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Physiotherapy and ‘The Young Athlete': Education, advocacy, and the upcoming ACPSEM biennial conference

28 May, 15 | by BJSM

Association of Chartered Physiotherapists in Sports & Exercise Medicine blog series @PhysiosinSport

By Claire Treen @ClaireTreen

biennel conferenceIn recent months, politicians in the UK have – quite rightly – talked a lot about the NHS. However, perhaps because many teens don’t vote, we don’t hear as much about the challenges of bone growth, adolescent and young adult mental health, eating disorders and adapting to change in academic and social environments. My colleague Dr Dominique Thompson, University of Bristol Director of Student Health, recently highlighted this in a 3 minute BMJ podcast.

As Sport and Exercise Physiotherapists, youth and parents often confide in us. It is therefore especially important to both be informed about key youth health issues and advocate for their importance.

I’ve worked with many teens, particularly young runners and tennis players, in a university environment over the last 10 years. My colleagues and I have noted recurrent challenges around screening and safeguarding young athletes.

Questions we have raised in our continuing professional development  sessions include:

What do we understand about adolescent growth and its influence on musculo-skeletal development and injury?

How do we prevent today’s star first XV rugby player from being tomorrow’s persistent pain sufferer?

What are the implications of applying high load to areas such as the spine, hip and groin during adolescence?

We are constantly challenged in our work to support young people as they transition from developing or elite junior athletes into an elite senior environment. How can we best do this, and who should be involved?

How can the ACPSEM biennial conference strengthen our capabilities?

With a focus on ‘the young athlete,’ the upcoming ACPSEM biennial conference (this October in Brighton) aims to help answer some of these questions.

Conferences not only provide presentations on ‘hot-topics’ from leaders in the field, but also a chance to interact with others facing similar clinical scenarios, and discuss these – and more – multifaceted questions.

What are the benefits of being an ACPSEM member?

Being an ACPSEM member gives you a discount, and helps you become part of a group of skilled physio professionals. You can also access continuing professional development through journal subscriptions and an organised and well mentored pathway.

The early bird catches the worm…everyone who books before May 31st gets a discounted price and a free (unfilled) Vivomed kit bag and entry into raffle prizes.

Register today! Hope to see you there!

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Claire Treen @ClaireTreen is a Physiotherapist at University of Bristol Sports Medicine Clinic, Coombe Dingle Sports Complex

Transfer Deadline Day in Football: A look beyond the camera lens, into the medical room

26 May, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine  a BJSM blog series

By Steffan Griffin (@lifestylemedic)

2300 GMT on the second of February marked the transfer deadline close in England and Wales. It signalled the end of a panic-ridden dash to snap up the athletes required to make a run for the top-spot. The £45 million spent in the last 24 hours of the window in the Premier League alone this year emphasises the perceived importance of this day to football clubs.

football cover may 2015The media frenzy surrounding the saga shows helicopters landing outside training grounds and players being ushered through back doors in order to “dot the i’s and cross the t’s” in time for the deadline. When the terms are agreed and a mutual agreement reached between player and club, only a medical stands as a barrier.

So what goes on in the medical examination behind these closed doors?

Whilst the process as well as the perceived importance of it differs from club-to-club, Hywel Griffiths, Head of Medical Service for Cardiff City FC provided an insight into their system:

“The club doctor and I will start with a full head-to-toe musculoskeletal assessment, consisting of joint examinations as well as strength and proprioceptive assessments”.

Following this MSK MOT, it’s off to the local private hospital for a detailed medical examination, where cardiac screening and any further indicated tests are carried out #NoExpenseSpared. But can’t they get this information from the player’s previous club, or the player himself?

“You can’t always rely on the previous club or the player to provide the precise information you need” explains Hywel. “Both parties may have a vested interest in the process, and when you’re paying the equivalent of a mansion for these players, you have to ensure that they won’t break down on arrival and are safe to train & play”.

It seems this message has reached the new generation of British professional football players too, with Bristol City FC’s Wesley Burns stating that he “personally wouldn’t hide any injuries that could possibly hinder a move, because it’s within the new club’s rights to not only fine the player and former club, but to terminate that player’s contract”.

What about the role of the oft-seen on Match of the Day fire-breathing managers, can they affect the medical or transfer process?  How do you deal with these personalities? “At the end of the day you have to be professional and do your job, you’re not there to pass unhealthy players. Although managers can be influential, as demonstrated in the blood-gate saga in rugby, your role first and foremost is to seek assurances regarding the health and wellbeing of the individual concerned. Anyway, the manager won’t get a good performance from someone who isn’t healthy, so it’s in everybody’s interest that you’re able to determine all the facts about a player”.

So following the medical, what happens? “After all the relevant checks have been performed, we will bring all of the information we have to a consensus meeting where a decision between the medical staff is made”. Only following this will the club manager and secretary be notified of the decision, and the signing can be completed. It also seems that the ‘deadline’ is not all as commanding as it seems, with clubs able to sign players on the condition that a full medical is passed the subsequent day (just don’t tell Sky Sports News!).

With the bumper TV deal flooding the English Premier League with even more money, we will undoubtedly see a number of high profile transfers in the coming years, so spare a thought for those involved in giving the deals the green light and should you find yourself in this position in years to come, in the words of a seasoned professional “remember your role”.

For related reading: See BJSM’s May 2015 issue on Football Medicine

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Steffan Griffin (@lifestylemedic) is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

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.

