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Patellofemoral Clinical Symposium & Research Retreat, September 2015: Space is limited, register now!

24 Jul, 15 | by BJSM

Researchers and clinicians interested in Patellofemoral Pain have two unique opportunities to strengthen the relationships that drive research evidence to support clinical practice, learn, and advance knowledge:

kneepain4th International Patellofemoral Pain Research Retreat, Manchester, September 2, nd 3rd and 4th, 2015

  • The Research Retreat is a gathering of scientists who meet every two years to present new research findings and review the science regarding patellofemoral pain. If you are a researcher or a clinician interested in PFP research, you will not want to miss this event.

2nd International Patellofemoral Pain Clinical Symposium, Preston, Sept 5th, 2015

  • The Clinical Symposium, Unravelling Patellofemoral Pain, features latest research and consensus statements, lively debates, small group workshops with world leaders. It is designed for clinicians who are treating patients with patellofemoral problems. Gain clinical expertise through better understanding of the mechanisms causing pain latest management strategies.

At both events, attendees will learn from leaders in the field, expand their networks, and hopefully develop new collaborations to ensure future research remains at the cutting edge informing clinical practice.

Space is limited so register now.

For more information go to: http://www.uclan.ac.uk/conference_events/International_patellofemoral_pain_research_retreat_and_clinical_symposium.php

#iPFP2015

Eight tips to get on an editor’s good side

21 Jul, 15 | by BJSM

By Velvet Garvey (@velvetgarvey)

Picture a small office, where 3 people sit working on computers. Ping! One of them gets a new email and groans.

“Urgh, it’s Dr Jones. He’s got more amends for his paper.”

“Let me guess, he’s added more commas!”

writers bookHave you ever been Dr Jones, pedantically inserting unnecessary punctuation into an article you’ve submitted for publication? Or perhaps you’ve missed a deadline, or worse, rushed a paper to get it in on time, neglecting your figures and submitting an incomplete reference list?

These are some of the things that pain editors, who work hard to communicate your experiences and opinions to the world as quickly yet accurately as possible. While they are an essential part of the research process, some authors disregard an editor’s role. What many fail to see is that publishing an article in a journal, magazine, newspaper or website is a crucial opportunity for you to build a relationship with that title’s editor.

Why should you care about your relationship with an editor? Not only does it make the publishing process a more pleasant experience, it can also make it faster, giving you more time to write your NEXT paper and get that published too.

Also, because they interact with so many medical professionals every day, editors are usually very connected. If an editor likes you, you’re more likely to be called up for opportunities like presenting at a conference or joining an editorial board.

So, how can you get on an editor’s good side? Here are 8 ways:

  1. Treat them like a person.

If you’re corresponding with an editor, the easiest way to make a good impression is to find out their name. Beginning an email with “Dear Editor” just doesn’t cut it. “Dear Sir” is even worse.

How do you find out the name of an editor? Open up a copy of the publication. The list of staff working on it (called the ‘masthead’) should be printed on one of the first pages. And if you’re not sure if the editor is a man or woman from their name, the friendly guys at Google should be able to provide you with a photo.

  1. Stay in touch

Editors like it when writers communicate with them. It makes the process to print go so much smoother. Do your best to write back to emails promptly, and if you’re too busy to give them a detailed reply, at least write and tell them you’ll get to their email soon. Similarly, if you find that you have over-committed yourself and can’t actually submit the paper on time, tell your editor before the submission date.

If you need to pull out of a paper, you can save a lot of face by suggesting someone else who might be a good fit to write on that topic. From the moment your article is accepted for publication, that article will be entered into an editorial calendar so it’s likely the editor will need to replace it with a paper on a similar topic.

  1. Get your figures right

For most editors working in health and medicine, their single biggest time drain is sorting out the figures that an author has sent in. If you want to stand out and be someone that an editor wants to work with again, send in figures that they can use. This may sound obvious but you’d be surprised how often I’ve been sent figures that are actually just screen shots. For a figure to be usable in a print publication it has to be editable, large enough to print (usually around 1 MB) and you have to have permission to use it, meaning you can’t just take a photo from Google images and submit it. If you’re not sure if your figures are appropriate for the publication, contact the editor early in the process so you can work together on a solution before your deadline. Trust me, nothing gets an editor gushing about an author like good figures.

