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Beating the odds: How the ACPSEM CPD pathway can help physios who want to work in sport

4 May, 16 | by BJSM

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

By Nikki McLaughlin @Nikkimacphysio

Having just read @sianknott‘s recent blog on behalf of @sport_wales, I am inspired to give a brief synopsis of how to use current and existing infrastructures of governing and professional bodies to progress through your career as a sport physio – being an Olympic year, what better time to share the info.

Rabbit in headlights

Where do I go from here???

Now when you first start out it’s a bit like a rabbit in the head lights – you don’t know where to go or what to do…so my main aim for this blog is to give some advice and personal experience on where you can go as a newly graduated physio who wants to work in sport, or for those looking for more exposure in multi sport events.

I wouldn’t say I am the most experienced sports physiotherapist out there but if I didn’t have the help and support from some key figures in the sports physio world (you know who you are), I would never have worked with some of the teams I have, or travelled to the farthest corners of the world. Therefore, I am merely just trying to return the favour by  “Paying it forward”.

CPD Pathway and Education-Going for gold.

Firstly, I have found and continually use the Association of Chartered Physiotherapists in Sport and Exercise Medicine (ACPSEM) as a great resource for  professional development and networking. The organisation has a clear and structured CPD and educational pathway. The process is straight forward and the “pathway provides a road map to help sports physiotherapists to plan, implement and reflect upon their learning”.

The ACPSEM accreditation levels are internationally recognised by the International Federation of Sports Physiotherapists, theBritish Olympic Association and Sports National Governing Bodies. Evermore, employers are using the CPD levels as essential criteria on their job descriptions to ensure that they can be confident in the physiotherapists sporting experience. With more competition in the marketplace from other sports practitioners, the pathway can add value to your professional credibility.

Secondly, the organisation clearly has some influence within the market place. It’s members regularly liaise with Health Professions Council and Chartered Society of Physiotherapy to inform them of any changes and/or updates of working practices of physiotherapists working in sport medicine.

To volunteer or not????

As you enter into the sporting world it is very easy to get caught up in the volunteering process.  Now I for one feel strongly about this and speak from experience. All too often you hear of physios covering or volunteering for sports to gain experience but quite often end up working alone or exposed, and I’m not against volunteering but what I will say and question is what are you getting from it?

Perhaps an example would help better here? – If you a covering a social sporting side to gain experience and you are the sole practitioner and responsible for trauma cover, question are you really going to benefit from it or are you just exposing yourself to a potentially vulnerable situation?

working alone pitchside

Exposure pitch side the need for team support is essential

If however, you are involved within a team there is no reason why you cannot volunteer and access the previously mentioned ACPSEM pathway documentation and mentoring system. This will support you to clearly define objectives and learning outcomes from within your role making the experience more worthwhile.

If you really seek a structured experience, with exposure within multi sport events then BUCS as an organisation is a  great place to start.  Throughout my career I have been heavily involved and still am. The cohort of physio and medics are so varied in their professional and sporting backgrounds that the information or learning you can gain is invaluable regardless of experience. Is it costly? simple answer no, all you have to do is give your time and be willing to work the hours and in environments your not used to.

BUCS volunteer

BUCS events, particularly the larger ones, provide an excellent opportunity for doctors and physiotherapists looking to enhance their sporting experience. BUCS currently operate two multi-sport events where are large number of doctors and physiotherapists come together to work and share knowledge and skills.  Involvement in the domestic programme can additionally lead to a variety of international opportunities. I can say that these have been some of the best working trips I have been on and made some real life-long friends.

For domestic events, BUCS provides expenses and daily rates for ACPSEM qualified physiotherapists and doctors. Students and newly qualified individuals are also able to be involved in a shadowing capacity. Interested in volunteering click here

If after reading this blog your keen to progress further in the Sport and Exercise Medicine world, then volunteer and get involved because who knows, you may be attending the next World University Games, Commonwealth Games or  Olympics Games………………………

See you there😉


 Nikki McLaughlin @Nikkimacphysio works at Baseline Physiotherapy in Cardiff and Caerphilly,


Getting the best out of athletes: Load, Injuries and Determination

2 May, 16 | by BJSM

By Rory Heath (@roryjheath) and Xanni von Guionneau

The Arsenal SEMS Conference “Marginal Gains in Sports Medicine” provided deep insight into attaining and maintaining the highest level of sporting performance in professional athletes. As the elite athletic population becomes more homogenous, the value of “marginal gains” in achieving podium finishes and championship titles is more important than ever.

Below are our takeaway points focusing on Load, Injuries and Determination; we hope they provide a competitive edge to your practice!


  • One way to objectify ‘performance’ is to measure “load”; the stressors that affect a player’s physical and mental homeostasis. “Load” can be separated into “external”; the demands placed on an athlete through training and competition, or “internal” factors of psychological stress from the sport or other life events. (Halson, 2014)
  • “External” load is sport specific. Cyclists may calculate load by analysing power output for time duration, whilst Rugby players must factor in collisional, metabolic and mechanical load. E.g. Load = ((Duration X RPE ) +( X Number of collisions ))
  • Load is unique to the individual and their playing position – a tight head prop will experience larger mechanical and collisional loads than a scrumhalf, requiring individualised parameters
  • Monitoring “load” allows tailoring of future sessions and tapering/peaking approaches to match days
  • Be aware of OED and MEDs! The Optimum Effective Dose (OED) has its place in the preseason, building strength and speed. When load increases in-season, the Minimal Effective Dose (MED) is adequate to maintain or further training adaptations
  • “You can collect as much data as you want, but without conversations, data is meaningless” Nigel Jones
  • Success with metrics such as HRV require communication and understanding amongst the entire team, from medical staff to players
  • Understand the demands of your player to provide focused training and treatment – “Don’t put square pegs in round holes” Shad Forsythe


  • Although data is only a small part of the decision, “load” can predict injury risk – “The majority of our players have an injury – it is our job to help them decide whether this will stop them playing” Nigel Jones
  • The management aim for >90% player availability by optimising load management, recovery and player resilience
  • If an injury occurs, Dr Jones’ team will reflect on its aetiology.
  • Shad’s athletes focus on hip extension and thoracic mobility in their recovery work

