Medication use in athletes selected for doping control at the Sydney Olympics (2000)

Medicalization of Sport? A Mixed-Method Study on the Use of Medications in Elite Ice Hockey

Ice hockey is a high-risk sport known for its dominant macho culture. The purpose of this study was to examine experiences surrounding medication use among male, elite ice hockey players in Norway. A mixed-method design was employed, which first examined medications registered on doping control forms (DCFs) (n = 177) and then involved semi-structured focus group interviews (n = 5) with elite athletes (n = 25). Overall, 68% of the DCFs contained information about ≥1 medication. Among the most registered medications were NSAIDs and hypnotics (20% and 19% of all DCFs, respectively). During the interviews, numerous athletes reported using analgesics to manage injuries and pain caused by the sport, often being motivated by sacrificing themselves for the team during important matches and playoffs. Hypnotics were used due to high cumulative stress due to heavy training and competition load, late-night matches, and playing in a semi-professional league. Athlete support personnel (ASP), including physicians and trainers, were the athletes' main sources of information. The athletes often displayed a profound and non-critical trust in the advice and products provided to them by their team physician. The findings indicate that male, elite ice hockey players, through their excessive and somewhat ignorant use of medications, expose themselves to health risks and inadvertent doping.

Nutritional Supplement Use in a UK High-Performance Swimming Club

The aim of this study was to observe the nutritional supplement practices of highly trained swimmers on a national talent pathway, since it is often reported that swimmers engage in widespread supplement use at the elite level. Thus, this study employed a validated supplement intake questionnaire with forty-four swimmers from a high-performance swimming club, which had three distinct talent stages: development (aged 11-14 years, n = 20), age-group (aged 13-17 years, n = 13), and national level (aged ≥ 16 years, n = 11). Ninety-eight percent of the interviewed swimmers reported using at least one supplement, with performance (34%) and recovery (19%) cited as the primary reasons. National swimmers used more total supplements (8.1 ± 3.4 supplements) compared to age-group (4.8 ± 2.0 supplements, p = 0.003, g = 1.17) and development (3.9 ± 1.7 supplements, p < 0.001, g = 1.69) swimmers, mostly because of a greater intake of ergogenic aids (2.4 ± 1.4 supplements vs. age-group: 0.5 ± 0.5 supplements, p < 0.001, g = 1.12; vs. development: 0.1 ± 0.2 supplements, p < 0.001, g = 1.81). Parents/guardians were the primary supplement informants of development swimmers (74%, p < 0.001, V = 0.50), whereas performance nutritionists informed ~50% of supplements used by age-group and national swimmers (p < 0.001, V = 0.51). Based on these results, supplement education and greater focus on basic sport nutrition practices may be required for parents/guardians at the development level. Moreover, further research is needed to support the high number of ergogenic aids used by national swimmers, with the efficacy of these supplements currently equivocal in the applied setting.

Analgesic Use in Sports

BACKGROUND

Consumption of medication to alleviate pain is widespread in Germany. Around 1.9 million men and women take analgesics every day; some 1.6 million persons are addicted to painkillers. Analgesic use is thought also to be common in sports, even in the absence of pain. The aim of this study was to assess the extent of painkiller use among athletes.

METHODS

In line with the PRISMA criteria and the modified PICO(S) criteria, a systematic literature review was registered (Openscienceframework, https://doi. org/10.17605/OSF.IO/VQ94D) and carried out in PubMed and SURF. The publications identified (25 survey studies, 12 analyses of doping control forms, 18 reviews) were evaluated in standardized manner using the Newcastle Ottawa Scale (NOS) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews).

RESULTS

Analgesic use is widespread in elite sports. The prevalence varies between 2.8% (professional tennis) and 54.2% (professional soccer). Pain medication is also taken prophylactically in the absence of symptoms in some non-elite competitive sports. In the heterogeneous field of amateur sports the data are sparse and there is no reliable evidence of wide-reaching consumption of painkillers. Among endurance athletes, 2.1% of over 50 000 persons stated that they used analgesics at least once each month in connection with sports.

CONCLUSION

Analgesic use has become a problem in many areas of professional/ competitive sports, while the consumption of pain medication apparently remains rare in amateur sports. In view of the increasing harmful use of or even addiction to painkillers in society as a whole, there is a need for better education and, above all, restrictions on advertising.

Athletes' use of analgesics is related to doping attitudes, competitive anxiety, and situational opportunity

This study aimed to investigate athletes' hypothetical use of non-steroidal anti-inflammatory drugs (NSAIDs), a behavior similar to doping, and its association with doping attitudes, competitive anxiety and situational opportunity. One hundred twenty-two sport science students completed an online survey assessing biographical information, doping attitudes, and competitive anxiety. Students' intention to use analgesics was measured via two different hypothetical situations using the vignette technique. The favorable situation included an absence of potential witnesses and presence of an attractive good whereas witnesses were present in the unfavorable situation and an attractive goal was absent. The results of two hierarchical multiple regression models showed that doping attitudes and competitive anxiety, especially worry, predicted the use of analgesics. In the situation featuring a favorable opportunity, worry was the strongest predictor, whereas in the situation of an unfavorable opportunity, doping attitudes was the strongest predictor for using NSAIDs. Results indicate that NSAID use is associated with positive attitudes toward doping and competitive anxiety, and that it is situationally dependent. Future research perspectives and practical implications are discussed.

Analysis of Sport Supplement Consumption by Competitive Swimmers According to Sex and Competitive Level

Sports supplements (SS) are commonly used by athletes to improve their performance. SS use by competitive swimmers is reported to be prevalent but there is no evidence of such use by elite swimmers, either male or female. The objective of this research was to study the patterns of SS use by competitive swimmers based on sex and competitive levels (national and international); Methods: Using the categories of the Australian Institute of Sport (AIS), a total of 102 competitive swimmers (59 men and 43 women) completed a validated self-administered questionnaire on the use of SS; (3) Results: Overall, 86.9% of swimmers had consumed SSs with no differences observed between males and females (p = 0.247) or between competitive levels (p = 0.597). The SS that were most consumed by swimmers were caffeine (53.5%), sport drinks (52.5%), sport bars (51.5%), and vitamin C (43.4%). SSs categorized as medical supplements were consumed significantly more frequently by international swimmers (p = 0.012), with significant differences also found in the level—sex interaction (p = 0.049); (4) Conclusions: Compared to other sports disciplines, the prevalence of SS consumption is high in competitive swimmers regardless of performance level or gender. However, the consumption of medical supplements was greater in swimmers at a higher performance level.

Dietary Supplements as Source of Unintentional Doping

Background

The substances used in sport could be divided into two major groups: those banned by the World Anti-Doping Agency and those which are not. The prohibited list is extremely detailed and includes a wide variety of both medicinal and nonmedicinal substances. Professional athletes are exposed to intense physical overload every day. They follow a relevant food regime and take specific dietary supplements, which is essential for the better recovery between trainings and competitions. However, the use of “nonprohibited” dietary supplements (DS) is not always completely safe. One of the risks associated with the use of dietary supplements is the risk of unintended doping—originating from contaminated products. The presence of undeclared compounds in the composition of DS is a serious concern. The aim of this study is to evaluate the risk of unintentional doping.

