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Are you getting the most out of BJSM Education?

31 Oct, 14 | by BJSM

By Babette Pluim @Doc_Pluim

BJSM is a multimedia portal for original research, critical reviews and timely debate in sport and exercise medicine. As education is a BJSM cornerstone, we have a dedicated BJSM Education website:

BJSM Education offers high-quality, peer-reviewed educational material for clinicians whose practice relates to sport, exercise, and physical activity promotion. It supports the entire readership from established consultants in sports and exercise medicine (physiotherapists and physicians) to trainees and professionals from other disciplines with an interest in SEM.

CKJ skellyThe most popular features on the BJSM Education website are:

  1. Educational videos
  2. ECG learning modules
  3. Tendinopathy toolkits
  4. Case based learning
  5. Review papers with MCQs
  6. Image Quizzes
  7. i-tests

The ‘Educational videos’ instruct physicians and physiotherapists on how to perform systematic physical examinations. They also provide information about the latest evidence-based exercise prescription programs. The most recent additions to the library include videos promoting healthy body image in sport and calling for action against sexual harassment in sport.

The ‘ECG learning modules’ provide valuable lessons in interpreting ECGs; assisting physicians to identify benign ECG changes seen in athletes and differentiate those from pathological patterns

The ‘Tendinopathy toolkits’ provide clinicians with evidence-based, and expert-led, information to facilitate clinical decision-making in the management of tendinopathy of the Achilles tendon and of the lateral epicondyle.

The ‘case based learning’ section contains a large selection generously provided by the AMSSM, and also includes elaborate interactive case histories created by some of the world’s leading experts, immersing you in an interactive learning environment.

The section containing ‘Review papers with multiple choice questions’  tests your knowledge and also provides you with a Completion Certificate.

The ‘Image quizzes’ based on real-life cases, provide the opportunity to test and update your knowledge by identifying the most likely diagnosis. These are ideal for the busy clinician or trainee who wants a quick and easy learning bite.

The ‘i-tests’ (‘i’ for ‘imaging’) have been specially created for updating one’s skill in interpreting imaging.

This is only a small selection of what you can find at BJSM Education (PowerPoints related to Concussion Consensus,[1,2, pictorials essays, podcasts etc.).

EVERYTHING is available free to our subscribers!

N.B. The modules developed in conjunction with BMJ learning require you to register with BMJ learning but only takes seconds and is also free.

Are you getting the most out of your BJSM access?

The mix of web, video, audio, MCQ and Q+A offers a truly blended environment for effective learning. All the 13 sports medicine and sports physiotherapy societies affiliated to BJSM, with a combined membership of over 10,000, have contributed to further development of this site and we are continuously interpreting more material from each member society.

Make sure you don’t miss out and visit the BJSM Education website soon!



  1. Provvidenza C, Engebretsen L, Tator C et al. From consensus to action: knowledge transfer, education and influencing policy on sports concussion Br J Sports Med 2013;47:332-8.
  2. McCrory P, Meeuwisse WH, Abry M et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258

Technology and Digital Health – the future for SEM?! Part two of a series from the RSM Exercise Medicine Conference, 2014

29 Oct, 14 | by BJSM

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

By Rory Heath (@Roryjheath)

arm technologyMoore’s law states that technological developments double every year.. It also predicts that computer processing power will exceed all human brains combined by 2045. These trends are relevant to healthcare settings as the use of technological tools rise exponentially. Technology has huge potential in medicine to save money and time, aid acute treatment in hospital and serve as a tool to promote exercise as a disease preventative measure.

To share learning and encourage discussion about health + technology, here are the highlights from my Royal Society of Medicine (RSM) Exercise Medicine Conference session notes:

Wearable Tech – the future of healthcare. Mr Maneesh Sethi

  • Devices themselves are simple, with long battery life. The complicated software is in the user’s phone or other complimentary devices.
  • Wearable technology is a rapidly growing industry, with 150 million units estimated to ship next year.
  • Devices can currently track statistics such as: heart rate, temperature, O2 saturation, and perspiration rate. Healthcare can use the trend of ‘the empirical human’ to collect data, forewarn of disease and track progress.
  • Wearable technology allows tracking of larger sample populations in studies.
  • ‘We don’t know what we already do’. We overestimate our physical activity, and underestimate our calories ingested. Technology can provide unbiased data of our day-to-day activity.

How to form good exercise habits in the brain. Mr Maneesh Sethi

  • Exercise is a great ‘Keystone habit’ as it has subsequent positive knock-on effects on health behaviours.
  • The brain will associate an activity with habit when completed everyday, from 20 days (an easy activity) to 66 days (a more difficult activity).
  • Behaviours are difficult to initiate as they require executive function and energy. Habits become passive brain functions that require little energy, and are easier to maintain.
  • We become ‘dependent’ on habits. We notice when they are not fulfilled. Can we utilise this feeling to promote beneficial health behaviours?
  • Habits can be initiated through training; ‘Cue, routine, reward’. Behaviour = Motivation, Activity, Trigger. Technology can be used to provide these factors. Alternatively, technology can provide punishment to condition, borrowing from Pavlov’s experiments.
  • ‘Microhabits’ can promote greater change. They provide a progression to make change step by step. For example:
    Week 1: ‘Put on your gym clothes’.
    Week 2: ‘Put on your gym clothes, unlock the front door’.
    Week 3: ‘Put on your gym clothes, unlock the door and take a step outside’.

Biosensors and big-data – how elite sport and jet engines are transforming medicine. Dr Jack Kreindler

  • Data is great, but is it functional? First and foremost, when we collect data we must know what to do with it. We should use the huge amount of data available due to the exponential rise in technology (Moore’s law) to target healthcare’s biggest problems.
  • As price cuts set in we should embrace using technology to process patients’ data in healthcare. The cost of avoidable hospitalisation due to chronic disease is huge – can we use technology to prevent this?
  • Novel uses of technology: 3D printing of tracheal template covered with stem cells used successfully as a transplant in vivo by Dr Martin Elliot, GOSH.

Democratisation of exercise using technology. Mr Brian Snyder

  • Athletic technology allows the normal population to access treatment normally reserved for elite athletes. Coaching can be unaffordable and unreachable, but cheap technology allows people to access coaching in their own homes.
  • Exercising at home through videos is a linear process and offers no feedback. The use of technology allows interaction between the software and the person, promoting feedback and adaptation.
  • Using approaches found in the computer gaming industry, technology can be used to encourage people to exercise and motivate them to continue exercising.

Wearable sensors and physical activity research. Dr Aiden Doherty

  • Accelerometers are cheap and useful in research. They can be used on a large scale to measure the activity of populations.
  • Accelerometer accuracy is greatest at the hip, but usage at the wrist provides better compliance.
  • Wearable cameras are a useful tool to identify individual behaviours, assess environment (possible use in urban planning).

Using digital to build a health and fitness community. Ms Lulu Skinner

  • The advent of smartphones and computers as platforms for apps is quickly being used to promote exercise through online communities.
  • Technology and online presence can promote exercise by reducing barriers felt by the public , namely by, providing education and increasing confidence through advice and feedback.
  • Approaches taken by apps to make exercise competitive and constructive increase motivation.

Once again, I’d like to thank the organisers of the Exercise Medicine conference for producing a highly interesting and informative event. As a young medical student, it was a great opportunity to further my knowledge of a topic sparsely found in the medical school curriculum, whilst also cultivating new contacts with fantastic people. Next year’s event has already been scheduled and I highly recommend you reserve a place in your diary!

If you want to read part one of this two part series, go HERE.


Rory Heath (@roryjheath) is a third year medical student at King’s College London (KCL) and has a keen interest in sport, diet and exercise. He has played county rugby and rugby league for London and South. He is currently the KCL representative of the undergraduate London Sport & Exercise Medicine Society (LSEMS). ( He runs a Blog at

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.

Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy?

27 Oct, 14 | by BJSM


In response to:

Robert-Jan de Vos, Johann Windt, Adam Weir. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956. 

Dear Editor,

Recently a systematic review was published in your journal by de Vos et al (1) on the effect of PRP (Platelet rich plasma) injections in the treatment of chronic lateral epicondylar tendinopathy. They conclude there is strong evidence that PRP injections are not efficacious in the management of chronic lateral epicondylitis (LE).

