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Primary care sports med to ‘pitchside’ gymnastics: Travelling across the pond to dip my toes in the USA SEM scene

26 Jun, 16 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine a BJSM blog series

By Michael Akadiri

texas orthaepedic hospitalThis Spring, I travelled across the pond from the UK to the USA to take the fortuitous opportunity of a 6-week study elective. In line with the country’s nickname as ‘The Land of Opportunity’, I viewed this trip as my opportunity to delve further into the ever growing speciality of Sports and Exercise Medicine (SEM).

Primary Care Sports Medicine

The setting for my first three weeks was the Orthopedic Specialty Institute (OSI) in Orange, California shadowing Dr Kruse, a primary care sports physician (most akin to a SEM consultant in the UK). Primary care sports physicians in the US typically undertake three years of Family Medicine Residency (training), followed by a one year Sports Medicine Fellowship.

Know Your Sport!

Dr Kruse is one of the USA Gymnastics’ Team Physicians. Therefore I observed the management of various gymnastic injuries in clinic. Among the great insight I gleaned was the very useful lesson: Know your sport! History taking is a much smoother process when the clinician understands the sport specific terms used by the historian to describe their mechanism of injury. What is a Tumble Track? High Bar?

These upcoming Olympic Games should be watched for education as well as entertainment!

No screening? No participation!

Outside of the clinic, I observed two High School Pre Participation Physical Examinations (PPE). All athletes from Junior High School (c. 12 years old) and above must undergo and pass an annual PPE in order to participate in any sport. The PPEs were held in May to permit adequate treatment time for those who had ‘failed’ over the summer break. Is this a concept that we should introduce on our shores to provide better holistic care for our Secondary School athletes?

Sports Orthopaedics

I spent the latter three weeks in Houston at the Texas Orthopedic Hospital (TOH) to observe the experienced Sports Orthopaedist, Dr Elkousy. He specialises in arthroscopic surgery of the knee and the shoulder. Sports Orthopaedists typically spend five years undertaking an Orthopaedic Residency followed by a One Year Sports Medicine Fellowship.

Taking the long term view

A footballer tears his/her ACL. It’s reconstructed and the player successfully returns to play? Success right?

What about the long-term sequelae?

A handful of former college (American) Football and Basketball players with previous ACL tears presented the clinic with moderate to severe OA as early as 37 years old! Whilst we await further research on the risk factors for early OA in athletes, should more consideration be given to the long-term effects of participating in elite sport?

Final thoughts

What an educational and thought provoking six weeks! Amongst all the teachings, I feel the most important lesson is that there’s a lot more to sports medicine than the pitchside care of athletes. The bread and butter of our practice is the clinical care of the active population.

Mr Michael Akadiri is a final year medical student at the University of Nottingham. He is set to graduate in the summer of 2016 and commence work as a junior doctor in the South Thames Deanery. As an undergraduate, he co founded and led Nottingham’s University SEM Society as President for two years.  

Dr. Liam West BSc (Hons) MBBCh (@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.

Sit Less, Get Active! First MOOC to deliver and evaluate physical activity promotion, call to action: sign-up or share

22 Jun, 16 | by BJSM

By Adam Bleakley (Foundation Doctor, NHS Lothian) and Evan Jenkins (Medical Student, University of Edinburgh)

Physical activity is regarded as a global public health priority (Kohl, 2012), and physical inactivity the biggest public health problem of the 21st century (Blair, 2009).

Physical inactivity and sedentariness, “silent killers”, are associated with increased morbidity and reduced life expectancy (Lee et al. 2012, Levine 2015). Despite this, about one third of the global population are inactive (Hallal et al. 2012). In 2012, almost half of England and Scotland’s population did not meet the physical activity guidelines, and physical activity further decreases with age (British Heart Foundation, 2015).

It is imperative to further promote benefits of physical activity, work on strategies that will increase population levels of physical activity and make it an important part of people’s everyday lives.

bike moocSit Less, Get Active MOOC

Here, at the University of Edinburgh (Usher Institute for Population Health Sciences and Informatics, Physical Activity for Health Research Centre, Sports and Exercise and School of Informatics), we are the first to offer a “Sit Less, Get Active” Massive Open Online Course (MOOC), on June 30th, 2016. This new, interactive MOOC promotes and evaluates physical activity.

For those thinking, “what’s a MOOC??”: MOOCs are online courses that can be taken by anyone from any part of the world in their own time as long as you have access to the Internet.

