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Olympic Games: Special Considerations—Medical Care for Olympians

Chapter · April 2019

DOI: 10.1007/978-3-030-10433-7_45

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Special Considerations: Medical Care for Olympians

Pohl, David J* ; Schwartzman, Garrett*; Hutchinson, Mark R*^; Moreau, Bill^; Bahr, Roald#;
McCormack, Robert **; Juan-Manuel Alonzo***; Andre Pedrenelli^^ Roberto Nahon^^^

*University of Illinois at Chicago, USA; ^United States Olympic Committee Vice President of
Sports Medicine, USA; # Chief Medical Officer and Department Chair for Olympiatoppen and
the Department of Sports Medicine at the Norwegian Olympic Training Center in Oslo.
Norway; **Chief Medical Officer Canadian Olympic Team, Canada; ***Chief Medical Officer
Qatar Olympic Team, Past Spanish Medical Team; ^^Team Physician Brazilian Olympic Team
and National Men’s Soccer Team^^^Head of Brazilian Olympic Medical Services

INTRODUCTION

The purpose of this chapter is to present and review the unique challenges that the
sports medicine clinician may face regarding the Olympic Games and Olympic level athletes.
Specific anatomic injuries as well as sports specific injuries have been covered elsewhere in the
text. Several factors make the Olympic Games a unique event regarding sports medicine care.
It is not only one of the largest mass sporting events in the world, it often represents the
penultimate competition of an athlete’s career. Unique challenges include acclimatization to a
new country, travel, geography, foods, and language. The athlete not only has pressure from
their coach and the fans of that particular sport, but also a global audience and the pressures
coming from stress related to representing their country. From the medical planning and
organization perspective, the Olympic games is a multi-sport, international, mass-sporting
event. For the host country, the organization must provide optimal communication,
transportation, and facilities to care for thousands of elite level athletes. For national
organizations, preparations can begin years in advance of the games and include planning how
dependent they wish to be on the host countries medical plan; which facilities may be used in
case of emergencies; what equipment, staff, and medications will be necessary to retain
independent care of their own athletes; and arranging local licensure, contacts and training
facilities for its athletes through-out the course of competition.

BRIEF HISTORY

The Modern Olympic Games began in Athens, Greece in 1896, and encompassed 241
male athletes competing for 14 countries across 43 events in nine sports. [1] These first sports
included Athletics, Cycling, Fencing, Gymnastics, Shooting, Swimming, Tennis, Weightlifting and
Wrestling. The Summer Olympics have been held in 18 different countries and grown
significantly since that time. During the 2016 Summer Olympic Games, hosted in Rio de Janeiro,
Brazil, over 11,238 athletes (6,179 men and 5,059 women) competed for 207 nations in 306
events in 28 sports. [2]

 12000

10000

8000

6000

4000

2000

0
1890 1910 1930 1950 1970 1990 2010

Summer Athletes Winter Athletes

Figure #1. Athletes participating in Olympic Games by Year

While initially part of the Summer Olympics, snow and ice sports split into a different
Olympic Games, forming the Olympic Winter Games. The First Winter Olympic Games were
held in 1924 in Chamonix, France. During those Games 258 athletes (245 men and 13 women)
from 16 nations competed in 16 events across 5 sports that included Bobsleigh, Curling, Ice
hockey, Skating, and Nordic skiing. [3] The Winter Olympics have grown in size and scope along
with their Summer counterparts. The 2018 Winter Games in PyeongChang, South Korea
featured 2,922 athletes (1,680 men and 1,242 women) competing for 92 nations in 102 events
in 15 sports. [4]


2016 Summer Sports 2018 Winter Sports
Aquatics Field Hockey Shooting Alpine Skiing Luge
Archery Football Table Tennis Biathlon Nordic Combined
Athletics Golf Taekwondo Bobsleigh Short Track Speed
Badminton Gymnastics Tennis Cross-country Skiing Skating
Basketball Handball Triathlon Curling Skeleton
Boxing Judo Volleyball Figure Skating Ski Jumping
Canoeing Modern Pentathlon Weightlifting Freestyle Skiing Snowboarding
Cycling Rowing Wrestling Ice Hockey Speed Skating
Equestrian Rugby Sevens
Fencing Sailing
Table #1 – 2016-18 Olympic Sports

