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Sports Medicine postgraduate studies for physiotherapists…life changing?

24 Jan, 15 | by BJSM

Zuzana Machotka (@drzuzi) takes a look at the literature on postgraduate studies in Physiotherapy.

Evolution of physiotherapy education

Photo courtesy of: mleiboff , Flickr CC

Photo courtesy of: mleiboff , Flickr CC

Physiotherapy education has changed dramatically over the past century. Initially taught in colleges and hospitals, Physiotherapy Studies were predominantly skill-based and clinically-focussed. Physiotherapy soon became a university degree and adopted a clinical science framework.(1, 4) Graduate physiotherapy students are now equipped with a broad range of knowledge and skills and are increasingly contribute to healthcare politics and health promotion, update clinical skills and stay abreast of current research trends.(1)

Professions develop in response to practice and society needs.(4) For physiotherapists, this means greater accountability for individual practices, refinement of knowledge and skill and greater acknowledgement of evidence based practice.(5-7) Postgraduate programs have played an important role in the development of the Physiotherapy Profession and have become increasingly accessible around the world. The focus of postgraduate coursework in Physiotherapy is threefold: to increase knowledge, improve clinical reasoning skills and help students become educated consumers of research.(6, 8, 9)

A UK-based qualitative study explored the perspectives of masters level physiotherapists and who had continued in clinical practice after graduation.(6)The study found that graduates viewed their experiences as ‘life changing’ and ‘career changing’. They reported increased motivation, an increased desire to participate in self-directed learning and were better equipped to critically judge their own performance. Combining newly developed skills with an existing skillset was perceived as a major benefit of undertaking a master’s program. The development of critical thinking skills and knowledge of research methods made graduates more confident in the workplace, improved their ability to deal with complex clinical scenarios and resulted in enhanced career opportunities. Graduates also reported a greater awareness of patient’s values and a greater ability to educate patients; qualities recognised as attributes of expert clinicians.(10) Other expert attributes described by the graduates include greater efficiency with time, increased ability to practice patient-centred rather than disease-focused care, regular reassessment of objective and subjective data, greater emphasis on documentation, and the ability to predict patient outcomes.(5, 10, 11)

There are a number of benefits associated with postgraduate physiotherapy education:

  • Expands and refines clinical skills (5, 6, 8, 9, 12-16)
  • Expands knowledge and understanding (6, 9, 12, 14-16)
  • Enhances and improves research skills (4, 6, 16)
  • Improves patient outcomes and communication (5)
  • Increases creativity and innovation in clinical practice (12)
  • Enhances clinical reasoning skills and clinical decision making (12, 15)
  • Increases individual’s confidence (6, 12)
  • Increases research skills, awareness and activity (6, 12, 15)
  • Builds on critical judgement, independent learning and learning from others (6, 9, 12)
  • Enhanced job satisfaction (5, 8)
  • May provide improved career structure and enhance career pathway opportunities e.g. extended scope practitioner opportunities, specialisation, consultant jobs (5, 6, 8, 15, 16)
  • Provides professional development and continuing education (5)
  • May increase income/remuneration (8)
  • Better understanding of the importance of patient centred care and education (6)

Sports physiotherapy postgraduate studies

Sports physiotherapy combines musculoskeletal physiotherapy and an athlete management approach. This approach brings together multiple stakeholders including sporting clubs and administrators, coaches, the athletes themselves and their family. Postgraduate sports physiotherapy programmes encourage greater critical evaluation and use of evidence based principles to support clinical reasoning and justify management. Postgraduate sports physiotherapy programs follow an athlete management approach by offering supervised clinical practice by experts in the field.(17, 18) A recent study found that the most powerful learning experience during a postgraduate program was being directly observed by a mentor while interacting with patients and being provided with feedback of performance.(9) Mentoring allowed students to understand how to critically analyse their own practice and knowledge base.

National regulatory bodies and other authorities require information to monitor the quality of service provisions, especially when teams travel internationally.(18) Employers of sports organisations, health centres and the leisure industry benefit from recognition of higher learning and education and can gain greater confidence in the clinician.

Less barriers and more awareness needed

Government and public awareness of the availability of further education can increase confidence and possibly the need for higher remuneration to acknowledgement increase in knowledge and clinical skill base. However there are a number of key barriers to the uptake of postgraduate study:

  • Lack of time (8, 14, 15)
  • Lack of employer encouragement and support (12-14)
  • Lack of financial support (8, 12, 13, 15)
  • Family commitments (8, 14, 15)
  • Lack of awareness and availability of postgraduate programmes (6, 12, 13)
  • Past negative educational experiences and perceived poor academic ability (12, 13)

Postgraduate education continues to be taken up by the minority.(12) One of the major barriers to enrolment in postgraduate studies is a lack of awareness of the programs that are available. With an increasing number of postgraduate programs on offer to physiotherapists in the field of sports physiotherapy we believe it is timely to feature a selection of these programs and highlight their various formats.


For related material see our previous blogs from our undergraduate perspective blog series, where we’ve heard from two physiotherapists and a doctor about undertaking a MSc in Sports and Exercise Medicine. 


