Dr Ian Plummer

http://oxfordcroquet.com/tech/temlett/index.asp

Oxford Croquet

J A Temlett

Professor of Clinical Neurology
Department of Neurology and General Internal Medicine
University of Adelaide and Royal Adelaide Hospital
Adelaide Australia

Contents

Part 1 Accidents Affecting Croquet Players
Part 2 Medical Conditions Affecting Croquet Players
    Normal Aging
    Selected Commonly Encountered Conditions or Diseases
        Back Pain
        Cardio-respiratory Conditions
    Selected Neurological Disease States
        Parkinson's Disease (PD)
        Alzheimer's Disease (AD)
        Non-Alzheimer's Dementias (FTLD)
        Strokes
        Traumatic Brain Injury (TBI) and Head Injury
        Psychiatric Illness
        Medication Side Effects on Croquet Players
        Specific General Medical Conditions Warranting Therapy
    Visual Acuity
References

Introduction

This contribution examines three different facets of injury or disease affecting players of either Golf or Association Croquet.

Croquet is played socially at many clubs worldwide with national, regional and international competitions. It is prudent to consider some of the fortunately rare mishaps which may curtail the ability to enjoy playing the game. Sometimes physical or mental conditions cause premature retirement from croquet and may very rarely be fatal.

Part 1 discusses common accidents encountered whilst playing croquet, many of which are entirely avoidable.

Part 2 deals with medical illnesses and progressive incapacity influencing good croquet play. These are disease states, be they of the mind, brain, musculoskeletal system or cardio respiratory systems. Some diseases are temporary, some progressive, some may improve on treatment and some deteriorate in spite of best advice and management.

Part 1 Accidents Affecting Croquet Players

Inevitably, the non-energetic nature of croquet attracts the elderly and retired population (sadly the younger generation does not find it sexy enough). Some players will die naturally of cardio respiratory disorders and some, sadly, while in play.

Accidents however may also expedite complications that may hospitalise individuals leading to morbidity and mortality from other complications. Accidents such as falls are the commonest. Falling may occur when tripping over unappreciated balls, hoops, mallets or side lines/strings. They are mostly avoidable! Nevertheless accidents still occur when one is concentrating on one's own game, e.g. stepping back and falling over an obstacle required for the game itself.

Ground slopes, especially slippery ones when wet or layered with ground fruit or leaves, are very tricky. Most clubs will anticipate the hidden dangers, so will clear these regularly, especially before visitors arrive, but wet grass slopes are always a hazard.

The consequence of these falls fortunately is mostly hurt pride, but fractures in osteopenic women, the radial bone in the arm or hip fractures are more serious and even head injuries are reported.

Barriers, hedges & vegetation and gates or fences all protect croquet lawns from invasion from stray animals. In the constitution of South Terrace Adelaide I found our hedge was grown to be 'sturdy with thorns' to keep out foxes and lions! Within the courts however thorny hedges lacerate or may damage eyes when foraging for misplaced balls.

Clubhouse ladders and machinery together with poisons are a subtle and sometimes not so subtle source of serious injury. Furthermore electrical and mechanical safety is paramount but not the focus of this article.

Deliberate abuse, be it mallet swings, temper tantrums or frustration with errors in play and thoughtlessness should be firmly discouraged and the dangers indicated. Serial offenders should have another vocation suggested. One ex-croquet player adopted golf after serial croquet mallet abuse. On a fairway in the first week, frustrated and in anger, he struck a golf club against a tree and wound the shaft about the tree with such force that the 4 iron club head fractured his OWN wrist. While potentially humorous (I'm sure he and his wife did not find the anger displayed funny at all!), it underpins the need to contain frustration and consequent croquet disappointments, which beset all of us at some point.

Part 2 Medical Conditions Affecting Croquet Players

Before we discuss specific neurological diseases it is well to appreciate the effects of normal aging upon motor skills and balance in the elderly.

Normal Aging

The motor system, sensory system, cerebellum and basal ganglia affect balance and posture, and all change, progressively worsening with age. Figure 1 shows work I completed some years ago related to balance and why anyone, let alone someone with Parkinson's disease or even over 60 years is not advised to climb ladders! It is clear that one's reaction time is just not good enough to avoid rapid corrections in balance. However what impact may this have on croquet players with their feet firmly on the ground? Some insight into posture and balance, as it affects croquet strokes, is instructive.

