We know that case-based learning is the most effective and fun way to improve clinical skills. So BJSM provides opportunities!

Under the “Education” tab on the home page, click on Image Quiz. You’ll find real-life cases – ideal for medical students and junior doctors. (We tested our EIC on two and are pleased to report he got them right!).

Our newest cases are of (i) a triathlete with unusual calf/Achilles region pain and (ii) a water-skier who came to grief while attempting his start.

These cases will help you recognize clinical scenarios and help you gain confidence in interpreting imaging. These new case include a lateral x-ray of the ankle/ultrasound scan of the lower leg and an MRI of the hamstring region. As a side teaching note, remember that precise localisation of hamstring injuries is important as the location of injury affects prognosis. (Carl Askling’s work – listen to his podcast here).

Thanks to Arthur Kievit (PhD fellow) and Gino Kerkhoffs (orthopedic surgeon) from the Department of Orthopaedic Surgery at the Academic Medical Centre, Amsterdam, Netherlands for the hamstring quiz. The Dutch Sports Medicine Society (VSG in Dutch) is a BJSM member society – all VSG members have full access to BJSM and the VSG guides one issue of BJSM annually.

Thanks also to Dr James Thing (Sports Physician in training), Dr James Sarkodieh (Radiology in training) and Dr Muaaze Ahmad (Consultant Radiologist) from the Royal London Hospital for the case about the calf/Achilles pain.

Follow this link to the newest quizzes

Keep an eye out for future quizes – they’ll be flagged on BJSM’s Facebook and Twitter channels. Drs Kievit, Kerkhoffs and Thing will keep the Image Quizes coming and feel free to submit cases yourself! Please contact me on bpluim@euronet.nl and I’ll make it easy for you. Best Image Quiz for the Year gets a free copy of a best-selling sports medicine book!

Yours in sport,

Babette Pluim, Deputy Editor BJSM

@DocPluim

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

By Lucinda Poulton¹, Paul Kelly², Justin Richards², Moiz Moghal³, Wilby Williamson^2,3

Affiliations

1. University of Oxford Medical School (4^th Year Medical Student)

2. British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford

3. OxSport, Nuffield Orthopaedic Centre, Oxford.

Lack of physical activity is a major risk factor for mortality, yet 25% of students at Oxford medical school are unaware of the World Health Organization global guidelines for physical activity¹. There is concern that this gap in awareness and understanding is not limited to our medical students.  With the arrival of Public Health England, there is an increasing responsibility for all doctors to consider the challenges of preventive medicine. Understanding the problems patients face and having the confidence to tackle them is critical. Weiler and colleagues highlighted a UK nationwide deficit in the provision of medical student teaching on physical activity and have championed a call for reform². A survey of 4-6^th year medical students at the University of Oxford aimed to identify where gaps in local education could be improved. The results identified three hurdles to changing patient behaviour – students’ education, knowledge and attitudes to physical activity.

First, searching for physical activity in the Oxford curriculum drew a blank. Whilst other leading risk factors for global mortality such as smoking cessation and dietary changes, were covered, physical activity was not mentioned in the core curriculum. Perhaps this explains why, when asked to rank risk factors for global mortality, physical activity was ranked bottom of the pile by the majority of students.

Should we describe the lack of curriculum as a false start? It certainly appears to leave the students struggling at the next hurdle: grasping the basic knowledge of the role physical activity plays in prevention and treatment of non-communicable diseases. More than 60% of students believed there was no evidence to support promoting physical activity as a preventive approach to bowel and breast cancers ³.  More worryingly, 16% of students said the same for cardiovascular health. Overall, 85% of students felt they had inadequate knowledge of the role of physical activity in preventing and treating chronic disease.

Encouraging behaviour change in patients requires more than just knowledge of guidelines. The ability to motivate, promote patient’s capabilities and identify opportunities for change requires medical professionals to take ownership of this problem, and to have the confidence to do so.

Three groups of 5^th year students were asked to list everything they had, or had not done, in the past week that was a threat to their health. They all keenly acknowledged the risks they took in not eating enough fruits and vegetables, riding bikes without helmets or over indulging in some other vice. But of the 50 students surveyed, none identified a lack of physical activity as a personal risk they had taken. Yet when specifically questioned approximately 90% did not meet physical activity guidelines (150 minutes per week)⁴. How can tomorrow’s doctors encourage physical activity behaviour change when they don’t see it as a problem in themselves?   With the rising burden of non-communicable diseases it is increasingly important for medical students to be prepared and to feel motivated to gain the knowledge and expertise needed to promote physical activity. However, over three-quarters of students felt they hadn’t received enough training, and a majority lacked the confidence to provide advice to patients on physical activity.

Oxford currently leads the world in medical student education⁵. Now they are taking steps to guarantee students receive appropriate training in physical activity and preventive medicine. However, this is a global issue, and our fear is that we are joining a small minority of institutions where educational reform is being driven by passionate physical activity researchers and clinicians. Nationally and internationally, are others taking up the call to champion undergraduate physical activity education? Will the gap in curriculums be filled?

