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

1 May, 15 | by BJSM

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

By Steffan Griffin (@lifestylemedic)

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

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

Why is adherence important?

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

Who is most likely to drop-out?

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

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

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

Tip 1: Inform,,

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

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



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

Tip 2: Be #SMART,,

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

Tip 3: #SmashThroughBarriers,,

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

harry potterTip 4: #TeamEffort

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

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

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


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

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

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

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

How can I summarise these tips?

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

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

Focusing on each factor¹⁰

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

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

Relatedness: create an empathetic and positive environment

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


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

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

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

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

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

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

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

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

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

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


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

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Gait analysis: a Sports Physiotherapist’s overview of strengths, limitations, and tips 

28 Apr, 15 | by BJSM

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


At this time of year, runners of all abilities are training for and recovering from organised runs: shorter 5-10km distances to the London Marathon. Thus, it is timely that Tom Goom, Sports Physiotherapist from The Physio Rooms, Brighton and East Sussex and creator of RunningPhysio, answers our questions about gait analysis.

By @tomgoom

gait 1 goom

  1. Who should see a physio for a running gait review?

People most likely to benefit from running gait analysis are those with a running related injury, particularly a persistent one. Of the common running injuries, patellofemoral pain has arguably the most evidence to support gait retraining. Studies have shown reduced patellofemoral load with an increase in step rate and reduction in stride length (Lenhart et al. 2014Wilson et al. 2014) and very promising results in patients with patellofemoral pain (Noehren et al. 2011Willy et al. 2012).

At present there is minimal evidence to show that altering running gait can prevent injury or improve running performance. Gait retraining has the potential to improve performance but to date there are very few studies demonstrating this. Some research suggests that runners may self-optimise their gait pattern (Moore et al. 2012). Altering gait from a runner’s self selected ‘normal’ may acutely reduce running economy and have a negative impact on performance. We have to bear this in mind when making gait changes and ensure it feels comfortable for the runner.

Considering the available evidence, we cannot say gait analysis is something all runners should do, or that it will benefit everyone. The gait research evidence base is growing but at present there are few long term studies or high quality RCTs. It’s worth considering the pros and cons as there are a number of arguments for and against gait retraining.

  1. What unique skills do sport and exercise physios bring to running gait analysis?

Sport and exercise physios are in a great position when it comes to analysing and understanding running gait. Our knowledge of pain, pathology, biomechanics and motor learning allows us to reason through how changes might help an athlete. Physios are skilled at movement analysis which is a huge part of assessing gait. One area where we perhaps could improve is our understanding of the implications for performance. It’s easy, as a physio, to focus on treating pain but with athletes we must keep performance a priority too. Working with other members of the multidisciplinary team can help us provide comprehensive, integrated care.

  1. How do you do gait analysis? Do you use video runners?

At present I do the majority of my gait analysis using an iPhone 5S or iPad Air to video and the Übersense App. Having experimented with a few options I find this most convenient in a clinical setting. I use a mixture of treadmill and outdoor running assessment (particularly on the running track where possible) depending on the patient and the facilities available. I video from the side, back and front usually at a runner’s preferred speed. Gait analysis is like other assessments, it can be modified to suit the patient. For example, you might examine gait over a range of speeds, when the athlete is fatigued or on an incline or specific surface depending on when symptoms occur.

I start with an overall look at running kinematics, working down from top to toe to identify movements that might be related to the athletes pain/ injury. For example, excessive hip adduction during stance has been associated with patellofemoral pain (Noehren et al. 2012). It’s important not to get too focussed on one area or one part of the gait cycle. Try to be systematic to get a good overview.

Running demonstrating an 'over-stride' with associated changes in kinematics at the hip, knee, shin and foot

Running demonstrating an ‘over-stride’ with associated changes in kinematics at the hip, knee, shin and foot. Photo courtesy of @RunTechnique


Next I look at specific factors that have been studied in the research and we have a reasonable understanding of their effects on loading. This includes footstrike pattern and transition, stride length, step rate and stride width. All these factors interact with each other and with overall kinematics and kinetics.

Goom 3

Runner with narrow step width with an increase in hip adduction and rearfoot eversion. Food for thought…the runner above is completely symptom free and has no history of injury. Should we change her running style?

Once you’ve gathered all this information the big challenge is what to do with it! Our analysis is only really as good as our ability to clinically reason through what we find. There are no magic bullets or one size fits all approaches with gait analysis and retraining.