Materials and Methods

Literature search was done through PubMed, Science Direct, Google Scholar, and Web of Science. Studies investigating the presence of undeclared compounds, in dietary supplements, banned by WADA met the inclusion criteria. The last search was conducted in June 2021. The present review is based on a total of 50 studies, which investigated the presence of undeclared compounds in DS.

Results

The total number of analyzed DS is 3132, 875 of which were found to contain undeclared substances. Most frequently found undeclared substances are sibutramine and anabolic-androgenic steroids.

Conclusion

More than 28% of the analyzed dietary supplements pose a potential risk of unintentional doping. Athletes and their teams need to be aware of the issues associated with the use of DS. They should take great care before inclusion of DS in the supplementation regime.

Chronic prescription medication use in endurance runners: a cross-sectional study in 76,654 race entrants - SAFER XV

OBJECTIVE

To determine the prevalence of chronic prescription medication (CPM) use in distant runners (by age and sex) and to compare CPM use in 21.1 km vs. 56 km race entrants.

METHODS

A cross-sectional study of 76,654 race entrants who completed a pre-race medical screening questionnaire during race registration, which included questions on the use of CPM and CPM use in eight main categories of CPM. Prevalence (%, 95%CIs) and prevalence ratios (PR) are reported.

RESULTS

The prevalence of any CPM use was 12.5% (12.2-12.8). CPM use was higher in older age categories vs. the youngest age category (31-40 yrs vs. ≤30 yrs: PR = 1.4; 41-50 yrs vs. ≤30 yrs: PR = 2.1; >50 yrs vs. ≤30 yrs: PR = 3.4) (p < 0.0001) and females vs. males (PR = 1.1; p < 0.0001). The use of any CPM was significantly higher in 21.1 km vs. 56 km race entrants (PR = 1.2; p < 0.0001). Prevalence of CPM use in main categories was: blood pressure lowering medication (3.7%), cholesterol lowering medication (3.6%), asthma medication (3.1%), and medication to treat anxiety/depression (2.6%). The pattern of CPM in the main categories differed between 21.1 km and 56 km race entrants.

CONCLUSIONS

One in eight race entrants use CPM, with a higher prevalence of use among older race entrants, female vs. males, and 21.1 km vs. 56 km race entrants. Frequent CPMs used are blood pressure lowering medication, cholesterol lowering medication, asthma medication, and medication to treat anxiety/depression. The use of CPM medications may increase the risk of medical complications during exercise, and these data help identify subgroups of entrants that may be at higher risk for race medical encounters.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Nonsteroidal anti-inflammatory drugs and paracetamol use in elite-level Olympic-style weightlifters: a survey study

BACKGROUND

Although the high prevalence of analgesic use in various sports disciplines is well-known, it has not been reported among Olympic-style weightlifters yet. We aimed to determine the frequency of the nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol use in elite-level Olympic-style weightlifters, the weightlifters' attitudes towards NSAIDs and paracetamol use, and the total daily, weekly and monthly doses of NSAIDs and paracetamol.

METHODS

A total of 166 (46 female, 120 male) Olympic-style weightlifters enrolled for this study. Data was collected through an interviewer-administered questionnaire distributed during national championships. The Assessment of Spondyloarthritis International Society-NSAID equivalent score, total doses of acetylsalicylic acid and paracetamol were calculated daily, weekly, and monthly.

RESULTS

The mean age of participants was 18.9±4.7 years. Only 11.4% of athletes stated that they used the drug only when the physician prescribed it. More than half of the athletes (57.2%) stated that they used at least one of the analgesics the day before the competition day. The most common form reported by the athletes was the concomitant use of medications (31.3%). The mean total acetylsalicylic acid, NSAID and paracetamol doses of 95 athletes using analgesics were daily: 500.0±95.0 mg/105.0±71.4 mg/555.6±160.1 mg, weekly: 1166.0±899.4 mg/145.2±176.6 mg/1166.7±892.8 mg, and monthly: 3461.1±4940.7 mg/201.5±274.0 mg/2750.0±3841.9 mg, respectively.

CONCLUSIONS

The frequency of analgesic and anti-inflammatory medication use among the elite-level Olympic-style weightlifters is very high.

Risk Associated with the Use of Selected Ingredients in Food Supplements

This review focuses on four new product categories of food supplements: pre-workout, fat burner/thermogenic, brain/cognitive booster, and hormone/testosterone booster. Many food supplements have been shown to be contaminated with unauthorized substances. In some cases, the ingredients in the new categories of dietary supplements were medicinal products or new synthetic compounds added without performing clinical trials. Some of the new ingredients in dietary supplements are plant materials that are registered in the pharmacopoeia as herbal medicines. In other cases, dietary supplements may contain plant materials that have no history of human use and are often used as materials to 'camouflage' stimulants. In the European Union, new ingredients of dietary supplements, according to European Food Safety Authority or unauthorized novel food. Furthermore, selected ingredients in dietary supplements may be prohibited in sports and are recognized as doping agents by World Anti-Doping Agency.

Prevalence of use of permitted pharmacological substances for recovery among athletes

Objectives: Food supplements and medicines which are not on the list of prohibited substances of the World Anti-Doping Agency are included in the group of permitted pharmacological agents for athlete’s recovery.

The aim of this study was to describe qualitatively and quantitatively food supplements (FS) and over-the-counter drugs use among athletes in the last six month.

Methods: This was a cross sectional study. Data on food supplements and the over-the-counter drugs, usage were collected during 2018 by self-administered, anonymous questionnaire.

Results: A total of 112 athletes completed the survey. A total of 51.8% (n = 58) athletes reported the use of food supplements. The use of medical supplements was reported by 50.0% (n = 56) of athletes, 26.8% (n = 30) reported using ergogenic supplements, 1.8% (n = 2) using of sports food and 4.5% (n = 5) using other supplements. The use of over-the-counter drugs was reported by 35.7% (n = 40) of athletes. The over-the-counter analgesic drugs were used by 95% (n = 38) of over-the-counter drug users. Concomitant administration two or more over-the-counter drugs was reported by 40% (n = 16) athletes. Doctors and coaches had no advisory role in the use of food supplements or over-the-counter drugs.