References

1. http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html

2. Weiler R. Et al, Physical activity education in the undergraduate curricula of all UK medical schools: are tomorrow’s doctors equipped to follow clinical guidelines?, Br J Sports Med, 46, 1024-6 (2012)

3.http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/lifestyle/physicalactivity/physical-activity-and-risk-of-cancer

4. https://www.gov.uk/government/publications/uk-physical-activity-guidelines

5. http://www.timeshighereducation.co.uk/world-university-rankings/2012-13/subject-ranking/subject/clinical-pre-clinical-health

Acknowledgement

Dr Natasha Jones and Dr Julia Newton

Oxsport, Nuffield Orthopaedic Centre, Oxford.

Contact

Wilby Williamson, Academic Clinical Fellow, Oxford

wilby.williamson@dph.ox.ac.uk

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Dr. Fred H. Brennan, Jr.

Born in Boston in 1965 and having run the race twice, the Boston Marathon has always been a special event for me. I returned in 2013 for my fifth year as a medical volunteer.

This time would be special. My 18-year old daughter would be working and shadowing me as part of her senior year high school project. She had been contemplating her career choice; an emergency department nurse or an athletic trainer. This day, Patriot’s Day in Massachusetts, would be a day that would shape her career choice and forever bind us together.

We arrived in Boston a little after 6 am. Plenty of time for us to get a coffee and bite to eat at the Starbucks just 75 yards shy of the finish line on Boylston Street. We made our way down to the finish line and took a few pictures of Alyssa standing under the media bridge. It was quiet at 6:30 am except for a few media personnel setting up their cameras in preparation for one of the world’s greatest marathons. The Grand Stands were empty but would be packed with family members, fans, men, women and children in just a few short hours -all excited to watch their runners finish the grueling 26.2 mile event. We could never have imagined that the very spot where I was taking photos would later be littered with bomb blast debris, human flesh, and bones.

Arriving at the pre-race meeting Alyssa was impressed with the abundance of volunteers, smiling faces, camaraderie, and organization of this massive event. The meeting introduced the new and prior volunteers to the logistics of the medical support structure at the Boston Marathon. Chris Troyanos, the medical coordinator, thanked and praised last year’s volunteers for their incredible efforts caring for over 2000 athletes suffering the effects of record breaking heat. This day was expected to be cool with a bit of a breeze. Cramps, nausea, post-race collapse, and mild hypothermia were anticipated….the usual marathon ailments. We broke from the meeting and dispersed to our respective medical treatment areas along the race course and near the finish line.  Alyssa and I went to Med Tent B, approximately 1-2 blocks from the finish line, where I would spend the next two hours coordinating my team of approximately two hundred volunteers.  Our volunteers were excited, motivated, and anxiously awaiting our first potential patients. We were able to view the finish line area on two large flat screens monitors set up in the tent. Approximately 3 hours into the race we began to get a slow trickle of patients who were cold and cramping. At 4 hours we were approximately 75% full of patients who were cold, exhausted, and worn out from the trek from Hopkinton to Boston.

At 4 hours and 9 minutes into the marathon, our lives would change forever. I will never forget the look on Alyssa’s face when the first bomb went off…then the second one. We heard and felt the blasts.  Everyone in the medical tent froze in place. The flat screen monitors went dead, cell phones stopped working, and we lost all communications with the rest of the medical command. I stood on a milk crate and got on the tent intercom system. “We all need to stay calm. We don’t know what has happened yet but there is a good chance that we will receive causalities. Stay in the tent, take care and stabilize your current athletes, and let’s get the tent ready to receive trauma casualties.” The response from the volunteers was incredible. No panic, no hesitation, and a total team effort. During this time the first responders at the finish line, including Tent A marathon medical personnel, heroically triaged and stabilized the casualties. We were told to stay put in Med Tent B as the blast area was not secured and more explosive devices were possible. We received 3 minor shrapnel injured patients and saw the psychological effect on the spectators. People were running frantically trying to either get away from the blast area or looking in horror for their loved ones in our medical tent.  Runners were diverted to the Boston Commons as the course finish area was secured and evacuated. Amazingly most of the casualties were evacuated from the finish area within 30 minutes.  It was an incredulous response to a tragic event.

So what lessons were learned and how does this change the future of endurance event medical coverage? I will shed some light on this from my year in the 28^th Combat Support Hospital in Iraq where we frequently responded to tragic events like this.

