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A risk of leaving players to lie on the ground without medical attention – death.

29 Aug, 15 | by Karim Khan

By Dr Efraim Kramer

PLDocsAs medical professionals, we have a duty to care for the sporting ill and/or injured. The health and welfare of those on the field of play is primary and paramount. What Mr Mourinho, as a commercially successful, highly motivated and acknowledged coach sometimes seems to deny is that sportsmen and women are not only injured on the football field, but may die and have indeed died. Seven football players died of Sudden Cardiac Arrest in the past three months alone — the youngest was an 11-year-old South African.

Enough noise, criticism and condemnation was make during the FIFA World Cup, Brazil 2014, concerning the various incidents of concussion and management of apparent back injuries for FIFA to update its regulations. Yet along comes Mr Mourinho, counters and criticizes his medical staff for doing exactly what they are meant to do and why they were employed in the first place and yet there is hardly any noise, muted criticism and no obvious condemnation.

I wonder if Mr Mourinho would like the medical staff to leave him lying on the ground in cardiac arrest under after the final whistle because it would not be in the interest of the game to try and resuscitate him whilst the game was in motion. The highly trained, very experienced and well-motivated medical staff who undertake duties during sports events have one primary goal – to care for, or save the patient who lies on the ground needing their assistance, skills and attention. No coach, manager or any other official is going to change that no matter the score, no matter the seeming importance of the match.

I am in full support of Dr Eva Caneiro’s management of Chelsea player Eden Hazard in the first round of the English Premier League (2015). Her work clearly met the expected and required scope of FIFA’s medical education and teaching philosophies and courses globally, as described by Prof Jiri Dvorak, FIFA Chief Medical Officer. We health professionals need to stand united and firm on this matter.

Dr Efraim Kramer is:

Head: Division of Emergency Medicine, Wits Medical School.

Extraordinary Professor: Section Sports Medicine. University of Pretoria.

Member: FIFA Medical Assessment + Research Center.

Netcare “Angels over Africa” Flight Physician.

BJSM Virtual Conference – The Back: pain, injury, diagnosis and treatment

29 Aug, 15 | by BJSM

‘Back pain is youth leaving the body’ – Anon

Welcome to the fourth virtual conference blog – a collection of podcasts and blogs that, this time focuses on one of the most troublesome presentations in sports medicine – the athlete with back pain. So if you enjoyed our tendons, shoulder and hamstring collections, kick back and allow world-class clinicians guide you through everything you ever wanted to know (or most things anyway…).

The O’Sullivan Show

  1. Effective treatments for back pain – practical tips within a guiding framework, with Kieran O’Sullivan

Dr Kieran O’Sullivan shares his expertise on what to do and what not to do – lessons from 15 years of providing specialised clinical care and engaging in top level research. Specifically, ‘What is the role of patient advice, targeted exercises, and novel therapies including injections?’

  1. Tiger Woods in the Crosshairs. The role of ‘core’ strength and common misconceptions, with Professor Peter O’Sullivan

This podcast covers the media furore around Tiger Woods’ back pain while playing in the 2014 US PGA. He discusses the pathology, why the media suggested that Woods’ ‘sacrum went out’, and why ‘core strengthening’ may not be the holy grail of SEM. These pearls also apply to the management of low back and other pain, in a myriad of settings.

This goes hand in hand with his blog and BJSM paper that centred on (i) common misconceptions in relation to back pain and (ii) clinicians’ common diagnostic and management dilemmas regarding the mechanisms for, and the management of, recurrent and disabling back pain disorders. Easy reading with 5 key take-home points.

  1. Two cases of low back pain – the expert view, with Professor Peter O’Sullivan (@PeteOSullivanPT)

Still a bit confused or want to double-check you’ve got it mastered? Look no further – the Curtin University Prof  takes you through the diagnosis and management of two completely different cases, offering clinical pearls for you to use in clinic whether you’re a medical student or consultant. A refreshing and logical overview of a confusing area – no #shazam, just good medical common sense.

Lower back injuries in cricket players, with Alex Kountouris

With cricket featuring heavily in the news at the moment for obvious reasons (#Pomicide…), if you want to know more about one of the most prevalent injuries that affects fast bowlers, look no further than this fantastic podcast with Australian physio Alex Kontouris. He discusses strategies for the prevention and treatment of lumbar spine injuries in cricket, and answers some interesting questions posed to him from twitter!

Stabbed in the back – moving the knife out of back pain, with Jorgen Jevre jorge

An innovative blog and concept relating to the need to move the goalposts in back pain management.