Until 1992 the Summer and Winter Olympic Games were held in the same years, after
which the Winter Games were switched to the even years between Summer Olympics to help
with planning the two massive events. The International Olympic Committee (IOC) is the
organization responsible for planning and putting on the Olympic Games. Established in 1894,
the IOC is an international, not-for-profit organization who’s stated goal is “to ensures the
regular celebration of the Olympic Games, supports all affiliated member organizations[sic] of
the Olympic Movement and strongly encourages, by appropriate means, the promotion of the
Olympic values.” [5] As of 2018 the IOC consisted of 100 active members, 41 honorary (or past)
members, and one honorary president, all of who’s role is to represent and promote the
interests of the IOC and of the Olympic Movement.
Several of these members serve as Chairpersons of one of the 27 IOC Commissions. One
such group, The Medical and Scientific Commission, is tasked with providing “a guiding
reference for all other sports organizations on matters relating to the protection of the health
of athletes.” [6] To this end, the Medical and Scientific Commission has worked to increase
research on, and dissemination of, relevant educational topics. Since 2011 the IOC has
sponsored triennial meetings to discuss and spread information on injury prevention. The IOC
World Conference on Prevention of Injury and Illness in Sport focuses on the clinical aspects of
sports and exercise medicine. These goals have also lead the publication of 25 IOC Consensus
statements since 2004. Topics are wide-ranging and have included Sudden Cardiovascular
Death in Sport (2004), Sexual Harassment and Abuse in Sport (2007), Asthma in Elite Athletes
(2008), Sports Nutrition (2010), Concussion in Sport (2013), Relative Energy Deficiency in Sport
(2015), Sex Reassignment and Hyperandrogenism (2015), and Dietary Supplements (2017).
Similarly, the Medical and Scientific Commission has published several educational tools
available for athletes, coaches, and physicians. These tools range from articles and brochures to
videos to the “Get Set – Train Smarter” smartphone/tablet application, and topics include injury
prevention, harassment and abuse in sport, female athlete health, safeguarding athletes, and
healthy body image. As of this book’s publishing, these resources are available on the IOC’s
website at https://www.olympic.org/educational-tools.
As part of their commitment to promotion of the health of athletes and protection of
clean athletes, the Medical and Scientific Committee is intimately involved in detecting and
preventing doping. The IOC has established a zero-tolerance policy towards doping to combat
cheating and works in conjunction with the World Anti-Doping Agency (WADA) to monitor and
detect athletes in violation of this policy. Further discussion of WADA and doping is presented
later in this chapter.

PATHWAYS TO SERVE AT OLYMPIC GAMES

There are numerous pathways to become part of the health care team at the Olympic
Games and those paths vary from country to country and from games to games. The host
country carries the responsibility of providing services to all residents of the Olympic Village,
usually through establishment of a Polyclinic. Each national organization will also decide to
what extent to provide their own medical care to their athletes and how much to rely on the
host country’s services. Specific application processes will vary for each national organization,
and those wishing to serve should contact their national organization or the host country’s
organization committee.