Sign up here (it’s that easy): https://www.coursera.org/learn/get-active

Join us on a journey to learn how to sit less and become more active. Use this free course to learn how to monitor your own activity, set physical activity goals and make physical activity a habit- or share it with networks that you think it will benefit. We will present various examples on how to sit less and be more active in various settings such as your neighbourhood, home, work or educational environment, to help you incorporate the ones that fit the best to your lifestyle.

The MOOC is 3 weeks long with a commitment of not more than one hour per week. This course also offers you a unique opportunity to receive weekly physical activity health messages and monthly video reminders for 6 months after the initial 3 week-course as nudges to help you sit less and stay more active.

And if you are a health professional, use knowledge gain through this course to empower your patients to be more physically active. However, if time is the constraint, you can simply “prescribe” the course to your patients.

MOOC_TeamThe core MOOC team includes (in alphabetical order): Dr Graham Baker, Dr Danijela Gasevic, Professor Dragan Gasevic, Dr Andrew Murray, Professor Nanette Mutrie, Professor Chris Oliver, and Helen Ryall. We are grateful to all volunteers and partners who have advised us, endorsed us or worked with us in many capacities such as The Scottish Government, NHS Health Scotland, NHS Health Lothian, Sustrans Scotland, Edinburgh Leisure, SPORTA, Cycling UK, and Queen Margaret University.

How to sign up and share

The course starts on June 30, 2016, and it will run three to four times per year. You can sign up to Sit Less, Get Active MOOC by registering online via link: https://www.coursera.org/learn/get-active

Follow us on Twitter @GetActiveMOOC for a daily dose of physical activity promotion. If you have any questions, please contact the Team Lead Dr Danijela Gasevic at danijela.gasevic@ed.ac.uk And don’t forget, Sit Less and Get more active for your health and happiness!

#MOOCGetActive

References:

Blair, SN. Physical inactivity: the biggest public health problem of the 21st century. BJSM 2009: 43:1-2. OPEN ACCESS HERE

British Heart Foundation. Physical Activity Statistics 2015. Accessed at https://www.bhf.org.uk/publications/statistics/physical-activity-statistics-2015 on June 18 2016

Hallal PC, Andersen LB, Guthold R, Haskell W for the Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012;380(9838):247-257.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60646-1/abstract

Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, Kahlmeier S. The pandemic of physical inactivity: global action for public healthThe Lancet, 2012;380(9838):294-305.

Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzy PT for the Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012, 380(9838):219-229.

Levine JA. Sick of sitting. Diabetologia 2015, 58(8):1751-1758

‘No pain, no gain’. The best way to train? Erasmus MC study project evaluates two different exercise therapies for patellar tendinopathy in a RCT with the innovative 3D Ultrashort echo time (UTE)-MRI technique

19 Jun, 16 | by BJSM

By Robert-Jan de Vos @rj_devos and Edwin Oei

Oei_deVos_ErasmusMC

Authors Robert-Jan de Vos and Edwin Oei

Patellar tendinopathy is an overuse injury that causes pain and impaired performance in jumping athletes. Prevalence is high in elite volleyball (45%) and basketball (32%) athletes.1 Symptoms can become long-standing Furthermore, there is currently no convincing evidence for second-line treatments such as shockwave therapy and platelet-rich plasma.2,3 Exercise therapy and load management are the best initial treatment options for tendinopathies. Therefore, it is important to improve exercise protocols as a first treatment of choice.

Does the type of exercise therapy really matter?

This is a question that a physiotherapist or sports physician can encounter when dealing with patients suffering from patellar tendinopathy. Exercise protocols can differ widely in design and hypothetical working mechanisms. The two extremes of protocols are (i) the progressive tendon-loading protocols with symptom-based progression criteria and (ii) the painful heavy-load eccentric exercises. There is currently no high-quality evidence to suggest one protocol above the other.

What is the background of the painful eccentric and the progressive tendon-loading exercise protocols?

Although painful eccentric exercise protocols have been promoted as standard care based on positive results in early studies4, a recent systematic review demonstrated that these are not associated with improved tendon structure and are ineffective when applied in-season.5 Progressive tendon-loading exercise therapy for patellar tendinopathy is a novel concept in sports medicine. A recent study advocated for a progressive 4-stage criteria-based exercise protocol with the aim of encouraging a less ‘reactive tendon’ and restoring collagen alignment.6 This protocol consisted of progressive isometric, isotonic, plyometric, and sport-specific exercises. Isometric exercises reduce pain and decrease motor cortex inhibition of the quadriceps muscle. This novel approach would enable jumping athletes to resume sports within the limits of pain, with improved muscle function, and possibly a sufficient tendon structure reorganisation.