“The time for change is long past due. The time is now. Let us move patients away from simplistic models of injury and faults. Away from pathologic scans and shiny scalpels. We can gravitate towards a new dawn for back pain management. Researchers can drive the change. Clinicians can be the change. And the patients deserve the change.”

Inspiring and eye-opening read!

“Should I have an MRI right now?” – Explaining the role of MRI in new low back pain, with Nash Anderson

MRI – friend or foe? A sample conversation based on studies and social media which can help to explain to athletes, patients and the public why MRIs are no magic bullet in diagnosing new low back pain every time. NEW blog – hot off the press!

And that’s it! Hope you enjoyed trawling through the resources from some hugely influential names – please do let the BJSM know your thoughts/questions on twitter, Facebook and the Google+ SEM community, we are always open to suggestions for improvement!

“I’ve come here for an argument”

26 Aug, 15 | by BJSM

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

By Sam Blanchard

I’ve recently made the move from the clinical environment into academia (whilst still getting the occasional clinical fix when I can). Part of this move was to set up some new MSc modules at the University of Brighton. The way we wanted this to run was based on facilitating discussion rather than me standing up and banging on about what I would do in different situations – no-one is going to enroll for that! But for this to work, it relies on people feeling comfortable talking about their own practice, something that surprisingly, people are very reluctant to do. People seem very uncomfortable disclosing what they do and how they do it, especially when surrounded by peers.

A while back I read a blog re-tweeted by IFL Sciences (@IFLScience) about how a disagreement is different to an argument. Now rather than me ineloquently blurring these definitions and confusing you more, why not allow the genius of Monty Python to explain.. Please watch this brief 3 min video (here) for the rest of the blog to make sense.

The original clip goes on a bit longer and in true python fashion, gets stupider. But this clip can translate into our practice. It is perfectly reasonable and healthy to argue. We are not going to learn from each other by accepting that that other guy sat in the room, who has more experience than me, treated his ankle sprain using those exercises, so that’s what I should do.

No! Why? We should be asking “Why those exercises for that individual?

There are many roads to Derby:


A completely random destination (just so happened to be one of the cities I can spell). But this image sums up what I think about clinical reasoning. It also demonstrates what I encourage our students to accept when questioned about their practice. This applies to undergraduate students going on placement or masters students discussing case studies in tutorials or equally, qualified clinicians discussing practice over a coffee in the staff room.

Let me explain. Most of us have at some point ignored the sat-nav, right? Intentionally or not. But it simply re-routes and will eventually lead you to your destination. The same with rehabilitation & treatment. We may all have the same goal & end point, but how we get there is different. The route we chose depends on many factors.

Letting the sat-nav make the decision:

For a relatively less experienced clinician, the situation may be this:

“I’ve only ever been to Derby once, but when I did go, that route worked pretty well for me, so I’m going for it again. Why risk it.”

This is the equivalent of following a departmental protocol or being led by a more experienced clinician. Perfectly legitimate but after a time the question will become, “have you tried other ways?” Yes that’s a pretty direct route, but sometimes it’s not about the speed you get there. An example I can think of was a player with a partial ACL injury that occurred just before Christmas. My strength & conditioning colleague and I made the decision to prolong his rehab until the pre-season, despite realistically being able to get him fit for the last 2 games of the season. But there was no advantage to that, the games weren’t key to league position or a must win final. Instead we were able to focus more on smaller details, enhance his “robustness” and ultimately, we had no re-injuries with him the following season. We decided to take the more scenic route and enjoy the drive. Sometimes, it shouldn’t be other people asking why you have done something, but yourself (do this internally, arguing with yourself in a cubicle at work could have very different consequences to the intended career development).

Thanks Sat-Nav, but no thanks:

This option comes after you have driven to & from Derby a few times. Or if you insist on keeping it relevant to practice, an exposure to a certain injury within a set population. Experience may tell you that the route suggested by Sat-Nav has an “average-speed check” of 50 mph for 25 miles, so you may choose one of the alternate routes. This is the same as saying, “I wanted to use squats for his knee rehab, but it aggravates his hip so instead I used dead-lifts.” Someone has asked you why you went that route, the answer is reasoned and justified and neither party needs to be offended. But you have argued your point.

An argument is different to a disagreement:

An example of this not being constructive may be:

“I prefer this route because the services have a Costa Coffee and not Starbucks. I hate Starbucks.” This opinion, without any justification may turn into a disagreement. “I don’t ever use a wobble cushion in my rehab, just don’t believe in them.” A genuine statement that I heard years back when I was studying myself. There was no rationale and every counter argument was met with “Nope. Don’t buy it.”

This is a disagreement. Something I disagree with… Oh, balls.