  1. Advantages/disadvantages of using video/programmes

Some technology is better than others for gait analysis. My preference for the iPhone 5S is because it has a high frame rate (120 frames per second) which allows excellent slow motion analysis. Other phones and cameras can certainly rival this though so it is worth shopping around. A smart phone and app makes a good combination that is easy to use in clinic. Of course we’d all like an 8 camera 3D motion system with force plate and instrumented treadmill but this is far beyond the reach of most clinics! Such systems allow more detailed analysis of kinematics and kinetics but all approaches have some limitations. For example rotational movements (such as hip rotation) are difficult to measure, as is pronation (we might be seeing movement of the shoe rather than the foot and ankle).

  1. Do you work closely with other sport and exercise professionals? If so, what are the advantages of this?

We can learn a great deal from other members of the MDT. I work with running coaches, S&C coaches, nutritionists, personal trainers and sports physicians wherever possible. I often work with a running coach during a gait assessment. They can help with the performance aspects and provide the athlete with valuable cueing and feedback during training.

Gait anaylsis and retraining can play a valuable role in managing running injury as part of a comprehensive treatment programme. In runners we are often trying to achieve a balance between how much someone runs and how much their body can cope with, balancing loading habits with load capacity.

goom 4

Training structure and progression plays a vital role in injury developement and its management. Training error is thought to be responsible for 60-70% of running injuries (Neilsen et al. 2012). Input from a running coach to provide an appropriate training programme can help ensure successful return from injury, reduce injury risk and achieve performance goals.

Input from an S&C Coach can also be very valuable. Recent research suggests strength and conditioning can reduce risk of overuse injury (Lauersen et al. 2013) and improve running performance (Rønnestad and Mujika 2013).

An integrated care approach that includes gait retraining, appropriate training structure and progressive strength and conditioning can help injury management and prevention by modifying loading habits and improving load capacity.

goom 5

For more information on evidence based running gait analysis and management of running injuries see Tom’s Running Repairs Course.


Tom Goom is a physiotherapist The Physio Rooms, Brighton and East Sussex. He has over 10 years of experience and a very keen runner! Tom started RunningPhysio in March 2012 to help those training for marathons that spring, since then it’s developed into a resource used by runners all over the world. Tom has written for Running Fitness, Men’s Running Uk, and the British Journal of Sports Medicine blog. His work has featured on Kinetic Revolution, Bartold Biomechanics and a host of online sports sites.

If you are a UK physio and not already a member of UK Physios in Sport, check our website for member benefits. Tremendous value on your CPD events, opportunities to network with the leaders in UK sports physio as well as valuable access to 4 sports physio journals including BJSM and JOSPT.  Benefits begin at £21 pounds for students and <£5 per month for all Chartered Physiotherapists.


Exercise Medicine 2015

24 Apr, 15 | by BJSM

By Joe Lightfoot (@JosephLightfoot)

 Exercise Medicine 2015, a two day conference run by the Royal Society of Medicine (RSM – @RSMSEM) this June 19-20th will bring together world leading experts on physical activity.

Physical activity is arguably the most important factor in health. This conference is for all individuals with an interest in health, fitness and physical activity. Now in it’s third year, Exercise Medicine 2015 includes themes on:

  • The built environment
  • Special populations
  • Resistance training
  • Digital health
  • Exercise for specific conditions

We’ll equip individuals with the knowledge to help more people be physically active, introduce new research in rapidly evolving fields and present information on key areas and how it can impact exercise medicine.



Key speakers include:

  • Prof Karim Khan – Exercise is Medicine for older people’s bones and brains
  • Dr Brett Smith -What does the research evidence tell us about disability and physical activity?
  • Simon Allford,Incorparating activity into design
  • Prof Heather McKay – Physical activity strategies for children and youth.
  • Mr Ian Ritchie – Surgeons and physical activity: Leading by example
  • Chris Beardsley – Real world strategies to get people stronger
  • Dr Hamish Reid – Department of Health – Helping healthcare professionals educate their patients about physical activity
  • Prof Steven Blair – The Global Energy Balance Network

PLUS – designated networking time, healthy lunch and drinks reception

Early bird and student discount tickets are now available. For more information, please visit:

Dr. Joe Lightfoot is passionate about exercise medicine and sits on the RSM council for Sport & Exercise Medicine.

Podcast cluster #1: Hamstring injuries

22 Apr, 15 | by BJSM

By Steffan Griffin (@lifestylemedic)

Do you want to brush up on a certain topic this week but can’t spare the time to trawl through the archives? As always, we try to make it as easy as possible for you to access freely available BJSM learning resources #ShapingThePath. So, if you want to learn about Hamstring’s A-Z, with experts such as Carl Askling and David Opar, scroll down for our top 5 suggestions.


  1. Hamstring Injuries with Carl Askling:

Sweden’s Carl Askling explains new ways to categorise hamstring injuries – all ‘hammy’s are not the same! Listen to tips on how they can be diagnosed, treated, and monitored during the rehabilitation phase. He shares nuggets on how to assess athletes post-hamstring injury for return to sport, an often difficult and confusing process. Club doctors have been sacked for getting this wrong!