The primary aim of our research program that has recently been funded by GE Healthcare and the US National Basketball Association (NBA) is to assess whether the recently advocated 4-stage exercise protocol6 focusing on progressively developing load tolerance of the tendon (gradual adjustment) is more effective than the painful heavy-load eccentric exercise protocol7 (‘no pain, no gain’) for the treatment of patellar tendinopathy in jumping athletes. The secondary aim is to validate the novel 3D ultrashort echo time (UTE) MRI technique for quantitative imaging of the patellar tendon, by determining its responsiveness to exercise treatment, its correlation with clinical symptoms over time, and its predictive value of treatment response.

What is the novelty of the 3D Ultrashort echo time (UTE)-MRI technique?

UTE-MRI is an innovative development in the field of tendon imaging.8 Unlike regular MRI techniques on which tendon structure typically is difficult to assess owing to the tendon’s low water content and resulting “black” appearance, UTE-MRI detects signal from tendons and visualises tendon abnormalities more accurately (Figure 1). Hence, with UTE-MRI it is possible to evaluate tendon structure and measure the amount of water in the tendon, both of which can be altered in tendinopathy, and which may improve after exercise therapy. While most research with UTE-MRI has been conducted with two-dimensional approaches based on a limited number of cross-sections acquired in the tendon, we will use a novel three-dimensional (3D) UTE-MRI method, provided to us as a research prototype from GE Healthcare. This software, which is not yet commercially available allows rapid imaging of the entire patellar tendon.

With current regular imaging modalities there is a disconnection between pathology on imaging and patient-reported pain. Identifying prognostic factors could lead to personalised medicine. Therefore, we additionally aim to develop novel quantitative 3D UTE MR imaging biomarkers for the assessment of patellar tendinopathy with the use of advanced image analysis and machine learning methods applied on the acquired MRI data.

‘No pain, no gain’. The best way to train? Erasmus MC study project evaluates two different exercise therapies for patellar tendinopathy in a RCT with the innovative 3D Ultrashort echo time (UTE)-MRI technique

Figure 1: On a conventional MR image (left panel) the patellar tendon (arrow) appears as a dark structure of which the internal structure is not visible. With the use of 3D UTE-MRI (right panel, image acquired in same subject), it is possible to acquire signal from the tendon (arrow), which can be used to determine the tendon’s internal structure.

 

 What is the study design?

We will perform an open randomised controlled clinical trial. Jumping athletes aged 18-35 years will be studied. We aim to recruit basketball players and volleyball players who play at least three times per week and who have been diagnosed with patellar tendinopathy by a sports physician. The diagnosis of patellar tendinopathy will be made clinically with subsequent ultrasonographic confirmation to ensure that we will include patients with symptomatic patellar tendinopathy.

A total of 76 eligible patients will be randomly assigned to one of two different exercise protocols:

1) A progressive 4-stage criteria-based exercise protocol6

2) A 12-week painful heavy-load eccentric exercise protocol with subsequent maintenance exercises7

In both study groups, we will advise a standardised symptom-based return to sport during this period. Pain scores will be used to progress through the subsequent phases of return to sport in all athletes by a sports physician who is not involved in data acquisition. The time frame and outcome measures are displayed in Figure 2.

We will start the project in this summer and we expect to publish the results within 3 years after initiation.

Figure 2: Time line of the study

Figure 2: Time line of the study

References

  1. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med 2005;33(4):561-7.
  2. Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. The Cochrane database of systematic reviews 2014;4:CD010071.
  3. Ioppolo F, Rompe JD, Furia JP, et al. Clinical application of shock wave therapy (SWT) in musculoskeletal disorders. Eur J Phys Rehabil Med 2014;50(2):217-30.
  4. Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep 2013;12(3):175-82.
  5. Drew BT, Smith TO, Littlewood C, et al. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med 2014;48(12):966-72.
  6. Malliaras P, Cook J, Purdam C, et al. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther 2015:1-33.
  7. Purdam CR, Jonsson P, Alfredson H, et al. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2004;38(4):395-7.
  8. Juras V, Apprich S, Szomolanyi P, et al. Bi-exponential T2 analysis of healthy and diseased Achilles tendons: an in vivo preliminary magnetic resonance study and correlation with clinical score. Eur Radiol 2013;23(10):2814-22.

 

About the authors

Robert-Jan de Vos is a sports physician and post-doc researcher at the department of Orthopaedics in the Erasmus MC University Medical Centre in Rotterdam, the Netherlands. His research focuses on imaging and treatment of tendinopathies and injury prevention in football and running. He is also club doctor of Excelsior Football club.