An argument doesn’t have to be raised voices or expletives. It can be someone wanting to develop their own thinking and reasoning, therefore probing your experience – “But WHY did you chose that? (subtext = help me learn!)”

Equally it can be someone pushing you to develop. “You use that exercise for all of your patients.. why?” (“Come on, push yourself a bit more. Get out of that comfort zone”)

I’ve started to do a little presentation at the start of our modules to explain this thinking, I will be asking “why?” A lot, but I don’t want people retreating or getting defensive. Asking “why” is not a sign that I disagree with you. Arguing is not a sign that I disagree with you. If you feel comfortable with those concepts, you have either done an MSc already, or you are ready to do one! For those not on twitter, firstly – how are you reading this blog? Secondly, get on there. There are prime examples of arguments about clinical practice everyday and very quickly, normal jovial exchanges are resumed (I would highly commend Tom Goom (@tomgoom) for this attribute). But also, it is a good place to observe some people misunderstanding an argument and presuming it is a disagreement (I won’t name people, I don’t want to get in a disagreement).

Yours in sport,



Sam is a senior lecturer in physiotherapy at the University of Brighton, working on both the undergraduate BSc program and the post-graduate MSc Sports Injury Management. He is also the ACPSEM regional representative for the south east & conference director of the upcoming “Young Athlete” conference in Brighton, 9-10th October.

Performing Arts Medicine: How can it add to one’s clinical practice?

23 Aug, 15 | by BJSM

By Dr Farrah Jawad

The MSc in Performing Arts Medicine (PAM) at UCL provides a great opportunity to appreciate the issues affecting the performing artist and draw on similarities between performing artists and athletes.  Performing artists train for many hours, sometimes in suboptimal conditions, and are subject to acute and chronic injury and illness just like athletes.  As a part-time PAM MSc student whilst continuing with my full-time Sport and Exercise Medicine training, I have been learning about these issues pertaining to the performing artist in lectures and in seminars.

orchestra close upLast term we had a seminar with David Hockings, Principal Percussionist with the BBC Symphony Orchestra and Head of Percussion at the Royal College of Music, who talked to us about the challenges musicians can face, often rehearsing and performing for many hours with insufficient lighting, adjustable seating, carrying heavy instruments and equipment in between performances, and more.  There are vast ergonomic differences between instruments that make up a percussion section, let alone the entire orchestra, and there can be great variation in the types of injuries performing artists can sustain subsequently.  The same, of course, applies to different dance disciplines and the MSc in PAM is a chance to consider all of this.

I am about to enter my second year of the part-time MSc PAM course, which can be taken full or part-time.  There is also a postgraduate diploma course available.  There are eight compulsory modules which include:

  • Musculoskeletal and Neuromuscular Performance Related Injury
  • Research Methodology
  • Environmental Issues, Travelling and Touring, Governance and the Law
  • Drugs and Disability within the Performing Arts World
  • Performance Psychology
  • Clinical Management of the Professional Voice
  • Assessment and Rehabilitation of the Performing Artist
  • Science of Dance and Music Performance

MSc students undergo a research project with a subsequent presentation and viva examination.  Students have coursework and examinations throughout the year.  Following the MSc, one could progress to further academic work such as a PhD.

More details on the MSc can be found via this weblink:

The MSc in Performing Arts Medicine will add to one’s clinical practice and prospective careers may include working for orchestras, bands, dance companies and participating in the practitioners’ scheme at the British Association of Performing Arts Medicine (BAPAM).

See the BJSM articles below for some further reading on Performing Arts Medicine topics:

H Fredriksen, B Clarsen. Abstracts from the IOC World Conference on Prevention of Injury & Illness in Sport, Monaco 2014: 97: High Prevalence of Injuries in the Norwegian National Ballet. Br J Sports Med 2014;48:7 595-596

C Ekegren, R Quested, A Brodrick. IOC World Conference on Prevention of Injury & Illness in Sport: Posters: Epidemiology of injuries among elite pre-professional ballet students. Br J Sports Med 2011;45:4 347

D Hamilton, P Aronsen, J H Løken, I M Berg, R Skotheim, D Hopper, A Clarke, N K Briffa. Dance training intensity at 11–14 years is associated with femoral torsion in classical ballet dancers. Br J Sports Med 2006;40:4 299-303

Nolet, R. Virtuoso hands. Clin Rheumatol (2013) 32:435–438



Dr Farrah Jawad is currently a ST5 doctor in Sport and Exercise Medicine and part time Performing Arts Medicine MSc student at UCL.  She co-ordinates the BJSM Trainee Perspective blog.

