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Research in high-performance sports medicine: from the bench, to the bedside…to the podium
  1. C A Speed1,2,
  2. S A Ingham3
  1. 1Sports and Exercise Medicine, Cambridge University Hospital, Cambridge, UK
  2. 2Medical Services (East), English Institute of Sport, Cambridge UK
  3. 3English Institute of Sport, EIS Performance Centre, Loughborough University, Loughborough, UK
  1. Correspondence to Dr C A Speed, Sports and Exercise Medicine, c/o Box 219, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; cathy.speed{at}btinternet.com

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Introduction

High-performance sports medicine (HPSM) is an area of medicine that deals with individuals who can be unique and complex. They can represent the extreme of the spectrum of normality in relation to their physiological, psychological and behavioural characteristics, and can be exposed to extreme stresses in a range of environments.

When sport and exercise medicine (SEM) started as a discipline in Greco-Roman times, so too did interest develop in the effects of exercise on the human body.1 However, it was not until the 20th century that the field of exercise physiology really evolved. In the 21st century, ‘exercise sciences’ have expanded far into the reaches of metabolic and molecular sciences. Sport- and exercise-related research has become a vast field, ranging from biomechanics, all areas of clinical medicine and applied sciences, through to genetics, psychology, behavioural and neurosciences and technology. Nevertheless, our understanding of high-performance athletes (HPAs) remains limited. The field is rich in opportunities in research. There is the potential to enhance our understanding of adaptations and responses to extreme stimuli. Research can enhance the delivery of medical care to our athletes, and assist with the safe optimisation of human performance. Research in this field can also provide valuable insights into models of health and disease.

This article provides an overview of the framework of research models and methods. We outline some of the challenges of research in HPSM and discuss opportunities in developing the field. Some of the issues raised can relate to SEM as a whole.

Models of research

Medical research can be broadly classified as basic, applied or translational. Basic (‘pure’) research involves the fundamental expansion of knowledge without necessarily an obvious application. It lays down the foundation for applied research, which aims to apply the knowledge gained through basic research to address a specific practical problems or purpose. An example would be basic research on the nature of x-rays by Roengten, allowing applied research to develop their use in medical imaging.

‘Translational research’ is a clinical research concept that refers to the rapid translation of research from the laboratory, clinic or population to clinical applications. This process is often described as ‘from the bench to the bedside’ and seeks to accelerate applied research to provide healthcare outcomes.2 Although basic research feeds applied and translational research, observations and discoveries in clinical research can feed basic sciences research back in the laboratory (figure 1).

Figure 1

Pathways of research in SEM and HPSM: between the bench, the bedside and the podium.

HPAs include power athletes, endurance athletes, those with a high level motor skill development and with a wide variety of different skill sets (eg, racquet sports, sailors, hockey players, etc). By definition, HPAs are often at the upper end of the normal distribution, in terms of their functional, physiological and psychological capabilities. For example, the elite athlete may be gifted with 9 litre forced vital capacity or a maximum oxygen uptake of >80 ml/kg/min, or can withstand 150 miles of running each week. They may handle ∼15 times their body weight through a single leg landing in the step phase of a triple jump, or lift twice their body weight above their head. These humans are rare extremes, thus preventing large cohort studies.3 These subpopulations can have distinct clinical issues that differ from the general population. They work in often unusual and at times extreme environments. They can have different behavioural patterns and show dissimilar physiological responses to a variety of stresses.4 Hence, they may respond to clinical interventions differently.

Relevant research outcome markers include standard clinical outcome measures, but performance related outcomes are also a priority. Factors such as these underline the need for integrated multidisciplinary focused research in HPAs. Translational research in the general population (including recreational athletes) can be advanced one step further in the evaluation of the HPA: ‘from bench to bedside…. to trackside…. to podium.’

Examples of the interlinking of different types of research are outlined in table 1.

Table 1

Journey from the bench to the podium: examples of forms of research

Hence, translational research in the HPA can provide insights into the limits of human performance and potentials for performance optimisation. It also can enhance the management of medical issues in this group. All forms of research—basic, applied and translational—have important roles in HPSM research. Basic research provides building blocks. Applied research gives us products, tools, equipment, training models, etc. Translational research allows rapid development of drugs and therapeutics. ‘Advanced’ translational research in HPSM focuses purely on our unique population of HPAs. In many cases, therapeutic approaches developed for other populations are effectively utilised in the management of the HPA. However, research is needed to identify differences that may exist in areas such as drug metabolism and therapeutic effects of interventions.

Another significant advantage of research in the HPA is the exploration into mechanisms of disease and potential therapeutic strategies. High training stresses may mimic the stresses of illness. Novel injuries and illnesses may lead to new investigative techniques. Responses to interventions may lead to the development of novel therapies in the general population, the recreational athlete and those with diseases (table 2).

Table 2

From podium back to the bench and bedside: using research in the high-performance athlete to influence understanding and management of disease

Challenges in clinical research in HPSM

It is clear that research in HPSM is an exciting field that can provide benefit not only to the elite athlete but to the general population and those with chronic disease. However, we are faced with challenges, which have to date limited the development of the field. These include methodological challenges, the need for expertise and openness. Cross-fertilisation is needed between research groups, involving clinicians and scientists within and without HPSM.

For research in clinical HPSM to establish itself, it must score high on grading systems for evidence, and must adhere to the same principles of ‘rigour, respect and responsibility’ that applies to all scientific researchers.5 However, the evidence base in many areas of SEM is small, and it is even smaller in HPSM. Scoring on evidence-based scoring systems is often low.6 Subject numbers are limited, and access to these subjects is lacking due to potential interference by study protocols with training and competition. The effect sizes seen may be small and have little impact in the general population, and yet they may be highly relevant to high performance. There is hence a need for collaborative work across groups and across nations. Integrated multidisciplinary expertise is required, and proactivity from a range of professionals who have experience in research is vital. ‘Secrecy’ about key areas of investigation due to the need to ‘gain the competitive edge’ has the potential to stifle academic collaboration and scientific advancement. Solutions to this must be sought.

Without addressing such issues, the impact of research in HPSM will be weakened, and funding in the face of these issues will be hard to secure. International collaboration is much needed in this respect, and study populations that train intensively but are not burdened by the limitations of competition are required.

Back at the ‘coalface,’ at times we need to accept that absence of high category evidence is not evidence of lack of effect. Quasi-experimental research is not acceptable. However sound clinical judgement in the face of lower-grade research evidence is often the harsh reality, until such times that international collaborative research studies and feasible protocols have been established. When reviewing the current evidence base, the clinician in HPSM must ask: how does the available evidence base apply to my patients? Are the treatments feasible in my setting? What might be different about the benefits/harms of such approaches in my patient population? How will my patients priorities and values influence the decision?7 ‘Good science is common sense at its best’ (Thomas Huxley).

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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