1.  We must now be prepared to be first responders for mass trauma. A team or teams of volunteer medical personnel with trauma training and/or experience should be pre-determined. They should meet with local EMS supporting the event to discuss available assets and how the volunteers can augment the EMS system.
2. A trauma bag (s) should be assembled and include basic oral airways, tourniquets, curlex bandages, ACE wraps, SAM or other extremity splinting materials, some IV starter kits with normal saline. This list is certainly not all inclusive.  These bags should be at the race start, the race finish, and at aid stations along the course.
3. Think before jumping into the scene. Make sure the scene is safe and secured. Terrorists will wait for first responders to act then set off a second explosive device to wipe out those responders.  “Dirty bombs” laced with chemical agents are also a real possibility.  First responders can quickly become casualties if they are exposed to chemical agents. And contaminated patients brought back to your medical tent will quickly contaminate your medical treatment area.
4. When triaging casualties think about those interventions that can quickly save a life. Firm pressure on a bleeding wound, a tourniquet, an oral airway, quick stabilization of a long bone or pelvic fracture.  You may have to walk away from someone who you could save in an emergency department so that you can tend to a greater number of injured who will survive with your simpler but more timely intervention, such as an application of a tourniquet.
5. If ever in an event like this remember to talk it out. Share your feelings and experience with anyone you trust or who wants to listen. It is therapeutic and will help minimize the chances of the “unseen” injuries that can haunt those injured (Post Traumatic Stress Disorder) and those who helped them.

I could not be more proud of the Boston Marathon medical volunteers who responded to this tragic event.  As with the tragedies of 9/11 this event once again made us all realize the important things in life; family, friends, freedom, and faith. Thankfully my daughter Alyssa is fine. She will be a terrific ED nurse someday. And she now wants to run the Boston marathon as a tribute to those who were killed and injured. Maybe we’ll cross the finish line together…Boston Strong!

**************************************************

Fred H. Brennan, Jr is currently the medical director at Seacoast Orthopedics and Sports Medicine in New Hampshire and a team physician for the University of New Hampshire. Dr. Brennan studied at the University of New England College of Osteopathic Medicine, completed his family medicine residency at Albany Medical Center and a sports medicine fellowship at the University of Toledo.  A member of the American Medical Society for Sports Medicine (@TheAMSSM), he chairs the musculoskeletal ultrasound committee.   Previously he was an active duty physician for the US Army with service during Operation Iraqi Freedom as a trauma physician. An avid endurance athlete, he is a Hawaii Ironman finisher and a two-time Boston Marathon finisher.

The AMSSM is one of BJSM’s 13 member societies – clinical societies who partner with BJSM to advance the missions of the organizations. The January 2013 issue of BJSM was guest edited by the AMSSM.

Undergraduate perspective on Sports & Exercise Medicine - a BJSM blog series

By Bryn Savill (@BrynSavill) 

The evidence behind exercise as medicine is substantial and it can no longer be ignored.¹ Prof. Blair (2009) named physical inactivity the “Biggest public health issue of the 21^st Century” after discovering that physical inactivity was killing more Americans than smoking, diabetes and obesity combined.² Cardiff Exercise Medicine Symposium hopes to explore the wealth of evidence about physical activity, and inspire us all to be more active and proactive in promoting physical activity both at an individual and policy level.

Symposium Rationale

Physical activity promotion in the UK is limited. This is not unexpected given the reality that healthcare is influenced heavily by the drug, devices and diagnostic trades with the aim of boosting their share price³. Further, the NHS has a strong track record of favoring interventions that involve something to swallow, breathe in and/or a syringe. We need to develop the skills, tools, and collective capacity to not only prescribe exercise as medicine but also move it to the front lines of government healthcare agendas. Of the four key adjustable risk factors to health: alcohol, smoking, food and physical activity – only physical activity seems to lack champions in the higher echelons of government.  We must act now and thrust this physical inactivity plague into the limelight. Physical activity is the polypill that we have been searching for; a moderate level of fitness causes a 44% reduction in mortality ⁴ – how many drugs are that effective?

Physical Inactivity vs Obesity

Everyday the newspapers, TV, and media are full with stories about the obesity crisis whilst we see little press on physical inactivity: yet which is the bigger public health issue – obesity or physical inactivity? Prof. Steven Blair has shown in a number of papers that being fit can alleviate the risks of being fat,^5,6,7,8 and Weiler et al. (2010) argue that health policy should focus on physical inactivity not obesity.⁹

Prof. Blair will be presenting his latest research in the field at the symposium, whilst Prof. Terence Wilkin will be discussing the link between physical activity, genetics and childhood obesity. 

Sedentary behaviour

High levels of sedentary behaviour are damaging to our health, and sitting forms part of our everyday life so it’s an issue which we must address although I’m not in any way saying we should ban sitting; that’s mad! Indeed, sedentary behaviour is now included in the UK physical activity guidelines with the general advice to “minimise the amount of time spent sitting”.

Dr Emmanuel Stamatakis will discuss realigning are public health priorities with sedentary behaviour on the afternoon of Cardiff Exercise Medicine Symposium. 

National exercise guidelines – evidence or opinion?

There is growing confusion over how we should become active, perhaps stoked by programs such as the BBC documentary, “The Truth about Exercise” and Andrew Marr’s recent appearance on the BBC. Whilst providing mixed messages to the public can only serve to negatively impact physical activity levels, we need the debate and research between exercise professionals to continue so we can formulate clear evidence-based guidelines.