Dietary Supplement and Food Contaminations and Their Implications for Doping Controls

A narrative review with an overall aim of indicating the current state of knowledge and the relevance concerning food and supplement contamination and/or adulteration with doping agents and the respective implications for sports drug testing is presented. The identification of a doping agent (or its metabolite) in sports drug testing samples constitutes a violation of the anti-doping rules defined by the World Anti-Doping Agency. Reasons for such Adverse Analytical Findings (AAFs) include the intentional misuse of performance-enhancing/banned drugs; however, also the scenario of inadvertent administrations of doping agents was proven in the past, caused by, amongst others, the ingestion of contaminated dietary supplements, drugs, or food. Even though controversial positions concerning the effectiveness of dietary supplements in healthy subjects exist, they are frequently used by athletes, anticipating positive effects on health, recovery, and performance. However, most supplement users are unaware of the fact that the administration of such products can be associated with unforeseeable health risks and AAFs in sports. In particular anabolic androgenic steroids (AAS) and stimulants have been frequently found as undeclared ingredients of dietary supplements, either as a result of cross-contaminations due to substandard manufacturing practices and missing quality controls or an intentional admixture to increase the effectiveness of the preparations. Cross-contaminations were also found to affect therapeutic drug preparations. While the sensitivity of assays employed to test pharmaceuticals for impurities is in accordance with good manufacturing practice guidelines allowing to exclude any physiological effects, minute trace amounts of contaminating compounds can still result in positive doping tests. In addition, food was found to be a potential source of unintentional doping, the most prominent example being meat tainted with the anabolic agent clenbuterol. The athletes’ compliance with anti-doping rules is frequently tested by routine doping controls. Different measures including offers of topical information and education of the athletes as well as the maintenance of databases summarizing low- or high-risk supplements are important cornerstones in preventing unintentional anti-doping rule violations. Further, the collection of additional analytical data has been shown to allow for supporting result management processes.

Oral non-steroidal anti-inflammatory drug use in recreational runners participating in Parkrun UK: Prevalence of use and awareness of risk

Objective

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in endurance running and by elite athletes. We examined the pattern of use of NSAIDs, the purpose of use and knowledge of the adverse effects of NSAID use in a population of recreational runners at Parkrun UK.

Methods

An online observational non-interventional cross-sectional survey of Parkrun UK participants being over the age of 18, on Parkrun UK’s mailing list, and residing in the UK.

Key Findings

Runners (n = 806) had a high use of NSAIDs in the past 12 months (87.8%). The average age of respondents was 48.39 years. There was a significant association between those taking an oral NSAID in the last twelve months and those with a sporting injury (χ2 = 10.89, df = 1, n = 797, P = 0.001). Ibuprofen was the most commonly used NSAID (81.1%). A third of runners had experienced an adverse drug reaction associated with NSAIDs, usually gastrointestinal. Half of runners used NSAIDs with no advice, and patient information leaflets were the most common source for those that had advice. Ninety-four per cent of runners would like more information on the harms and benefits of NSAIDs.

Conclusions

Some recreational runners have a high use of NSAIDs, which is chronic in nature and a potential health risk. Recreational runners want more information on the harms and benefits of NSAIDs. Race event organizers should provide evidence-based advice on the use of NSAIDs.

Influence of Pain Killers on the Urinary Anabolic Steroid Profile

Anabolic androgenic steroids (AAS) are prohibited as performance-enhancing drugs in sports. Among them, testosterone and its precursors are often referred to as “pseudoendogenous” AAS, that is, endogenous steroids that are prohibited when administered exogenously. To detect their misuse, among other methods, the World Anti-Doping Agency-accredited laboratories monitor the steroid profile (concentrations and concentration ratios of endogenous steroids, precursors and metabolites) in urine samples collected from athletes in and out of competition. Alterations in steroid profile markers are used as indicators for misuse of anabolic steroids in sports. Therefore, especially their metabolic pathways with possible interactions are crucial to elucidate. As steroid metabolism is very complex, and many enzymes are involved, certain non-prohibited drugs may influence steroid metabolite excretion. One important group of steroid-metabolizing enzymes is aldo–keto reductases (AKRs). An inhibition of them by non-steroidal anti-inflammatory drugs (NSAIDs), which are neither prohibited nor monitored, but frequently used drugs in sports, was demonstrated in vitro. Thus, this work aims to investigate the influence of NSAID intake on the urinary steroid profile. Kinetic and inhibitory studies were performed using 5α-dihydrotestosterone as substrate. The results obtained from in vitro experiments show that ibuprofen inhibits AKR1C2 and thus influences steroid biotransformation. For in vivo investigations, urine samples prior, during and postadministration of ibuprofen were analyzed using routine methods to monitor the steroid profile. Changes in markers of the steroid profile of volunteers were observed. The combination of in vitro and in vivo results suggests that monitoring of ibuprofen may be useful in doping control analysis. The presented work illustrates the importance to consider co-administration of (non-prohibited) drugs during antidoping analysis. Intake of multiple substances is likely leading to interfering effects. Divergent results in antidoping analysis may therefore be observed and misinterpretation of analytical data may occur. Similar considerations may be appropriate for other fields of forensic applications.

Preparticipation Evaluation

Although the specific content has been recommended, debated, and extensively reviewed over the past several decades, the preparticipation evaluation (PPE) has become standard of care for athletes as they prepare for organized athletic participation. The PPE seeks to detect conditions that predispose the athlete to injury or limit full participation in certain activities. Of particular interest, underlying cardiovascular and musculoskeletal conditions are sought because they are frequently associated with mortality and morbidity in athletes.

The Prevalence of Legal Performance-Enhancing Substance Use and Potential Cognitive and or Physical Doping in German Recreational Triathletes, Assessed via the Randomised Response Technique

This study investigated the use of performance-enhancing substances in recreational triathletes who were competing in German races at distances ranging from super-sprint to long-distance, as per the International Triathlon Union. The use of legal drugs and over-the-counter supplements over the previous year, painkillers over the previous 3 months, and the potential three-month prevalence of physical doping and or cognitive doping in this group were assessed via an anonymous questionnaire. The Randomised Response Technique (RRT) was implemented for sensitive questions regarding "prescription drugs […] for the purpose of performance enhancement […] only available at a pharmacy or on the black market". The survey did not directly state the word "doping," but included examples of substances that could later be classed as physical and or cognitive doping. The subjects were not required to detail what they were taking. Overall, 1953 completed questionnaires were received from 3134 registered starters at six regional events-themselves involving 17 separate races-in 2017. Of the respondents, 31.8% and 11.3% admitted to the use of dietary supplements, and of painkillers during the previous three months, respectively. Potential physical doping and cognitive doping over the preceding year were reported by 7.0% (Confidence Interval CI: 4.2-9.8) and 9.4% (CI: 6.6-12.3) of triathletes. Gender, age, experience in endurance sports, and number of weekly triathlon training hours were linked to potential physical or cognitive doping. Given the potentially relevant side effects of painkiller use and physical and or cognitive doping, we recommend that educational and preventative measures for them be implemented within amateur triathlons.

Retrospective study of the use of medication and supplements during the 2018 FIFA World Cup Russia

Objective

Examine the intake of medication and supplements used by top-level players during the 2018 FIFA World Cup Russia.

Participants

736 top-level players

Setting

The team doctors uploaded a list of the medications used by each player to the online reporting tool within 72 hours of each match of the 2018 FIFA World Cup Russia.

Outcome measures

Average number of medications used per player per match and during the tournament; average number and percentage of players using at least one medication per match and during the tournament.

Results

54% of the players took at least one medication during the tournament and 39% took at least one medication before each match. The most used medications were non-steroidal anti-inflammatory drug (NSAID) (38.6%), followed by other analgesics (13.8%) and medications for insomnia and anxiety (13%). On average, 0.72 medications were taken per player per match and 1.32 per player during the tournament. The mean number of medication intake per player per match was higher during the knockout stage compared with the group stage (0.88±1.36 vs 0.65±1.08, p<0.001). Players from South America and North and Central America took more medications per match compared with the players from Africa (0.9±1.14 and 0.98±1.1 vs 0.48±0.83, p<0.001 in both cases).

