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Major new study on health benefits of swimming released

23 Jun, 17 | by BJSM

SWIM ENGLAND MEDIA RELEASE

  • Swimming is uniquely placed to support people throughout their entire life.
  • Swimming lowers the risk of early death by 28 per cent.
  •  Swimming lessons help children to develop skills quicker.
  • Swimming and aquatic activity is a safe, cost effective and viable option for
    healthcare professionals to signpost patients.
  • Call for more research on the impact of physical activity on mental health and long term conditions.

A new study that evidences the health and wellbeing benefits of swimming has been
released today by Swim England. The report shows that the unique benefits of water make it the perfect place for people of all ages to exercise, particularly those with long term health conditions. The report also found evidence that swimmers live longer and regular swimming helps older people stay mentally and physically fit. Importantly, it also showed that participation in swimming lessons can help children to develop physical, cognitive and social skills quicker than those who do not have lessons.

Swim England commissioned the independent report and will use the findings to raise
awareness within the health profession that swimming is a safe, cost effective and viable option to signpost patients.

The national governing body for swimming in England is also calling on the wider health and sports sector to come together and invest in further research on the impact of physical activity on mental health and long term conditions.

Jane Nickerson, Swim England CEO, said: “It is evident from the report that swimming has enormous potential to support the health and wellbeing of the nation. The unique properties of water means that unlike other activities, no one is restricted from taking part.

“The report particularly highlights the benefits of swimming and aquatic activities for people with mental health concerns or problems with their joints and muscles. This supports findings from our Dementia Friendly Swimming project, but is an area where further research across the health and sports sector is required. “We will use the report findings to continue to develop our Health and Wellbeing Model and our Aquatic Activity for Health qualification. We will also be working closely with the swimming workforce and health practitioners to increase awareness of the benefits of swimming and make it a viable option for signposting patients.”

Mike Farrar, Swim England Group Board Chairman and former CEO of the NHS Confederation, said: “For too long, national guidelines have concentrated on the cardio vascular benefits of exercise undertaken by healthy people, rather than on those who are less fit or have long term health conditions. “To fully understand the links between physical activity and health in the general population, we would need to see more national resources invested into research. This report shows that activities like swimming really do have the potential to be a game-changer in supporting the health of this nation, especially at a time when cuts to services means less money for long-term care.”

The reports remit was developed by the Swimming and Health Commission under the
Chairmanship of Professor Ian Cumming. The Health Education England Chief Executive, said: “The Swimming and Health Commission was established by Swim England to explore the evidence base for the health benefits of swimming. The resulting academic report is a ground-breaking collection of papers that identify striking and robust evidence for the significant improvements in health and quality of life that swimming produces.

“Swim England is the first sport governing body to support such an in-depth investigation of its relationship with health and wellbeing and I would like to applaud them for their foresight and for producing a piece of work that I am sure will become a reference document for many years to come.”

The full Health and Wellbeing Benefits of Swimming report and Swim England’s response can be accessed via: j.mp/HealthCommissionReport

For more information or to arrange an interview, please contact Alison Clowes via
alison.clowes@swimming.org or 07919 548039

The Health and Wellbeing Benefits of Swimming report was commissioned by the Swimming and Health Commission on behalf of Swim England to explore the impact of swimming on physical, mental and social wellbeing. It has been written by a range of eminent academics and is supported by the Chief Medical Officer, Professor Dame Sally Davies.

About Swim England
Formally known as the Amateur Swimming Association, Swim England is the national governing body for swimming in England. It helps people learn how to swim, enjoy the water safely, and compete in all aquatic sports. The vision of Swim England is of a nation swimming and it strives to inspire everyone to enjoy the water in the way that suits them. Each month millions of people are able to enjoy swimming, diving,
water polo and synchronised swimming, having been through the Swim England Learn to Swim Programme. Swim England also supports its members, clubs and athletes, and runs qualification and education programmes to develop the workforce. For more information visit swimming.org/swimengland

Sport pre-participation screening for asymptomatic atlanto-axial instability (AAI) in Down Syndrome (DS) patients

22 Jun, 17 | by BJSM

Faculty of Sport and Exercise Medicine

POSITION STATEMENT

Introduction

Down Syndrome (DS) is a clinical syndrome comprising of typical facial features and various physical and intellectual disabilities due to extra genetic material on chromosome 21, with one in every 1,000 babies born in the UK affected (1). DS patients are at risk of atlanto-axial instability (AAI) although AAI can occur in other conditions, such as rheumatoid arthritis, but this position statement deals specifically with DS patients and asymptomatic AAI.

AAI, also referred to as atlanto-axial subluxation, is defined as increased movement between the 1st (atlas) and 2nd (axial) cervical vertebra joint articulation, the atlantoaxial joint (2). AAI in DS patients is due to a combination of ligament laxity and bony abnormalities of the atlantoaxial joint. AAI is reported to occur in 6.8 – 27% of the DS population (3) (4) although this varies depending on the age of the patients which you are screening. Less than 1-2% (3) (5) of these patients are then thought to later develop symptomatic AAI although the natural history and progression of AAI is not well understood (2).

The risks associated with AAI are neurological injury from excessive movement of the cervical vertebra impinging on and then damaging the spinal cord although the risk of this during sporting activities is extremely rare (2) (6). Clearly physical activity and sports participation for DS patients has many biological, psychological and social benefits (7) and the Faculty of Sport and Exercise Medicine (FSEM), United Kingdom (UK) wish to promote safe physical activity and sport for all. The FSEM, UK has therefore produced a statement regarding sport pre-participation screening for asymptomatic AAI in DS patients.

Plain lateral cervical spine radiography as a screening test for asymptomatic AAI

  • Cremers et al (6) followed up 91 asymptomatic AAI patients for 1 year after screening them with lateral cervical spine radiography, letting them either participate in unrestricted sport or restricting their sporting activities. They found no difference between the groups in terms of motor or neurological function. They concluded that there is no evidence to support plain radiography screening for asymptomatic AAI.
  • There are diagnostic inconsistencies surrounding asymptomatic AAI on plain radiography, with, for example, Morton et al (8) reporting that it occurs at 4mm whilst other authors 3mm (9) (10) and some 4.5mm (5).
  • AAI diagnosis on plain xray can also change as the patient gets older (4): in 1986 Morton et al (8) followed up 90 children aged between 4-19 yo for 5 years after screening them with plain cervical x-ray and overall the AAI prevalence decreased at follow-up.
  • Obtaining plain lateral cervical spine radiography and then the necessary measurements for AAI is technically difficult (6).
  • Symptomatic AAI is rare in DS patients (2).
  • Plain lateral cervical spine radiography (including neutral, flexion and/or extension views) cannot therefore be recommended as a screening test for asymptomatic AAI in sport (10) (6) (8) (2) (4).