At the Symposium, Prof. Jamie Timmons will clear up the confusion by identifying if high intensity interval training has a role to play in the national exercise guidelines. 

Final Thoughts

It’s our responsibility, students and healthcare professionals alike,  to lobby for change, and form a voice to create a compelling fight for the role of physical activity in the health of the nation. Have you ever spoken to anybody who didn’t deem exercise as beneficial for your health? The response is most likely an emphatic “no.” However, do you have the expertise to lead by example and rally for change? Are you up to date with the latest developments in the exercise medicine field? Why not come to Cardiff Exercise Medicine Symposium to learn more about how we can construct effective models of physical activity intervention, the role of sedentary behaviour, the genetics of physical activity, and the interface between obesity and physical activity.

Remember we as emerging and seasoned healthcare practitioners can provide one of the seven “best investments” to combat this public health disaster¹⁰ – Listen to Fiona Bull’s podcast on the “Seven Best Investments”

Cardiff Exercise Medicine Symposium 2013 will be held on the 15^th June at the University Hospital of Wales. For more information on Cardiff Exercise Medicine Symposium & to register CLICK HERE 

References

1 Department of Health (2012). Let’s Get Moving – A Physical Activity Care Pathway. 

2.Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009;43:1–2.

3. Stamatakis E, Weiler E, and Ioannidis JPA. Undue industry influences that distort healthcare research, strategy, expenditure and practice: a review. Eur J Clin Invest 2013. Article first published online: 25 MAR 2013

4.Lee DC, Sui X, Ortega FB, et al. Comparisons of leisure-time physical activity and cardiorespiratory fitness as predictors of all-cause mortality in men and women. Br J Sports Med 2011;45:504–10.

5. Ortega FB, Lee DC, Katzmarzyk PT, Ruiz JR, Sui X, Church TS, Blair SN. The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness. Eur Heart J. 2013 Feb;34(5):389-97.

6. McAuley PA, Artero EG, Sui X, Lee DC, Church TS, Lavie CJ, Myers JN, España-Romero V, Blair SN. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc. 2012 May;87(5):443-51

7. Lee DC, Sui X, Church TS, Lavie CJ, Jackson AS, Blair SN. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol. 2012 Feb 14;59(7):665-72.

8. Lee DC, Park I, Jun TW, Nam BH, Cho SI, Blair SN, Kim YS. Physical activity and body mass index and their associations with the development of type 2 diabetes in korean men. Am J Epidemiol. 2012 Jul 1;176(1):43-51.

9.Weiler R, Stamatakis E, Blair S. Should health policy focus on physical activity rather than obesity? Yes. BMJ 2010;340:c2603.

10. Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD prevention: investments that work for physical activity. Br J Sports Med 2012;46:709–12.

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Bryn Savill BSc (Hons) is a fourth year medical student at Cardiff University, Wales, having undertaken an intercalated BSc in Sports and Exercise Science at Loughborough University. He sits on the undergraduate committee of the European College of Sports and Exercise Physicians (ECOSEP) and is a Move. Eat. Treat. Ambassador.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

It is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). I had that feeling today when, after an article in this morning’s Guardian newspaper, I read two recent papers published by a Danish group of researchers led by Hanne Albert in the European Spine Journal (links below).

Infection and low back pain!?

The papers relate to the possibility of an infective cause in a sub-group of patients with chronic low back pain. This sub-group is those patients with Modic changes. Modic changes (MC) are bone oedema in the adjoining vertebra to one in which there is a disc herniation. MC are present in 46% of patents with chronic low back pain compared to 6% in the general population. MC can only be reliably detected using MR imaging. A number of previous studies have demonstrated the presence of bacteria especially Propionbacterium acnes (P. acnes) in disc nucleus tissue evacuated at surgery from patients with lumbar disc herniation.

The first paper Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? reports on 61 patients who had nuclear disc material removed while undergoing surgery for chronic low back pain. Microbiological cultures were positive in 28 (46%) patients, of which 26/28 were anaerobic cultures, 2 (3%) aerobic and 4 (7%) mixed. In the discs with a nucleus with anaerobic bacteria present, 80% developed MC in the vertebrae adjacent to the previous disc herniation, compared to none in the aerobic group and 44% with negative cultures. They concluded that the occurrence of MCs in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc.

How do intervetebral discs become infected?

Organisms such as P. acnes are commonly found in hair follicles in the skin and in the oral cavity. They frequently invade the circulatory system during tooth brushing where they do not present an immediate risk because the blood stream is an aerobic environment. When an intervertebral disc is herniated, nuclear material extrudes into the spinal canal. Within a short time, neocapillarisation begins in and around the extruded nucleus material, inflammation occurs and brings with it macrophages. So far so good – no debate about any of that.

The innovation of the authors is their proposal that avascular and thus anaerobic disc provides an ideal environment for these anaerobic bacteria to flourish. In this setting, anaerobic bacteria that are normally inconsequential (low virulent) may enter the disc and give rise to a slowly developing infection.