The rhythm of mallet swing for example depends on many years of training. Not only must the mallet be held perfectly straight when contacting the ball, but also the swing momentum must be smooth and pendulum-like, preferably moving from the shoulders with firm wrists and very different to a squash, tennis or golf stroke.

So any factor that threatens any of these neurological-driven skills is bound to make striking the ball dead-centre and with the correct power and timing would determine and often lessen accurate stroke execution.

Of course experience, practice and determination all improve one's game with time. However these age related factors should be weighted against determined practice factors that make this progressively harder or, at times, impossible.

Skeletal injuries are most common and are dealt with very well in other articles which I reference here (1):

• Joint
• Muscle
• Strain

Selected Commonly Encountered Conditions or Diseases

Back Pain

Low lumbar back injuries are very common. Few of us would escape this aliment at some point in our playing career. Fortunately the discs and vertebra remodel dynamically and very few people should require surgery; I would recommend fewer still.

Back pain comes from a host of sites mechanically. First there are the intervertebral discs, then the facet joints, the vertebra themselves and finally the ligaments connecting these all together. These allow easy bending, straight posture and good balance. If any of these structures causes pain mechanically, it causes protective muscle contraction or spasm, narrows the foramen (holes through which the nerves exit or enter) and further cause muscle spasm and aggravated pain. This results in us not wanting to play croquet at all. And if this persists, or is recurrent, long periods of rest are demanded. Physiotherapy or therapies, including pain killers and relaxants, are then usually required. Sometimes foolishly steroids are abused, pain killers used to excess and unrealistic surgery is demanded from impatient players.

Nature has given us common sense; use it! A dynamic back requires training to be kept fit and even then can give temporary discomfort. To play through the "pain threshold" is not only foolish, but ignoring your body's inherent sensing system may lead to irreversible problems over time. As we age, so do our bones, joints and ligaments.

In contrast there are times when a disc is prolapsed and presses on a nerve root, causing intractable pain or loss of function demanding urgent MRI neuroimaging and sometimes surgical intervention. As a clinical neurologist the vast majority of now-unstable back problems I treat, are for what in retrospect was an unneeded laminectomy. Put another way, unnecessary lumbar operations, while temporarily alleviating the problem and assuming the correct disk is operated upon, will take away the dynamic bendable vertebral discs and form a rigid pillar. That guarantees additional stress on the level above and below the laminectomy. This can lead to the multiple "failed back" operations, analgesic abuse and psychological problems. The new fashionable keyhole micro-discectomies, which are operations to remove the disc, have the same problem associated with the older laminectomy procedure, albeit less vertebral instability. Both procedures are still a type of surgical back assault!

Cardio-Respiratory Conditions

To be able to play prolonged hours of croquet, good heart and lung capacity is required. Obesity, unfitness, or restricted oxygenation from whatever cause, will impact upon consistent performance. Smokers with obstructive pulmonary function, uncontrolled asthma, restrictive lungs from being overweight or having restrictive fibrotic lung compliance will all be causes of poor lung function or sufferers of angina, ischemic heart disease, or past heart attacks (infarction) may impair heart function. Some could be improved by medication or modified lifestyles; some cause a more permanent restriction of best play.

Selected Neurological Disease States

Parkinson's Disease (PD)

PD is an extrapyramidal illness, affecting mainly but not exclusively the basal ganglia. The basal ganglia coordinate TIMING in the main, when affected by too much or too little dopamine in the midbrain and basal ganglia. The result equals slowness (bradykinesia or hypokinesia). Other neurochemical disturbances also affect speed, accuracy or dexterity. Aside from slowness, PD patients have muscle rigidity, tremor and impaired posture, all of which compound improper stance, balance, swing and timing of all croquet strokes.

Alzheimer's Disease (AD)

Memory breakdown, a function of the medial temporal lobe or hippocampus specifically, is the core feature of AD. Hence one initially may lose strategic thought or planning (executive function), then lose ones way about court, and finally confuse hoop approach order.

However, if any strategy out of the ordinary is presented, the frontal lobe and temporal lobe defects in AD make it difficult to cope with new changes or to learn new tasks.

One advantage, I guess, is that every game is a new challenge and grudges or unkind remarks will rarely be remembered. It is a strange paradox, sometimes observed, when new tasks are quite beyond a demented individuals ability, they having played decades of croquet, are able to semi-automatically string along a good three or four ball break during a game.