  1. Hunt A, Adamson B, Higgs J, Harris L. University Education and the Physiotherapy Professional. Physiotherapy. 1998;84(6):264-73.
  2. Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ. 2004;329(7473):1017.
  3. Sackett DL. Evidence-based medicine. Seminars in Perinatology. 1997;21(1):3-5.
  4. Warren SC, Pierson FM. Comparison of Characteristics and Attitudes of Entry-Level Bachelor’s and Master’s Degree Students in Physical Therapy. Physical Therapy. 1994;74(4):333-48.
  5. Jull GA, O’Sullivan P. The future for postgraduate specialty clinical course work masters programs in Australia. The Australian journal of physiotherapy. 2006;52(2):75-6.
  6. Stathopoulos I, Harrison K. Study at Master’s Level by Practising Physiotherapists. Physiotherapy. 2003;89(3):158-69.
  7. Jones S, Bellah C, Godges JJ. A Comparison of Professional Development and Leadership Activities Between Graduates and Non-graduates of Physical Therapist Clinical Residency Programs. Journal of Physical Therapy Education. 2008;22(3):85-8.
  8. Sran MM, Murphy S. Postgraduate physiotherapy training: interest and perceived barriers to participation in a clinical master’s degree programme. Physiotherapy Canada Physiotherapie Canada. 2009;61(4):234-43. Epub 2010/09/03.
  9. Petty NJ, Scholes J, Ellis L. Master’s level study: learning transitions towards clinical expertise in physiotherapy. Physiotherapy. 2011;97(3):218-25. Epub 2011/08/09.
  10. Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute Dimensions that Distinguish Master and Novice Physical Therapy Clinicians in Orthopedic Settings. Physical Therapy. 1992;72(10):711-22.
  11. O’Sullivan P, Jull G. The future for postgraduate specialty clinical course work masters programs in Australia. -editorial. Australian Journal of Physiotherapy. 2006;52(2):75-6.
  12. Gosling S. Physiotherapy and Postgraduate Study. Physiotherapy. 1997;83(3):131-5.
  13. Gosling S. Physiotherapy and Postgraduate Study. Physiotherapy. 1999;85(3):117-21.
  14. Glover P, Bulley C, Howden S. Influences on physiotherapists when deciding to study at Masters level: An exploratory study. Advances in Physiotherapy. 2008;10(1):14-20.
  15. Beeston S, Rastall M, Hoare C. Factors Influencing the Uptake of Taught Master’s Programmes Among Physiotherapists. Physiotherapy. 1998;84(10):480-6.
  16. Green A, Perry J, Harrison K. The influence of a postgraduate clinical master’s qualification in manual therapy on the careers of physiotherapists in the United Kingdom. Manual Therapy. 2008;13(2):139-47.
  17. Phillips N. Postgraduate specialisation in sports physiotherapy–academic or clinical expertise? Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2009;10(3):83. Epub 2009/07/21.
  18. Bulley C, Donaghy M. Sports physiotherapy competencies: the first step towards a common platform for specialist professional recognition. Physical Therapy in Sport. 2005;6(2):103-8.


Zuzana Machotka (@drzuzi) is a Clinical Researcher at the International Centre for Allied Health Evidence at the University of South Australia, a Physiotherapist at Olympic Park Sports Medicine Centre in Melbourne and an Anatomy Facilitator in the Physiotherapy Department at Monash University. Her clinical interests include the management of pelvic and hip dysfunction. Zuzana travels with the Australian Paralympic ski team and is a physiotherapist for an Australian rules football team in Victoria, Australia.

Sitting Ducks – Sedentary Behaviour and its Health Risks: Part One of a Two Part Series

21 Jan, 15 | by BJSM

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

By Rory Heath (@Roryjheath)

The recent Inaugural Active Working Summit, January 8th, 2015, brought together representatives from healthcare, scientific research and commercial organisations with an aim to promote wellness at work.

At BJSM, we’ve covered the benefits of exercise on the brain before and even proposed a ‘Tour de Office’. Here, we profile a great example of progress in the field, demonstrating the latest research into problems and their solutions.

I will present the Summit’s findings as part of a two part series: 1. Sedentary Behaviour & its Health Risks and; 2. Implementation of Active Working  and related workplace behaviours changes.

Setting the Scene – How Much Time Do We Sit? Changing Patterns of Sedentary Behaviour. Dr Stacy Clemes, Senior Lecturer in Human Biology, Loughborough University

  • During waking hours 65% of an average person’s day is spent sedentary; 9-10 hours for adults.
  • Sitting at work = 60% of total daily sitting time on a weekday, but even on weekends people still sit for 8 hours.
    - Activity at work can have great effect to reduce sedentary behaviour time!
  • High work sitters spent >7.5 hours sitting at work.
    - How many hours does a typical medical student spend sitting down in preclinical?
  • Even in the ‘active’ education and retail sectors, employees spend >6 and 2 hours respectively sitting at work, with 10 and 6 hours totally spent sitting over the day. Employees in Telecommunications spend >12 hours sitting a day!
  • More sedentary at work = more sedentary at home. Unfortunately, these people do not tend to compensate by increasing activity in their leisure time. (Clemes et al., 2015)

Why Sitting is Bad – Effects on Heart Disease, Obesity and Diabetes.
Dr Jason Gill, Reader, Institute of Cardiovascular and Medical Sciences, University of Glasgow

  • Even if a person completes the recommended daily 30 minutes of exercise, the amount of time spent sitting in the day still substantially affects mortality risk.
  • Diabetes; A major cause of blindness, amputation and mortality. NHS diabetes spending is projected to double to £16.9 billion by 2035 (see here).
  • People that sit the most have a 112% increase in the Relative Risk (RR) of Diabetes and a 147% increase in the RR of cardiovascular events compared to people who sit down the least. Overall mortality is increased by 50%. Sitting down has similar mortality rates to smoking (Wilmot et al, 2012, Diabetologia)
  • It’s been shown that prolonged sitting adversely affects glucose metabolism. However, sitting with ‘light-moderate’ intensity breaks can significantly reduce glucose and insulin levels.