Conclusion

The intake of NSAIDs decreased during the 2018 FIFA World Cup compared with previous FIFA World Cups, but stayed at a high level. The high number of medications taken is a cause for concern, and therefore, players, medical staff and coaches should be made more aware of the possible side effects of a high medication intake.

Compliance with needle-use declarations at two Olympic Winter Games: Sochi (2014) and PyeongChang (2018)

Objectives

We describe compliance with the ‘IOC Needle Policy’ at two Winter Olympic Games (Sochi and PyeongChang) and compare these findings to those of the Summer Olympic Games of Rio de Janeiro.

Method

All needle-use declaration(s) (NUD) received during the course of the 2014 and 2018 Olympic Games were reviewed. We recorded socio-demographic data, the nature and purpose of needle use, product(s) injected, and route of administration. Data were analysed descriptively.

Results

In total, doctors from 22 National Olympic Committees (NOCs) submitted 122 NUD involving 82 athletes in Sochi; in PyeongChang, doctors from 19 NOCs submitted 82 NUD involving 61 athletes. This represented approximately 2% of all athletes at both Games, and 25% and 20% of all NOCs participating in Sochi and PyeongChang, respectively. No marked differences in the NUD distribution patterns were apparent when comparing the two Winter Olympic Games. The most commonly administered substances were as follows: local anaesthetics, non-steroidal anti-inflammatory drug and glucocorticoids. Physicians submitted multiple NUD for 24% of all athletes who required a NUD.

Conclusion

A limited number of NOCs submitted NUD suggesting a low incidence of needle use or limited compliance (approximately 2%). A key challenge for the future is to increase the rate of compliance in submitting NUD. More effective education of NOCs, team physicians and athletes regarding the NUD policy, its purpose, and the necessity for NUD submissions, in association with the enforcement of the appropriate sanctions following non-compliance are needed.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Acute ibuprofen ingestion does not attenuate fatigue during maximal intermittent knee extensor or all-out cycling exercise

Recent research suggests that acute consumption of pharmacological analgesics can improve exercise performance, but the ergogenic potential of ibuprofen (IBP) administration is poorly understood. This study tested the hypothesis that IBP administration would enhance maximal exercise performance. In one study, 13 physically active males completed 60 × 3-s maximal voluntary contractions (MVCs) of the knee extensors interspersed with 2-s passive recovery periods, on 2 occasions, with the critical torque (CT) estimated as the mean torque over the last 12 contractions (part A). In another study, 16 active males completed two 3-min all-out tests against a fixed resistance on an electronically braked cycle ergometer, with the critical power estimated from the mean power output over the final 30 s of the test (part B). All tests were completed 60 min after ingestion of maltodextrin (placebo, PL) or 400 mg of IBP. Peripheral nerve stimulation was administered at regular intervals and electromyography was measured throughout. For part A, mean torque (IBP: 60% ± 13% of pre-exercise MVC; PL: 58% ± 14% of pre-exercise MVC) and CT (IBP: 41% ± 16% of pre-exercise MVC; PL: 40% ± 15% of pre-exercise MVC) were not different between conditions (P > 0.05). For part B, end-test power output (IBP: 292 ± 28 W; PL: 288 ± 31 W) and work done (IBP: 65.9 ± 5.9 kJ; PL: 65.4 ± 6.4 kJ) during the 3-min all-out cycling tests were not different between conditions (all P > 0.05). For both studies, neuromuscular fatigue declined at a similar rate in both conditions (P > 0.05). In conclusion, acute ingestion of 400 mg of IBP does not improve single-leg or maximal cycling performance in healthy humans.

Analgesic and anti-inflammatory drugs in sports: Implications for exercise performance and training adaptations

Over-the-counter analgesics, such as anti-inflammatory drugs (NSAIDs) and paracetamol, are widely consumed by athletes worldwide to increase pain tolerance, or dampen pain and reduce inflammation from injuries. Given that these drugs also can modulate tissue protein turnover, it is important to scrutinize the implications of acute and chronic use of these drugs in relation to exercise performance and the development of long-term training adaptations. In this review, we aim to provide an overview of the studies investigating the effects of analgesic drugs on exercise performance and training adaptations relevant for athletic development. There is emerging evidence that paracetamol might acutely improve important endurance parameters as well as aspects of neuromuscular performance, possibly through increased pain tolerance. Both NSAIDs and paracetamol have been demonstrated to inhibit cyclooxygenase (COX) activity, which might explain the reduced anabolic response to acute exercise bouts. Consistent with this, NSAIDs have been reported to interfere with muscle hypertrophy and strength gains in response to chronic resistance training in young individuals. Although it remains to be established whether any of these observations also translate into detriments in sport-specific performance or reduced training adaptations in elite athletes, the extensive use of these drugs certainly raises practical, ethical, and important safety concerns that need to be addressed. Overall, we encourage greater awareness among athletes, coaches, and support staff on the potential adverse effects of these drugs. A risk-benefit analysis and professional guidance are strongly advised before the athlete considers analgesic medicine for training or competition.

Analgesic Management of Pain in Elite Athletes: A Systematic Review

OBJECTIVE

To identify the prevalence, frequency of use, and effects of analgesic pain management strategies used in elite athletes.

DESIGN

Systematic literature review.

DATA SOURCES

Six databases: Ovid/Medline, SPORTDiscus, CINAHL, Embase, Cochrane Library, and Scopus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical studies involving elite athletes and focused on the use or effects of medications used for pain or painful injury. Studies involving recreational sportspeople or those that undertake general exercise were excluded.

MAIN RESULTS

Of 70 articles found, the majority examined the frequency with which elite athletes use pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anesthetics, and opioids. A smaller set of studies assessed the effect of medications on outcomes such as pain, function, and adverse effects. Oral NSAIDs are reported to be the most common medication, being used in some international sporting events by over 50% of athletes. Studies examining the effects of pain medications on elite athletes typically involved small samples and lacked control groups against which treated athletes were compared.

CONCLUSIONS

Existing empirical research does not provide a sufficient body of evidence to guide athletes and healthcare professionals in making analgesic medication treatment decisions. Based on the relatively robust evidence regarding the widespread use of NSAIDs, clinicians and policymakers should carefully assess their current recommendations for NSAID use and adhere to a more unified consensus-based strategy for multidisciplinary pain management in elite athletes. In the future, we hope to see more rigorous, prospective studies of various pain management strategies in elite athletes, thus enabling a shift from consensus-based recommendations to evidence-based recommendations.

Amateur endurance athletes’ use of non-steroidal anti-inflammatory drugs: a cross-sectional survey

Objective

To explore amateur endurance athletes’ use and views about non-steroidal anti-inflammatory drugs (NSAIDs).

Methods

An online cross-sectional survey of amateur athletes at four athletic clubs.