In our opinion the conclusions drawn in this study are too firm and not properly supported by recent literature. In the review, PRP injections are compared to different other injection therapies as control group. In three of the included studies PRP injections are compared to corticosteroid injections (2,4,7). In current literature and stated by the authors of current review there are several studies that demonstrate a short term (4- 6 weeks) beneficial effect of glucocorticoid injections on pain in the treatment of lateral epicondylitis (11,12,13,14). The review by Krogh et al (11) found no long term benefits of glucocorticoid injection over placebo. After 12 months, conservative treatment appears more effective: 8 till 9 of 10 patients are pain free versus 7 of 10 patients having had corticosteroids. Therefore it cannot be used as a control group to investigate the efficacy of PRP injections, in fact it is even not ethical to use these as a comparison in future trials. The follow up of the study by Omar et al (7) was only 1.5 months. This may explain why there were no differences in outcome measures between the PRP and the corticosteroid group. The meta-analysis by Krogh et al (11) also showed that autologous blood, PRP, prolotherapy and hyaluronic acid were all more efficacious than placebo in the treatment of LE.

A relevant question in the discussion about the treatment of LE with injection therapies is the difference in effectiveness between PRP and autologous whole blood. The included study by Thanasas et al (5) shows a trend of decreasing VAS scores in favor of the PRP group (VAS improvement of 4.4 points (71%) compared to mean VAS improvement 3.4 points (58%)), no significant differences are found. The study by Creaney et al (6) showed no difference in VAS scores between PRP and autologous whole blood.

Because a meta-analysis has the highest level of evidence we performed a systematic search in Pubmed/Medline to identify trials comparing PRP with ABI in the treatment of LE. Four publications were identified (5,6,9,10). This first meta-analysis should be updated in the future to summarize the most up to date evidence.

To support these findings we have pooled data of the study by Thanasas et al (5) and data of  recent studies on the effect of Platelet-rich plasma versus autologous whole blood for the treatment of LE by Raeissadat et al (9, 10). This shows no differences in VAS painscores after six weeks (table 1) and 6 months (table 2) after treatment with PRP or autologous whole blood. Standard Deviations (SD) are estimated based on ranges or 95 % confidence intervals.

Table 1: VAS pain score after 6-8 weeks

Table 1: VAS pain score after 6-8 weeks


Table 2 PRP letter

Table 2: VAS pain score after 6 months


Creaney et al (6) and Thanasas et al (5) both used a (different) functional outcome score. Data of the two studies were pooled and showed no differences in functional improvement between PRP and autologous whole blood (table 3).

Table 3: Functional improvement at 3 months

Table 3: Functional improvement at 3 months

It is possible that the two studies by Raeissadat and colleagues (9, 10) used the same dataset, given the overlap in inclusion period. If this is the case, it would perhaps be better to consider them as one study. Due to the high level of heterogeneity, no firm conclusion can be drawn. Nevertheless, it is questionable to what extend there is a relevant difference in the treatment effect between PRP versus whole blood. When there is no difference in treatment effect, treatment with autologous whole blood is preferred due to the higher costs of preparation of PRP.

To answer this question, a high quality study is needed to compare the effects of autologous whole blood with PRP and placebo in the treatment of LE. In current literature the injections therapies are performed manually and blindly and are therefore not properly comparable (11). Future studies should be performed in a standardized way by an ultrasound guided reproducible and well defined injection technique to make the interventions comparable.


Renee Keijsers

Denise Eygendaal

Michel P. J. van den Bekerom


  1. de Vos, R-J, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic reviewBr J Sports Med doi:10.1136/bjsports-2013-093281.
  2. Peerbooms JC, Sluimer J, Bruijn DJ, et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38:255–62.
  3. Gosens T, Peerbooms JC, van Laar W, et al. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 2011;39:1200–8.
  4. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41:625–35.
  5. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med 2011;39:2130–4.
  6. Creaney L, Wallace A, Curtis M, et al. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45:966–71.
  7. Omar AS, Ibrahim ME, Ahmed AS, et al. Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: randomized clinical trial. Egypt Rheumatol 2012;34:43–9.
  8. Mishra AK, Skrepnik NV, Edwards SG, et al. Platelet-rich plasma significantly improves clinical outcomes in patients with chronic tennis elbow: a double-blind, prospective, multicenter, controlled trial of 230 patients. Am J Sports Med 2014;42:463–71.
  9. Raeissadat SA, Rayegani SM, Hassanabadi H, Rahimi R, Sedighipour L, Rostami K. Is Platelet-rich plasma superior to whole blood in the management of chronic tennis elbow: one year randomized clinical trial. BMC Sports Sci Med Rehabil. 2014 Mar 18;6(1):12.
  10. Raeissadat SA, Sedighipour L, Rayegani SM, Bahrami MH, Bayat M, Rahimi R. Effect of Platelet-Rich Plasma (PRP) versus Autologous Whole Blood on Pain and Function improvement in Tennis Elbow: A Randomized Clinical Trial. Pain Res Treat. 2014;2014:191525. doi: 10.1155/2014/191525. Epub 2014 Jan 20.
  11. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2013 Jun;41(6):1435-46.
  12. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 Dec;68(12):1843-9. Epub 2008 Dec 3.
  13. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319:964-968.
  14. Smidt N, Lewis M, Van der Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006;33:2053-2059.

What difference can a comma make? My personal story of influencing SEM and population-based physical activity in India

24 Oct, 14 | by BJSM

By Dr Rajat Chauhan,

Sports-Exercise Medicine & Musculoskeletal Medicine Physician; BJSM Associate Editor (India) @drrajatchauhan

For the first time in humankind, this current generation will die at a younger age than their parents. Two-thirds of all deaths today happen because of Non-Communicable Diseases e.g lifestyle diseases like Diabetes, Cholesterol, and Cancer. Surprisingly, 50 percent of these premature deaths may be prevented simply by being physically active. Even 50 percent of breast cancer is preventable if women are physically active.


Bangalore sunrise

Bangalore sunrise

The flight back to India

It was exactly eight years ago, when I was on a British Airways flight from London to Delhi. The air-hostess asked me if I was going on a vacation. I smiled and said, “I’m going back to practice Sports and Exercise Medicine.” She laughed aloud and said, “Are you serious? There are no sports in India besides maybe cricket, which is barely a sport in the first place. Who will you practice Sports Medicine on?

When I was doing a Masters Degree in Sports (and Exercise) Medicine from Queen’s Medical Centre at Nottingham University, all I wanted to do was help athletes win Olympic medals. I wanted to be involved with elite sportspeople by being a team doctor. I wanted to live a life of elite sport, even if it was not I who was competing and winning gold (a dream I had always held). I also saw it as a privledge to just support a team.

During the 2006 Melbourne Commonwealth Games, Christine Ijeoma Ohuruogu beat the then 400 m Olympic champion, Tonique Williams-Darling, to win the gold medal. Just a few months prior, I had played a role in Christine getting rid of her back pain, which could have stopped her from performing at her peak level. It seemed to me that I was happier than Christine herself on her achievement.

The awakening

But it then suddenly hit me. Now what? Was my calling in life only to help athletes excel at their chosen sport? I felt very lost. Was there a bigger cause I was meant to contribute to?

The British Air-hostess’s comment was very naive and innocent but one that unintentionally also stated the obvious – we humans have stopped doing what comes naturally to us, movement. As a matter of fact, we all moved before even being conceived, when sperms decided to ‘move’ the ultra distance. It’s our basic instinct, which we are in rush to forget about.

I realized that what really excited me was getting people moving again, and if they moved already, making them move more efficiently. I wanted to change lives of masses by helping to make everyone physically active, as ‘physical inactivity’ is the largest killer in today’s modern, but sedentary world. I called my own personal move-mint Get India FiT, or GIFT.

Sports & Exercise Medicine in Bangalore

I had moved back to India to take on the role of founder head of Sports & Exercise Medicine Department in one of the top corporate hospitals in Bangalore, IT capital of India. It’s not very often in the healthcare industry that a 30 year old is asked to head a department and I loved the challenge.

