MARCH 2006 – No.12

IN THIS ISSUE

PUBLISHED BY UEFA’S FOOTBALL

DEVELOPMENTDIVISION

REAPINGTHE HARVEST

THE STATE OF THE PITCH

CANNABIS AND SPORT

FIT TO MANAGE?

BRUCOSPORTCONGRESSIN BRUGES

MEDICINEMatters

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COVERAndriy Shevchenko takes the ball past Greek defender Ioannis Goumas in Ukraine’s 1-0 win in Athens en route to their first-ever FIFA WorldCup final, this summer’s tournament to be played in Germany from 9 June to 9 July 2006. From a medical point of view, the tournament will also offer an exceptional learning experience.PHOTO: FOTO-NET

to harmonise methodologies isanother step in the right direc-tion, as it will permit other stu-dies to be correlated with ourown. Much of this issue of Medi-cine Matters is devoted to mat-ters related to injury studies –and we make no apology for that.

Detecting ‘patterns’ in a shorttime-span is, scientifically, risky.But some interesting talkingpoints have already emerged.Overall, the incidence of injuryamong the clubs involved in ourstudy has fallen in the last fouryears. But is it a coincidence, for example, that the significantdecreases have occurred in the2002/03 and 2004/05 seasons? In other words, after the FIFA

Dr Urs Vogel, Chairman of the UEFA Medical Committee.

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Four seasons later, we are onceagain watching attentively asplayers prepare for the FIFAWorld Cup in a year which alsoincludes the African Cup of Nations. But there have beenchanges. UEFA, for example, haslightened the UEFA ChampionsLeague burden by removing agroup phase. FIFA has insistedthat the final whistle be blownon all domestic competitions ingood time for players to preparefor the finals in Germany.

During the same four-year period, UEFA’s injury studies havegathered momentum and avaluable databank has not onlybeen established but is also be-ing put to good use. The move

BY DR URS VOGEL

FOUR-GONE It doesn’t feel as though almost four years have passed since we sat down to discuss the aftermath of the FIFA World Cup – and, in the case of some of the pre-tournament favourites, it amounted to something more akin to a post-mortem. Many star players were reported to have under-performed and a high percentage of European failures to live up to expectations were put down to mental and physical fatigue. There was a great deal of talk about excessive workloads.

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World Cup and the UEFA Euro-pean Championship, when onewould instinctively suspect thatthe incidence of injury would rise.Could the possible explanation be that, while we are monitoringthe top stars’ ability to cope withthe physical and psychologicalburdens of major tournaments,the rest of the professional work-force is finally able to benefitfrom a decent rest?

What’s more, attitudes havechanged as a result of injury studies which have undoubtedlyincreased awareness of the medical issues to be addressed.Reliable data about injury risksduring pre-season training havegiven coaches food for thought.Four years ago, ‘rotation’ was not a frequently used word in thefootballing lexicon. But therehave now been significant movesin terms of designing and util-ising squads with a view to dis-tributing workloads on a moreequitable basis.

The wise use of substitutes has becomean importanttactic in modern football.

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But only time – and continued research – will determine whetherwe are winning the crusade to reduce the risk of injury. In a sense,the two World Cups will provideinteresting points of reference.

CONCLUSIONS

The new UEFA Champions League format has taken some of the pressure off the players. Here, Ze Roberto in Bayern Munich’s UEFA Champions League tie against Club Brugge.

After the tournament in Ger-many, will we express the sameconcerns as we did in 2002? Four years have gone by and wemay be able to start drawingconclusions.

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REAPINGTHE HARVESTUEFA’s injury studies have been a recurrent theme in Medicine Matters and the state of play is that one of the fundamental aims of the project is now beginning to be achieved. The study was not conceived as an esotericcompilation of figures. The objective was – and is – to provide feedback to team doctors which can enhancetheir efforts to prevent injuries.

Some of the top clubs involved in UEFA’s project have now beenmonitored over a period of four fullseasons – which means that the database has now become a valuabletool and that answers can now beprovided to some of the most fre-quently asked questions. Clubs andfootball organisations often ask, for instance, whether the risk of injury in the top-level game has increased. There is now enough solidevidence to respond that it has not –and that it has even decreased.

The ongoing project now featuresvisits by UEFA’s research team to the clubs which have participated inthe study, with a view to establishinghow to develop the research andwhat further elements could produc-tively be incorporated into the moni-toring programme.

At the end of each season, there is direct feedback to the clubs in theform of a detailed résumé of theirown results, along with mean figuresfrom other teams, enabling compar-isons to be made. Clubs and nationalassociations are aware that UEFA can now provide reliable data and,for instance, the Italians are keen to receive figures related to non-contact muscular injuries, while theEnglish have expressed more interestin issues such as groin injuries or the effects of a winter break on theincidence of injury.