Key findings

Of a sample of 129 of amateur athletes, 68% (n = 88) reported using NSAIDs in the previous 12 months (84.4% in triathletes, 70.9% in runners and 52.5% in cyclists). Overall, ibuprofen was the most popular drug (n = 48). There was a lack of knowledge of adverse drug reactions, with only 26% of use advised by a doctor or pharmacist.

Conclusions

There is high usage of NSAIDs in amateur athletes, including before and during events, largely without professional health advice. Informational needs of amateur athletes are not being met.

Athletes and Supplements: Prevalence and Perspectives

In elite sport, where opponents are evenly matched, small factors can determine the outcome of sporting contests. Not all athletes know the value of making wise nutrition choices, but anything that might give a competitive edge, including dietary supplements, can seem attractive. Between 40% and 100% of athletes typically use supplements, depending on the type of sport, level of competition, and the definition of supplements. However, unless the athlete has a nutrient deficiency, supplementation may not improve performance and may have a detrimental effect on both performance and health. Dietary supplements are classified as a subcategory of food, so manufacturers are not required to provide evidence of product safety and efficacy, nor obtain approval from regulatory bodies before marketing supplements. This creates the potential for health risks, and serious adverse effects have been reported from the use of some dietary supplements. Athletes who compete in sports under an anti-doping code must also realize that supplement use exposes them to a risk of ingesting banned substances or precursors of prohibited substances. Government systems of regulations do not include specific laboratory testing for banned substances according to the WADA list, so a separate regulatory framework to evaluate supplements for their risk of provoking a failed doping test is needed. In the high-performance culture typical of elite sport, athletes may use supplements regardless of possible risks. A discussion around medical, physiological, cultural, and ethical questions may be warranted to ensure that the athlete has the information needed to make an informed choice.

Ibuprofen alters human testicular physiology to produce a state of compensated hypogonadism

Concern has been raised over increased male reproductive disorders in the Western world, and the disruption of male endocrinology has been suggested to play a central role. Several studies have shown that mild analgesics exposure during fetal life is associated with antiandrogenic effects and congenital malformations, but the effects on the adult man remain largely unknown. Through a clinical trial with young men exposed to ibuprofen, we show that the analgesic resulted in the clinical condition named "compensated hypogonadism," a condition prevalent among elderly men and associated with reproductive and physical disorders. In the men, luteinizing hormone (LH) and ibuprofen plasma levels were positively correlated, and the testosterone/LH ratio decreased. Using adult testis explants exposed or not exposed to ibuprofen, we demonstrate that the endocrine capabilities from testicular Leydig and Sertoli cells, including testosterone production, were suppressed through transcriptional repression. This effect was also observed in a human steroidogenic cell line. Our data demonstrate that ibuprofen alters the endocrine system via selective transcriptional repression in the human testes, thereby inducing compensated hypogonadism.

Needle-use declarations at the Olympic Games Rio 2016

AIM

We report on the results of the 'IOC Needle Policy' applied during the course of the Games of the XXXI Summer Olympiad in Rio de Janeiro, Brazil. The policy was intended to empower physicians to ensure appropriate clinical use of needles within team medical environments, enhance the safety of those responsible for housekeeping services and others in the Olympic environment, and permit documentation of such procedures as an adjunct to the doping control programme. Any needle use required the submission of an 'Injection Declaration Form' to IOC medical officials.

METHOD

All 'Injection Declaration Forms' were reviewed and archived. The declarations provided basic information regarding the nature of the needle use and the product(s) involved, the physician, athlete and respective National Olympic Committee (NOC). The details of the declarations were subsequently categorised.

RESULTS

A total of 367 declarations were received from physicians representing 49 NOCs. Needle-use declarations were more common in athletics, gymnastics, football and aquatics. A single product was administered in 60% of the cases, and more than one product was administered in 40%. The majority of declarations indicated the use of local anaesthetics, glucocorticoids, non-steroidal anti-inflammatory drugs and analgesics.

CONCLUSION

The introduction of a 'Needle Policy' in the Olympic Games setting was intended to minimise the use of needles by non-physicians, promote evidence-based practice and to deter needle-based doping practices. Declarations were received from 49 of 209 NOCs suggesting either that needle use is minimal among certain teams or opportunities remain to enhance compliance with such policies at future games.

Medication and Supplement Use in Disability Football World Championships

BACKGROUND

Individuals with an impairment comprise more than 15% of the world's population, many of whom can benefit greatly from participation in sport. The provision of medical services in disability sport is a challenging area with a lack of scientific evidence. Given the positive impact that sport can have on the people with an impairment, it is vital that measures are taken to better understand the medical issues posed by disability sport. It is well established that medications and supplements are overused in sport, particularly within professional football, but there is no current evidence on medication or supplement use in elite disability football.

OBJECTIVE

To examine and describe the use of medication and supplements in disability football, before and during international tournaments, and to identify the profile of substances used by category.

DESIGN

Prospective, descriptive, cohort study.

SETTING

International Blind Sport Association Football World Cup 2015 and the International Federation of Cerebral Palsy Football World Cup 2015.

PARTICIPANTS

Two hundred forty-two elite-level disability footballers, classified with B1 visual impairment or cerebral palsy.

METHODS

Team clinicians were asked to document all medication and supplements taken in the 48 hours before each match.

RESULTS

This study recorded the use of 1648 substances in 242 players, with more than one half (53.1%) classified as supplements. There was an overall rate of 1.26 substances used per player per match and a medication use rate of 0.59 medications per player per match. Seventy percent (170/242) of players reported using at least one substance per tournament, with 57.9% (140/242) using at least one prescribed medication (63.6% of players at International Blind Sports Association World Games and 57.7% of players at International Federation of Cerebral Palsy World Cup). The most commonly prescribed category of medications was nonsteroidal anti-inflammatory drugs, representing 39.3% of all reported medications.

CONCLUSION

This study highlights the potential overuse of medication and supplements in disability football, particularly in the use of nonsteroidal anti-inflammatory drugs. These trends are comparable to previous research in Fédération Internationale de Football Association World Cup competitions.

LEVEL OF EVIDENCE

Not applicable.

Diclofenac pretreatment modulates exercise-induced inflammation in skeletal muscle of rats through the TLR4/NF-κB pathway

Nonsteroidal anti-inflammatory drugs, such as diclofenac, are widely used to treat inflammation and pain in several conditions, including sports injuries. This study analyzes the influence of diclofenac on the toll-like receptor-nuclear factor kappa B (TLR-NF-κB) pathway in skeletal muscle of rats submitted to acute eccentric exercise. Twenty male Wistar rats were divided into 4 groups: control-saline, control-diclofenac, exercise-saline, and exercise-diclofenac. Diclofenac or saline were administered for 7 days prior to an acute eccentric exercise bout. The inflammatory status was evaluated through mRNA levels of cyclooxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), interleukin-6 (IL-6), IL-1β, and tumor necrosis factor alpha (TNF-α), and protein content of COX-2, IL-6, and TNF-α in vastus lateralis muscle. Data obtained showed that a single bout of eccentric exercise significantly increased COX-2 gene expression. Similarly, mRNA expression and protein content of other inflammation-related genes also increased after the acute exercise. However, these effects were attenuated in the exercise + diclofenac group. TLR4, myeloid differentiation primary response gene 88 (MyD88), and p65 were also upregulated after the acute eccentric bout and the effect was blunted by the anti-inflammatory drug. These findings suggest that pretreatment with diclofenac may represent an effective tool to ameliorate the pro-inflammatory status induced by acute exercise in rat skeletal muscle possibly through an attenuation of the TLR4-NF-κB signaling pathway.