Conference Highlights from the Concussion in Sport conference at the Sports Surgery Clinic in Dublin

21 Aug, 15 | by BJSM

By Steffan Griffin (@lifestylemedic)

You may have seen @BJSMPlus – our conference twitter handle feeding various clinical pearls from events around the world – going into overdrive at the recent ‘Concussion: Diagnosis and Rehabilitation’ conference at the Sports Surgery Clinic in Dublin early last month #sscConcussion

This fantastic event, expertly organised by Colm Fuller and the rest of the team at SSC not only provided teaching from some of the world’s premier concussion experts, but also raised some intriguing questions and stimulated some great debate. Additionally, the conference provided an ideal opportunity to launch the innovative Post Concussion Rehabilitation Pathway that aims to improve the recovery process in concussed athletes.

In case you missed out – below are some highlights and impactful tweets – enjoy! All of the day’s stats are easily accessible via the 2012 Zurich Consensus Document, a must-read:

The Athlete’s Perspective Ruby Walsh

concussion 1


It was, perhaps, appropriate that a conference on Concussion was opened by horse-racing legend, Ruby Walsh. As Prof Paul McCrory and Dr Michael Turner later informed us, horse racing is the most high risk sport for developing concussions. During his talk, Ruby ignited a theme which was to recur throughout the day – “Concussion is not a new story and the media storm does not mean it’s a new issue, it’s simply in the news more often”.

Concussion Management – New Ideas and Global Consensus Professor Paul McCrory PhD

  • We need to resort to scientific evidence and not media speculation when considering all aspects of a concussion – a culture of fear exists which may be unfounded.
  • An example of this is the issue of suicide amongst NFL footballers in the USA – “Rate of suicide in 3049 retired NFL footballers (who played > 5 seasons) is 40% of age-matched non-footballers” – meaning that sport may confer a protective effect!
  • At the moment – scans don’t rule in concussion, only rule out more serious pathologies
  • Second Impact Syndrome should be called Single Impact Syndrome- there doesn’t have to be a second impact
  • Examples of how concussions can be prevented include: coaching (eg tackle technique in collision sports), neck muscle strengthening, and rule changes (eg NFL rule banning hits with the crown of the helmet).
  • Mouth guards have no role in preventing concussion.
  • Our understanding of the pathogenesis of concussion is still very rudimentary. Do we know all of the causative pathways? Do NSAIDs put you at increased risk?
  • The Mild/Moderate/Severe classification of concussion is inadequate in comparison to most other conditions. Breast cancer, for example, is classified according to clinical features, histological findings, hormonal receptor status and evidence of metastases- concussion has a long way to go.
  • Concussion has a wide and varied profile, with aspects stretching across many different clinical realms – it means that there is unlikely to be a single diagnostic test.

concussion 2

Taking a Targeted Approach to Concussion Rehabilitation Professor Willem Meeuwisse MD, PhD

  • Normal recovery is dependent on age – an important factor to consider with young athletes.
  • Much of the early management of concussion features reassurance and education.
  • What comprises the ‘difficult’ concussion patient?
    • Persistent symptoms
    • Multiple concussions
    • Concussions with diminishing force
    • Seizures
    • Structural brain injury
    • Paediatric injury
    • Multiple co-morbidities

concussion 3

  • Dix-Hallpike test & Walk-whilst-talk test can be used to assess the potentially concussed athlete – whilst the latter may be used as a management tool


Long Term Monitoring of the Retired Athlete Dr Michael Turner

  • Consensus statements must be taken with a pinch of salt – evidence constantly evolving and many of the recommendations are based on the ‘I just know’ principle.

concussion 5

  • Jockeys are the athletes at greatest risk of developing a concussion. In professional racing a jockey falls off a horse in 1 out of 16 rides, compared to amateur racing where jockeys fall off once every 8 rides. The difference relates to skill level. One jockey dies every 250,000 rides.

Analysis of CSF Biomarkers in Concussion Dr Sanna Neselius MD, PhD

concussion 6

  • Concussions may lead to an increased risk for chronic injuries.
  • Several concussions will lead to delayed recovery.
  • Neurofilament light (NFL) which although varies with time-of-day may correlate with amount of head trauma.
  • NFL may have more of a role to play in delayed recovery than in the initial assessment period.
  • Subdural haematoma is the most common sports-related intracranial bleeding.


A Physiological Approach to Assessment and Treatment of Concussion and mTBI Professor Barry Willer PhD

  • Return to Play can happen when the athlete can exercise fully without exacerbation of symptoms.
  • Issue with return-to-play (RTP) guidelines – return when ‘asymptomatic’ – but when are athletes, let alone controls, fully without symptoms?
  • No evidence to support ‘radical rest’, simply academic suggestion – deconditioning may even confer risks to the athlete.
  • Role for exercise testing followed by graded exercise protocol (%HRmax) in getting athletes asymptomatic faster, thus potentially accelerating RTP?
  • Poor exercise tolerance in the acute phase post concussion may be a marker of poor prognosis.