HOST COUNTRY/ CITY ORGANIZING COMMITTEE

Planning for medical care during the Olympic Games begins years before the opening
ceremonies. Facilities, transportation and supplies must be obtained to account for any
potential injury or illness that an athlete may suffer. Additionally, organizers must also plan for
illnesses and injuries with coaches, national delegates, officials, members of the media,
spectators, and members of the Olympic workforce.
As part of a larger network of medical care, the host country establishes one or more
Polyclinics for athletes and their support staff. These centers are typically capable of managing
most medical complaints, and as the name implies, offer a variety of medical specialties
including primary care, sports medicine, physiotherapy, chiropractic, podiatry, optometry,
ophthalmology, and dentistry. There are typically additional specialists on-call, including
orthopedic surgery, cardiology, otolaryngology, obstetrics and gynecology, dermatology,
neurology, psychiatry, and gastroenterology. There is a pharmacy, laboratory, and advanced
radiology suite including x-ray, ultrasound, and MRI scanners. The Polyclinics are aimed at
making an accurate diagnosis quickly to allow for competent treatment of the athletes so that
they may return to their competition as soon and as safely as possible. [7]
The Polyclinics are typically located in the Olympic Villages where a majority of the
athletes stay, and are staffed by a variety of expert, yet volunteer, medical professionals
including physicians, nurses, physiotherapists, masseurs, technicians, and administrative staff.
The Polyclinic runs in conjunction with the Olympic Village: opening several days before the
start of the Olympic Games, operating 24 hours per day, and finally shutting their doors after
the closing ceremony.
For the first time, the Polyclinic at Rio 2016 also utilized an Electronic Medical Record
(EMR) during the treatment of their patients. [8] This allowed for better communication among
the treatment team and also assisted with injury and illness data collection. Since 2008 the IOC
has sought to establish an injury and illness surveillance system to better track, study and
hopefully prevent the various maladies afflicting the top athletes in the world. The IOC used the
2008 Beijing Summer Olympics as a model. The IOC injury surveillance system standardized
injury definition, as well as methods and forms for reporting such injuries. This system ensured
the comparability of results and thereby provided important epidemiological information,
directions for injury prevention, and the ability to monitor long-term trends in the frequency
and circumstances of injury. [9] This system was then expanded in 2010 for the Vancouver
Winter Olympics to include illnesses. [10] This injury and illness surveillance system asks the
medical teams of each National Olympic Committee (NOC) to report the daily occurrence (or
non-occurrence) of any injuries or illnesses suffered by their constituent athletes on
standardized report forms. The same information is also obtained from the Polyclinic and other
medical facilities associated with the Olympic Games and cross-referenced.
The total incidence of injury in the Rio Games (8%) was the lowest reported since
implementation of the IOC surveillance system. [8] Previously, the reported injury rates had
been above 10%, specifically 10% in Beijing 2008, [9] 11% in Vancouver 2010, [10] 11% in
London 2012 [11] and 12% in Sochi 2014. [12] Specific injuries, sport specific injury rates, and
severity of injuries vary from year to year, and while beyond the scope of this chapter, are
reported and discussed after each Olympic Games. [8-12]
 Services at the Polyclinic are provided free-of-charge to athletes and members of their
national delegations, and many individuals seek elective care during the Games from the expert
staff and utilizing the advanced health care technology available to them. [13] For scale, the Rio
2016 Polyclinic was staffed by 180 medical professional who covered 3,500 square meters and
160 rooms. [7] In total, 1015 radiologic examinations were performed, including 607 MRI scans
(59.8% of total studies). [14] The previous record of 650 patient consultations in one day during
the London 2012 Olympic Games was easily surpassed by the Rio 2016 Polyclinic when it
treated 900 patients in one day. [15]
But Polyclinics are just one part of the medical care offered at the Olympic Games.
During the 2016 Rio Olympic Games over 3000 volunteers were utilized across all aspects of the
medical care team. [16] The importance of early planning and effective communication among
the numerous groups and agencies involved has been well established. [17] First Aid and
appropriate medical care must be provided at the various Olympic sites, including the training
and sporting venues and any affiliated hotels. Specific levels of services provided will vary by
year and location. Most medical needs are addressed within the Olympic system, and rarely
result in transfer to outside hospitals. [17] However, consideration should be made for any
medical need, from simple first aid up to and including mass casualty incidents and emergency
transfers. Organizers should establish individualized emergency plans for each specific venue
based on anticipated staff and supplies on site, and proximity and transport to other resources.
Organizers should therefore coordinate with local hospitals, off-site medical facilities,
ambulance and emergency responders to facilitate transfers, referrals or other necessary
services.


