Sports Medicine & Orthopaedics

Researchers hope new biomarkers will lead to potentially life-saving sports pitch-side test for brain injury

CT scans of human brain base of skull to top

Researchers at the University of Birmingham have identified inflammatory biomarkers which indicate whether the brain has suffered injury.

The team, led by Professor Antonio Belli, at the University’s College of Medical and Dental Sciences, now hopesto use these new biomarkers to develop a test which can be used on the side of a sports pitch or by paramedics to detect brain injury at the scene of an incident.

Dr Lisa Hill, of the Institute of Inflammation and Ageing at the University of Birmingham, said: “Traumatic brain injury (TBI) is the leading cause of death and disability among young adults and, according to the World Health Organization, by 2020 TBI will become the world’s leading cause of neurological disability across all age groups.

“Early and correct diagnosis of traumaticbrain injury is one of the most challenging aspects facing clinicians.

“Being able to detect compounds in the blood which help to determine how severe a brain injury is would be of great benefit to patients and aid in their treatment.

“Currently, no reliable biomarkers exist to help diagnose the severity of TBI to identify patients who are at risk ofdeveloping secondary injuries that impair function, damage other brain structures and promote further cell death.

“Thus, the discovery of reliable biomarkers for the management of TBI would improve clinical interventions.”

Inflammatory markers are particularly suited for biomarker discovery as TBI leads to very early alterations in inflammatory proteins.

In this novel study published in Scientific Reports, blood samples were taken from 30 injured patients within the first hour of injury prior to the patient arriving at hospital.

Subsequent blood samples were taken at intervals of four hours, 12 hours and 72 hours after injury. These blood samples were then screened for inflammatory biomarkers which correlated with the severity of the injury using protein detection methods.

In the laboratory, the team used a panel of 92 inflammation-associated human proteins when analysing the blood samples, which were screened simultaneously.

The serum biomarkers were analysed from patients with mild TBI with extracranial injury, severe TBI with extracranial injury and extracranial injury only and all groups were compared to a control group of healthy volunteer patients.

The results identified three inflammatory biomarkers, known as CST5, AXIN1 and TRAIL, as novel early biomarkers of TBI.

CST5 identified patients with severe TBI from all other cohorts and, importantly, was able to do so within the first hour of injury.

AXIN1 and TRAIL were able to discriminate between TBI and uninjured patient controls in under an hour.

Dr Valentina Di Pietro, also of the Institute of Inflammation and Ageing at the University of Birmingham, said: “Early and objective pre-hospital detection of TBI would support clinical decision making and the correct triage of major trauma.

“Moreover, the correct diagnosis of TBI, which is one of hardest diagnosis to make in medicine, would allow clinicians to implement strategies to reduce secondary brain injury at early stage, for example, by optimising blood and oxygen delivery to the brain and avoiding manoeuvres that could potentially increase intracranial pressure.

“In addition, this has potential implications for drug development, as novel compounds could be given immediately after injury and potentially commenced at the roadside, if there was sufficient confidence in the diagnosis of TBI.

“We conclude that CST5, AXIN1 and TRAIL are worthy of further study in the context of a pre-hospital or pitch-side test to detect brain injury.”

  • doi: 10.1038/s41598-017-04722-5

Heading a football causes instant changes to the brain

Researchers from the University of Stirling have explored the true impact of heading a football, identifying small but significant changes in brain function immediately after routine heading practice.

The study from Scotland’s University for Sporting Excellence published in EBio- Medicine is the first to detect direct changes in the brain after players are exposed to everyday head impacts, as opposed to clinical brain injuries like concussion.

A group of football players headed a ball 20 times, fired from a machine designed to simulate the pace and power of a corner kick. Before and after the heading sessions, scientists tested players’ brain function and memory.

Increased inhibition in the brain was detected after just a single session of heading. Memory test performance was also reduced by between 41% and 67%, with effects normalising within 24 hours.

