Wednesday, 28 November 2012

Why doping should not be allowed in sport

In a recent post I looked at the Lance Armstrong saga (which is kind of old news now), and doping in the sport of cycling as a whole. In response to that post, I received a number of e-mails and messages, which was great to see. 

Interestingly, most of the comments were not about a solution to doping in cycling, but rather were focused on this article written by J. Savulescu, B. Foddy and M. Clayton. The general consensus was that doping in sports is wrong, but that the  authors make a pretty convincing case to the contrary. 

Rather than actually exploring a solution to doping in cycling as promised, this blog will take a quick look at why performance enhancing drugs (PEDs) in sport should not be allowed in direct response to the arguments presented by Savulescu, Foddy and Clayton. To get a full appreciation for their arguments, take a read through the article first.

Argument #1

(1) In the article, the authors state that the pros of doping outweigh the cons for athletes given today’s risk/reward infrastructure for athletic success versus getting caught. The financial gain of being the best seems to outweigh the relatively small risk of being caught, and then the diminutive punishment handed out if caught is not enough of a deterrent.

While this argument clearly shows why some athletes do opt to dope, it by no means presents a reason why PEDs should be allowed. Instead, this argument actually helps in identifying an area that we can work on to further discourage the use of PEDS. In addition, it has recently become apparent that agencies, such as USADA, are taking steps in the right direction in correcting this supposed imbalance with the risk/reward to doping.

Take the Lance Armstrong scenario and how USADA has now set a strong precedent with this case. Armstrong was banned for life and stripped of all of his major accomplishments, despite never testing positive (room for debate here). He was not simply banned for 2 years, nor was he stripped of only a couple of victories. Instead, almost his entire career was erased. Granted, this type of punishment was justified based not only on his personal use of PEDs, but also his involvement with trafficking and covering up the cheating. Regardless, this sanction should undoubtedly act as a deterrent to any rider who wants to become the best. It shows that whether you test positive or not, you will eventually get caught, and unless you confess, everything you’ve ever worked for will be taken away. So are the penalties too forgiving? Maybe in some cases, but the punishments are headed in the right direction.

The second part of the authors' argument assumes that the relatively low likelihood of getting caught makes it impossible to discourage athletes from doping. The article references the fact that only 10-15% of athletes at a major competition are tested. Of that 10-15%, a majority will not test positive simply because the type or dose of the PED is not detectable.  However, does this mean that only 10-15% of athletes need to be worried, and the others can relax? No. The testing is random, and therefore the entire collection of athletes must consider being tested as a real possibility. While this does not have the same impact of testing every single athlete, it undoubtedly will impact the decision to dope beyond just 10-15% of athletes. In addition to this, as mentioned above, athletes can still be sanctioned without positive tests, adding an additional deterrent.

The authors state that cleaning up the sport is unattainable, and see this as reason to allow drug use. Instead, this seems to represent where we have room for improvement, rather than a reason to allow PEDs. The good news is that these improvements are already being put into place.

Argument #2

(2) The article’s second argument discusses the assumption that the use of PEDs violates the spirit of sport. They argue that if everybody had equal access and equal opportunity, the use of PEDs would level the playing field and ensure that race winners are not those who have won the genetic lottery. As with the implementation of training, tactics, and nutrition, the use of PEDs would provide an additional parameter that an athlete can manipulate, and thus add more uncertainty and variability to who wins. As a result, the authors believe that it is a misunderstanding to think that using PEDs violates the spirit of sport.

The issue with this argument is that it completely ignores what the spirit of sport entails, despite listing its tenants in the article itself. They are as follows:

· ethics, fair play and honesty

· health

· excellence in performance

· character and education

· fun and joy

· teamwork

· dedication and commitment

· respect for rules and laws

· respect for self and other participants

· courage

· community and solidarity

How does sticking a needle into your arm show courage (I guess if you have a phobia of needles, then you might be able to convince me)? How does rubbing a cream into your skin display dedication and commitment? How does popping potentially harmful pills display a concern for health? Even after reading the argument, I fail to understand how the use of PEDs does not violate these tenants.

If one trains to his or her maximum ability and competes with integrity and courage, yet fails to win, this is undoubtedly an unsettling feeling. However, this effort satisfies all of the components to the spirit of sport, and I think most athletes can agree that there is a sense of pride for going down swinging with this type of defeat.

Now, take this same athlete, conduct the same training, and win because a needle was injected at the right time. At this point, the dignity the athlete had for losing despite an honest effort is taken away. Even if the athlete wins, he or she knows that that their victory had not been earned. This reminds me of Rocky 4 . Rocky ran up mountains and threw logs around; Drago trained with drugs and fancy 1980’s technology. Even if Rocky lost that fight, we all would still love his courage and will to fight for victory in an honest way. Rocky exemplified the spirit of sport in its truest form. Now picture that same movie, except Rocky has the needle injected into him. All of a sudden, that honesty and integrity is lost, and the spirit of sport he represented disappears with it.

The spirit of sport is not to drug away genetic differences, but to compete in spite of them. After all, a true underdog victory is one of the greatest things to watch in any sport!