CARING FOR THE NATIONAL TEAM

In addition to providing local service during the Olympic games, the International
Olympic Committee empowers each national Olympic committee to either take advantage of
host country services, establish and develop their own health care team, or, more commonly, a
blend of their own team balanced with host equipment and providers. All providers are subject
to the rules and licensure regulation of the host country which are usually liberalized for visiting
physicians and health care providers during the Olympic Games and restricted to the care of the
team’s athletes and entourage. In general, you have to get a temporary medical license within
the host country to serve as a medical provider.
Approaches to creating a health care team vary from country to country based on a
myriad of factors ranging from size and specific needs of delegation, past history and
organizational history of the individual national governing body, with occasional political
influence. Fundamentally, the core goals and missions are the same regardless structure an
include: fielding a healthy team, safely optimizing athletic performance, and efficient and
effective response to injury and illness. Another key factor in the success of a health care team
is their ability to work together across specialties and skill sets with the singular focus on
athlete wellness and performance.
Ideally organizational planning to address the core goals and missions begins years
before the Olympic Games and includes a national reporting structure that optimizes
communication between health care professionals, athletes, and administrative leadership.
Such structure can define expected roles and responsibilities of health care providers, design a
health support system for athletes long before the games that can optimize their health and
performance, provide access to necessary therapeutic and diagnostic equipment, and
treatments prior to and during the Games, and establish a chain of command that optimizes
communication between athletes, coaches, health care providers and administrators.
Establishing a unified system of medical record keeping (ideally via an electronic medical
record) is essential for continuity of care, communication between health care professionals,
and can be used for medical research and future optimization of performance.
For Team USA, the health care team at the Olympic Games is brought together and led
by a Chief Medical Officer who is formally employed by the United States Olympic Committee
and Head Team Physician, who is a volunteer physician, with a long history expertise in sports
medicine and established service to elite Olympic level athletes. They, with other professional
staff, begin years in advance of the games to develop programming to preserve athletes health
for national level athletes and optimizing collaborative sports medicine programming with
individual national sports governing bodies. It is their responsibility to create plans for medical
emergency responses, review of athletes’ periodic health evaluations, staff education (Anti-
doping and SafeSport for example), staff selection, background checks, medical equipment and
medications requirements for their team at the Games. Team USA has several national
training sites where national level athletes can receive treatment, become educated about their
health and optimize high performance outcomes through-out the Olympic quadrennium. The
actual medical team at an Olympic Games is a blend of USOC professionals, volunteer health
care providers, and nominated national governing body health care providers who are
credentialed with approval of the United States Olympic Committee. Regarding professional
qualifications, the sports medicine team for Team USA at the Olympic Games includes primary
care physicians, orthopaedic surgeons, chiropractic physicians, physical therapists, athletic
trainers, massage therapists as well as nutritionists, exercise physiologists, and sports
psychologists. The USOC leadership strives to create a positive athlete-centric environment
within the collaborative multispecialty health care team that focuses on the preservation of
athlete health, while supporting high performance outcomes.
For team Canada the organization is similar, with a Chief Medical Officer who works
with a head physician and a head therapist. As noted above planning for the games starts years
in advance and the medical team leads will perform site visits to determine the needs and
specific challenges for the Games. Along with the National Sports Organizations, strategies are
developed to prepare the teams for optimal performance at the Games. These plans need to
include management of a variety of potential stressors including heat, nutrition, local health
risks, travel fatigue and jet lag. Experts are engaged to help develop specific protocols, so
recommendations can be made to the athletes, coaches and their support team.
Between games, the athlete’s health is managed directly by the national sports organization or
through regional Canadian Sports Institutes. Our goal is to have an integrated support team for
each sport that includes physicians, therapists, strength and conditioning, sports scientists,
nutritionists, and sports psychologists. This group (Integrated Support Team) is responsible for
optimization of athlete health. This includes performing an annual health examination, anti-
doping education (including medication and supplement reviews) making sure the athletes
have an optimized dental care, appropriate physiologic monitoring, vaccinations, base line
concussions testing (high risk sports), cardiac screening, etc. The goal is to not only care for
injuries and illnesses that present but to also monitor the athletes, to ensure optimal health.
All physicians working with the Canadian National Teams are required to hold the Diploma in
Sport Medicine. The Canadian Academy of Sports and Exercise Medicine developed this
‘certificate of qualification’, in cooperation with the Royal College of Physician and Surgeons of
Canada. It consists of a validated, OSCE based examination. There are similar qualifications
required for each of the other expert provider groups including the Diploma in Sports
Physiotherapy, Certification by the Canadian Sports Massage Therapy Association, Fellowship of
The Royal College Chiropractic Sports Sciences, etc. Canada brings a large team of health
professionals to the games. This reflects the fact that athletes have prioritized the health care
team to optimize their performance (rated most important group after coaches). The larger
sports will nominate their own practitioners and the Canadian Olympic Committee tries to
ensure continuity of care as much as possible (within the constraints of limited accreditation).
There is also a small “core” team that supports smaller sports and rounds out the skill set of the
overall Canadian Health Services Team.
The Olympic Games present special challenges and it is not always the best athletes that
wins, but the one that is best prepared to handle the Olympic environment. To help our health
team prepare for this unique, high-pressure, environment we organize workshops and team
preparation seminars in the lead up to the Games. At these sessions we not only table top
scenarios but also stress the importance of communication and value/importance of working as
one Canadian team at the games. Post Games debriefs are also carried out, as we constantly
strive to improve our health care delivery and plan for the next quadrennial.
For Team Norway, Olympiatoppen, the national training site, serves as the hub for all
athlete support, including health care. Although preparations for each Games are intensified
towards the end of each Olympic cycle, the goal is to ensure that there is continuous, optimal
medical care during the 4-year period. Olympiatoppen is set up with a sports medicine
department with full- or part-time doctors and physical therapists specialized in sports
medicine, orthopedics, rehabilitation, psychiatry and allergy/asthma, serving all types of
national team athletes, senior or junior, as well as students at elite sports schools. Day-to-day
care is also provided by the medical teams of each national federation, in close collaboration
with the Olympiatoppen team. Specific pre-Olympic preparations begin with the appointment
of a Chief Medical Officer and Chief Physical Therapist 2-3 years before each Olympic Games,
and the formation of a large medical team consisting of all Olympiatoppen and national
federation physicians and physical therapists engaged in the care of candidate athletes and
their teams. Except for a few smaller federations with less resources, the medical teams are
under contract. At the same time, candidate athletes are offered an extensive screening
examination organized by Olympiatoppen to establish their health status and develop a specific
plan of preventive initiatives. The screening examination is thought to represent a key event,
establishing a close relationship between the athlete and his/her medical team. This is also the
starting point for weekly, continuous health monitoring using a smartphone app as a
communication and surveillance tool for the athlete and his/her medical team. In Norway, the
focus is less on the selection of the smaller medical team going to the Olympic Games to
provide on-site care, and more on the large team working between Games ensuring that
athletes are healthy on the night of the Opening ceremony.