Even though it would make sense to anyone that physical activity is good for you, it’s not something that appeals to hospitals, definitely ones that need to sustain their five star existence. They need patients. But to take on the healthcare industry, I needed my army, of which I started building.

Acceptance of failure

A couple of months back, while having lunch with a friend Jonathan Gil Harris, I expressed how miserably I had failed at my mission in India. I had not yet been able to train the foot soldiers of the healthcare industry and the physiotherapists, to international levels. Since this friend was involved with a new university, I suggested he set up a physiotherapy course with a new approach. I figured you can’t train the youth in a certain field if they have got into it for all the wrong reasons. They often wanted to do medicine or had no clue what else to apply for. To make matters worse, till before I got into Sports-Exercise & Rehabilitation business in India, their pay packages were usually worse than the guards. Poor salaries neither motivated them to learn any more nor work with passion. Most would quit soon enough to pursue completely unrelated careers.

Gil and I agreed that we needed to something about this state of affairs urgently. He told me that this was a Liberal Arts university so we couldn’t start the suggested course. Gil also happens to be Dean of Academic Affairs and a Professor of English. I had no clue that a stroke of his pen, rather tongue, would put a comma in a place, that would help me achieve what I had originally moved to India for.

Sports, Exercise & Medicine

He thought for a while and then said, “you were the missing piece in this whole jigsaw.” He suggested that I take over as Director of Sports, Exercise & Medicine at Ashoka University. Ashoka University envisions to be India’s first ranked in higher education institution among the celebrated Ivy League international universities.

Sadly, the education system is such in India that some young people are active until 10th or 12th grade at most, but suddenly become very sedentary once they hit college. In today’s tech-savvy world, it’s happening even sooner. On a regular basis, I am now seeing 10-20 year olds coming with severe back, neck and knee problems that, only a decade ago, was seen commonly only amongst the senior citizens.

The bigger scope of SEM

Sports, exercise and increased physical activity have far more benefits than just getting healthier or winning medals. For me, the other benefits of sports – the career and, indeed the life skills they instill and enhance, outweigh the gains of fitness and prizes. These ‘soft skills’ can’t be taught in a classroom and they are for life: punctuality, discipline, sportsperson spirit, team spirit, respect for team members and opponents, camaraderie, leadership, honesty, confidence and self belief.

Role models needed for Move-mint

Doctors need to play a bigger role in making society more physically active. But we doctors can’t do it alone. We don’t have enough interactions to make a global difference without the work of others.

The students being accepted to Ashoka University already have all the characteristics to be value leaders of society. I want to use this opportunity to spread knowledge and practice of the benefits of physical activity like social wildfire. The focus shouldn’t only be about making these students active, but making them aware of their day to day role and their contribution to the larger strategy. The whole Sports – Exercise – Medicine needs to be integrated well into their curriculum, no matter what their chosen subjects.

In 4 years, Ashoka will have 4,000 students. Over a decade, these students would have touched more than a million lives. These students will work from within as seeds of this GIFT movement and over years they will make change happen. I have been at it for over a decade now. This is the tipping point that I have been waiting for.

Suddenly a ‘comma’ has justified my move to India and given me a clear direction. At Ashoka, we’ll be able to create not only leaders in physical activity treatment and promotion, but Young Indian Athletes.


BASEM/FSEM Conference ‘Walk 500 Miles’, October 2014: Reflections on the Top 5 Themes

21 Oct, 14 | by BJSM

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

By Dr Rebecca Robinson @rjprobinson

Reg OCtEdinburgh October 2014

1) Before we walk 500 more…

2014 marked the first year of a joint BASEM/FSEM annual conference with the Faculty of Sport and Exercise Medicine. Held in Edinburgh’s Assembly Rooms, the conference was a hub of energy, with attendees ranging from highly experienced sport and exercise physicians to proactive medical students sharing ideas in a strongly supportive atmosphere.

Dr John Maclean’s poignant eulogy for the late Dr Stuart Hillis was a fitting reminder to celebrate excellent mentors. Dr Hillis, a founding father of SEM was posthumously awarded the Sir Roger Bannister Award for outstanding contribution to Sport and Exercise Medicine. Additionally, the award of Honorary Faculty fellowship to Professor Karim Khan reflected his continuing and invaluable contribution to Sports and Exercise Medicine. We are fortunate to have a wealth of experienced and supportive senior physicians in our specialty. As a still-young specialty we are often reminded of the challenges ahead. We may have 500 miles to walk but it was a moment to reflect and thank those who have trail blazed the first 500.

2) Are Elite Athletes any different from the rest of us?

To what degree can we credit genetics in sprint performance, enhance and interpret physiological factors from VO2 max to red cell mass, and just how strong are the upper bodies of world class cyclists compared to weightlifters? Presentations from Professor Yannis Pitsalidis, Dr Barry Fudge, and Calvin Morris provided compelling evidence and raised further questions for research, with one certainty: that world-leading scientific knowledge is providing a performance-enhancing stimulus to elite programmes.

Insights into injuries incurred in golf drew expertise from the medical team attendant at the recent Ryder Cup, led by Dr Roger Hawkes and explained the principles of biomechanics and profiling to an attentive audience. Across the conference, BOSTA (British Orthopaedic Sports Trauma Association and Arthroscopy Association) and BIMM (British Institute of Musculoskeletal Medicine) brought theory behind practice to the table with opportunities for practical sessions.

3) Careers in Sports Medicine

The range of speakers and perspectives in this stream included: NHS, Private and Military Sport and Exercise Physicians. It was valuable for trainees and new consultants at all stages, as they addressed important issues about the scope of future practice from their own depth of experience.

Whilst elite sport offers great opportunities for team involvement, experience, and travel, Dr Phil Batty’s salient advice was a reminder that our foremost duty of care is always to the patient. Align conduct as a Team Physician with your regulatory body’s rules and do not be afraid to stand up for your principles despite perceived pressures.

The mantra to remember was: “You cannot talk yourself out of a situation you’ve behaved yourself into.”

REg OCtBallet demonstration BASEM October 20144) ‘Be More Dancer’

It was a privilege to be treated to the Royal Ballet School’s performances both at the Gala Dinner and demonstrations during the fascinating insights into ballet medicine on Friday morning. Appreciating perhaps one of the most graceful forms of human performance was coupled with insight into the unique challenges of injury, as reported by Drs Ian McCurdie and Philippa Woodward.

The dancers on stage brought to life the focus of the morning session; perhaps if we can be ‘more dancer’ in our approach to our own work and in our perceptions of patients’ potential, we can surpass expectation.

5) ‘Exercise-The Way Forward’

The mandate for physical activity as medicine has never been greater. There is strong evidence that cardiorespiratory fitness reduces mortality in chronic disease, benefits health independent of BMI, and enhances surgical recovery. In the final day session, Dr Harry Burns urged delegates to work together to ‘join the dots’ on promoting and implementing ’physical activity as medicine’. Collaboration between CCGs and hospital specialties are essential, as is work within the wider community to ensure integrated environmental and social policy – vital to supporting wellbeing. It is time to incorporate physical activity into every consultation. Investment in lifelong physical activity promotion for patients from early childhood should involve the whole family and continue through to active ageing. Programmes for community-wide education and engagement are necessary to empower, integrate, and mobilise everybody, everyday.


Dr Rebecca Robinson is currently an ST6 in Sports and Exercise Medicine Based in Sheffield, working with GB Boxing, Swimming and Team England at the 2014 Commonwealth Games. She is currently competing for GB in Mountain Running. Twitter: @rjprobinson

Assessing Nutritional Knowledge in Elite Badminton Players: Study Results

16 Oct, 14 | by BJSM

By Freddy Brown, and Prof Cathy Speed


smash-in-badmintonBackground: Badminton is an “intermittent” racquet sport, requiring technical skill and sport-specific-fitness. This study aimed to assess the nutritional knowledge of badminton players to shape the delivery of future support, and to facilitate fuelling and recovery strategies.