Sedentary Behaviour and Risk Co-Relation to Cancer and Mental Health.
Dr David Dunstan, Professor & Head, Physical Activity Laboratory, Baker IDI –

Positive associations between Cancer and Sedentary Behaviour exist:
– Lung cancer increases by 54%
– Uterine cancer 66%
– Colon Cancer 30% increased risk.

Despite these associations, there is a lack of high quality studies. ‘We may see stronger relationships between sedentary behaviour and cancers if we measured it better’.

  • Potential mechanisms – Sedentary behaviour contributes to an interrelated network of increased body fat, altered production of sex hormones, metabolic dysfunction, leptin, adiponectin and inflammation, encouraging cancer development.

Mental health

The risk of anxiety and depression is significantly higher in those who sit more while increased activity shows better subjective mental heath and vitality.
Potential mechanism: Physical activity displaces sedentary behaviour and has proven benefits. Perhaps there is also a ‘social withdrawal hypothesis involvement’.

  • Sitting has a higher rate of subjective fatigue than standing.

A Brief Overview of Global Sedentary Science Research.
Dr Sebastien Chastin, Senior Research Fellow in Behaviour Dynamics, Glasgow Caledonian University

  • 1953 ‘London Bus Study’ – bus drivers had a higher mortality rate due to Cardiovascular Disease compared to the more active bus conductors. If a conductor’s ‘Low level activity’ is beneficial, this should translate similar benefits in our modern world. (J Morris et al., 1953)
  • Start Active, Stay Active states that all ages should ‘minimise the amount of time spent being sedentary for extended periods’. It’s now time to convert studies and new policy into change and progress in the workplace.
  • For every €100 spent on Nutrition, €35 is spent on Physical Activity but only €6 Euros are spent on Sedentary Behaviour research ➔ more funding is needed.

The Sitting Time Bomb – Are We Prepared?
Dr Tom Yates, Senior Lecturer in Physical Activity, Sedentary Behaviour & Health, Diabetes Research Centre, University of Leicester

  • We are now victims of our own environment. Historically human mortality was due to infective causes; now our greatest killers are self-inflicted Physical Inactivity, Smoking, Diabetes and CVD.
  • We spend £8 billion on T2D, 14 billion on CVD and 9 billion on cancer. These are preventable – it is the interaction of our genes and our environment that is causing these diseases.
  • The classic medical solution is to provide a pill:
    Pharmaceutical companies spend between $873 million to $8 billion in drug development. This completely dwarfs the money spent on research into sedentary behaviour.
  • We treat obesity through invasive, dangerous surgery. We must find a preventative, cheaper, safer option; through changes to environment and policy. It is possible – look at the change in smoking.

Takeaway thoughts

Public Health focuses on promoting Exercise but neglects sitting, where people spend the majority of their time. There is a grey area between moderate and sedentary activity that needs to be addressed in public health policy.

  • You can still be active whilst sitting. Fidgeting and moving around can reduce time spent sitting still. Choose your office furniture wisely, choose ergonomic chairs and sit-stand desks.
    ‘Just moving around will lead to benefits’.
  • We urgently need large scale long term intervention studies to evaluate effect of interventions to reducing sitting on health outcomes in real world settings.

#ActiveWorking is gaining momentum and will continue to change workplaces in the future. To see tweets from myself and others from the event, enter #ActiveWorking on Twitter. To find out more about the event, check out (@getGBstanding) and (@ACTIVEworking), and subscribe to hear the latest details of next year’s event.

In the meantime; stand, walk, fidget and move as much as you can before the second blog is posted!

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 Cardiff Medical School graduate and now a junior doctor at the John Radcliffe Hospital, Oxford. He is an Associate Editor for BJSM and 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.

Stem cell therapy and other novel needle-based therapies for back pain: Disconnect between evidence and practice

19 Jan, 15 | by BJSM

By Dr. Kieran O’Sullivan, University of Limerick, Ireland

And Prof. Peter O’Sullivan, Curtin University, Australia

The 14-time Grand Slam winner, Rafael Nadal’s recent struggles to participate at the highest level due to ongoing low back pain (LBP) once again brings the issue of novel therapies offering tantalizing cures to the fore; he is undergoing stem cell therapy (SCT). So it is timely to explore: i) what this therapy potentially offers, ii) the quality of the supporting evidence, iii) its comparison to other needle-based therapies, and iv) what the use of several novel needle-based therapies in the last decade (e.g. stem cell therapy, platelet-rich plasma, dry needling) reveal about attitudes to management of pain in sporting populations.

What is stem cell therapy and why consider it?

 Stem cell therapy (SCT) has opened up exciting avenues in health research across many disciplines. Focusing on the role of SCT in LBP, its proposed mechanism of action is regeneration of local spinal structures which are degenerative and/or presumed to be damaged.[1-3] There are several different methods of using SCT. This piece focuses on mesenchymal stem cells (MSCs) as they have been the most promising candidate cells for relief of pain, showing good differentiation potential towards cartilage, tendon and bone cells.[4, 5] Typically MSCs are extracted from the patient’s bone marrow and inserted into the affected region as undifferentiated MSCs, or a short while later as differentiated cells. Hopes for its potential in clinical practice were raised when it became clear that changes in cell structure could be observed in the host tissue very quickly (weeks) after only one treatment.[6, 7]

How good is the evidence of effectiveness?