Local inflammation in the adjacent bone (MC Type 1) may be a secondary effect due to cytokine production or microbial metabolites (e.g. propionic acid) entering the vertebrae through normal disc nutrition. P. acnes is known from the skin to trigger an adjacent inflammatory response. P. acnes cannot multiply in the highly vascular aerobic bone and are therefore not present where the MC occur.

All good in theory but what about an RCT?

The second paper is entitled Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy.  this paper reports the efficacy of antibiotic treatment in this group of patients with MC lesions and chronic low back pain. This double blind RCT study examined 162 patients with chronic low back pain (> 6 months duration) occurring after a previous disc herniation AND who had MC changes in the vertebrae adjacent to the previous herniation. Subjects were randomised to either 100 days of antibiotic treatment (Bioclavid) of two different dosages or placebo. Outcomes were evaluated at baseline, end of treatment and at 1 year follow up.

Primary outcomes were the well accepted disease-specific disability Roland Morris Questionnaire as well as the report of lumbar pain. The antibiotic group made highly statistically significant improvements on all outcome measures; the improvement continued from 100 days follow up until 1 year follow up. For example, on the disease specific disability, the antibiotic group was 15 at baseline, 11 at 100 days and 5.7 at 1 year compared to placebo (15, 14, 14). The report of lumbar pain decreased much more in the antibiotic group who started at a score of 6.7 and improved to scores of  5.0 (100 days) and 3.7 (1 year). The placebo group mean report of lumbar pain stayed constant at 6.3 from baseline through 100 days and 1 year (lower is better, of course).

Biologically plausible time course

Patients also reported that pain relief and improvement in disability commenced gradually, for most patients 6-8 weeks after the start of the antibiotic tablets and for some at the end of the treatment period. Improvements reportedly continued long after the end of the treatment period, at least for another 6 months, and some patients reported continuing improvement at 1-year follow up. The improvement seen in the antibiotic group at 1 year follow up was approximately twice that observed at the end of the 100 day treatment period, suggesting that a biological healing process that starts only when and after the bacteria have been killed.

Half the treatment group took one Bioclavid (amoxycillin-clavulanate 500mg/125mg) tablet three times a day while the other half took two tablets. The authors state that the long duration of antibiotic treatment is commonly prescribed for post-operative discitis. There was a trend towards an improvement with double dose, but did not reach significance.

What should we make of these papers?

This treatment is certainly an exciting possibility for one of the most difficult management challenges in medicine.  At this stage all the authors are saying is that in a particular sub-group of patients with chronic (>6 months) low back pain, those with Modic changes on MRI scan after lumbar disc herniation may respond well to long term antibiotic treatment. We are reluctant to prescribe long term antibiotics for reasons of potential development of resistance but there seems to be a rationale for long term use in this situation. Further studies need to assess the efficacy of shorter terms of treatment. Because this is the BJSM blog, we can point out to readers that the group’s pilot study was not accepted by a number of famous journals but saw the light of day via BJSM’s ‘peer-review fair review’ process. That paper came out in 2008.

I would think on the basis of this research it is reasonable to prescribe the recommended antibiotic program to those who strictly meet the clinical and MR imaging criteria. Especially if the only alternative seems to be surgery which has limited efficacy in these patients and is obviously vast more expensive than a course (albeit prolonged) of antibiotic therapy. Remember if you have this infection surgery will not be treating the cause.

It took the Nobel prize winning research  on Heliobacter and its relationship to stomach ulcers of West Australians Barry Marshall and Robin Warren to alert the skeptical medical community of the potential of infective causes of common conditions. Many investigators are currently seeking infective causes for a wide variety of common and uncommon medical disorders. This research will encourage such investigation. Undoubtedly we will find more causal infective relationships. Further work needs to be done to answer a range of questions (which antibiotic, what dose, how  long etc), but these two papers are an exciting step forward in the management of a very difficult condition. If I were a sufferer of chronic low back pain I would be feeling a little more optimistic after the publication of this research.

Dr Peter Brukner (@PeterBrukner), MBBS, FACSP, Sports Physician, Melbourne, Australia, is an experienced team physician and writing in his capacity at BJSM Senior Associate Editor and regular blogger.

Cover of December 2008 BJSM issue that included this group’s pilot study. We congratulate the Albert group of researchers for their persistent pursuit of better outcomes for patients – well done! For their 2008 BJSM paper see this link  http://bjsm.bmj.com/content/42/12/969.full

HEADLINE FOR THE TIME-POOR: Here is the link to the slides for your presentations, but please don’t alter them without the permission of the Consensus Statement authors.

During the 4th International Conference on Concussion in Sport (Zurich 2012) attendees revised and updated the Consensus Statement. The new 2012 Zurich Consensus Statement builds on previously outlined principles and furthers conceptual understandings. Using a formal consensus-based approach, contributors developed this document primarily for use by a spectrum of Sports Medicine (recreational, elite or professional) physicians and healthcare professionals.

