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MD to PhD: Returning to school to explore physical activity in respiratory disease

22 Nov, 14 | by BJSM

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

By Dr. Ruth Pearson

OLYMPUS DIGITAL CAMERADiversity and flexibility of both training and career possibilities was part of the appeal for my perusal of Sport and Exercise Medicine Training. Now, compelled by a fervent obsession with health improvement through physical activity, I am returning to student life and embarking on a clinical PhD. Through an exciting collaboration between Loughborough University’s School of Sport, Exercise and Health Sciences and the Leicester Respiratory Biomedical Research Unit, my PhD will explore Physical Activity in Respiratory Disease. Against the backdrop of the new multi-million pound National Centre of Sport and Exercise Medicine and amidst the surrounding buzz of athletic ability and achievement there is no excuse for a lack of inspiration.

Physical activity improves health. This statement is well established. We also know that its lack is a risk factor for mortality. Exercise and physical activity as part therapeutic interventions are becoming more and more employed across a wide range of diseases including respiratory diseases such as COPD. Pulmonary rehabilitation provides a good example. Although some of the outcomes of muscle and cardiovascular training may seem logical, the we need to learn more about the influence of physical activity on the actual disease processes.

Further, translating knowledge into behaviour change at individual and population levels are one of our biggest challenges. As the development of technology and labour-saving devices escalates, the need for novel approaches to encourage physical activity grows.

An interdisciplinary lens to tackle complexity in health 

The 2012 Olympics in London are fading into the past, but on the Loughborough University Campus, the legacy lives on in the form of the National Centre of Sport and Exercise Medicine. As the building’s construction reaches its final stages, anticipation about its occupation increases. The new facility will house researchers, clinicians, applied practitioners, and translational scientists who will work together to address five key areas: Physical Activity in Disease Prevention, Exercise in Chronic Disease, Sports Injuries and Musculoskeletal Health, Mental Health and Wellbeing, and Performance Health.

Why respiratory disease? 

Well, although I find the relationship between physical activity and a wide range of diseases interesting, respiratory disease and respiratory physiology has always been particularly fascinating. I recall a particular encounter as a medical student: I was introduced to an elderly gentleman who had had a partial pneumonectomy for TB when he was younger. Despite having part of his lung removed, his level of function was not significantly reduced. COPD is a heterogeneous condition and there is frequent disparity between symptoms and function with some of the implicated causes being physical deconditioning, dynamic hyperinflation and skeletal muscle dysfunction. This tells us that there are many questions surrounding respiratory disease and physical activity, and I look forward to further investigation.

Meanwhile, as the war against physical inactivity rages on, I am battling a potentially less active lifestyle as I now spend more time in library and labs than on clinical rounds.  Lucky for me, I am armed with my new pedometer and standing desk!

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

Ruth Pearson trained at St George’s Hospital and following training through the Acute Care Common Stem pathway, began training in Sport and Exercise Medicine.  She has spent three years as a registrar in the East Midlands before recently stepping out of programme to commence a PhD.  She has always enjoyed playing and being involved in sport.

Farrah Jawad is currently a ST4 doctor in Sport and Exercise Medicine in London and co-ordinates the trainee perspective blog series. 

De Vos, Windt and Weir respond to: “Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy?”

19 Nov, 14 | by BJSM

One of the great things about social media (blogs, Twitter, etc.) is that it encourages dynamic dialogue and discussion. Academics and practitioners alike benefit from the new insights and ‘food for thought’ this generates. With this tenet in mind, here is a letter from Robert-Jan de Vos, Johann Windt and Adam Weir in response to the BJSM blog: Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy? that was written in response to de Vos, Windt and Weir’s publication:  Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956. …comprende? We hope so. 

LETTER TO THE EDITOR BY DE VOS, WINDT, AND WEIR

With great interest we read the letter to the editor regarding our systematic review on the use of Platelet-rich Plasma (PRP) injections in patients with chronic lateral epicondylar tendinopathy.1 We compliment the authors on their efforts to improve scientific quality in this field. The BJSM Blog is a fantastic forum to host discussions like this and we would encourage other readers to share their thoughts as well. There is a lot of common ground between the two groups but we were surprised that our systematic review conclusions were described as being ‘not properly supported by recent literature’. We would like to emphasise that it was properly designed and performed according to the PRISMA guidelines. In response to this criticism we address some aspects of the letter and explain why we think our systematic review is of value in the field of tendinopathy.

Diagnostic terminology

We hope that we are on the same page regarding the diagnosis. The authors use a different terminology and refer to ‘chronic lateral epicondylitis’. We know that inflammatory theories in tendinopathy are currently popular, but the generally accepted term is “tendinopathy” for these conditions.2 This might sound as a semantic discussion, but if authors in a research field cannot agree on terminology and diagnostic criteria for a certain condition, it will be very hard to make comparisons in scientific literature.

Meta analysis

While meta analysis is generally accepted to be the highest level of evidence you should always consider if it is correct to use this technique. By presenting a meta-analysis in the way the authors have done, study design labels (e.g. RCTs or CCTs) are used to imply high study quality and low risk of bias. The assessment of risk of bias is a key step in conducting systematic review and possible meta analysis. It plays an important role in the final assessment of the strength of the evidence. The first question we should ask is whether the included studies have a low risk of bias. If not, it is questionable if the outcome really reflects the efficacy of PRP or the effect of studies with a high risk of bias. We feel that to present a meta analysis one must also first assess the risk of bias and argue the case as to why it is valid to perform a meta analysis. It is known that lower study methodological quality is associated with better treatment outcomes in patellar tendinopathy.3 To simply pool the outcomes of all RCTs performed in this field does therefore not automatically imply a ‘highest level of evidence’.