  1. Format your references

Editorial staff can also lose hours fixing references. Each publication has it’s own style of referencing. This should be outlined in their Author Guidelines, but you can also duplicate the style by looking at a copy of the publication.

You can really help your editor by formatting your references both within the text and in your reference list so that they closely match the style as much as possible. You might think that it’s the job of the publication to edit your references, but chasing up or formatting references can take editorial staff half a morning, whereas it might take you a few extra minutes here and there as you write your paper.

  1. Check your proofs

A lot of work goes into preparing an article for print so if the editorial team send you a proof to check, please, please, please read it carefully and send back your feedback as soon as possible. Mistakes, however small, are the stuff of nightmares for an editor, so help him or her to get some sleep by double-checking elements that often get glanced over such as headings, figures legends and author details.

And don’t forget – if you change the order of any of your text at any time, the order of your references might change too. Don’t assume that your editor will pick this up; by the time your proofs are ready, your editor has looked at your paper so many times that she may glance over tiny, superscript numbers.

  1. Don’t be too pedantic

While editors love it if you look over your proofs with the rigor of a pre-participation examination, they won’t thank you for being too picky with your corrections. Journals have a style guide, so help your editor and their production team out by not being too fussy about things like spelling, capitalisations and punctuation. If they want to spell it ‘CAM’ rather than ‘cam’ (as in, impingement), let them.

  1. Be patient

Editors are usually working on multiple issues and titles at once. While one issue is being printed, another is being commissioned and yet another is being edited. For this reason, the time from when your paper is accepted to the time it’s published can often span many months. You will need to be patient.

If your paper is particularly time sensitive, let the editor know this up front, and mention that if they feel they can not publish the paper by a specific date, you might need to submit it elsewhere.

Of course if you feel a lot of time has passed since you submitted your paper and you haven’t heard from your editor, refer to point 2 – get in touch!

  1. Spread the word 

These days we all want clicks, and your editor is no exception. If your published paper is available online, spread the love by sharing a link to your paper or abstract on social media channels such as Facebook, Twitter and LinkedIn. If it’s only in print, perhaps you could take a photo of the cover and share that.

Many publishers, especially book publishers, prefer writers with a strong online platform and while this probably won’t win you any favours when it comes to a peer-reviewed journal, you never know who else is watching you engage with your followers. And let’s be honest, who doesn’t want to appear on the BJSM Top 10 Articles list. So, get tweeting!

As an editor, the best part of my job is working with authors. Laughing at a funny email, smiling at a catchy headline, nodding along with a conclusion that ties the paper together perfectly – these are the reactions that you can elicit. So don’t get groans; get on your editor’s good side and develop a relationship that will last for the rest of your professional life.

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

Velvet Garvey is an Australian editor and writer who has worked on publications such as the Aspetar Sports Medicine Journal and Anaesthesia and Intensive Care. She aims to help medical professionals communicate compelling content … and to be sedentary for as little time as possible. Contact: velvetgarvey@gmail.com

The American Dream? Lessons from an elective in Orthopaedics & Sports medicine

16 Jul, 15 | by BJSM

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

By David Bui (@David_Bui_)

I recently had the privilege of undertaking a three-tiered elective in the United States of America (USA). 1) The “Harvard Medical School Exchange Clerkship” program in Paediatric Orthopaedics at Boston Children’s Hospital; 2) The Hospital for Special Surgery (HSS), Cornell University; and finally 3) The Cleveland Clinic Sports Health. My few-month stint resulted in travelling to 3 USA states, 2 Ivy League institutions, 2 #1 ranked Orthopaedic programs (paediatrics and adults) and working with sports doctors and athletes from professional and college teams for hockey, basketball, baseball, football and rrestling, as well as dancers and ballet companies. It really was that busy….