Follow @rj_devos

Edwin Oei is a musculoskeletal radiologist and assistant professor at Erasmus MC University Medical Centre in Rotterdam, the Netherlands. His research focuses on advanced MRI techniques to study musculoskeletal disorders.

Worin bestehen die Vorzüge körperlichen Trainings hinsichtlich Gedächtnis und kognitiver Funktion?

16 Jun, 16 | by BJSM

To read in english go HERE

Antwort auf eine Frage im Rahmen eines Online Kurses der McGill Universität, Kanada („MOOC“ *): „Auf den Körper kommt es an“

von Dr. Julia Alleyne

Dr. Alleyne (Twitter account: @JKAlleyne) ist Fachärztin für Sportmedizin zu deren Erfahrungsschatz u. a. ihre Funktion als leitende Medizinerin für Kanada bei diversen olympischen Spielen, sowie bei den Pan-Pazifischen Spielen 2015 gehört. Sie hat zahlreiche führende Positionen in der kanadischen Akademie für Sport- und Bewegungsmedizin (Canadian Academy of Sport & Exercises Medicine “CASEM”), eine der Mitgliedsgesellschaften des BJSM (Anm.: British Journal of Sports Medicine), innegehabt. Ihre akademische Arbeit an der Universitiy of Toronto verbindet sie mit der Tätigkeit als Ärztin bei „Toronto Rehabilitation“.

German translation by Isi Schneider @isi69schneider

German translation by Isi Schneider @isi69schneider

 Weltweit sind geschätzt 44 Millionen Menschen von Demenz und verwandten kognitiven Störungen unmittelbar betroffen (CDC 2014). Der Nutzen eines körperlichen Trainings für Menschen mit einer Demenzerkrankung überwiegt bei Weitem die Risiken, trotz der kognitiven Einschränkungen der betroffenen Personen. Die optimale Art der Betätigung um die kognitive Verarbeitung erfolgreich zu verbessern liegt entweder in einem Ausdauer- oder Krafttraining, oder einem beständigen aktiven Lebenswandel.

Die am meisten verbreitete Ursache von Demenz ist der Altersprozess in Verbindung mit Erkrankungen der Gefäße. Aus diesem Grund, nachdem körperliches Training bekannter Weise in der Lage ist das Vorkommen von Bluthochdruck, koronarer Herzkrankheit und Schlaganfällen zu mindern, wird durch Training auch das Altern der Blutgefäße im Gehirn verlangsamt.

Nachweis des Trainingseffekts

Um die Anatomie des Gehirns begutachten zu können, haben Colombe et al. (PNAS 2004) Kernspintomographien älterer Erwachsener unter die Lupe genommen, die sechs Monate lang dreimal pro Woche spazieren gegangen sind, und fanden dabei signifikante Verbesserungen im Volumen der grauen und weißen Substanz. Teresa Liu-Ambrose, verantwortliche BJSM Redakteurin, benutzte funktionelle MRT-Verfahren, um die Gehirnfunktion älterer Erwachsener zu untersuchen, die zweimal pro Woche an einem Krafttraining teilnahmen (Arch Int Med 2010). Sie entdeckte dabei signifikante Verbesserungen in der Hirnfunktion, die auch nach Beendigung des Trainings noch über 12 Monate hinweg anhielten. Diese Veränderungen bestanden u. a. in einem verbesserten Erinnerungsvermögen, der Dauer der Zeitspanne bis zu einer kognitiven Rückmeldung sowie der Fähigkeit, Anweisungen korrekt umzusetzen.

Aber was ist mit den Persönlichkeitsveränderungen und den Stimmungsschwankungen, die mit dem kognitiven Verfall einhergehen? Behrman et al. (Practitioner 2014) haben mit einem ähnlichen Ansatz die bekannten Vorzüge von Training auf depressive Symptome extrapoliert und Trainingseffekte auf ältere Erwachsene unterschiedlicher Jahrgänge näher untersucht. Dabei fanden sie bei Patienten mit milden bis moderaten depressiven Symptomen und damit einhergehender Demenz positive Zusammenhänge zwischen zunehmender Aktivität, wie z.B. Spazierengehen oder Tanzen, und Verbesserungen von Stimmung und Selbstwertgefühl, während andererseits negative und verwirrende Gedanken weniger wurden. Beim Vergleich mit einer Arzneimittelbehandlung stellten sie fest, dass Training genauso effektiv und in der Regel in der Lage ist, den Bedarf nach Medikamenten mit möglichen Nebenwirkungen herabzusetzen.