Whether the changes to the brain remain temporary after repeated exposure to a football and the long-term consequences of heading on brain health, are yet to be investigated.

Played by more than 250 million people worldwide, the ‘beautiful game’ often involves intentional and repeated bursts of heading a ball. In recent years the possible link between brain injury in sport and increased risk of dementia has focussed attention on whether football heading might lead to long term consequences for brain health.

Cognitive neuroscientist Dr Magdalena Ietswaart from Psychology at the University of Stirling, said: “In light of growing concern about the effects of contact sport on brain health, we wanted to see if our brain reacts instantly to heading a football. Using a drill most amateur and professional teams would be familiar with, we found there was in fact increased inhibition in the brain immediately after heading and that performance on memory tests was reduced significantly.

“Although the changes were temporary, we believe they are significant to brain health, particularly if they happen repeatedly as they do in football heading. With large numbers of people around the world participating in this sport, it is important that they are aware of what is happening inside the brain and the lasting effect this may have.”

Dr Angus Hunter, Reader in Exercise Physiology in the Faculty of Health Sciences and Sport, added: “For the first time, sporting bodies and members of the public can see clear evidence of the risks associated with repetitive impact caused by heading a football.

“We hope these findings will open up new approaches for detecting, monitoring and preventing cumulative brain injuries in sport. We need to safeguard the long-term health of football players at all levels, as well as individuals involved in other contact sports.”

In the study, scientists measured levels of brain function using a basic neuroscience technique called Transcranial Magnetic Stimulation (TMS). The findings from this study, funded by the NIHR Brain Injury Healthcare Technology Cooperative (HTC) are the first to show the TMS technique can be used to detect changes to brain function after small, routine impacts.

  • doi: 10.1016/j.ebiom.2016.10.029


Competitive football players have superior vision, study suggests

The visual abilities of competitive football players are substantially better than those of healthy non-athletes, according to the first-ever comprehensive assessment of visual function in English Premier League players, published in Science and Medicine in Football.

Average visual clarity, contrast sensitivity, and near-far quickness of competitive footballers (both elite and intermediate) were significantly better than those of non-athletes. However, results showed there was no difference in visual function between the elite and intermediate players.

Interestingly, defensive players displayed faster near-far quickness than offensive players. According to the researchers, this visual function may be particularly helpful to defenders who are responsible for ensuring that the ‘offside trap’ is not broken and typically have to quickly switch their attention, and therefore eye gaze, between several opponents in near and far locations.

In the study, researchers from Liverpool John Moores University in the UK recruited 49 elite male players from an English Premier League football club as well as 31 intermediate male players (university level). They examined visual functions that are considered critical to sport performance in players of different skill levels and playing positions using the Nike SPARQ Sensory Station.

The assessments included visual clarity (ability to see detail at a given distance), contrast sensitivity (ability to detect an object against a background), near-far quickness (ability to change eye gaze and attention between near and far distances), and target capture. The researchers then compared these data to those from a study of 230 healthy non-athletic men and women using the same apparatus.

The study highlights the importance of good vision in football and the potential for gaining a competitive edge through vision support and training. However, the authors stress the limitations of the study and the need for further investigation to consider the specific visual demands of player position and the role for regular eye examinations.

According to the Professor Bennett: “While these findings add to the growing evidence that a good level of vision could be important in dynamic invasion sports, future studies need to determine the precise nature of the relationship with on-field performance.” •

  • doi: 10.1080/24733938.2017.1330552

Expert arthroscopic surgery at Belhoul Specialty Hospital

Middle East Health speaks to Dr Dhaval Sagala, Specialist Orthopaedic Surgeon at Belhoul Specialty Hospital, Dubai about his specialty and orthopaedic surgery in general.

Middle East Health: Please tell us about your specialty areas of surgery?

Dr Dhaval Sagala: I specialize in treatment of Sports injuries and shoulder problems.