All papers available at

Commentary on UK Faculty of Sport and Exercise Medicine Position Statement

18 Aug, 15 | by BJSM

”Heart Safe” communities – Why public AEDs are a good idea

By Steven Poon, MD, and Jonathan Drezner, MD, Center for Sports Cardiology, University of Washington

John Drez ECGRecently, the Faculty of Sport and Exercise Medicine (FSEM), an organization that promotes the specialist field of Sports and Exercise Medicine in the U.K., released a position statement in favor of Public Access Defibrillation programs (read it HERE).1 We applaud the FSEM’s efforts and strongly support public access to Automatic External Defibrillators (AEDs). Medical research clearly demonstrates that early use of AEDs in the treatment of sudden cardiac arrest (SCA) improves survival rates. A longitudinal, multi-center surveillance study (Cardiac Arrest Registry to Enhance Survival – CARES) in the U.S. has shown an overall survival rate of 7-10% after SCA without bystander intervention. However, studies evaluating Public Access Defibrillation in the U.S. and worldwide have shown a marked increase in survival rates, from 50-70%.2-3 In school athletic venues, survival rates to hospital discharge for young athletes with SCA reached 89% when on-site AEDs were available and used.4

We commend the statement for its concise, accurate and easily understood description of AED function, simplicity of use, portability and the vital role this device plays in increasing survival. Equipment manufacturers have emphasized the ability of bystanders to follow clearly marked application instructions and voice prompts to promote appropriate use. Furthermore, AED use has become a vital part of basic life-saving courses, such as that offered by the American Heart Association, with strong encouragement for lay person use of AEDs in emergency situations.

In addition to the excellent information presented in the FSEM position statement, other important elements for a successful Public Access Defibrillation program include AED location and placement, equipment maintenance, and an emphasis on recognizing SCA.  The success of Public Access Defibrillation programs is directly linked to ensuring that AEDs are readily available and accessible in public gathering locations. A study in Los Angeles showed increased survival rates by placing AEDs in areas with high pedestrian density such as airports and public swimming pools.5

What more can be done?

We would emphasize that proper planning to identify the optimal AED locations is crucial. Sports and fitness facilities are strategic venues to place AEDs because of their high population density and increased risk of SCA associated with exercise; survival rates are high when AEDs are available and used within exercise facilities.4 However, despite strong evidence that these are prime locations for AEDs, many exercise facilities still do not have AEDs in place.7 As a point of emphasis, AEDs should be accessible at all times to be most effective, with appropriate signage and public access – some studies have shown an unacceptable percentage of devices inaccessible or locked away at the time of need such as at night or on weekends.6

Equipment maintenance is another consideration for long-term success of a Public Access Defibrillation program. AED batteries and leads should be checked based on manufacturer guidelines (usually monthly). Within the sports medicine community, additional preparation and anticipation, including simple ‘readiness’ checks prior to sporting events, are important for emergency planning. The responsibility to properly maintain publicly located AEDs can be ill-defined, and this can lead to devices not being regularly serviced and checked. . Many AEDs now perform self-checks every 24 hours and will trigger an alarm if the battery is low or the leads need replacing. However, ensuring proper upkeep and designating the individuals responsible is essential to the program’s success.

Critical to survival and the prompt initiation of CPR and AED use is the rapid recognition of SCA. Proper management of SCA will only ensue if the emergency is recognized. The medical community can help educate the general public to understand that witnessed collapses are frequently SCA. In 2007, an inter-association task force released Guidelines for SCA recognition and management within the athletic setting.8 This document underscores that brief seizure-like activity can be a confusing hallmark of SCA in athletes, and SCA should be assumed in any (non-traumatic) collapsed and unresponsive athlete to eliminate delays in starting CPR or retrieving and applying an AED.8

The FSEM have taken a bold step to foster and improve heart safety within the U.K.  As sports medicine professionals, we should strongly support Public Access Defibrillation programs and ensure proper emergency planning and access to AEDs within our communities.