Alternative sport pre-participation screening techniques for asymptomatic AAI

  • For sport pre-participation assessment, a focused history and neurological examination of DS patients should be undertaken by an appropriately qualified medical professional or chartered physiotherapist (6) (4), with the preference for the professional to be someone who cares for the patient regularly, on an ongoing basis and is therefore aware of their baseline function (6), e.g. General Practitioner (GP)/Family Physician.
  • Selby et al (10) conclude that both plain x-ray and physical examination are insensitive for screening for AAI in DS patients.
  • For the neurological examination, Morton et al advise (8) checking for gait disturbance, neck movements, tendon reflexes, and plantar responses. This is similar to British Gymnastics, who have developed their own information sheet and undertake their own screening questions, with no radiological screening (11). This is also supported by Down Syndrome Association (12).

The 3 screening questions consist of (11):

  1. Does the person show evidence of progressive Myopathy? Yes/No
  2. Does the person have poor head/neck muscular control? Yes/No
  3. Does the person’s neck flexion allow the chin to rest on their chest? Yes/No

To help with question B, the person’s neck control can be assessed by: laying the person on their back with legs straight and they are then pulled to a sitting position by their hands, with the examiner pulling them from the front (11).

Depending on the results of the neurological examination, assessment of neck control and the 3 screening questions, there will essentially be 2 options for the patient:

  • Unrestricted sports participation;
  • Restricted sports participation.

High-risk sports for DS patients and symptoms of AAI to be aware of

  • Sports considered to put DS patients at higher risk of developing symptomatic AAI include (2):
    • Gymnastics including Trampolining;
    • Diving,
    • Butterfly stroke and diving starts at swimming;
    • Pentathlon;
    • Contact sports such as martial arts, rugby and soccer;
    • High jump.
  • AAI symptoms for patients, family members, health and sport professionals to be aware of include (13) (11) (4):
    • change in gait or use of arms or hands,
    • change in bowel or bladder function,
    • neck pain,
    • stiff neck,
    • head tilt,
    • how the child positions his or her head,
    • change in general function, or weakness.
  • These ‘warning’ symptoms need to be promoted to the general population, patients, family members and health professionals, e.g. through a public health campaign (4), to allow them to act if they identify an issue.
  • Specific signs and symptoms for health professionals to be aware of when they are examining a DS patient at risk of AAI include (2):
    • Easy fatigability;
    • Difficulties in walking;
    • Abnormal gait;
    • Neck pain;
    • Torticollis or head tilt;
    • Incoordination and clumsiness;
    • Sensory deficits;
    • Spasticity;
    • Hyper-reflexia;
    • Clonus;
    • Extensor-plantar reflex;
    • Other upper motor neuron and posterior column signs and symptoms.

Acute management of symptomatic AAI

  • If you suspect symptomatic AAI, the patient’s spine should be immobilized and an urgent, same day cervical spine x-ray and MRI and neurosurgical consult arranged (5).

Promoting safe sport for DS patients

  • To facilitate safe sport for DS patients we need to promote neck conditioning exercises for this cohort of patients, similar to the neck programme promoted in patients with chronic neck discomfort (14), as well as safe sporting practices, e.g. appropriate supervision when undertaking higher risk sports such as trampolining or rugby.

Conclusion

Plain radiography cannot be currently recommended to screen for asymptomatic AAI. DS patients undergoing a sport pre-participation screening should have 3 questions asked as per the British Gymnastics programme and a neurological and neck control assessment undertaken. Neck conditioning exercises should be generally promoted amongst the DS population. Awareness of potential signs and symptoms of symptomatic AAI need to be raised amongst DS patients, family members and professionals caring for this group of patients as well as the need to provide appropriate supervision when DS patients are undertaking certain ‘high-risk’ sports. These measures will then allow DS patients to maximise the biological, social and psychological benefits of physical activity and sport participation.

 

Sources of Funding: No sources of funding were used when compiling this position paper.

Competing interests: Nil declared.

Conflicts of Interest/Disclosures: Nil

Ethical Approval: Not required.

Authors’ contributions: NH led the conception and design of the position paper and prepared the first draft of the manuscript. All authors were involved in critical revisions and reviewing background reading.  All authors critically reviewed the manuscript and approved the final version submitted for publication.  All authors read and approved the final manuscript.

Authors: Dr Christopher Tomlinson1; Dr Alastair Campbell2; Dr Alison Hurley3; Mr Eoin Fenton4; Dr Neil Heron 5, 6, 7, 8.

Email address for correspondence: nheron02@qub.ac.uk

Affiliations: 1 Sport and Exercise Medicine Physician, English Institute of Sport; 2 Radiology Department, Musgrave Park Hospital, Belfast Trust; 3 Radiology department, Dublin; 4 Neurosurgery Department, Blackrock Clinic, Dublin; 5 Dept of General Practice and Primary Care, Queen’s University, Belfast; Centre for Public Health Research, Queen’s University, Belfast; 7 Centre of Excellence for Public Health Research (NI); 8 Elected Council Member of the Faculty of Sport and Exercise Medicine (FSEM), United Kingdom (UK).

Address for correspondence: Dept of General Practice, Queen’s University, Dunluce Health Centre, Level 4, 1 Dunluce Avenue, Belfast, BT9 7HR.

References

(1) Roizen NJ, Patterson D. Down’s syndrome. The Lancet 2003 4/12;361(9365):1281-1289.

(2) Committee on Sports Medicine and Fitness. Atlantoaxial instability in Down syndrome: subject review. American Academy of PediatricsCommittee on Sports Medicine and Fitness.. Paediatrics 1995;96(1, Part 1):151-4.

(3) Nader-Sepahi A, Casey ATH, Hayward R, Crockard HA, Thompson D. Symptomatic atlantoaxial instability in Down syndrome. Journal of Neurosurgery: Pediatrics 2005 09/01; 2017/03;103(3):231-237.

(4) Myśliwiec A, Posłuszny A, Saulicz E, Doroniewicz I, Linek P, Wolny T, et al. Atlanto-Axial Instability in People with Down’s Syndrome and its Impact on the Ability to Perform Sports Activities – A Review.. Journal of Human Kinetics 2015;12(48):17-24.

(5) Cohen W. Current dilemmas in Down syndrome clinical care: celiac disease, thyroid disorders, and atlanto-axialinstability.. American Journal of Medical Genetics 2006;142C(3):141-8.