A body of basic science (animal) data suggests that in closely controlled environments, MSCs can increase the expression and production of type II collagen and the extracellular matrix in intervertebral discs with a view to enhancing nutrition and consequent regeneration.[2, 8-10] However, not all animal studies have demonstrated a benefit.[11] Interestingly, in those studies using larger animal models which more closely replicate the human intervertebral disc, there was no benefit from the use of MSCs.[11] Furthermore, the evidence from small human studies is less than convincing.[12, 13] There is currently a notable lack of adequately powered, blinded randomised controlled trials (RCTs) examining the effectiveness of MSCs in LBP. This is somewhat surprising given the fact that such therapies are easier to study in RCTs than more complex behavioural interventions.

The use of MSCs in knee cartilage defects and knee osteoarthiritis has been examined over a longer period of time. Once again, animal studies are encouraging[14] and uncontrolled human studies show promise.[15] However, there does not appear to be a clear clinical benefit in humans based on their reported knee pain experience in RCTs, even if the cartilage appears to have benefitted through an increase in volume.[16]

In conclusion, based on current evidence, while MSCs appear to be capable of regenerating tissue in animal models, changes in tissue structure (i) are not always replicated in human studies and (ii) do not appear to lead to reductions in pain and disability.

How does this evidence compare to other needle-based therapies?

Needle-based therapies usually aim to aid tissue repair (e.g. MSCs, prolotherapy, platelet-rich plasma) and/or provide direct pain relief (e.g. epidural and facet joint injections). The evidence for most needle-based therapies is underwhelming, whether they are focussed on tissue repair, pain relief or used to deliver medication[17] [18]. For example, epidural injections for LBP and/or leg pain have at best a short-term effect on pain.[19-21] The size of this effect is of marginal clinical significance, with a number needed to treat of 11.4,[22] and the benefit is lost at medium- and long-term follow-up.[19, 20] The evidence is remarkably similar for facet joint injections,[23] prolotherapy,[24] dry needling,[18, 25] acupuncture[18, 26] and platelet-rich plasma.[27, 28] This is not to say that these interventions are never of assistance. Nevertheless, it does highlight that despite ongoing developments in such interventions, there is a consistent pattern in the limited effectiveness of such interventions. The need for accurate blinding and control arms in studies is of critical importance, as the benefits are almost entirely absent in very well conducted placebo controlled RCTs.[21, 26]

What does this tell us?

While the story of SCT seems tantalising as a new cure for LBP – the clinical data does not currently support this enthusiasm. The story of SCT and other needle-based therapies for LBP again highlights the limitation of reducing the understanding of a person’s pain experience and associated disability down to a single structural cause. We know that almost half of asymptomatic people under the age of 30 years have degenerate discs on MRI imaging [29, 30] and that the association between disc degeneration and pain or disability is weak to moderate at best.[29, 31] Furthermore prospective studies have failed to demonstrate that these findings are predictive of pain and disability.[32] Many asymptomatic athletic populations have also demonstrated such findings on imaging and these are poorly correlated with previous, current and future LBP experiences.[33-35] Therefore the presumption that an MRI finding of disc degeneration is the cause of a person’s LBP,[1] which then becomes the target for SCT or other needle-based therapies, may represent flawed logic in many situations.

Furthermore if the disc degeneration is symptomatic, it is likely to be infleunced by various other biopsychosocial risk factors such as movement control strategies, conditioning, training loads, technical factors linked to individual sports, lifestyle factors, tissue sensitivity, immune system function, a person’s beliefs and their psychological status.[36] Therefore simply applying SCT or other needle-based therapies to a degenerate disc without addressing other important risk factors for pain and disability may result in the therapy failing. In the same way that ‘disc replacements’ and ‘fusions’ for LBP have not demonstrated long term superior effects for LBP over conservative care,[37, 38] the isolated use of SCT and other needle-based therapies will likely follow the same path as other reductionist approaches in the management of complex disorders like LBP.

Is there a role for SCT and other needle-based therapies for LBP in sport?

The implementation, and indeed removal, of novel therapies in clinical practice should be done in line with the available evidence.[39] It appears clear however that SCT, like other popular therapies of our time such as platelet-rich plasma and dry needling, has managed to gain appeal in the absence of strong evidence that it enhances recovery over and above existing rehabilitation options. Clearly, more research is required to determine whether an athlete with LBP associated with a clear tissue injury and impaired repair processes, could benefit from this therapy while controlling for the other risk factors linked to the disorder. However a silver bullet seems unlikely for complex disorders like LBP. Many would suggest that the ability of some needle-based therapies to provide short-term pain relief justifies their role as a “window of opportunity” for rehabilitation and recovery. We accept that selecting those who require some pain control to help them overcome their pain, for example in some acute pain situations may be beneficial. However, the aforementioned blinded RCTs currently suggest the effect on pain is usually absent or very small, with large numbers of patients needing to be treated with such therapies for a single patient to demonstrate a clinically significant benefit.