Return to Play”

  • The injury doesn’t leave just a physical toll. Psychological effects (doubt, insecurity, fear) change the athletes view towards injury, subsequently effecting recovery and return to play
  • Returning to play comprises physical, psychological and contextual factors
  • Recovery is not a linear path and is not predictable!
  • A tailor made programme can address stressors and psychological barriers unique to the individual
  • Communication between all members of the medical team, the athlete and the family is needed to maintain steady progress
  • “Visualisation” of RTP is a useful tool to speed recovery
  • Pair a newly injured athlete with someone further down the road to recovery: positive mentoring potentiates a positive outlook


  • Although athletes may perform with injuries or in pain, they should not participate if there is a significant risk of further injury.
    • Imagine player recovery as a battery; a full battery of green bars shows adequate recovery, whilst a power level fading into a red zone implies poor recovery, accompanied by the risk of illness, injury and burnout. Effective recovery serves to recharge the battery and prevent the athlete going into the red
  • It is important to promote player understanding and ownership of their recovery. England Rugby use a “points based” system to incentivise recovery, providing players with quantifiable targets of positive actions
    • For example; a player is required to total 100 points in a day, selecting activities from broad headings of food, sleep, “headspace” and more specific methods such as cryotherapy or contrast hydrotherapies


  • Approach athletes through both a team and an individual approach. Shad’s approach at Arsenal for ‘Off pitch support’ is 80% team (Positive lifestyle changes, mobility maintenance and muscle activation sessions) and 20% individual (focused physiotherapy, individual dietary prescription)
  • Athletes can be “admired for talent but respected for work ethic” – Richard Moore
  • “I worried I hadn’t suffered enough” is a common thought of elite athletes pertaining their preparation for competition.
  • “Hunger” stems from early enjoyment and positive experiences of sport during childhood, with a subsequent feed-forward mechanism of further training to improve winning. On the contrary, “Hunger’ is brought by a fear of losing
  • Determination can be genetic, illustrated by the products of selective breeding of huskies. However, this genetic role is difficult to isolate in humans – “Performance in sport is highly multifactorial”Nigel Jones
  • There is no ‘cookie cutter’ approach to talent ID. Jamie and Andy Murray have very different character traits and personalities, yet both have succeeded in their sport
  • The first thing to look at in Talent ID is the parents – the environment shapes athletic potential.

We’d like to thank Arsenal SEMS for holding such an exciting and informative conference! See you there on March 21st next year!

You can find Dr Nigel Jones (@theboxingdoctor), Shad Forsythe (@ShadForsythe), Dr Clare Arden (@clare_ardern) and Mr Richard Moore (@RichardMoore73) on Twitter.

Interested to find out more? Check out related BJSM material:


J Windt, T J Gabbett, D Ferris, and K M Khan. 2016.Training load–injury paradox: is greater preseason participation associated with lower in-season injury risk in elite rugby league players? 

JL Cook, C Purdam. 2012. Compressive load a factor in the development of tendinopathy?



Rory Heath (@roryjheath) is a fourth year medical student at King’s College London with a keen interest in SEM and elite performance. He has played county rugby and rugby league for London and South and enjoys blogging. He is currently Secretary for the nationwide Undergraduate Sports and Exercise Medicine Society (USEMS), an Ambassador for Move.Eat.Treat and organises SEM-focused events in the London area. 

Xanni von Guionneau is a second year medical student at King’s College London. She has a background in multiple sports including rowing and swimming, currently representing the KCL Cycling and Triathlon teams! She has a growing interest in Sports Medicine, especially Orthopaedic injuries. 


Halson SL. Monitoring Training Load to Understand Fatigue in Athletes. Sports Medicine (Auckland, N.z). 2014;44(Suppl 2):139-147. doi:10.1007/s40279-014-0253-z.

An unlikely candidate, a year as Professor of Physical Activity for Health

27 Apr, 16 | by BJSM

By Prof Chris Oliver

chris oliverAfter losing over 12 stone in weight, cycling across America, becoming a cycle campaigner, writing some policy on active travel and starting a few physical activity projects I became honorary professor physical activity for health at the University of Edinburgh. The “Sit Less, Walk More” message had finally come home to me. I had certainly lost my work life balance and after writing hundreds of numerous papers and passing an alphabet soup of post nominals, I was seriously ill with metabolic syndrome and diabetes. Although I was a successful trauma orthopaedic surgeon at the Royal Infirmary of Edinburgh, my life was collapsing around me. I had a gastric band in 2007 and got physically active, a shopping list of things to do to recover my life and get back to the things I did as a medical student got seriously out of hand. I never expected to get back to expedition whitewater kayaking or to ride 3,415 miles across the USA, this was a surprise. Coming off call in 2013 allowed me to recover from considerable professional burnout, I never should have gone back on call after having my gastric band. After all this, neither did I expect to become a professor or be in the media. I really just wanted to pay back to everyone the second chance at life I had been given. In 2013 the BBC Scotland Adventure Show made a mini-documentary about my weight loss and advocacy roles. I had hit the national media.

Meeting Professor Nanette Mutrie at the Physical Activity for Health Research Centre, University of Edinburgh was a life changing event and in the spring of 2015 I was conferred as honorary professor, a job with no exact role or even title, just to be available! With my somewhat nerd like computer skills I deliberately intended to grow my social media networks as much as possible to enable me to meet and network with as many physical activity advocates as possible. I grew my Twitter, Facebook, LinkedIn, Klout and Wikipedia profiles to engage. Certainly press, TV and radio occurred, often by initial engagement with Twitter. A consistent professional message on the positive aspects of physical activity has grown networks well. I had some professional media training. I had useful engaging radio interviews on BBC Radio Scotland on weight-loss surgery, sugar tax and various aspects of obesity. In January 2016 I featured in a BBC Scotland News documentary, “Car Sick” on the relationship between cars, bicycles, pollution and physical activity. Television seems easier to control than radio call-ins!