(6) Cremers MJG, Bol E, de Roos F, van Gijn J. Risk of sports activities in children with Down’s syndrome and atlantoaxial instability. The Lancet 1993 8/28;342(8870):511-514.

(7) Andriolo R, El Dib R, Ramos L, Atallah A, da Silva E. Aerobic exercise training programmes for improving physical and psychosocial health in adults with Down syndrome.. Cochrane Database of Systematic Reviews. 2010;12(5):CD005176.

(8) Morton R, Khan M, Murray-Leslie C, Elliott S. Atlantoaxial instability in Down’s syndrome: a five year follow up study.. Archives of Disease in Childhood 1995;72(2):115-8.

(9) Roy M, Baxter M, Roy A. Atlantoaxial instability in Down syndrome–guidelines for screening and detection.. Journal of the Royal Society of Medicine 1990;83(7):433-5.

(10) Selby K, Newton R, Gupta S, Hunt L. Clinical predictors and radiological reliability in atlantoaxial subluxation in Down’s syndrome. Archives of Disease in Childhood 1991;66(7):876-8.

(11) British Gymnastics. Atlanto-axial instability information pack. British Gymnastics 2012;1(1):1.

(12) Charleton P, Dennis J.
Neck Instability (Craniovertebral Instability)
A GUIDE FOR PARENTS AND CARERS. Down Syndrome Association Health Series 2013;1(1):1.

(13) Bull MJ, Committee on Genetics. Health supervision for children with Down syndrome.. Paediatrics 2011;128(2):393-406

Should we be screening for gambling addiction in our athletes?

20 Jun, 17 | by BJSM

By Sean Carmody @seancarmody1

“On every advert you have a bet here and there. You cannot be surprised if people bet. You incite people to bet.” – Arsene Wenger

In March, the sports medicine community traveled to Monaco for their three-yearly pilgrimage.

And the hot topic? Screening in Sport.

Much of the conference debate centred on whether we could screen for (and ultimately, predict) injury in athletes. Largely thanks to Roald Bahr’s keynote (and influential paper here), there was loose consensus that it was not presently possible to accurately screen for future injury, but the screening process was still useful to detect current injury and build rapport with athletes.

Just over a month after the conference closed, the relationship between gambling and professional sport was thrust into the spotlight with the news that Joey Barton had received an 18-month ban for breaking the Football Association’s rules on gambling. Predictably, Barton came out fighting against the ban with a statement which included the following;

“Surely they need to accept there is a huge clash between their rules and the culture that surrounds the modern game, where anyone who watches or follows football on TV or in the stadia is bombarded by marketing, advertising and sponsorship by betting companies, and where much of the coverage now… is intertwined with the broadcasters’ own gambling interests… If the FA is serious about tackling gambling I would urge it to reconsider its own dependence on the gambling industry.”

While it doesn’t detract from his offence, Barton has a point. The temptation to gamble is ubiquitous, and few sports are spared from the bombardment. Rugby League, once heralded for their principled rejection of sponsorship money from gambling companies, is now host to competitions such as the BetFred Superleague and the Ladbrokes Challenge Cup. As the late narco-terrorist Pablo Escobar noted; “Everyone has a price, the important thing is to find out what it is”. In this sporting climate, it comes as no surprise that there is a long list of athletes who have succumbed to gambling addiction.

The research on athletes and gambling is relatively limited. However, Michael Calvin (who incidentally co-wrote Joey Barton’s autobiography) sheds further light on the scale of the issue in his excellent new book “No Hunger in Paradise: The Players. The Journey. The Dream”. In interviews with important figures who are combatting the problem, he ascertains that young footballers – specifically targeted due to their premature wealth – are the subject of predatory marketing material by gambling companies. This is concerning considering research which has found that rates of problem gambling are typically highest between the ages of 18 and 24. Calvin also reports that 70% of presentations to the Sporting Chance Clinic relate to gambling addiction. These findings, coupled with the high proportion of athletes who declare bankruptcy soon after retirement (according to a 2009 Sports Illustrated article 78% of NFL players are broke within 2 years of hanging up their cleats), suggests a bleak outlook for the relationship between gambling companies and professional sport.

With this in mind, should we screen our athletes for gambling addiction?

A relatively recent survey carried out in almost 350 footballers and cricketers, found that 6% met the criteria to be classed as ‘problem gamblers’ – more than three times the rate when compared with men in the general population. When you make the rough comparison between that finding and the classical epidemiological studies in football – gambling addiction is nearly as common as quadriceps strains (7%) and much more common than head injuries (2%) (Ekstrand et al., 2011). Perhaps the finding that will make key stakeholders (eg coaches, CEOs) take notice, is the additional evidence that the performance of some players is affected by worries related to their gambling habits, which often take place on the team coach or in hotels, and is (ab)used to soothe their boredom.

In summary, Joey Barton is not the first athlete, and surely won’t be the last, to become a victim of the professional sporting environment which tempts the impulsive to gamble. Further we need more research to better understand the factors which predispose athletes to gambling addiction, and sport-specific screening tools may be required. Moreover, due to its potential to affect performance and result in serious mental health issues, gambling addiction must be considered alongside commonly assessed issues in athletes such as musculoskeletal injury and cardiac screening.

Key Resources:

DSM-5 Diagnostic Criteria for Gambling Disorder.

Sporting Chance Clinic for the treatment of behavioural problems among professional and amateur sports people.

Sean Carmody is a Junior Doctor working in London. He tweets regularly on topics related to sports medicine and performance (@seancarmody1).

Are we destroying junior talent? 25% reinjury rate among children who have ACL reconstructions!

16 Jun, 17 | by BJSM

By Lars Engebretsen

The number of ACL injuries in children is rising.  Many of us see this daily in our clinics, however, each one of us have just a few–perhaps 10-20 a year.  These are active children. In my country, Norway, the majority of these children are injured while skiing. On other continents, other sports dominate. What we have in common that these are often the best child athletes and the most daring ones.

Across the globe, many of these children do not see an orthopaedic surgeon and the injury goes undetected. However, in the developed world, many are referred to orthopaedics and they often undergo surgery. More than 50 different procedures have been published for this setting.  All publications have only short-term followup; there are none with follow up > 10 years.

At the June 2017 International Society for Arthroscopy, Knee Surgery and Orthopaedic  Sports Medicine (ISAKOS) meeting in Shanghai, an expert group agreed that the paediatric ACL reinjury rate after the various surgical procedures was about 25%.  What does this mean?  In short, we do not know what happens to children who rupture their ACL. Do they grow up like their friends, doing sports or prioritizing education and going on with their life? Or does the injury and treatment change their lives?