In einer 2010 von Sofi et al. (J Int Med 2011) durchgeführten Meta-Analyse überprüften die Autoren Studien, in denen Erwachsene ohne Demenzsymptome rekrutiert wurden und in deren Verlauf die kognitive Funktion der Probanden gegenüber möglichen Zusammenhängen mit dem anatomischen Vorhandensein einer Erkrankung überwacht wurde, um feststellen zu können, ob sich das Risiko des kognitiven Verfalls bei sportlich aktiven Erwachsenen verändert.
Es wurden fünfzehn prospektive Studien mit Erwachsenen mittleren Alters gefunden, die einem regelmäßigen aktiven Lebenswandel nachgingen. Die gesamte Analyse folgte mehr als 30.000 Probanden über den Verlauf von 1-12 Jahren und ergab, dass das Risiko des kognitiven Verfalls bei Probanden mit einem hohen Aktivitätsniveau um 38% herabgesetzt war, sowie um 35% bei Menschen mit niedriger bis mittlerer Aktivität, verglichen mit sitzenden Versuchspersonen.

Wie sieht es mit nachteiligen Ergebnissen aus?

In meinem Bemühen eine ausgewogene Forschungslage zu präsentieren, habe ich eine Literatursuche zu möglichen nachteiligen Ergebnissen bezüglich kognitiver Funktion bei aktiven älteren Erwachsenen durchgeführt. Das Resultat ergab lediglich ein paar nachvollziehbare Warnhinweise… ruhig anfangen und langsam aufbauen, um eine Überlastung des Bewegungsapparates zu vermeiden, den nötigen Energiebedarf decken und sicherstellen, dass neue Trainingstechniken unter Anleitung und entsprechender Aufsicht erfolgen. Das Hauptergebnis war jedoch, dass sich die kognitive Leistung durch Training nicht verschlechtert; dies ist die entscheidende Kernaussage!

Zusammengefasst lässt sich sagen, dass zwischen den schützenden Effekten körperlicher Aktivität auf die kognitive Leistungsfähigkeit und dem Erhalt einer adäquaten zerebrovaskulären Versorgung des Gehirns mit Blut und Sauerstoff sowie durch unmittelbare endokrine Mechanismen ein enger Zusammenhang besteht. Durch die positiven Effekte von Training auf die Reduktion kardiovaskulärer Risiken wird das Vorkommen damit assoziierter zerebrovaskulärer Ereignisse in Folge von Diabetes, Bluthochdruck, Adipositas und Störungen des Fettstoffwechsels ebenfalls herabgesetzt – und damit auch der krankheitsinduzierte kognitive Verfall. Ein aktiver Lebenswandel schützt darüber hinaus mit einer hohen Wahrscheinlichkeit das Gehirn durch die Stimulation von Neurotrophinen die, wie ihr Name bereits nahelegt, das Wachstum und Überleben von Nervenfasern sichern. Zu guter Letzt lassen aktuelle Forschungsergebnisse vermuten, dass körperliches Training in der Lage ist, stressbedingte Kortisolwerte zu senken, wodurch ebenfalls die kognitive Funktion langfristig erhalten bleibt.

Abgesehen jedoch von jeglicher Wissenschaft kann ich mich an eine öffentliche Kampagne der vergangenen Jahre erinnern, die selbstbewusst mit dem Slogan Be smart, exercise your heart („Sei schlau, trainiere Dein Herz“) geworben hat. Ich denke die zu Grunde liegende Botschaft lernt langsam laufen – kein Wortspiel beabsichtigt!

P.S.: Dr. Alleyne ist Mitglied der internationalen Expertengruppe, die Fragen von Studenten im Rahmen des MOOC https://www.mcgill.ca/tls/projects/mcgillx/body101x beantwortet.

* Anm. d. Übers.: “MOOC” – “Massive Open Online Course” = Offenes Online Seminar

Der englischsprachige Originaltext ist im Blog des British Journal of Sports Medicine erschienen:

http://blogs.bmj.com/bjsm/2016/02/27/what-are-the-benefits-of-exercise-on-cognitionmemory-answer-to-a-question-from-mcgill-universitys-mooc-massive-open-online-course-the-body-matters/

Übersetzt von

Isabel Schneider

M.A. Englisch als Fremdsprache

MA Sportwissenschaften

Dozent an der H:G Hochschule für Gesundheit und Sport, Technik und Kunst

Isabel.Schneider@my-campus-berlin.com

Physio-Motion – Beratung und Dienstleistungen rund um Sport, Bewegung und Gesundheit

www.physio-motion.de

www.facebook.de/physi0motion

www.youtube.de/physi0motion

@isi69schneider

 