  1. Hamstring Injuries – the American perspective:

A golden overview for the rush-hour traffic with former Olympian and now Professor of Sports Medicine, Tom Best, co-medical director of Ohio State University Sports Medicine. Pearls of wisdom from the injury process to the role of massage and NSAIDs in the rehabilitation process.

  1. Hamstring Injuries in football with Jan Ekstrand:

This goes nicely with the May’s FIFA-edition of BJSM, providing a fantastic overview of SEM in football, from the role of football in global health to injury prevention strategies at the World Cup! One of the most respected researchers in the field, UEFA Champions League Study lead Professor Jan Ekstrand, discusses football-specific issues in hamstring injuries in football players. Are they the same clinical entity or do they need special treatment?

  1. Diagnosing and treating acute hamstring injuries:

Introducing the most popular BJSM podcast EVER! Robert-Jan de Vos speaks to Gustaaf Reurink, author of the already famous 2014 NEJM paper on the role of PRP in acute hamstring injuries. In addition to summarising the results of this game-changing study, the Dutch sports physician discusses the value of clinical tests and MRI in acute hamstring injuries, and whether they can predict return-to-play and re-injury. Great clinical relevance.

  1. Eccentric hamstring exercise – they work in practice but not in theory?

Internationally experienced physiotherapist Nicol van Dyk leads the discussion around Nordic hamstring exercises. What’s the role of eccentric strength in hamstring strain injuries as well as in their prevention and rehabilitation. Stellar guest is Dr David Opar, a rapidly emerging voice in this field. They discuss the injury mechanics as well as the revolutionary ‘Nordbord’ Nordic hamstring device, that looks into the potential of this device in prevention, treatment and rehabilitation of hamstring injuries.

This should be enough for the drive to work for a week, or all the better if you listen to them whilst being active! Although you might be tempted to keep these to yourself, especially if people are wondering where all of this new-found wisdom has come from…remember #SharingIsCaring so please share with your colleagues or interact with us via twitter ( @BJSM_BMJ), Facebook or our Google + SEM Community!  And BJSM has a great mobile app – free on both platforms. Ideal way to follow BJSM podcasts plus way more – blog, YouTube videos ++.

BJSM – Impress your colleagues and live at the forefront of #EvidenceBasedPractice.



Steffan Griffin (@lifestylemedic) is a medical student at the University of Birmingham, currently completing an intercalated Sport & Exercise Science degree at Cardiff Metropolitan University. As the conference lead for USEMS and an associate editor for the BJSM, he is passionate about pursuing a career in SEM.

The Prince Philip Medal presented to Dr. Richard Budgett OBE for outstanding achievements in SEM

19 Apr, 15 | by BJSM

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

On 17th  March 2015 The Institute of Sports and Exercise Medicine (The ISEM)) awarded the Prince Philip Medal to Dr. Richard Budgett OBE. This was presented by HRH Prince Philip, the Duke of Edinburgh who, in his role as Honorary Fellow of The ISEM, hosted the event at Buckingham Palace.  The event celebrated Dr. Budgett’s outstanding achievements and contributions to the field of sports and exercise medicine (SEM), in the presence of his family. This was only the third time this award has been presented since the establishment of The ISEM in 1958getting award.

The Institute was established as a representative body for sport and exercise medicine before it was a recognized speciality, and was instrumental in this recognition. It aims to be the central resource for research, expert multidiscipinary and multiprofessional advice, and commentary and communication on important national and international issues in SEM, through the Fellows and Advisory Board. The aim at present is to focus on the role of physical activity both for preserving and maintaining health, as well as in the treatment of disease.

Dr Budgett is an ex-British Olympic rower who was part of the British coxed fours who won the gold medal at the 1984 Los Angeles Olympic Games. He attended the 1992 and 1994 Winter Olympics as the doctor for the British Bobsleigh Team and was the Chief Medical Officer to the British Team at the 1998, 2002 and 2006 Winter Games. Having  led Team GB Medical Team at the 1996, 2000, 2004 and 2008 Summer Olympic Games, London 2012 was his 12th Olympic Games.

He was awarded an OBE in 2003 and was appointed lead physician for the South East region of the English Institute of Sport (EIS) based at Bisham Abbey. In 2005 he was appointed to the World Anti Doping Agency list committee. Elected to the council of the Faculty of Sports and Exercise Medicine in 2007, he was appointed Chairman of BASEM in 2008 and awarded the Fellowship of the Royal College of Physicians in 2011.