It has never been Medicine Mat-ters’ policy to ‘name names’ but the much-publicised case of MichaelOwen’s fifth metatarsal fractureprompted the English media toquestion his presence in this sum-mer’s FIFA World Cup. UEFA’s data-base included details of 19 such injuries, which allowed a mean ab-sence of 76 days to be established.The evidence also suggested thatsurgery signified a lower risk of re-injury. UEFA could therefore offer reassuring data to the player,his club and his national association.

In other words, the seeds sown overthe last four years are beginning toproduce a harvest. Continued feed-back will, we hope, allow physiciansto advance still further in the cru-sade to prevent injuries, to avoidburn-out syndromes, and to estab-lish viable balances between workand recovery periods during longand demanding campaigns.

RESEARCH = VALUABLE EVIDENCEHarmonising methodologies has enabled studies of injury patternsto be effectively interlocked and forvalid comparisons to be made. Atthe same time, UEFA’s injury studyhas helped to promote individualstudies within national associationswhere there is concern about the

incidence of injury in domestic competitions.

A case in point is Turkey, where Professor Mehmet Binnet, a mem-ber of UEFA’s Medical Committee,initiated the country’s first injurystudy along with Dr Onur Polat, his fellow chairman of the TurkishFA’s Medical Committee.

The pioneering study embraced 406 footballers enrolled in 15 clubsbelonging to the Turkcell PremierLeague. Data were collected ac-cording to UEFA norms over a period covering 9,190 hours (820match hours and 8,370 traininghours). During this time-span, teamdoctors recorded and reported 330 injuries at a mean of one injuryper 27.85 hours.

Processing the data revealed signifi-cant trends. 142 injuries (43%) oc-curred during the 820 match hours,while 188 (57%) corresponded to injuries sustained during training.When compared with similar stud-ies, the salient feature was the high incidence of injuries duringtraining.

Further analysis uncovered othersignificant trends. ‘Contact injuries’resulting from tackles or collisionsaccounted for 30.72%. The remain-ing 69.28% were non-contact injuries. The figures suggested to the researchers that non-contact injuries had increased in relation to previous seasons and that the high ratio of non-contact injuriesrepresented a strong indicator ofphysical overuse and/or return toactivity before recovery had beencompleted.

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The study also grouped figures according to geographical areas,providing further food for thought. The teams based in the Marmara re-gion (broadly speaking, the westernseaboard facing Greece) recordedthat 45.45% of the injuries regis-tered during the season were of thenon-contact type. Of the injuries af-fecting teams in the more northerlyBlack Sea region, 68.25% were non-contact. And in the central Anato-lian area, the incidence of non-con-tact injuries peaked at no less than94.12%.

With regard to the nature of the injuries, 50.96% were of low inten-sity, with the player absent fromtraining and match play for less thanone week; 40.51% were labelledmoderate, with the player absent forbetween one week and one month;and 8.12% came into the ‘severe’category and entailed absences inexcess of a month. The breakdownby regions revealed that the Anato-lian teams suffered 46.30% in termsof mild injuries; 44.44% moderate;and 9.26% serious. In the Black Searegion, the figures were 49.23%,41.54% and 9.23%, while the Mar-mara clubs posted the lowest inci-dence of severe injury (57.35%,36.76% and 5.88%).

30.85% of injuries affected the thigh,20.18% the ankle, and 12.38% thegroin. 37.61% of injuries were classedas strains, 24.41% as sprains, and15.24% were evidently attributableto overuse.

Important conclusions were drawnfrom the country’s first injury study,which clearly indicated a need forcorrectly designed training pro-

grammes and a review of entiretraining cultures. Clubs were urged to check whether specific enduranceand elasticity routines were being implemented and the importance of adequate warm-up and warm-down procedures was underlined.The high ratio of non-contact mus-cular injuries suggested a need to upgrade preventive measures.

At the same time, analysis of injurypatterns revealed one fact that couldbe the starting point for debate.Muscle injuries are most common at football clubs which change theirtechnical staff more than once a season. Interpretations of this infor-mation can take various channels, as it could be coherently argued thatsquad members might be tempted to overexert themselves on the training ground to impress a newcoach or, conversely, that the newcoach is often tempted to launch anew regime by working the playersharder than his predecessor.

Whatever the answers, the undeni-able conclusion is that the Turkish injury study provided persuasive evidence in the case for reviewingphysical training methods with a view to reducing the high ratio ofnon-contact injuries.

CONTACT DETAILSUEFA’s injury studies have been ex-tended to final tournaments of othercompetitions – and it is interesting tonote that the highest ratio of non-contact injuries was registered in thefinals of the 2005 European Under-19Championship played in Northern Ireland. The study embraced

495 match hours and 899 traininghours. Sixteen players sustained 17 injuries during the tournament,only two of which were in trainingand only three of the match injurieswere due to foul play.