References

Transfer deadline day: Juan Cuadrado headlines spending. BBC Sport http://www.bbc.co.uk/sport/0/football/31104357

Acknowledgements

Sincere thanks to both Hywel Griffiths and Wesley Burns for giving their time to provide an insight into an area not well known to most students and trainees

Further Resources

CNN Article into medical: http://edition.cnn.com/2015/02/02/football/football-medical/index.html

It’s not just BJSM talking about healthy nutrition – real food…

21 May, 15 | by BJSM

Whether listening to the radio or reading the newspaper in the last few weeks, it’s likely that you noticed the BJSM gaining a fair amount of media coverage. The attention has centred on the issue of diet & weight loss (not surprisingly, fuelling a more spirited debate than the average hamstring injury article!), specifically, an editorial by Dr Aseem Malhotra, which suggests that physical activity without consideration of diet, is insufficient in the fight against obesity.

obesity 1

Some media outlets portrayed the article as driving a nail into the coffin of physical activity as a preventative health modality, failing to mention that the editorial argued strongly that a minimum of 30 minutes of physical activity a day provides a great return-on-investment for all-round health. @DrAseemMalhotra simply questioned the evidence-base regarding the effectiveness of physical activity alone in reducing obesity, an independent health issue in its own right. He also provides a call-to-action to “bust the myth of physical inactivity and obesity,” namely the misconception that if you exercise you can eat whatever you want with no health concern.

That article was preceded by a perspective from the University of South Carolina and ACSM’s esteemed Professor Steven Blair, a BJSM Senior Associate Editor. He and two colleagues point out the imbalance in energy balance research, and call for further investigation into the concept of ‘energy flux’ in causing obesity; the Global Energy Balance Network is already undertaking some of this work.

Professor Blair directy rebutted to the Malhotra editorial as a blog on the Global Energy Balance Network website and shared this via his wide reach on Twitter (@StevenNBlair). That blog is about to be accepted as an editorial in BJSM and it, and another relevant editorial will be in BJSM issue #15 (July) – curated by the South African Sports Medicine Association.

So what actually works?

Whilst obesity levels expand and expand, discussion around the optimal diet to reverse this trend include the practice of reducing carbohydrates and increasing fat intake. The optimal extent of these changes are also the topic of intense debate. BJSM published an editorial by Professors Noakes and Phinney on the argument for a low carbohydrate, high fat diet #LCHF. Dr Peter Brukner, (@PeterBrukner) a self-avowed #LCHF convert, interviewed Professor Noakes on this BJSM podcast. Importantly, BJSM has commissioned a counterpoint from leaders in sports nutrition and performance.

If you are open to challenging ideas, here are links to the #LCHF summit conference highlights1,2,3, whilst you can also enjoy Dr Malhotra’s provocative podcast on #DontFearTheFat and the more recent one clarifying his editorial.

Whether you’re a #LCHF advocate or have never heard of it before, one of the most impressive educational resources that discusses the issue is a TEDx video by Dr Sarah Hallberg – Medical Director of the Medically Supervised Weight Loss Program at IU Health Arnett. She provides insight into the cultural interests that led to the normalization of high carb low fat diets, and proliferated the diabetes and obesity epidemic. She also explains practical, diet based, strategies to combat these diseases. So if you want to learn more about why you shouldn’t fear the fat, sit back (or stand…) and enjoy.

Whilst cutting carbohydrates has historically been associated with celebrity diets, the mounting evidence is hard to ignore, as is this diet’s establishment as a sustainable and effective way to fight obesity. If you need further convincing (or haven’t the time to watch the clip), why not listen to Dr Jason Fung discuss the issues of insulin and diet in relation to type 2 diabetes and obesity. Enjoy these resources and join the conversation on our social media platforms (Twitter, Facebook & Google+).

Blog References

http://blogs.bmj.com/bjsm/2015/03/12/part-1-to-lchf-or-not-to-lchf-thats-the-dietary-question/

http://blogs.bmj.com/bjsm/2015/03/15/part-2-to-lchf-or-not-to-lchf-thats-the-dietary-question/

http://blogs.bmj.com/bjsm/2015/02/22/have-we-found-the-key-to-open-the-door-to-optimal-nutrition-day-3-at-lchf-summit-cape-town/

The role of exercise intervention in adopting a ‘choosing wisely culture’ in clinical practice

18 May, 15 | by BJSM

fsem_v_Variation_1

News Release – The Faculty of Sport and Exercise Medicine

The Faculty of Sport and Exercise Medicine UK (FSEM) supports the launch of a Choosing Wisley Programme in clinical practice by the Academy of Medical Royal Colleges. As the NHS faces a £30bn funding gap by 2020[i] the need to tackle preventable illness and disease effectively and efficiently has never been greater.

Medical decisions based on the best match between what is known about the benefits and harms of each intervention and the goals and preferences of each patient is a common sense approach outlined in the Choosing Wisely in the UK report. However, the pressure on general practitioners and doctors to provide a quick solution is enormous, while sickness and absence rises with an increase in many preventable conditions.

A sustainable alternative intervention is available, which can improve public health for the long term and reduce the pressures facing the NHS. Physical activity and Exercise Medicine are under resourced and under used by the health profession and can provide cost effective prevention and intervention for many common conditions and illnesses [ii].

A good example of this in practice is the management of musculoskeletal (MSK) conditions, which account for up to 30% of all primary care consultations [iii]. Sport and Exercise Medicine doctors can offer alternative pathways in managing common MSK conditions. The majority do not convert to surgery or need disease modifying drugs and can be managed in different models of care which streamline the pathway for patients and can be more cost effective for commissioners, while still attractive for hospital trusts.

If the NHS routinely offered an effective and patient centred programme of physical activity and exercise medicine interventions, it could lead to a real reduction in the over-use of more established clinical treatments.

For further information view the FSEM’s Manifesto – Making the Physically Active Choice.