During the presentation, Dr Budgett outlined his work with the International Olympic Committee (IOC) in supporting the development of the Active Cities programme, which is focused on supporting those cities wishing to increase physical activity levels within their populations. Inactivity is the greatest public health concern in industrialised countries, and the UK government spends £10 billion per year in lives lost, directly linked to this.  Despite this, and the knowledge that physical activity is beneficial to the physical, mental and social quality of life, a quarter of the adult population in the UK, are classed as physically inactive. The IOC’s support for this programme, the UK’s epithet of ‘the lazy man of Europe,” aims to change this in the future.

The guests were from a wide range of backgrounds. Beyond just medicine, they represented charities, academia, industry and politics. Among them were Sir Phillip Craven, President of the International Paralympic Committee, Dame Tessa Jowell, who was integral to the process of bringing the 2012 Olympic Games to London, and Kevin Cahill, Chief Executive of Sports Relief and Comic Relief. All were introduced individually to HRH Prince Philip who then recounted amusing episodes in his many years of equestrian activities and associated injuries. The day was very enjoyable and doubtless one which guests will remember for many years to come. In addition to the presentation, guests discussed the challenges of changing national and regional policies towards physical activities and sport, with a view to improving public understanding of sports and exercise medicine and its potential impact on patient outcomes.

Many congratulations once again, to Dr Budgett OBE both for his award and   his tremendous achievements and ongoing contribution to Sports and Exercise Medicine.


Dr Katy Hornby is an ST3 in Sports and Exercise Medicine trainee in London. Katy has a background of EM training, and works with the England Women’s and Rosslyn Park Rugby Team. She has recently been elected a board member of The ISEM. Her main interests lie in paediatric sports injuries and concussion.

The Institute of Sports and Exercise Medicine now has a Twitter account- please follow us on @The_ISEM, or visit the website- www.chhp/TheISEM . We welcome comments on how we might best engage the public in the pursuit of health and well-being.

Trust me, I’m a football doc – What do they think of us?

16 Apr, 15 | by BJSM

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

By Dr. Natalie Shur (@NatalieShur)

The Royal Society of Medicine’s new meeting “Football Medicine: A matter of perspective”, featured a star-studded line-up of individuals involved in professional football. It was not just an opportunity for audience members to directly ask players, coaches and media experts about their perspective working in the beautiful game, but it delivered some hard hitting take home messages about the demands of working in football medicine at the elite level.


Dr Shabaaz Mughal of Tottenham Hotspur gave insight into the pressures medical staff face at this level in professional sport, under the media spotlight. This was candidly illustrated with previously unseen footage of the on-pitch resuscitation of Fabrice Muamba. This highlighted the need for medical teams to be skilled and up to date with cardiopulmonary resuscitation, to have an emergency action plan (EAP) in the event of serious incidents. It also served as a discussion point in basic cardiac screening for players enrolled in a professional team. Dr Mughal stressed the importance of staying up to date with other evolving areas surrounding pitch-side medicine such as concussion, which is governed at present by the 2013 consensus statement. The consensus statement has recently received growing attention after several high profile players returned to the pitch after sustaining head injuries. Premier League rules have been amended for the 2014/15 season to reflect that the team doctor’s decision is final in deciding whether a player who has sustained a head injury is deemed fit to return to play.

The evolution of football medicine was described through the experiences of footballers old and new. Gary Mabbutt, MBE described his difficulties after his diagnosis of type 1 diabetes, when a series of doctors deemed him unfit to play due to the high risk of hypoglycaemic episodes. This initial bad start had left him cynical of doctors in general and demonstrated the need for a strong level of trust and connection between player and medic. He and Kevin Bond reminisced about the non-existence of injury prevention training or modern rehabilitation techniques in their era. Kevin Bond stated that any injury they sustained received “some ice, some ultrasound, and if you were lucky, a bit of a massage.” The role of the football medic has changed. Where previously doctors did not come onto the pitch. The responsibility of a team doctor is now far reaching from pre-season baseline screening, travel medicine, setting up injury surveillance programmes, to dealing with illness, injury and mental health problems that may arise in the extended team. It is a 365-day per year job, where you are expected to be on-call any time of the day and night. An important lesson for any junior doctor to consider…

The security of the football medic was also touched upon. Jermain Defoe explained that some players consult a different physiotherapist or doctor from the club medical team, sometimes even flying abroad to do so, as they had helped them rehabilitate after an injury in the past. Although this may undermine the support given by the club medical team, there exists a mentality to do whatever it takes to get the player back onto the pitch as soon as possible. It is this ethical dilemma that makes elite sports medicine so unique. Whilst the health and well-being of the player is priority, there is a nagging thought at the back of the mind to get players fit as quickly as possible. A BJSM blog by Dr Michael Stone last year alluded to the insecurity of being a football doctor, largely because they answer to the manager, not the club. This cut-throat climate, where the backroom staff are a disposable commodity according to who is managing at the time, is not for everyone. Ultimately, however, as Younes Kaboul explained when asked what he wanted from his medical team, he replied “the best treatment.” These are athletes in the spotlight, at the peak of their careers, doing what they love. They want to get back to playing football as soon as possible and are willing to travel far and wide to seek the best individuals who will help deliver this possibility.

