The blog of a travelling psychiatrist and football lover. Who happens to be a halfway decent photographer. Takes a cynical view of the world

Archive for the tag “TUE”

Sam Allardyce. A symptom of what is wrong in sport right now. Things need to change

Anyone reading the sports pages over the last few months would have seen an increasing plethora of negative sports stories that mostly revolve around greed and corruption, occasionally simply cheating.

Today we learned that a salary of 3 million pounds and the ideal job is not enough for Sam Allardyce, who not only displayed simple greed in the search of another 400,000£ but also a curious mixture of arrogance and stupidity. He has of course left the FA tonight “by mutual consent”. Unfortunately one suspects that this is not even the tip of the iceberg. Money flows in football, well at least in the premiership and greed seems close behind. The Leicester owner left the ground via a helicopter on the pitch tonight.  There is simply too much money there and clearly even more amounts of temptation. Maybe the most worrying thing is the arrogance to presume that he would get away with this. Rumours have been rife for many years about managers, agents and owners involved in various illegal money-making ventures. Little or nothing was proven by various investigations. Yet we know from this summer that corruption is also rife in UEFA and FIFA. Again the common denominator is the money. Match fixing has reared an ugly head in football and cricket increasingly and again money is the temptation. Cycling and athletics have had scandals of their own, also tangentially related to money but involving simple cheating and potentially “bending the rules”. Doping has been discovered for many years but increasingly so recently, leading to Russia essentially being banned from the Rio olympics. We know what we know but we also imagine there is much that we do not know.  There has been probable abuse of TUEs where legal medications are prescribed for reasons that may be dubious and certainly some believe to be invented.

Sport is fun and exciting and fans go to football games in the dark and rain because they support their team and believe each team will try their utmost to win. If fans lose their faith in the simple matter of honesty then sport is dead. Fans also may imagine things when unexpected results are seen. A win by Bangladesh over another senior test playing nation may be regarded as suspicious as opposed to celebrated. Own goals will be looked at as potentially deliberate. The fun will have gone and when fans leave the sport then the money will go too. The rules in sport are there for a reason and not simply historical. They are there to provide fairness in competition and the rules agents and clubs must abide by are there equally to provide fairness.

It is not just the ridiculously huge sums of money paid to the players, especially in football, but the equally ridiculous sums paid by SKY and BT Sports. This leads also inadvertently to a betting culture where sport is played not simply to see who wins, but to see who can win the most money (by being in the Champions League for example), but where the same sport is flaunted at home to the “spectators” who are enticed to bet on any parameter that can be measured in a game. Half-time adverts on TV are predominantly related to betting usually showing happy smiling faces of those who win. I have yet to see an advert showing what happens when betting gets out of control and ruins a life or a family.

So the simple pleasure of competing and winning gets diluted by the financial returns that overlay the event. Excessive betting is another factor killing the morals of sport. Players are regularly convicted of betting on games, from which they are prohibited to do so. Joey Barton this week has been accused of that crime. This is very separate to match-fixing but again synonymous with the greed for money which is attainable.

Things must change. The effects of money on the various sports, football in particular, must be significantly reduced. The term Greed Creed can be applied almost at will. Sam Allardyce is a symptom of the problem which may be far more widespread than we realise. I have little doubt that anything will happen but this should be a turning point when sport looks at itself and realises that it is the sport that matters, not the money.

Therapeutic Use Exemptions (TUE) and Harm. The solution is obvious for Sportsmen and Doctors in Asthma and ADHD

Matt Dickinson , the chief sports writer in The Times, writes an excellent article today 16/9/16 regaring TUEs. Essentially the article reads that more athletes than ever are being granted TUEs and there is a healthy degree of scepticism as to the likelihood that a large proprotion are actually essential. All fair points. However the real debate is why is the medical evidence to support a TUE is not more solid? This is the clear missing factor.


As a doctor I would be looking at many illness features before offering an opinion or report. Firstly if an athlete is only requesting TUE rarely, why? The types of illness cited mostly here by Matt Dickinson are long term and in general terms stable over a few months, notably asthma and ADHD. It would be a hard hearted person to determine that an asthmatic, and most cases of asthma ( not all though) develop in childhood and early adolescence, cannot compete in sport due to the need for medication. It also needs to be said upfront that asthma does kill people annually and regularly, it can be a very serious illness. Stopping medication is rarely a safe nor sensible thing to do, so to be allowed to continue medication when in competition is essential and medically necessary. And this is the point. Medication usage is generally stable. So TUEs when granted should refect the regular need for a medication over months. Competition is intense sure, but also so is training. Exertion levels are not likely to vary enormously. A TUE should never for example allow a medication to be started just prior to competition. In simple terms, the asthma medication carries on as normal. To be convinced to start a new medication, steroid for example, there needs to be serious evidence of a deterioration in asthma that would not just have occurred overnight. Hence the intermittent usage of Kenalog (triamcinolone) for example could only be entertained on a strictly seasonal basis if hayfever symptoms had been  prominent annually at that time of the year. It requires some explanation why Bradley Wiggins took only 3 injections of Triamcinolone June 2011, June 2012 and April 2013, if these medical facts are indeed correct. They may not be. It would also be interesting to entertain the spcific pollens giving the allergy.


For ADHD it is much the same. The diagnosis of ADHD is made generally with a history of symptoms that have been present in certain well prescribed patterns for many years. Adults diagnosed with ADHD must have shown evidence of long standing symptoms present since before 12 years old. The need to treat ADHD generally does not differ markedly over a period of time, in that the likelihood that a treatment needs commencing immediatley prior to an event is minimal. Treatment needs tend to be stable. Stopping ADHD treatment is not a good thing either.

Lastly Matt Dickinson points out that ADHD is relatively common in adults, he cites 4-6% of the adult population, which is a little high, maybe 3-4% is probably correct using the updated DSM-5 diagnostic criteria. But his scepticism about Major League Baseball players having ADHD in 10% of cases might be unfounded. ADHD is more common in sportsmen as many of the illness facets tend to be helpful in sport provided they are harnessed appropriately. Thus 10% is not an unreasonable estimate, though no thorough research seems to have been done on this. Creativity, hyperactivity and hyperfocus are features of ADHD and as such gymnasts like Simone Biles as an example may do well despite having ADHD. They too however need treatment. Impulsivity is the one feature of ADHD that does often get sportsmen into trouble. Lastly an interesting recent medical finding is that asthma is far more common in those with ADHD than the general population. The reason is not clear.

00005945So where should the scepticism come in? Firstly any sudden TUE prior to a competition needs a full investigation and critical analysis. Secondly any TUE where there is an unexpected and changed medication need, especially if intermittent, needs again careful analysis. If sportsmen are using TUEs as legal loopholes then it is the duty of doctors to stop this happening, and thats far easier than many imagine.


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