This blog is to challenge clinician and researcher readers to initiate studies on not only the short-term technical aspects of the treatment of the ACL injury. We already have data on meniscal and cartilage injury as well as additional ligament tears. Although disagreements between groups exist, it appears there are as many meniscal tears in children who have surgical reconstruction as there are in children who choose nonoperative treatment of the injury.  Growth disturbances occur after surgical treatment, but these are rare.  The irony is that we seem to have good technical capability to deal with these challenges, but the injury still seems to have a major impact of the child. Very few, if any of the children become high level athletes in pivoting sports. We lack information on their quality of life and premature OA development when they turn 25.

These issues can only be solved by long-term follow up in multicenter collaborations across universities and nations. This needs a long-term commitment by those of us who have the children’s interests close at heart.  In October 2017, the international Olympic Committee will host an expert group from all parts of the world with leaders from AOSSM, ESSKA, ISAKOS, SLARD and expert PTs who also specialize in treating and researching these patients. The group will prepare ahead of time and spend three days drilling into the literature and discussing the clinical issues. The meeting will result in an international consensus statement that should set the stage for future research.  What I learned at ISAKOS was that the high number of reinjuires mean we need to improve our game!

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

Professor Lars Engebretsen has published over 400 articles and book chapters, with a citation index (H-index) of 56. He is among the world’s most productive researchers. He uses clinical, epidemiological and basic science methods to address questions in the areas of general sports medicine, knee ligaments, cartilage as well as the prevention of sports injuries and illnesses.

He was inducted into the AOSSM Hall of Fame in July 2015 and became an ESSKA Honorary member in 2016 and an ISAKOS Honorary member in June 2017 . He received the Nordic Prize in Medicine in 2016.

A (resource packed!) overview of Sports and Exercise Medicine (SEM) intercalated degree courses

14 Jun, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog series

By James Murphy

This blog follows up my previous post where I broadly discussed intercalation FAQs (READ IT HERE). Here, I intend to give medical students interested in intercalating in SEM an overview of their different options. I provide, to the best of my ability, a comprehensive list and basic description of the SEM and closely related courses offered in the UK. The information is from course web pages and from my own contact with course directors. My own observations on the courses are shown in bold italics.

Sports and Exercise Medicine courses

Sports and Exercise Medicine MSc, Nottingham University

All students on the MSc course complete compulsory modules as well as a research project.

The compulsory modules include anatomy and the assessment of sports injury. The ‘Pitch side Care of the Injured Athlete’ compulsory module is a great opportunity for students to get hands on experience in pitch side care. As part of this module students study and attend an “advanced emergency care course”(1) and also provide first aid cover at some University sports pitches. The other compulsory modules are: ‘Physical Activity in Health and Disease’ and ‘Research Methods’. The optional modules are listed on the course page.

https://www.nottingham.ac.uk/pgstudy/courses/medicine/medical-sciences/sports-and-exercise-medicine-msc.aspx

Despite the stated entry requirements, the course directors are open to applications from intercalating students.

BSc Sports and Exercise Medicine, Queen Mary, University of London

On this course students complete 120 credits, organised in to six modules. The modules are: ‘Research Methods’, ‘Injuries and medical problems in sport’, ‘Literature reviewing’, ‘Research project’, ‘Biomechanics and rehabilitation’ and ‘Exercise as a Health tool’. The breakdown of the modules is on the below website.

http://www.smd.qmul.ac.uk/undergraduate/courses/intercalated/sem/index.html

The taught research methods and literature reviewing modules prepare students to carry out research and critically appraise papers. Relating research skills to sports and exercise medicine literature allows students to appreciate the importance and application of the skills. As part of the degree students undertake a systematic review and a full research project, many students work towards, and succeed in having their work published.

BSc (Med Sci) Clinical Medicine, Glasgow University

Students can apply to undertake the Sport and Exercise Medicine subject and research project within this Clinical Medicine Degree. The degree is split into four different areas:  the ‘Core Course’ (which aims to provide students with “transferable research skills”(3)), the ‘Specialist subject’, ‘Medical Statistics’, and a ‘Research project’. For their specialist subject students can apply to take the SEM course. The SEM course aims to cover “exercise in health promotion, disease prevention and treatment of disease states”.(3)

Students undertake three modules: ’Clinical Sports Injuries’, ‘Sports Medicine in Practice’ and ‘Exercise in Clinical Populations’.

University of Glasgow B.Sc. (Med. Sci.) Clinical Medicine Sport and Exercise Medicine – Course information

http://www.gla.ac.uk/schools/medicine/undergraduate/intercalateddegrees/clinicalmedicine/

Sports and Exercise Science courses

Sports and Exercise Science (intercalated), Loughborough University

Students taking the Intercalated degree study alongside the final year Sport and Exercise Science BSc students. Intercalated students take 120 credits worth of modules from a great variety of options (the list can be found on the website below). Alongside their modules students complete a research project and have the opportunity to observe sports medicine practitioners in NHS clinics in Leicester.

http://www.lboro.ac.uk/departments/ssehs/undergraduate/courses/ses-intercalated/

In my opinion the list of modules offered on the Loughborough course is the most varied amongst all the SEM or SEM-related courses in the UK. With no compulsory modules this course provides students complete control over what modules make up their degree.

BSc in Medical Sciences (Sports Health and Exercise Science), University of Hull.

This degree offers students the “opportunity to engage with the theories and methods related to the bio-scientific study of sport and exercise, including sports injury.”(7) Students choose 120 credits, 40 of which are the dissertation module. Students choose at least two of ‘Human Locomotive Systems’, ‘Ageing, Obesity and Health’, ‘Fitness and Injury Prevention’. Furthermore students choose another two from ‘Environmental Physiology’, ‘Performance Enhancement and Injury Prevention’, ‘Psychology in Sport Rehabilitation’, ‘Sport and Exercise Nutrition’, ‘Exercise Physiology’.

The general areas students can undertake their research project in are: psychology, exercise physiology, biomechanics and sport rehabilitation.

http://www.hyms.ac.uk/undergraduate/intercalated-degrees/intercalation

University of Hull, Sports Health and Exercise Science 2016 programme description

Sport and Exercise Science (intercalated) BSc (Hons), Cardiff Metropolitan University

Here intercalating students study ‘Biomechanics of Sport and Exercise’ and “an independent project in one or more of Biomechanics, Physiology or Psychology”(8) and then choose three optional modules.