My initial university project was to develop the University of Edinburgh Undergraduate Medical Teaching Resource. Engagement with developing the curriculum in Edinburgh has been slow but editorials in the BJSM have helped develop physical activity teaching throughout the United Kingdom. In Edinburgh all medical students will take a six-year undergraduate course with compulsory intercalated BSc, so it’s planned from 2018 to have a course for medical students in physical activity. It would be hoped these doctors would become leaders in physical activity advocacy. We undertook a review of the knowledge of medical student knowledge of the CMO guidelines for physical activity and not surprisingly discovered that 85% of Edinburgh medical students did not know the guidelines, we’ll shortly be publishing a detailed paper. We now have significant plans to redesign and redevelop our university educational resource for physical activity.

I experimented with Lego as a tool to understand the mind maps of physical activity and inspired Nathan Stephens NHS Leadership Fellow at the Royal College of Surgeons of Edinburgh to develop some innovative physical activity infographics One of my students wrote a short blog on physical activity infographics.

I was invited to join the NHS Scotland Health and Social Care Physical Activity Delivery Group, this group delivers the Physical Activity Policy for the Scottish Government. It’s notable that the recent Scottish budget did not deliver any extra funding for active travel and even a 1% transfer of funding from roads to active travel was ignored. Being a member of the Cross Party Group for Cycling at Holyrood I see access to ministers a key for developing good bold physical activity policy. I’ve attended several NHS Scotland physical activity events. I conclude that it would be good to see a Physical Activity Cross Party Group evolve at Holyrood. Government funding needs to be placed in the correct places and not encased in silos. There needs to be an increased “political will” to support physical activity and negate the effects of physical inactivity. We all know the ticking economic time bomb that is being caused by physical inactivity. Senior government policy makers and leading ministers must quickly engage with vigorous physical activity policy, however unpalatable it may seem.

Throughout the year I gave various lectures: I was told to find out about altmetrics and give a lecture to the department. I was doubled billed with the Scottish CMO, Catherine Calderwood to give a “Health and Wellbeing” lecture to a secondary school in Glasgow, I particularly enjoyed this and would hope that one of the pupils one day would perhaps cycle across the USA, perhaps decades away. I presented results of a small survey on cycling and coffee and wrote some more scientific articles on caffeine and coffee. My inaugural institute professorial lecture “How not to be a surgeon, cycling to physical activity” was started with my entrance cycling into the lecture theate on a Brompton bike, a serious example of active travel.

With members of PAHRC we have a multiagency grant submission into investigate the effects of 20mph speed limits on active travel in Edinburgh; walking, cycling and the built environment in Edinburgh, the results are awaited.

There are some great people in PAHRC. Sharing an office with Dr Andrew Murray, the ultramarathon runner has been interesting and we have both worked to promote physical activity as much as we can, however we both have day jobs! With Dr Danijela Gasevic and her team at PAHRC are developing a MOOC, Massive Online Open Course in Physical Activity and Assessment. The MOOC will launch in May 2016 and has over 13,000 people signed up, we are currently signing up about 100 people a day. You can join here, no idea what the final numbers joining will be.

The surgery I currently perform is complex hand and wrist reconstruction surgery. The technical details of the surgery is still so much fun and I spend most of my time now teaching operative surgery. I cannot do surgery forever so a longer term career in physical activity post retirement in the next five years or so looks a great opportunity. The first year has been fun! Thanks Nanette!

Prof Chris Oliver

Honorary Professor Physical Activity for Health, University of Edinburgh


Twitter @CyclingSurgeon



Struggling to provide evidence-based care to your patients? A knowledge broker can help: Case study of the Achilles Tendinopathy Toolkit

24 Apr, 16 | by BJSM

By Alison Hoens

It isn’t easy. You want to provide your patients the most effective treatment but you are faced with a mountain of information from an insurmountable number of sources through endless links in your Google search. It isn’t just the volume of information; interpretation is thwarted by differences in methodologies and confusing statistics.  You are not alone in feeling overwhelmed. Increasingly healthcare is recognizing the need for expertise to help with ‘Knowledge Translation’ (KT) and calling upon Knowledge Brokers (KB) to navigate clinicians through the ‘forest of dense content’ to reach the destination of ‘practice bliss’.

KB communicationKnowledge translation has been described with > 125 terms ! But no matter what term is used, the message is the same – knowledge is not enough. Simply producing and disseminating knowledge does not lead to a change in practice. Shockingly, research suggests that it takes 17 years to get 14% of research findings adopted into practice1.  Further, typical strategies to support evidence-informed practice (EIP), such as providing educational materials or didactic lectures, elicit a meager average 10% change in practice2.

A relatively new KT strategy to support EIP is the use of a knowledge broker. A knowledge broker is an intermediary who bridges the gap between evidence and practice and functions as a catalyst to link researchers, clinicians, and decision makers to facilitate co-creation or synthesis, translation, dissemination, and implementation of evidence to change practice3. Essentially, the knowledge broker’s main roles are to act as an: 1) information manager 2) linking agent 3) capacity builder 4) facilitator and 5) evaluator4 (those interested in learning more about these roles can check out a video abstract for our recent manuscript HERE). Indeed, Meyer et al (2010) states that knowledge brokers do more than transfer knowledge, they transform knowledge such that Brokered knowledge is knowledge made more robust, more accountable, more usable; knowledge that ‘serves locally’ …” (pg. 123)5. Basically, a knowledge broker helps, with experts from research and clinical realms, to find, interpret and reshape knowledge so that it can be used more readily in the hands of a clinician.

Practical experience – A KB’s secrets!

I serve as the Physical Therapy Knowledge Broker (PT KB) situated within the Department of Physical Therapy at the University of British Columbia (UBC). Reflecting the breadth of stakeholders, the position is jointly funded by the University, the  provincial professional body (Physiotherapy Association of British Columbia) and the research institutes of two large health regions ( Providence Health Care and Vancouver Coastal Health).

This 0.5 FTE position has enabled partnerships between more than 335 researchers, clinicians and decision makers to enable approximately 2.5 million dollars of funding for 19 rehabilitation relevant research projects and the development of 23 resources and tools to support evidence-informed practice. These resources have been accessed over 164,000 times by physiotherapists throughout the world and have been shared through 24 webinars and more than 50 presentations locally, nationally and internationally. All resources are freely accessible HERE.