Literatur

  1. Stanley J. Colcombe et al; Cardiovascular Fitness, Cortical Plasticity, and Aging Proceedings of the National Academy of Sciences of the United States of America. Vol. 101, No. 9 (Mar. 2, 2004), pp. 3316-3321.
  1. Liu-Ambrose T. et al; Resistance training and executive functions: a 12-month randomized controlled trial, Arch Intern Med. 2010 Jan 25;170(2): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448565/  (siehe auch http://bjsm.bmj.com/content/43/1/25).
  1. Behrman S, Ebmeier KP.; Can exercise prevent cognitive decline? Practitioner. 2014 Jan;258(1767):17-21, 2-3.
  1. Sofi et al; Physical activity and risk of cognitive decline: a meta-analysis of prospective studies, Journal of Internal Medicine, Volume 269, Issue 1, pages 107–117, January 2011

 

 

 

#ItTakesAVillage Thanks to entire BJSM community for efforts to improve patient outcomes & health

14 Jun, 16 | by Karim Khan

Impact factor day makes me think of the phrase in David Bowie’s ‘Heroes’‘just for one day’. There is a lot of attention on one metric ‘just for one day’. But the BJSM community works to improve the health of patients for 365 days most years, 366 days in Olympic years. Today is a good day to acknowledge the heroes in the BJSM community. It’s a big community. Hence the also appropriate #ItTakesAVillage

TaksAVillage

Every clinician wakes up motivated to help. To listen, to do his or her best to alleviate pain and improve function and ultimately quality of life in the hundreds of thousands who attend clinics of various forms the world over. Every ‘off-field’ member of sports teams gives unselfishly so players can maximise their potential and play safely. Folks with academic posts teach with enthusiasm, advocate fearlessly and embrace knowledge exchange with those at the front lines.

Teamwork is critical for the BJSM to add value. At BMA House Claire Langford is tireless and available 24/7. Malcolm Smith, James Smallbone, Christine Janssen, Leticia Amorin, Rosemary Hall and Rebecca Vickerstaff ensure quality in every element of our product. Janet O’Flaherty has steered BJSM since it became part of the BMJ group in 1995. Claire Bower was, and remains, without equal. Success does not come overnight and we thank Duncan Jarvies and Harriet Vickers for vision. We have had support to the very top of BMJ group – thank you Peter Ashman, Allison Lang and Dr. Fiona Godlee.

Because BJSM comes in various fomats we cannot live without James Walsh (podcasts), Callista Haggis (blogs), Steffan Griffin (Facebook), Marcos Agostinho / Nash Anderson / James Sherlock / Zach Spargo (Google +), all those in our Twittersphere, and Ania Tarazi (who created the award-winning mobile App). In each category, heroes, such as Markus Laupheimer Nicol van Dyk and Liam West have supported those leaders in the various media channels. Our newest addition, @YLMSportScience, joins @DocAndrewMurray to lead the infographic department. Vicky Earle is world leader for medical art and BJSM covers.

NorwayCover

BJSM’s heroes are leaders and members of 23 clinical societies that guide us for international relevance. We have created podcasts in 5 languages. Our special partner, the International Olympic Committee supports 4 BJSM issues annually – chockablock full of key Consensus Statements, linkages to sport federations and driving the sports injury prevention agenda. The IOC’s 9 international research centres form an R&D hub that communicates with the world via BJSM and other journals as appropriate.

Along with Professor Ugur Erdener and Dr Richard Budgett, Professor Lars Engebretsen (Editor for IOC supported issues) deserves particular recognition. He is a true supporter of non-operative sports medicine and sports physiotherapy when (often!) these forms of care are appropriate. Thank you to Cherine and Denise for taking particularly good care of all BJSM staff. We thank Sports Federations (IFs) specifically; among them FIFA, FINA, FIS, and World Rowing have been prominent partners. BASEM has been a staunch and engaged supporter and we look forward to extending our work with Chairman Dr Mike Stone.

Every submission, podcast presentation, YouTube contribution, @mention, Facebook like, Google+ comment, cover image posted in a presentation, and ‘hello’ at a conference has contributed to making BJSM more valuable for our constituency.