Like much of sports medicine, football medicine is an ever-evolving arena with a unique set of demands and benefits. Being part of an elite sports team, rejoicing in the successes, but also mourning the losses is a gratifying experience. On the contrary, working in such an exposed environment, making quick decisions in front of fans and the media may seem daunting.

But isn’t that part of why you became doctor? To be constantly challenged, excited, involved in a continuously developing science and deliver care when stressed and tired and somehow come out the other side feeling like you have done some good? Football medicine: it is a matter of perspective.


Dr Natalie Shur BMedSci (Hons) MBChB (@NatalieShur) is an NIHR Academic Clinical Fellow in Sports and Exercise Medicine, East Midlands deanery and committee member of the RSM Sports and Exercise Medicine division.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Supporting young athletes to stay (and excel) in sport: what’s the role of the medical team? And what does expanding our view of maturation have to do with it?

14 Apr, 15 | by BJSM

baby shaving

By Sam Blanchard (@SJBPhysio_sport)


Age is just a number, right? Or is that just something adults say to convince ourselves our body clock is ticking differently to the kitchen clock and the seemingly more frequent turns of the calendar?

When working with young athletes I think these two clocks are undoubtedly out of synch. Line up three 13 year olds and try and guess their age. You would think one was just about to sit their 11+ at school, one could buy you a lottery ticket and the other – well they probably look about 13.

Despite individual differences in the rate & timing of maturation, we categorise athletes by their chronological age, often to fall in line with their school year. But at what cost? Barnett & Dobson (2010) recorded 33% more than average AFL players being born in the first month of the season and 25% less than average in the last month of the season. Similar trends are also seen in the English Premier League. Although that may not sound too alarming, as high as 75% of young athletes will drop out of sport around the age of 13. I want to consider the reasons and implications for this along with the question “what can the medical team do about that?!”

Adolescent growth
peak heigh velocity

Children grow at their fastest rate in the first two years of infancy. However, we’re unlikely to see them in sport at this age! It is not until the adolescent growth spurt that we start to see issues relating to co-ordination and performance (Hewett et al 2004, Quatman-Yates et al 2012). As well as increased incidence of apophyseal injuries like Osgood-Schlatters, we also see an increased risk of joint injuries, which I discuss in an upcoming BJSM podcast, related to control of long-levers.

In girls we see this growth spurt around the age of 11-12 & in boys usually around 13-14 and it’s within this time that we see growth rates escalate up to 10-12cm per year. As with everything though, there are outliers. Without our crystal ball, it’s tricky to tell who will hit their spurt at what time. Using the Mirwald calculation (2002), we can get an estimate of the onset of this Peak Height Velocity (PHV) as well as a predicted height at the end of maturation (+/- 5cm). In males we have a tell-tale sign suggesting they have surpassed their PHV, indicated by facial hair. A quick, non-invasive assessment indicating that their growth may now settle to a few centimetres a year, which is much more manageable. In females, the development of breast tissue and the onset of menarche would also be secondary signs of maturation. Although a little more invasive due to questioning, menarche is a key stage of development that triggers hormonal changes of which the medical team should be aware.

What implications does this have?

Let us go back to those stats, with most professional sportspeople being born closer to the start of the season. Growing up, you are more likely to have a head start on the rest of your peers in school. Especially in the years preceding PHV, so around ages 6-12. The danger here is that the older children will be better at games than the younger children – this is do with development of motor learning, co-ordination, potentially size. So already we start to filter out chronologically younger children due to confidence & waning participation. With growth spurts starting around 13 years old, perhaps the 75% of drop-outs are from those born later in the calendar year? How much potential are we missing out on in these early years? I am being careful not to discuss one sport in particular, because different sports in different countries will have different cut-offs for age groups – regardless of “when” in the calendar, there will always be an oldest & youngest (chronologically) either side of this cut off.


Romelu Lukaku aged 16. Now an international football player. But what about the players surrounding him, I wonder?

By the time children reach Peak Height Velocity, the chances of them “specialising” in a sport will have increased. Chances are they are within an academy of sorts relating to their specific sport. Here we start to see a conflict between physical & technical development. Early developers that can physically outplay their peers won’t be challenged in a way that develops their technical side – why learn how to outwit an opponent when you can just hold them at arm’s length? Equally late developers may not be able to get near the play for similar reasons. The argument with the late developers however, is you start to see them problem solve in other ways – “how can I create space for myself?” or “I need to be a step ahead of the play in order to avoid a crunching tackle.”