For further evidence of the effectiveness of exercise medicine in treating MSK conditions view – A Fresh Approach in Practice

References

[i]  NHS England 2013

[ii] A Fresh Approach – FSEM NHS information document 2012

[iii] A Fresh Approach in Practice – NHS Information document 2014

 

Make sure to be on the right side in the war on science

16 May, 15 | by BJSM

By John Orchard

@DrJohnOrchard highlights the importance of the scientific method emphasising that it should be the rock on which all health practice is based. This blog is edited slightly from the canonical Sport Health co-publication. Sport Health is a member publication for Sports Medicine Australia (follow @SMACEO)

One of my favourite sayings from my medical education is “only 50% of what we do in medicine actually works, but you have to keep doing everything because you don’t know which 50% is helping”. The best part of the saying is the underlying admission that even the most genius- or god-resembling doctor has limited knowledge of the effects of many recommended medical treatments. One unfortunate part of the saying is that the 50% figure is totally made up, but it (the plucking from air of the figure ‘50%’) is almost  self-parody. There is no doubt that the percentage of ‘fully effective’ medical treatments (i.e. options which are more effective than placebo or doing nothing) is lower than both practitioner and patient imagine. A better picture of health treatments (but which does not neatly fit into a one-liner) follows:

  1. Proven evidence-based interventions which we know are biologically effective beyond reasonable doubt because of the weight of scientific study demonstrating this;
  2. Possibly-effective interventions which have biological-plausibility of possible effectiveness but for which the jury is still out scientifically because of lack of high-quality studies;
  3. Placebo-effective interventions which actually work in the real world because they are non-harmful and because the patient thinks they will help actually achieve a better response than doing nothing;
  4. Ineffective interventions which have no biological effect and where the placebo effect does not deliver any bonus over doing nothing (and can be considered net negative not because of harm but because of opportunity cost/wasted resources);
  5. Placebo-harmful interventions (‘nocebo effect’) which have a negative effect because the patient was actually worried about the intervention and this negatively influenced recovery or for which the patient developed a side effect purely because of warning that it may occur (rather than any biological reason);
  6. Harmful interventions which actually end up making the patient worse because of biological damage done from the intervention.

Those of us working in health care know that almost no one (neither practitioner nor patient) ever tries to stick to category A interventions only and there is a good reason for this: category C (placebo-effective) interventions are helpful in so many cases  you would be foolish to not utilise them. However, the key to getting a good category C response is that both practitioner and patient believe the intervention is in category B. So to summarise the three keys to being a good health practitioner are to:

  • Believe in, and practise, evidence-based health care where possible;
  • Embrace a modified version of Primum non nocere (which translates from Latin as “firstly, do no harm”), meaning only expose the patient to potential harm if it is very clear that the benefits outweigh the risks;
  • Be optimistic; where the evidence-base is weak and you are relying on natural healing and the placebo effect, you should be optimistic, as it actually can be effective (moving category D interventions up to category C).

Just to throw a spanner in the works – in case everything described seems really simple so far(!)- is the likelihood (backed by scientific evidence) that more invasive and expensive procedures can give rise to a greater placebo effect than cheaper and less risky ones. Particularly if you are convinced that your problem is so bad that you need a pill/injection/operation to treat it! If exposing yourself to the risky effects of an invasive intervention is required to get a placebo effect then it may actually be worth it.

How does this apply to sports and musculoskeletal medicine?

First, our evidence-base is thin. Which should not surprise any of us, given the age of our specialty is. Most of what we do has a limited evidence-base (meaning that it is neither proven to be effective nor ineffective) and hence there is a heap of room for the selling of optimism. In moments of falling into despair, it might seem to be preferable to be working in an area of medicine or health care where there were more blockbuster treatments like vaccines, antibiotics or life-saving emergency treatments that definitely worked.

But a beacon emerging from that gloom is the certainty that exercise itself the closest thing that health care has to a miracle cure for just about everything. The true Panacea. Exercise prevents and/or treats cancer, cardiovascular disease, diabetes, osteoporosis, arthritis and depression (let’s just round it up to >75 per cent of all causes of mortality and morbidity in Western countries). The evidence-base about the value of exercise is extremely strong and further research needs to concentrate on ways to increase the uptake of exercise. This is where the sports and exercise medicine professions can come in. The “keep them on the park” mentality of the collective sports medicine professions is extremely valuable in terms of net outcome (more exercise) even if the means (applying placebo-effective interventions in many cases) is not always based on solid science.

Second, the interplay between the various placebo effects and health outcomes may lead patients to reject mainstream medicine for two different and opposite reasons:

On the one hand, mainstream medicine (when practised based on the evidence-base) may provide too little hope for some patients. A sports medicine example could be “sadly it looks like your knee osteoarthritis isn’t curable and we can only offer you suggestions to mitigate but not cure the pain and disability”. In this circumstance, some patients may seek an alternative practitioner who can offer the hope that mainstream medicine doesn’t profess to be able to give.

On the other hand, in mirror image circumstances, the reputation of mainstream medicine can be harmed when a widespread intervention gets discredited and revealed to have been only effective as a placebo and was maybe even harmful. We may be heading into an era where there is a group of patients who distrust mainstream sports medicine for having organised so many knee arthroscopies for arthritis prior to studies checking whether it was effective. Like any other area of life, there will be occasional scandals and corruption in health care and medicine.

So, like the cliche about the rock and the hard place, where there is no proven effective treatment, a clinician can be criticised for (a) not trying anything or (b) paradoxically for trying something that didn’t work and had no evidence-base.

What’s the solution?

Something needs to guide us out of this fog, and the saviour is the scientific method. In the glass-half empty world, it could be seen as a disgrace that so many ineffective knee arthroscopies for arthritis were done between 1980 to 2010 without scientific evidence to prove their efficacy. In the glass-half full world, which is where you need to live to be a successful health practitioner, it is a triumph of science that (eventually) a common procedure was assessed properly and found wanting. The disgrace will be if segments of the medical profession take too long to respond to the evidence, but it is not a disgrace to have tried a biologically-plausible treatment (knee arthroscopy for knee osteoarthritis) for a condition that is chronic and painful. Science moves along slowly but the scientific method should be the rock on which all health practice is based. One of my recent book readings I’ve enjoyed has been Shrinks: The Untold Story of Psychiatry by Jeffrey A. Lieberman. This excellent book has the underlying theme that evidence-based medicine is the way psychiatry progressed out of the dark ages.

