthat weight loss and excessive trainingcan disturb reproductive function inmen, as has been shown in women,although the research results aresomewhat equivocal. E. Randy Eich-ner describes the possible causal fac-tors in Exhaustive exercise and libidoin men: can you keep it up? (SportsMedicine Digest 1992; 14: 5). Results ofmost studies of testosterone concen-tration in athletes find that intensiveexercise, for an hour or less, regardlessif it is power or endurance basedactivity, tends to increase plasmatestosterone levels. How this increaseoccurs is unclear. In contrast, con-tinued exercise lasting a few hours orlonger tends to reduce testosteronelevels. A review of 10 other studiessuggests that the point where elevatedtestosterone concentration begins tofall often occurs after 2-3 h of con-tinuous exercise. How this fall occursis also unclear, yet possible contribu-tors include: (1) haemodilution; (2)suppression of testicular function bysurges in blood cortisol; (3) suppres-sion of the hypothalamic-pituitaryaxis, so as to inhibit the pulsatilerelease of luteinizing hormone (whichdrives the testicular production oftestosterone). Other complaints re-garding sexual function include lowsperm counts and decreased libido. Ofcourse not all studies of male endur-ance athletes have found such abnor-malities in sexual function!The stretch shortening cycle (SSC), a

functional contraction of muscle thatoccurs when a muscle contracts eccen-trically (lengthens under tension) andthen immediately contracts concentric-ally (shortens under tension) is thephysiological mechanism involved inplyometric training. Although thisprinciple is well accepted little re-search has been performed to dateexamining The stretch-shortening cy-cle of the quadriceps femoris musclegroup measured by isokinetic dyna-mometry (Helgeson K. and GajdosikR. L. Journal of Orthopaedic and SportsPhysical Therapy 1993; 17: 17-23).Twenty-four subjects (19-35 years)were recruited including 12 men and12 women, all free from current lowerleg extremity pathologies or injury.Results showed a significant increasein peak torque and a decrease in timeto peak torque for a concentric contrac-tion of the quadriceps muscle groupafter an eccentric and isometric pre-load compared with a concentric con-traction alone. Men could producegreater peak torque than the women,

as expected; however, their standar-dized peak torque was also greater.This difference cannot be completelyexplained by factors such as body size,lean body mass and muscle cross-sectional area. It is unknown whetherfibre type dominance could partiallyexplain the differences; there is noconclusive evidence that there is anysignificant difference between slowand fast twitch muscle fibres in quad-riceps muscle of men and women.This testing protocol could be used tocompare quadriceps femoris muscleperformance on an isokinetic dynamo-meter with functional activities such asthe vertical jump or following aplyometric training programme.

Physical training by adults in endur-ance activities such as distance run-ning, swimming, and cycling resultsin well defined anatomical, physio-logical and metabolic adaptationswhich could collectively be termed the'fitness effect'. While these changesfollow a predictable pattern, themechanisms by which they occur arenot always well known. Whetherprepubertal children are as capable ofimproving maximal oxygen uptakefrom endurance training as adults is adebated question that has long in-terested exercise physiologists. It is,however, a significant one, since itbears importance for coaches andphysical educators in providing safetraining regimens. This issue is ex-plored in Trainability of the cardio-respiratory system during childhood(Rowland T. W. Canadian Journal ofSport Sciences 1992; 17: 259-63). Itappears that studies examining thetrainability of children have been besetwith methodological flaws that haveprecluded firm conclusions aboutadult-child differences. Most studiesof children that have involved adequ-ate intensity, type and duration oftraining have demonstrated the samequalitative changes as would be ex-pected from adult subjects. However,some information suggests that chil-dren may need a greater exerciseintensity than adults to trigger cardio-vascular adaptations to training. Otherdata raise questions regarding differ-ences in autonomic influences in theheart and myocardial function in chil-dren that could relate to age-dependent responses to training.Strenuous and unaccustomed re-

petitive, calisthenic-type exercise mayresult in a syndrome known as exer-tional rhabdomyolysis. If the exerciseis accompanied by heat stress anddehydration a potentially severe com-plex may result between rhabdomy-olysis, myoglobinuria and acute renalfailure. Priscilla M. Clarkson describesthis syndrome in Worst case scenarios:exertional rhabdomyolysis and acute