Corticosteroids

We fully agree with the authors that corticosteroid injections should not be used for control groups in PRP studies. We support the approach to leave these studies out of the final evaluation because of the detrimental effect of corticosteroids.4 Corticosteroid injections should be discouraged in the routine management of tendinopathy and they are not suitable as a control group because of the detrimental long-term effects.

Placebo as control

The authors present their analysis of PRP vs autologous blood injections. We would stress the need for more placebo-controlled RCTs, rather than comparison to another active treatment. Creaney et al. randomised patients to a PRP or autologous blood injection and found no significant differences in outcome.5 They then concluded that both autologous blood and PRP injections are useful second-line therapies to improve clinical outcomes. However, it would only be possible to draw this conclusion if a placebo-arm was used in the study. Comparison with autologous blood injections would only make sense if this would was “usual care” for tendinopathies. A previous systematic review showed that there was strong evidence that autologous blood injections are not efficacious6, so the use of autologous blood injections in routine care or as a control group cannot not be advised.

Should we abandon PRP?

In our opinion the authors do not present a case for the use of PRP in clinical practice. They provide us with a meta analysis where no difference is found between PRP and autologous blood injections.

We feel that at the current time there is strong evidence that both PRP and autologous blood injections are not efficacious. The fact that autologous blood is cheaper than PRP cannot be used to argue a case for it being preferred. In our clinical practice we prefer to use neither.

We are aware that the conclusion of our systematic review is not popular,7 as attention for PRP treatment is still growing. We still feel that our review conclusion is robust and it is also supported by other high-quality placebo-controlled studies in the field of musculoskeletal medicine.8-10 To end again on a positive note we agree with the authors’ final comment, where they advise for more placebo-controlled studies.

References

  1. de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med 2014;48(12):952-6.
  2. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ 2002;324(7338):626-7.
  3. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 2000;10(1):2-11.
  4. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376(9754):1751-67.
  5. Creaney L, Wallace A, Curtis M, Connell D. 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(12):966-71.
  6. de Vos RJ, van Veldhoven PL, Moen MH, Weir A, Tol JL, Maffulli N. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull 2010;95:63-77.
  7. Gosens T, Mishra AK. Editorial in response to the systematic review by de Vos et al: ‘Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review’. Br J Sports Med 2014;48(12):945-6.
  8. de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010;303(2):144-9.
  9. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, et al. Platelet-rich plasma injections in acute muscle injury. N Engl J Med 2014;370(26):2546-7.
  10. Schepull T, Kvist J, Norrman H, Trinks M, Berlin G, Aspenberg P. Autologous platelets have no effect on the healing of human achilles tendon ruptures: a randomized single-blind study. Am J Sports Med 2011;39(1):38-47.

 

Sleep as a recovery tool for athletes

17 Nov, 14 | by BJSM

Article originally published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital

 

By Charles Samuels and Lois James, Canada

The athlete sleep screening questionnaire©

“If your athletes go to bed, fall asleep within 30 minutes, sleep through the night with brief awakenings, feel refreshed within 60 minutes of waking most days (5/7 days/week) then congratulations: your athletes are normal sleepers!”

(Dr Samuels, 2013)

dirtbike

We know from decades of research that sleep is important for human performance1-3. So, why would we even think about screening athletes when it comes to sleep? Why not just apply basic principles of sleep and generalize from the research that’s been done in other areas such as law enforcement4-7, the military8-11 or aviation12-15? As a result of this research and knowledge athletes, coaches, sport medicine physicians and trainers are interested in understanding the relationship of sleep to training, recovery and performance in athletes. The complicating factor is that athletes, and elite athletes in particular, are very different than the average individual or members of occupational groups such as law enforcement and the military, on whom prior research is based. Athletes have unique physical and mental demands, have to accommodate rigorous competition and training schedules, and have to adapt to difficult travel regimes. So we have to be careful and specific about applying what we know about sleep to athletes. There is a clear need for developing valid, reliable tools to screen and monitor athlete sleep behaviours as the basis for understanding and developing effective interventions.

Most countries are developing high performance training programmes for National/Olympic team athletes and are committed to investing in every available tool to help them succeed. We know from the scientific study of sleep that it promotes physical and mental recovery16,17. However, the theoretical principles behind the relationship between sleep and recovery have only just started to be explored in athletic populations. Without a structured assessment of relevant sleep behaviours and the development of valid, reliable tools to acquire accurate data we will have nothing upon which to base useful research questions. Without these tools there will be no way to drive data collection, analyse the data and determine how sleep may affect training, recovery and performance. Finally, valid, reliable data collection methods are necessary to monitor the effectiveness of therapeutic interventions.