Use of Non-Steroidal Anti-Inflammatory Drugs among Participants in a Mountain Ultramarathon Event

The aim of this study was to evaluate and compare the prevalence of non-steroidal anti-inflammatory drugs (NSAID) consumption immediately before, during and immediately after three mountain ultra-endurance runs that differed in their course distance. This observational study took place at the Ultra Mallorca Serra de Tramuntana (Mallorca, Spain), an ultra-endurance mountain event with runners participating either in a 112-km (Ultra, n = 58), a 67-km (Trail, n = 118) or a 44-km (Marathon, n = 62) run competition. Participants in the study answered, within an hour after finishing the competition, a questionnaire focused mainly on NSAIDs consumption. Among study participants, 48.3% reported taking NSAIDs at least for one of the time-points considered: before, during and/or immediately after the competition, with more positive responses (having taken medication) found for the Ultra (60.3%) than for the Trail (49.2%) and the Marathon (35.5%). Among consumers, the Ultra participants reported the lowest intake before and the highest during the race, while participants in the Marathon reported similar consumption levels before and during the race. In conclusion, a high prevalence of NSAID consumption was found among athletes participating in an ultra-endurance mountain event. Competition duration seemed to determine both the prevalence and the chronological pattern of NSAID consumption.

Patterns of Nutrition and Dietary Supplements Use in Young Egyptian Athletes: A Community-Based Cross-Sectional Survey

The aim of this study was to investigate the pattern of basic and sport nutrition as well as perspectives of young Egyptian athletes. Structured interview survey measuring knowledge, attitudes, beliefs and behaviors about basic and sport nutrition was administered to adolescent athletes recruited from 4 sport clubs and 2 fitness centers in Greater Cairo governorate. A total of 358 participants aged 13–18 years completed questionnaires. Basic nutrition knowledge was reasonable in almost all domains except fast food. Fixed breakfast (78.5%), home meals (lunch, 70.7%), and healthy snacks (55.8%) were the most positive features of the basic dietary pattern. More than 70% perceived themselves as knowledgeable about sport nutrition. The prevalence rate of sport supplement intake was (48.9%, n = 175), predominantly sport drinks (66.9%) and creatine (54.3%). Coaches were the primary source of sport nutrition information. Forty-four percent of participants (n = 77/175) reported supplement consumption during competition seasons only. Better physical appearance and enhancement of athletic performance were the major motivations for supplement intake. These findings indicate the necessity of a comprehensive nutrition education program targeting not only athletes and parents, but also coaching staff, health trainers and all sport team officials.

Use of nutritional supplements by Danish elite athletes and fitness customers

The nutritional supplement (NS) industry is one of the fastest growing in the world, and NS use in Denmark is among the highest in Europe. However, the exact use in elite athletes and fitness customers targeted for doping control is unknown. Information from 634 doping control forms obtained in 2014 was evaluated (elite athletes: n = 361; fitness customers: n = 273). The majority of female (92.6%) and male (85.0%) elite athletes and female (100.0%) and male (94.0%) fitness customers declared using one or more NS. The use of non-ergogenic NS was more prevalent in women than in men and in younger (15-34 years) compared with older (35-49 years) subjects, but it was less prevalent in intermittent compared with endurance and power/strength sports. Additionally, fitness customers who tested positive for doping also reported using more NS than subjects testing negative, indicating an association between NS and doping abuse. The present results demonstrate a very high prevalence of NS usage in both elite athletes and fitness customers. This highlights the importance of a strong national regulation of NS to avoid contamination of NS with doping substances.

High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs

The use of medication in international football has been monitored since the 2002 FIFA World Cup. Team physicians were asked to provide information on prescribed medication 72 h prior to each match for every player. 69% of adult male players reported using medication, with more than half the players using non-steroidal anti-inflammatory drugs (NSAIDs). Up to one-third of all players used NSAIDs prior to every match, regardless of whether they took the field or not. The mean intake of medication was significantly higher during the FIFA Women's World Cup (0.85 vs 0.77 substances per player and per match in men, p<0.001), whereas the use of NSAIDs was similar to that for men. In the Under-20 and Under-17 male competitions, the use of medication was lower as 60% of players used some kind of medication and 43% of the players used NSAIDs during the tournaments. Despite the potential side effects of medication, especially of NSAIDs in the recovery process after a sports activity, there is no evidence of decreasing intake. The reported incidence is alarming, and moreover is most probably underestimated, since self-medication by the players or treatment already prescribed by club physicians is not included in the published reports. Future studies should focus on the daily dosage, time of treatment and especially the medical indication for painkilling agents to better understand the underlying factors.

Prevalence of Dietary Supplement Use by Athletes: Systematic Review and Meta-Analysis

BACKGROUND

Dietary supplements (DSs) are commercially available products consumed as an addition to the usual diet and are frequently ingested by athletes.

OBJECTIVE

Our objective was to examine the prevalence of DS use by athletes.

DATA SOURCES

PubMed, Ovid MEDLINE, OVID Healthstar, and Cumulative Index to Nursing and Allied Health were searched for original research articles published up to August 2014. Search terms included specific sports, specific DSs, and other terms.

STUDY SELECTION

Studies were selected if they were written in English, involved athletes, and provided a quantitative assessment of the proportion of athletes using specific DSs. Percent of athletes using specific DSs.

SYNTHESIS OF DATA

Methodological quality of studies was assessed by three reviewers using an 8-point scale that included evaluations for sampling methods, sampling frame, sample size, measurement tools, bias, response rate, statistical presentation, and description of the participant sample. Where there were at least two investigations, meta-analysis was performed to obtain summary (pooled) prevalence estimates (SPEs) on (1) DS use prevalence by sport and sex, (2) DS use prevalence by elite versus non-elite athletic status, and (3) specific DS prevalence for all athletic groups combined. Meta-analyses included evaluations of homogeneity and publication bias.

RESULTS

A total of 159 unique studies met the review criteria. Methodological quality was generally low with an average ± standard deviation of 43 ± 16% of available rating points. There was low homogeneity for SPEs when compiled by sport, athletic status, and/or specific DSs. Contributing to the lack of homogeneity were differences in studies' objectives and types of assessments used (e.g., dietary surveys, interviews, questionnaires). Despite these limitations, the data generally indicated that elite athletes used DSs much more than their non-elite counterparts. For most DSs, use prevalence was similar for men and women except that a larger proportion of women used iron while a larger proportion of men used vitamin E, protein, and creatine. No consistent change in use over time was observed because even the earliest investigations showed relatively high use prevalence.