Turning Achilles research into changes in clinical management

An example of the KB role in successfully transforming knowledge to “make it more useable” is the Achilles Tendinopathy Toolkit ( Co-created with research and clinical experts, and recently updated to include new literature, the toolkit includes: (1) a summary of the evidence, clinical implications and ‘take home messages’ for nonpharmacologic interventions such as manual therapy, exercise, low level laser therapy, orthotics, shock wave, ultrasound, taping etc;  (2) an algorithm to guide the sequence of interventions; (3) and appendices including (a) exercise programmes (b) low level laser dosage calculation (c) tabulated details for each article reviewed and (d) a review of common medical interventions. It has been accessed over 85,000 times by therapists throughout the world. Moreover, a recent cross-sectional study demonstrated favourable findings regarding the impact of this KT strategy on the knowledge and attitudes of British Columbia physical therapists6.

The PT KB position provides an opportunity to enable researchers, clinicians, patients, and decision-makers to unite in efforts to support clinicians in the feasible provision of individualized evidence-informed care to our patients.

Your turn

So, what can you do today to support your EIP? Try out some of our free resources at and advocate for developing KB positions in your healthcare communities.


  1. Balas E, Boren S. Managing Clinical Knowledge for Health Care Improvement. In: van Bemmel JH, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart: Schattauer Verlagsgesellschaft mbH, 2000:65–70.
  2. Straus SE, Tetroe JM, Graham ID, editors. Knowledge translation in health care: moving from evidence to practice. Chichester (UK): Wiley Blackwell; 2009.
  3. Hoens, A. and Li, L.C. 2014, The knowledge broker’s “Fit” in the world of knowledge translation, Physiotherapy Canada: 66:3:223-227.
  4. Glegg S & Hoens A. Role domains of knowledge brokering: A model for the healthcare setting. Journal of Neurologic Physiotherapy. Journal of Neurologic Physical Therapy. 2016;40: 115–123). org/10.1097/NPT.0000000000000122. Video abstract:
  5. Meyer M. The rise of the knowledge broker. Science Communication 32, 1 (2010) 118-127. DOI : 10.1177/1075547009359797.
  6. Ezzat AM, Schneeberg A, Huisman ES, White LD, Kennedy C, Levesque LA, Scott A, Hoens AM. Is it effective? A cross-sectional evaluation of a toolkit to support evidence-informed management of Achilles Tendinopathy. Disability and Rehabilitation. DOI10.3109/09638288.2016.1160447


Alison Hoens holds two positions:  (1) Physical Therapy Knowledge Broker within the Department of Physical Therapy, Faculty of Medicine and (2) Research, Education and Practice Coordinator for Physiotherapy at Providence Health Care. At Providence Health Care she is responsible for research, education and evidence-based practice support for over 120 Physiotherapists and Rehabilitation Assistants across the spectrum of acute, rehabilitation and residential care settings. In her role as Knowledge Broker she facilitates partnerships between researchers, clinicians and decision makers for rehabilitation relevant research and the development of resources and tools to support evidence-informed practice.


Interested in Sports and Exercise Medicine? Three ‘must dos’ I learnt at the Football Medicine Strategies Conference

21 Apr, 16 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog

By Rory Heath (@roryjheath)

In a rare moment of free time at the recent Isokinetic “Football Medicine Strategies” Conference, an audience of thirty prospective SEM clinicians gathered to attend an exclusive lunch break Q&A with Dr Peter Brukner and Professor Karim Khan.

handsup“How do we get the job?”

“How do we stand out?”

“Where can we get experience?”

We all know SEM can be a challenging career; as a student it can seem impossible to gather practical experience. Furthermore, competition to apply for training programmes is daunting, whilst job security is ever-changing. Luckily, Brukner and Khan discussed some of the key areas to ensure your success at staying in the game!

Three key guidelines:

Get Experience

  • Even the biggest and best careers start with humble beginnings. Dr Peter Brukner started gathering experience as a volunteer for his Melbourne University Australian Rules football team. This commitment of standing on rainy pitches in biting cold winds was rewarded by the position of Team Doctor for the Australian Universities team on their international tour to Canada.
  • Get Qualified! Even as an undergraduate, a basic First Aid qualification could be the key to getting some pitchside experience.
  • When Brukner and Khan were training, vocational practical experience were a necessity to become an SEM physician; nowadays, certified training programmes and structured academic courses (MSc., PhD etc.) allow easy access to develop your interest. Don’t let these courses just become three letters after your name; use them to show your determination by involving yourself with research projects, experience and skill development.
  • If you are struggling to find practical experience, further your learning by hitting the books. Demonstrating interest in a sub-topic within SEM is attractive to clinics and sports teams and makes any further applications for experience stand out from the rest.
  • Social media streams on Twitter, Facebook and Google+ can be a great tool to explore the SEM landscape; keep up to date with recent publications, follow conference snippets from @BJSMPlus and interact with the Undergraduate Sports and Exercise Medicine Society @UndergradSEMS.

Work in a Team

  • Respect your elders (and experience). Recognise that the sports medicine team comprises multiple professions with diverse strengths and weaknesses, working in a ‘horizontal model’. Specific messsage for medical students interested in SEM. You can learn tons and tons from physiotherapists.
  • Despite differing backgrounds and qualifications, many members of the team will have far more relevant experience than you. This “Horizontal model” of team organisation respects the value each component, removing an executive decision by incorporating an inclusive, multi-disciplinary approach to management.
  • ‘Up-skill’ yourself! Use your exposure to different professions to share valuable skills. Discuss medical management with your physiotherapist colleague and learn about joints, movement pattern and targeted exercise prescription in return. You both develop as practitioners and can provide better and more efficient care to the patient.
  • Know your own limits. When a patient presents with a problem, a clinician’s job is to identify this pain, specify further causes and manage appropriately. Even if you have ‘up-skilled’, often the best management is to refer to an appropriate expert in the field; be it physiotherapist, a nutritionist or a performance coach.

Be Valuable!