Over the past several years the University of Calgary Sport Medicine Sleep and Human Performance Research Initiative has developed the Athlete Sleep Screening Questionnaire (ASSQ) ©. This tool is designed to capture athlete sleep behaviours, identify athletes with abnormal sleep and primary sleep disorders, and determine the frequency with which athletes have difficulty with sleep when travelling. The ASSQ© screening system stratifies athletes into those who require basic sleep education, assessment with the sport medicine physician, and those who require a sleep medicine consultation and investigations. The goal of this article is to provide:

  1. A clear understanding of the relationship between sleep and recovery.
  2. An understanding of the ASSQ©, and how it can be used to benefit elite athletic teams.
  3. A summary of ASSQ© results collected from teams and athletes to date.

THE RELATIONSHIP BETWEEN SLEEP AND RECOVERY

Sleep factors have been shown to have a direct effect on executive cognitive function18, metabolic control of energy balance, appetite and weight19,20 and tissue repair21. Cognition, metabolism and tissue repair are critical physiological processes that contribute to training capacity, recovery and performance. Recent research on athlete populations has provided objective evidence that confirms the importance of sleep in athlete development and performance16,22.

The relationship of sleep to post-exercise recovery and regeneration can be viewed in a structured fashion:

  1. Sleep length (total sleep requirement: hours/night, plus naps).
  2. Sleep quality (sleep disorders, environmental disturbance or sleep fragmentation).
  3. Sleep phase (circadian timing of sleep).

These three parameters of sleep are the key factors affecting the overall recuperative outcome of the sleep state23. They affect an athlete’s ability to train, maximise the training response, perform and recover24. Capitalising on the restorative power of sleep will help maximise energy, mood, decision-making skill and reflex response. In addition, attending to the importance of sleep will reduce the risk of overtraining/under-recovery, enhance resistance to illness and improve recovery from injury25.

SLEEP LENGTH

For sleep to be recuperative it must be of adequate duration. This is a universal principle, but applies especially to athletes whose physical recovery may need to be greater than the average individual. Sleep requirements change over the course of an individual’s life; in particular the amount of sleep required. For example, 8 to 12 year olds need about 9.5 to 10 hours, 12 to 16 year olds need about 9 hours, and 16 to 22 year olds need about 9 to 10 hours per night. Naps can count towards total sleep time, should be restricted to 30 minutes and should be scheduled between 2 to 4 pm for the average sleeper. Strategic napping may be particularly beneficial for young athletes who, due to school commitments and training, may not be able to achieve the recommended amount of sleep per night.

SLEEP QUALITY

Maintaining a regular sleep/nap routine, establishing a comfortable sleeping environment and monitoring for sleep disorders can maximise sleep quality. A key indicator of sleep disorders is excessive sleepiness, despite adequate sleep length. This is due to ‘non-restorative’ sleep, which is poor quality due to interruptions from sleep disorders such as insomnia, sleep apnoea or restless legs syndrome. Sleep disorders are common and treatable, but often remain undiagnosed. It’s especially important to find out if young athletes suffer from sleep disorders because intervention at a young age could make a huge difference for their long-term athletic development and performance. Travel can also affect sleep quality, so jet lag management and sleep scheduling while traveling is critical26.

SLEEP PHASE

The circadian system regulates the feeling of sleepiness and wakefulness throughout the day, which directly affects athletic performance. After awakening in the morning the average individual feels alert until about 2 pm, when the ‘afternoon siesta’ feeling kicks in. This tends to last for 30 to 60 minutes and then alertness rises again with a peak in the evening around 6 to 8 pm. After this point sleepiness increases, which facilitates the onset of sleep at bedtime. Each athlete has a preferred sleep schedule that suits his or her circadian phase; however, training, school, exposure to technology and work commitments can have a substantial impact on the athlete’s ability to match their circadian phase to the available time for sleep. If the circadian phase and sleep schedule are not matched (out of phase), the amount of sleep that can be achieved, as well as the quality of that sleep, will be affected. For example, adolescents have a natural tendency to become night owls, delaying bedtime. The delay in sleep onset (12 am to 1 am) in combination with having to get up for school (7 to 8 am) and the fact that adolescents need 9 to 10 hours of sleep per day results in a chronic sleep debt that affects daytime performance, alters mood, increases appetite and impairs post-exercise recovery23.

From a clinical perspective, we want information on athletes’ sleep behaviours to solve existing problems and help them improve post-exercise recovery and regeneration. However, it’s equally important to gather data from athletes at the aggregate level to start drawing some inferences or “best practices” that can apply to particular sports or athletes in general. The Athlete Sleep Screening Questionnaire© (ASSQ) has both strong clinical relevance, but also allows us to gather population-level data, learn about trends in athlete sleep behaviour, and start providing the athletes, coaches and support staff with some answers about how they should manage athletes’ sleep.

THE ATHLETE SLEEP SCREENING QUESTIONNAIRE

The ASSQ© has been about 6 years in the making. Our goal was to create a questionnaire that gathered information on athlete sleep behaviours to enable nationwide screening of a large population of athletes, provide efficient data gathering for research and validation, and to implement targeted clinical intervention. The ASSQ© is derived from standard sleep screening questionnaires and made up of 23 items representing four domains that capture the essence of the key sleep parameters of interest. The sleep difficulty score is used to categorise respondents into four meaningful categories that are associated with specific interventions:

  1. No clinical problem = education.
  2. Mild clinical problem = education and monitoring.
  3. Moderate clinical problem = see the sport physician.
  4. Severe clinical problem = sleep physician.