Remember that BJSM is the only place to find the 12 systematic reviews that support the consensus statement. We also have 5 podcasts by Co-leads Paul McCory and Winne Meeuwisse on our podcast page.

An informative PowerPoint presentation, and the main outcomes of the 2012 Conference on Concussion in Sport, is now freely available on the BJSM Education website.

The PowerPoint presentation contains:

• An outline of the consensus process
• A description of the definitions used for concussion and traumatic brain injury
• The evaluation of an athlete suspected of suffering a concussion
• The management of a concussed athlete
• The modifying factors that might influence evaluation and management
• Special populations
• Prevention
• And an overview of the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and the Child SCAT3

You are free to use these slides (link here) for your own presentations, but please don’t alter them without the permission of the Consensus Statement authors.

If you wish to insert your own slides to create a customized presentation, please use a different theme, or colour, to distinguish your slides from the ones prepared by the Concussion in Sport Group.

Sincerely,

Babette Pluim, Deputy Editor BJSM

@DocPluim

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series

By Nicki Phillips (@NicolaPhillPT)

As a sports physiotherapist, I’ve worked in some strange places and covered events from High Performance to local charity matches. A recent trip ranks up there as one of the more extreme experiences and as one of the most enjoyable. I also learned a few things along the way.

Richard Parks is an ex-international rugby player who took up mountaineering expeditions after retiring through injury playing days. He asked me to provide physio support on an 11 stage mountain bike race in Nepal.

Richard had just returned from a solo R&D expedition in Antarctica where he was preparing for Project X – a world first, which he is hoping to complete at the end of this year. He had lost 15Kg in body weight after burning 6-8000 calories a day over 36 days on his own on the ice. He was also injured after skiing in a forward lean position whilst pulling an 80Kg polk across snow over difficult terrain, with a prevailing wind driving into his left side for most of those 36 days.

Preparation (and rehabilitation)

With 3 weeks turn around, he was about to embark on a series of challenges leading up to Project X, whilst being filmed for a UK Channel 5 series. The first was the Yak Attack – 400Km of racing with a total altitude gain of 12000m. The race peaked at 5416m and the temperatures ranged from around 35°C to -15°C before wind chill. This was Richard’s first ever mountain bike race and the film crew were going to record how he coped……

A week’s altitude acclimatization allowed us a little more time to continue rehab and recovery, which given the proximity to the event had to be mainly soft tissue work as there was not enough time to transfer the control work we had started into a functional pattern he could use effectively in this sort of event. I think this brings home the importance of timing of interventions- as physios we have a lot of options in our tool box – the difficult thing is using the right ones at the right time.

Ready, set, go! 

The race started out of Kathmandu and the course led towards the Annapurna circuit. The initial few days were very hot, very dry and very dusty. At this stage we were still managing his injury as well as trying out different recovery strategies in preparation for his future expeditions. Temperatures over the first few days were in the 30’s, so recovery had a significant rehydration element.  The film crew was also out in that heat for long periods in the middle of the day as they were covering the race from motorbikes. The combination of necessary protective clothing in the heat as well as the very rough terrain led to inevitable minor injuries, through repeated impact and fatigue. My treatment sessions were extended as more people developed problems. I also ended up treating and/or giving MSK advice to 6 or 7 of the other riders at different points in the race. I’ve yet to tour anywhere and not end up giving advice to some others that wasn’t initially planned.

Most of the days, I was taken from start to finish in a jeep, which was pretty hair-raising on some of the narrow routes with very steep drops. When the trails got too narrow, all support staff had to walk, with porters to carry most of our kit. Over those 3 days I walked approximately 65-70Km and gained 3000m in altitude, reaching the Thorong La Pass at around 5400m. Fortunately, my very thoughtful athlete didn’t expect treatment on those days and in fact looked after me more than I did him, as the cyclists finished hours before we did.

Richard was entering his element as we got into the high altitude sections. Having summited the highest peaks on very continent, 5000m was a walk in the park! Despite being the hardest, those were his favorite days and he was one of the very few people on the race who didn’t use Diamox during the high stages. By the high altitude days temperatures were more in the region of -15°C, with snow up to mid thighs in places. On the pass day there were 3 cases of snow blindness, 1 frostbitten toe and a few cases of frost nip amongst the riders.

There were two UK based race doctors providing volunteer support. Their main caseload was the typical travel sickness symptoms, with no significant altitude issues, which was impressive considering the speed that we gained height over a few days. They also dealt with one collision injury where the rider was hospitalized briefly.

Treatment reflections from the race

There were a few things I learned whilst reflecting on treatment sessions. The needs analysis for returning to maximum performance in his eventual goal was complex, especially as large portions of it are still a secret. The added challenges for the documentary series throughout the year (a 5 day ultra marathon in Peru and a double Iron Man in North wales) created additional time constraints on specific aspects of rehab because of the varied conditioning and movement skills needed in those activities compared to the endurance skiing that will be needed for the final challenge this year. Having returned from Nepal, we are now working on running form and Cardiff Blues Rugby have kindly given us access to their Alter G treadmill to increase volume and intensity of the running whilst controlling muscle tendon unit load.