The optional Modules are: ‘Exercise Physiology for Sport Performance’, ‘Exercise Physiology for Health’, ‘Sport Psychology’, ‘Exercise Psychology’.

http://www.cardiffmet.ac.uk/schoolofsport/courses/Pages/Sport-and-Exercise-Science-(Intercalated)-BSc-(Hons).aspx

BSc in Sport and Exercise Science, Brighton and Sussex Medical School

Intercalating students join the final year of the BSc Sport and Exercise Science course at the University of Brighton. However, students are also given the chance to attend second year lectures and laboratory sessions if they wish. On the course students develop research method skills and complete a dissertation. Final and second year modules can be found in the “Course in detail”(9) section on the below webpage.

https://www.brighton.ac.uk/courses/study/sport-and-exercise-science-bsc-hons.aspx

Students hoping to gain hands on experience are able to complete a placement at a sports medicine practice on campus (numbers permitting).

BMedSci Sports Science Medicine, University of Edinburgh

This course combines SEM with the sports performance and exercise sciences (biomechanics, physiology, psychology and skill acquisition). Students can gain an “understanding of sports injuries and the health, performance and rehabilitation role that exercise can play in active sports people, specific patient groups and the wider population”.(11) The connection with the university’s SEM centre allows students to shadow members of the multidisciplinary SEM clinics. Students also acquire transferable skills such as literature appraisal, and how to plan and execute a research project.

https://media.ed.ac.uk/media/Intercalated+Honours+in+Sports+Science+Medicine/1_8iujw34v/42261371

http://www.ed.ac.uk/medicine-vet-medicine/undergraduate/medicine/mbchb/intercalated-honours

B.Sc. Sport Science in Relation to Medicine, University of Leeds

This flyer explained that on the course students have the chance to develop “research, analytical and critical evaluation skills,” and learn about “the major sport science disciplines – biomechanics, exercise physiology, psychology and motor control.”(12) The course also provides students the chance to study “the links between exercise and health from a scientific perspective”.

As part of the course students undertake a research project and compulsory modules in ‘Interdisciplinary issues in Sport and Exercise Sciences’, ‘Advanced Exercise Physiology’ and ‘Sports Medicine, Health and Nutrition’. Students also complete 40 credits of optional modules.

Information was obtained from B.Sc. Sport Science in Relation to Medicine course flyer, kindly sent to me by Stuart Egginton, Professor of Exercise Science at the University of Leeds.

List of References

  1. https://www.nottingham.ac.uk/pgstudy/courses/medicine/medical-sciences/sports-and-exercise-medicine-msc.aspx
  2. http://www.smd.qmul.ac.uk/undergraduate/courses/intercalated/sem/index.html
  3. http://www.gla.ac.uk/schools/medicine/undergraduate/intercalateddegrees/clinicalmedicine/
  4. University of Glasgow B.Sc. (Med. Sci.) Clinical Medicine Sport and Exercise Medicine – Course information
  5. http://www.lboro.ac.uk/departments/ssehs/undergraduate/courses/ses-intercalated/
  6. http://www.hyms.ac.uk/undergraduate/intercalated-degrees/intercalation
  7. University of Hull, Sports Health and Exercise Science 2016 programme description
  8. http://www.cardiffmet.ac.uk/schoolofsport/courses/Pages/Sport-and-Exercise-Science-(Intercalated)-BSc-(Hons).aspx
  9. https://www.brighton.ac.uk/courses/study/sport-and-exercise-science-bsc-hons.aspx
  10. http://www.ed.ac.uk/medicine-vet-medicine/undergraduate/medicine/mbchb/intercalated-honours
  11. https://media.ed.ac.uk/media/Intercalated+Honours+in+Sports+Science+Medicine/1_8iujw34v/42261371
  12. Sc. Sport Science in Relation to Medicine course flyer.

Other Resources

USEMS website

http://www.thestudentroom.co.uk/wiki/A_Brief_Guide_to_Intercalated_Degrees

Acknowledgements

Much of the information in this article is taken from course webpages and handbooks with the permission of the Universities. My thanks go to the course directors and leaders who gave me permission to include the courses in this article. Their help and support was much appreciated.

About the author:

James Murphy has completed four years of medicine at Newcastle University and is currently intercalating on the MSc Sports and Exercise Medicine course at the University of Nottingham.

Manroy Sahni (@manroysahni) co-coordinates the BJSM Undergraduate Perspective blog series. Please send your blog feedback and ideas to: manroysahni@gmail.com

Introducing the winners of the 2016 BJSM cover competition

11 Jun, 17 | by BJSM

A HUGE thank-you to everyone who voted for their favourite cover. We had the biggest voter turnout ever! So we awarded three book prizes rather than two. Meet this year’s winners:

From a young age, Lise-Ann O’neill, a chartered physiotherapist, was interested in Sports Medicine. She explains,

“My father was a footballer and I spent a lot of time watching his matches while growing up. I was always fascinated by the person running onto the pitch when a player was injured and what exactly they were doing. My interest in sports medicine really started there. When I later studied physiotherapy, I realised that I found musculoskeletal injuries to be most interesting area to study. When I qualified, it then made sense to combine the two and work both pitch side and in private practice.”

Lise-Ann has worked extensively in soccer at national and international level in Ireland. She is currently working in private practice in Dublin and continues to work in underage international soccer.

She is an avid @BJSM_BMJ  Twitter follower (to keep up with the latest football injury research), and regularly listens to BJSM podcasts while running.

When asked about the most pressing issue in Sports Medicine today, she said:

“I think the biggest issue facing us is early sport specialisation and overtraining in young athletes. We are seeing athletes specialising in a single sport at a much younger age and training at a much higher intensity than in previous decades. Subsequently, there are growing numbers of young people attending physiotherapy for injuries related to overtraining. It is possible that some of these injuries could lead to problems in later life or shorten an athlete’s career. Equally, it is possible that some of these injuries could be prevented with appropriate advice on training load or using injury prevention programs such as the F11+. As clinicians, we need to be able to offer the best, evidence based advice and care to our young athletes so that they can continue to compete without suffering avoidable injuries.”

David Poulter has practiced physiotherapy in the Twin Cities area of Minnesota for the last 22 years. Before that he bounced around the globe, with undergraduate training in Physiotherapy in the UK and post graduate training in Australia and New Zealand. David is a longstanding and avid participant in endurance sport, starting as a swimmer and cyclist and naturally transitioning to triathlon. Being an endurance athlete helps him better understand his patients.

David is passionate about managing and treating athletes at high school, college and elite levels. He views one of the biggest challenges in Sports Medicine as promoting the evidence on active injury management and minimizing the passive management via medication and modalities.