We wanted the tool we created to provide practical answers. We retain the theoretical concepts of sleep length, sleep quality and sleep phase; but translate results into simple ‘do this / don’t do that’ recommendations. In a nutshell, we are illuminating sleep problems, educating athletes that don’t suffer, finding the athletes that do and getting those athletes help.

The ASSQ© process is very straightforward. A team physician typically requests access to the questionnaire and is emailed a link to the online site. The athlete goes online and fills out the questionnaire, we download the response, review the results, and send a letter back to the doctor giving them advice for their athlete. If an athlete presents with a moderate or severe clinical problem a Skype consult is set up with the principal investigator, and a visit to a sleep doctor scheduled if necessary.

RESULTS FROM THE ASSQ©

Between its launch in 2011 and the end of 2013, 307 elite athletes have completed the ASSQ©. Of these, 132 are male, and 168 are female. Athletes have participated from BMX, curling, rugby, alpine skiing, biathlon, bobsleigh, cycling, para-olympics, skeleton, speed-skating, swimming, volleyball, water-polo, and wrestling. Some athletes have also participated anonymously, where sport is not reported. Tables 1 and 2 below show the number of participating athletes where the team is known (248/307), the average hours slept per night and the average sleep difficulty score for each team. Sleep difficulty scores greater than 12 indicated clinically significant sleep disturbance and required follow-up consultation.

Within these teams, distinctive sleep profiles have started to emerge. For example, skeleton, swimming, and rugby athletes tend to sleep less and experience greater sleep difficulty, whereas curling and cycling athletes tend to sleep more and experience less difficulty sleeping than other sports.

Approximately 13% of athletes screened with the ASSQ to date have had sleep difficulty scores requiring them to have follow-up Skype consults. Females have tended to have slightly higher sleep difficulty scores than males, although not significantly so. Athletes’ increasing age and reduced sleep were significantly associated (P=0.01). Also, increasing age and increased sleep difficulty were significantly associated (P=0.03). Not surprisingly, a significant relationship was found between total sleep time and sleep difficulty score, with athletes who sleep less tending to have higher sleep difficulty scores (rho=-0.52).

Athletes who reported satisfaction with their sleep tended to have total sleep times averaging over 8 hours per night, whereas athletes reporting dissatisfaction with their sleep tended to have total sleep times averaging less than 7 hours per night. This finding is consistent with previous research demonstrating that extended hours of sleep are related to increased performance in intercollegiate athletes27. As dissatisfaction with sleep increased, so did average sleep difficulty score, suggesting that athletes are pretty good judges of their own sleep – if they are dissatisfied, chances are they are getting poor quality sleep.

Team case study:

The Canadian Women’s National Curling Program was very invested in sleep screening in preparation for the Olympic Trials and the 2014 Sochi Olympic Games. The national team coach initiated the screening, and 22 athletes were screened from across the country. The data from the athletes who were screened were analysed at the team level to provide a sleep profile for the team as a whole:

  • The median hours slept a night was 8 hours (with a range of 5.30 hours to 9.15 hours).
  • Comment: While the median was reassuring the range revealed that there was at least one athlete (possibly more) who was/were severely sleep deprived (<6 hours/night).
  • On average the athletes took 2 to 3 naps per week (average nap length 31 to 60 minutes).
  • Comment: This was encouraging that athletes napped, however routine napping for 20 to 30 minutes a day was recommended for all athletes.
  • On average it took the athletes 15 minutes or less to fall asleep.
  • Comment: This was a normal sleep onset latency.
  • Very few of the athletes had trouble staying asleep, or used medication to help them fall or stay asleep.
  • Comment: This was very encouraging. Inappropriate use of sedative medication is common amongst athletes and should be monitored and controlled.
  • The average level of satisfaction with sleep was “somewhat satisfied” or “neither satisfied nor dissatisfied”.
  • Comment: This question is the most predictive question for high probability of a clinically significant sleep disturbance.
  • The majority of the athletes did not snore or routinely gasp, cough or choke in their sleep.
  • Comment: While the likelihood of sleep apnoea is low in this population, the impact of the disease is significant and if treated can have substantial implications for the athlete.
  • The median sleep difficulty score for the athletes was 10.
  • Comment: The early validation data suggests that a score greater than 12 indicates clinically significant sleep disturbance and requires follow-up consultation.
  • 30% (n=7) of the athletes had a sleep difficulty score greater than 12, and required follow-up Skype consultation
  • The majority of the athletes experienced difficulty sleeping while travelling for their sport, however, the majority did not experience performance disturbance while travelling.
  • Comment: This indicated that there was value in developing a jet lag and travel fatigue programme to assist athletes with this disturbance.

CONCLUSION

Sleep is the foundation of recovery and critical to the management of athletic training regimens. Sleep is often ignored and compromised by athletes as a result of their busy schedules, other demands such as work and school, and most importantly by the intrusion of technology (cell phones, computers and tablets) into their life. This technology inhibits normal sleep physiology and fosters a heightened state of arousal, which acts as a barrier to the onset and maintenance of the sleep state. Understanding the actual sleep behaviours of athletes, how sleep parameters affect training and performance, and the impact of specific interventions on sleep and performance is important. This information will provide athletes, coaches and support staff with the tools necessary to manage sleep and improve athletes’ tolerance of strenuous training regimens. A better understanding of sleep behaviour and the effect of interventions will provide important solutions for the management of the negative impact of travel on athlete health and performance. The ASSQ© and global sleep screening of large populations of elite athletes will provide the information necessary to develop research methods, design informative studies and provide effective interventions. This article provides insight into how this can be achieved along with examples and early results of the work accomplished by the Canadian Own the Podium programme in preparation for the Sochi Winter Olympics.