Physios always have to adapt techniques based on the environment when working in sport – but there were some pretty extreme environments in the middle of the Himalaya. Keeping your patient warm whilst doing a treatment session on a narrow “bed” in a tea lodge with no heating was pretty challenging at times. I also had to be very selective in what equipment I took with me as for the latter part of the race our kit was carried by porters, so weight was of the essence. Deciding on the bare minimum was a challenge as was needing to create a lighter option than my usual physio bag.

We tried out a few different recovery options for future trips and a very useful combination turned out to be Sigvaris® compression socks used with Firefly® disposable muscle stimulation devices. This significantly reduced the amount of recovery massage needed, with lower than expected muscle soreness, which we recorded daily on a VAS scale. We also recorded daily VAS scales on perceived exertion, and perceived performance during the race, sleep quality and energy level before the race. Further analysis of this data alongside the slightly different recovery and treatment options, will give us a fairly comprehensive picture of the best options to look at for Richard to manage this aspect on solo expeditions.

From a treatment perspective, a complication I hadn’t anticipated and perhaps should have, involved needing to treat neck soreness from the camera Richard wore on his crash helmet. Although it was quite small and light, the added lever arm on top of his head when controlling the bike over some very rough terrain took its toll.

I had expected to treat his back because of the initial injury and had prepared by asking a colleague at Cardiff University, Liba Sheeran to help with some alternative techniques to adapt how I could treat Richard more effectively in that environment. We turned that into a small masterclass session with the MSc Sports Physiotherapy group, which I then fed back on my return…… so already this trip has been used to compliment teaching within one of our programmes. That’s what is so good about engagement opportunities like this. They can be very hard work but usually fun, yet can bring some elements of teaching to life.

Another aspect that was relatively novel for me was that the purpose of doing this challenge was to make a TV programme. The filming took a very high priority. This occasionally affected how I operated as a physio/support staff. Typically, following a particularly difficult race stage, as a physio, I would let the athlete offload negative issues but would aim to move on from dwelling on the previous event towards a more positive approach for the next day. From a creative perspective, the film crew naturally wanted the drama of mishaps and the resulting reactions, so kept bringing Richard back to talk about how tired or frustrated he felt. The situation was a minor one but I probably had to work much harder at bringing Richard back to where he would usually be during recovery because the needs of the TV programme content took precedence over performance related issues.

It was physically really challenging at times, especially as I had only had a few weeks notice and I would normally train for a few months before a trek like this but I enjoyed every minute of it. I was with a great bunch of people and got the chance to return to a part of the world that is breathtakingly beautiful. My advice to anyone else is to seize these opportunities when they come your way – you never know where they’ll take you!!

For more on this adventure, read Richard’s Blog HERE.

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Dr Nicola Phillips (@NicolaPhillPT) is a reader at Cardiff University, President of the International Federation of Sports Physiotherapy and Vice President of ACPSEM.

Web: http://www.cardiff.ac.uk/sohcs/contactsandpeople/q-z/phillips-nicki-dr-overview_new.htm

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

 By Drs. Andrew Murray (@docandrewmurray) and David White (@rightwhite1)

Health systems worldwide need to think differently. Fancy new medications and rescue helicopters may help once people become unwell, but the 2010 Global Burden of Disease study highlights that over 70% of disease burden in the UK is caused by Non Communicable Diseases- whose principal root causes include physical inactivity, smoking, and excess alcohol.

Physical Activity

Bulletproof evidence worldwide proves that physical inactivity kills a lot of people and makes a lot of people ill through chronic disease. Time and resources need to be directed towards getting people off the couch, which will increase life expectancy, decrease health inequalities, and save lorry loads of cash for health boards and the UK economy.

23 and a half hours is a video worth sharing whilst the 2012 Lancet series highlighted the problem as “pandemic”.

What works to get people active?

Comprehensive and systematic approaches to address excess alcohol and smoking have had considerable success- smoking rates have declined by over 25% in the last 30 years in Scotland.  The same is required for physical inactivity

 “7 Investments that Work for Physical Activity” show where to get maximum bang for your buck. They are evidence supported and applicable to local and national communities.  The 7 investments have also influenced a National Implementation Plan for Physical Activity in Scotland, as well as guided Local Authorities and Community planners.  In Scotland, action plans are moving forward in each of these “7 investment areas.”

As one example, within Health and Social Care the Scottish Government has outlined plans to:

1)    Embed physical activity for health into undergraduate and postgraduate curriculums, CPD and workforce development.

2)    Embed physical activity for health into primary care, using a simple validated assessment tool, brief advice and brief intervention.

3)    Embed physical activity for health into secondary care using a National Secondary Care Pathway.