There may be a role for integrated management approaches that target biopsychosocial risk factors in conjunction with novel therapies such as SCT and other needle-based therapies for the management of LBP – however currently the jury is out on this. While the risks for many needle-based therapies are relatively small,[40] as these risks increase [41] it becomes harder to justify their use considering the very small benefits observed. It appears that both athletes and healthcare professionals are almost innately drawn to novel therapies and treatments which focus on local “issues in the tissues”, and the current use of SCT appears to reflect a pattern where adopting novel therapies in clinical practice runs ahead of the evidence.[39]

Instead, we advocate an approach where the unique contributing factors for each athlete are considered, and where treatment options offered to each athlete are based on the best available evidence. In the event that local tissue sensitivity is seen as a significant barrier to rehabilitation and recovery, local therapies which provide at least some pain relief may have a role. However, the existing range of needle-based therapies to date have not demonstrated such an effect is clinically worthwhile, especially in terms of long-term management of chronic pain conditions like LBP.


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  40. Pak J, Chang J-J, Lee JH, Lee SH. Safety reporting on implantation of autologous adipose tissue-derived stem cells with platelet-rich plasma into human articular joints. BMC Musculoskelet Disord 2013;14(1):337
  41. Epstein N. The risks of epidural and transforaminal steroid injections in the spine: Commentary and a comprehensive review of the literature. Surgical Neurology International 2013;4(S2):S74–S93

Tough Mudder, The Rise of the Obstacle Course: What Medical Teams Need to Consider

16 Jan, 15 | by BJSM

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

By Dr Natasha Beach

Gone are the times when a marathon or triathlon were on the ‘bucket list’ as the “must do” mass participation event.  Recent years have seen the rise of military style obstacle assault courses worldwide which present new challenges for the medical teams providing pre-hospital care.

tough mudderTough Mudder is one such event – consisting of a 10-12 mile obstacle course designed to test all-round strength, stamina, teamwork, and mental grit of the “Mudders”. Some of the challenges that Mudders face include scaling high walls, submerging themselves in iced water and dodging live electrical cables in their pursuit to complete these mud based courses. Nearly one million people worldwide took part in this growing event in 2013 and this year saw eight events within the UK and Ireland.

One would expect that those choosing to take part in such a demanding event would be at their peak of physical fitness after months of preparation.  For the majority this is true, with many having prepared for months or years prior.  However, these events have become the target of many charity runners and groups of friends who may have persuaded each other to sign up last minute. This does present potential challenges to the medical teams who may have to deal with those less suitably prepared.

The three functional areas of the medical team

In the most simplistic of terms the medical facilities can be divided into three functional areas: a main medical tent (usually near the finish line), transport, and obstacles. The particular challenge with these courses is anticipating the level of risk that each obstacle poses – this must be considered both in isolation (i.e. the structural design) but also in the context of where within the course each obstacle is placed and what precedes it. For example, climbing a twelve foot wall would be relatively easy if placed early on in the course when competitors are clean and full of energy. However, the risk profile changes dramatically if the wall is placed after a water-based obstacle ten miles into the course when participants are tired and covered in mud.

Vehicle access around the courses poses its own logistical challenge as large areas of the course may be inaccessible to land ambulances. One alternative being utility task vehicles which provides the maneuverability and fast response times required for the difficult terrain, however can only carry seated casualties.  This would be insufficient as the only form of transport as some casualties may require transport in a lying position. Off-road ambulances have the advantage of being able to carry patients on a trolley but are comparatively slow and cumbersome. Therefore a combination of both is required around the course to ensure access to all areas with the ability to transport any type of injury.

Prior to the event, those responsible for medical provision need to review the course with the aim of assessing the terrain and therefore the likely response times and vehicles required. Both access to the obstacle and likely injuries must be considered.  An obstacle with a high-risk of causing injuries which would require stretcher removal being is placed in an area inaccessible to an off-road ambulance would require to be moved.  A close working relationship between event organisers and medical providers is therefore needed for example a joint site visit with the Medical Director, event organiser and course designer in the run-up to the event helps to highlight and rectify any potential issues.

After considering the obstacle type, location, access, distance from the finish medical tent and the climate, the Medical Director can make an assessment of the resources required, taking into account the equipment needed and the skill set and number of personnel, along with their distribution within the three functional areas mentioned.

From experience, these events can result in both medical and trauma based incidents. Therefore those present on site need to have the skills to deal with both – or at least be allocated to an area where their skillset will be best utilised. Unlike many events (such as marathons etc.) where the majority of the workforce are first aiders, with more advanced levels of support present in the minority, obstacle courses such as these require a more even distribution of expertise in order to manage the injury inflow and reduce the impact on local NHS resources where possible.

The popularity of events such as Tough Mudder look set to continue for years to come and with continued investment resources and time in developing comprehensive and detailed response systems we should continue to provide participants with a challenging but safe experience and probably the toughest event on the planet.


Dr Natasha Beach is an ST5 Sports Medicine Registrar in London and Medical Director for Tough Mudder Ltd.

Dr Farrah Jawad is an ST4 Sports Medicine Registrar in London and coordinates the BJSM TP Blog.

Final preliminary round of the BJSM cover competition: vote now

14 Jan, 15 | by BJSM

Which cover will join the other finalists in the 2014 BJSM cover competition? Have your say, by voting now!

And in case you missed it, here’s a recap of prizes (we will collect the e-mail addresses of voters for the prize draw in the next and final round):

chad cook second editionOrthopedic Manual Therapy (2nd Edition), by Chad Cook


Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd Edition), by Chad Cook


Prize winners now have the chance to select either of the above books, or one of our original prizes:

BJSM coverBrukner and Khan’s Clinical Sports Medicine, 4th Edition, 2012.

cover The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr. 