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

Charles H. Samuels MD, CCFP, DABSM  is a Medical Director at the Centre for Sleep and Human Performance and a Clinical Assistant Professor, Faculty of Medicine, University of Calgary, Institute of Public Health

Lois James Ph.D is a Research Assistant Professor at the Department of Criminal Justice and Criminology, Sleep & Performance Research Center, Canada. Contact: lois_james@wsu.edu

References

  1. Dijk DJ, Duffy JF, Czeisler CA. Circadian and sleep/wake dependent aspects of subjective alertness and cognitive performance. J Sleep Res 1992; 1:112-117.
  2. Van Dongen HPA, Dinges DF. Investigating the interaction between the homeostatic and circadian processes of sleep-wake regulation for the prediction of waking neurobehavioural performance. J Sleep Res 2003; 12:181-187.
  3. Cohen DA, Wang W, Wyatt JK, Kronauer RE, Dijk D, Czeisler CA et al. Uncovering residual effects of chronic sleep loss on human performance. Sci Transl Med 2010; 2:14.
  4. Vila BJ. Tired cops: the importance of managing police fatigue. Washington DC: Police Executive Research Forum 2000.
  5. Vila BJ, Morrison GB, Kenney DJ. Improving shift schedule and work-hour policies and practices to increase police officer performance, health, and safety. Police quarterly 200; 5: 4-24.
  6. Vila BJ. Impact of long work hours on police officers and the communities they serve. Am J Ind Med 2006; 49:972-980.
  7. Vila B, C Samuels. Sleep problems in first responders and the military. In: Kryger MH, Roth T, Dement WC ed. Principles and Practice of Sleep Medicine, 5th ed. Philadelphia, Pennsylvaia: Elsevier Saunders 2010.
  8. Haslam, DR. Sleep loss, recovery sleep and military performance. Ergonomics 1982; 25: 163-178.
  9. Miller NL, Nguyen J. Working the nightshift on the USS STENNIS: implications for enhancing warfighter effectiveness. Proceedings of the Human Systems Integration Symposium 2003.
  10. Doheney SW. Sleep logistics as a force multiplier: an analysis of reported fatigue factors from Southwest Asia warfighters. Thesis 2004. Monterey, California: Naval Postgraduate School.
  11. Arendt J, Middleton B, Williams P, Francis G, Luke C. Sleep and circadian phase in a ship’s crew. J Biol Rhythms 2006; 21: 214-221.
  12. Neri DF, Shappell SA. Work/rest Schedules and Performance of S-3 Aviators during Fleet Exercise 1992 (NAMrL-1382). Pensacola, Florida: Naval Aerospace Medical Research Laboratory 1993.
  13. Brown D. Performance Maintenance during Continuous Flight operations, A Guide for Flight Surgeons (No. NAVMED P-6410. (01 Jan 2000)).
  14. Dijk DJ, DF Neri, JK Wyatt, JM Ronda, E Riel, A Ritz-De Cecco et al. Sleep, performance, circadian rhythms, and light-dark cycles during two space shuttle flights. Am J Physiol 2001; 281: R1647-1664.
  15. Caldwell JA. Fatigue in aviation. Travel Med Infect Dis 2005; 3:85-96.
  16. Meeusen R, Duclos M, Gleeson M, Rietjens G, Steinacker J, Urhausen A. Prevention, diagnosis and treatment of the overtraining syndrome. Eur J Sports Sci 2006; 6: 1-14.
  17. Halson SL. Nutrition, sleep and recovery. Eur J Sports Sci 2008; 8:119-126.
  18. Jones K, Harrison Y. Frontal lobe function, sleep loss and fragmented sleep. Sleep Med Rev; 5: 463-475.
  19. Knutson KL, Van Cauter E. Associations between sleep loss and increased risk of obesity and diabetes. AnnN Y Acad Sci 2008; 1129:287-304.
  20. Sharma S, Kavuru M. Sleep and metabolism: an overview. Int J Endocrinol 2010; Doi 10.1155/2010/270832.
  21. Maquet P. The role of sleep in learning and memory. Science 2001; 294:1048-1052.
  22. Reilly T, Edwards B. Altered sleep-wake cycles and physical performance in athletes. Physiol Behav; 90:274-284.
  23. Samuels C, Alexander B. A comprehensive strategy for long-term athlete development. Canadian Sport for Life 2012.
  24. Walker, M. (2010). Sleep, memory and emotion. Prog Brain Res, 185, 49-68.
  25. Jurimae J, Maestu J, Purge P, Jurimae J. Changes in stress and recovery after heavy training in rowers. J Sci Med Sport 2004; 7:334-339.
  26. Samuels C. Jet lag and travel fatigue: a comprehensive management plan for sport medicine physicians and high-performance support teams. Clin J Sport Med 2012; 22: 268-273.
  27. Mah C, Mah K, Kezirian E, Dement W. The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep 2011; 34:943-950.