Methods: The General Nutrition Knowledge Questionnaire was administered online to 26 players on the GB Badminton Squad. The questionnaire was comprised of the following sections:

1) awareness of dietary recommendations;

2) knowledge of food sources of nutrients;

3) making practical food choices;

4) awareness of diet-disease associations; and

(5) knowledge of antioxidant vitamins.

Results: Players scored 70.8% on awareness of dietary recommendations, 62.3% on knowledge of food sources of nutrients, and 67.7% on using knowledge to make food choices. The group scored significantly lower than the highest scoring section on the technical questions regarding disease-associations and antioxidants (47.9% and 17.9%, respectively). The group scored highest on questions mentioning sugar, but significantly lower for questions mentioning fat (73.1% vs. 55.2%, p= 0.01).

Conclusions: Future interventions should use this knowledge of healthy eating and nutrients to shape education for fuelling and recovery. Education should also focus on increasing athletes’ knowledge of fats, particularly those suggested by the literature to impact positively on performance, wellness, and rehabilitation.

What are the new findings?

  • Badminton players on the GB Performance Programme showed favourable scores compared to previously studied athletic populations, scoring particularly well on awareness of dietary recommendations, knowledge of food sources of nutrients, and food choices.
  • Poorer knowledge was shown in the subjects of disease-associations and antioxidants.
  • The group scored but significantly lower for questions mentioning fat compared other macronutrients.

How might it impact on clinical practice in the near future?

  • Future interventions should use this knowledge of healthy eating and nutrients to shape education for fuelling and recovery.
  • Education should also focus on increasing athletes’ knowledge of fats, particularly those suggested by the literature to impact positively on performance, wellness, and rehabilitation.


Epigenetics – what is it all about?! A RSM Exercise Medicine Conference, 2014 blog mini-series

12 Oct, 14 | by BJSM

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

By Rory Heath (@Roryjheath)

I attended this summer’s Exercise Medicine conference at the Royal Society of Medicine (RSM). The conference had a great mix of applied science and the more modern and fashionable application of digital technology in health, sports and exercise. This is the first of a two part series on the conference’s two central components: Epigenetics and Technology.

I first share my learning points from the lectures on Epigenetics (Deingintion – the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself);

‘Introduction to Epigenetics and Exercise’: Professor William Brown

  • In Agouti mice, maternal diet affects offspring coat colour and offspring health.
  • How can we affect human prenatal epigenetic changes? Feed pregnant mothers folic acid, vitamin B12, choline chloride and betaine to change epigenome to reduce offspring cancer and diabetes risk.
  • fit woman walkingMay et al. (2012) suggest mothers who moderately exercise had ‘more fit’ babies, whilst Clapp et al. (1990) suggest mothers who exercised at ~50% pre-conception had smaller babies.
  • Epigenetic changes (methylation of DNA) can be used to estimate age of tissues. Cancerous tissues can display an extra 36 years of methylation.
  • Twin studies are useful to compare epigenetic changes. We can also use individuals for epigenetic changes, as humans have both right and left sides. ‘We are our own monozygotic twin’.
  • Exercise reduces methylation of tumour suppressor genes, increasing expression
  • 60yr old men who exercise have decreased methylation of PAX3 (involved with facial anatomy, muscle and training response), almost as low as 20yr old men. Increased PAX3 development is shown phenotypically as facial asymmetry. Can exercise prevent ageing?
  • Exercise changes the methylation profile of different genes in different ways – can ‘flip’ epigenetic profiles. Can exercise reverse ageing?

‘Breast Cancer Epigenetics and Exercise’: Dr Karen Lillycrop

  • David Barker, 1986 described that low birth weight is associated with heart disease.
  • Studies during the Netherlands’ 1944 famine illustrated effects of poor intrauterine environment on epigenetic changes – children predisposed to obesity and diabetes. Epigenetic changes in individuals are still prevalent 60 years after the famine. Diet is that important.
  • Methylation marks are gained from early life, throughout life. Environment affects methylation marks strongly at prenatal, neonatal and pubertal periods. Minimising damage requires education of both parents and children.
  • Is the obesity crisis attributable to changes in our epigenetic modifications?
  • Physical Activity (PA) is associated with decreased breast cancer risk, increased glucose tolerance and insulin sensitivity. PA can help to reverse epigenetic changes in offspring due to poor intrauterine environment.
  • Is there a negative cycle involving generations of poor maternal education and nutrition, offspring nutrition, development and academic performance?

Epigenetics of Metabolic diseases and exercise’: Dr Tina Ronn

  • Exercise has much higher effects than expected on gene expression. This results in systemic effects – Exercise that does not improve cardiovascular fitness can still improve biomarkers (Cholesterol, BP, etc.).
  • Exercise affects the expression of genes whose products are involved in inflammation (producing adiponectin, bradykinin).
  • 6 months of an exercise intervention causes genome wide changes in epigenetic changes in muscle and fat.
  • Exercise-induced epigenetic changes can change cellular metabolism. This may be a mechanism for how exercise can impact upon type-2 diabetes.

These lectures on epigenetics illustrate the importance of public health initiatives to educate and promote exercise and healthy nutrition. The key periods of pregnancy, neonatehood and puberty should be targeted to ensure the young and next generations are aware of lasting effects their health choices may have. Finally, the beneficial effects of exercise throughout life on the epigenetic landscape serve to reinforce the necessity of exercise for all, regardless of age.

Keep your eyes peeled for next version of the conference in June 2015, and in the shorter term, part 2 of my blog series: Technology and Digital Health – the future for SEM?!


Rory Heath (@roryjheath) is a third year medical student at King’s College London (KCL) and has a keen interest in sport, diet and exercise. He has played county rugby and rugby league for London and South. He is currently the KCL representative of the undergraduate London Sport & Exercise Medicine Society (LSEMS). ( He runs a blog at

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 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.

Rapid triage, massive waves, and paramount preparation: An emergency physician reports from Billabong Pro 2014 Surfing Competition

9 Oct, 14 | by BJSM

Claire Roche, Emergency and Sports Medicine Physician from the Gold Coast Hospital, Australia shares her experiences from the Billabong Pro 2014 in Teahupoo, Tahiti. Billabong Pro is one of the world’s “heaviest big wave” professional surfing competitions.

By Dr. Claire Roche

surf 1Teahupoo, a small village at “the end of the road” on the island of Tahiti, buried deep in the heart of French Polynesia, translated from Tahitian means; wall of skulls, which is a story of its own. This magical village with views like that of a picture postcard is the home to one of the worlds’ most unforgiving surf breaks. Known amongst surfers as “chopes”, Teahupoo is a wave which achieves up to 25 feet on large swells breaking onto a razor sharp reef where spectators could stand in knee deep water less than 50 metres away if they wish. If the surfer makes “the drop” they will have a ride of a lifetime – inside a tube of aggressive energy and power only the wave of teahupoo is capable of producing. Alternatively one moment of hesitation will result in death or severe injury, sadly, of which there are many stories.

Teahupoo is the home of one of the main events on the world surfing tour, The Billabong Pro. Large surfs were predicted for the competition this year and this event was going to run in some of the biggest surf that the event had seen over the last 10 years. One sentence remains in my mind from our first ASP meeting with event organisers and that was:

”A winner is to be crowned and a winner has to have no fear of paddling into and descending the face of a 12-15ft wave, this will split the worlds’ top 40 surfers as this takes a certain personality to achieve”.

surf 2So, what is the surfer’s aim? It’s to ride perfectly into a tube, deep enough so the surfboard is invisible and then, to be driven out in an explosion of spray. This would earn a high score and a roar from the crowd of dare devil boats strategically positioned in the channel to have the closest possible view of the perfect wave. Yes, really, rogue waves have pitched a little earlier than expected and pulled spectators “over the falls.”

The medical team and centre

As the Emergency Physician for this incredible event, preparation for any event is paramount. The medical team for this event consisted of :

  1. Myself, an Emergency Medicine Physician based on the Gold Coast of Australia,
  2. A Sports Medicine Physician based in Brisbane, Australia,
  3. Two highly skilled careflight helicopter retrieval paramedics based in Queensland, Australia; and
  4.  A local Tahitian General Practitioner (to help arrange local emergency services).