As the whirlwind has come to a close, here are a few FAQs and tips regarding my USA elective.

icehockeyWhy go abroad for Sports Medicine?

Sport is bigger than national boundaries. You only need to look to the Olympics to see the international reach. Given Sports and Exercise Medicine can involve looking after professional athletes on a global scale, it makes sense to get global experience. I am a big believer in getting outside my own comfort zone to challenge myself – normally good things follow!

Why the USA?

The USA takes sports seriously. 114.5 million people watched Superbowl XLIX – more than 4 times the Australian population! Or double the UK! They also take their medicine seriously, with 17.9% of their $16.7 trillion GDP attributed to healthcare, and the highest medical research investment of any country worldwide. This follows onto Sports Medicine. When you count the home, visiting and neutral medical staff, there are a minimum of 27 doctors present at an NFL game! With this much investment into sports, medicine and sports medicine – you’d be crazy not to want a piece of the action.

  1. Practical tip: Plan early, wait late

The USA medical system is tightly regulated. Typically, overseas doctors must sit the United States Medical Licensing Examinations (USMLE) if they want to have patient contact, otherwise you’re restricted to “observerships”. As a student, there are a few programs that don’t require this (e.g. Harvard) or others that may waive the requirement after a nicely worded letter from your university (e.g. Cornell and the Hospital for Special Surgery). As such, planning early as to whether you want to sit this exam, or to get the appropriate paperwork to have it waived is crucial.

The landscape of sports coverage in the USA is different from the UK and Australia in that institutions pay to be the healthcare providers for professional teams. Finding out which doctors and institutions manage teams and take students is half the challenge!

Keep in mind that if you’re a non-American medical student you typically have to wait until about 2 months before your placement before you get sent your acceptance letter, which can make things tricky logistically, but its definitely worth it. #PatienceIsKey

  1. “If you ask, the worst they can say is no; if you don’t ask you’ll never know.”

This is a variation on @Liam_West’s BJSM tip, “You make your own luck”. The USA is a land of opportunity. You need to put yourself out there though, show you’re keen. I emailed about 50 different doctors, universities, teams or programs all up! Want to do sports coverage? Ask! The vast majority of my electives weren’t specifically with sports teams or individual team doctors, but by working within the system, meeting people at department meetings or sending a few emails I was able to experience many aspects of sports medicine, including being rink-side in ice hockey coverage and court-side at a university basketball stadium. I had no idea people could specialise in Paediatric Orthopaedic Sports Surgery, or Dance Medicine, or purely Lacrosse. Want to do research? Email ahead and say so! A few of my friends wrote book chapters, and another wrote and published 2 papers, so it’s definitely possible!

  1. When in Rome…

“Do as the Romans do”. American medical students work hard. Much like you do I’m sure #NoBias but bear with me… “Away rotations” or “sub-internships” or “electives” are basically 1 month job interviews. The learning curve is huge, but it just motivates you to work harder; you’re working with some of the best! I remember ultrasound meetings and rounds in the early mornings and journal clubs late at night. When everyone is working around the clock, you’ll be swept away with it as well. Take call. Work overtime. Talk to the residents and fellows. Go to the local games, either on the sideline or in the stands. Contact the local Medical Society, find out what events are on and get involved. American sports are unique, but components of their medical management are easily transferrable to other contexts. For example, baseball is a great arena to study the ‘Throwing Shoulder’ and American football has injury profiles similar to rugby.

Overall, if you plan ahead, put yourself out there and dive into it! Make your elective, the trip of your lifetime.

David Bui is a final year medical student at the University of New South Wales, Sydney Australia. He is the current President of the University of New South Wales Sports Medicine Society

Twitter: (@David_Bui_)

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

First round of the BJSM Cover Competition 2015 (new format!): great way to review and vote for your faves

14 Jul, 15 | by BJSM

BJSM ranked #1 of 81 in Sports Sciences for ‘Immediacy’ – papers cited within a year of coming out.