For Team Brazil, the planning of the medical department of the Brazilian delegation, known in
Brazil as Team Brazil begins long before the Olympic year. Besides all knowledge accumulated in
the history of the Brazilian Olympic Committee (COB) in South American, Pan American and
Olympic (summer and winter) games, there is an effort to remodel all medical services during the
four-year period that preceded the Games, culminating in the available service not only to
athletes, but to all of those in Team Brazil (coach, technical commission and staff). Two main
principles are used for the medical department for the Games. First is the highest number of
follow ups possible of athletes, not only during missions but for the whole period. The second
principle was to standardize assessment and team training in sport events that preceded the
Games, including briefing and debriefing for the events.
The entire process of planning the medical team is a result of building a risk matrix for
each sport, where the COB MD is able to optimize the use and avoid waste of financial and human
resources. A pre-selection of professionals that would be responsible for each sport allows the
possibility to enhance knowledge because of interactions with original team staff, such as
physicians, physiotherapists, psychologists, and coaches, making work with athletes easier and
enhancing doctor-patient relation. Furthermore, this improves knowledge in sports that Brazil is
competing in for the first time, such as in Rio the sports of badminton, golf, field hockey and
rugby, representing a total of 46 athletes. For the Rio Games, this planning allowed thorough
assessment and planning for the largest Olympic team Brazil has ever fielded; indeed, larger than
any other sports event. The COB supplied and staffed all official athlertes in the village as well as
two exclusive training centers for COB athletes, covering over 1000 people, 465 of these being
athletes, and 342 events, considering official training sessions and competitions.
Assessments were divided into two categories: disease (26% of total assessments) and
orthopedic and trauma (74% of total assessments). The most common complaint for diseases
was upper airway infection, comprising of 25% of complaints, and diarrhea, 7% of complaints.
Among orthopedic cases, the main diagnosis was muscle soreness, comprising of 37% of
assessments, followed by back pain with 11% of complaints. Several key lessons were learned in
medical team development for the games but particularly from the Rio Games. One that stands
out is the importance of previous integration with each sport and its multidisciplinary teams. A
legacy outcome of the Rio Games was the inauguration of the Olympic Laboratory of Brazil,
where sport teams have direct access to lab and performance evaluations, making possible to
assess health in a more individualized way related to high performance.


For Team Qatar, the health care team is appointed by the Qatar Olympic Committee
among health practitioners working at Aspetar Hospital (the national sports medicine hospital),
usually by choosing those professionals with larger experience at previous Olympic Games. The
Chief Medical Officers (CMOs) who were sport medicine physicians formally employed by
Aspetar usually are appointed some months is advance. The Qatar CMOs put together medical
teams of sport physicians, sport physiotherapists and massage therapists working with national
federations qualified to Olympics. The Qatar CMOs were responsible to assist medical team
members to get adequate licensing and accreditations, provision of medications and medical
equipment as well as getting the necessary permit for importing all equipment and medication.
The vision of the Qatar medical team has been to create a focused group of sport health
practitioners with good internal co-ordination and communication to deal with a small Olympic
team of 30-40 athletes.
For Team Spain, the Chief Medical Officer is appointed more than one year in advance
by the Spanish Olympic Committee among the members of its Medical and Scientific
Commission. The CMO is a Sports Physician, Orthopedic Surgeon or Medical Doctor with
extended experience related to the Olympic Games, management of health for elite athletes as
well as appropriate language skills. The Spanish CMO assembles a medical team of sport
physicians, sport physiotherapists, and other health allied professionals that are especially
knowledgeable and skilled within their relevant national federations to accompany their
individual sport teams. These health professionals know their athletes very well and take care
of their athletes´ health during the competitive and training seasons prior to and during the
Olympic Games. Additionally, some sport physicians and sport physiotherapists are usually
appointed to support athletes from individual team sports that do not meet the Olympic quota
to bring health team accompanying persons. The Spanish CMO traditionally organizes
informative workshops and coordination meetings during the mission preparation to assure all
medical team members are aware of important logistic aspects (such required vaccinations, jet-
lag preparations, acclimatization camps, etc.) and to review communication pathways and
guidelines. The Spanish CMO is responsible for assisting medical team members to get
adequate licensing and accreditations, provision of medications and medical equipment as well
as getting the necessary permit for importing all equipment and medications. At the Rio
Olympic Games, the Spanish medical team included 25-30 sport health practitioners to care for
its Olympic team of 300-400 athletes, and fulfilled its goal of being internally well-coordinated
and communicated assuring optimize health of its athletes to provide a foundation that they
could excel in performance.


