INTRODUCTION

  1.  As a Physician working full time with Elite Athletes in the field of Sports Medicine, the use and abuse of technology for the Enhancement of performance is a constant conundrum. While superficially often appearing a clear cut delineation between legitimate and illegitimate use of performance enhancing technology, the reality of elite sport means that this distinction is often very blurred. In a world where the World Anti-Doping Agency (WADA) is trying to create a "level playing field", the athletes and coaches within the elite domain, are searching for ways to "get the edge". It is in this environment that the sports physician is required to work—challenged by the sport to provide new and innovative means of enhancing recovery and injury prevention and challenged by WADA and their own ethics to work within legitimate means. Entirely appropriate and innovative means of injury rehabilitation/management may well fly in the face of the standards and regulations of WADA creating a challenging environment for the Sports Physician.

  2.  Despite strong opinions on both the direction that WADA is taking and the inconsistencies it displays in implementing its own code, I will restrict my discussion to those pragmatic issues that I encounter in my clinical practise, looking after elite Track and Field in the United Kingdom.

  3.  I would like to preface this discussion by highlighting the plight of the "national governing body Doctor", as "sports medicine" is often implicated in the implementation and development of doping regimens. In my experience, the official team doctor is the last person that potential cheats will be utilising for this information, as this Doctor will invariably have the interests of the entire sport at heart. Hence, if the medical practitioner is involved, it is usually not the governing body official. Furthermore, I would like to state that the views expressed herein are mine, and may not represent the views of UK Athletics.

  4.  In the following submission I would like to raise some of the issues, with examples, that confront the sports physician, charged with dealing with the health, wellbeing and performance of elite athletes, regarding the use of HET's in sport under each of the four component sections.

POTENTIAL FOR HET'S TO BE USED FOR ENHANCING SPORTS PERFORMANCE

  5.  By way of introduction to this topic it is necessary to clarify the role of the sports physician working in an elite sports environment. This environment is no longer the domain of the amateur athlete working with his or her slightly eccentric coach, but is now a multi-disciplinary arena in which the Sports Physician often plays a key co-ordinating role. While in the past the Physician was involved in the diagnosis and management of injury, increasingly the Physician is involved in maximising performance—most simply illustrated by the task of preventing injury and illness, and more challengingly, by the application of techniques to optimise performance.

  6.  As is most clearly demonstrated in team sports, it is often the ability to keep key performers on the track, and not injured, which determines outcome, and hence any techniques utilised to maximise healing and minimise recovery time, should be considered performance enhancing.

  7.  An example of the maximising recovery from injury or illness may be as simple as the use of anti-oxidant (eg. Vitamin C) medication to prevent illness or enhance injury recovery—a simple procedure, with limited evidence base and well within the bounds of acceptability of most individuals and WADA.

  8.  To pursue the same example, one of the most complex injuries to manage within our sport is a tendinopathy (for example Achilles tendinopathy). This is an area in which there is increasingly a wide variety of treatment techniques being utilised (eg. Injections such as Sclerosant, homeopathic traumeel, Saline dilatation, Cortisone) but more recently in the equine world, stem cell therapy has been trialled with promising results28[28]. Given the difficulty in treating this condition it is more than likely that, if this therapy were shown to be efficacious, that it could be a reasonable treatment for tendinopathies. In this situation, the use of stem cells may be the most appropriate treatment for a difficult clinical condition, but the use of stem cells in athletes may be frowned upon. One could foresee a situation whereby the athlete is disadvantaged by not being able to utilities what may be an appropriate treatment, as a result of seemingly arbitrary delineations of what is permitted and not permitted. A topical example of this may be the WADA regulations on the use of asthma medications (B2-Agonists) which may negatively impact upon the care of elite athletes[29].

  9.  Further use of stem cells could be envisaged in the area of acute muscle damage, where the use of fibroblasts would clearly be beneficial, with the potential to be injected immediately into the area of damage, thereby enhancing injury repair.

  The ability to differentiate between this seemingly legitimate use of stem cells and the use of stem cells for muscle/performance enhancement is unlikely to be possible.

  10.  The recent identification of a possible genetic predisposition to tendon injury raises the possibility of genetic manipulation as part of both prophylactic and treatment for tendinopathies. While this may be a step forward for medicine, it would significantly challenge the WADA Code as it currently stands.

  11.  The use of Growth Factors (GF) in sport is prohibited[30]. However, GF are increasingly utilised in mainstream medicine as a legitimate approach to enhancing healing[31]. They are prohibited in sport primarily as a result of there potential for abuse and performance enhancement. However, as GF technology improves, so will there utilisation. It is very possible that GF will be utilised as part of everyday mainstream management of our most common sports injuries in the near future. This will clearly be at odds with the WADA code.