Breanne Kunstler is a PhD Scholar at the Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia (read her recent publication here). Her PhD work is in identifying the methods physiotherapists use to help adults become physically active. She aims to help move successful evidence-based physical activity interventions into practice. Specifically, through helping physiotherapists in ‘real world’ settings increase the physical activity levels of their patients. Breanne views Sports Medicine clinicians as having a critical role in supporting people of all capabilities, all around the globe to become more active.

When asked about her favourite BJSM blog she said:

“ Train for life: exercise is medicine, because of the fantastic contrast between exercising for performance and exercising to live. Not enough of us embrace the notion that exercise is important for everyone to live a healthy life and maintain independence. You don’t have to be training for the Olympics to do exercise!

I also really appreciate how this entry (as well as others on the blog) was written for a lay audience, making it understandable to more than just clinicians (patients/community members too!). The BJSM is putting in the effort to support research dissemination in more ways than just publishing journal articles.”

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I think it’s safe to say that their new copies of Brukner and Khan’s Clinical Sports Medicine, 5th Edition, and Grieve’s Modern Musculoskeletal Physiotherapy will be put to good use!

Highlights from the 2017 future of football medicine conference

7 Jun, 17 | by BJSM

By Dr Chris Garnett

On 13-15th May 2017, the largest annual football medicine event in the world took place at the iconic Camp Nou in Barcelona.  ‘The Future of Football Medicine’ Conference, organised by the Isokinetic Medical Group in association with FIFA, brought together 2,500 delegates and 197 of the world’s most renowned speakers from 90 different countries. Over the 3 days, researchers, clinicians and sports scientists delivered talks and workshops on the latest sports medicine research, injury prevention, rehabilitation, and optimisation of player and team performance.

A top journalist meets an International Football Manager: Roy Hodgson

The footballer’s groin pain was a topic covered particularly well with expert guidance provided by Dr Per Holmich, Dr Ulrike Muschaweck and Andreas Serner. Groin pain is a common injury in football and can be challenging for clinicians to manage. In 2015 the ‘Doha agreement meeting on terminology and definitions in groin pain in athletes’ defined four clinical entities – adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain.1 Acute adductor injuries account for approximately two thirds of acute groin injuries in football and primarily involve the adductor longus muscle.2 The hip flexors, in particular the rectus femoris and iliopsoas, are the second most frequent. A similar pattern is seen in chronic groin injuries with adductor-related being the most common, followed by iliopsoas-related and inguinal-related injuries. Typically in sport, groin injuries occur during a change of direction, however, in football, kicking is the most commonly reported injury mechanism.2 For both adductor-related and iliopsoas-related groin injuries a conservative approach with an exercise treatment programme is usually effective.

Inguinal-related groin pain, previously termed sportsman’s groin or hernia, is a weakness of the posterior wall of the inguinal canal usually caused by overuse rather than a specific traumatic event. This leads to a localised protrusion of the posterior wall which compresses the genital branch of the genito-femoral nerve and can also displace the rectus abdominis muscle causing increase tension at the pubic bone.  Clinically, athletes complain of pain that is exacerbated with physical activity which can radiate to the inner upper thigh or scrotum. The pain is reported as sharp or sometimes burning in character which is a typical sign for nerve compression and disappears with rest. Dr Muschaweck recommends an initial conservative approach for managing inguinal-related groin pain focussing on rest, physiotherapy (massage, muscle strengthening and core stability training) and medication. This treatment approach should not exceed 8 weeks due to potential nerve damage. If conservative treatment fails, surgical reinforcement of the posterior wall of the inguinal canal should be performed. This can be achieved by a minimal repair technique, which is an open mesh-free technique that also allows exploration of the pain-causing nerve and replacement of the rectus abdominis muscle. Mesh implantation is not recommended due to the risk of an extensive foreign body reaction with local scar formation. The Minimal Repair technique has been shown to be an effective and safe way to treat inguinal-related groin pain and according to Dr Muschaweck can return athletes to full activity in 14 days.3

Further learning points from the conference

Hamstring injuries – Are exercises the best medicine? Askling

 

  • Indications for acute surgery in MCL injury – bony avulsion, intra-articular prolapse, knee dislocation and possibly combined cruciate/MCL injury and in an elite sportsperson – Professor Fares Haddad
  • Hamstring injuries that involve the intramuscular tendon result in a prolonged RTP and higher risk of re-injury – Dr Peter Brukner
  • Wait on average 7-10 days post-injury before ACL reconstruction to enable the knee to extend fully and bend freely – Mr Andy Williams
  • 80% of discogenic low back pain will resolve with conservative management within 8-10 weeks – Mr Damian Fahy
  • Avoid the use of ice and long-term NSAID use in Achilles tendinopathy as they may reduce muscle and tendon adaptation – Seth O’Neill
  • There is no evidence for the use of PRP in muscle injuries – Dr Gustaaf Reurink
  • Pubic bone oedema reflects load and not injury – Dr Per Holmich

Follow the link below for a highlights video of the conference

http://www.footballmedicinestrategies.com/en/

References

  1. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. B J Sports Med 2015; 49: 768-774
  2. Serner A, Tol JL, Jomaah N, Weir A, Whiteley , Thorborg K, Robinson M, Holmich P. Diangosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med 2015; 43(8) 1857-1864
  3. Muschaweck U, Berger L. Minimal repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia; 14(1) 27-33

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Dr Chris Garnett is a Sport & Exercise Medicine registrar (ST5) based in Yorkshire. He currently works at the National Centre for Sport and Exercise Medicine in Sheffield and provides medical support for the GB boxing squad at the English Institute of Sport and Huddersfield Giants Rugby League Club.

Dr Farrah Jawad is a Sport & Exercise Medicine registrar in London and coordinates the BJSM Trainee Perspective blog.

Mountain sports: what should a sports doctor check before authorizing patients to go at high altitudes?

3 Jun, 17 | by BJSM

Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series

By David Eidenbenz,

with the contribution of Dr. Sandra Leal

Mountain sports such as hiking, trail running, or ski touring are becoming increasingly popular. Trail access is improving, allowing people to go to higher altitudes. For both moderate and sustained efforts, caution is necessary before venturing to high altitudes, especially for people with pre-existing chronic diseases.

Since not every country has a mountain medicine specialist, sport physicians may be increasingly confronted with questions such as: “May I go skiing at 3700m despite my history of heart attack?” In this blog, we review:

  1. The potential altitude-related problems of patients planning high altitude activities and;
  2. How to lead a careful assessment of the pre-existing diseases in a sports medicine setting.