Our 18 member societies guide us to hot topics. Did you miss an issue? Here’s a quick way to scan this year’s archive. Every two months, we’ll revisit 4 previous issues, and invite you to vote. Yep, BJSM is the only sports clinicians’ journal with new content twice-monthly. Crazy!

Win a prize! Six winning covers move to the final of course (just like a massive sporting event). Voters in the final round will enter a draw to win a prize (TBD), and profiled on the BJSM blog. See last years winners HERE.

You have one week to vote in each round.

These first 4 issues of the year were crafted by: (i) the IOC (see the rings :)), (ii) the Canadian Academy of Sport & Exercise Medicine (CASEM/@CASEMACME), (iii) the American Medical Society for Sports Medicine (AMSSM/@theAMSSM)) and (iv) our physical activity editors, Profs Trost & Blair (see also @ISPAH).

 

January 49 (1)

January 49 (1)

January 49 (2)

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February 49 (3)

February 49 (3)

February 49 (4)

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Fortius International Sports Injury Conference (FISIC) – A conference you can’t afford to miss…

11 Jul, 15 | by BJSM

Wimbledon is well underway, cricket season is in full flow, football season is commencing and 20 national rugby squads are preparing to compete in the 2015 Rugby World Cup – needless to say it is another exciting summer of sport.

With the home Rugby World Cup tournament fewer than three months away, the 50-man England squad are in boot camp at Pennyhill Park, then on to high altitude training in the Rocky Mountains, with the aim of being the fittest team in the tournament by the time the action kicks off in September.

The squad will be pushing themselves to their limits, while their medical teams will be working hard to minimise injuries. Perfect timing then for the Fortius International Sports Injury Conference (FISIC) which coincides with a brief interlude in play before the Quarter Finals, and gives team medical personnel a unique opportunity to participate in a world-class, multidisciplinary congress.

fisic june 2015

The full two-day conference, which takes place on October 13th-14th in central London, offers a unique multi-disciplinary approach, and a strong international faculty including many leading experts in Sports Orthopaedics, Elite Sports and Sports Exercise Medicine.

The theme of FISIC ‘15 is Treatment, Recovery and Return to Play, and the programme covers a wide range of key issues and hot topics in sports injury treatment and recovery, as well as specialist sessions from the World Rugby faculty and joint specific presentations.

All sessions will have a multidisciplinary element but are named plenary, surgical, MDT or GP according to their primary target audience. Speakers will emphasise themes of “from science to clinical practice”, “optimising recovery” and “clinical excellence”.

The surgical sessions will involve a series of short lectures with approximately half the session time allowed for debate and discussion. Although some of the MDT sessions will follow this format, others may involve lengthier talks but will still allow ample time for debate.

Some of the programme highlights for Sports Exercise Medicine professionals

The Future of Cell Therapies – Fact or Fiction: covering the current status of stem cell therapies in cartilage repair, bone marrow aspirate and cell therapies, and the PRP debate

Bone Health: covering the biology of bone repair; Bone health in the female athlete; Vitamin D deficiency, supplements & use as a hormone to enhance injury recovery; medical treatments to aid bone repair, and the use of exogen.

Dr Bob Cantu, Dr Caroline Finch, Dr Jon Patricios and Dr Willie Stewart from the World Rugby advisory board discuss the science of concussion, how to recognise and remove it, including management of the difficult case and what we know of the potential long-term consequences.

The science of muscle injuries & repair going on to Acute injuries: Best medical management for successful RTP; imaging acute lower limb muscle injuries: Predicting return to play; best management & optimising RTP following contusion injuries & myositis ossificans; chronic recurrent tears and return to function; surgical indications for hamstring injury.

World Rugby leads a session on player anthropometrics, the demands and current trends in injury in Professional 15 a side Rugby, Community & age-group rugby; skills needed to work pitch-side in rugby union and how practitioners can reduce the risk of injury to a team.

A session on return to play covering: the psychology and nutritional aspects of return to play; RTP post max-fax injuries; the environment needed to facilitate smooth RTP; objective criteria for safe return to play.