If we move outside of team sports and look at individual events like athletics, how can we maintain the motivation for late developers to keep competing against physically more advanced peers?

What can we do?

Children aren’t’t born into academies, they are developed in grassroots. Perhaps along with coach education, we need to be discussing maturation and physical development with those involved in recruiting. In football there are extensive networks of scouts assessing grassroots talent. A little bit of knowledge of physical maturation combined with their sporting knowledge could open their eyes to previously ignored players.

The IFSPT definition of a sports physiotherapist includes “enhancing sports performance” (Competency 4: IFSPT competencies here) – so it’s incorrect for physiotherapists or strength & conditioning coaches to think they don’t have a role in talent ID or nurturing. We need to be part of the discussion about managing young players and encouraging development, not just of those early developers that may burst onto the scene at 16, 17 years old – but equally those late developers that may be a hidden talent, whispering in the background.

Detailed knowledge of growth & maturation, along with patience and attention to detail, can help us individualise training for players. When to work on balance & co-ordination or when to start loading in the gym. When to challenge players outside of their comfort zone or when to retreat way back into it. This involves playing the long game – and may be something that traditionalists feel uneasy about. But if we can create an environment where its fluid for players to move between age groups without the stigma of “playing up” or “playing down” then perhaps we can help improve the statistics of teenagers remaining in sport – perhaps even the odd one or two making it professional.

age chart ot post

A new way of thinking about age groups? The red circles highlight where one individual may fall biologically at any one time. The diagram above uses the format that English Football clubs follow – the breakdown of age groups may change between sports and between countries. Diagram by Sam Blanchard.

The diagram above is perhaps how we should be considering our grouping of players. Rather than a straight continuum progressing linearly from one age group to another, understand that players’ development will overlap across divisions. A smaller under-15 can physically present the same as an early developer in the u13s, suggested by the red circles overlapping multiple age groups during the adolescent growth spurt. If we can encourage coaches, players and parents to be comfortable with this then perhaps we can start talking about players competing “across” age groups, rather than “up or down”. It is also important to understanding that player development is a continual process, requiring regular assessment & re-assessment.


The exciting part about working in sport is that our role extends beyond injury management & prevention. We are an important cog of large machine that helps develop & maintain sporting talent. In youth athletes in particular, we have a big responsibility to nurture and develop talent and ensure that the technical demands of training are balanced with physical attributes. Even though the odds of a young athlete making it professional are slim, if we can keep them interested enough that they continue playing at some level as an adult, this will very likely have a positive impact on their life.


Sam Blanchard (@SJBPhysio_sport) is a senior lecturer in physiotherapy at the University of Brighton. He is also the South East representative for the ACPSEM (Physios in Sport) and Lead organiser of the 2015 biennial conference in Brighton, 9-10th October: “The Young Athlete” early bird tickets available until 31st May 2015 please visit for more information. He has recorded a BJSMpodcast on this topic that is in production right now.

Activity among people with chronic low back pain: How activity behaviours reflect beliefs

10 Apr, 15 | by BJSM

For Body Matters, the Massive Open Online Course (MOOC) 23,000+ participants, led by Professor Ian Shrier, hosted by McGill University, Canada.

By Kieran O’Sullivan (@kieranosull)

University of Limerick Kieran O'Sullivan.  .  Pic Sean Curtin Photo.Disability due to chronic low back pain (CLBP) has actually increased in recent decades, indicating a need for significant change in CLBP management1. Improved outcomes in other chronic health conditions (e.g. cardiovascular diseases, cancer), illustrate the requirement of changes in both (i) beliefs and (ii) behaviours. For example, for cigarette smoking rates to be reduced, both clinicians and the public had to (i) really believe smoking was a major concern and (ii) only then did smoking behaviours shift to reflect this evidence.

While we know that increasing activity levels among people with CLBP significantly reduces disability, people with CLBP often remain relatively inactive2. While this “behaviour”may be criticised, one may argue that this is a sensible strategy to adopt based on their existing (albeit inaccurate) beliefs. For example, let’s look at some common inaccurate beliefs held by people with CLBP:

  1. The idea that pain is always an accurate indicator of whether a body part is damaged is still widely held3, despite being completely out of touch with contemporary neuroscience4. For example, people with what appears to be significant tissue “damage” often report no pain, while others with seemingly “normal” scans can report terrible pain5.
  2. Many forms of activity, e.g. running6 and bending7, 8 which are not harmful to the body, are considered somewhat dangerous and a potential cause of “wear and tear”3.
  3. Finally, recuperation from CLBP is considered to be more related to the “magic” hands (or needle / scalpel / scan) of the clinician or health service rather than factors the person themselves can learn to control such as physical activity, stress management, sleep and thoughts9.