Vote now in the final preliminary round:

October 2014, Volume 48, supliment 2

Supl Cover: September 2014


Cover 19 October 2014 (i)

Cover 19: October 2014 (i)














Cover 20 October 2014 (ii)

Cover 20: October 2014 (ii)














Cover 21: November 2014 (i)

Cover 21: November 2014 (i)














Cover 22: December 2014

Cover 22: December 2014 















Is sports medicine ready to be hacked?

10 Jan, 15 | by BJSM

By sports physiotherapist @NicolvanDyk (Qatar)

Let’s face it, technology is drastically changing the world of medicine. Electronic records have revolutionised entire health care systems, robotics redefined precision and apps now assist the diagnostic process. To give patients the best care possible, it’s important not to be left out in the (technological) cold: we need to adapt and innovate. However, advances in medical technology take time, money, effort and years of development, testing (more testing) and approvals. Is there a faster way around this?

hackathonMIT Sports Medicine Hackathon

As part of the Global Entrepreneurship Week, the Qatar Sports and Technology Park (QSTP) held the first Sports Medicine Hackathon in Doha, Qatar. If you are trying to figure out which athletic disciplines form part of a hackathon, stop. It’s not that kind of –thon. A hackathon (“hack” referring to explorative programming and “marathon” meaning to lasting a while) brings people from different fields and backgrounds—clinicians, engineers, coders, entrepreneurs, software developers and designers—together in one place. Invited speakers pitch current problems in the field (in this case sports-medicine) and teams pick the problem they are most interested in and spend the two days designing the software and/or hardware to solve it. The competitive nature of the hackathon adds to the brainstorming and initiative, although lots of cross pollination is allowed between groups. On the second and final day, in a two minute pitch, the group presents their idea to the judges. Prizes are awarded to the most innovative, impactful, and implementable solutions. There are countless networking opportunities and there is the occasion to turn the idea into a viable business at the end of the weekend.

Is this the future of medical innovation?

Some startups have been developed (and been successful) at these events. Pillpack for instance helps patients manage their medication usage. RubiconMD is a hackathon brainchild which streamlines referrals to specialists. A simple tool like Smartscheduling reduces no shows, and could save the health care industry up to $150 billion annually. At the Medstart 2-day hackathon hosted by Tufts School of Medicine, a group developed an app based eye movement tracker, which could serve as a reliable on-field concussion testThese are the gamechangers we need. Yes, we agree that some vigorous science now needs to take place. To have a real impact on sports medicine, the next step would be to realise the idea and let science run its course: set up a hypothesis, randomized control trials, or some verification that allows us to trust the innovation. In order for us to move away from archaic traditional methods of problem solving, we need to leverage our modern day advantage of being able to pool resources. As @ChrisLee reminded us during the QSTP Hackathon “fail fast and change quickly.”

Hackathon’s are springing up everywhere.  

The Hackathon phenomenon has grown more and more popular, and is gaining momentum through MIT Hack Medicine (@MITHACKMED), who nurtures these events, holding hackathons on a global scale. An industry problem solved by a supercloud of brainstorming by people with different skill sets. This is what a hackathon represents. Perhaps it is the “blue sky” idea which has made these events so popular. It’s a Steve-Jobs-Richard-Branson like idealogy of letting your mind to explore freely and find ideas that shift the current paradigm. And yes, a bunch of nerds wearing hoodies and drinking coffee all day might not sound appealing right away (except of course if you are one of those people), but it might be exactly what we need. Sports Medicine Hackathon’s could be the perfect platform for accelerated knowledge integration, shared problem solving and ultimately, innovation. Medicine, get ready to be hacked.

More skiers, less injuries, and the characteristics of ‘risk-takers’: A brief research update on injuries in alpine sports

8 Jan, 15 | by BJSM

Is skiing less dangerous than we may think? With the winter sport more popular than ever, there is a downward trend in injuries. What are the reasons? Why do injuries still occur?

skiingMartin Burtscher and Gerhard Reudl, two leading professors in the field, share their thoughts on the striking downward trend in injuries associated with alpine skiing in a CMAJ Blog. They state “Assuming a death rate of 1 per 1 million skier days and an injury rate of 1-2 per 1,000 skier days a total of 400 fatalities and 400,000 to 800,000 injured skiers would result. That may be enough to fill newspapers daily but they actually represent a relatively low death and injury risk… Put another way, for the individual who skis for 20 days per winter season on average, 1 death would occur within 50,000 years and 1 injury within 25 to 50 years.”

Still, injuries do happen. We highlight some key findings from BJSM research below.

Who is more likely to be a risk taker?

Risk taking behavior is associated with younger ages, higher skiing ability, male sex, lower body mass index and those with a higher than average speed. Read more in the BJSM Original article on Factors associated with self-reported risk-taking behaviour on ski slopes.

Snowboarders injuries when listening to music are less frequent but more severe. 2014 Original Article in BJSM: Listening to a personal music player is associated with fewer but more serious injuries among snowboarders in a terrain park: a case-control study.

Skiing safely

Although head injuries account for 9–19% of all winter sport injuries reported by ski patrols and emergency departments, the use of ski helmets has been shown to reduce the head injury risk up to 60% among children and adults. Learn more on the successes and challenges of helmet-use uptake in this BJSM Editorial: Is ski helmet legislation more effective than education?

Taken together, the evidence suggests that a fear of serious injury should not prevent you from being active on the slopes, and skiing is safer than ever before. Still, some basic safety precautions may help you experience none of the hazards and all of the health benefits associated with skiing.