A session on disability sport will cover sports science and coaching in sports medicine; performance physiotherapy for disability sport; the athlete/ paralympian perspective; complexity of sports psych in disability sport; Athlete classification and ethical issues in disability sport

The Adolescent Athlete: will cover spinal pain in adolescent sports, strength and conditioning training; apophysitis and soft tissue injuries; CL tears and reconstruction in children & adolescents; Osteochondritis Dissecans and imaging the Adolescent Athlete.

There will also be a wide range of joint specific sessions including: Knee sessions on the Meniscus, Cruciates, Patellofemoral Syndromes In Sport; Foot & ankle sessions on Mid Portion Tendinopathies, Insertional Tendinopathies, The difficult mid- season foot injuries, Ankle & Midfoot Injuries, Ankle Instabilities; Shoulder and elbow sessions on Gleno humeral instability, Spectrum of Shoulder Injuries, Elbow Instability, dislocations, MCL, biceps and triceps injuries and tendonitis; as well as specialist Spine, Hip and Groin and Wrist and Hand sessions

CPD points have been applied for and it’s expected that there will be 6 points for each day of the conference.

You can find out more on the conference website, www.fisic.co.uk.

 

Mental Health in Sport Conference, 28th July 2015: Register now!

8 Jul, 15 | by BJSM

mausley logo

Maudsley Learning will host its 2nd annual conference focusing on mental health within the sports industry later this year. Once again we’ll bring together high profile sporting bodies, coaches, medical professionals and others involved in player welfare, safeguarding and performance to discuss key issues around mental health and wellbeing in the sport industry.

Speakers

Prof. Dr. Astrid Junge, head of research, FIFA Medical Assessment and Research Centre
Sarah Cecil, lead sport psychologist (Multi-sport), English Institute of Sport
Dr. Ian Beasley, head of medical services, The Football Association
Ian Braid, CEO, British Athletes Commission
Pippa Bennett, former chief medical officer, England Women’s Football Teams
Angus Mugford, director, personal and organisational performance, IMG Academy
Dr. Phil Cooper, co-founder, State of Mind
Brendon Batson OBE, chairman, Professional Players Federation
Oliver Jones, Head Coach, Brooklands Tennis Club

Learning Outcomes

* Achieving parity of esteem between physical and mental health in elite sport
* Identifying best practices around enhancing mental wellbeing of athletes
* Benchmarking mental wellbeing in sport
* How can sporting bodies monitor the mental wellbeing of athletes
* Enhancing the psychological competence of elite coaches
* Exploring the mental/behavioural implications of concussions in contact sports
* Examining the impact of sport on mental health enabling people with mental health problems enter competitive sports
* Facilitating conversations for collaborations in a pan sport mental health network to share best practice and enable elite athletes to perform better

Professional Development

* This is a fantastic opportunity to anyone in the sports industry in understanding the importance of mental health and wellbeing and its impact on athletes’ performance and personal wellbeing
* Key learnings from experts and other sports
* Great networking opportunity
* Certificate of attendance can be provided on request
* This event is CPD accredited for all members of the RPDPS register

Who should attend

* Coaches
* Medical professionals
* Player welfare professionals
* Safeguarding professionals
* National governing bodies
* Player associations
* Player welfare managers
* Sports psychiatrists
* Sports psychologists
* Academics / Students
* Club owners
* Senior decision makers
* Policy makers

Key Links

Promotional code: BJSM – Offers 45% off standard delegate rate…
Link to brochure: http://bitly.com/MHinSport15
Link to booking page: https://gcmh2015.eventbrite.co.uk
Contact: events@maudsleylearning.com

mental health

Are the new cricket helmet standards enough: what does the evidence say?