Image via Jeff Rouk

International Scientific Tendinopathy Symposium 2014 winner of clinically relevant research by a young investigator: Congrats to Ebonie Rio

13 Nov, 14 | by BJSM

runners-kneeThe BJSM £1500 prize for best clinically relevant research by a young investigator was awarded at the International Scientific Tendon Symposium. The winner was Ebonie Rio for her paper: Exercise reduces pain immediately and affects cortical inhibition in patellar tendinopathy (co-authors Dawson Kidgell and Jill Cook).

The judging panel consisted of Prof Malcolm Collins (scientist, South Africa), Dr. Guy Simoneau (physiotherapist, Canada), Dr Hazel Screen (scientist, Britain), and Dr Jon Rees (rheumatologist, Britain). Fourteen potential papers were ranked on abstract before the conference and the top 4 were judged on their research presentation. 

We caught up with Ebonie Rio to learn more about her, and the award’s impact:

Can you share your academic background with the BJSM blog community?

I have a Bachelor’s of Applied Science in Human Movement, a Bachelors of Physiotherapy (hons), a Master’s of Sports Physiotherapy, and am currently a PhD candidate, in Monash University’s Monash Tendon Research group (Australia), in the Department of Physiotherapy. My Clinical experience involves time at the Australian Institute of Sport, Physio for Disney’s The Lion King (Melbourne and Shanghai), Australian Ballet Company, Victorian Institute of Sport, 2006 Commonwealth Games, 2010 Winter Olympics, and the  2012 Paralympics.

What was your favourite session of ISTS 2014?

I really enjoyed listening to Jo Gibson and her very clinically relevant presentation on management and evidence relating to central sensitisation for upper limb disorders.

Why are you excited to have won the award?

I am so grateful to BJSM and the committee for the award. It is such an honour as the standard of research presented was fantastic and there are so many wonderful young researchers emerging.  I am excited as it will allow us to forge ahead with one of the many project ideas on our whiteboard!

Thanks Ebonie, we look forward to your future publications!

Groin Pain in Athletes: First (Ever!), World Conference #Groin2014

11 Nov, 14 | by BJSM

By Ania Tarazi

On November 1-3, Aspetar Orthopaedic and Sports Medicine Hospital launched the inaugural World Conference on Groin Pain in Athletes at Aspire Zone in Doha, Qatar. International experts on groin pain convened during six sessions over three days to discuss developments in the field.

aspetarOn day 1 experts discussed groin pain epidemiology, risk factors and clinical examination and outcome measures. The day 2 presentations were on imaging and treatment of groin pain in athletes. The final day focused on the treatment of hip pain in athletes.

In this Groin Pain Storify, I compiled key themes and takeaways using the live feed from attendees and the audience that streamed the conference online from Aspetar’s website. For those not familiar, “Storify” allows you to capture all of the tweets, and other social media posts – including photos and graphs- in sequence.

We look forward to the conference consensus statement to be published in BJSM in 2015.

https://storify.com/aniatarazi/1st-world-conference-on-groin-pain

 

Prizes, Excitement, Legacy: BJSM Cover Competition 2014

7 Nov, 14 | by BJSM

Every year at BJSM, we aim to exceed ourselves in the rigour of our content (usually guided by our member societies), the relevance of our special issues, and the creativity on our covers. That’s why we love the cover competition. It allows us to reflect on this past year of continued growth, while hearing from you, our readership, to learn what resonates the most.

Stay tuned for more details about the surely fabulous prizes. For now, please vote in the first round:

 

Cover 1: January 2014 (i)

Cover 1: January 2014 (i)

 

Cover 2: January 2014 (ii)

Cover 2: January 2014 (ii)

 

 

 

 

 

 

 

 

 

 

 

 

Cover 3: February (i)

Cover 3: February (i)

Cover 4: February 2014 (ii)

Cover 4: February 2014 (ii)

 

 

 

 

 

 

 

 

 

 

 

Cover 5: March 2014 (i)

Cover 5: March 2014 (i)

March 6 2014

Cover 6: March 2014 (ii)

 

 

 

 

 

 

 

 

 

 

 

Professor Karim Khan Awarded Honorary Fellowship of the Faculty of Sport and Exercise Medicine UK

6 Nov, 14 | by BJSM

 By Beth Cameron, PR & Communications, Faculty of Sport and Exercise Medicine @FSEM_UK

Prof Karim Khan and Dr Roderick JaquesProfessor Karim Khan was awarded Honorary Fellowship of the Faculty of Sport and Exercise Medicine at the BASEM/FSEM joint Annual Conference, Walk 500 Miles, on Thursday 2 October 2014. Professor Khan received the award in recognition of his international career in Sport and Exercise Medicine.

Professor Khan is a truly international sports physician. He was educated in Australia, and studied Medicine and Medical Research at the University of Melbourne. He was awarded a PhD in Medicine by the University of Melbourne with a thesis titled “The effect of mechanical loading on the musculoskeletal system: clinical and laboratory studies”.  More recently he has studied and completed an MBA from the University of British Columbia, Canada.

His career spans the globe. Starting in Australia, he moved to Canada and is currently working in Qatar as the Director of Research and Education at Aspetar Orthopaedic and Sports Medicine Hospital. He is in his 7th year as Editor in Chief of the British Journal of Sports Medicine, which has become the leading international academic journal and digital media hub for the speciality.