When we consider even just these three widely held beliefs, it seems clear why people with CLBP avoid activity, as it is often associated (at least initially) with some pain, which they deem to be an indication of further damage. Add in the fact that healthcare programmes often significantly understate the role of self-management strategies such as physical activity, and the observed low levels of activity are not at all surprising.

In summary, to increase activity levels among people with CLBP, we need to (i) shape their beliefs and better contextualise what is happening to their body (e.g. rarely is tissue damage the biggest concern); (ii) eliminate fears that everyday activities are dangerous even if they are difficult initially, and (iii) empower patients to regain control through active self-management strategies such as physical activity.

Finally, we could learn from other public health initiatives (e.g. non-smoking areas, taxation on cigarettes) and indeed other non-healthcare environments10, 11 on how we can help shape these behaviours to make it easier for people to make a better, more active lifestyle choice12 (e.g. why is the stairs usually harder to find than the elevator in a hotel; why are some cities more cyclist and pedestrian friendly).


  1. Deyo, R.A., S.K. Mirza, J.A. Turner, et al., Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 2009. 22(1): p. 62-68.
  2. Griffin, D.W., D. Harmon, and N. Kennedy, Do patients with chronic low back pain have an altered level and/or pattern of physical activity compared to healthy individuals? A systematic review of the literature. Physiotherapy, 2012. 98(1): p. 13-23.
  3. Goubert, L., G. Crombez, and I. De Bourdeaudhuij, Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain, 2004. 8(4): p. 385-394.
  4. Butler, D.S. and G.L. Moseley, Explain Pain:(Revised and Updated). 2013: Noigroup Publications.
  5. Brinjikji, W., P. Luetmer, B. Comstock, et al., Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 2015: In Press.
  6. Lane, N., J. Oehlert, D. Bloch, et al., The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. The Journal of Rheumatology, 1998. 25(2): p. 334-341.
  7. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J, 2010. 10(6): p. 554-566.
  8. Wai, E., D. Roffey, P. Bishop, et al., Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J, 2010. 10(1): p. 76-88.
  9. Verbeek, J., M.-J. Sengers, L. Riemens, et al., Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine, 2004. 29(20): p. 2309-2318.
  10. Heath, C. and D. Heath, Switch: How to change when change is hard. 2010, New York: Broadway Books.
  11. Thaler, R.H. and C.R. Sunstein, Nudge. 2008: Yale University Press.
  12. Trost, S.G., S.N. Blair, and K.M. Khan, Physical inactivity remains the greatest public health problem of the 21st century: evidence, improved methods and solutions using the ‘7 investments that work’as a framework. Br J Sports Med, 2014. 48(3): p. 169-170.


Dr Kieran O’Sullivan is a lecturer at the Department of Clinical Therapies at the University of Limerick, Ireland. He has been awarded €1 million in funding and has over fifty peer-reviewed publications. He has been awarded ‘specialist’ status by the Irish Society of Chartered Physiotherapists. He has a particular interest in the management of chronic musculoskeletal conditions such as chronic low back pain.

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Announcement of the BJSM 2014 Cover Competition prize winners, drum roll please…

9 Apr, 15 | by BJSM

A huge thank-you to everyone who voted in this year’s cover competition. Thanks to the record number of voters in all rounds. And thanks for your comments on the BJSM covers – which you may use in your presentations and social media to illustrate key points. Read the interesting career development stories from the a new sports medicine book prize winners below.

1. Dr. Eamonn Delahunt (@EamonnDelahunt)

Eamonn 1Tell us about your educational background and current involvement in Sports Medicine.

I graduated with a BSc Physiotherapy in 2003 from University College Dublin. Upon graduation, I received a PhD scholarship from the Irish Research Council for Science, Engineering and Technology. Whilst completing my PhD, I worked part-time in a Sports Medicine and Physiotherapy clinic. I am currently a senior lecturer at UCD and teach in under-graduate and post-graduate physiotherapy and sports science programmes, and also supervise PhD and research MSc students. I recently received the honorary title Specialist Member of the Irish Society for Chartered Physiotherapists (discipline Sports Medicine).

What has been your inspiration? 

I developed a keen interest in sports physiotherapy clinical practice following a placement in 2nd year of my undergraduate education. After this placement I began to study Brukner & Khan’s Clinical Sports Medicine. I still have my original copy of the 2nd edition- it is just about holding together. From reading this book, I developed an interest in sports medicine and physiotherapy research by mainly consulting the bibliographic reference list at the end of each chapter. During the summer period between 3rd and 4th year of my under-graduate education I sourced an “extra” placement in a Sports Medicine and Physiotherapy clinic and this solidified my interest. After this there was no other option for me; I wanted to practice and research in the areas of sports medicine and sports physiotherapy.