Argument #3

(3) The third argument the authors present takes a closer look at how allowing PEDs would facilitate leveling the playing field in terms of the genetic lottery. As we have already touched upon, some people are born with physical attributes that leave them better equipped to compete in certain sports. For instance, those who have a genetic pre-disposition to a higher hematocrit, or red blood cell density, will have an increased ability to transport oxygen to their muscles and thus perform better in endurance oriented sports. Then, with the use of drugs like EPO, this genetic advantage can be taken away, which the authors believe is fair.

Here, the authors falsely assume that the genetic lottery is the only type of “lottery” that results in unfair advantages in sport. What about the individual who is born into a rich family and thus has access to the best equipment? What about the athlete who is fortunate enough to be surrounded by intelligent and encouraging mentors earlier in their life? What about the athlete who is born in a part of the world where higher education in fields such as human physiology, athletic training, and other topics advantageous to performance are easily attainable? What about the athlete who is born where proper nutrition itself is accessible?

Genetics is not the only reason why some athletes are born lucky.

If you haven’t done so already, check out the book ‘Outliers’ by Malcolm Gladwell. It discusses how hockey players with birthdays in the first 3 months of the year are the most likely to make it to the NHL. Why? Because they were bigger as kids. This size advantage got the athletes more attention and better coaching early in life.  They made the AAA teams, and this all carried through into adulthood.

Some have the advantage of the genetic lottery, some have other advantages. Just because some are born with lucky genes, that does not translate into definite success. It is only a single piece to the puzzle.

I would have to say it is fairly safe (and by fairly I mean extremely) to argue that Lance Armstrong has much better genes than me. There is no way I will ever be able to develop the V02 max he possesses when in peak form. However, with training, my 1st marathon ever was faster than his 1st marathon ever. Genetics does not equate to winning.

If this issue is looked at a little more closely, the leveling of the playing field that the authors discuss may not actually be taking place at all.  Imagine how legalizing PEDs would impact the poor, neglected athlete who has no training experience and a serious lack of proper equipment, yet still manages to excel because of his or her genetic aptitudes. Who are we to decide that these types of individuals should no longer excel? 

Allowing PEDs would not level the playing field; it would simply skew in favour of the genetically disadvantaged and otherwise advantaged subset of the population.

Argument #4:

 The next argument presented by the authors is essentially a counter argument to the notion that PEDs would just be for the rich. It references the cost to train, race, purchase high altitude tents ($7000 US) among other expenses, and how they compare to the relatively “inexpensive” EPO ($122/month).

This argument fails to acknowledge that (1) $122/month actually IS expensive and (2) even if the PEDs are affordable, it is not a reason to use them.

$122/month equates to just under $1500/year. Is this cheaper than some expenses that high end athletes accrue? Yes. But this is an expense that most athletes cannot incorporate into the baseline cost of doing business. Consider, for example, the 2011 Boston marathon. The prize structure is set up so that the 15th place runner received $1500. Just enough to cover the cost of EPO for the year. In 2011, that 15th place runner finished in 2:16:54. A blazing time at one of the highest profile races in the world gave him just enough money to use EPO for the year. The 16th place runner finished in 2:17:35, still an amazing time and a great finishing position. This runner is elite, and yet received no prize money. So would the use of PEDs be affordable to all high end athletes? I think it is pretty clear that the answer is no.

While it is true that PEDs are not affordable to many athletes, arguing this is irrelevant. Does being able to buy drugs provide reason to use them? The core reasons why PEDs should not be allowed has nothing to do with unequal distribution. Even if each and every athlete had the same access to the drugs (which they do not), it still violates spirit of sport and competition.  

Argument #5:

The next argument this article presents looks into how allowing and subsequently regulating the use of PEDs would result in an increased level of safety. They argue that the use of EPO, for example, is only dangerous when you start to increase your hematocrit over 0.5. So, athletes should be allowed to dope up to that level, and then be monitored to ensure that they stay there.

This is a complicated issue because it must be looked at on a case-by-case basis. First of all, the authors do admit that any drug that induces potential danger to the athletes should be banned (such as anabolic steroids).

“We should permit drugs that are safe, and continue to ban and monitor drugs that are unsafe,” they state.

That's a step in the right direction.

One of the main  "safe drugs" that is discussed in this argument is EPO. Once you start increasing your hematocrit above 0.5, the viscosity of your blood starts to get to the point where it is a challenge for your heart to push the blood through your blood vessels. This can result in death, simply due to an inability to adequately transport oxygen throughout your body.