Tie funding to evidence-based practice?

So fundamental is the scientific method that respect of it (or otherwise) should be the key criterion for health care funding and even registration. Because medicine is an inexact science, there is room for healthy skepticism about some of the controversial less-proven beliefs within it (with say, the replacement of the “stress” hypothesis of stomach ulcers with the Helicobacter pylori discovery being a great case in point). However when skepticism reaches a point that it involves rejection of a body of scientific knowledge that is beyond reasonable doubt, based on personal opinion, it becomes dangerous quackery. Within health-care, the anti-vaccination movement is the most prominent anti-science, anti-medicine movement at the moment. Being anti-vaccination is almost a calling-card for being anti-science and there is a good argument that you should not be licensed as a health practitioner if you reject the scientific method (i.e. practice on the basis that your personal experience and beliefs are more valid or accurate than anything that anyone has formally studied and published).

The field of Chiropractic gives rise to the debate between scientific and fundamentalist (called vitalistic within chiropractic circles) branches of the same profession. There has been recent debate at Macquarie University, Sydney about whether it is appropriate to teach Chiropractic degrees at the University. There has been a “soft” policy in the past of Sports Medicine Australia (SMA) that chiropractors should be discouraged from membership as an insufficient professional qualification, although this has been relaxed in recent years. I suggest a significant minority of chiropractors appear to be anti-science and anti-medicine. They may literally believe, for example, the original tenet of chiropractic that spinal malalignment is the underlying basis for all human disease, and therefore that the correct treatment of all medical conditions is spinal manipulation. This gets particularly touchy when some chiros allegedly ask their patients to reject, say, cancer chemotherapy in favour of spinal manipulation; or suggest that parents bring their ill newborns into chiropractic manipulation clinics rather than to GPs or emergency departments. That chiropractic is a refuge location for many in the anti-vaccination movement is also somewhat damning of the profession as a whole. For those who are fans of Twitter and anecdotes of chiropractic extremism, a ‘must follow’ is @Reasonable_Hank.

In defence of the (hopefully majority of) chiropractors, many in the real-world practice-wise have much in common with more mainstream professions. Chiropractors are part of sports medicine teams at major sporting events in reputable teams that practice according to evidence. Chiropractors may give evidence-based advice about return to physical activity wherever possible, and combine this with some effective treatment and doses of plenty of harmless but placebo-effective treatment which achieves this (very healthy) goal (of increased physical activity). There is an organised group of Chiropractors and Osteopaths called COCA (www.coca.com.au) in Australia which specifically is trying to move in the evidence-based medicine and science direction. Is it fair to tar these chiropractors with the brush of the rogue-end vitalists? There certainly would be physiotherapists and even medical doctors with ‘alternative’ anti-science mindsets, although their numbers may be less frequent. It does challenge the evidence-based chiropractors in groups like COCA to try to dissociate themselves from their fundamentalist colleagues, but it also challenges those of us in mainstream medicine to try to avoid, as much as possible, being pots calling the chiropractic kettle black.

Although I’ve tried to stay optimistic, a more distressing finish to this article has to be an acknowledgment that the anti-vaccination movement has many parallels outside health. It is terrific that the Australian government favours vaccination, but in other areas of science their policy stance is woeful. Climate change denial is the worst of it, but draconian cuts to the funding of basic science research in Australia and the removal of the portfolio of Minister for Science all point to an agenda against anti-science.

Comments on the USA

It gets far worse in the USA, the world epicentre of climate-change-denial and also where there are schools which are teaching creationism over evolution with political backing. There is evidence that politicians have interfered into science funding in the USA to not allow scientists to research public health benefits of gun control laws. Sadly there are two republican Presidential nominees who are specialist doctors by profession (Rand Paul and Ben Carson) but whose quoted political views on scientific matters seem incompatible with an understanding of the basic principles of the scientific method. Both apparently disbelieve basic scientific facts such as evolution and that the Earth is older than is stated in the Bible. Because of the openness of the democratic process, this does not disqualify them from being politicians. Obviously I have no information on their respective medical practices, but I’d be horrified if they had similar disregard for science when it came to decisions about whether to operate on a patient, for example. My concern is that it is too dangerous to run the libertarian “freedom of speech” arguments when it comes to medical staff. Healthcare professionals should have a limit placed on how much they can let any individual view override the scientific knowledge base, with the value of vaccination being a case in point. There is a good public safety argument that regulators should restrict healthcare licences to practice to those who respect the scientific method.

It is distressing that research on climate change, for example, is seen for the most part to be a left versus right wing political issue, when in reality it is a science versus quackery/corruption issue. I hope that I am preaching to the converted that the loyalty of modern health practitioner should not be to “God, king and country” (in that order) but to “science and medicine” in that order. Without science our health professions are worthless but because of it they amongst the most noble of all human pursuits. #ImWithScience (=I’m with science for Twitter)

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 @DrJohnOrchard  is a sports physician located in Sydney, NSW. The opinions expressed are his own personal opinions.