CONCLUSION

It was difficult to generalize regarding DS use by athletes because of the lack of homogeneity among studies. Nonetheless, the data suggested that elite athletes used dietary supplements far more than their non-elite counterparts; use was similar for men and women with a few exceptions; use appeared to change little over time; and a larger proportion of athletes used DSs compared with the general US population. Improvements in study methodology should be considered in future studies especially (1) defining DSs for participants; (2) querying for very specific DSs; (3) using a variety of reporting timeframes (e.g., daily, 2-6 times/week, 1 time/week and <1 time/week); (4) reporting the sampling frame, number of individuals solicited, and number responding; (5) reporting characteristics of volunteers (and non-volunteers, if available); and (6) using similar methods on several occasions to examine possible temporal trends among athletes.

Medications and Nutritional Supplements in Athletes during the 2000, 2004, 2008, and 2012 FIFA Futsal World Cups

Objective. To examine the use of medications and nutritional supplements among top-level male futsal players during international tournaments. Materials and Methods. This retrospective survey of the four consecutive 2000 to 2012 FIFA (Fédération Internationale de Football Association) Futsal World Cup tournaments analyzes data about the use of medications and nutritional supplements by each player prior to every match. A total of 5264 reports on 1064 futsal players were collected from the 188 matches played. Results. A total of 4237 medications and 8494 nutritional supplements (0.8 and 1.6 per player per match, resp.) were prescribed, and 64% of the players used at least one type of medication over the four tournaments. The most frequently prescribed medication was nonsteroidal anti-inflammatory drugs (NSAIDs) (41.1%), whereby 45.7% of all players consumed at least one NSAID during the tournament and 27.4% did so prior to every match. Conclusions. The intake of medications, particularly of NSAIDs, is frequently high among top-level futsal players and follows a similar pattern to that found in FIFA Football World Cups. Campaigns should be instituted to understand this prescription practice by team physicians involving professional football players, with the aim to decrease its use and to prevent athletes from potential short- and long-term risks.

Ginger (Zingiber officinale) as an Analgesic and Ergogenic Aid in Sport: A Systemic Review

Ginger is a popular spice used to treat a variety of maladies, including pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used by athletes to manage and prevent pain; unfortunately, NSAIDs contribute to substantial adverse effects, including gastrointestinal (GI) dysfunction, exercise-induced bronchoconstriction, hyponatremia, impairment of connective tissue remodeling, endurance competition withdrawal, and cardiovascular disease. Ginger, however, may act as a promoter of GI integrity and as a bronchodilator. Given these potentially positive effects of ginger, a systematic review of randomized trials was performed to assess the evidence for ginger as an analgesic and ergogenic aid for exercise training and sport. Among 7 studies examining ginger as an analgesic, the evidence indicates that roughly 2 g·d(-1) of ginger may modestly reduce muscle pain stemming from eccentric resistance exercise and prolonged running, particularly if taken for a minimum of 5 days. Among 9 studies examining ginger as an ergogenic aid, no discernable effects on body composition, metabolic rate, oxygen consumption, isometric force generation, or perceived exertion were observed. Limited data suggest that ginger may accelerate recovery of maximal strength after eccentric resistance exercise and reduce the inflammatory response to cardiorespiratory exercise. Major limitations to the research include the use of untrained individuals, insufficient reporting on adverse events, and no direct comparisons with NSAID ingestion. While ginger taken over 1-2 weeks may reduce pain from eccentric resistance exercise and prolonged running, more research is needed to evaluate its safety and efficacy as an analgesic for a wide range of athletic endeavors.

Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey

OBJECTIVE

To examine the use of medication of top-level male players during the 2014 FIFA World Cup Brazil.

DESIGN

Retrospective survey.

PARTICIPANTS/INFORMATION

736 top level players.

SETTING

The teams' physicians disclosed a list of the medications used by each player within 72 h before each match of the 2014 FIFA World Cup Brazil.

OUTCOME MEASURES

Average number of medications used per player per match or during the tournament; average number and percentage of players using at least one medication per match or during the tournament.

RESULTS

67.0% of all players took various types of medication during the tournament. The most used medications during the tournament were non-steroidal anti-inflammatory drugs (NSAIDs), by 54.2% of all players, followed by analgaesics (12.6%); β-2 agonists were only used by 0.5%. On average, 0.8 medications per player were used before each match. More players were reported taking medications during the knockout round than during the qualification round (0.36±0.48 vs 0.49±0.50, p<0.001). Players from the South American and Asian Confederations took twice as many medications per match as players from the African Confederation (1.17±1.55 and 1.01±1.26 vs 0.48±0.69, both p<0.001).

CONCLUSIONS

There was high use of NSAIDs during the 2014 FIFA World Cup. Although the intake of NSAIDs per match (0.35±0.46 vs 0.31±0.48, p<0.01) in the 2014 FIFA World Cup decreased compared to the 2010 FIFA World Cup, the average use was still higher than in the 2006 FIFA World Cup, and the average number of all used medications per player remained the same level as 4 years prior, with all its implications for the player's health. More efforts need to be undertaken worldwide in order to reduce the administration of medications in sports, through continuous education for players, starting from a young age, as well as for doctors and paramedics.

National Athletic Trainers' Association position statement: Preparticipation physical examinations and disqualifying conditions

OBJECTIVE

To present athletic trainers with recommendations for the content and administration of the preparticipation physical examination (PPE) as well as considerations for determining safe participation in sports and identifying disqualifying conditions.

BACKGROUND

Preparticipation physical examinations have been used routinely for nearly 40 years. However, considerable debate exists as to their efficacy due to the lack of standardization in the process and the lack of conformity in the information that is gathered. With the continuing rise in sports participation at all levels and the growing number of reported cases of sudden death in organized athletics, the sports medicine community should consider adopting a standardized process for conducting the PPE to protect all parties.

RECOMMENDATIONS

Recommendations are provided to equip the sports medicine community with the tools necessary to conduct the PPE as effectively and efficiently as possible using available scientific evidence and best practices. In addition, the recommendations will help clinicians identify those conditions that may threaten the health and safety of participants in organized sports, may require further evaluation and intervention, or may result in potential disqualification.

Nonsteroidal anti-inflammatory drug use and endurance during running in male long-distance runners

CONTEXT

The effect of ibuprofen on pain tolerance during exercise is controversial, and its effects on endurance performance have been poorly investigated.

OBJECTIVE

To investigate the effect of prophylactic administration of the nonsteroidal anti-inflammatory drug ibuprofen on the time until the self-report of fatigue (tlim) in runners with exercise-induced muscle damage.

DESIGN

Randomized controlled clinical trial.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty healthy male long-distance runners (age = 18.8 ± 0.4 years, maximal oxygen consumption = 55.5 ± 5.9 mL·kg(-1)·min(-1)).

INTERVENTION(S)

Participants were assigned to 2 groups (ibuprofen group = 10, placebo group = 10) to perform tlim trials (speed corresponded to their previously determined secondventilatory thresholds) 48 hours before and 48 hours after the induction of a lower limb muscle-damage protocol (isokinetic dynamometry). One hour before the second tlim trial, the ibuprofen group received 1.2 g ibuprofen, and the placebo group received lactose orally.

MAIN OUTCOME MEASURE(S)

Time until self-reported fatigue, heart rate, respiratory quotient, oxygen consumption, and perceived exertion were recorded during each tlim test.