There are sports medicine and sports physiotherapy conference organisers the world over who have heroically ensured great value for participants. We laud those heroes, thank you for our previous collaborations, and look forward to working with you as a media channel.  Our network aims to work hand in hand with yours to add value for participants. Particular thanks for all the work involved in the International Concussion in Sport Consensus Meetings 2012 and 2016 – Professors Paul McCrory, Winne Meeuwisse, Jiri Dvorak.

This short list of just some of the BJSM community underscores the wealth of talent that comes together to improve patient outcomes via improved clinical care, health promotion and injury prevention. In a complicated world, a feature of the BJSM community is the level of cohesion – working together for the common goal (patient outcomes) where possible.

A group I have already flagged in recent tweets has been the Editorial Board and our manuscript reviewers. Among those who filtered >1300 papers a year to provide just the best 200 to our busy readers, we thank Associate Editors and Senior Associate Editors. Prof Jill Cook provided 7.5 years of key service to foster the physiotherapy community’s input to BJSM. Given the importance of Systematic Reviews, we point out Dr. Clare Ardern – Systematic Review Editor.

Although titled ‘Deputy Editors’, Dr Babette Pluim (Sports & Exercise Medicine) and Professor Kay Crossley (Sports Physiotherapy) have been working as Editors to put out 24 issues of BJSM annually. The BMJ is pleased to announce both being promoted to ‘Editors’ to reflect their commitment and acumen. #Heroes. herosBetter

Our large team is essential as our constituency numbers 7.125 billion. No apologies for a 150-member editorial board! We need more help – volunteer! (info.bjsm@bmj.com) We need you today and every day. Not ‘just for one day’!

May I use this opportunity to say ‘thank you’ for the privilege of serving with you all.

Karim Khan.

 

 

#WeActiveChallenge: the WeCommunities launch fun, interactive social media campaign to promote activity

13 Jun, 16 | by BJSM

By Naomi McVey @NaomiMcVey

The case for increasing physical activity among the global population is compelling, but achieving this is far more complex. Despite comprehensive guidance from national and international organisations[1][2][3][4], and increasing emphasis on supporting the health of the NHS workforce[5][6][7], the reality of knowing how and where to start, and fitting exercise into busy lives, can be challenging for many people.

livestrong stairsExamples of high profile physical activity campaigns are those that inspire realistic, achievable change. Last year, influenced by our own experiences of juggling work and family life the @WeAHPs team developed a grassroots social media campaign focused on motivating ourselves, colleagues and families to get up and active.

#AHPsActive

The #AHPsActive campaign launched on twitter in July 2015. People taking part were asked to tweet a picture of them ‘getting active’. Inspired by Sport England’s This Girl Can campaign this was about being fun, realistic and achievable. We simply challenged our colleagues to be healthy role models and do a little more than they did before.

Support for the campaign took us by surprise and a blog from Exercise Works kick-started an online competition pitching allied health professionals head-to-head with nurses in the last two weeks in August. We wanted the #AHPsActive #NursesActive competition to:

  • raise the profile of the importance of peer support and role modelling in physical activity
  • help us practice what we teach as health care professionals
  • motivate, inspire and create a sense of community.rope pull

Activity and reach

raftingWe used twitter analytics to encourage the AHPs v nurses aspect of the competition and also promoted an award for the best photo, with the final decision made by FabNHSStuff.

Between July and September more than 800 people used the #AHPsActive hashtag in over 2500 tweets. In the 2-week competition alone over 1000 people got involved, with a twitter reach of over 7 million people. This included hundreds of photos of healthcare professionals, their teams, friends and families taking part in a huge range of activities around the world. Ice hockey in Finland, mountain climbing, cycling, skateboarding, wall-scaling, skydiving, mud running and much more: the campaign resulted in a vibrant online library of images showing nurses and allied health professionals taking part in physical activity. Smiling, sweaty and having fun.

How much did this cost? Nothing – just the time and enthusiasm of the people organising the campaign and taking part.

The 2016 campaign

This year we are planning to get bigger and better. This summer the campaign will expand across all the WeCommunities.  As a group of nurses, midwives, health visitors, AHPs, doctors, pharmacists, paramedics, finance professionals and commissioners with over 100,000 combined followers we feel well placed to influence the healthcare workforce as peers and colleagues.

Our aims build on those of last year. We know that awareness of physical activity guidelines can be lacking in healthcare professionals and students[8] as well as the general population[9] so we’re planning to promote recommendations as part of the campaign as well as resources to help achieve these. Taking place on twitter, we are asking people to share new and more photos. We’ll be using twitter analytics to encourage competition between the different communities, and with support from Public Health England we’ve teamed up with Virtual Runner UK to provide 500 WeCommunities medals as well. We’ll also develop ways to measure the impact of the campaign.