5 Jul, 15 | by BJSM

The untimely death of Philip Hughes along with the recent Cricket World Cup and a relatively new British Standard for helmets has fuelled the debate for further research into the role of helmets. World-renowned expert on this subject Andrew McIntosh profiled these issues in a recent BMJ blog. He writes:

back-foot-drive cricket“It became clear to me that whilst the original cricket helmet standards were not optimised for the intended function; they were a lot better than nothing. There were other issues with the adjustability of the face guard that exposed cricketers to facial impact risks and also ignored basic safety engineering practice. Cricketers could tilt the face guard down and create gaps large enough for cricket balls to penetrate leading to facial and ocular injury. David Janda and I assessed the performance of a selection of cricket helmets in 2001 using what we considered to be realistic and reliable projectile tests and compared these to other helmets (published in BJSM in 2003)… We concluded that projectile tests in which a ball is fired at the helmet and face guard would be a more realistic assessment of the helmet performance, than simple drop tests. We also identified the type of information required to set the performance requirements. I won’t say that the cricket world at that time was particularly receptive to various proposals to progress those ideas…”

Read full blog HERE

Evidence informed best practice for athlete safety is of the utmost priority for BJSM. Thus, below we highlight a number of BJSM publications that contribute to the discussion of cricket helmets and player safety.

Reduction in injury for the junior athlete

In cricket, contrasting to some other sports where outcomes are ambiguous, the evidence clearly demonstrates a significant reduction in head/neck/facial injuries amongst junior cricketers following the introduction and compulsory use of headgear whilst batting. Caroline Finch’s group in NSW demonstrates the importance of enforcing this safety feature in this BJSM article here.

High-stake factors to consider for the professional athlete

The potential safety benefits of helmets in junior athletes are encouraging. However, the nature of the professional game where batters are often confronted by a ball travelling at over 140km/h means that safety at this level of the game is very much a different kettle-of-fish, and that helmets must be significantly robust to protect the athletes. In this article, Craig Ranson and colleagues reviewed video footage of over 30 head injuries sustained whilst wearing a helmet and worryingly concluded that significant head and facial injuries occur in cricket batters despite wearing of helmets and that helmet design and safety standards should be improved to provide increased protection.

Whilst improving safety standards is one part of the jigsaw, getting buy-in from the players is just as important. Again, Craig Ranson and Mark Young further highlight the issue with adjustable faceguards and how the peak-faceguard gap on most helmets can be adjusted to greater than ball diameter, whilst their fairly flexible nature can also allow the ball to funnel on to the face. They provide an insight into the ECB’s player education programme, and how by focusing on the #BrightSpots and the potential consequence of letting the team down (severe facial injury ≠ effective performance!), getting player buy-in can be made easier.

Where do we go from here?

In the BMJ blog, McIntosh states the next steps needed to improve on the encouraging British standards.

  • “Mandate helmet use in cricket rules to the best standard;
  • Ensure that ongoing claims of compliance are backed up by routine batch testing and third party certification bodies;
  • Run formal epidemiological studies, but supported by sports science, ergonomic, and biomechanical studies that will assist in the interpretation of the results;
  • Start the plans for the next revision to the standard.”

A constant revision of the British Standard is unquestionably a step in the right direction, and these well-thought proposed steps not only provide a sensible approach to optimising player safety, but also an example of how cricket can (and to some extent is) leading the way in confronting some of the safety issues in their sport in order to ensure the health and wellbeing of their athletes. One death occurring on the field of play is one death too many, and it is encouraging to see a collaborative and multi-disciplinary approach to ensure that any sport-related tragedies are consigned to the past.

 

Fit to Live? Genotype-positive Phenotype-negative Hypertrophic Cardiomyopathy

3 Jul, 15 | by BJSM

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

By Dr Christopher Speers

At a recent Cardiac Conditions Clinic with Dr William Bradlow (Consultant Cardiologist) at the Queen Elizabeth Hospital Birmingham, we reviewed a number of patients with Hypertrophic Cardiomyopathy (HCM) and Dilated Cardiomyopathy (DCM).

genesThese consultations produced numerous patient-centered exercise-related discussions, but one case in particular raised a challenging and novel exercise medicine dilemma; genotype positive-phenotype negative HCM.