RESULTS

Both groups reported increases in muscle pain in the knee extensors and flexors 48 hours after the muscle-damage protocol. We observed a reduction in the endurance performance of both groups (P < .01) but no difference between groups (P = .55).

CONCLUSIONS

Ibuprofen did not reduce the effect of muscle damage and pain on performance. Prophylactic use of nonsteroidal anti-inflammatory drugs did not have an ergogenic effect on running performance after exercise-induced muscle damage in male long-distance runners.

Dietary supplement usage and motivation in Brazilian road runners

Background

The consumption of dietary supplements is highest among athletes and it can represent potential a health risk for consumers.

Objective

The aim of this study was to determine the prevalence of consumption of dietary supplements by road runners.

Methods

We interviewed 817 volunteers from four road races in the Brazilian running calendar. The sample consisted of 671 male and 146 female runners with a mean age of 37.9 ± 12.4 years.

Results

Of the sample, 28.33% reported having used some type of dietary supplement. The main motivation for this consumption is to increase in stamina and improve performance. The probability of consuming dietary supplements increased 4.67 times when the runners were guided by coaches. The consumption of supplements was strongly correlated (r = 0.97) with weekly running distance, and also highly correlated (r = 0.86) with the number of years the sport had been practiced. The longer the runner had practiced the sport, the higher the training volume and the greater the intake of supplements. The five most frequently cited reasons for consumption were: energy enhancement (29.5%), performance improvement (17.1%), increased level of endurance (10.3%), nutrient replacement (11.1%), and avoidance of fatigue (10.3%). About 30% of the consumers declared more than one reason for taking dietary supplements. The most consumed supplements were: carbohydrates (52.17%), vitamins (28.70%), and proteins (13.48%).

Conclusions

Supplement consumption by road runners in Brazil appeared to be guided by the energy boosting properties of the supplement, the influence of coaches, and the experience of the user. The amount of supplement intake seemed to be lower among road runners than for athletes of other sports. We recommend that coaches and nutritionists emphasise that a balanced diet can meet the needs of physically active people.

Physician-prescribed medication use by the Finnish Paralympic and Olympic athletes

OBJECTIVE

Data about medication use by Paralympic athletes (PAs) are limited and no data concerning medication use outside Paralympics exist. The objective of the current study was to compare the use of physician-prescribed medication in PAs and Olympic athletes (OAs).

DESIGN

A cross-sectional comparative study.

SETTING

Finnish PAs and OAs receiving financial support from the Finnish Olympic and Paralympic committee in 2006 and 2009, respectively.

PARTICIPANTS

A total of 92 PAs (response rate, 75.0%; 92 of 123) and 372 OAs (response rate, 91.9%; 372 of 405) participated.

ASSESSMENT OF RISK FACTORS

Age, sex, and type of athlete (PA vs OA) were included as independent covariates in the logistic regression model analysis.

MAIN OUTCOME MEASURES

The use of physician-prescribed medication among athletes during the previous 7 days and 12 months.

RESULTS

Among the PAs, the use of physician-prescribed medicines (48.9% vs 33.3%; adjusted odds ratio, 1.99; 95% confidence interval, 1.13-3.51), painkillers (2.61; 1.18-5.78), oral antibiotics (4.10; 1.30-12.87), and anti-epileptic medicines (37.09; 5.92-232.31) were more common than among the OAs during the previous 7 days. Paralympic athletes had used significantly less asthma medicines than the OAs during the previous 7 days (4.3% vs 11.0%; adjusted odds ratio, 0.30; 95% confidence interval, 0.10-0.96).

CONCLUSIONS

The use of any physician-prescribed medicines, especially those to treat chronic diseases, seems to be more common among the PAs than the OAs. Paralympic athletes use significantly less asthma medicines than OAs.

Between medical treatment and performance enhancement: an investigation of how elite athletes experience Therapeutic Use Exemptions

BACKGROUND

Athletes can be allowed to use substances from the prohibited list (the doping list) if they have a medical condition. If so, a Therapeutic Use Exemption (TUE) is required. The boundaries between the use of pharmacological substances due to a medical need and doping are sometimes blurred. Although manipulating the system of TUE granting potentially represents an entry stage for doping, few studies examine how athletes perceive TUE management and relate this to current anti-doping policy.

METHODS

645 Danish elite athletes (mean age 22.12, SD=5.82) representing 40 sports completed a web-based questionnaire about their experience and perception of TUE (response rate: 43%).

RESULTS

19% of the respondents had been granted a TUE. 85% of athletes granted a TUE regarded their use of the TUE system as necessary to compete on equal terms with other athletes. Administrative hurdles for TUE prevented 7% of athletes from applying. 53% of the athletes considered that being "allowed" to dope by means of a TUE was of importance for their (hypothetical) wish to try out doping. 51% believed that athletes in their sport received TUEs without a medical need. Athletes granted TUEs had more than twice as high odds to distrust the efficacy of the system than athletes never granted a TUE. The belief that TUEs were misused was especially common among endurance athletes, regardless of them having experience with TUEs or not. 4% believed it would be okay to receive a TUE without a medical need.

CONCLUSION

The results confirm that TUE is a problem in anti-doping policy. The fact that distrust in TUE administration increases once an athlete has experience of TUEs represents a challenge for anti-doping policy. We suggest more critical research on TUEs be carried out in order to improve harmonization and increase transparency in the regulations.

Preventive Health Perspective in Sports Medicine: The Trend at the Use of Medications and Nutritional Supplements during 5 Years Period between 2003 and 2008 in Football

OBJECTIVE

To assess the prevalence of medication and nutritional supplement use in male Football Super League players and to observe the long term changes of players' attitudes during 5 years period (4 seasons).

STUDY DESIGN

Retrospective study.

MATERIAL AND METHODS

Review and analysis of 4176 doping control forms -declaration reports- about players' medication intake including; Super League, UEFA Cup and the UEFA Champions League matches. Team physician was asked to document all medications and nutritional supplements taken by the Football Super League players in the last 72 hours before each match.

RESULTS

A total intake of 5939 substances were documented, of which almost half 49.2% (n=2921) were classified as medications and 50.8% (n=3018) were nutritional supplements. The average consumption per player was 1.42 substance/match; 0.70 were medications and 0.72 of nutritional supplements. The supplements used most frequently were NSAIDs 24.6% (n=1460) accounting for almost one in four of all reported supplements. Diclofenac Sodium was the most frequently reported active pharmaceutical ingredient. Second most frequently used supplements were vitamins (22.2%). The average drug consumption reported per player has been increasing every passing year. It was 0.7 substance/match/player (0.4 medication; 0.3 nutritional supplement) in 2003-2004 season; was increased to 1.8 substance/match (0.8 medication; 1.0 nutritional supplement) in 2006-2007 season.

CONCLUSION

The trends seen in this survey point to an overuse of NSAIDs and vitamins in comparison with other medications, amoung Turkish Super League football players (p<0.001). The use of NSAIDs has increased but the medication groups did not differ significantly between seasons, in terms of distribution. This increasing use of medications especially of non-steroidal anti-inflammatory drugs and nutritional supplements is alarming and needs to be argued.