The sexy scalpel: unnecessary shoulder surgery on the rise

6 Jan, 15 | by BJSM


By Jørgen Jevne @jevnehelse

jorgenWhile we are supposed to be living in the era of evidence-based medicine (EBM), researchers are making us increasingly aware of the long distance between academia and daily clinical practice. This is highlighted by recent writings on low back pain [1] and knee arthroscopy [2].

Clinicians love to cling on to their safe havens and we often cite experience as a reason to uphold the status quo.

However, clinical experience can be deceiving [3] and in the age of evidence it seems rather anachronistic to hold experience above science when our opinions are being questioned.

EBM is not just about clinical experience and scientific studies. Although patient-centred care is an indisputable hallmark of modern medicine, a recent publication in JAMA highlights patients´ tendency to overestimate treatment benefits and underestimate harms [4].

Clinicians need to educate patients sufficiently and inform them about benefits and harms based upon the best clinical evidence, to ensure that they make sound judgements regarding their own health.

Enter science.

The numbers

A number of studies have looked at the rising incidence of acromioplasty for the treatment of what is known as subacromial impingement syndrome [5,6] – now more correctly coined subacromial pain syndrome [7].

A Finish study actually reported declining incidence of surgery, however, this positive development was contrasted by an increase in the private sector [8]. A recent UK study reported a staggering 750% increase in the rate of these surgeries from 2000-2010 [9].

The numbers, albeit large, are not a problem in their own right.

Had clinical outcomes been shown to consistently improve with surgery compared to conservative therapy, the increase could easily have been justified.

Unfortunately, they do not.

Not even close.

The problem

The devious shoulder complex often renders clinicians with frustrating uncertainty [10]. Furthermore, in the spirit of holistic assessments and biopsychosocial models of care, we are gradually cognisant towards other factors that influence patient presentations and outcomes [11-13].

For over twenty years, surgery has failed to provide superior outcomes compared to conservative therapy for the treatment of SAPS. The results are consistent and with methodology more rigorous, the differences are even smaller, as illustrated by recent systematic reviews [14].

Shoulder pain remains somewhat of a medical mystery and the ambiguities are nicely illustrated by a 2009 study, which showed that a bursectomy alone had comparable effects to removing the acromion and bursa [15]. Additionally, as some of the structures being surgically removed for decreasing pain have a stabilizing role in the shoulder-complex [16], the following quote seems appropriate:

It would be hard to imagine that a surgeon would suggest, or a patient would agree to, having the anterior cruciate ligament removed to treat knee pain [17].

Then there is the concept of placebo. Surgeons have generally been reluctant to perform placebo surgery and the reasons are of course multifaceted.

When our long held fortress of beliefs is being attacked, strong reactions are inevitable. The few orthopaedic placebo surgeries that have been published have had discouraging results [18,19] and created fierce debate within the scientific community. However, a recent systematic review does indeed show that the concept of placebo surgery is both warranted and ethically justified [20].

In the words of Carl Sagan: “Extraordinary claims require extraordinary evidence”. And while the claims might not be extraordinary, orthopaedic surgery has enjoyed amnesty from scientific inquiry for far too long [21].

While studies investigating placebo surgery for subacromial pain syndrome remain absent, 2015 seems to be the year we will have our first answers to this riddle [22].

The cure

History is filled with examples of long delays in the dissemination, acceptance, and implementation of high-level clinical evidence into clinical practice.

Make no mistake. There are many unanswered questions within conservative care of shoulder pain. This is not a speech of defense.

We definitely need more research. More honesty. More humility.

But in the light of the current evidence base, the benefits of surgical intervention for the treatment of SAPS seem glorified and overrated.

Conservative treatment appears underutilized and underestimated.

The solution should be obvious.

Providers of conservative care need to lift their game. We need to deliver patient-centered, evidence-informed, high-quality treatment based upon the very best of scientific rigor.

We need to make conservative care attractive. Accessible. Affordable.

We need to educate the public. We need to let patients know that exercise will have similar results as surgery.

That it will be cheaper and have more profound, long-lasting effects on patients’ health [23].

In other words:

We need to make exercise as sexy as the scalpel.


Jørgen Jevne is a dedicated musculoskeletal clinician and part-time researcher practicing in the small town of Hønefoss, Norway.