Non-Alzheimer's Dementias (FTLD)

Frontotemporal (lobar) dementias (FTD) the second commonest degenerative dementia and vascular dementia (VD), have frontal (mainly behavioural) and temporal (mainly language) disordered cognition. Impulse control, rational judgement and executive planning would tend to break down. Behaviour may become uncharacteristic, disinhibited, aggressive and at times apathetic and introverted. Empathy, tact, grooming, personality and general demeanour all change for the worse.

Confidence may be lost in all of these dementing progressive neurodegenerative illnesses.

Strokes

Vascular disease may be present as small vessel change with "vascular dementia", or more dramatically a stroke may manifest with a sudden hemi-paresis and an inability to hold a mallet, let alone continue playing effectively. There are different types of stroke: infarcts (atheroma or emboli), parenchymal (brain tissue) haemorrhage and subarchnoid haemorrhage, in addition to head trauma (subdural or parenchymal bleeds) or coup versus contra-coup brain injuries from motor vehicle accidents or falls (discussed below).

Likewise there are many different consequences. The career-ending strokes often are hemi-paresis or hemiplegic, visual loss or balance and gait strokes that make independent ambulation impossible. However some may more subtly affect cognitive function and concentration; some may cause pain or sensory loss and others affect language. All brain vascular insults make playing good croquet difficult.

Traumatic Brain Injury (TBI) and Head Injury

Trauma may produce cognitive change, seizures, sometimes focal or sometimes more generalised. All these events usually end croquet playing ability permanently. Dementia pugilistic affects boxers, sometimes years after they stop boxing. So too may contact sports (rugby, Australian or Gaelic football, roller-ball and so on) and repeatedly concussed individuals. If play continues when the brain is disorientated, successive brain traumas are very dangerous and commonly produce significant morbidity dizziness, memory loss, impaired concentration (working memory) and dementia. Motor vehicle accidents are similar in consequence, where the brain is smashed against the inner skull vault with the devastating consequence of permanent neurological damage.

Psychiatric Illness

This is a huge subject, I deliberately steer clear of this aspect in this paper, because psyche in croquet is very complex and I am not really qualified to comment critically. Briefly however, anxiety and depression, the commonest psychiatric burden to society, affect more than 10% of the population. Yet depressive disorders remain the "elephant in the room" and are insufficiently recognised in my opinion by both the lay and medically informed public. Anxiety and depression are linked. They affect drive, motivation and best play. This aspect of neuropsychiatry however should be addressed by more qualified authors.

Medication Side Effects on Croquet Players

Recreational drugs and toxins, such as alcohol, all affect play. Alcohol is specifically banned from consumption by the World Croquet Federation (WCF) Laws. This is a separate issue; drug testing today, as in all sport, should reduce abuse. Amateur sport codes currently do not have the strictest drug testing parameters or guidelines, but the WCF has applicable rules and this should be monitored in future. ALL medications should, in my view, be registered with the tournament manager or medical advisors; even antibiotics, cough mixtures or flu remedies should be listed. Random drug testing is another issue altogether. It is helpful to know, for example, when someone loses consciousness that they have diabetes mellitus or epilepsy.

Some prescribed medications do not affect play. However many players may not realise the more subtle changes associated with:

• Anticoagulants (blood thinners) - Warfarin, digabatron, anti-platelet drugs (aspirin or clopidogrel) and the added risk of falls, bleeding and subdural or intra-parenchymal haemorrhage.
• Antibiotics and Chemotherapeutic Agents - all cause peripheral neuropathy, diminished balance and sensory function in limbs, especially lower limbs.
• Asthma Medication – beta stimulants and pumps for bronchodilator cause increased tremor.
• Anti-Epileptic Agents (AED) – cause unsteadiness and ataxia or falls.
• Anti-Arrhythmic Agents and Pacemakers - may cause alteration in heart rate, blood pressure and unsteadiness.
• Antipsychotic Drugs - mood changes, sweating loss, temperature changes, heat intolerance, aggression, language disturbance and Parkinsonism.
• Benzodiazepines and Sedatives (including phenothiazine cough syrup, anti-emetics) - sedation, confusion, drowsiness and memory loss.
• Blood Pressure Drugs Antihypertensive Rx - postural dizziness, heat intolerance, unsteadiness and falls.
• Insulin and Oral Agents: Diabetics - hypoglycaemia will cause tremor, memory lapses and fatigue. It may cause confusion.