SPECIFIC LESSONS LEARNED:

Each Olympic Games is a unique experience that offers various learning points for future
events. Multiple variables affect an Olympic Games. Some are more obvious, such as the host
city and current world events; but others are less apparent, such as the climate and athlete
security. By reflecting on, and learning from, previous Games’ shortcomings, future
competitions can continue to produce outstanding events.
The first major event that provided serious lessons to future Olympic Games occurred
during the Munich 1972 Games. On the morning of September 5, 1972 eight Palestinian
terrorists took 11 Israeli Olympic athletes and coaches hostage. The attack eventually ended in
the death of all 11 Israeli Olympic athletes and five of the terrorists. The security at these
Games was intentionally meant to be out of sight as a “care-free” game. [18] Security personal
were primarily equipped to handle unarmed conflicts and not large-scale terrorist attacks.
What evolved out of these events was a change in tactics into a noticeable security presence at
the Olympic Games. It has now become standard protocol to make well-armed security
personnel visible to all who attend the Games. There are also demonstrations and numerous
sweeps of the venues prior to events occurring to ensure the safety of the athletes and
spectators. [18,19] This single event at the Munich 1972 Games may have had the most
profound and lasting impact on all future Olympic Games.
With the continued global spread of the Games, and more countries participating and
hosting, new challenges have arisen with various Games. An example of this is the air or water
pollution at various host cities, with the 2008 Beijing and 2016 Rio Games being prime
examples. Prior to, and during, the Beijing Games one of the major concerns was the air quality
and pollution that athletes would be facing. Beijing has been consistently ranked as one of the
cities with the worst air quality in the world. A number of factors contribute to this, including
industrialization, climate, as well as geography (the mountains around Beijing help to trap the
already poor air in the valley). [20] Prior to the Olympics, organizers took numerous steps in
order to attempt to alleviate the dense pollution, including closing factories and restricting
driving. However, studies conducted during the 2008 Games suggested that the particulate
matter in the air was still “2.9, 3.5, and 1.9 times higher than those in Atlanta, Sydney, and
Athens.” [20-22] Double the amount of pollutants in the air can have profound effects on the
respiratory system. Research has shown that this amount of particulate matter in the airways
can lead to substantial inflammation and smooth muscle dysfunction. Given the extremely
strenuous nature of most Olympic events, this does not provide and ideal environment for
athletes to perform at their optimal levels. [23] Although very few negative effects were
reported due to the poor air quality in Beijing, athletes should still be aware of the potential
effects of pollution and take appropriate steps to protect themselves in future Games. The
steps taken by Beijing to decrease air pollution did have a lasting effect on the host country
itself. Samples taken from individuals following the Beijing Games continued to show lower
levels of inflammatory markers in the airways than prior to the Olympic Games. [23]
The 2016 Rio Games presented another pollution challenge for the International
Olympic Committee; water pollution. The poor water quality was highly publicized prior to the
Rio games. An article published prior to the Games stated that the athletes “will be swimming
and boating in waters so contaminated with human faeces that they risk becoming violently ill
and unable to compete.” [24] There were multiple reports of athletes becoming sick prior to
the Games during Olympic test events, including rowing and sailing. An estimated 1400 athletes
came in direct contact with the contaminated water due to the nature of their sporting events.
[8] The main issue with Rio was the failure to handle waste effectively, as most sewage in the
city was not treated. The same Associated Press report found dangerously high viral loads
throughout the city just days before the Olympic Games began. [24] Despite efforts by the city
to improve water quality, viral and bacterial loads were similar during the Games as they had
been at previous testing times. This underlines the difficulty of solving the problem. Despite the
concern prior to the games, there were only a minimal number of athletes who became sick
from the water. [25] Given the persistent poor quality of the water, these low infection rates
are likely more due to awareness and preventative measures taken by individual athletes and
teams than the attempted clean up by the host country. In the end, whether the issue is air or
water pollution, the IOC and individual organizing committees must be aware of these specific
challenges that face a possible host city, and work to correct or reduce the potential exposure
to ensure the safety and optimal performance of the athletes. Additionally, team doctor must
also be aware of the potential threats from environmental pollution and may wish to take their
own measures to reduce their athletes’ exposure. In the above examples, this could include
bringing bottled water or respirator masks for their contingents.
Finally, given the mass numbers of people and athletes crowding into a city during the
games, it is inevitable that various communicable diseases should be a worry of IOC organizers
and team physicians. The London 2012 and Rio 2016 Games gave Olympic physicians helpful,
yet hard earned lessons to ensure that athletes stay healthy and are able to compete at their
optimal levels. According to data collected by the IOC Injury and Illness Surveillance System,
the incidence of illness during the Rio Games (5%) was the lowest reported since illnesses
began being recorded in 2010. [8] London 2012 and Vancouver 2010 each showed a 7% illness
rate [10,11], while Sochi 2014 reported an 8% illness rate. [12] Respiratory and gastrointestinal
diseases account for a majority (68-75%) of the reported illnesses. [8,12,17] The ability to
identify the most common illnesses and possible causes can help keep athletes at their optimal
levels in future Games.
Given the diversity of host cities around the world it is necessary to consider the variety
of local infections that may not affect athletes while in their home countries. A unique
infectious aspect of the Rio games that required physician awareness was the Zika virus
outbreak. With the prevalent mosquito as a vector for human transmission, the cases of Zika
infection increased prior to the games. [26] Research into the virus found that it caused
minimal affects in the infected individual, at the most a severe upper respiratory infection, but
the real concern was the devastating birth defects, especially microcephaly, found in newborns
of infected mothers. This caused grave concern among many athletes and spectators, especially
due to the childbearing age of many Olympians. The world community took extensive action
and was able to learn about the virus prior to the games. This information helped with
prevention techniques, especially encouraging anti-mosquito and safer sex precautions. [27,28]
As a result, there was not an increase in cases during the Games. Rio 2016 helps demonstrate
how local disease or infections must be studied ahead of the Games and thus may be
prevented in the future. Team physicians should also consider specific precautions for their
athletes and delegations based on the potential infections and vectors they may encounter.
With the mosquito-borne Zika virus physicians employed mosquito nets and bug spray to help
prevent infection. By considering previous examples and studying the upcoming environment,
team physicians can gain the tools to handle most any future geographic infectious diseases
they may encounter. [29]