140 Br J Sp Med 1993; 27(2)

renal failure (Gatorade Sports ScienceInstitute, Sports Science Exchange 1993;4, No. 42). Exertional rhabdomyolysisis the degeneration of skeletal musclecaused by excessive unaccustomedexercise. Symptoms include musclepain, weakness and swelling, myoglo-binuria, and increased levels of muscleenzymes and other muscle consti-tuents in the blood. Myoglobin re-leased from damaged muscle cells may

spill over from the blood resulting in adark colour urine. In certain situationsmyoglobin can precipitate in thekidneys and cause renal failure. Themechanism by which myoglobinuriacan lead to acute renal failure is notcompletely understood. However,kidney failure most often occurs whenheat stress and dehydration are pre-sent. A lack of physical conditioningfor the specific exercises performed

plus an insufficient degree of acclima-tization to heat are contributing fac-tors. A viral infection or an attempt ata novel diet manipulation before com-petition may affect this condition.Because severe cases of rhabdomyo-lysis and kidney failure are rare, it isthought some individuals may have asubclinical muscle disorder that onlybecomes apparent when the aboveconditions present.

Correspondence

Clenbuterol: a medal in tablet form?Huw Perry MBWest Glamorgan Health Authority, 36 Orchard Street,Swansea, SAl 5AQ, UK

Sir

Before the last Olympic Games, few people had heard ofclenbuterol, the controversial drug that was responsible formost of the expulsions from the games. There seems to beconfusion about what class of drug it actually is.

Clenbuterol is a sympathomimetic agent with Nt-agonistproperties. It is not a steroid but a substituted phenylethanol-amine with anabolic properties. There is no licence in theUK for human use although it is used orally in Germany,Italy and Spain as a therapy for asthma. It has also beenused as a bulking agent in animals. The literature containsno reputable scientific papers that show muscle-enhancingeffects in humans. Papers on animal studies do exist toshow that clenbuterol does have an anabolic effect on bothcardiac" 2 and skeletal muscle'7. The mechanism of itsskeletal anabolic effect has been suggested to be I-adrenoceptor mediated" 6 and the effects on cardiac musclevia a cyclo-oxygenase metabolite of arachadonic acid2. Thefavourable effect of clenbuterol on muscle growth ispossibly also due to a specific increase in protein depositionand not to changes in the water content of musculartissue3 4. Obviously one cannot automatically extrapolatethese anabolic effects in animal studies to humans.However, it should be noted that clenbuterol has been usedas a pharmacological ergogenic aid in sport on a wide-spread basis for the past 21/2 years in the UK. Initially thecost on the black market was approximately 135.00 poundssterling for 90-100 tablets, now it is down to approximately40.00 pounds sterling, showing the abundance of the drugon the black market. In the past year I have spoken to atleast 50 clenbuterol misusers, the vast majority of whomwere impressed by its anabolism, even when using it in theabsence of other steroids. The current disclosure ofclenbuterol is an indicator of the huge amount of sportingsubstance misuse (taken in megadoses) which is so

prevalent in the UK at the moment, especially amongnon-competitive recreational 'athletes'.Many of our clients who present themselves at drug

agencies for needles and syringes to administer theiranabolic steroids, reported that, in the past, while takingonly clenbuterol they experienced palpitations, tremor andsweating.

Physicians seeing over-muscled young people (male andfemale) should bear in mind that they may be takinganabolic drugs and be aware of the side-effects, or of thedrug interactions which may exist, if the physicianprescribes any medication for that individual. One of theless appreciated side-effects of clenbuterol is potentiallyserious hypokalaemia which may result from P2-agonisttherapy.

References1 Sillence MN, Matthews ML, Spiers WG, Pegg GG, Lindsay

DB. Effects of Clenbuterol, ICT118551, and sotalol on thegrowth of cardiac and skeletal muscle and on 2-adrenoceptordensity in female rats. Naunyn Schmiedebergs Arch Pharmacol1991; 333: 449-53.

2 Palmer RM, Delday MI, McMillan DN, Noble BS, Bain P.Maltin CA. Effects of the cyclo-oxygenase inhibitor, fenbufen,on clenbuterol induced hypertrophy of cardiac and skeletalmuscle of rats. Br J Pharmacol 1990; 101: 835-8.

3 Perez-Lamas F, Sastre TF, Zamora S. Influence of dietaryprotein level on growth: effect of clenbuterol. Comp BiochemPhysiol [A]. 1991; 99: 671-5.