Highlights from the Female Athlete, BASEM Spring Conference 2015

14 May, 15 | by BJSM

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

By Sean Carmody (@seancarmody1)

“Too often in sport, doctors are men and they don’t understand”

That was the opinion of Paula Radcliffe last January in reference to the effects of menstruation on athletic performance. Clearly a challenge had been laid down to Sport and Exercise Medicine (SEM) as a discipline to deliver better care, that pays attention to sex and gender, to female athletes. With that in mind, the recent BASEM Spring Conference on the theme of The Female Athlete was particularly timely. Key themes and sub-topics from the conference are highlighted below.

tired-athletesThe Relative-Energy Deficiency in Sport – Professor Sundgot-Borgen

  • The Female Athlete Triad doesn’t account for effects of reduced energy availability among male athletes.
  • Relative Energy Deficiency in Sport (RED-S) recognises the importance of energy availability for optimal health and performance but presents a more comprehensive approach than the triad’s limited triangular view.
  • Risk factors for developing relative energy deficiency include; restrictive eating, injuries and illness, specialisation, decline in performance level, casual misinformed comments by coaches on physical appearance.
  • Risk of developing RED-S can be minimised by: educational programs for athletes and coaches, re-emphasising weight as a performance parameter, avoid critical comments about body shape, increase athlete awareness of effect of optimal energy intake on performance, open communication to encourage discussion around eating problems.
  • Further research is required to examine energy deficiency among male athletes and Paralympians.

See also: IOC Consensus Statement on Relative Energy Deficiency in Sport.

Bone Health in Athletes – Dr Julia Newton

  • Bone is a biological machine and adapts to load and function.
  • 7% of maternal bone is lost to the fetus during pregnancy.
  • The adolescent period is key- bone mass increases by 25-40% in puberty.
  • Factors which can affect the attainment of peak bone mass include; exercise, endogenous hormone profile, energy deficiency associated amenorrhoea, timing of puberty, smoking, teenage pregnancy, anorexia, exogenous hormones whilst still accruing bone.
  • Factors which lead to bone loss include; low oestrogen or testosterone, increasing age, corticosteroids, decreased weight or muscle mass, smoking and alcohol.
  • There is a 2-4 fold increased risk of stress fractures in amenorrhoeic athletes.
  • Vitamin D deficiency is an independent risk factor for stress fractures.
  • Treatment options for low bone mineral density include; calcium and vitamin D supplements, impact exercise, addressing contributory lifestyle factors.

Ballet: The Vitamin D and Bone Mineral Density Story – Professor Matthew Wyon

  • Ballet dancers undertake rigorous training; 38 hours per week at least.
  • They are considered prime candidates for developing the female athlete triad.
  • The research examining the prevalence of low BMD among ballet dancers is limited, however initial studies suggest 40% have low bone mineral density.
  • The average ballet career ends at 24, so it is important to keep long term health of the athlete in mind.
  • Ballet dancers are commonly deficient in Vitamin D. They train and perform indoors, have restricted diet practices and do not commonly supplement.
  • Diet has poor effect in restoring Vitamin D levels apart from a few exceptions (eg oily fish).
  • There is a potential link between vitamin D deficiency and increased incidence of injury.

To Bleed or not to Bleed – Mr Michael Dooley

  • A sports gynaecologist concerns themselves with the effects of the menstrual cycle on performance, amenorrhoea and relative energy deficiency in sport, contraception and infertility.
  • The percentage of women participating in the Olympics has increased from 11.5% in 1960 to 44.5% in 2012, meaning that understanding the effects of the menstrual cycle on performance is a relatively new issue.
  • Women have won gold medals, and broken world records at all stages of the menstrual cycle.
  • Swimmers have demonstrated a premenstrual worsening of performance with improvement during the menstrual cycle.
  • ACL rupture is 4-8 times higher in women, and appears to occur more often in the ovulatory phase of the cycle.
  • Amenorrhoea leads to an increased risk of stress fractures.
  • Athlete quote; “Having a carefully prepared plan to manipulate my cycle to avoid competition has helped my mental preparation, performance and enjoyment”.

Gymnastics – Dr Chris Tomlinson

  • Gymnastics is a weight-dependent sport demanding intensive training regimes.
  • Gymnastics involves young, skeletally immature athletes who are at risk of overuse and traumatic injuries.
  • Common injuries in gymnastics include shoulder impingement, osteochondral defects in the elbow, lumbar spine stress fractures, and ACL rupture.
  • Physicians take a twice-yearly menstrual history from gymnasts, and a once yearly SCAT score as a baseline, DEXA scan twice annually to examine body composition.
  • Daily weighing in gyms is common and can lead to public shaming. 20% of gymnasts show evidence of an eating disorder.
  • Weighing should be carried out in a private setting (eg in a clinical consultation room away from coaches and other athletes).
  • Retiring gymnasts should be equipped with the skills to cope, and the appropriate social support structures should be put in place.

The Female Elite Athlete: A practical approach to the medical issues – Dr Anita Biswas

  • Common problems among female athletes include stress fractures, ACL rupture, low energy availability and mental health issues.
  • All support staff should be aware of issues surrounding training load and menstrual cycle.
  • The EIS Vitamin D strategy includes: screening for deficiency and supplementing accordingly.
  • Faddy diets such as carbohydrate restriction are often practiced by female athletes.
  • The EIS carry out annual medical screening including questions around menstruation and eating habits.
  • Information sharing between sports will improve athlete care.

Sean Carmody is a final year medical student at the Hull York Medical School. He tweets regularly on subjects relating to sports medicine and performance @seancarmody1.

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.

Practical application of cardiac research: the way forward, for BOTH general medicine and sports medicine

11 May, 15 | by BJSM

Cardiology is a hot topic in sports medicine at the moment and also remains of major interest in the general medical field. As an example, Jessica Orchard received the Royal Australian College of General Practitioners (RACGP) National Best General Practice Research Article in Australian Family Physician (AFP) Award, 2015. Together with co-authors from The University of Sydney, Jessica was lead author on “iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study”, Open Access in Australian Family Physician, 2014 [1].

alive cor iECG

AliveCor iECG (Disclosures: AliveCor have provided free covers for study purposes. No author or associated institution has received any financial payment from AliveCor, nor owns any shares in AliveCor.)

The GP-SEARCH pilot study demonstrates a highly practical way to introduce modern technology (iPhone ECG screening) into general practice screening for atrial fibrillation, a common heart rhythm problem in older adults. The study highlights the approach’s feasibility both in terms of available technology, and practice nurses’ suitability for screening delivery. Obtaining a single lead ECG (usually lead I) rhythm trace on a smartphone screen (using an attached cover) takes less than a minute.