  • You’ve got to be good. If you’re not good, you will fall by the wayside.
  • Explore your interests and embrace opportunities to ‘up-skill’ with the aim of “differentiating” By enhancing your skill-set you provide unique value to teams and clinics; resulting in better employment prospects.
  • “Networking” carries negative connotations of excessively goal-orientated shallow socialising. Instead, view gathering experience in SEM and working as part of team as an essential process of self development. ‘Develop your network’ as South Africa’s Dr Jon Patricios says  @JonPatricios.  The organisations you contribute to and the friends you make will naturally take you to bigger and better things.
  • Be patient; gathering experience may take time to get off the ground. However, once the initial inertia is overcome, opportunities will begin to gather at an increasing pace! Once the first structures are put into place, your network will grow itself and opportunities will arise.

Takeaway points

  • Volunteer at your local/university sports club to lay the foundations for your SEM career.
  • Turn up, show interest and be friendly – the interesting cases will come to you.
  • Enhance your individual value within a multi-disciplinary team by being a good listener. Interested enquiry. “How do you manage this?, What do you think about that?” Aim to be interested rather than interesting… (latter will follow naturally in time!)
  • Build your network – via experience, conferences & social media.
  • Develop your skill set to improve your patient care.
  • Differentiate yourself by pursuing specialist interests. Why should a team, clinic, hire you?
  • Start now!

Rory Heath (@roryjheath) is a fourth year medical student at King’s College London with a keen interest in SEM and elite performance. He has played county rugby and rugby league for London and South and enjoys blogging. He is currently Secretary for the nationwide Undergraduate Sports and Exercise Medicine Society (USEMS), an Ambassador for Move.Eat.Treat and organises SEM-focused events in the London area. 

Research career opportunity: The Department of Physical Therapy, High Point University

19 Apr, 16 | by BJSM

The Department of Physical Therapy, School of Health Sciences at High Point University announces a search for a research-focused faculty member. The Department of Physical Therapy at High Point University offers all of the resources of a research-intensive institution with none of the stress!

highpointWe are currently housed in the Human Biomechanics and Physiology Laboratory, a 13,000 square foot facility including 24, 3D motion capture cameras strategically placed to include coverage of the court and turf functional areas, an environmental chamber, metabolic carts, a forceplate treadmill, wet lab, and a DEXA scanner.

The faculty is a close-knit, collaborative group that is both accomplished and highly productive. We are proud to be expanding in 2017 with the addition of classrooms, an anatomy lab, a pro bono clinic, a low field MRI, and additional research space.

High Point University’s 320-acre campus is located in High Point, North Carolina, USA and forms part of the Triad region with the cities of Greensboro and Winston-Salem. US News & World Report annually ranks the university as a #1 regional college in the South.

Interested parties should contact the Department Chair, Professor Eric J Hegedus:

Via phone: 336-906-2133


Via email:

The Maria Sharapova drug story: What’s the evidence? Does Meldonium treat heart conditions and diabetes?

17 Apr, 16 | by Karim Khan

By David Nunan @DNunan79

SharapovaMany have commented on the how, who, what and ethical implications following Maria Sharapova’s shock revelation of her failed drugs test. Few have looked in more depth at the why?

The evidence for “why?” in this case falls in to two key areas. First is the evidence that Mildronate (or Meldonium) is indicated for the conditions Maria was taking it for, apparently to “combat a magnesium deficiency, heart problems and because of a family history of diabetes”.

Second, is the question of whether the drug enhances exercise and sporting performance. I will tackle the second issue in my next blog; here I focus on the question:

“What is the evidence for Mildronate/Meldonium to treat heart problems (abnormal ECG), indications for diabetes (familial history) and magnesium deficiency in a 17-year-old athlete?”

Meldonium’s Wikipedia page provides background information on the drug, such as common trade names (“Vazonat”, “Idrinol”, “Msmall”, “Quaterine”, “MET-88”, and “THP”), its chemical name (trimethylhydrasine), one of its Latvian manufacturers, Grindeks, and its widely adopted use throughout Latvia and other Baltic states. It isn’t licensed in the United States or Europe.

A number of clinical trials are cited, unfortunately the links to each of these are dead but they all appear to be conference proceedings.

Grindeks’ own website highlights pre-published results from a 2010 Russian/Latvian/Lithuanian/Ukrainian collaborative phase III RCT. Mildronate proved safe and effective for treatment of angina. The drug’s creator wrote:

“As the author of this medication I have always been sure about the therapeutic effectiveness of Mildronate®…” and “[R]esults of the just-finished multinational clinical trial once more approve effectiveness and the high safety of Mildronate® in the treatment of angina in combination with the standard therapy.”

The webpage does not provide enough detail to ascertain if the study was published in a peer-reviewed journal nor if the protocol was pre-registered.

However, a bit of digging around the website reveals a publication for this study in Seminars in Cardiovascular Medicine.

A double-blind, placebo-controlled trial in 371 chronic CHD patients with stable angina aged between 24 and 82 yrs of age (mean ~61 yrs) was performed to assess the effect of 12 months treatment with mildronate on exercise capacity as primary outcome (so not angina onset). In the 278 that completed the study (no details given for drop outs), patients randomized to mildronate improved performance on a cycling ergometer test by an average of 55 seconds.

My comparison of the study against the CONSORT statement suggests several limitations. I couldn’t find methods for (i) the sequence generation of the random numbers needed for randomisation, (ii) allocation concealment or (iii) blinding of investigators. Again, diverging from CONSORT, there is no statistical analysis section. Therefore, I respectfully posit that the findings from this paper would be classed as having risk of bias for internal validity. This would be considered a limitation were a group like the FDA (Federal Drug Agency) asked to approve the drug for clinical practice.

There appears no pre-registered protocol although reporting bias based on methods described in the paper appears low. Adverse effects were not considered as an outcome nor any reported. No information on funding is given and no conflicts of interest are stated. The study lead author and one of its principle investigators are Editors for the journal in which it was published.

But I’ve just committed one of the sins of a none-EBM approach – cherry-picking (2nd definition in link). Perhaps you want a more systematic approach?

A search of PubMed for “Mildronate” OR “Meldonium” gives 217 returns, 108 of which are in Russian. Filtering for systematic reviews in humans – which would give the highest level of evidence for the efficacy and effectiveness as a treatment for these conditions – gives zero returns.

Filtering for the next level of evidence (RCTs) and only for Mildronate/Meldonium or its drug class gives 22 hits (Figure 1); 11 of which are RCTs (9 in Russian), 4 pharmacokinetic studies (all in English) and 7 studies (all in Russian) where study design/methods are unclear.