Professor Khan is authorised as a Sports Medicine Physician by the Canadian Academy of Sports Medicine (CASEM) and the Australasian College of Sports Physicians (ACSP). He is a Fellow of the American College of Sports Medicine and Sports Medicine Australia. He served as Sports Physician to several teams, from a range of disciplines from Ballet to Basketball. His main research areas are in exercise promotion for health (including bone health and falls prevention) and pathogenesis and imaging of tendinopathies. He has published over 250 original research articles in addition to 3 books. He is a co-author of Brukner and Khan’s Clinical Sports Medicine, which has been published in three languages and is in its 4th edition. In 2001, Professor Khan was awarded the Australian Prime Minister’s Medal for service to sports medicine. In 2012, he was profiled in ‘The Lancet” with a biography titled ‘Good Sports’.

The FSEM awards up to two Honorary Fellows per year via its Members and Fellows Committee. The award of Honorary Fellow is made where there is an outstanding contribution to the specialty of Sport and Exercise Medicine throughout an individual’s professional career.

Customised foot orthoses for Achilles tendinopathy RCT: responding to the critics

3 Nov, 14 | by BJSM

By Dr Shannon E Munteanu, Lisa A Scott, Daniel R Bonanno, Dr Karl B Landorf, Dr Tania Pizzari, Prof Jill Cook, Prof Hylton B Menz
-achillesOur group’s randomised controlled trial (RCT) that evaluated the effectiveness of customised foot orthoses for Achilles tendinopathy was recently published in the British Journal of Sports Medicine. The abstract can be viewed here, and the full text of the study protocol can be viewed here.
 
As with any RCT that provides unfavourable results for a commonly-used intervention, our trial has attracted some degree of criticism on blogs and social media. Rather than entering into ongoing debates across multiple platforms, we have instead summarised our responses to these criticisms below.
Criticism #1: The sham orthoses were not ‘biomechanically inert’
In order to measure the treatment-specific effectiveness of an intervention, controlled trials often use placebo groups to compare the experimental intervention to – the best example being the use of inert pills in pharmaceutical trials. However, this is not possible when evaluating interventions which have a physical or mechanical effect (i.e. those commonly used for musculoskeletal disorders). In these trials, the control group is provided with a ‘sham’ intervention, which can be defined as “a treatment or procedure that is performed as a control and that is similar to but omits a key therapeutic element of the treatment or procedure under investigation” (note the added emphasis). Put simply, a sham intervention is not a placebo.
 
Our trial published in the British Journal of Sports Medicine compared the effectiveness of customised orthoses to sham orthoses for people with Achilles tendinopathy undergoing an eccentric exercise program. The sham orthosis was a contoured, vacuum-moulded device constructed from 4.0 mm thick ethylene vinyl acetate (EVA) with a density of 90 kg/m3 (i.e. very soft) and had an identical covering fabric to the customised orthosis. The sham device was selected based on a previous study which showed that it produced only small effects on plantar pressure (10% reduction in peak pressure under the heel) while still being considered a credible intervention by participants.
 
After this study was published, the following comment was made in relation to the selection of control interventions in orthotic studies:
 
“…the best you can do is to minimise the influence that the control orthoses have upon the variable of interest” (link).
 
We agree. However, since the publication of our RCT, some have argued that the sham device was not actually a sham because it was not biomechanically ‘inert’, for example:
 
“There is no such thing as a “sham” foot orthosis, and the sooner this is recognised the better” (link)
 
“Not sham orthoses at all. This study actually compared two different types of orthoses” (link)
 
“Does this mean they are completely “inert” and will not change any kinetic parameters at the foot-orthosis interface?” (link)
 
These comments represent a misunderstanding of what a sham intervention is. It is obvious that no device placed in the shoe can be truly biomechanically inert. However, at no stage have we claimed that the sham device used in our trial was inert – we have simply argued (and have evidence to show) that they have as minimal effect as possible while still being considered a credible intervention. Credibility of the sham is critically important when evaluating a real intervention against a sham intervention, otherwise resentful demoralisation comes into effect in the sham group, which might bias the findings.
 
Interestingly, a previous RCT that evaluated the effectiveness of customised orthoses for pes cavus also used a sham device for the control group (an insole made from 3-mm latex foam). This device had similar effects on plantar pressure to our sham device (reductions in pressure-time integrals of 9%, 11% and 6% in the rearfoot, forefoot and midfoot, respectively). However, the response to this trial could not have been more different, and no criticism has been made of this sham device. The fact that this study found customised orthoses were more effective than sham devices may explain the different responses to these two trials.
 
If there are any lingering doubts that the sham orthoses had minimal mechanical effects and were markedly different to the customised orthoses, we provide the following movie for your perusal:
<iframe width=”420″ height=”315″ src=”//www.youtube.com/embed/Vv42SCh8DIw” frameborder=”0″ allowfullscreen></iframe>
Criticism #2: The customised orthoses were not appropriately prescribed
Researchers conducting trials of customised orthoses are faced with the unavoidable dilemma of how to individualise or ‘customise’ the orthoses. This is a long-standing problem and arises because there are currently no evidence-based or consensus guidelines in relation to the prescription of foot orthoses – an issue that is explored in this commentary paper. An ambitious attempt to try and achieve this commenced in July 2009 but to date has produced no outcome (and has been described as an ‘epic fail’ by one of its proponents).
 