This is seen in patients who have a family history of HCM, and have tested positive for a genetic mutation attributed to causing HCM.  However, they have normal ECGs and echocardiograms with no evidence of cardiac hypertrophy or left ventricular outflow tract obstruction. Therefore they are diagnosed as having ‘genotype positive-phenotype negative HCM’.

Are genotype positive-phenotype negative individuals at increased risk of Sudden Cardiac Death?

We know that HCM is phenotypically heterogeneous; with the age of onset, severity of symptoms, and relative risk of Sudden Cardiac Death (SCD) showing inter-patient variability even within family members with the same genetic mutation (1, 2).

Some studies have shown that particular genotype sub-groups, for example mutations of Troponin TNNT2 correlate with a higher risk of SCD.  There is also evidence that some genotype positive-phenotype negative individuals have impaired relaxation of myocardium, altered energy metabolism, and phenotypic changes such as crypts. This inherently abnormal cardiac tissue may predispose to adverse events (2, 4).

However there are only a very small number of cases of SCD in genotype positive-phenotype negative individuals described in the literature, making deductions challenging (2, 3, 4).

At present the clinical implications of these pre-hypertrophy cardiac changes are not known, and the real risk of SCD is thought to be significantly lower than that in clinical HCM (2, 4).

So what exercise advice should we give?

The governing bodies are clear on competitive sport exemption in individuals with clinical HCM. However the genotype positive-phenotype negative sub-group poses both an ethical and practical dilemma; it is not known if individuals will develop left ventricular hypertrophy or when this may occur. Developing clinical HCM would increase the risk of SCD, becoming particularly dangerous if undiagnosed in those engaged in competitive sport. At present there is no agreed international consensus on management.

The 36th Bethesda Conference 2005 states; ‘Although the clinical significance and natural history of genotype positive-phenotype negative individuals remains unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.’ (5)

However the European Society of Cardiology (ESC) 2006 position paper states; Based on the level of present knowledge, the decision for participation in competitive sport should be individualized. However, prudent recommendation suggests restriction of these individuals from participation in competitive sports, especially those with high cardiac demand (i.e. high dynamic, high static sports), and to recommend prudently amateur and leisure time sport activities.’ (6)

2014 ESC guidelines on HCM management have since relaxed this approach to some degree; ‘In definite mutation carriers who have no evidence of disease expression, sports activity may be allowed after taking into account the underlying mutation and the type of sport activity, and the results of regular and repeated cardiac examinations.’ (4)

It is clear that this subgroup of genotype positive-phenotype negative individuals need long-term regular follow-up with 12-lead ECG, echocardiogram, exercise stress testing and cardiac MRI, particularly if engaging in regular sporting activity. The adjunct of genetic profiling may aid with risk stratification in the future.

The implications of this diagnosis and potential restriction from sporting activity are far reaching for the individual, having both negative psychological and physiological effects.

An individualised risk stratified exercise prescription with careful specialist follow-up must form the basis of current and future management. However further research is essential to enable us to understand the natural history of genotype-positive phenotype-negative HCM and the real risk of SCD in this sub-group.

What did we recommend?

In line with the ESC recommendations we worked with our patients, exploring the potential risks and current evidence, and together formulated an exercise prescription. We agreed upon maintaining a healthy level of fitness through regular exercise at an intensity level where one can still hold a conversation, with the stipulation of regular cardiology follow-up.

References

  • Ho CY. Genetics and clinical destiny: improving care in hypertrophic cardiomyopathy. Circulation. 2010; 122:2430Y40.
  • Sylvester, J. et al. The Dilemma of Genotype Positive-Phenotype Negative Hypertrophic Cardiomyopathy. Current Sports Medicine Reports. Volume 13 & Number 2 & March/April 2014.
  • Richard, P. et al. Advising a cardiac disease gene positive yet phenotype negative or borderline abnormal athlete: Is sporting disqualification really necessary? Br J Sports Med 2012;46(Suppl I):i59–i68.
  • 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. European Heart Journal. (2014) 35, 2733–2779.
  • 36th Bethesda Conference. Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology. Vol. 45, No. 8, 2005
  • Pelliccia A, et al. Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis and pericarditis. European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:876–885.