4 Perez-Lamas F, Zamora S. The influence of clenbuterol ongrowth in rats. Comp Biochem Physiol [A]. 1991; 99: 242-4.

5 Bates PC, Pell JM. Action and interaction of growth hormoneand the beta-agonist clenbuterol on growth, body compositionand protein turnover in dwarf mice. Br J Nutr 1991; 65: 115-29.

6 MacLennan PA, Edwards RH. Effects of clenbuterol andpropranolol on muscle mass. Evidence that clenbuterolstimulates muscle beta adrenoceptors to induce hypertrophy.Biochem J 1989; 264: 573-9.

7 Claeys MC, Mulvaney DL, McCarthy FD, Gore MT, MarpleDN, Sartin JL. Skeletal muscle protein synthesis and growthhormone secretion in young lambs treated with clenbuterol.J Animal Sci 1989; 67: 2245-54.

Br J Sp Med 1993; 27(2) 141

BASM Education ProgrammeThe British Association of Sport and Medicine holds Introductory, Intermediate and Advanced Courses inSports Medicine annually.The Introductory Course held at Lilleshall Hall National Sports Centre, Shropshire, is a one-week

intensive course designed primarily for general practitioners and physiotherapists although suitable for alldoctors with an interest in sports medicine. This course is generally a prerequisite for the Intermediate andAdvanced Courses. PGEA approval is given for 5 days under the categories of 2.5 days Health Promotionand 2.5 days Disease Management.The Intermediate Course (Sports Specific Injury Management and Normal Examination of Joints) is also

one week long and held at Lilleshall Hall National Sports Centre. This course concentrates on the properexamination of normal joints with regard to the management of sport specific injuries. There is a strongfocus on the coaching and training involved in each sport. PGEA approval is given for 5 days under thecategories of 2.5 days Health Promotion and 2.5 days Disease Management.The six Advanced Modular Courses are held at weekends at various locations throughout the country.

These comprise three Injury modules which focus on the clinical examination, diagnosis and managementof both acute and chronic injuries; treatment and rehabilitation programmes are also outlined. Two ExercisePhysiology modules examine aspects of training and fitness assessment with respect to cardiorespiratoryand musculoskeletal physiology. The final module, 'Medicine of Sport and Exercise' concentrates on arange of topical issues from 'Exercise in Elderly People' and 'Osteoporosis' to 'Update on Nutrition' and'Diabetes and Exercise'. PGEA approval is given for each module.These courses provide the academic training necessary to sit the Society of Apothecaries Diploma in

Sports Medicine as well as the Royal College of Surgeons and Physicians (Glasgow and Edinburgh)Diploma in Sports Medicine for medical practitioners.

Current Programme for 1993

Date Course Venue

January 22-24

March 12-14

April 2-4

April 25-30

September 3-5

September 26 - October 1

October 29-31

November 19-21

Advanced Physiology: cardio-respiratory physiology

Advanced Physiology: musculoskeletal system

Advanced Injury: Acute and Chronic Injuries to theUpper Limb

BASM Introductory Sports Medicine Course

Advanced Injury: Acute and Chronic Injuries to theHead, Neck, Spine and Pelvis

BASM Introductory Sports Medicine Course

Advanced Injury: Acute and Chronic Injuries to theLower Limb

BASM Congress (Eastern Region)

Bradford RoyalInfirmary

Liverpool JohnMoores University

RAF Wroughton(Swindon)

Lilleshall Hall NSC(Shropshire)

Milton KeynesGeneral Hospital

Lilleshall Hall NSC(Shropshire)

RAF Wroughton(Swindon)

Cambridge

Courses planned for 1993November Intermediate Sports Medicine Course

Br J Sp Med 1993; 27(2) 143

Notes for Authors

ScopeThe British Journal of Sports Medicine covers all aspectsof sports medicine and science - the management ofsports injuries; all clinical aspects of exercise, health andsport: exercise physiology and biophvsical investigationof sports performance; sports psychology; phvsio-therapv and rehabilitation in sport; and medical and sci-

entific support of the sports coach.

Types of PaperOriginal papers (not normally over 3000 words, fulllength accounts of original research)Review articles (up to 4000 words, providing concise in-

depth reviews of traditional and new areas in sportsmedicine)Case reports (up to 1000 words, describing clinical case

histories with a message).

RefereeingAll contributions are studied bv referees whose names

are not normally disclosed to authors. On acceptance forpublication papers are subject to editorial amendment. Ifrejected, papers and illustrations will not be returned.Authors are solely responsible for the factual accuracy oftheir papers.