Screening application in Sports Medicine

iPhone cardiac

Athlete showing iECG reading

Jessica is currently investigating the utility of the same device (an iPhone single lead ECG App that can take a rhythm reading in under a minute) for diagnosis and screening in sports medicine settings. Cardiac conditions are very topical in sports medicine with the sad news of regular arrests and some sudden deaths in high level athletes around the world, the latest of which was Rugby League Welsh international Danny Jones 2 weeks ago. Jessica also blogged for BJSM on the advances in preventing sudden cardiac death at the IOC Prevention of Injury and Illness in Sport at Monaco in April 2014. Both rhythm disorders and outlet disorders can predispose to sudden death in sports and the single lead ECG is particularly useful at quickly assessing rhythm. Some arrhythmias that can lead to symptoms (including collapse) on the sporting field are very transient and obtaining a rhythm trace quickly is extremely valuable.

Related Research

With both a public health and law background Jessica has contributed two first author BJSM papers on the topics of:

  1. Reforming the bidding process for major sporting events to promote physical activity [2] and;
  2. Preventing radiation overexposure in sports medicine diagnostic investigations [3].

She was also a co-author on a recent cardiology paper protocol also using the iPhone ECG in BMJ Open [4].

References

  1. Orchard, J., Freedman, S., Lowres, N., Peiris, D., Neubeck, L. (2014). iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study. Australian Family Physician, 43(5), 315-319.
  2. Orchard, J., Orchard, J., Driscoll, T. (2010). Comparison of sports medicine, public health and exercise promotion between bidding countries for the FIFA World Cup in 2018. British Journal of Sports Medicine, 44(9), 631-636.
  3. Orchard, J., Orchard, J., Grenfell, T., Mitchell, A. (2014). Ionising radiation: three game-changing studies for imaging in sports medicine. British Journal of Sports Medicine, 48(8), 677-678.
  4. Lowres, N., Freedman, B., Gallagher, R., Kirkness, A., Marshman, D., Orchard, J., Neubeck, A. (2015). Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: A study protocol. BMJ Open, 5(1), 1-5.

Podcast Cluster #2: Shoulder Injuries

7 May, 15 | by BJSM

By Steffan Griffin (@lifestylemedic)

Moving on from our hamstrings focus in the last podcast cluster, and to further last week’s listening enjoyment of David Opar & Carl Askling, we have rounded-up podcasts with more huge names from the world of SEM. They provide pearls of wisdom on a variety of shoulder pathologies, from rotator cuff tendinopathy to AC joint disruption.

8 podcasts from 5 world-renowned speakers with a combined total of 15,000+ listens:shoulder x0ray

Scroll down and enjoy!

Dr Ben Kibler- The Shoulder in Sport: why tennis serves are a ‘weapon’ and the integral role of biomechanics in shoulder pathology http://bit.ly/1EMiCsF

Scapular dyskinesis in shoulder injury: scapular involvement in various shoulder injuries and clinical implications http://bit.ly/1EMiF7I

Ann Cools – The Spectacular Scapula: Dig deeper into the role of the scapula in shoulder injuries, especially in overhead athletes. Features nuggets on the role of eccentric training in the rehabilitation process as well as what to expect in the shoulder of aging tennis players  http://bit.ly/1EMiRUr

Prof Jeremy Lewis- #ConfusedAboutTheCuff? Learn insights that address these questions: What role does the subacromial bursa play in rotator cuff tendinopathy, and what does the future hold in terms of management? http://bit.ly/1EMjddJ

Four bread-and-butter shoulder problems + special bonus* with:

Prof Mark Hutchinson http://bit.ly/1EMjrSj

His MSK exam videos have been watched by over 5 MILLION* people online http://bit.ly/1aLulve, so the BJSM tracked him down and asked him to cover 4 shoulder-related clinical cases and one special bonus for you #GOLD.

Prof Bob McCormack- Active shoulder research + Experience of 3 Olympic Games = 3 fantastic shoulder podcasts.

Shoulder dislocation, common but controversial. So conservative rehabilitation first or reconstruction? #MillionDollarQuestion http://bit.ly/1EMkUIg

Mid-clavicular fracture – Open surgery or collar and cuff? http://bit.ly/1KWdmE4

What’s the best management for a complete (Grade III) AC joint dislocation? The results of a national multi-centre trial http://bit.ly/1EMlvJX

Don’t forget – you can listen to these on the free BJSM app, where you can also access other blogs, podcasts, articles +++! So whether these entertain you on your daily commute or grace your ears whilst being active, please feel free to share with your friends & colleagues as well as let us know your thoughts on Twitter (@BJSM_BMJ), Facebook & Google +. #SharingisCaring

Swimming Induced Pulmonary Oedema – raising awareness about this potentially life-threatening condition

5 May, 15 | by BJSM

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

 

By Dr Ralph Smith, Dr Jim Kerss & Dr Daniel Brooke

With the new season approaching, Triathlon is one of the fastest growing participation sports in the United Kingdom (UK). The swim component of a triathlon is usually held in open water (fresh water lakes, rivers or sea based). Alongside triathlon, there has been a recent surge in participation in open water swimming events. Both events attract competitors varying in age, ability and fitness levels. There are risks in addition to significant health benefits of participation, and there is a growing requirement for on-site medical care. Event medical staff must be aware of and prepared for the specific illnesses and injuries that present in these sports.

In 2014, whilst providing medical cover at UK based open water triathlons, we (the authors) encountered two cases of Swimming Induced Pulmonary Oedema (SIPE). This is a rare and potentially life-threatening condition which is increasing in frequency with the sport’s growing popularity. Thus, our aim in writing this blog is to raise awareness and improve the recognition of SIPE amongst athletes and event medical staff.

open-water-swimming-tips

Background

SIPE is also known as immersion pulmonary oedema. It was first described in the 1980s in healthy scuba divers1. Since then, there have been over three hundred reported cases in triathletes, swimmers and divers2 which include fatalities3.