  • Faculty of Sport and Exercise Medicine, “Position Statement: Automatic External Defibrillators in Public Places.” July 2015.
  • Culley LL, Rea TD, Murray JA, et al. Public access defibrillation in out-of-hospital cardiac arrest – a community based study. Circulation 2004;109:1859-1863.
  • Ringh M, Jonsson M, Nordberg P, et al. Survival after public access defibrillation in Stockholm, Sweden – a striking success. Resuscitation 2015;91:1-7.
  • Drezner JA, Toresdahl BG, Rao AL, et al. Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports. Br J Sports Med 2013;47:1179-1183.
  • Eckstein M. The Los Angeles public access defibrillator (PAD) program: Ten years after. Resuscitation 2012;83:1411-1412.
  • Hansen CM, Wissenberg M, Weeke P, et al. Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends. Circulation 2013;128:2224-2231.
  • Drezner JA, Asif IM, Harmon KG. Automated external defibrillators in health and fitness facilities. Phys Sportsmed 2011;39:114-118.
  • Drezner JA, Courson RW, Roberts WO, Mosesso VN, Link MS, Maron BJ. Inter-Association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. Heart Rhythm. 2007;4:549-65

The Premier League and the Professional Footballers Association must censure Chelsea: by Professor William Tormey

15 Aug, 15 | by Karim Khan


Medical ethics clashes with team priorities

Jose Mourinho’s actions in criticising Dr Eva Carneiro and physiotherapist Jon Fearn for attending an injured player on the pitch at Chelsea must be vigorously challenged. The General Medical Council’s ‘Good Medical Practice’ states that the doctor must make the care of the patient the first concern and take prompt action if the doctor thinks that patient safety, dignity or comfort is being compromised.

The treatment of Dr Eva Carneiro by Chelsea was unprofessional, carried out in public and should have consequences. Her judgement was denigrated despite her obvious concern for the injured player. Public humiliation is no way to treat any club doctor.

The attendant massive publicity demands that the British Medical Association and the professional bodies involved in sports medicine insure that medical ethics are respected. The Premier League and the Professional Footballers Association must censure Chelsea and publicly assert support for good professional standards in their medical services. There should be no equivocation.


Professor William Tormey

Biomedical Sciences

Ulster University


Northern Ireland

Phone 00353872544646


There are no financial associations and no conflicts of interests

“Should I have an MRI right now?” – Explaining the role of MRI in new low back pain

12 Aug, 15 | by BJSM

A sample conversation explaining the necessity of MRIs – inspired by social media.

By Nash Anderson B.Sc. M.Chiro @sportmednews

Low back pain blogMany people come to see me because they are suffering from a new occurrence of back pain. Globally, pain in the lower back is one of the most common causes of disability. One comment I often hear in those visits is: “Should I have an MRI scan before I start my treatment?”  My short answer to these questions is “An MRI is generally not required for new onset back pain, however sometimes it is. We’ll see what is best for you and will cooperate with your doctor”.

There are many causes of a new low back pain. Simple mechanical back pain is the most common type. Although an MRI is the gold standard for diagnosing many causes of back pain, we are aware that it is not useful in most cases of new low back pain complaints as most cases have simple mechanical causes. How do we explain that something established as the gold standard of back pain diagnosis is not the best idea for their back pain? I’ve written a sample conversation based on studies and things I’ve learnt on social media which can help to explain to athletes, patients and the public why MRIs are no magic bullet in diagnosing new low back pain every time.

Q: “Surely, if you can see more then you have a better idea of what is going on?”

A: Yes, you can see a lot more. Being able to see inside the human body with incredible detail is miraculous. However, do we have a much better idea what is going on compared to a normal physical exam and a comprehensive history? Not necessarily. There is not always a correlation between what we see on an MRI and what you are suffering from.

An ‘incidentaloma’ is a harmless mass found that is seen on MRIs that is unlikely to be causing problems. The term incidentaloma can be extended to other features on an MRI which are incidental. These incidentalomae (the plural of incidentaloma, I may have just made up a word!) may lead to more testing, more costs, more stress and unnecessary invasive treatments. People who have MRIs are much more likely to go down a surgical route which may not necessarily have better outcomes.

To diagnose someone solely off their scan and not their symptoms or their history is called ‘BARF’ or Brainless Application of Radiologic Findings. ‘VOMIT’ or Victim of Medical (or modern) Imaging (or investigational) Technology) is an (other) acronym for our times. This term VOMIT first coined by Richard Hayward in 2003 in the BMJ, is a term for patients who suffer unnecessary interventions for abnormalities observed by imaging or other investigational technology, but not found during surgery – Richard Hayward. This can also be those who have incidental abnormalities on imaging which alter recommendations. Having an MRI early on means that someone is much more likely to be judged by their scan rather than by their symptoms or history.