All but one of the injuries occurredduring the first week of the twelve-day tournament. Only one wasclassed as ‘major’ while five were‘moderate’ (1-4 weeks).

Non-contact injuries accounted for 59% of the total and were con-centrated into the final 30 minutesof match play.

Several injuries occur during training.

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Franck Dja Djedje of France (left) fights for the ball with Matthew Mills of Eng-land during the 2005 European Under-19Championship in Northern Ireland.

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One coherent explanation was thatthe Under-19 Championship wasstaged during the last fortnight ofJuly, when most teams are still inpre-season training. Preparation programmes therefore take on evengreater significance and it could beimportant for the Under-19 interna-tionals to dedicate time to fitness exercises during the ‘close season’.

The European Women’s Champi-onship final round, played in Eng-land during the month of June, reg-istered a lower ratio of non-contactinjuries. Yet the percentage (36%),coupled with the 41% recorded by the men at EURO 2004, highlightsthe frequency of muscle injuries intoday’s football.

Contusions accounted for 44% ofthe injuries at the women’s tourna-ment – exactly double the percent-age registered at EURO 2004. How-ever, the men’s finals in Portugalyielded four fractures (9% of all in-juries), whereas none were recordedin England – arguably a reflection of physical intensity and body mass.Once again, the risk of injury wasmuch greater during match play(36.0 per 1,000 hours) than in train-ing (2.5). In this respect, the women’sparameters were similar to the men’s(32.2 per 1,000 hours of match playat EURO 2004 / 2.9 in training).

One of the interesting observationsto emerge as a common denomina-tor at all three tournaments (thetwo EUROs and the Under-19s) wasthat the incidence of injury was very significantly greater during the initial group matches than in the subsequent fixtures played on a knock-out basis.

SPEAKING THE SAME LANGUAGE

What is a ‘severe’ injury? What is a ‘recurrent’ injury? Is the Achilles tendon ‘ankle’ or ‘lower leg’? Youmight have clear answers to all threequestions. But will a physician at the other end of Europe come upwith the same responses?

It is no secret that variations in defini-tions and methodologies can gener-ate significant differences in the re-sults and conclusions obtained frominjury studies, making it difficult tocompare like with like. Even thoughmedical journals have developedstrategies such as the Consort state-ment in response to this problem,fundamental differences have per-sisted in published studies of footballinjuries. This represents a key issuefor UEFA when it comes to collatingstudies on a pan-European basis, so it is good news that a consensusagreement has now been reached,laying the foundations for a harmoni-sation in methodologies and termi-nologies. It signifies a great step for-ward and, as far as we know, footballis the first sport to have drawn upsuch a consensus statement.

The move started with informal dis-cussions during the 1st World Con-gress on Sports Injury Prevention inOslo in June 2005. FIFA’s Medical As-sessment & Research Centre (F-MARC)then agreed to act as hosts for a consensus group formed by experts(from three continents) involved inthe study of football injuries – amongthem a member of UEFA’s MedicalCommittee, Prof. Jan Ekstrand. Aworking document identifying key

issues related to data collection andreporting served as the basis for discussions at a two-day meeting inZurich, leading to the production of aconsensus statement to be publishedin leading sports-medicine journals in Europe and North America.

UEFA’s injury studies fully complywith the agreement and it meansthat other studies conducted by, for instance, individual national asso-ciations – such as the Turkish projectoutlined in this issue – can be inter-polated with our data. Clubs who adhere to the newly agreed formatfor recording injuries will, in conse-quence, be able to hold their dataagainst other studies in order to determine whether injury ratios areabove the norm in certain categories.

In answer to the questions posed inthe opening paragraph, the severityof injuries is gauged by the numberof days that elapse between the daythe injury is sustained and the date of the player’s return to full partici-pation with the rest of the squad in training and availability for teamselection.

It is now clarified that the injury oc-curs on ‘day zero’ (rather than ‘day1’) and that, consequently, a playerwho withdraws from training but is available for full participation thefollowing day should be reported ashaving suffered a time-loss injurywith a severity of ‘0 days’. This will be classed as a ‘slight’ injury, with‘minimal’ being the term adopted foran injury that entails absence for 1-3days, ‘mild’ for the 4-7 day bracket,‘moderate’ for 8-28 days, and ‘severe’where absence exceeds that time-span. The category that none of us

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Physician Dr Ulrich Schmieden and physiotherapist Christel Arbinicare for the injured German forward Sandra Minnert during the Women’s EURO 2005 final against Norway.

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want to record is the ‘career-endinginjury’.