Presentation

Typically affected patients usually present during or shortly after swimming (or diving) with:

  • Acute Shortness of Breath
  • The absence of water aspiration
  • Cough which is often productive of copious pink frothy sputum
  • Examination signs consistent with acute pulmonary oedema

Investigation & Management

In the pre-hospital setting, it is paramount appropriate resources are available for a safe water evacuation to prevent drowning. After an initial assessment (using an ABCDE approach including oxygen saturations +/- supplementary oxygen if clinically indicated) the patient will likely require transfer to hospital for further investigations and management.

In the acute hospital setting, investigations should include a chest radiograph (CXR), 12 Lead Electrocardiogram (ECG), Echocardiogram and measurements of cardiac enzymes. There is often evidence of hypoxia on oxygen saturations, pulmonary oedema on CXR, and raised cardiac enzymes. However, it is important to note that these tests can be normal.

The symptoms of SIPE usually resolve within 24-48 hours of presentation – sometimes without the need for any treatment such as Oxygen or diuretics. Despite this prompt evaluation of cardiac and pulmonary function one must exclude any underlying pathological cause. Investigations usually show normal underlying cardiac and pulmonary function, however, Peacher et al recently suggested that the role of cardiopulmonary dysfunction in SIPE may be underestimated, particularly in the older athlete, and that an episode of SIPE may unmask subclinical disease2. Rates of recurrence are as high as twenty two percent4 and are unpredictable. The medical team should advise that further episodes can occur and explain appropriate safety precautions. Indeed in one of our cases the patient suffered a further episode whilst open water swimming.

Pathophysiology

Due to the sporadic nature of SIPE and the inability to reproduce it under experimental conditions the exact pathophysiology remains somewhat elusive and debated5. The prevailing hypothesis is that cold water immersion leads to peripheral vasoconstriction, central blood pooling and increased cardiac preload2. In combination with the increased cardiac output from exercise this results in an elevated pulmonary artery pressure, increased hydrostatic pressure and alveolar oedema. Tight fitting wetsuits may exacerbate the situation through compression of peripheral blood vessels, further increasing central blood pooling and cardiac preload6.

Is the condition more common than we think?

As symptoms tend to resolve spontaneously, those with a milder episode of SIPE may not always seek medical attention as their symptoms could resolve when exiting the water and resting. Indeed Miller et al surveyed 1400 triathletes and found 1.4% of athletes had experienced symptoms that were suggestive of SIPE, suggesting significant under reporting7. Such an incidence would have resulted in almost 20 presentations at Ironman UK 2014 (1,982 competitors).

Future suggestions

Medical staff working at mass participation sporting events that include an open water swim component should suspect SIPE in competitors who are unusually short of breath, particularly if they have a cough productive of pink frothy sputum. Investigation is necessary to exclude any underlying cardiopulmonary dysfunction but this may be normal. Communication about the potential diagnosis of SIPE should be made when transferring affected patients to hospital to alert colleagues of this condition. Race organisers, athletes and medical staff should be educated in the recognition of SIPE and its management, particularly considering the rapid raise in popularity in triathlon and open water swimming.

References

  1. Wilmshurst PT, Nuri M, Crowther A et al. Cold-induced pulmonary oedema in scuba divers and swimmers and subsequent development of hypertension. Lancet 1989 Jan;14;1(8629):62-5.
  2. Peacher DF, Martina SD, Otteni CE, Wester TE, Potter JF, Moon RE. Immersion Pulmonary Edema and Comorbidities: Case Series and Updated Review Med Sci Sports Exerc. 2014 Sep 12. [Epub ahead of print]
  3. Scuba divers’ pulmonary oedema:recurrences and fatalities. Diving Hyperb Med. 2012;42(1):40-4.
  4. Adir Y, Shupak A, Gil A, Peled N, Keynan Y, Domachevsky L, Weiler-Ravell D. Swimming-induced pulmonary edema. Chest. 2004;126(2):394-9.
  5. Wenger M, Russi EW. Aqua jogging-induced pulmonary oedema. Eur Respir J. 2007;30(6):1231-2
  6. Spiteri DB, Debono R, Micallef-Stafrace K, Xuereb RG. Recurrent swimming-induced pulmonary oedema (SIPE) in a triathlete. ISMJ. 2011;12(3):141-4.
  7. Miller C, Calder-Becker K, Modave F. Swimming-induced pulmonary oedema in triathletes. Am J Emerg Med 2010 Oct;28(8):941-6.

 

 

 

 

About the Authors

 

Ralph Smith is an ST3 SEM trainee in the Thames Valley Deanery. Prior to entering the training programme, he completed an MSc in SEM and his General Practice training. He is currently works in rugby union with Henley Hawks and Wasps Academy. He has keen interest in endurance sports and started open water swimming and triathlons last year.

 

Jim Kerss is an ST5 SEM trainee in the North West Deanery based at the English Institute of Sport in Manchester and is the British Para-Swimming Team Doctor. He has a keen interest in medical education and is currently undertaking a NW Deanery Medical Education Fellowship. He is the current Trainee representative on the SEM SAC and co-ordinates the UK SEM Speciality Trainee teaching days.

 

Daniel Brooke is a GP ST2 working in Surrey with a keen interest in pursuing SEM. He has extensive experience covering a wide range of sports across the UK.

 

Dr Farrah Jawad co-ordinates the BJSM Trainee Perspective blog.

Doctors’ role in physical activity adherence: how can we keep patients on the road to better health?