Dr Christopher Speers BSc(Hons) MBChB MRCP(UK) is a ST3 Sport and Exercise Trainee in the West Midlands Deanery. He works with Bristol Rugby, British Universities and Colleges Sport, and is an Amateur Boxing Association Medical Officer. 

Dr Farrah Jawad is an ST4 Sport and Exercise Trainee and co-ordinates the BJSM Trainee Perspective blog.

FSEM Supports Concussion Guidelines for the Education Sector

30 Jun, 15 | by BJSM

fsem_v_Variation_1The Faculty of Sport and Exercise Medicine UK (FSEM) is supporting new Concussion Guidelines for the Education Sector, produced by the Forum on Concussion in Sport and Physical Education in conjunction with the Sport and Recreational Alliance.

The guidelines have been created in order to alleviate parental concerns around the safety of school sport and to ensure a consistent and suitable management protocol is available to those working with children in the education sector.

Endorsed by an independent expert panel of Sport and Exercise Medicine, Neurology and Health specialists, the guidelines have a clear message on how to handle a suspected concussion in school aged-children and above, including the dangers of returning to play too soon. Concussion can occur during any physical activity and these simple guidelines will help those working in education to follow the four principles of concussion management:

RECOGNISE – REMOVE – RECOVER – RETURN

Dr Mike England, Fellow of the FSEM, Community Rugby Medical Director of the Rugby Football Union and Facilitator of the guidelines comments: This has been a ground breaking initiative, with sport, education and health coming together to address a very important issue. We hope teachers will find these guidelines useful, as it is imperative that those working in the education sector know how to recognise concussion and take action. If I had to pick out one key message it would be if in doubt sit them out.”

Dr Roderick Jaques, President of the FSEM comments: “We identified the education sector as a priority area through our call for a national consensus on the prevention, assessment and management of concussion. We are now delighted to see the launch of concussion guidelines to help teachers, school staff, coaches, parents and carers to be aware of the danger signs and how a suspected concussion should be managed in the absence of a trained medical professional.”

The FSEM called for a national best practice consensus on concussion, for all sectors where concussion is encountered, last year and has been working with the UK National Sporting Bodies and Medical Royal Colleges. Easy to follow guidelines, like this, could be developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.

View the Concussion Guidelines for the Education Sector at www.sportandrecreation.org.uk/concussion-guidelines

Also see related BJSM material:

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Full text free online. (downloaded >100 k times)

Guest blog by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands

 

 

The sedentary office: the need for more pragmatic guidelines

26 Jun, 15 | by BJSM

Letter to the Editor by: Dr Kelly Mackenzie, Specialty Registrar in Public Health / Academic Public Health Fellow

In response to:  JP Buckley & A Hedge et al (2015). The sedentary office: a growing case for change towards better health and productivity.

We welcome the development of quantifiable targets relating to workplace sedentary.  However, given the low quality evidence, it was expected that the recommendations would have been more pragmatic.

For desk-based workers, an initial target of two hours per day of standing/light activity eventually progressing to four hours per day, would be difficult to accumulate without the use of environmental and/or ergonomic adaptations such as adjustable-height desks.  As these interventions have a relatively high initial cost (around £300-1000 for an adjustable-height desk1), this recommendation is unlikely to be achievable in most workplaces.  Financial gains due to increased productivity and decreased absenteeism can be made to offset these costs, but tend to only be realised in the longer-term, so will not provide a viable justification for many organisations.

Instead, initial recommendations need to provide realistic targets that involve no/low cost changes that can be accumulated incidentally throughout the working day e.g. by encouraging standing/walking meetings.  The recommendations could then be taken up by a range of organisations, hence promoting maximal public health benefits.

References:

  1. Height Adjustable Desks.com, https://heightadjustabledesks.com/ (Accessed on 16th June 2015)
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