So yes, keeping the hematocrit at 0.5 would decrease the risks associated with the drug. But those are not the only risks. A recent study did a great job of summarizing some of the key adverse reactions to the use of EPO:

"Adverse effects of recombinant human erythropoietin

  •  Flu-like symptoms: Commonest side effect which subsides within 24 hours
  •  Allergic and anaphylactic reactions
  • Seizures and hyperkalemia: Rare
  • Hyperviscosity
  • Thrombosis: A meta-analysis involving nearly 10,000 cancer patients indicates that treatment with rhEPO increases the risk of thrombosis
  • Hypertension
  • Possibility of cancer progression: There is somewhat less convincing evidence that rhEPO enhances tumor progression
  •  Pure red cell aplasia (mainly reported in patients with CKD): Autoantibodies in the serum can neutralize both rhEPO and endogenous EPO. This was mainly observed in CKD patients, especially after SC injection. Its incidence after 2000 has reduced, especially with the IV formulations”
Do these issues only arise when the drug is used in excess? Or would the chronic use of EPO to maintain a hematocrit level of 0.5 throughout a 15-20 year career also lead to these adverse reactions? At the end of the day, I would not want to take the risk, and I know I would not be alone. This drug may be safer to use if hematocrit levels are monitored, but the legalization of EPO would also encourage people to use a drug that could potentially lead to a number of other adverse reactions.

The only fool-proof way to ensure that nobody suffers adverse reactions to EPO is fairly simple; don't use it. It is extremely difficult to die at the hands of a drug that never enters your system. This is where the money should be spent; discouraging athletes from using EPO rather than monitoring and regulating its use.


There is no doubt that J. Savulescu, B. Foddy and M. Clayton present some arguments that warrant debate and thought.  But when this debate and thought is applied to what they present, the flaws in their logic quickly shine through.  Our testing protocols may not be perfect, but they are headed in the right direction.  Taking away the genetic lottery would not level the playing field, but only skew it in favour of a select group.  The use of PEDs is not a cost that most athletes can or should attempt to afford, and the side effects will still be a worry even if the drugs are regulated.   Finally, and most importantly, the use of PEDs quite clearly violate the spirit of sport.  When logic is applied to what  J. Savulescu, B. Foddy and M. Clayton present, our thoughts quickly match up with what the intuition of most have been saying all along: the use of PEDs in sport should not be allowed. 

Wednesday, 21 November 2012

Frozen Shoulder

Here is my article from this month's addition of the New Hamburg Independent health section.  It is a basic summary of a common and poorly understood shoulder condition: adhesive capsulitis.

As always, feel free to comment or e-mail if you have any questions!

The truth about frozen shoulder

Shoulder pain is a very common problem affecting Canadians. There are a diverse range of tissues that can become injured and lead to shoulder pain including; muscles, ligaments, nerves and even cartilage within the joint.

However, there is another relatively common source of shoulder pain that seems to be poorly understood and is often misdiagnosed. This condition is referred to as ‘frozen shoulder’ or ‘adhesive capsulitis’.

Adhesive capsulitis affects 2-5% of the general population, but affects anywhere between 10- 34% of people who suffer from diabetes or thyroid conditions.

Common symptoms of this disorder include pain and/or reductions in range of motion that get progressively worse, sharp pain with certain movements, and an abnormally hard or abrupt end feel when moving the shoulder.

This collection of symptoms, while concerning, does not mean you suffer from adhesive
capsulitis by necessity. Rotator cuff tears, fractures and even arthritis can present in a similar fashion. However, the key issue with adhesive capsulitis is the length of time it requires
to heal. In fact, research has shown that adhesive capsulitis can take anywhere between 18-24 months to completely resolve.

Throughout this time frame, the condition is typically divided into three phases. Stage one, otherwise referred to as the ‘freezing’ stage, is characterized by a progressive loss of range of motion of the shoulder and increased pain. Stage two, the ‘frozen’ stage, describes a period of time where the shoulder pain and range of motion reaches and remains at a plateau. Finally, the third ‘thawing’ stage is marked by range of motion that slowly improves, accompanied by gradually decreasing pain.

So, why does adhesive capsulitis take so long to improve? The honest answer is that scientists and doctors are not completely sure. Some studies have shown it is related to blood flow, and how your arm connects to the shoulder blade.

Surrounding the joint where the humerus connects to the shoulder blade, there is a bag
of connective tissue that contains a joint fluid to help facilitate smooth and frictionless
motion. Studies have shown that with adhesive capsulitis, there is a significant amount of inflammation and adhesions that build up between that joint capsule and the joint itself.

In order to be symptom free, the joint capsule must be detached from the underlying bones and heal fully. There is poor blood supply to these structures, and that partially explains why it takes so long for the capsule to return to normal, and for full motion to be restored.

Nobody wants to suffer for 18-24 months. So what can you do to help improve your recovery time? The first line approach should include conservative measures to help maintain and improve your range of motion. Shoulder mobilizations, soft tissue therapy and a strong commitment to a rehabilitation plan may help control symptoms and maintain function.

In more persistent cases, surgery may be worth considering. For example, surgeons may opt to enter the shoulder joint arthroscopically, and cut the adhesions between the capsule and underlying bones.

With whatever you chose to do, it is important to keep in mind there is no evidence showing one treatment to be better than the other. What may work for one person may have no impact on another.

Also, with this condition, it is very important to not get discouraged. While it is a long wait, one should keep in mind that most cases of adhesive capsulitis will get better on their own within 24