In our trial, the customised orthoses were individually prescribed based on an assessment of participants’ Foot Posture Index and bodyweight. At the time the study protocol was published, there was some concern regarding the lack of a heel lift (this is discussed later), but our approach attracted the following positive comments:     
   
“I am excited to see Shannon, Karl, Hylton and company trying to tackle this important subject since Achilles tendinitis is a very common injury in my sports medicine practice and it would be nice to see how the individuals all respond to the different protocols” (link)
 
“…they have made the effort to make the devices more custom than any other study that I have seen…If they have a pronated FPI, they get the medial heel skive, if neutral it is a basic shell, and if a supinated FPI they get a device to control supination as described in Josh Burns paper…the devices are made at a laboratory from slipper casts, so should be close to what many Podiatrists would prescribe” (link)
 
However, on the publication of the RCT results, the mood changed considerably:
 
 “Is giving everyone the same prescription even a true definition of a custom device? Not for me…” (link)
 
“It’s really hard for me to get excited about custom foot orthosis research unless the custom foot orthoses used in these studies are the types of foot orthoses used by those who are most experienced and expert at foot orthosis therapy” (link)
 
To reiterate – there are no evidence-based or expert consensus guidelines in relation to the prescription of foot orthoses. Until such guidelines are produced, there is no basis upon which to argue that our prescription approach was inappropriate.
Criticism #3: Why no heel lift?
Heel lifts are commonly recommended as a treatment for Achilles tendinopathy, based on the assumption that elevating the heel decreases Achilles tendon loading. In designing the trial, we considered adding a heel lift to the orthoses but eventually decided against this. This was criticised when the study protocol was published and again when the RCT results were published:
 
“I would have thought that if one was to design an experiment on custom foot orthoses for Achilles tendinopathy that one would have used a custom foot orthosis with a heel lift added to the orthosis since this is the type of custom foot orthosis that nearly every good sports podiatrist that I know of uses in their orthoses for patients with Achilles tendinopathy” (link)
 
“Of course there should have been heel lifts on the foot orthoses” (link)
 
“Clinically speaking I think it’s reasonable to say that most practitioners would incorporate a heel raise” (link)
 
So why no heel lifts?
 
Put simply, the evidence to support the use of heel lifts in Achilles tendinopathy is extremely limited. First, our systematic review revealed no trials of heel lifts as a treatment for AT. Second, the biomechanical evidence that heel elevation decreases Achilles tendon loads is not at all convincing. At the time the study was designed, three studies had examined the biomechanical effects of heel elevation on Achilles tendon loading:
 
-         Reinschmidt and Nigg (1995) found no difference in plantarflexion moments when subjects ran in shoes which differed in heel height (2.1-3.3 cm), and concluded that “the results of this study did not support the speculation that changes in heel height would reduce the plantarflexion moments of the ankle joint, and thus, the Achilles tendon forces…the treatment or prevention of Achilles tendonitis with a raising of the heel is based on anecdotal evidence and not on research”
 
-         Dixon and Kerwin (1998) assessed the effects of 7.5mm and 15mm heel lifts on Achilles tendon force during running, and found that Achilles tendon forces increased with greater heel elevation. They concluded that “the finding that increased heel lift may increase maximum Achilles tendon force suggests that caution is advised in the routine use of this intervention”
 
-         Farris et al (2008) assessed the effects of 12 and 18mm heel lifts compared to a no-lift control condition in 6 female runners, and found no difference in peak Achilles tendon forces or maximum Achilles tendon strain between conditions, concluding that “Heel lifts alter ankle mechanics during running. However, this appears not to affect peak AT force or strain”
 
In the time between the commencement of our trial and its publication, one study has been published that suggested that heel lifts may have beneficial effects on Achilles tendon loading:
 
-         Farris et al (2012) assessed the effects of 12 and 18mm heel lifts on Achilles tendon strain in ten female runners, and found that, compared to the control condition, strain reduced (by 1.9%) with the 18mm lift but did not change with the 12mm lift.
 
Would our prescription protocol have changed if this study had been published prior to the commencement of our trial? No – on balance, the evidence is not overly supportive of the use of heel lifts in Achilles tendinopathy. Interestingly, a recent biomechanical study found that contoured orthoses without a heel lift reduced Achilles tendon load in 12 runners, so it cannot be argued that orthoses must have a heel lift in order to be effective in the treatment of Achilles tendinopathy. Furthermore, even if there was good evidence to suggest that heel lifts reduce Achilles tendon loading, the question then arises: why not simply use a heel lift rather than incorporating a heel lift into a customised orthosis?
 
In summary, our trial is the most rigorously designed study so far undertaken to assess the effectiveness of customised orthoses in the treatment of Achilles tendinopathy in individuals undergoing an eccentric exercise program. We stand by our conclusion that foot orthoses, prescribed according to the protocol in this study, are no more effective than sham foot orthoses for this condition. We welcome further high-quality RCTs evaluating foot orthoses by other investigators, particularly if they believe that they can prescribe more effective foot orthoses.
Originally posted: http://hyltonmenz.blogspot.ca
Originally

 

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: http://bjsm.bmj.com/site/education/

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!

www.bjsmeducation…

References

  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.

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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). (https://www.facebook.com/TheLondonSEMSociety). He runs a Blog at roryjheath.wordpress.com

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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