Studies were published between 1989 and 2015. The study already looked at in detail on the manufacturer website was not picked up in the search.

First thing of note is that there are a number of RCTs assessing the efficacy of Mildronate/Meldonium but no systematic review.

Ascertaining details from each of the 11 RCTs is limited by language restrictions. It appears the largest included 512 patients and the smallest only 35. Clinical conditions assessed in each trial are listed in Box.


Patient populations included in 11 RCTs of Mildronate/Meldonium

Coronary heart disease (CHD) [2 studies]
Post MI heart failure with [2 studies] or without [1 study] type 2 diabetes (T2DM)
Ischaemic stroke [1 study]
Post MI [1 study] and after PCI [1 study]
CVD [2 studies]
T2DM with neuropathy [1 study]

I note that I cannot read the Russian papers so my comments are restricted to English language papers. It may be that the Russian studies are high quality and cover off the limitations I see in the English language publications. Only one of the English language studies was pre-registered. However, this was done after the trial had started. (On a separate note, I have many reservations about current processes for trial registration — more on this issue here).

None of the English language studies assessed patients with ECG abnormalities specifically (although these will be indicated in a number of the patient groups), nor pre-diabetes or magnesium deficiency, nor in adolescents!

Focusing on English language evidence of the drug for treating ECG abnormalities, the abstract from one study reports a trial of 1000mg/day intravenous Mildronate for 10-14 days in 30 patients aged 45 to 75 years with CHD led to “a decrease in the number of arrhythmia episodes.”

A second English language trial abstract (with only 2 authors) reported that 12 weeks Mildronate (no information on delivery or dose) “decreased the number of epinventricular extrasystoles (p = 0.002) and the number of paroxysmal rhythm disturbances (p = 0.001)” in 67 myocardial infarction survivors aged 40 to 70 years of age.

It’s not possible to assess the risk of bias, the source of funding or conflicts of interest for these English language trials. Neither trial was pre-registered. Taking a leap of faith, let’s assume these trials are at low risk of bias/no conflict of interest etc., they suggest that short-term (intravenous) use of Mildronate may reduce the frequency of ECG abnormalities in people aged 40 to 75 years of age and suffering from CHD or having survived a myocardial infarction.

But these English language studies are too small to be conclusive. A lack of information on delivery mode in one trial impacts on external validity as it is sold to be taken either orally or intravenously.

So what about treating ‘indicators for diabetes’?

Tne trial reports “a statistically significant improvement in renal functioning: GFR [glomerular filtration rate] increased by 20% vs 2% (p < 0.05); proportion of patients with exhausted FRR [function renal reserve] decreased (p < 0.05)” and “A hypoglycemizing ability of Mildronate was noted” in 30 patients aged 43 to 70 with heart failure and T2DM randomised to 1 g/day Mildronate (no information on delivery mode) for 16 weeks.

A second open label trial by the same group found “Mildronate administration improved clinical condition of the study group vs controls by neuropathy and symptoms count scales.” in 70 patients with T2DM & neuropathy randomised to 1 g/day for 12 weeks.

Again, it’s not possible to assess bias and potential conflicts of interest. External validity would appear poor given the patient population and no data on glycaemic control!

Evidence for Mildronate/Meldonium in magnesium deficiency is easy! However, cardiac arrhythmia may be a symptom of a magnesium abnormality (too much or too little) that provides a (albeit poor) mechanistic link for Mildronate/Meldonium use.

Overall, there is some English-language evidence from a few small RCTs that short-term use of Mildronate/Meldomium at 1g/day (intravenously but possibly orally) reduces occurrence of cardiac arrhythmia in high risk (older) patients with CHD. It may also improve renal function in heart failure patients with T2DM and neuropathy symptoms in T2DM.

However, the English-language trials providing this “evidence” are very likely too small and there is high uncertainty about the risk of bias, the quality of the data, conflicts of interest and a lack of data on potential harms.

The question begs “Does the evidence support the decision of the family physician to prescribe Mildronate to a year 17 year old athlete for *treatment* of an abnormal ECG, indicators of diabetes and magnesium deficiency over a 10 year period?”

What would you say if you were on the jury?

In my followup blog (Next week!) I’ll examine whether Mildronate/Meldonium appears to enhance performance.



David Nunan is a Departmental Lecturer and Senior Researcher at the Nuffield Department of Primary Care Health Sciences, University of Oxford. He is also a senior tutor at the Centre for Evidence-Based Medicine and a member of the Evidence Live 2016 local organising committee.

Follow @dnunan79



Care of sports team and endurance athletes, exercise Rx in primary care, and anti-doping: stellar line-up of pre-conference courses May, 2016 in Victoria, Canada – register now!

15 Apr, 16 | by BJSM

CASEM logoThere is still time to sign up for the Canadian Academy of Sport and Exercise Medicine (CASEM) Pre-conference courses held the 3 days before CASEM’s annual scientific meeting May 18-21, 2016: “High Performance on the Pacific Edge”.  All courses are now accredited.

This two-day course, chaired by Dr. Taryn Taylor, will address and prepare physicians to provide medical care to athletes. The target audience is a physician of any specialty, with or without their CASEM diploma, who wishes to develop and enhance their knowledge of and skill in the care of the athlete and the role of the team physician. This course may also be of interest to allied health professionals who are involved with the care of sports team athletes.

This program has been accredited by the College of Family Physicians of Canada and the BC Chapter for up to 12 Mainpro-M1 credits

Hosted by CASEM but presented by Exercise is Medicine Canada (EIMC) all delegates are invited to attend the one day program on “Exercise Prescription in Primary Care” – The Exercise Vital Sign (EVS) is the most important vital sign you need to monitor with the majority of patients seen in primary care today.  Learn how to efficiently integrate the EVS into your daily practice and to provide basic exercise counselling and prescription for your patients to prevent, manage and treat chronic diseases.

This program meets the accreditation criteria of the College of Family Physicians of Canada and has been accredited for up to 6 Mainpro-C credits and 0 Mainpro-M1 credits.