Physiological changes

High altitude is defined as an altitude over 2500m, but physiological changes occurs from 1500m (1). The inspired partial oxygen pressure decreases exponentially with the increase in altitude and the decrease in arterial oxygen partial pressure reduce the oxygen supply for the tissues (2). A sympathetic activation with consequent higher energy needs, tachycardia, hyperventilation, pulmonary arteries vasoconstriction, cerebral arteries vasodilation and fluid retention are some of the physiological responses.

Common altitude related diseases

The main illnesses related to altitude are acute mountain sickness (AMS), high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE) (3) (4).

The occurrence of AMS depends on the speed of ascent: a fast ascent increases the risk of suffering from AMS. This concerns people who are for example visiting the Machu Picchu, Peru (2430m), skiers taking the cable car to the Klein Matterhorn, Switzerland (3883m) or trekkers to the Everest Base Camp flying from Kathmandu to Lukla, Nepal (2860m). Situations involving a quick ascent may not allow a proper acclimatization. Hypothermia, dehydration and exhaustion are also components of altitude exposition with increased risk for frostbites.

How to prevent altitude related diseases?

Key components of pre-travel consultation include travel itinerary review with altitude reached each day, number of nights spent at high altitude (>3000m), rest days, medical support, medical history, medications and immunizations (5). Optimal acclimatization is a key point in altitude travels, allowing a physiological adaptation to altitude. If no universal rules about acclimatization exist, it is generally recommended, once the altitude of 2500-3000m is reached, not to go beyond 300-600m of difference of level between two nights of sleep, and to take a rest day every 3rd-4th day (3). Finally, the effort should be moderate, hydration enhanced, and ingestion of carbohydrate-rich food, promoted.

Who is at increased risk?

Despite adequate acclimatization, some people will not tolerate altitude exposure. It is currently not possible to predict who will suffer from altitude sickness or not. It depends on genetic and acquired dispositions (5,6). The acclimatization and standards precautions allow to reduce the risk of experiencing high altitude illnesses, except for people with severe altitude intolerance (7).

Regarding patients suffering from pre-existing chronic diseases, the Figure 1 proposes a non-exhaustive list of important comorbidities needing a particular look before departure. General recommendations for people with comorbidities are listed in Table 1.

Investigations

First of all, the functional capacity at sea level should be good.

  • Routine laboratory tests and electrocardiogram are part of the normal check-up before traveling in high altitude.
  • For people ≥ 50 years old and/or with history of cardiovascular events, it is recommended to add an ergometry and an echocardiography.
  • The hypoxia altitude simulation test is available in some specialized centres: by asking the patient to breathe a mixture of gases (oxygen and nitrogen) with an oxygen saturation of 10.5 %, the test simulates the conditions encountered at the Mont Blanc altitude (4800 m).
  • Patients with an oxygen saturation ≤ 92% at rest, and those with COPD and chronic hypercapnia under oxygen-therapy, should undertake a hypoxia altitude simulation test.
  • Other specific tests should be evaluated according to the pre-existing diseases.

To answer our introducing question: a patient with history of heart attack with preserved LVF and a good physical condition is first allowed to go skiing up to 2500m. As myocardial oxygenation is sufficient after 3-4 days acclimatization, he will then be able to go at an altitude of 3700m.

In conclusion

  • Go slow and acclimatize
  • Have your disease under optimal control
  • Evaluate your oxygen needs
  • Pursue your usual medication and prepare an emergency set
  • Be able to recognize and treat eventual altitude illnesses

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David Eidenbenz is a second year internal medicine resident based in Biel, Switzerland, and previously worked in an emergency medical service. He recently completed the “International Diploma in Mountain Medicine”. Email: daveiden7@gmail.com

 Dr. S. Leal, SEM is a specialist and Master in Mountain Medicine

If you would like to contribute to the “Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercice Medicine” Blog Series please email justin.carrard@gmail.com for further information.

 

References

  1. Imray C, Booth A, Wright A, Bradwell A. Acute altitude illnesses. BMJ. 15 août 2011;343:d4943.
  2. Dehnert C, Bärtsch P. Can Patients with Coronary Heart Disease Go to High Altitude? High Alt Med Biol. 1 oct 2010;11(3):183‑8.
  3. Hackett PH, Roach RC. High-Altitude Illness. N Engl J Med. 12 juill 2001;345(2):107‑14.
  4. Schoene RB. Illnesses at high altitude. Chest. août 2008;134(2):402‑16.
  5. Sanford C, McConnell A, Osborn J. The Pretravel Consultation. Am Fam Physician. 15 oct 2016;94(8):620‑7.
  6. MacInnis MJ, Lohse KR, Strong JK, Koehle MS. Is previous history a reliable predictor for acute mountain sickness susceptibility? A meta-analysis of diagnostic accuracy. Br J Sports Med. janv 2015;49(2):69‑75.
  7. Richalet J-P, Lhuissier F-J, Larmignat P, Canouï-Poitrine F. Évaluation de la tolérance à l’hypoxie et susceptibilité aux pathologies de haute altitude. /data/revues/07651597/v30i6/S0765159715001847/ [Internet]. 22 nov 2015 [cité 26 févr 2017]; Disponible sur: http://www.em-consulte.com/en/article/1016514
  8. Seys SF, Daenen M, Dilissen E, Van Thienen R, Bullens DMA, Hespel P, et al. Effects of high altitude and cold air exposure on airway inflammation in patients with asthma. Thorax. oct 2013;68(10):906‑13.
  9. Luks AM, Swenson ER. Travel to high altitude with pre-existing lung disease. Eur Respir J. avr 2007;29(4):770‑92.
  10. Levine BD. Going High with Heart Disease: The Effect of High Altitude Exposure in Older Individuals and Patients with Coronary Artery Disease. High Alt Med Biol. juin 2015;16(2):89‑96.
  11. DeLoughery TG. Anticoagulation Considerations for Travel to High Altitude. High Alt Med Biol. 17 juill 2015;16(3):181‑5.
  12. Latshang TD, Bloch KE. How to treat patients with obstructive sleep apnea syndrome during an altitude sojourn. High Alt Med Biol. 2011;12(4):303‑7.
  13. Dillard TA, Berg BW, Rajagopal KR, Dooley JW, Mehm WJ. Hypoxemia during air travel in patients with chronic obstructive pulmonary disease. Ann Intern Med. 1 sept 1989;111(5):362‑7.

Conference Alert!!! South African Sports Medicine Association Congress 2017 “Integrate. Accelerate. Elevate.”

