July 2009

Sports Medicine: An athlete’s oasis in the Middle East

If the sheiks built it, they would come. Sure enough, an all-star team of Western specialists has converged on the tiny Gulf nation of Qatar to practice state-of-the-art sports medicine in the best facility that natural gas fortunes could buy.

7qatarfigure1by Craig R. Bottoni, MD

The Middle East is one of the fastest growing regions in the world. The money derived from the vast hydrocarbon reserves has catapulted the countries in the Arabian Gulf onto the world’s economic and political stage. The countries have wisely poured vast amounts from this windfall into developing their domestic infrastructure. Health care has been clearly designated as a high priority. New general and subspecialty hospitals are popping up throughout the Gulf. These new opportunities have attracted top-notch architects and engineering firms from Europe and North America. Virtually unconstrained by cost, the hospitals are being built with the latest cutting edge technology. Once completed, these centers are now are attracting the best and brightest physicians and surgeons from around the world.

Following many yeas as a British protectorate, Qatar gained its independence in 1971. The country of Qatar is a small peninsula (approx. 7100 mi2) off of Saudi Arabia that juts into the Persian Gulf. It lies about 250 miles north of the more well-known Arabian hotspot of Dubai in the United Arab Emirates and south of the island nation of Bahrain.

7qatarfigure2vertUnlike some of its neighbors, who have built their wealth from oil reserves, Qatar sits on the world’s third largest natural gas reserves. Under the guidance of the Emir of Qatar, Sheik Hamad bin Khalifa Al Thani, the technology to exploit these resources was developed and is now being utilized to harvest this natural resource. The culmination of his vision is that Qatar is now one of the world’s largest exporters of liquefied natural gas. Through innovative petrochemical processes, the gas is also converted into a myriad of other products for export. Much of the wealth derived form this resource is being directed to build the country’s domestic infrastructure, including a commitment to invest 5% of the income derived from the gas sales towards health and education within Qatar.

This small country and its inhabitants have a true passion for sports. As in most European countries, soccer reigns supreme. In December 2006, Qatar became the first Middle Eastern country to host the Asian Games, the largest sporting event after the Olympics. The event was a huge success for the small Gulf country. And in an even more unexpected occurrence, Qatar took the gold medal in men’s soccer.

Aspetar’s origins
To serve the athletes of the 15th Asian Games, a world class medical center for sports injuries was planned to open prior to the event. Thus, Aspetar Orthopaedic and Sports Medicine Hospital was conceived. Before this, the country’s elite athletes often traveled to orthopedic sports medicine centers in Europe or the U.S. to receive treatment or surgery. Unfortunately, because of construction delays, the hospital did not open to outpatient services until April 2007. Following completion of the four state-of-the-art operating theaters and the recruitment of a world class surgical department, the hospital became fully operational in December 2007.

The benefactor and Qatari leader who conceived of the hospital is the Emir’s son, Sheik Jassem Bin Hamad Al Thani. The Director General entrusted with coordinating and supervising the construction and certification of the hospital is Dr. Mohammed Al Ali. Under his guidance and direction, the key leadership positions were filled. The mandate from the beginning was that no expense would be spared in ensuring the highest level of care. Surgeons, sports medicine physicians, radiologists, physical therapists, nurses and other medial specialists were recruited from around the world, the salient criteria being expertise and experience in sports medicine and the care of athletes. A cadre of physiologists and researchers would strengthen the exercise science department, which included one of the few normobaric adjustable oxygen tension dormitories in the world. This suite of 24 rooms, where the oxygen tension can be adjusted to a level that mimics living at high altitude, can stimulate the body’s production of erythropoietin and theoretically increase aerobic performance. A similar change in oxygen tension increases red blood cell capacity in elite endurance athletes when they travel to high altitudes to train, but this facility allows our athletes to stay home at sea level.

All about the athletes
The primary mission of the hospital is to allow the patient-athletes to achieve their maximum potential. The elite athletes of Qatar are members of their respective federations (e.g. football [soccer], basketball, handball, etc.) or members of the Qatar National or Olympic teams. In addition, there are 16 first division sports clubs, which are similar to NCAA Division 1 university sports teams in the United States but are not academically affiliated. These clubs recruit and sponsor athletes—some as young as 10 or 11 years old—in soccer, basketball, handball and other sports who then compete in organized leagues within Qatar and throughout the Gulf region.