DOPING

Doping is an unfortunate reality that affects every Olympic Games. Although the first
doping tests were instituted at the 1968 Winter Olympic Games in Grenoble, France, the World
Anti-Doping Agency (WADA) was not established until 1999. [30] The organization’s mission is
“to lead a collaborative worldwide movement for doping free sport.” The organization
publishes a code that 660 international sports organizations and government bodies must
adhere to when competing in sanctioned sporting events. The code provides a coordinated
approach to anti-doping strategies and research activities for the participating organizations.
[31]
For the 2018 PyeongChang Games the entire Russian Olympic Committee was
suspended from the due to evidence of state sponsored doping, cover-up and manipulation
extending back to the 2014 Sochi Games. With this renewed emphasis placed on catching and
example of punishing cheaters, it is even more important for physicians to be aware of, and
compliant with, the rules of WADA. The list of banned substances and methods is easily
obtainable from the WADA website as a downloadable file. An example is shown below in
Figure #2. It is important to note that there are unique substances banned for each sport, as
well as for inside and outside of competition season. One specific example is the prohibition of
beta blockers in shooting sports, as they help to slow heart rate and steady the hand while
shooting.

Figure #2. Taken from The World Anti-Doping Code, International Standard, Prohibited List
January 2018
WADA does offer exemptions for certain medications based on athlete medical
conditions. This is called a Therapeutic Use Exemption (TUE), and must be applied for by the
medical team. The TUE is narrow and specific in scope, and a documented medical condition
must be present prior to any exemption being granted. There are specific sets of criteria
regarding diagnostic testing, documentation and alternative medications that vary for each
medication and medical condition. These guidelines must be followed to ensure the exemption
is granted. It is important for the treating physician to be aware of any chronic or acute medical
condition that may require a TUE, as failure to apply and receive an exemption can result in a
positive test for the athlete and subsequent disqualification from competition and possible
forfeiture of previous results.
Physicians and athletes must also be compliant with WADA monitoring and testing
policies. This includes random and timed drug tests, both in and outside of competition.
Therefore, athletes and physicians must be aware of any substances that the athlete is
ingesting or utilizing, including supposedly allowed dietary supplements such as creatine and
protein. Survey data from 2012-2016 showed 57% of United States high-school teenagers used
protein supplementation and 34% used creatine supplementation. It was also shown that a high
percentage of these supplements were contaminated with banned substances, including
steroids. [32] While there are several third-party companies that will test and certify
supplements against WADA standards, athletes are still ultimately responsible for everything
they ingest, and should exercise caution when choosing and using supplements. [33,34]
Overall, it is the responsibility of the physician and the athlete to have an open and
candid conversation regarding doping, and the rules that WADA has provided. If there is any
question as to the legality of a substance, multiple resources exist to ensure that the athlete is
not in violation of any anti-doping rules. In the event that an exemption is required, there is
also a clearly defined means for providing this to the athlete. There should be minimal hurdles
or difficulty in the partnership between the physician and athlete to keep Olympic sports free
from doping.