4)    Inspire medical leaders to prioritise getting people active, championing this in health boards, royal colleges, hospital or department.

Conclusion

Health boards and governments that bury their heads in the sand and hope that the problem of physical inactivity will go away may be consigning their populations to poor health outcomes, and their children to a dark economic future. Those with an interest in Sports and Exercise Medicine are uniquely placed to help populations “sit less and move more.” Sharing and helping implement “7 investments that work” will increase life expectancy, improve life quality, and save cash for the communities, health boards and governments . There is considerable scope and opportunity to create jobs, and make a difference in this area.

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Dr Andrew Murray (@docandrewmurray) is a registrar in SEM and worked for a year as the Scottish Government’s first Physical Activity Champion.

http://www.youtube.com/watch?v=WKvd-yPFuKM&list=PLsRNoUx8w3rM_7URm7bIQXHvQzSOOVigQ&index=5

 Dr David White (@rightwhite1) is currently employed as the Physical Activity Champion within the Scottish Government, working in the offices of the Chief Medical Officer, and the Minister for Commonwealth Games and Sport.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

By Ann Gates (@exerciseworks)

‘Fun exercise advice, every clinic consult.’ Photo credit: Dean Skiba and David Baird, Inclusive Fitness UK.

Many diseases and long term health conditions respond clinically to exercise medicine. Just like medicines, such as statins, different exercises and physical activities have the ability to transform patient’s lives, control their symptoms and prevent and treat disease successfully. The evidence for the clinical practice of ‘exercise as a medicine’ is supported by the UK Chief Medical Officers, the World Health Organization and many international medical organisations. However, it is ultimately prescribed and supported by the health care team that provides direct patient care.

For this reason, within medicine and health care settings we must encourage the perspective that exercise advice and support are critical aspects of ‘world class, personalised patient care’. Many patients may benefit from exercise advice as part of the management and treatment protocols for their diseases and lifestyles. This includes non-communicable diseases and acute problems, such as surgery.

The list of medical evidence supporting specific exercises and fun physical activities for improving quality of life and physical and mental health on personal, national and international levels includes: type 2 diabetes, cancer, heart disease, stroke, osteoporosis, Parkinson’s disease, hypertension, obesity, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), back pain, anxiety, depression, asthma, peripheral arterial disease, pre and post operative surgery…..

Many health professionals practice medicine because they love patient care and using their skills and knowledge to help patients improve their health. Providing quality exercise advice has a similarly clinically satisfying outcome. Patients can improve their mobility, experience life changing better health and more importantly see their symptoms improve and their risks of serious health problems diminish. This may be demonstrated through improved blood pressure control, better lipid profiles or just simply improved strength and balance that helps reduce falls risk.

A great, inspiring video (see link here) shows how careful motivational support, together with the right exercise advice, at the right time, can transform patient health.

After all, when that patient says:

“Hey Doc, that exercise advice you suggested…….”

“It worked! I can now take my grandchildren to the park, and share in the joy of them growing up…”

“Well, that’s just fantastic!” replied the doctor. “Your blood pressure readings are down, I see you’ve lost weight, and management of your blood pressure is looking good.”

Because patients are worth that ‘brief intervention!”

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Ann Gates BPharm(Hons) MRPharmS

Founder of Exercise Works!

Video kindly provided with permissions via FitBehavior : promoting health through inspiring patient stories! @FitBehavior

In relation to its size, the patellofemoral joint (PFJ) is one of the most described joints of the human body. This may be partly attributed to the high prevalence of patellofemoral pain (PFP) in active people, the controversies concerning the underlying aetiological mechanisms, and the recalcitrant nature of the symptoms. The natural history of this syndrome and the chance for developing patellofemoral osteoarthritis later in life are still enigmatic.

PFP experts plan to tackle this problem head on when they meet for the third annual Patellofemoral Pain Research Retreat and Clinical Symposium, Sept 18-21st, 2013, in Vancouver, British Columbia Canada.

The Patellofemoral Research Retreat (September 18-20) provides researchers and clinicians an opportunity to learn, network, and present.

Keynote speakers will include Professor Irene Davis, a world expert in patellofemoral pain and running bio-mechanics, and Professor Paul Hodges, Director of the NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury, and Health at the University of Queensland in Brisbane, Australia.

Abstracts for presentation at the research retreat will be accepted until April 30.

As in previous years, this gathering will be intimate and intense. It will culminate with the creation of a consensus statement that summarizes the current state of the science and suggests future directions.

Clinicians will also not want to miss the first-ever one-day International Patellofemoral Pain Clinical Symposium (September 21) at the same location. Speakers include renowned experts such as Irene Davis, Paul Hodges, Jenny McConnell, Kay Crossley, Christopher Powers, and Erik Witvrouw. Topics will include innovations in the understanding of PFP, proximal vs distal contributions to PFP, and specific or local exercises for management of PFP.

For more information:

visit www.ipfrr.com or contact Erin Macri at erin.macri@hiphealth.ca