Now travelling to the West Coast, this one-day workshop, chaired by Dr. Andrew Marshall, is designed specifically to address sport medicine clinical issues in swimming, biking and endurance/ultra running.  As endurance events such as Ironman and ultra-running become mainstream, sport medicine physicians are faced with the challenge of providing prevention strategies and treatment and management to the types of injuries high volume training can cause.

This program has been accredited by the College of Family Physicians of Canada and the BC Chapter for up to 7 Mainpro-M1 credits 

It is said that “Doping is a hindrance to sports ethics and a threat to the health of athletes” – CASEM will provide a comprehensive 3-hour session on all you need to know about doping in your role as a sport medicine physician.  Experts will be on hand from CCES and WADA and experienced Team Physicians will provide their insight and own experiences.

This program has been accredited by the College of Family Physicians of Canada and the BC Chapter for up to 3 Mainpro-M1 credits 

The 2016 Victoria meeting will provide a plethora of plenaries and workshops over 3-days in Victoria, BC.  Delegates will be housed at the beautiful Fairmont Empress Hotel connected to the Victoria Conference Centre where the CASEM meeting will bring together experts in the field of sport medicine.

This program has been accredited by the College of Family Physicians of Canada and the BC Chapter for up to 16 Mainpro-M1 credits 

SOCIAL PROGRAM- The social program has been set and we are once again pitting teams against each other as we head to a local pub for a CASEM dedicated Trivia Night on Thursday at the “Sticky Wicket”.  We have made a significant change to the Gala Dinner in 2016.  We are moving it to Friday night in the Empress’ famous Crystal Ballroom and we encourage you all to attend.  Over and above the sumptuous 4-course dinner, the Victoria band Timebenders will play into the wee hours of Saturday morning – as a consideration to the oldies out there we have started programming for Saturday a smidgeon later!  The 5km sightseeing run will return and give delegates a chance to experience Victoria sights and sounds on foot –  100% of monies collected will be donated to a local charity.

Last but not least, each delegate will receive a CASEM surprise gift in their registration packs – what is it?  Register to find out!

Information and registration for ALL programs can be found at: 

Hamstring highlights from Arsenal FC SEMS March 2016 Conference

13 Apr, 16 | by BJSM

By Dr. Ronan Kearney (@KearneyRonan)

The Arsenal FC Sport and Exercise Medicine conference (FC SEMS) brought together world experts to advance the knowledge base in muscle injury prevention, treatment, rehabilitation, and return to play in football.

The topic of hamstring injury (HSI) featured strongly. Here are 6 ‘take home messages’ for sports and exercise medicine professionals.


  1. Mechanism of injury

Understanding the mechanism of action of the injury can help identify whether the HSI was obtained during sprinting or stretching. A more proximal HSI with tendon involvement generally means a longer return to play (RTP) for the injured athlete.

  1. Communication is key

Comprehensive communication between medical and coaching staff is vital to ensure the injuried athlete is managed appropriately. The player and manager should be informed of the risk of re-injury following a HSI. The risk of HSI re-injury is greater when there is intratendonis rather than musculotendinous involvement. Mode and methods of communication will differ depending on the managers preference, as eluded to by Dr. Nigel Jones, England Rugby Union Team Doctor. Dr. Jones also highlighted the important ability to adapt to the needs of the coaching staff.

  1. Importance of hamstring lengthening

Prof. Karim Khan highlighted recent evidence suggesting a faster RTP following acute HSI with a lengthening type hamstring rehabilitation programme (‘L’ protocol) rather than a conventional hamstring rehabilitation programme. The ‘L’ protocol as described by Carl Askling (1) involves three core hamstring lengthening exercises: ‘The Extender’, ‘The Diver’, and ‘The Glider’.

The benefits of lengthening the biceps femoris muscle fascicles (BF) were also mentioned by Dr. David Opar, who noted that short BF and weak knee flexion lead to an increased risk of HSI. Ultrasound estimation of BF length has potential for practical use in helping to identify high risk HSI players who would benefit from a hamstring lengthening programme. Or should hamstring lengthening programmes be advised to all players regardless of fascicle length? Nonetheless BF length is a modifiable risk factor in HSI.

  1. Do we really need MRI for hamstring injuries?

Shorter RTP times are noted in players with a normal MRI HSI than a HSI with abnormal findings on an MRI. The need for MRI in HSI is questionable, however it can be argued that the knowledge of a shorter estimated window of RTP could prove benficial to both player and team for both footballing and rehabilitative decision making. Interestingly during the conference a vote was running on the BJSM Plus Twitter page: “Hammy injury to star striker – MRI to determine RTP time? Would you?’ 66% of voters agree that they would get an MRI. Would you?

Prof. Khan mentioned a recent study considered controversial by some (2). The study suggests that MRI does not add value over and above patient history and clinical examination in predicting time to return to sport in acute HSI. Score of maximal pain at onset, forced to stop playing within 5 minutes of injury, length of palpable tenderness, and painful resisted knee flexion can account for 29% of a time to RTP prediciton following acute HIS whereas the addition of MRI only adds 2% to the prediciton. In the words of Dr. David Opar; “if the scan and other investigations are normal but the player still feels injured, then the player is injured.”

  1. The mind matters for RTP

Dr. Clare Ardern highlighted that readiness to RTP not only deals with physical and functional readiness but also encompasses psychological readiness (3) and suggested the Injury-Psychological Readiness to Return to Sport scale (I-PRRS) (4) as a potential simple to use measure of RTP readiness. Prof. Khan noted that physical readiness for RTP in HSI can be estimated using a simple yet effective Askling ‘H’ test (5)

  1. Training the skilled athlete

Mr. Shad Forsythe, head of performance at Arsenal FC, spoke passionately about the importance of player specific training where one-size-fits all really doesn’t fit-all as teams consist of mesomorphs, endomorphs and ectomorphs or ‘stubbies, chubbies, and beanpoles’. Maybe if this is taken into consideration we can reduce the incidence of HSI among elite football players from its 4% increase in recent times.