Why you are excited to have won a new sports medicine book?

I currently have a strong interest in teaching and learning pedagogy. I am a strong believer in the principle of research-aligned teaching. I also try to practice the principle of research-enriched learning and teaching. The IOC Manual of Sports Injuries will provide an excellent supplementary resource to my current teaching, particularly for a final year module that I teach called Sports Injury Management.

What’s your favourite thing about the BJSM blog?

I love the utility of the blog as a learning resource for undergraduate students. We regularly use it to launch discussions in class. I have to say that the BJSM mobile app works well — great to reach the blog, download and listen to podcasts!

When not teaching or practicing Sports Medicine we will likely find you…

Watching UCI World Tour races on Eurosport.

2. Suzan de Jonge @Suus_DJ

Suzan de jongeECOSEP_photos_4
Tell us about your educational background and current involvements

I’m a clinical registrar and research trainee in Sports Medicine in Medical Center The Hague in the Netherlands. I combine the clinical training for sports physician with a PhD-project on Achilles tendon injuries at the Orthopaedic Department of the Erasmus University Medical Center in Rotterdam. I’m a member of the national board of the Netherlands Association of Sports Medicine (VSG), as well as national chairperson of the board of registrars in Sports Medicine in the Netherlands. Last year I won the ECOSEP travelling fellowship and visited several sports medicine centres in five European countries. I hope to finish both my PhD-thesis and the specialist training for sports medicine this year.

What inspired you to become involved in Sports Medicine?

What attracted me to sports medicine, and continues to fuel my interest is the great diversity of problems (and solutions).

Why you are excited to have won a new sports medicine book?

The focus of training for sports medicine in the Netherlands lies more on exercise therapy than manual therapy. So I would love to receive Orthopedic Manual Therapy by Chad Cook to help me learn more about this field.

What’s your favourite thing about the BJSM blog?

While I do enjoy the diversity of topics on the BJSM blog, I have to admit I like the BJSM podcasts the most.


A preventative strategy to target “The Nation’s Hidden Health Threat” (physical inactivity)

7 Apr, 15 | by BJSM

News Release – The Faculty of Sport and Exercise Medicine

The Faculty of Sport and Exercise Medicine (FSEM) UK is asking MPs to recognise physical inactivity as one of the largest health threats in the UK. In its Manifesto to Improve Public Health, the FSEM sets out 8 priorities to put physical activity at the core of the UK’s healthcare system via a national preventative strategy.

kids-walkPhysical inactivity is now a major cause of ill health in the UK, equivalent to smoking and alcohol abuse[i], it is also a much larger health threat than obesity[ii] and directly contributes to 1 in 6 deaths.[iii] Currently, physical activity is not a frequently used health intervention in the UK and the FSEM calls upon politicians, policymakers and the next Government to address this.

Dr Roderick Jaques, President of the FSEM comments: “The healthcare agenda has been focused for too long on obesity whilst physical inactivity, a larger health threat, has gone largely unrecognized  Addressing physical inactivity through prescribed exercise provides a fresh approach to the prevention and management of avoidable diseases like cancer, diabetes, heart disease and many common musculo-skeletal conditions.

“Exercise medicine can also provide sustainable treatment for excess weight, obesity and mental health and it has an enormous application for workplace wellness and rehabilitation. Our manifesto includes essential priorities for the next Government to put physical activity at the core of healthcare and communities, providing a sustainable solution to public health and the pressures facing the NHS.”

The FSEM supports a recent study by the Academy of Medical Royal Colleges[iv] recognising exercise as a “miracle cure”, too often over looked. The report focuses on the less well-known benefits of regular physical activity and the increasing risks of a sedentary lifestyle and asks doctors to take a leading role in the fight against a sedentary lifestyle.

Sport and Exercise Medicine is a relatively new and largely under-capitalised specialty in the NHS, it has a huge application across both primary and secondary care to improve public health. The cost of physical inactivity to the UK is now £20 billion per year[v]; putting physical activity at the heart of our healthcare system would not only save lives, it would save the NHS substantial amounts of money.

See Dr. Khan’s recent and related blog on the best ‘dose’ of physical activity HERE

Follow the FSEM’s campaign on Twitter, @FSEM_UK #HiddenHealthThreat


[i] Royal College of Physicians and Surgeons of Glasgow: Maintaining health and treating illness through regular physical activity January 2015

[iii] Public Health England: Everybody active every day November 2014

[iv] Academy of Medical Royal Colleges: Exercise the miracle cure February 2015

[v] All Party Commission on Physical Activity: Tackling Physical Inactivity a Co-ordinated Approach 2014

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