Historically, the description of recur-rent injuries has been diverse. A re-current injury is now described as “an injury of the same type and atthe same site as an index injury,which occurs after a player’s returnto full participation from the indexinjury”. A recurrent injury occurringwithin two months of a player’s re-turn is an ‘early recurrence’, one oc-curring between two and 12 monthsis a ‘late recurrence’, and a repeat injury suffered more than a year lateris to be described as a ‘delayed recur-rence’. This entails detailed registra-tion of the index injury, as a repeatof an injury imprecisely marked as‘knee’ or ‘thigh’ may not be a gen-uine recurrence.

The consensus statement also de-fines ‘match exposure’ as games be-tween teams from different clubs,with matches between teams fromthe same club classed as training exposure – as is match activity thatforms part of a player’s rehabilitationafter injury. ‘Training exposure’ re-lates exclusively to sessions wherethere is physical exertion, meaningthat team talks, blackboard tacticalwork and sessions with psychologistsor physios are excluded. On the other hand, warm-up and warm-down routines should be recorded as training exposure.

The classification of injuries is dealtwith in great detail in the document,along with baseline norms for therecording of data and a standard injury report form. Two alternativemethods of recording injuries arecontemplated: one is based on time

loss; the other – more time-consum-ing for the medical staff – on theneed for medical attention. In otherwords, the latter will include a rela-tively large number of incidentsrecorded as ‘severity: zero days’. Anumber of hypothetical cases are contemplated in the consensus state-ment, such as a player who sustains a groin injury. The team physicianconsiders that the injury does notwarrant immediate treatment andthe player continues to take part in training and matches. However, the player elects, two months later, to undergo surgery and then requires90 days of rehabilitation. In the ‘medical attention’ format, the caseshould be recorded as a zero-day injury on the date when the physicianwas consulted and then as a 90-dayinjury as from the date of surgery. In ‘time-loss’ mode, only the 90-dayperiod would be recorded.

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Ole Gunnar Solskjær is treated for a foot injury. Later the Manchester United forward suffered a knee injury, followed by surgery which sidelined him for more than a year.

Raul suffered a contact injury which will keep him out of the game for three or four months this season.

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Much the same would apply to aplayer who suffers an ankle sprainduring a match but plays on, receives medical attention afterthe game, continues full trainingfor six days using ankle taping,but aggravates the injury duringthe next match and requires 15days of rehabilitation. The moredetailed ‘medical attention’ mode would give a fuller picture(describing the initial sprain as a zero-day injury), whereas the‘time-loss’ method only recordsthe ultimate 15-day injury.

For team physicians, the consensusstatement not only makes inter-esting reading but also lays thefoundations for thoroughly reli-able interchange of information –which can only be positive in thecrusade to reduce the incidence of injuries in the game of football.

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THE STATE OF THE PITCHUEFA has decided to extend its monitoring of artificial surfaces. The report by Professor Jan Ekstrand published in the previous issue of Medicine Matters suggested no substantial difference in injury risks between artificial turfand natural grass but, since the study was initiated, thegoalposts have been moved slightly by the introduction ofnew criteria, testing formulae and norms for approval.

FIFA has now established a ‘star sys-tem’, whereby only two-star artificialsurfaces will be acceptable for elitecompetitions, with one-star surfacesacceptable for lower-level games orin certain developing countries.

Under the new regime, UEFA andFIFA have agreed to cooperate on research and monitoring duties, with the former focusing on the toppro level in Europe and the lattermonitoring other continents and the amateur game.

In practical terms, this means thatUEFA’s team will spring into action as soon as clubs install two-star sur-faces. And the monitoring will not be restricted to a comparative studyof injury incidences. Each club will be visited and feedback from playerswill be included in UEFA’s database.So will detailed information aboutthe state of the surface, as artificialpitches will be tested on an annualbasis so that the condition of thepitch can be correlated with injurydata. Clubs will also be obliged tokeep a detailed logbook related topitch maintenance – and this infor-mation will also be included in theUEFA database.

For the purposes of the study, Europewill be divided into northern, central

and southern sectors. Three coun-tries will be pinpointed within eachregion and the study will monitortwo clubs per country, giving anoverall total of 18. Data collectionwill be meticulous, with a view toproducing homogenous, reliable information embracing a period ofseveral years. In other words, an

artificial pitch may seem fine whenit is laid, but the idea is to monitorits performance with the passage oftime and to establish levels of wearand tear on the pitch – and theplayers…

BY THE WAY…“This is a medical study and it did not consider the effects of artificialturf on playing styles or the qualityof football produced on this type of surface.” That sentence, featuredin the report in the previous issue of Medicine Matters, has provokedquestions and comment.

This jigsaw puzzle was assembled into the artificial pitch at East End Park,Dunfermline in 2003. The SPL had the artificial pitch replaced in 2005.

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The artificial pitch that is home to Vags Boltfelag (VB),located amid the dramatic coastal landscape of the Faroe Islands.

The design of footwear custom made for artificial pitches.