Our medical centre for the event consisted of a 20ft by 10ft wooden hut with one bed located on the shore 200 metres from the surf break which in the code red year 2011 was actually pushed back several metres by the incredible swell. This caused the Billabong pro to go on hold and attracted the big wave surfers from all over the world to jump on last minute flights to Tahiti. Working closely with the Tahitian water patrol, practice runs would retrieve a surfer from the impact zone to medical attention within 2 minutes. The first days of our arrival in Tahiti were spent practicing with water patrol cervical spine protection on the back of a jet ski and safe transfer onto a spinal board at the shore.

Unforgiving falls: from cervical spine injuries to ruptured globes

surf 3Within four hours of the competition start, our preparation was put into practice. Local wildcard Tumatar Puhetini fell awkwardly from a 12ft plus wave, was held under for most of a set and arose from the 6ft white wash obtunded with thoracic back pain, bleeding from his occiput. Sadly he was the first of many competetors to take unforgiving falls into the reef. Rapid transfer for stabilisation with ABC preparation inside the medical hut, oxygen and a fully prepared intubation table with ALS algorhythms between posters of the surf made what appears to be a primitive tent actually, as the online surfing magazine, surfline described a small Teahupoo ER. Stabilisation in the medical area and then transfer to the local hospital for imaging occurred. Fortunately, several hours later after undergoing imaging of his thoracic spine, Tumatae was home.

The competition this year got off to a sombre start after a local trialist Kevin Bourez (brother of Michel Bourez currently ranked world number 3) took a bad fall head first into the reef resulting in a subdural haematoma, mandible fracture, orbital fractures, maxillary fractures and a ruptured globe. After multiple surgeries and an ICU stay in the capital, Papeete, Kevin was discharged with a good prognosis. Still, the story reiterates the unforgiving nature of a wave where one moment of hesitation or one foot not positioned perfectly on the board can have life changing repercussions. Teahupoo to date has claimed three lives, left several with life changing spinal injury and has scarred 4

Preparation is key

To provide medical cover for such an event requires preparation for several scenarios, we cover all the entourage travelling with the surf tour (up to 200 people living with local families in crowded dwellings). This entails journeys to give IV fluids and supportive treatments to members of staff struck down by ailments such as influenza, gastroenteritis and tropical disease such as dengue fever whilst also keeping in mind other endemic problems to the area such as leptospirosis which hold high mortalities if missed. Often people surf out of hours in groups and a rogue wave often takes out several of the group, the sea of boats all hoping to get a close up glimpse and photo of the surfers are easily pulled into the suck down of the wave. This sequence of events can produce a major incident of multiple casualties in a region with only minimal medical personnel. It disturbed me how children in nappies were in boats watching this unpredictable wave with no life jacket; a lady breast feeds a neonate in a boat in between heats; boats knocked into each other trying to get to the best spot to view the surfers rides. Then there is the surfer who is desperate to get that 10 point ride with adrenaline pushing him to go for a wave that would seem unmakable.

Paramount in this situation is a major disaster plan. Rapid triage of patients to different areas, control of media and press, security assistance, and a close relationship with local medical and emergency services to aid an evacuation plan are all necessary.

surf 5Surely this is what an Emergency Physician thrives on?

But, the scenarios we talk of are all the same as what we deal with in our place of work: ABC, major disaster plans, evacuations, rapport between team members will always give the best outcome in what can seem bedlam. It is an honour to work in such an environment and an honour to care for those who risk their lives for the perfect wave.

Post-exercise recovery: Effects of whole-body cryostimulation exposure in sport and medicine

6 Oct, 14 | by BJSM

Article originally published in the Aspetar Sports Medicine Journal as part of a Targeted Issue on Post-Exercise Recovery and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital


By Christophe Hausswirth, France

Elite athletes often train intensitively or compete over consecutive days. Cumulative fatigue over such periods of training or competition can reduce athletic performance. Adequate recovery between training sessions and/or competitive events is therefore essential to minimise the risk of fatigue and optimise performance. In this context, the use of whole-body cryotherapy (WBC) as a tool to aid recovery shows benefits on some inflammatory parameters, possible improvement of antioxidant status and improvements in mood and mild depression. Heating the body is supposed to be beneficial to athletes’ recovery, to treat muscle pain and as part of rehabilitation after injury. It has been already demonstrated that WBC stimulates the physiological reactions of an organism which results in analgesic, anti-swelling, antalgic immune and circulatory system reactions and could improve recovery after muscular trauma injury. Definition is needed as to the precise context in which athletes may use this tool to optimise recovery in relation to improving sleep patterns, optimising the parasympathetic system and increasing their general well-being.


Exercise-related stress is often increased due to environmental conditions, particularly those relating to temperature changes. For every sporting activity there is an ideal ambient temperature. Any deviation from this reference temperature will have a negative impact on performance.

Indeed, physical activity in a warm or cold atmosphere means that the body and the mechanisms involved in temperature regulation have to work harder. Although very effective, these thermoregulatory mechanisms may not be able to cope with extreme conditions.

They do, however, allow the body to adapt during chronic exposure. Artificial cooling of ambient temperature is an evolving technique, both to prepare athletes for competitions in difficult conditions and to improve the body’s recovery capacity.


The first very low temperature cold rooms appeared in Japan in 1989, when Yamauchi used a cryogenic chamber to treat rheumatism. The indications for WBC were subsequently extended to various inflammatory conditions. WBC was then offered to treat pain and prevent post-traumatic oedema, with exposure limited to to 2 to 3 minutes.

One of the most well-established physiological responses to cold exposure is triggered by the decrease in skin temperature, promptly stimulating cutaneous receptors and their sensory afferents to excite sympathetic adrenergic fibres, in turn causing the constriction of local arterioles and venules. The resulting decrease in blood flow to the periphery or injured/inflammed tissues reduces local metabolic processes, thereby attenuating the inflammatory response and the formation of oedema around the injured tissues1.

Reported reasons for using WBC include decreased joint pain and disorders, improved general well-being, decreased fatigue perception2 and reduced symptoms of psychiatric disorders such as anxiety and depression3. WBC is also extensively used in self-treatment or body hardening against respiratory tract infections and musculoskeletal pain4, as well as parasympathetic reactivation after intensive exercise5.


What is known today: a review of scientific data

How well WBC restores biological constants following intensive training remains unclear. Studies are therefore ongoing in the field of athlete recovery.

Although we still lack scientific hindsight on the link between recovery, sport and cryostimulation, this paper will summarise the effects of WBC on some relevant parameters and practical applications from our point of view. This will help to identify possible applications in the field of recovery in sport. The first parameter subjected to in-depth studies was inflammation; some studies associate recovery with the kinetics of appearance of inflammatory and/or muscle injury markers. At INSEP (French National Institute of Sport, Expertise and Perfomrance) we have been working for 4 years to help both the medical and the performance-related recovery process.