31 May, 17 | by BJSM

Dr. Patho Zondi (SASMA President)

Siyakwamukela!

(isiZulu: We welcome you!)

The Organising Committee is pleased to invite you to the 17th Biennial Congress of the South African Sports Medicine Association (SASMA) – “Integrate – Accelerate – Elevate”. The title for 2017 emphasizes the importance of integration across various platforms in order to accelerate rehabilitation, and elevate performance. The topic of integration has never been more relevant in sport, particularly interdisciplinary integration, cultural integration and integration with technology. A thoughtfully crafted programme will thread together themed academic content, skills workshops, and panel discussions to inspire and empower clinicians, academics, learners and leaders. SASMA is a multi-disciplinary organization with the Congress targeting all professionals, health care providers and post-graduate students interested in sports medicine and exercise science. For full congress details visit: www.sasma2017.co.za

Purpose of the Congress

The SASMA Congress is the flagship academic and clinical meeting for professionals involved in sports medicine and exercise science in South Africa. Proudly hosted in South Africa, the Congress attracts high profile international and local clinicians and researchers both as speakers and delegates. The congress brings together clinicians and academics, to encourage dynamic and meaningful conversations around latest research and best practice in order to enhance the care of our patients. The Congress also provides excellent networking opportunities.

Why Attend?

  • Explore majestic South Africa (Cape Town) in all it’s October glory
  • Excellent networking opportunities and great social events

Also…

  • Professional Support and Collaboration
  • Enhance Clinical Practice and Patient Care
  • Promote and Present Scientific Research
  • Continued Education and Skills Development for Professionals

Congress Highlights

  • Pre-Congress Workshops
    • Physio workshops lead (Cliff Eaton, UK)
    • Fieldsided Emergency Care (Prof Efraim Kramer, RSA)
    • Exercise is Medicine Workshop
  • More than 15 confirmed Intenational speakers including: Evert Verhagen, Blaise William, Babette Puim, Leslie Bonci, Claire Bower, Vincent Goutebarge, Stanley Herring, Angela Smith, Michael Turner, Kate Ackerman, Willem van Mechelen, Aurelia Nattiv
  • Student Presentations
  • Hands on Muskuloskeletal sonar course
  • Clinical Themes including
    • Paediatric Sports Medicine Course – lead by Dr’s Jon Patricios (RSA), Kate Ackerman (USA), Angela Smith (USA), Stanley Herring (USA)
    • Sports Cardiology – lead by Dr Adie Horak (RSA) by Prof Mayosi (RSA)
    • Paralympic Medicine – lead by Prof Wayne Derman (RSA)
    • Sports Specific Sessions
    • Load and Injury Management – lead by Prof Martin Schwellnus (RSA) and Dr Jeroen Swart (RSA)
    • The Female Athlete – lead by Dr’s Kate Ackerman (USA), Aurelia Nattiv (USA), Ettie Barsky (RSA)
    • Exercise is Medicine – lead by Prof’s Christa Janse Van Rensburg (RSA), Willem Van Mechelen (Amsterdam), Vicki Lambert (RSA)

We really look forwarding to seeing you in South Africa!

To find out more visit www.sasma2017.co.za

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Dr. Patho Zondi – SAMSA President

Dr. Liam West – BJSM Medical Education Editor

And the winner of best 2016 BJSM cover is..

28 May, 17 | by BJSM

SPORTS CARDIOLOGY: LOWERING RISK IN ATHLETES is the winning cover for 2016! Thank you to everyone that voted. The IOC Exercise & Pregnancy in Athletes Expert Group issue came in a close second.

January-50-2: Sports Cardiology: Lowering Risk in Athletes

We caught up with Dr. Jonathan Drezner, Editor of the Sports Cardiology issue, to ask him a few questions.

BJSM: Congratulations! How do you feel about winning “BJSM best cover” for 2016?

This is a great honor!  BJSM has a long history of unique and striking covers that draw attention to the important content of each issue.  To be selected as the 2016 best cover is an unexpected distinction.  But the real credit must be given to the brilliant work of Vicky Earle – BJSM graphics and cover specialist – who behind the scenes makes every cover special and a winner in its own right!

What important message does this cover illustrate?

The January 2016 BJSM issue was a special issue dedicated to sports cardiology and lowering athlete risk towards the prevention of sudden cardiac death (SCD).  This topic has captured the interest and efforts of the sports medicine community for many years.  Most recently, epidemiologic data has drawn attention to the differential risk of SCD in athletes – i.e. the concept that some athlete groups are at higher risk than others.  The cover depicts blindfolded people bumping into an elephant and imaging different risky outcomes.  One could interpret many things from this.  In the sports cardiology world, many have chosen to keep their head in the sand about athlete risk… unwilling to accept new science and robust data defining high risk groups and continuing to promote misinformation about incidence rates that depict a “rare” problem not worthy of our intervention.  We must open our eyes to the problem.  The very athletes we are charged of caring for and ensuring their safety on the playing field continue to die.  As a medical community, our response has been slow and clouded by debate, misperceptions, and faulty science.  For some, we must take off our blindfolds to see the true risk!  The solutions are not easy and many potential preventive strategies have their own challenges and limitations, but until we open our eyes as a discipline we cannot move forward.

This cover also carries a personal meaning for me.  In October 2015 I was honored to participate in the SASMA conference held in Johannesburg, South Africa.  The conference embodied collaboration and mentorship and inspired education at all levels.  It also featured a sports cardiology symposium.  After the conference the visiting faculty were treated to a safari experience with Dr. Jon Patricios and his family. It was an incredible experience with memories for a life-time. The elephant on the cover is a reminder of my experience in South Africa and also motivated the title and substance of my warm-up for this special issue: “ ‘Big Five’ of sports medicine: preparation, teamwork, passion, mentorship and collaboration. ”

 What in this issue, stands out for you as the ‘gold standard’ of SEM work?

This issue had many terrific articles.  The original research by Dhutia et al. represents a benchmark study that shed critical understanding on short QTc cut-offs in athletes.  It is one of many important contributions by Professor Sanjay Sharma and his research team from St. George’s University of London and the outstanding charity organization CRY (Cardiac Risk in the Young).  This study was used to help define QTc threshold values in the new International Criteria for Electrocardiographic Interpretation in Athletes: Consensus Statement (BJSM 2017 May;51(9):704-731).

In your opinion, where do we head from here?

First, Vicky must continue to guide the cover masterpieces of BJSM!  From a sports cardiology perspective, we must strive for better prevention, identification of athletes at risk, and safe participation in sports and exercise for all.

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Stay tuned for the official announcement of the prize winners.

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