The preliminary study conducted by a panel asked to assess injury risks on the two types of surface suggested that artificial surfaces donot detract from the game in termsof incidence figures. The debatingpoint, however, is whether it de-tracts from the game by removingelements from its rich playing texture.

It might be a valid argument, for instance, to claim that lesser tractionon an artificial surface could reducethe risk of studs locking into the turf and causing ligament damage.On the other hand, that relative lack of traction sometimes promptsplayers to complain about greaterdifficulties in turning quickly.

However, many of the players’ comments focus on the difficulty of chipping the ball on an artificialsurface or ‘getting under it’ to hit a lofted pass. In terms of matchanalysis, that could translate intosignificant changes. ‘Ball-to-feet’passes become more prevalent, to the detriment of traditional wing play culminating in crosses.Corners have a greater tendency to be played short, as the takersometimes experiences difficulty in getting a boot far enough underthe ball to deliver a more classicallofted centre.

In other words, the purpose of including that sentence in the last issue was simply to alert the readerto the fact that there’s more to theartificial turf v. natural grass ques-tion than meets the medical eye…

Europe’s first full-size outdoor artificial football pitch was inaugurated inNovember 1971 by the first athlete to break the four-minute mile barrier, RogerBannister, flanked by the captains of the footballteam of HighburyGrove andHolloway school in London.

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The consumption of substances derived from cannabis, such as hashish (resin) and marijuana (“grass”, “pot”), particularly in the form of “joints”, is reported to be widespread.

CANNABISAND SPORTBY DR MARTIAL SAUGY AND DR LYDIA AVOIS,LAUSANNE ANTI-DOPING LABORATORY

There is evidence to support theo-ries of an upsurge in the use of thistype of drug in some countries. Theproblem affects society in generaland sport is not immune to it mak-ing it a potential problem that thefootballing world cannot ignore.This has caused increasing concernand uncertainty among young play-ers, parents, coaches and managers.

Sportspeople who consume can-nabis derivatives generally restrictthemselves to low doses. Consump-tion usually takes place outsidesports facilities and so is outside thecontrol of team coaches and/or doctors. This lack of control is accen-tuated by the fact that testing forthe substance only occurs duringcompetitions.

Statistics gathered from laborato-ries accredited by the World Anti-Doping Agency (WADA) show thatcannabis is easily the most commondrug causing positive results, in particular ahead of testosteroneand nandrolone. Positive resultsonly relate to competition testing.They do not take into account anypositive doses found in urine sam-ples taken out of competition; theseare not reported by laboratories.

The main active ingredient of can-nabis is delta-9-tetrahydrocannabi-nol (THC). As cultivation methodshave developed, it has become pos-sible to grow cannabis plants thathave significantly higher levels ofTHC than before. This high THClevel may reinforce and change theimmediate effects of consumption.

The effect of a high level of THC in terms of long-term damage tohealth has not been well docu-mented, although any activity re-quiring concentration and energywill be affected by its use.

The effects of cannabis derivativesare varied and can have physicaland psychological repercussions aswell as influencing a player’s socialbehaviour. Isolated or infrequentconsumption can lead to:1. mild intoxication2. a sedative effect on behaviour3. slower reaction times4. memory problems5. a tendency towards drowsiness.

In terms of the effects on the body,although heightened sensory per-ception can be expected, THC alsoengenders a certain heaviness, significant relaxation and excessivefatigue of the limbs. As the dose increases, the user may experiencehallucinations, an alteration of theperception of reality and a markedreduction in concentration. Further-more, as these products are gener-ally smoked, consumption by in-halation can only have a negativeeffect on sporting performance and the player’s health (detrimentaleffects on the lungs, oral cavity and upper respiratory tracts).

As regards psychological and socialbehaviour, cannabis accentuates themood of the person concerned. So a user may become carefree, happyand relaxed, but also risks becom-ing stressed, depressed or paranoid.Other effects on a user include

reduced inhibition and developing a certain indifference.

Chronic consumption leads to psychological dependence, a chronicsedative effect and even social detachment.

Does cannabis have a doping effect?

The question often asked in the case of a positive result for cannabisis whether it was consciously usedfor doping purposes. The responsemust be that this substance can onlyindirectly improve performance: itcan have a euphoric effect, reducinganxiety and increasing the sociabil-ity of a player who may be particu-larly nervous before an importantmatch. It can also have a relaxing effect after the game. In this way,cannabis can be considered as adoping product which calms themind. It has already been shownthat the use of cannabis in sportingenvironments is basically motivatedby the feeling of relaxation andwell-being obtained, allowing theuser to sleep more easily. However,if consumed regularly, it risks be-coming harmful to performance andmotivation.

It is when cannabis is consumed reg-ularly that the signs become appar-ent in young athletes. There may be changes in behaviour duringtraining as well as inconsistent per-formance, concentration or motiva-tion. Particular care should be takenwhen a player is vulnerable, for example if lacking support, during

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until urine samples return negativeoutcomes can be as much as fourweeks (two weeks on average) after the most recent consumption.