Simple abnormalities can be very common. A large study scanned individuals of different ages with no back pain. Despite the fact that these people had no back pain, abnormalities were seen in a large percentage (~76%) of scans. One example is that bulges or protrusions in people with low back pain seen by MRI are often coincidental. 60% of asymptomatic middle aged people have disc bulges. Seeing these changes on an MRI is much more likely to guide someone towards surgery and this may not necessarily lead to better outcomes. Some of the degenerative changes that we see on scans on people with new low back pain are not necessarily things we need to worry about. Many of these changes are more likely to come with age. If these changes were described as ‘getting wrinkles or grey hair’, they would be less frightening.

Q: “When is an MRI useful for new back pain?”

A: For new low back pain (simple aches and pains in the lower back), an MRI is often not required however, these do have their use. Occasionally back pain is caused by something serious rather than a simple mechanical problem. In these cases imaging is useful and can be lifesaving. In these cases, there are usually other situations that go with the back pain that may warrant and MRI including:

  • Weight loss that you cannot explain
  • A high temperature and fever over 102° F/ 40 degrees Celsius.
  • Loss of bowel or bladder control
  • Loss of feeling or muscle weakness in the legs
  • A history of cancer
  • Serious trauma
  • Tried conservative treatment (physio/chiro/osteo) treatment for over 6 weeks with no improvements.

It is also a good that our patients and athletes understand not to jump into scans unnecessarily as many are personally funded. MRIs are expensive. They can be a substantial cost to an individual or organisation at ~ £300 per scan ($500).


A – There is no need to perform MRIs for new low back pain unless there is good reason to suspect there might be another cause for the pain. An unjustified MRI early on can lead to further testing, costs, stress and unnecessary invasive treatments.

I hope this sample conversation helps practitioners communicate to their athletes and patients about MRIs and when they are useful for a new case of back pain. The resources below and conversations with excellent practitioners on social media have inspired me to better answer this common question.


VOMIT (victims of modern imaging technology)—an acronym for our time BMJ 2003;326:1273 (7 June), doi:10.1136/bmj.326.7401.1273)[1]

1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Boos N1, Rieder RSchade VSpratt KFSemmer NAebi M.

If you have any questions or comments feel free to contact me on social media @sportmednews or

Let’s get a conversation started on the BJSM Google+ Group –  Sports & Exercise Medicine clinicians –

Thank you for reading this article!


Nash Anderson BSc. M.Chiro (@sportmednews) is an Australian graduate of Macquarie University in Sydney. He works in private practice as chiropractor in Farnham, Surrey at Farnham Chiropractic Wellness. Nash is the founder of, a sport and health resource for clinicians and the public.

Automated External Defibrillators in Public Places: FSEM Position Statement

8 Aug, 15 | by BJSM

By Dr Zafar Iqbal & Prof John Somauroo 

@FSEM_UK Position statement

sealSudden Cardiac Arrest (SCA) is a major cause of death in developed Western countries with an estimated 60,000 cases annually in the UK. Every week in the UK 12 young people under 35 years of age die from SCA due to undiagnosed cardiac conditions. In addition, SCA occurring in those over the age of 35 is often due to coronary artery disease (the number one cause of death in the western world). In England, the ambulance service attempt resuscitation in approximately 25,000 cases per annum. However, only rarely are they able to provide defibrillation early enough for the patient to survive.

Most cases of SCA are due to Ventricular Fibrillation (VF), which is a shockable rhythm and could be returned to a normal sinus rhythm with the use of an Automated External Defibrillator (AED). The single most influential factor in improving survival is treatment with a life-saving defibrillation shock from an AED. Conditions for defibrillation are optimal for only a few minutes after the onset of VF and the best way of ensuring prompt defibrillation is having an AED nearby:

  • Using an AED is easy and can cause no harm; the Resuscitation Council (UK) states. “An AED [defibrillator] can be used safely and effectively without previous training” (RCUK Guidelines, 2010). AEDs are compact, portable, effective, require little maintenance and can be stored for long periods.
  • AEDs analyse the heart’s rhythm and will only deliver a shock if it is indicated. Once activated, the AED guides the user through each step of the defibrillation process by using voice and visual prompts.
  • Defibrillation is the use of a high-energy electric shock that stops the chaotic rhythm of VF and allows the normal, organised, electrical rhythm of the heart to re-start. This can allow the pumping action of the heart to return.
  • Standard AED pads are suitable for use in children older than 8 years. Special paediatric pads, that attenuate the current delivered during defibrillation, should be used in children aged between 1 and 8 years if they are available. If not available, standard adult-sized pads should be used. The use of an AED is not recommended in children aged less than 1 year. However, if an AED is the only defibrillator available its use should be considered (preferably with the paediatric pads described above).
  •  Following SCA, survival rates drop 7-10% every minute without defibrillation and therefore it is essential AEDs are publicly accessible. The majority of SCAs in the UK take place out of hospital where AEDs are not readily available.
  • In 2012, official figures reported that fewer than one in five people who suffer a cardiac arrest in the UK receive adequate care from bystanders. In some areas of the UK, just 1 in 14 people who suffered a cardiac arrest survived.
  • Survival rates in the UK are poor compared with international standards. For example, in Seattle in the United States and Stavanger in Norway, where many citizens are trained in cardiopulmonary resuscitation (CPR), survival from out of hospital SCA with a shockable rhythm is 52%.
  • Urgent defibrillation using an AED is the best way to re-establish the heart’s natural rhythm and CPR is also necessary to keep the patient alive. Evidence from the US shows that if an emergency ambulance is called and immediate bystander CPR is used, followed by early defibrillation and effective post-resuscitation care, survival rates following cardiac arrest can exceed 50 per cent.
    • CPR alone = 5% survival
    • CPR + early defibrillation = 50% survival
  • It is recommended that all school leavers are proficient in CPR and AED use.
  • All public AEDs should be registered with the local Ambulance Service Trust (AST) to confirm the AST is aware of the AED and can log it onto a local database. This will help ensure that an AED is accessed quickly if needed.