ManuscriptsAuthors are urged to write as concisely as possible.Four copies should be submitted, tvped on only one

side of the paper (quarto or A4) in double spacing with a

margin of 30mm at the top and bottom and on bothsides. Papers should be arranged in the following orderof presentation: title of paper; names and qualificationsof the authors; address of the place at which the workwas carried out; an abstract of the paper (100-200 wordsin length); 4-6 keywords; the text; acknowledgements(if any); references; tables; abbreviated title for use as a

running headline; captions to figures (on separate sheetof paper).

IllustrationsDrawings and graphs should be on heavy white papercard or blue-lined coordinate paper using black ink.Label axes appropriately and clearly. Please use a selec-tion of the following symbols: +, x, O, 0, A, V, Et ,

A, v. Photographs should be of fine quality, largeglossy prints suitable for reproduction and the topshould be indicated. Negatives, transparencies or x-ray

films should not be supplied, any such material shouldbe submitted in the form of photographic prints.Authors are asked where possible to draw diagrams toone of the following widths, including lettering,168mm, 354 mm. During photographic reproduction,the diagrams are reduced to 1/2 their size. The maximumdepth at drawn size is 500 mm. Authors are asked to use

the minimum amount of descriptive matter on graphsand drawings but rather to refer to curves, points etc. bysymbols and place the descriptive matter in the caption.Three copies of each illustration are required and theseshould be numbered in a consecutive series of figuresusing Arabic numerals. Legends should be typed indouble spacing on a separate page but grouped together.Each figure should be identified on the back - figurenumber and name of the author. Figures which havebeen published elsewhere should be accompanied by a

form 6f permission to reproduce, obtained from theoriginal publisher.

ReferencesThese should be indicated in the text by superscriptArabic numerals which run consecutively through thepaper. The references should be grouped in a section atthe end of the text in numerical order and should take theform: author's names and initials; title of article; abbre-viated journal title; y'ear of publication; volume number;page numbers. If in doubt authors should always writethe journal title in full. References to a book should takethe form: author's surname, followsed by initials; title ofbook in single quotes; editors (if any); volume numberedition (if any); name of publishers; place of publication;Xear of publication and page numbers. Where a paper iscited more than once in the text, the same superiornumeral should be used on each occasion. e.g.21 Sperrvn P15. sport antd .\fclidwpic. London: Butterworth., 1NS3.22 Ellitsgaard N and Warburg F. Mioveements causing ankle

fractures in parachuting. fBr I S'port; .\tlcd 19Sq; 23: 27-4.

TablesTables should be typed on separate sheets together witha suitable caption at the top of each table. Column head-ings should be kept as brief as possible, and indicateunits of measurement in parenthesis. Tables should notduplicate information summarized in illustratiols.FootnotesFootnotes should be used sparingly. Thex should be ill-dicated by asterisks (*), daggers (t), and double daggers(t), in that order. In the manuscript, a footnote should beplaced at the bottom of the page on which it is referred toand separated from the main text bv a horizontal lineabove the footnote. Footnotes to tables should be placedat the bottom of the table to which they refer.Drugs, Abbreviations and UnitsDrugs should be referred to by their approved, not pro-prietarn, names, and the source of anx new or experi-mental materials should be given. If abbreviations areused these should be given in full the first time they arementioned in the text. Scientific measurements shouldbe given in SI units, but blood pressure should continueto be expressed in mmHg.ProofsAuthors are responsible for ensuring that all manu-scripts (whether original or revised) are accurately typedbefore final submission. Two sets of proofs will be sentto the author before publication, one of which should bereturned promptly (by Express Air Mail if outside UK).The publishers reserve the right to charge for anychanges made at the proof stage (other than printerserrors) since the insertion or deletion of a single wordmay necessitate the resetting of whole paragraphs.SubmissionFour copies of the complete manuscript and illus-trations should be sent to Dr P. N. Sperrvn, The Editor,British Journal of Sports Medicine, Butterwvorth-Heine-mann Ltd., 59 60 Grosvenor Street, London WViX 9DA,UK.All material submitted for publication is assumed to besubmitted exclusivelv to the British Journal of SportsMedicine. All contributing authors must sign a letter ofconsent to publication. The editor retains the customaryright to style and if necessary shorten material acceptedfor publication. Manuscripts will be acknowledged onreceipt. Authors should keep one copy of theirmanuscript for reference. Authors should include theirnames and initials and not more than one degree each.