  12.  Already techniques such as autologous blood injection and "blood spinning" are believed to work partly by the stimulation of growth factors. These techniques have found some notoriety in the media in recent times, but when used in the manner prescribed is likely beneficial, innovative and appropriate treatment regimen. These techniques are felt to work via the stimulation and activation of the bodies own growth factors, and these techniques are being scrutinised by WADA. The potential for abuse of these GF is theoretical and the ability to differentiate between legitimate and illegitimate use will be limited if not impossible.

  13.  Hence legitimate medical practice will in the near future challenge anti-doping authorities to accept appropriate forms of innovative intervention despite being at odd with the prohibited list. This will probably require a form of "Therapeutic Use Exemption" as is currently utilised for many medications, but this will not necessarily limit the potential for abuse.

  14.  The second manner in which medical practitioners may present a challenge is in the area of performance optimisation. Rather than just treating an injury, one may be looking, via a medical intervention, to enhance performance.

  15.  The least challenging example of this would be the management of an individual athletes ferritin levels. Ferritin is a blood borne measure of Iron Storage in the body. The lower limit of normal is usually in the range of 10 units, however in athletes an optimal range for performance is considered anywhere from 30 units upwards (although this is arbitrary and debated amongst clinicians). Hence this will be artificially elevated through either oral supplementation or injection—despite the athlete appearing to be in good health. This is the least challenging example of medical intervention to enhance performance, but there are many other similar situations. In a confidential medical environment, it is often left to the medical practitioner to make an assessment of the relative merits and ethical considerations of the intervention.

  16.  I hope that these examples illustrate that human enhancement technologies, or novel medical approaches are both being used currently, and have an immense potential for increased use in the future. The delineation of what is considered legal or illegal will most likely be arbitrary, increasing the difficulty for enforcement. While the initiatives occurring under WADA should be praised, the challenge in the future will be in the encouragement of appropriate medical interventions which enhance the care of our athletes, and the prevention of inappropriate use of those same interventions.

STEPS ABLE TO BE TAKEN TO MINIMISE THE ILLEGAL HET'S IN 2012

  17.  Recognising that this is not my area of expertise, I can only express my experience. In most situations where performance enhancement has been sought via either legal or illegal means, the coaching staff are a key source of information. For this reason I believe that education (compared with just information) and ethical guidance should be incorporated heavily into coach education at the earliest opportunity.

THE CASE FOR HET'S IN SPORT

  18.  From a medical perspective, as presented above, it is clear that HET's are already and will progressively be integral to the maintenance of the elite athletes health, wellbeing and hence performance.

  19.  In my opinion there needs to be recognition of the appropriate use of HET's within the medical environment, and continued vigilance in the fight against inappropriate use. Medical practitioners should not be prevented from utilising appropriate management strategies, just because of their potential for abuse. The health of elite athletes should not be compromised in this manner.

  20.  WADA has clear guidelines as to why a substance will be included in the permitted list. However, inconsistencies in application of their own guidelines and lack of uniformity between sports and countries, has led to a loss of confidence in the WADA Code. A sound argument can be made for the medicalisation of sport by permitting the controlled use of all medications and techniques, to prevent their "dangerous" use, thereby taking out the need to be concerned with ergogenicity. My own opinion on this is that it depersonalises sport and will take away many of the attractions of sport, thereby destroying sport as we know it. I do however believe that there is a middle ground, whereby WADA place emphasis on the dangers, while de-emphasising the ergogenicity of different agents. This then allows one to rationalise why Nandrolone would stay on the list, but Caffeine would be removed (similarly why Altitude tents may continue to be permitted).

  21.  It is my belief that government intervention in this area would be very complex. Any direct intervention in order to either encourage or discourage HET use could be interpreted entirely differently depending upon individual interpretation. One mans legitimate ethical position, may be anothers illegitimate—a problem that constantly faces WADA. Furthermore, it is my understanding that WADA was developed for entirely this role, and that any intervention would potentially undermine this.

THE STATE OF UK RESEARCH

  22.  This is not an area that I am qualified to discuss.

SUMMARY

  23.  The medical care of elite athletes is an environment conducive to innovation and development, as athletes place the same demands on their practitioners as they do on their coaching staff. As a result sports medicine practitioners are often exploring and challenging conventional thought and management processes, utilising technologies in manners for which they may not have initially been designed. While the utilisation of these technologies is in the best interest of both the athlete and the sport there is no academic challenge, it is when this is not the case that the challenge exists.

May 2006

29   Orellana, J, R Prada, and M Marquez, Use of B2 agonists in sport: are the present criteria right? British Journal of Sports Medicine, 2006. 40: p 363-366. Back

30   WADA, The World Anti-Doping Code. The 2006 Prohibited List. International Standard. 2006, World Anti-Doping Agency: Montreal. Back

31   Molloy, T, Y Wang, and G A Murrell, The roles of growth factors in tendon and ligament healing. Sports Med, 2003. 33(5): p 381-394. Back