The survival rate from out of hospital SCA in the UK needs to improve to be comparable with other parts of the world. The major factor limiting the number of people who survive SCA is the ability to provide defibrillation within a critical time period. In countries with improved survival rates AEDs are more widely available and more of the public are trained in CPR. In the UK, as call-to-arrival times are usually greater than 10 minutes, ambulances often arrive too late to successfully resuscitate most people with out of hospital SCA. The best chance of survival for a casualty with SCA is prompt access to an AED, this could lead to a significant reduction in mortality in both children and adults.



By Dr Zafar Iqbal (Sports and Exercise Medicine Physician – London) &

Prof John Somauroo (Consultant Cardiologist, Specialist in Heart Failure, Cardiomyopathies and Sports Cardiology – Chester and Liverpool)


1. A guide to Automated External Defibrillators (AEDs) By Resuscitation Council (UK) and British Heart Foundation. December 2013

2. Papadakis, M., Sharma, S., Cox, S., Sheppard, M.N., Panoulas, V.F. and Behr, E.R. “The magnitude of sudden cardiac death in the young: a death certificate-based review in England and Wales.” Europace 2009 Vol.11, No.10, p1353-1358

3. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of

An Illustrated Atlas of Orthopedic MRI: Book review (two thumbs up!)

6 Aug, 15 | by BJSM

BJSM Book Review:
An Illustrated Atlas of Orthopedic MRI
Fischer, Guermazi, Roemer, Carrino, Crema, Grainger, Kijowski, Steinbach

Illustrated atlas MRI

This new sports imaging atlas provides the BJSM community with a wonderful atlas of images (there are 3283 MR case illustrations) and clinically relevant text. Image-based learning is certainly the trend in Radiology, and the authors are to be commended for compiling so many sports medicine images of generally outstanding quality in this volume.


Knee MRI

The book is well-organized by anatomic location, including spine which is unusual in sports imaging textbooks,  preceded by introductory chapters on examination technique (includes the most appropriate MR sequences for structural assessment of joints), and the most common bone, cartilage, tumor and muscle pathologies.  Diagnostic pitfalls are marked with exclamation marks, and differential diagnoses are highlighted, although the latter could be used more extensively.  Normal anatomy is illustrated at the beginning of each chapter, although the level of detail would not obviate the need for an anatomic atlas.  The numerous color line drawings are superb, and add further clarity to the text.

Using the shoulder as an example, this 637 page volume covers not only the more common clinical scenarios in sports medicine (eg rotator cuff tears), but also the more recent and controversial topics (eg microinstability/glenohumeral Internal Rotation Deficit or GIRD).  One of the discriminatory features of this image-rich text  is its evidence-based approach, as following each chapter there is a moderately comprehensive but not exhaustive list of references. is overall a superb addition to the sports imaging literature, and strikes the right balance between text, drawings, images, and reference material.  This book with be much-used companion for radiologists, sports medicine physicians, orthopedic surgeons, physiotherapists, and indeed any practitioner who uses imaging in managing patients. BJSM has a clear commitment to imaging research (1,2) and education and this book will be a valuable addition to many BJSM readers’ reference libraries.


  1. Orchard J. What role for MRI in hamstring strains? An argument for a difference between recreational and professional athletes. Br J Sports Med. 2014 Sep;48(18):1337-8.
  2. Forster BB. The game has changed… but it still needs to be played: the role of imaging tests using ionising radiation in the practice of sports medicine. Br J Sports Med. 2014 Apr;48(8):679.
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