Sport and cold exposure

In the sporting realm, WBC (in this instance, more accurately defined as whole-body cryostimulation) has been used at temperatures ranging from -110°C to -160°C with the aim of limiting the spread of muscle lesions after training or competing6. It has also been offered as a prophylactic treatment to reduce the risk of muscle lesions during intense training periods and to increase the antioxidant status after multiple exposures7. Despite the increasing popularity of WBC in sports, few studies have assessed its efficacy in accelerating the recovery of the athlete2,8. Very recently, post-exercise cold water immersion has been shown to aid recovery by altering blood flow9, and improving perceptions of recovery10 which may be reflected by changes in cardiac autonomic activity. WBC may also exert important effects on post-exercise recovery at the cardiovascular level. As exercise causes an intensity-dependent parasympathetic withdrawal and sympathetic increase, a prompt recovery of parasympathetic activity is desirable after exercise. Changes in cardiac parasympathetic activity as assessed by heart rate variability (HRV) analysis have emerged in the literature as a global recovery index that reflects the acute response of the body to exercise; an elevated level of parasympathetic activity allows rapid cardiodeceleration and faster recovery10,11. While Stanley et al10 demonstrated that both cold water immersion (5 minutes in 14°C water) and contrast water therapy, consisting of three cycles alternating immersion in cold (1 minute, 14.2°C) and warm (2 minutes, 35.5°C) water, significantly aided post-exercise parasympathetic reactivation compared to passive recovery (PAS) in trained endurance athletes, they also reported that this effect was larger with cold water immersion than contrast water therapy, suggesting that combining a greater cold stimulus increased the effectiveness of water immersion. While various water immersion protocols have been shown to accelerate post-exercise parasympathetic reactivation, the effect of dry air whole-body cryostimulation (range from -110°C to -160°C) on post-exercise autonomic recovery is not well-documented, even though this recovery method has become increasingly used in high level sport3,8. Only one study reported a significant increase in the HRV indices of parasympathetic activity following a WBC session performed after exercise in elite synchronised swimmers5. Similarly, in resting conditions, Westerlund et al12 found that a single session of WBC significantly augmented HRV indices of parasympathetic modulation in healthy non-athletic women, with a mean increase of approximately 50% in root mean square of the successive differences and high frequency power. The resulting increase in central pressure in turn activates the baroreflex, responsible for reducing sympathetic nerve activity while shifting autonomic heart rate control toward a parasympathetic dominance. However, in the case of healthy, recreationally active men training only a few times per month, the autonomic response to WBC has not been investigated. Further, the influence of WBC on blood parameters and subsequent cardiac and thermal responses compared to partial-body cryostimulation (PBC) technique has not been thoroughly evaluated.

Comparison in different techniques of cold stimulation

Modern cryotherapy techniques involve local, partial-body and whole-body exposures. WBC and PBC have been developed very recently and many devices are commercially available. The major differences in the two systems are:

  1. the temperatures (-110°C vs -160°C for WBC and PBC, respectively),
  2. whether the head is exposed to the cold stimulus (yes vs no for WBC and PBC, respectively),
  3. the source of cold stimulation (compressor vs nitrogen gas for WBC and PBC, respectively).

The infrared studies of the temperature response to 3 minutes WBC exposure reported that cold air on the entire human body was responsible for an obvious drop off in skin temperature whereas central temperature did not exceed the thermoregulation range during cryotherapy sessions13. Thermal mapping of the body could be influenced by local blood flow, degenerative and inflammatory state of the tissue. It was therefore previously reported that an enhancement of skin temperature profile could increase the diagnostic sensitivity of infrared imaging in patients13. The use of several types of cryostimulation raises new questions such as:

  • What is the optimal modality?
  • What are the duration and minimal temperature required to elicit physiological responses?
  • Is head exposure needed to induce general modifications?

During WBC the entire body is exposed to cold, including the face and neck, as opposed to a PBC session. It has been shown that the direct effect of cold on the head alone, via face immersion in cold water (without breath holding) aided parasympathetic reactivation significantly following exercise11. The results of a recent study conducted at INSEP showed that whatever the cryotherapy technique used, a single 3-minute cryostimulation induced a strong autonomic response, as rising plasma noradrenaline, systolic and diastolic blood pressures reflected increased sympathetic activation and as the rise in HRV indices suggested an augmentation of the parasympathetic control of heart rate. A likely greater parasympathetic activation was observed with the greatest body cooling obtained by exposing the whole body (WBC) to cold.


Figure 1: Examples of thermograms obtained immediately before (a, b) and after (c, d) a partial-body cryostimulation session (A) and a whole-body cryostimulation session (B). The black shapes represent the different body regions of interests for the front and back facing subject (Hausswirth et al14).

Contrary to localised cryotherapy obtained by the application of ice packs, cold towels or cold air-pulsed on a small body region, the air-based cryotherapy modalities examined in the present study14 involved either complete body cooling (WBC) or whole-body cooling except the head and neck (PBC), inducing an important decrease in whole-body temperature (Figure 1). An almost certain very large reduction in Tskin (skin temperature) of all body regions of interests was recorded after the 3-minute cryostimulation, in greater proportion with the WBC. The mean decrease in Tskin was 13.7°C (i.e. -42.9%) for WBC and 8.3°C (i.e. -26.1%) for PBC. As previously reported by Cholewka et al13, a larger decrease in Tskin was recorded in the legs and arms when compared with the torso and back (Figure 1). These authors reported a significant positive correlation between the decrease in Tskin and the body mass index of individuals, indicating that the effects of cryostimulation may be influenced by body composition.


Cold-related stimulation of the autonomic nervous system

Hear Rate Variability (HRV) indices and blood catecholamines are classically used to evaluate the modulation of the autonomic nervous system (ANS) in response to various stimuli such as cold or physical exercise5,11. The parasympathetic and sympathetic activities refer to the cholinergic and adrenergic phases of the ANS, in reference to their respective neurotransmitters (i.e. acetylcholine for the parasympathetic component and catecholamines for the sympathetic component). Given the lack of consensus on the accuracy of HRV analysis in assessing sympathetic activity, we stated that the activity of this component of the ANS was studied only through plasma catecholamine concentrations, while the parasympathetic component was studied through HRV analyses. Plasma noradrenaline concentrations were likely and very likely increased after the PBC and WBC sessions, respectively, suggesting increased sympathetic nerve stimulation. This increase in plasma noradrenaline was accompanied by a possible small increase in plasma dopamine after WBC only, but no response in plasma adrenalinewas recorded after PBC and WBC sessions. Similar findings (cold-induced increases in plasma noradrenaline without any changes in plasma adrenaline) have been reported after different modalities of cold exposure15. Since noradrenaline mostly originates from the sympathetic nerve endings and adrenaline from the adrenal medulla, we can suggest that both cryostimulation techniques activate the sympathetic nerve system. In addition, since an increase in plasma dopamine is typically related to sensations of well-being and pleasure, we can suggest a slightly greater effect of WBC in generating positive feelings. A previous study reported a significant increase in sensations of well-being when an exhaustive treadmill running protocol was followed by a WBC session2.

During cryostimulation, cold-sensitive cutaneous receptors excite the sympathetic α-adrenergic fibres, responsible for a peripheral vasoconstriction mechanism through the release of noradrenaline. Consequently, blood flow is redistributed toward the core, resulting in increased arterial pressure16. INSEP data suggested that systolic and diastolic blood pressure were very likely increased after WBC, but not after PBC, pointing to a lower sympathetic stimulation that may be related to the smaller decrease in Tskin obtained after PBC. Further, the decrease in Ttymp (tympanic temperature )recorded with WBC, as well as the stimulation of cold trigemino-cardiac reflex receptors located in the face may have accentuated the parasympathetic response after WBC, augmenting vagal output to the heart. As expected, the increase in blood pressure was associated with a large decrease in heart rate, that was larger after WBC (-15.2%) than PBC (-10.9%) likely reinforced by the concomitant triggering of the baroreflex which lowers the sympathetic tone of the ANS, shifting to a predominance of the parasympathetic tone.

We published recently published a paper of the effect of WBC single exposure on recovery in elite athletes5. To our knowledge, this is the first time that WBC was investigated as a recovery technique between two closely scheduled, sport-specific maximal exercise bouts. The two most important findings of this study were:

  1. using WBC shortly after a full-length synchronised swimming ballet resulted in a strong parasympathetic reactivation in elite swimmers, yielding two- to four-fold increases in vagal-related HRV indices compared to pre-exercise values within only 1 hour;
  2. WBC exerted a significant influence on metabolic parameters of recovery and subsequent exercise, with a larger clearance of plasma lactate and an increase in maximal aerobic work output during the second ballet. The latter was only matched by the effects of active recovery.

Inflammatory marker responses

Some authors have measured various markers of inflammation in subjects exposed to very low temperatures. Banfi et al7 showed that treating top-level rugby players with WBC for 1 week led to reduced rates of pro-inflammatory cytokines (IL-2 and IL-8) and increased levels of anti-inflammatory cytokines (IL-10). This is the only study in which the results can genuinely be related to recovery after intense muscular exercise. According to the authors, WBC should improve muscle recovery, although they were not able to measure to what extent.