The hospital has no emergency department. All referrals for care are coordinated through the outpatient department. The hospital currently is averaging approximately 2000 appointments per month. The individuals who receive the highest priority are the elite athletes. Other groups of patients seen in the hospital include recreational athletes who are not members of a club or federation, local Qatari residents with orthopedic injuries, and expatriates working in Qatar. A contract has also been established for U.S. military personnel with sports-related injuries. A little known fact is that the U.S. has a large Air Force base in Qatar, although Aspetar provides all four branches of the military with diagnostic, surgical and rehabilitation services that the military’s medical staff cannot provide in theater. Some of these patients have been treated and subsequently returned to duty in Iraq or Afghanistan, thus saving the military from having to send these soldiers to Germany or back to the U.S. for treatment.

Aspetar has two rehabilitation facilities, one expressly for female athletes, supported by a world class group of physical therapists and the latest cutting-edge equipment. The separate women’s rehabilitation is provided out of respect for the cultural practices of some patients, particularly those who are older. However, many of the female athletes do choose to work out with their male counterparts. The facilities include two hydrotherapy pools, four thalassotherapy tubs, massage tables, an outdoor pool and a spa with locker room facilities. For sport specific rehabilitation and strength training, a full sized gym and circuit training area is staffed by five strength coaches who collectively possess an impressive background in athletics and personal training.

Our first line of athletic injury treatment is a highly qualified team of sports medicine physicians, many of whom have been head team physicians and have had on-field experience with top level soccer teams in Europe. They all work within a structure within Aspetar called the National Sports Medicine Program (NSMP). Any athlete who is a member of a sports club or federation within Qatar falls under the control of the NSMP for his or her medical care. The prevention, treatment and post-injury rehabilitation of all athletes is coordinated by the NSMP. This is truly a unique project whose goal is to optimize the care of the high-level athletes within an entire country. The sports physicians work closely with the orthopedic surgeons at Aspetar to provide the best possible care for the athletes.

The cutting edge
Four orthopedic surgeons, all subspecialty trained in sports medicine, provide the patient-athletes with world class surgical care when required. During the first year of operation, Aspetar surgeons performed more than 450 operations. Given our specific athletic population, it was not surprising that lower extremity injuries were, by far, the most common presenting complaint. Knee operations predominated, with more than 150 anterior cruciate ligament reconstructions performed in the first year. Although this may not appear to be high when compared to university-based practices in North America, it is quite high given the relatively small population of eligible athletes in Qatar (the country’s population in 2008 was just 824,000 – smaller than that of Delaware).

Several “firsts’ were recorded at Aspetar during our inaugural year. Specifically, our first double bundle allograft posterior cruciate ligament (PCL) reconstruction was the first ever performed in Qatar. Three PCL reconstructions and several multi-ligament reconstructions were successfully performed as well. Our surgeons routinely perform knee, shoulder, elbow, and ankle arthroscopy with the primary goal of returning athletes to their sports as expeditiously as possible.

In November 2008, Aspetar hosted the first annual Aspetar Arabian Gulf Sports Medicine Conference. Surgeons and sports medicine specialists attended from all over the world. The conference included expert lectures and two live operations, an ACL reconstruction and an arthroscopic shoulder repair. In March, Aspetar received the prestigious FIFA Accreditation from the world governing body for soccer. This is an award given previously to nine hospitals around the world who have demonstrated world class medical care for athletes, research and education accomplishments.

Aspetar has an active research department which has already generated presentations and publications on acclamation to heat, training during Ramadan and related topics. In addition, Aspetar researchers recently received approval from FIFA for a randomized trial on the use of growth factors for acute muscle injuries. Although it is too early for statistically significant clinical trials data to have been collected, Aspetar surgeons have presented clinical cases at regional and international meetings.

Aspetar hospital, though still in its early stages, is an unequivocal success and a model for athlete medical care. We aspire to become the referral center for athletic injuries in the Arabian Gulf.

Craig R. Bottoni, MD, is chief of surgery at Aspetar Orthopaedic & Sports Medicine Hospital in Doha, Qatar.

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