CARING FOR OLYMPIC LEVEL ATHLETES OUTSIDE OF OLYMPIC GAMES

As discussed above, detecting and preventing doping is a point of emphasis for the IOC
and WADA. It is vital that physicians working with Olympic athletes know these doping rules
and the specific medication statutes of the athlete’s sport. Physicians should also be familiar
with the specific terminology, in-game rules, and biomechanical requirements of their athletes’
sports. Not only does this allow for improved communication regarding injuries, it also provides
additional credibility for the physician with the athletes, fostering an improved doctor-patient
relationship.
An additional, and sometimes only, opportunity to establish a doctor-patient
relationship with the Olympic level athlete is during the Preparticipation Physical Examination
(PPE) or Periodic Health Evaluation (PHE). While not mandated by the IOC, the PHE is
recommended by the IOC’s 2009 Consensus statement. [35] The main purpose of the PHE is to
screen for injuries or medical conditions that place the athlete at higher risk during
competition. Therefore, the PHE should be based on scientific evidence and established criteria,
and tailored to the athlete’s specific sport, age, gender, and race when appropriate. If a
condition is detected or suspected, additional workup and management should be performed
as necessary. In addition to screening for conditions and establishing medical care, the PHE can
also serve to ensure proper diagnosis and management of some silent conditions that still
affect performance, such as mild iron deficiency or astigmatism. [35] The PHE should be part of
an on-going process for elite athletes, and ideally performed far in advance of any major
competitions to allow for adequate treatment of any identified conditions.
Throughout the years and months leading up to the Olympic Games, a national team
physician may be called upon to perform other preliminary services for the teams and athletes
of their nation. These can range from performing the PHE to working national competitions or
Olympic Trials. Throughout this process communication with not only the athletes, but also the
training staff, coaches and national organizers, is crucial to helping the Olympic athletes
become or remain healthy enough to compete at the highest level.


UNIQUE CHALLENGES AT OLYMPIC GAMES

Licensure & access in foreign country:
National team physicians and other healthcare practitioners will need to obtain
licensure or accreditation in the host country for the duration of their visit, including any time
before or after the Olympic Games. This process will vary based on the home country’s laws
and regulations but will, at the very least, require registration of each national team healthcare
provider with the host country. After registration, the process has varied from simply allowing
registrants to practice within their usual scopes of practice without further licensure or
certification from the host country [36] to granting accredited physicians a temporary license to
practice during the duration of the operation of the Olympic Village. [16] The licensure or
accreditation will allow NOC team doctors to treat only members of their own national
delegation, unless specific permission is granted by another national organization. The
registration will also allow the NOC team physicians to request physiotherapy, medications,
imaging or other diagnostic services from the Polyclinic, but not outside facilities or hospitals.
Care should also be taken to ensure proper malpractice insurance, as the host country
usually does not provide coverage for NOC team physicians. National team physicians should
inform their insurance companies of the travel abroad with a sports team and confirm that they
have adequate coverage for that role. The host country will provide malpractice insurance for
the healthcare practitioners and services provided under their auspices, such as those offered
at the Polyclinic or at specific venues.

Language barriers/communication:
The official languages of the IOC and thus the Olympic Games are French and English,
and all official communications and signage must contain both translations. [37] If different
from those two, the dominant language of the host country will also be prevalent throughout
each Olympic Games. However, with over 200 nations participating in the Games, there are a
myriad of other languages spoken by athletes, national organization members and spectators
alike. As national team physicians are often restricted to treating their country’s own athletes
and committee members, communication and language barriers should be a relative non-issue.
In the instances where discussion or coordination is necessary with the host nation’s medical
services, or for physicians and medical staff who will be treating patients from a variety of
countries, effective communication is paramount. Therefore, translation services should be
made readily available to facilitate accurate and timely medical care. Such services can be in
person, over the phone or telecommunication, or, as technology continues to advance, via
smartphone or computer applications. The 2016 Rio Games employed over 8,000 professional
translators fluent in over 30 languages to assist throughout all aspects of the Games. [38]

Qualification/ Disqualification: RTP Decisions
If an injury occurs during competition, each sport has their own rules and medical
structure that dictates who is the first to respond to the athlete, whether that be the national
team doctor, physiotherapist or a physician from the sport specific International Federation.
[39] The medical providers of the host country are available to assist and advise throughout the
diagnosis and treatment process, but the ultimate return-to-play decision rests with the NOC
team doctor and IOC Medical Commission if necessary. [36]


Take Home Points

1. When caring for Olympic athletes, the health care professional must be aware of the
unique demands and pressures of this often once in a lifetime experience for athletes.
2. Injury and illness prevention is the key to optimal team performance at any Olympic
Games
3. Special planning and preparation is necessary to manage a national team in a foreign
country including travel, nutrition, and access to health care.

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