In this 5-day study, 10 top-level rugby players were placed in cryogenic chambers at -60 C for 30 seconds, then at -110 °C for 120 seconds. In addition, subjects followed their normal 3-hour daily training without changing their workload. While no significant difference was measured in terms of immunoglobulin or C-reactive protein levels (two markers of acute inflammation), the authors did show that creatine kinase and PGE2 prostaglandin concentrations were significantly reduced after 5 days of WBC (Figure 2). No control group was included in this study. The authors explain that the drop in creatine kinase is likely to result from the stimulation of noradrenalin secretion during exposure to cold, an effect demonstrated in Rønsen et al’s18 study. No assay of noradrenalin was performed in this study.


Figure 2: Variation in serum concentrations of muscle injury markers (prostaglandin and creatine kinase). The left panel shows a significant reduction in prostaglandin PGE2 (P <0.0001) “After WBC”. The right panel shows a significant reduction in creatine kinase (P <0.01) “After WBC”. Adapted from Banfi et al17 with permission from the Journal of Thermal Biology. WBC=whole-body cryotherapy.

Banfi et al17 observed a reduction in PGE2 associated with reduced creatine kinase levels. PGE2 is synthesised at the site of inflammation, where it acts as a vasodilator in synergy with other mediators, such as histamine and bradykinin. These mediators cause increased vascular permeability leading to oedema. Their reduction, after 5 days of WBC, seems to be a good indicator of improved muscle recovery. However, the absence of a control group in the study is a flaw which makes it impossible to reliably conclude on the efficacy of WBC in recovery. This research does, however, offer some suggestions as to the parameters likely to favour (or not) improved recovery.

In a recent study8 conducted in order to analyse the effect of two different recovery modalities on classical markers of exercise-induced muscle damage and inflammation obtained after a simulated trail running race. We chose to compare changes in immune cell mobilisation and C-reactive protein level because they are reliable indicators of acute performance deterioration, muscle damage and/or inflammation routinely evaluated in the general population and in athletes4,9. The major finding was that a single exposure to WBC significantly alleviated inflammation after strenuous exercise.

  1. Delta IL-1ra increased 1 hour after exercise following WBC compared to PAS
  2. Delta IL-1β was significantly suppressed 1 hour after exercise following WBC, compared to the PAS condition,
  3. WBC minimised the decrease of neutrophils 24 hours after exercise and
  4. C-reactive protein increase was strongly limited in the WBC group compared to the PAS group at 24 hours and until 48 hours after exercise. Data confirm that the treatment induces an anti-inflammatory protection effect and suggest that WBC reduced the time of recovery by positive effects on immunological parameters and the regeneration process for elite athletes.

Hormonal responses

Most studies of WBC have focused on the kinetics of biochemical markers and/or how various hormones evolve in response to exposure. It is widely believed that changes (or lack of changes) to endocrine parameters are relevant topics for research on improved athlete recovery. In this context, a recent study by Smolander et al19 compared WBC exposure (-110 °C for 2 minutes) to cold-water immersion (0-2 °C for 20 seconds). The two groups were subjected to either treatment weekly over a total of 12 weeks. Various hormones – growth hormone, prolactin and the thyroid hormones (TSH, T3, T4) – were analysed. The authors concluded that there were no significant variations in hormone levels for the WBC group. Prolonged exposure to cold seems to have no effect on the concentrations of these hormones. Based on this lack of effect of WBC on hormone levels, we can conclude that this procedure conforms to sporting ethics. These results are supported by those of another recent study by Banfi et al17, who indicated that, for a group of 10 athletes, none of the haematological parameters (e.g. red blood cells, white blood cells, haematocrit, haemoglobin, platelets etc.) were affected by five 2-minute exposures over 1 week. In an earlier study, Leppäluoto et al15 showed that exposure to WBC (three times per week for 12 weeks) induced a significant increase in plasma noradrenalin levels (Figure 3). The authors explain that the increases in noradrenalin levels recorded over the twelve weeks could play a role in relieving perceived pain, an effect seen in other studies using traumatising exercise. However, no scale of pain perception was offered in this purely descriptive study, which involved straightforward cryostimulation by WBC exposure.


Figure 3: Variations in plasma noradrenalin concentrations after 1, 4, 8 and 12 weeks of whole body cryotherapy. *Significant difference from initial value (P <0.01). Adapted from Leppäluoto et al15 with permission from The Scandinavian Journal of Clinical and Laboratory Investigation.

Immune responses

For a number of years, the immune system has been of particular interest to sports physiologists. The incidence of sore throats in very fit athletes initially helped doctors to detect overtraining syndrome. These intuitions were confirmed more recently by some very well-run American and UK studies.

In this context, Nieman20 observed that the immune response was impaired during repeated phases of prolonged high-intensity exercise, and that athletes responded poorly to bacterial and viral attacks, thus delaying recovery. Excessive sensitivity to respiratory tract infections seems to set in gradually, although it is well-described that the risk of respiratory infection follows a ‘J-shaped’ curve when plotted against training intensity, and that moderate exercise results in a low risk. Training is known to improve the immune response to a certain degree, while overworked athletes have reduced immune responses, in particular for immunoglobulins, ‘Natural Killer’ or ‘NK’ lymphocyte subgroups. While no study deals with the kinetics of how the immune system evolves after exposure to WBC, mainly because the procedure is so new, models involving swimming and immersion in cold water have been used for the last few years in Nordic countries and have provided indications on how the immune system is affected. This practice, which was developed more on a cultural than on a scientific basis, has always been empirically linked to improved resistance to infections. In this context, Dugué and Leppänen21 showed, in a study comparing populations swimming regularly in cold water or not, that plasma IL-6 levels, monocytes and leukocytes were all higher in cold-water swimmers. The authors concluded that the immune system of cold-water swimmers was controlling the inflammatory response better and that repeated exposure to cold (by immersion or not) could explain the improvement in defence against infections. It could therefore be suggested that repeated exposure in cold rooms (i.e. WBC) stimulates the immune system and reduces susceptibility to infections in acclimatised individuals. New studies on WBC should shed light on these hypotheses and offer insights into the relationships between immunity, cold and athlete recovery.

Antioxidant status responses

Physical exercise is known to be characterised by an increase in oxygen consumption, and consuming high levels of oxygen is associated with increased free radical production. Modulation of oxygenated free radical production plays a clear role in muscle recovery after exercise. High intensity exercise and/or exercise involving many eccentric movements are a true stress, producing metabolic by-products with significant effects on cellular structures. Oxygen-derived free radical species involved in oxidative stress are of various structures, but all are extremely reactive compounds which, once produced, will oxidise various cellular components. This oxidation can lead to cellular dysfunction and, among other things, to inflammatory disorders. A recent study by Dugué et al22 showed increased total plasma antioxidant capacity after 36 cold room sessions over 12 weeks (three times per week). These results contradict the authors’ initial hypothesis that values would be significantly reduced, and explain the improved protection. A single study investigated the effects of a WBC session (at -130°C) on the pro-oxidant/antioxidant ratio7. Plasma total oxidant status was significantly lower 30 minutes after exposure to WBC for 3 minutes (Figure 4). The next day, the total oxidant status level was still significantly lower compared to the basal level before WBC exposure. In addition, total antioxidant status values were significantly lower 30 minutes after exposure to cold, but did not differ from basal values the next day. However, in the case of athletes, cryostimulation is combined with physical exercises as part of regular training, and it is therefore difficult to know to what extent lipid peroxidation is the result of training and/or cryostimulation6.


Figure 4: a) Variations in plasma total oxidant status in resting subjects 30 minutes after cryostimulation and the next morning. *Significant difference between 30 min after cryostimulation and Next morning (P <0.05). b) Variation in plasma total antioxidant status in resting subjects 30 minutes after cryostimulation and the next morning. *Significant difference between Resting and 30 minutes after cryostimulation (P <0.05); **Significant difference between 30 min after cryostimulation and Next morning (P <0.01). Adapted from Lubkowska et al7 with permission from the Journal of Thermal Biology.