In conclusion, even though thedoping effects of cannabis have notbeen clearly established, this drug is on the list of prohibited productsand is the subject of competitiontesting. Given that the producttakes a long time to be eliminatedfrom urine, as well as the generalnegative effects over the long term on sporting performance,players should completely abstainfrom consuming cannabis in what-ever form and under whatever circumstances.

Doping is not merely a pharma-cological matter. It is a risky under-taking that compromises healthand sporting ethics. In a new definition published in the WorldAnti-Doping Code, cannabis is categorically considered a prohib-ited substance and has the capacity to end a player’s career.

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prolonged or repeated injury, whenisolated from family or if subject to excessive pressure for results onthe pitch. In these cases it is up tothe club coaches and doctors tolook out for any symptoms that mayappear and to intervene tactfully,although firmly, when necessary. In some cases referral to a psycholo-gist will be necessary.

Analysis and the kinetics of urinary elimination

According to the World Anti-Dop-ing Code, an abnormal result mustbe announced for cannabis if themain metabolite of THC, carboxy-THC, is discovered in a player’s urineat a level in excess of 15 micro-grams/litre as a result of competi-tion testing. This limit has been established to distinguish betweenactive consumers and smokers ofcannabis and players who may havebeen passively exposed to cannabissmoke. The limit also reduces therisk of a positive urine result afterthe consumption of some commer-cial products which may containtraces of cannabis. The use of hempseed and oil in the manufacture offood products has increased consid-erably in some Western countriessince the mid-1990s. The authoritieshave acted to impose limits on THClevels such that the consumption ofthese commercial products will notbring about positive urine results.

It should be noted that the elimina-tion of THC metabolites from urineis a very slow process and dependson an individual’s physiology. In thisway, a simple quantification of theurinary concentration of carboxy-THC reveals very little information

on the time elapsed since consump-tion. The quantity discovered inurine depends on various factors:1. the dosage of the most recent

consumption2. the time elapsed between

the most recent consumption and taking the urine sample

3. the manner of consumption(single dose or regular consump-tion)

4. the individual’s metabolism.

If these factors are taken into account, it is extremely difficult toestablish a relationship betweenurinary concentration and the effects on an individual’s psycho-motor skills.

Despite these considerations, somescientific studies have shown thaton the occasional consumption of a normal dose (a “joint”), the userwill have a positive result for car-boxy-THC for three, four or evenfive days, depending on the smoker’sbody mass. In this way consumingmarijuana with friends a few daysbefore a match could be disastrousfor a football player as there wouldbe a significant risk of failing a dop-ing test. The pretext of recreationaluse is no longer valid. Even if can-nabis is taken without the intentionof improving performance, the out-come will be a positive result if theurinary level exceeds the authorisedthreshold.

For regular users, smoking cannabisseveral times a week for example,urine samples would remain posi-tive for a much longer time afterthe most recent consumption. Sci-entific research published on thissubject has shown that the time

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Ten years ago, the former player(his career included seven years atArsenal FC) was invited to becomechief executive of the LeagueManagers’ Association, an organi-sation established in England in1992. Within six months, he sawhow the Wimbledon manager, JoeKinnear, suffered a heart attackduring a league visit to SheffieldWednesday and was fortunatethat the home club had highlyqualified medical staff on hand.

“Coupled with my own experience,”John Barnwell comments, “it mademe realise that health care for man-agers and coaches was necessary.Most of us are former players and,when you’re playing, you get used tolooking after yourself and having a lot of things done for you. Whenyou become a manager, you can easily find yourself 20 years olderand, instead of looking after your-self, you’re concentrating on lookingafter everybody else. Health prob-

lems can easily go undetected andbe allowed to escalate.

“You’re tempted to think that theclub will look after you – and somedo. But by no means all. In any case,in 1992, the mean figure for tenancyat a managerial job in the leaguewas two years and seven months. At the moment, the figure has already dropped to one year andseven months. In terms of long-termhealth care, a manager is, basically,on his own.”

John’s response was to try to implanta system offering preventive healthcare to managers. As it happened, it was Kevin Keegan who put him on the trail of Dorian Dugmore, acardiovascular specialist who, afteremigrating to Canada, had beenrepatriated by Adidas to spearhead a project aimed at company execu-tives. Ten league managers visitedthe Wellness International MedicalCentre in Stockport, near Manches-ter, during a pilot scheme. Its successled to the birth of the ‘Fit to Man-age’ project.