  1. O’Sullivan, P.: It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med, 2012. 46(4): p. 224-7.
  2. Jarvinen, T.L., Sihvonen, R., Englund, M.: Arthroscopy for degenerative knee–a difficult habit to break? Acta Orthop, 2014. 85(3): p. 215-7.
  3. Choudhry, N.K., Fletcher, R.H., Soumerai, S.B.: Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med, 2005. 142(4): p. 260-73.
  4. Hoffmann, T.C. , Del Mar, C.: Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med, 2014.
  5. Vitale, M.A., Arons, R.R., Hurwitz, S., Ahmad, C.S., Levine, W.N.: The rising incidence of acromioplasty. J Bone Joint Surg Am, 2010. 92(9): p. 1842-50.
  6. Yu, E., Cil, A., Harmsen, W.S., Schleck, C., Sperling, J.W., et al.: Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study. Arthroscopy, 2010. 26(9 Suppl): p. S142-7.
  7. Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., et al.: Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop, 2014. 85(3): p. 314-22.
  8. Paloneva, J., Lepola, V., Karppinen, J., Ylinen, J., Aarimaa, V., et al.: Declining incidence of acromioplasty in Finland. Acta Orthop, 2014: p. 1-5.
  9. Judge, A., Murphy, R.J., Maxwell, R., Arden, N.K., Carr, A.J.: Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J, 2014. 96-B(1): p. 70-4.
  10. Hegedus, E.J., Goode, A.P., Cook, C.E., Michener, L., Myer, C.A., et al.: Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med, 2012. 46(14): p. 964-78.
  11. Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., et al.: The pain of tendinopathy: physiological or pathophysiological? Sports Med, 2014. 44(1): p. 9-23.
  12. Littlewood, C., Malliaras, P., Bateman, M., Stace, R., May, S., et al.: The central nervous system–an additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. Man Ther, 2013. 18(6): p. 468-72.
  13. M, N.S., Lluch, E., Nijs, J., Struyf, F., Kangasperko, M.: The role of central sensitization in shoulder pain: A systematic literature review. Semin Arthritis Rheum, 2014.
  14. Saltychev, M., Aarimaa, V., Virolainen, P., Laimi, K.: Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disabil Rehabil, 2014.
  15. Henkus, H.E., de Witte, P.B., Nelissen, R.G., Brand, R., van Arkel, E.R.: Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. J Bone Joint Surg Br, 2009. 91(4): p. 504-10.
  16. Hockman, D.E., Lucas, G.L., Roth, C.A.: Role of the coracoacromial ligament as restraint after shoulder hemiarthroplasty. Clin Orthop Relat Res, 2004(419): p. 80-2.
  17. Lewis, J.S.: Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews, 2011. 16(5): p. 388-398.
  18. Sihvonen, R., Paavola, M., Malmivaara, A., Itala, A., Joukainen, A., et al.: Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med, 2013. 369(26): p. 2515-24.
  19. Moseley, J.B., O’Malley, K., Petersen, N.J., Menke, T.J., Brody, B.A., et al.: A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med, 2002. 347(2): p. 81-8.
  20. Wartolowska, K., Judge, A., Hopewell, S., Collins, G.S., Dean, B.J., et al.: Use of placebo controls in the evaluation of surgery: systematic review. BMJ, 2014. 348: p. g3253.
  21. Aspenberg, P.: Mythbusting in Orthopedics challenges our desire for meaning. Acta Orthop, 2014: p. 1.
  22. Beard, D.J., Carr, A.J., Rees, J.D., Cook, J., Tracey, I., et al.: Can Shoulder Arthroscopy Work (CSAW)., 2015.
  23. Hallal, P.C. , Lee, I.M.: Prescription of physical activity: an undervalued intervention. The Lancet, 2013. 381(9864): p. 356-357.


Exciting new prizes in 2014 cover competition: vote now

3 Jan, 15 | by BJSM

Happy New Year! We are halfway through our knock-out preliminary rounds for the 2014 BJSM Cover Competition, and excited to announce two new book prizes for voters (we collect email addresses, and select two as the winners in the upcoming final round). Drum roll please…

chad cook second editionOrthopedic Manual Therapy (2nd Edition), by Chad Cook


Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd Edition), by Chad Cook



Prize winners now have the chance to select either of the above books, or one of our original prizes:

BJSM coverBrukner and Khan’s Clinical Sports Medicine, 4th Edition, 2012.

cover The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr. 


That’s 4 evidence-based books, full of expertise from SEM leaders! Find out soon if you are the winner.

For now, please vote in our third preliminary round:

Cover 13: July 2014 (i)














Cover 14 July 2014 (ii)

Cover 14 July 2014 (ii)

Cover 15 August 2014 (i)

Cover 15 August 2014 (i)

Cover 16 August 2014 (ii)

Cover 16 August 2014 (ii)

Cover 17 September 2014 (i)

Cover 17 September 2014 (i)

Cover 18

Cover 18: September 2014 (ii)















“All About The Knee” ACPSEM Study Day – Manchester University

31 Dec, 14 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Penny Porter

The ACPSEM’s one-day study event (October 4th, 2014) at Manchester University was well attended by over 100 people. Here are some highlights from the day’s event.


Photo credit:

Dr. Lee Herrington (Senior Lecturer in Sports Rehabilitation, University of Salford) started the day off with a fascinating talk on the relationship between running, landing and squatting performance to Patellorfemoral pain. He discussed potential treatment by modifying movement with verbal and visual feedback. Following this, Paul Comfort explained the development of force, rate of force development and the implications for prevention and rehabilitation of ACL Injuries.

Dr. Duncan French (Lead, EIS Strength and Conditioning) then took to the floor with a great lecture, looking at low load blood restricted resistance exercises, and its use as a training and rehabilitation tool. Delegates tested his theories, by participating in a practical workshop.

James Moore held a very popular (and practical) session looking at assessment and management strategies for high hamstring tendonopathy. He provided some key interventions from a management perspective; James delegates thinking about several new options for managing hamstring injuries through exercise therapy.

Lastly, Karen Hambly discussed articular cartilage, and the implications for rehab. She expertly explained why rehabilitation after articular cartilage repair is so important, and clearly outlined the general principles of articular cartilage rehabilitation.

All in all, it was great to catch up on the latest research and practice for knee problems and rehabilitation, and see physio colleagues from around the UK with common physio and sporting interests.

Looking forward to the next study day in Brighton on October 9 and 10, 2015. The topic is “The Young Athlete”. Keep your eyes peeled for #TeenBuilding!


Penny Porter is a Physiotherapist in Bristol

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