Specific General Medical Conditions Warranting Therapy

• Asthma, Cardiac Failure and Obstructive Lung Disease - may curtail prolonged ability to play croquet. Medication may alleviate some symptoms BUT eventually these disorders progress, especially in smokers, and play is retired.
• Epilepsy - some partial or focal seizures may occur un-noticed by players. Mental "pauses" may precede a generalised collapse in complex partial epilepsy.
• Diabetes Mellitus - all diabetics, epileptics, cardiac patients and those on medication should inform the tournament manager BEFORE any event to ensure appropriate action is taken in case of collapse.
• Cardio-Respiratory Disorders - obstructive (usually but not always smoking damage), cystic fibrosis, or restrictive (fibrotic, collagen diseases, pneumoconiosis industrial disease) lung disease, cardiac failure, past heart attacks (myocardial infarction), abnormal rhythms, (atrial fibrillation and Warfarin) all affect oxygenation of blood and circulation to organs and brain.
• Joint Prosthesis - the commonest joint replaced is the hip joint. This produces immediate change in proprioception and knowledge of the position of the leg in space, related to the pelvis. Hence posture and balance change. Osteopenic fractures from falls are more common in postmenopausal women, but either gender as age advances incur risk. Osteoarthritis affects all, and reflects general long term wear and tear. While this does not usually stop the ability to play croquet, it requires a determined modified playing stance. Knee replacement(s) thereafter, strained ankles, broken bones, knee ligament injuries, bursitis, joint inflammation or effusions all affect play variably with joint limitation or pain.
• Peripheral Neuropathy – similarly to joints, the knowledge of where the limbs, especially the legs, are in space relative to the body is accurately monitored all the time by the sensory systems spindles and intrafusal fibres resident in muscles. This is conveyed to the brain centrally, allowing automatic fine adjustments to keep one stable and upright. Gait and balance are both influenced by this system of refined adjustment. If the sensory organ, or its pathway or the brain lobe (thalamus and parietal lobe), is defective in any way, imbalance and improper gait are expressed. Thus if the nerve is from a disease process, most commonly diabetes mellitus or a drug (say a chemotherapeutic agent), then balance and the croquet swing will be affected to a greater or lesser degree.
• Anti-Parkinson's Drugs - intermittent extrapyramidal function and playing ability.
• Sleep Apnoea - commonly overweight males, who snore and stop breathing off continuous positive airway pressure, have sleep somnolence, early morning headaches and decreased concentration and fatigue.

Multiple conditions compound and are not simply additive but rather exponentially incapacitating.

Normal factors in any sport, including croquet, are affected by fitness and variables such as fatigue, obesity, under nutrition, electrolyte disturbance, heat exhaustion or cold exposure. Most are anticipated and combated by, e.g. rain gear, warm clothing and responding to normal body thirst, preference (bananas), sugars and so on.

Visual Acuity

Deteriorating vision is a real problem for some, and few will overcome it successfully in time. The loss of one eye does not affect play aside from the loss of depth of field and the tendency to miss the middle of the ball especially when casting. One naturally uses a dominant eye in any event, much like you sight down the barrel of a rifle using one eye to aim with the other wide open; the image is concentrated on the sighting eye. The same occurs with the croquet swing and line-up.

However developing cataracts, astigmatism and especially macular or retinal problems (macular holes, retinal degeneration or detachment) all seriously affect play. Night vision may be better (cataracts) since the pupil dilates or worse in retinal degeneration. Macular vision is crucial to accurate play; night blindness and colour blindness are self-explanatory regarding their challenges. Also obviously, the need to wear spectacles may improve visual acuity, but provide a challenge in wet weather, wind or rain.

References

1. Burnett B,  Maui Croquet Gazette Article, 2nd March 2001, http://www.mauicroquetclub.org/coaching/injuries/. Accessed 12.v.2012

Appleton DR, A Survey of Croquet Injuries, J Royal Society of medicine 90 218. Accessed 12.v.2012

Jacques-Oliver C, Barr AE, Strata F et al., Peripheral and Central Changes Combine to Induce Motor Behaviour Deficits in a Moderate Repetition Task, Exp Neurol 2009 (20 234-245)