Even though some of the initial reac-tions were of the “Why do I needthat if I’m perfectly fit?” variety, over80 managers have taken advantageof a scheme currently being fundedby the English Premiership. One of the most persuasive arguments inthe project’s favour was actually thecase involving a high-profile coach at a high-profile club who didn’ttake advantage of the scheme. Re-arranged club commitments forcedhim to cancel three appointments at

John Barnwell as manager of Wolverhampton Wanderers FC parades the League Cup after the 1-0 win against Nottingham Forest FC in 1980.

FIT TOMANAGE?John Barnwell’s coaching career was truncated by a serious car crash when he was on his way home from a charity dinner arranged with a view to raising funds for cancer research. He was lucky to survive an impact which left the rear-view mirror embedded in his skull. Trying to analyse the underlying causes of the accident, he put much of it down to the sheer intensityof the managerial role at football clubs.

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the Wellness Centre and, before afourth could be made, he requiredemergency surgery for a life-threat-ening heart condition.

Dr Dorian Dugmore is also SecretaryGeneral of the World Council For Cardiovascular & Pulmonary Rehabili-tation and a board member of the

aneurysm of the aorta during a Liverpool game. These are someof the high-profile examples: there are many, many more.

The ‘Fit to Manage’ scheme set up by the Football League ManagersAssociation (LMA) at the behest ofJohn Barnwell was initially fundedby the Professional Footballers As-sociation (PFA) and, more recently,by the English Premiership. It hasbeen specifically designed to ad-dress the lifestyle and cardiovascu-lar health of the football manager.Cardiovascular screening of ex-athletes (nearly all managers beingformer footballers) has shown usthat the most common cause ofsudden death is due to degenera-

Johan Cruyff (second from left) filmed an anti-smokingcampaign after undergoing heart surgery while in chargeat FC Barcelona.

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Coaches in the English Premier League undergo cardiovascular tests these days.

Cardiovascular risk in English football league managers

A CAUSE FOR CONCERN?The stresses and pressures associatedwith the management of an Englishleague club have been highlightedrecently in the media. Average work-ing weeks range from 80-87 hours,with maximum levels reaching 100hours. Add to this constant TV, radioand newspaper scrutiny at Premierlevel. Often, just fighting to surviveputs managers in the limelight morethan ever before.

The lifestyle associated with suchpressure often means long hours onthe road, eating poorly – often witha ‘fast food’ diet high in saturatedfats and low in nutritional value.Add in a lack of planned exercise, therelentless pressure to win coupledwith a fear of losing your job if youdon’t, and you have a cocktail that ispotentially damaging to your health.

The last 20-30 years have yieldedclear evidence of cardiovascularrisk/events among league managers.Jock Stein’s sudden death from a myocardial infarction following theScotland v Wales game in 1985; heart

attacks suffered by Joe Kinnear and Barry Fry; Graeme Souness, andJohan Cruyff both receiving coro-nary artery bypass surgery and Gérard Houllier suffering a dissected

European Society of Cardiology’sWorking Group for Sport Cardiology,Exercise Physiology and Cardiac Rehabilitation, apart from being aformer player, qualified coach andhead coach of the Great Britain teamat the World Student Games. Medi-cine Matters asked him to describe hiswork on the ‘Fit to Manage’ project…

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Nevio Scala and his assistant Michael Henke had somenervous moments when BV Borussia Dortmund played away to Eintracht Trier in the German Cup in 1997.

tive ischemic heart disease (Thomp-son P.D., Exercise and Sports Cardiol-ogy, 2001). Indeed, significant ather-osclerotic narrowing of the coronaryarteries (> 75% in 2-3 major vessels)has been found in the majority insudden deaths in older athletes(Northcote et al, Sudden Death andVigorous Exercise, 1986).

A major challenge is emerging: theneed for ex-footballers who becomemanagers and coaches to take bettercare of their lifestyle and cardiovas-cular health. This identifies a furtherneed for such individuals to beguided towards making the transi-tion from sports-related health andfitness as players, to lifestyle-relatedhealth and fitness as managers andcoaches. This is being currently ad-dressed through the provision of theWarwick Business School’s ‘Certified(Football) Management Diploma’. It focuses on key elements of success-ful football management, especiallyhealth/fitness issues.

These include reduced participationin regular exercise; the nutritionalbalance between calories burned andexpended in post-playing days, whichoften leads to weight gain; and alter-ations in blood lipid levels and otherbiochemical markers that can affect cardiovascular risk (e.g. increasedadrenaline and cortisol levels duringgames). The need to balance the de-mands of management with personalfamily life was also among the issuesreflected in a recent TV documentary,showing that the clinical/physiologi-cal costs of managing a top gamewere higher in the two managers

undergoing electrocardiographic/blood pressure ambulatory monitor-ing during a game, compared withbeing pushed to exhaustion on the treadmill one week earlier in a clinical setting.