Dr. Ronan Kearney is a postgraduate M.Sc. Sport and Exercise Medicine student at Trinity College Dublin, Ireland. Ronan works with a number of sporting teams and is a senior house officer at the Sports Surgery Clinic, Dublin. Ronan will commence his General Practice specialty training in July with a view to Sport and Exercise Medicine specialisation.  (@KearneyRonan)


(1) Askling CM, Tengvar M, Tarassova O et al. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48:532–539

(2) Wangensteen A, Almusa E, Boukarroum S et al. MRI does not add value over and above patient history and clinical examination in predicting time to return to sport in acute hamstring injury. Br J Sports Med 2015;0:1–10

(3) Ardern CL, Osterberg A, Tagesson S et al. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med 2014;0:1–8

(4) Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic Training. 2009;44(2):185-189.

(5) Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc 2010;18:1798–803.

Balancing training load and tissue capacity

11 Apr, 16 | by BJSM

By Tom Goom (@tomgoom)

Originally posted on RunningPhysio blog

A key concept in preventing and managing running injuries is understanding the balance between training load and your capacity to handle that load. In a nutshell it’s a case of working within your limits and not pushing your training beyond what your body can cope with. Today we look at finding the balance and some important recent research…

The picture above shows a common scenario I see everyday treating runners in clinic; training load outweighs load capacity. They’ve pushed their training on, increased too rapidly and exceeded what their body can cope with. The result, something hurts! Our bodies are amazing, we’re made up of complex, living tissue that constantly adapts to load. Push it too far though and it can’t adapt quickly enough and what we often see is a reactive response. Tendon is a good example of this. When the load on the tissue exceeds its capacity to manage that load it reacts, often becoming swollen, sensitive and painful.

Unfortunately injured tissue’s ability to handle load is usually reduced. Scott Dye covers this nicely with his idea of an ‘envelope of function‘;

Staying with the tendon example, following injury a tendon that used to manage 20 miles or more of running may be painful with even a few minutes. This initial pain settles but it’s still likely that it won’t cope with going back to 20 miles straight away. Its capacity is reduced and will need gradually building up again. This is part of the reason why injury recurrence is common and previous injury is one of the key risk factors for developing further running injuries in future.

Training load

Tissue load is dependent on your training volume (how much), intensity (how hard), frequency (how often) and type. That’s not where it ends though, your other sports, work, habits, hobbies and anything in life that loads tissues all forms part of your overall load.

Loading tissues through sport and exercise is healthy and promotes adaptation such as strength gains, improvements in fitness, and even tissue healing. Problems often occur when tissue load increases too quickly which we commonly see from training error in runners. This graphic neatly summarises the key goal to avoid overloading your tissues, change gradually…

For more on this see our previous articles on injury prevention.

Tissue load capacity

The body’s ability to handle load is dependent on a host of factors including strength, movement control, flexibility, running gait and other biomechanical factors. Recent research by Jill Cook and Sean Docking highlights the importance of improving tissue capacity, not just in the injured tissue but throughout the kinetic chain,

Clinicians need to be thoughtful and skilled in normalising capacity across all soft tissues of the kinetic chain after injury to a single tissue.

Patellofemoral pain is a good example of this. We recognise that several areas from the hip and trunk down to the foot and ankle can influence load on the patellofemoral joint;

This excellent slide is courtesy of @DrChrisBarton, whose recent paper on best practice management of patellofemoral pain highlights the need for education to encourage activity modification alongside rehab that addresses all needs of the kinetic chain. Lack et al. (2015) provides further support for this with their evidence of the effectiveness of gluteal strengthening for patellofemoral pain.

If we can identify which area is key for each individual patient then we can maximise load capacity locally in the injured tissue and in all relevant tissues around it through targetted strength and conditioning.

A combined approach of modifying training and appropriate strength and conditioning is ideal for reducing running injury risk and redressing the balance between loading habits and tissue capacity;

A key concept from Cook and Docking (2015) is that rehab needs to be progressed so the load capacity of the tissues meets the needs of the patient. The picture below illustrates this nicely. They go on to raise another important point, it’s unlikely passive interventions (like massage, manipulation, acupuncture, injections etc) will have long term effects on tissue capacity. They may have some role in reducing pain but, put simply, you can’t massage strength into someone’s legs!

Source Cook and Docking (2015), courtesy of @BJSM_BMJ, reproduced with permission.

More than mechanics!…

Of course though we must remember we are much more than mechanics, and a bundle of tissues responding to load! Multiple personal factors play a part too and must be considered.

Research is starting to explore the role of sleep in injury risk and performance. Evidence from adolescent athletes suggests injury risk increases with less than 8 hours sleep per night. Stress may play a crucial role and has been found to slow healing by as much as 40-60%! Mental health may be a key factor and a positive view of return to sport has been associated with a greater likelihood of returning to your pre-injury level.

Diet and energy availability may also be play a role in injury risk. They have been found to be implicated in the development of bone stress injuries alongside a number of other factors that affect bone load capacity (Warden et al. 2014);

High BMI is associated with increased risk of running injury and has been linked to tendinopathy and plantar fasciitis. Evidence suggests age, genetics, hormonal changes around the menopause, metabolic issues and the use of certain antibiotics may all influence the risk of developing tendinopathy.

All of these factors have a link with tissue load capacity or its ability to adapt to load. Beyond this though we need to remember that pain isn’t just down to changes in the tissues. Pain itself will influence tissue capacity and needs to be addressed as a priority. Our beliefs, values, experience and attitudes towards this pain will all have an influence and can’t be forgotten. For more on this see @DerekGriffin86’s excellent guest blog ‘Why do I hurt?‘. Even the brain itself could potentially influence load capacity. Recent work by Rio et al. (2015)found cortical inhibition in athletes with patellar tendinopathy which reduced following isometric exercise and there’s evidence the brain may play a crucial role in regulating exercise performance.

The take home message here is that our ability to manage load and to train as much as we want to is affecting by a host of factors, all of which need consideration, especially following injury;

Closing thoughts: if you want to reduce injury risk, or plan effective rehab try to balance training load with capacity to handle that load. Sensible training structure with a planned, gradual progression and individualised strength and conditioning can be a powerful combination in achieving this. Remember too though that pain and injury go well beyond just ‘issues in the tissues‘! Consider if stress, sleep or general health concerns may be playing a part. And finally…

…A BIG thank you to @AdamMeakins who very kindly put together this video after our recent Running Repairs course which includes a little on tissue capacity and key points from the weekend. We have more courses coming up in 2016, see our course page for more details.





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