Middle East Health: Can you give us some background about how you gained experience in these specialties? And where you have worked?

Dr Dhaval Sagala: I had my training through various fellowships and observorships, mainly in Pune, India; Singapore and; Seoul, South Korea. I have worked in many hospitals with reputed surgeons of India and South Korea. I mainly practiced in Ahmedabad, India before I started working in Dubai.

Middle East Health: In Dubai – what sport injuries do you mostly treat?

Dr Dhaval Sagala:The most common sports injuries I treat in Dubai are ligament injuries of the knee, Tennis Elbow, tendon ruptures of the heel and shoulder dislocations.

Middle East Health: Why are these types of injuries more common?

Dr Dhaval Sagala: These injuries are usually the result of either acute trauma (such as a football accident) or repeated micro trauma (such as Tennis Elbow). The main reason these injuries occur is that these sports people start playing without adequate warmup and stretching beforehand, as well as incorrect training and ignorance about safety precautions. I call them ‘weekend warriors’ – in other words those who just enter the sportsground without adequate preparations on weekends or after office work.

MEH: What are the main challenges you find in treating these injuries?

Dr Dhaval Sagala:The main challenges I commonlyencounter is to educate the patients about the nature of their injury, the available treatment options and the need for a proper rehabilitation program after any surgery. Most patients find themselves on such a tight schedule that they cannot have a proper rest and exercise program after surgery and hence don’t achieve satisfactory results after surgery.

Middle East Health: Can you tell us about working at Belhoul Specialty Hospital – the team you work with / the professionalism of the assistants?

Dr Dhaval Sagala: As a surgeon, I expect three things: Operation Room discipline; availability of full armamentarium and trained staff for any surgical work to be successful. Fortunately, I am working at a hospital [Belhoul Specialty Hospital] which has undoubtedly the perfect combination of all these three things. The operating theatre staff are well trained, sincere and caring. A successful surgery is not just dependent on the expertise of the surgeon, but also on the contributions of trained assistants, the operating theatre environment and the professionalism of all involved.

Middle East Health: Can you tell us about the specialised equipment you use in surgery?

Dr Dhaval Sagala: Looking at my specialty, which is shoulder and arthroscopic surgery: Shoulder surgery requires the most advanced equipment namely, a beach chair positioning operating theatre table, arm-holding spider, and so on. Similarly, arthroscopic surgery requires a specialized visualization system – camera, full HD medical monitor, arthroscope and precision tools. For shoulder surgery, the patient is placed in a beach chair position for surgery which is not possible with routine operating theatre tables. The arm-holding spider is a specialised, flexible arm-holding device, which allows the surgeon to place the arm in the required position during surgery. For arthroscopic surgery, the surgeon needs to have good visualization of the interior of the joint, which is only possible if you have a good camera, HD monitor and good arthroscope. In a nutshell, this equipment is like an extension of the surgeon’s hands, and the better quality they are, the smoother will be the surgery. Fortunately, Belhoul Specialty Hospital has the best available in the market.

Minimally invasive anterior column reconstruction in spinal adult degenerative deformity

  • By Mr Robert Lee
    Consultant Spinal Surgeon

Spinal adult degenerative deformity encompasses a wide range of pathologies including spondylolisthesis (slip of one vertebra on another), scoliosis (sideways curvature of the spine) and positive sagittal balance (unable to stand upright due to flattening of the curves in the spine). Often all three of these conditions can present in one patient. Patients present with severe back and in particular leg pain due to degeneration of the intervertebral discs leading to compression of the nerves and ‘sciatica’.

Adult scoliosis is very different from the children’s population as children have flexible curves and no nerve compression. In contrast adult curves are stiffer and harder to correct. Also, due to loss of the disc height and morphology, the spine loses its natural lumbar curve, flats out and patients stoop forward.

Standard operative techniques include osteotomies of the spine where the vertebra is broken in two to correct the deformity and the spine is fused with pedicle screws and rods. This carries high complication rates including nerve damage, non-union and in rare cases, paralysis.