1 May, 15 | by BJSM

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

By Steffan Griffin (@lifestylemedic)

So your patient saw Mike Evans’ 23.5 hours video and s/he understands that physical activity is the polypill that will maximise their chances of living a healthy life (Also see this blog de-bunking physical activity myths). They even started walking for 10 minute periods three times a day. But that was twelve weeks ago and it’s since started getting dark earlier and their daughter has started another after-school class, which further limits their spare time. Is physical activity still a priority or will the habit gently dissolve?

We all know patients who have a yo-yo relationship with physical activity, but what can we do to try and facilitate a sustainable change? In these individuals, how can we maximise the chances of adherence to a physical activity pledge/programme? This blog adresses the evidence relating to certain interventions and techniques proposed to affect adherence. It also provides some top tips to use in practice.

Why is adherence important?

Long-term adherence to physical activity is essential for the maintenance of health benefits. It has a long-term survival benefit¹, and is linked to greater fitness improvements and disease-specific outcomes as well as increased physical function and quality of life². Yet as you know, around 50% will drop out of a PA programme within a few months³.

Who is most likely to drop-out?

Essentially, exactly the population we want to get and keep active! Demographic risk factors for low adherence include older age, female gender, non-white ethnicity and low socio-economic status. Couple this with pre-existing chronic disease and/or lower physical function and weight issues and you’ve found your perfect recipe⁴ for a yo-yoer.

How can we keep these patients on the straight and narrow?

As Jorgen Jevre stated in relation to lower back pain in his recent fantastic BJSM blog, there is no golden ticket in medicine, and this especially true in trying to get and keep patients being physically active. So after assessing your patient’s activity levels, what can you do in the time you have left with your patients?

Tip 1: Inform,,

  • mamilHow can being active benefit them?
  • What counts as activity?

Physical activity doesn’t have to mean becoming a MAMIL (middle age man in lycra).

#walkingdoeswonders

#SitLessStandMore

What does/did the patient enjoy? Enjoyment is a good indicator of long-term behaviour change.

Tip 2: Be #SMART,,

Goal-setting is a good way to increase adherence. Make goals Specific (Who, What, Where, When, Why?), Measurable, Attainable, Realistic and Temporal (setting subsequent shorter term goals is better than one huge longer-term one).

Tip 3: #SmashThroughBarriers,,

Identify the barriers and strategise on how they can be overcome. Teach the patient how to use this approach by themselves too.

Tip 4: #TeamEffort

Suggest that the patient involves those around them in their goals. Is group activity more suitable/realistic? Social support increases the connectedness to the activity and is more likely to lead to internalised behaviours,,, the ‘golden snitch’ of health psychology.

Tip 5: MI (not the MI you’re thinking about)

Motivational Interviewing is a patient-centred form of discussion used to strengthen an individual’s motivation for a specific goal by exploring the person’s own reasons for change⁷. It may sound a bit hippy, but you can’t argue with the fact that 80% of relevant studies report that MI outperforms traditional advice-giving⁸.

#TeachmehowtoMI

Essentially, instead of adopting an expert position, the goal is to guide the patient towards directing themselves as to why/how they might increase their PA. Whilst you provide information (with permission!), the key objective is to elicit some form of patient-based change-talk.

Step 1: Engage with the patient and establish an agreed focus for the conversation

Step 2: Evoke the patient’s own motivation to change, followed by planning if the person is ready for this.

Dr Brian Johnson provides a great overview and video examples of good practice in the fantastic ‘Motivate 2 Move’ module. This document also provides a fantastic example of using MI to increase PA.

How can I summarise these tips?

The ultimate goal for long term adherence is facilitate the internalization of the desired behaviours in patients. Deci and Ryan’s⁹ self-determination theory essentially deals with this, claiming that our inherent propensity for personal development and wellbeing are governed by a few basic pscychological needs:

  • Autonomy: the degree of personal control/choice in the matter
  • Competence: the degree of proficiency related to a certain behaviour, task or skill
  • Relatedness: the degree to which we feel connected to the behaviour in question

Focusing on each factor¹⁰

Autonomy: take the perspective of the client/patient, support their choices, minimise pressure

Competence: be realistic, limit negative feedback, provide optimally challenging goals

Relatedness: create an empathetic and positive environment

If you use these as the clinical framework to increase and maintain adherence in your patients, be it regarding physical activity or otherwise (diet, smoking, alcohol etc) and utilise the MI techniques, you will hopefully find that your patients are much better at sticking to the right path.

References

1. Morey MC, Pieper CF, Crowley GM, Sullivan RJ, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults [comment]. J Am Geriatr Soc. 2002;50(12):1929–1933

2. Belza B, Topolski T, Kinne S, Patrick DL, Ramsey SD. Does adherence make a difference? Results from a community-based aquatic exercise program. Nurs Res. 2002;51(5):285–291.

3. Dishman RK. Overview. In: Dishman RK, ed. Exercise adherence: It’s impact on public health. Champaign, IL: Human Kinetics; 1988.

4. Allen, Kelli, and Miriam C. Morey. “Physical activity and adherence.” Improving Patient Treatment Adherence. Springer New York, 2010. 9-38.

5. Rejeski WJ, Brawley LR, Ambrosius WT, et al. Older adults with chronic disease: benefits of group-mediated counseling in the promotion of physically active lifestyles. Health Psychol. 2003;22(4):414–423

6. The Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the activity counseling trial: a randomized controlled trial. JAMA. 2001;286: 677–687.

7. What is motivational interviewing? Motivational Interviewing Network of Trainers (MINT) http://www.motivationalinterviewing.org/ (Accessed 04/02/2015)

8. Rubak S, Sandback A, Lauritzen T, Chitensen B. Motivational interviewing: a systemic review and meta-analysis. British Journal of General Practitioners. 2005;55(513):305-312.

9. Ryan, R. and Deci, E. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000; 55, pp. 68-78.

10. Teixeira PJ, Carraca EV, Markland D, Silva MN, Ryan RM. Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act. 2012;9:78.

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

Steffan Griffin is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

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.

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