Of the first 54 managers (mean ageof 49) enrolled in the ‘Fit to Manage’scheme, 24 (44%) recorded diagnosedcardiovascular abnormalities and/orsignificant risk which included atrialfibrillation, atrial flutter, aortic steno-sis, significant ventricular ectopy, (cou-plets, triplets, runs), coronary arterydisease, angioedema and hypercholes-terolemia. These were recorded despite overall fitness levels being acceptable for age/sex (mean peakVO2 – 43 mls.O2.kg.min).

The previous discussion raises a bigquestion: Who cares for the carers?Should managers – together withthose appointing them and influenc-ing their performance – be stronglyencouraged to establish provision to look after their health as a stan-dard clause in future contracts? Suchan approach employed across Europecan only help to influence others in the game, including recreationalfootballers and spectators, to reducethe burden of illness associated with lifestyle/cardiovascular disease.The latter is emphasised in the recent recommendations of the European Society’s working groupon sport cardiology for competitivesports participation in athletes with/without cardiovascular disease.

Scotland manager Jock Stein and coach Andy Roxburgh move the goalposts during a training session prior to the EURO’80 qualifier against Norway in October 1978.

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EDITORIAL GROUPAndy RoxburghGraham TurnerFrits Ahlstrøm

PRODUCTIONAndré VieliDominique MaurerAtema Communication SA – CH-GlandPrinted by Cavin SA – CH-Grandson

October 2006 will mark the end of an era in sports medicine. The annual Brucosport congress in Bruges will be staged for the 25th and last time.

Dr Michel D’Hooghe.

The event has always been close to UEFA’s heart – not least becauseBrucosport was the brainchild of Dr Michel D’Hooghe, former chair-man of our Medical Committee, current chairman of FIFA’s MedicalCommission and, in the more politi-cal arena, a long-standing memberof the FIFA Executive Committee.However, there has been more toBrucosport than personal attach-ments to Michel and his team. Theevent has played a significant role in promoting the development ofsports medicine.

“The medical advances over these 25 years,” Michel D’Hooghe com-ments, “are obvious to everybodywho is old enough to remember thedays when a meniscus operation wasrelatively major surgery; when phys-iotherapy and rehabilitation weremore about immobilisation than mobilisation; and debates on doping focused on the use of anabolicsteroids rather than growth hor-mones and so on. But, basically, Bru-cosport came into being at a timewhen sports medicine in general andsoccer medicine in particular was notthat well structured. So the eventwasn’t just about its significance as a conference. It brought specialists together in a context that allowed

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CHAIRMANDr Urs Vogel, Switzerland

VICE-CHAIRMENProf. Jan Ekstrand, SwedenProf. W. Stewart Hillis, Scotland

MEMBERSProf. Mehmet S. Binnet, TurkeyDr Alan Hodson, EnglandProf. Wilfried Kindermann, Germany Dr Mogens Kreutzfeldt, DenmarkDr Jacques Liénard, FranceDr Pedro Correia Magro, Portugal Dr Alfonso Moreno Gonzalez, Spain Prof. Paolo Zeppilli, Italy

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them to exchange information and experiences. It was somethingnew and, in all modesty, I think it helped to bring structures up to a higher level.”

Asked to explain the decision tolower the flag after the 25th edition,Michel D’Hooghe comments “therehave been significant advances incommunication technology whichprove that Brucosport has fulfilledits purpose. When we started, therewere maybe two or three journals of sports medicine. These days, itwouldn’t take me long to jot downa list of 15 or 16. And that was be-fore the Internet burst onto thescene as an invaluable communica-tions tool. There are other reasonsfor bringing down the final curtain.Those of us who organise it are 25 years older, for example! And wehave lost some team members.Some participants have been comingto Bruges for 10 or 15 years andmight prefer to go somewhere else!At the same time, mergers withinthe pharmaceutical world have affected the sponsorship scenario.So we have decided to changecourse and, in the future, to organ-ise specialised events dedicated to specific areas such as trainers orwomen’s football.”

BRUCOSPORT CONGRESSIN BRUGES

So the final Brucosport will be heldon 13 and14 October and, as MichelD’Hooghe says “the idea is to, as we say in French, finir en beauté.”Helping him to ‘go out on a highnote’ will be an ‘all-star team’ se-lected from the previous 24 editions.The final word – on ‘Visions for theFuture of Sport’ – will be delivered by Jacques Rogge, Michel’s compa-triot who heads the IOC, while thefounder of Brucosport will take abow on a typically positive note by discussing ‘Visions for the Futureof Medical Follow-up in Football’.“There is still a lot of work to bedone and challenges to be faced inorthopaedics, psychology and so on. But one thing hasn’t changedover the last 25 years. We can help to produce better athletes but wecan’t guarantee better footballers!”

UEFARoute de Genève 46CH-1260 NyonSwitzerlandPhone +41 848 00 27 27Fax +41 22 707 27 34uefa.com

Union des associationseuropéennes de football