Newer surgical strategies address the source of the problem, realising that it is the disc and not the vertebra that is the problem. The discs can be removed and replaced with cages to restore the natural curve of the spine and indirectly decompress the nerves.

The Spinal Unit at the Royal National Orthopaedic Hospital (RNOH) is the biggest spinal department in the UK, dealing with these complex adult deformities on a regular basis.

Mr Robert Lee, consultant spinal surgeon and director of the minimally invasive fellowship program at RNOH, uses minimally invasive lateral interbody cages to address these deformities rather than the traditional osteotomy techniques. Via a small incision in the flank of the abdomen, multiple cages can be inserted to correct the curvature of the spine and indirectly decompress the nerves. This technique is called anterior column reconstruction.

Over 100 patients have had this procedure, with minimal blood loss and low rates of complications. The initial sixmonth to two-year results were presented at an international conference last year. Mr Lee also uses special planning software to plan and simulate the surgery as well as computer navigation technology to insert his pedicle screws posteriorly dramatically reducing the rate of screw malposition.

“At RNOH, we are at the forefront of innovative spinal techniques. Using special software, we can analyse the patient’s deformity and plan the surgery. The use of minimal invasive anterior column reconstruction and computer-navigated spinal surgery has greatly reduced patient complications with excellent early patient outcomes,” says Mr Lee.

  • The Royal National Orthopaedic Hospital is involved in a clinical study looking at the safety of the lateral access technique using a special type of retractor system.
  • For more information please contact the Royal National Orthopaedic Hospital Private Patient Unit:
    Call +44 (0)20 8909 5712

Blood results help to predict fitness improvements in older marathon runners

Endurance sport has a beneficial impact on physical and mental performance and this can be seen in blood test results. In collaboration with the Health and Prevention Center of the Healthcare Institution for City of Vienna employees, a group of researchers from the biobankat MedUni Vienna has now shown, in a study conducted with older marathon runners, that these laboratory data could be used in the opposite way to predict future changes in fitness. This information can be used to optimise individual training programmes.

The generally beneficial effects of endurance sport upon the health of older people has long been known. In the APSOEM Marathon Study, which has been running since 2009, MedUni Vienna’s biobank has already demonstrated that the cognitive ability and mental state of older marathon runners aged >60 are significantly better than those of comparable age groups who do not engage in any endurance sport. The data gathered in this study have now been used for a further study to investigate whether specific blood parameters can be used in the opposite way to predict future changes in fitness.

The biobank of MedUni Vienna and Vienna General Hospital is a central service facility dedicated to the storageof human tissue, cell material and body fluids for more in-depth diagnosis, academic research projects and clinical tests, as well as working-up samples by way of a medical service.

Since older people have greater potential for improving their fitness than younger people, a follow-up study conducted by a research group headed by doctor and molecular biologist Helmuth Haslacher from MedUni Vienna, in collaboration with Robert Winker’s team from the Health and Prevention Center of the Healthcare Institution for City of Vienna employees, took blood samples from 47 marathon runners before an ergometer test, in order to carry out laboratory tests to determine levels of analytes, including inflammatory markers, muscle and liver parameters.

Ergometer tests were repeated after an interval of three years and approximately two thirds of the athletes showed a decline in fitness since the initial test. In fact, it was possible to use theearlier blood results as a basis for predicting who had lost fitness by the time of the follow-up examination, whose fitness level had remained the same and whose had even improved. It was therefore demonstrated that blood tests can be useful for predicting future changes in fitness resulting from endurance training.

The next step for the study group will be to carry over the findings from the marathon runners to larger groups and other types of sport to find a future application for the research results. One possibility would be to develop an app for checking fitness.

  • doi: 10.1371/journal.pone.0177174



Date of upload: 16th Sep 2017

                                               Copyright © 2017 All Rights Reserved.