Responses for depressive symptoms

Some studies investigated the somatic and psychological effects of cold and seemed to reach a consensus on mood alterations. Even if somatic and psychological parameters seem somewhat removed from the topic of recovery in sport, they can obviously play an indirect role. Thus, the first studies on the subject showed that a short exposure to WBC improved sleep, sense of relaxation and mood, and that these effects can persist for hours or even days. In a more recent study, Rymaszewska et al3 studied the effects of WBC (-150 °C, 160 seconds, 10 times over 2 weeks) in 23 depressed patients on anti-depressant treatment. Using the 21 items on the ‘Hamilton Rating Scale for Depression’ (HRSD), the authors concluded that WBC exposure had a positive effect on HRSD scores, and thus helped alleviate symptoms of depression. Given these results, the authors very recently published another study, similar to their previous work, which included a control group of 34 patients3. After 3 weeks, the HRSD scores for the 26 patients suffering from depression were reduced by 34.6% in the WBC group, against only 2.9% in the control group. One neurobiological hypothesis states that depression results from a deregulation of the hypothalamic-pituitary-adrenal axis (hypothalamo-hypophyso-adrenergic axis). The authors relate the improved mood regulation and HRSD scores to this axis. In addition, it seems that WBC also has positive effects on patients’ biological rhythms. All these results could provide some help for the temporary psychological problems frequently encountered by athletes during training.



The published studies concentrate on physiological, biochemical and haematological parameters affected by WBC. It reduces proinflammatory responses, decreases pro-oxidant molecular species and stabilises membranes, resulting in high potential beneficial effects on sports-induced haemolysis, and cell tissue damage, which is characteristic of heavy physical exercise. Conversely, it does not influence immulogical or hormonal responses, with the exception of testosterone, estradiol, noradrenaline and myocardial cell metabolism. Interleukin concentrations are modified by WBC, which induces anti-inflammatory responses.

In the context of recovery between two training sessions, it has showed that a single session of WBC performed shortly after a maximal exercise exerted a strong influence on parasympathetic reactivation, yielding a two- to four-fold augmentation of in pre-exercise vagal-related HRV indices, only 1 hour post-exercise. In addition to the desirable effects of WBC identified in sport, future research should aim to determine whether the strong influence of WBC on parasympathetic reactivation at the cardiac level could present additional benefits over longer periods, as fatigue accumulation during periods of intensified training has been associated with changes in the autonomic modulation of heart rate in athletes.

The published data are generally not controversial, but further studies are necessary to confirm the present observations. Standardisation of exposures times and the number of treatments during each cycle could improve data comparison. Due to the impact on the parasympathetic reactivation, we hypothesised that further studies conducted on sleep efficacy are needed in order to speed-up the recovery of elite athletes.


Christophe Hausswirth, PhD is the Head of the Research Department and the Director of the Laboratory of Sport, Expertise and Performance, INSEP – French National Institute of Sport, expertise and Performance, Paris, France.



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Commonwealth catch up: Interview with Dr Danica Bonello Spiteri, Athlete and Doctor

30 Sep, 14 | by BJSM

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

Interview by Linda Evans

Like the Olympics, the Commonwealth Games only comes along once every four years. Nations that may be omitted from the Olympic pedigree, compete alongside some of the biggest names in sport. For many medics, this summer’s Glasgow Commonwealth Games combined passion and opportunity in Sport and Exercise Medicine. One SEM UK Registrar, also accomplished their dream of competing at the Commonwealth Games. A little over a month ago, Dr Bonello Spiteri finished 15th in the individual triathlon, competing for her home nation Malta. Since passing the finish line, Danica worked in Glasgow as a Sport and Exercise Medicine Doctor. I caught up with Danica to hear about these experiences.

Firstly, congratulations Danica on your brilliant performance in the individual triathlon at the Commonwealth Games. What made you begin triathlon?

I was involved in sports since a young age. I started off as a dancer from the age of 2, but gave this up at the age of 14 as I got into triathlon – which I preferred. Around the age of 14 I won a lot of track and field running medals, and my PE teacher recommended that my mum to send me to athletics training. I also enjoyed venting off energy with swimming and continued through the winter season. One day my swimming coach asked if I knew how to ride a bike, which I did – a BMX bike! He told me what triathlon was all about, and I loved the idea. So my mum managed to borrow a rather large mountain bike and I participated in my first triathlon. I came out of the water 1st lady (and 3rd overall with the men!), faded throughout the bike into 3rd lady, but I ran fast and won my first triathlon at age 14 (first female overall). Then I was hooked.

Danica Spiteri and Etienne Bonello

Danica Spiteri and Etienne Bonello

Triathlon undoubtedly requires a huge commitment in terms of training. How do you manage to balance this around your workload?

My training usually starts with a swim from 7:00-8.15 am and then I rush to get to work by 9am, work all day, and then train again after work. It’s hard to cope with it all. Being a trainee, I had to study for exams, attend courses and keep up to date with my reading. This means I don’t have much free time and getting enough sleep and adequate food intake can suffer! Sometimes I am too tired to go for my evening training, so I skip sessions to get rest. This means that on average I train about 15 hours per week. The positive side to this is that I avoid ‘overtraining’ and injury, so it’s kept me healthy and fit!

Being the Maltese triathlete of the year for the last ten consecutive years, you must have learnt a lot about how you race. Which aspects of triathlon do you excel at and how do you work to these strengths in a race?

I believe that I’m equally strong in all three disciplines and I enjoy the three of them equally well. Each discipline has bits I like and dislike. I probably struggle most in the swim section as I find it hard to make the front pack, but I have improved my swimming greatly over the past two years. I have also worked hard at my running, which has come along nicely too. At present, my favourite bit of the race is crossing the finish line, knowing I have raced to my best ability.

Alongside a very challenging sport, you embarked upon a demanding career. What made you choose medicine?

Two options interested me upon finishing my A levels – becoming a Medical Doctor or a Biology and Physical Education Teacher. When I made the grades, I opted for medicine. However, my desire to teach is still there, and I have lectured at the University of Malta for 5 years. Last year I also lectured at the Leeds University. In 2011, I moved to Leeds, UK, as a Specialist Registrar in Sports & Exercise Medicine. I am currently in my final few months of specialist training. Upon completion I intend to return to Malta and set up Sports & Exercise Medicine services, as this is greatly lacking – both in service provision and in public general knowledge.

What would your advice be to anyone who is interested in a career in medicine?

My Top 3 tips would be:

  1. You must have a passion for what you want to do, as without passion you will not get as far and it may become tedious.
  2. Love what you do and do what you love.
  3. Along the way you will meet many who will try push you down. Ignore them and follow your dreams. You will get there through determination and persistence.

What did you wish you had known at the start of your career that you know now?

I always thought that medicine was ‘just’ a five-year university program. But as soon as you exit you realise that your journey is just beginning! I had no idea that a doctor ‘never stops reading and learning’. But as long as it is related to Sports & Exercise Medicine, I am interested in reading more. My limitation is finding the time to read!

Not only have you had the opportunity to be an athlete at the Commonwealth Games, but you have also worked there. What has been your favourite aspect of working at the games?

The Commonwealth Games is a very friendly atmosphere and I enjoyed meeting new people, as well as working with old friends. It is also a satisfying to help athletes, as I understand what they are going through, andensure they arrive at the start line in their best condition possible.

Finally, what is the best thing about your job?

The best thing about my job is that it combines two things I really enjoy in life – sports and medicine.

I love all the opportunities I have come across. I have managed to meet like-minded colleagues and top athletes, travelled to various places around the world and developed a much deeper understanding of sports medicine. I have also used my medical knowledge to better understand triathlon training and sporting techniques. Best of all are the friendships I have made throughout the years. I now hope to return to my home country in Malta where I can transfer the knowledge to help raise the level of SEM.


Linda Evans BSC (Hons). Is a fourth year medical student at the University of Leeds. Social Media Secretary for USEMS and President and founder of Leeds Sport and Exercise Medical Society.

Twitter: @LindaEvans90 @USEMS and @LeedsSEMSoc

Danica Bonello Spiteri graduated from The Medical School of Malta in 2004. She completed her internship and basic specialist training in acute/general medicine in Malta, whilst completing her MRCP in 2009. She is also a member of the FSEM (UK) and is in the final months of her specialist SEM training. She is married to Malta’s national team cyclist, Etienne Bonello.

Dr Farrah Jawad coordinates “Sport and Exercise Medicine: The UK Trainee Perspective” monthly blog series.

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