So, join us and #GetActive this summer and help us role model a healthy lifestyle with the #WeActiveChallenge.

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Naomi McVey is a physiotherapist, community lead for the @WeAHPs and @Physiotalk twitter communities, and a fledgling runner.

The WeCommunities are an alliance of over 15 tweetchat communities including nurses, health visitors, midwives, doctors, AHPs and pharmacists. The communities are run by healthcare professionals, as volunteers, who believe passionately that through connecting people and sharing information, ideas and expertise we can improve health and healthcare. 

References

[1] NICE pathway on physical activity

[2] Department of Health UK Physical Activity guidelines 

[3] Murray etc al (2016) Scotland’s progress in putting policy about physical activity into practice. Br J Sports Med 2016;50:320-321  at http://bjsm.bmj.com/content/early/2016/01/18/bjsports-2015-095744

[4] Global recommendations on physical activity for health

[5] Physical activity in the workplace, NICE guideline PH13

[6] Simon Stevens announces major drive to improve health in NHS workplace

[7] White D, 2015. Promoting physical activity within Scottish hospital settings. Br J Sports Med 2015;49:1415-1416  at http://bjsm.bmj.com/content/49/21/1415.3.abstract?sid=984e0c91-c925-4cc5-906d-71aa084aa5bc

[8] Dunlop M and Murray A, 2012. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum, Br J Sports Med 2013;47:718-720 at http://bjsm.bmj.com/content/early/2013/01/10/bjsports-2012-091891

[9] Knox E at al., 2013. Lack of knowledge of physical activity guidelines: can physical activity promotion campaigns do better? BMJ Open 2013;3 at http://bmjopen.bmj.com/content/3/12/e003633.full

Team doctors have authority over managers to make medical decisions #PlayerSafety1st

10 Jun, 16 | by BJSM

ApologyWe’ve all caught wind of the recent media flurry after last Tuesday’s unreserved apology (and settlement) by Chelsea FC to former sports physician, Dr. Eva Carneiro (@EvaCarneiro). The team’s management were explicit that Dr Carneiro had acted completely appropriate when she ran on to the pitch to treat Eden Hazard in last August’s opening day match of the Premier League season (read more here).

This incident raises two critical issues: (i) Gender discrimination in sport; Dr Carneiro, also reached a discrimination settlement against the club’s former manager Mr Jose Mourinho, and (ii) A team doctor’s authority to make medical decisions, not the manager.

To applaud and celebrate all SEM practitioners who have a commitment to player welfare, we made football physiotherapist Lisa O’Neil’s editorial FREE (for one month only). Please read and share via this free link to spread good practice:

“No way Jose!” Clinicians must have authority over patient care: the manager’s scope of practice does not cover medical decisions  Please read and share via this free link

Please use the hashtag: #PlayerSafety1st

PS: Want even more more insight and expertise on best practice for team physicians? Check out @PeterBrukner’s BJSM editorial: Surviving 30 years on the road as a team physician. Here’s the free link.

PPS: And one more? Managing the health of the elite athlete: a new integrated performance health management and coaching model by Sports Physicians @PaulDijkstra and @DrNoelPollock, Dr Rob Chakraverty, @DrJuan MAlonso.

 

Apology2Rom

International Rugby Sevens Returns to Singapore: The Medical Team’s Perspective!

9 Jun, 16 | by BJSM

By Dr Dinesh Sirisena (@sports_med_doc) and Dr Joanne Probert (@probertjo)

Dinesh was both Field of Play Lead and Match Day Doctor, and Joanne was Medical Director at the 2016 Rugby Sevens.  They share their experience of being part of the medical team, when preparing for and delivering care and end with 5 take home points for anyone planning to do at a major sporting event in the future.

It was April 2016 and with the year well underway, one of the most highly anticipated events on the Singapore calendar rolled into town; the long awaited HSBC Rugby Sevens was back after a 10-year hiatus and there was an air of expectation.  Having just completed the Hong Kong stage, the 16 international teams arrived with plenty of support and Fiji were hot favourites having won the earlier event.  At the heart of the tournament is the anticipation that one team will be crowned victorious after two-days of high intensity, fast paced and zinging rugby, and thus began the Singapore stage.

rugby winners

Preparation is Key When Delivering Medical Care

Compared to its fifteens counterpart, the rapid turnover of matches (over 50 in total), high impact and non-stop activity for just under 15 minutes, presents unique challenges for medical teams supporting such events.  Even with past experience from tournaments such as Singapore Cricket Club and Schools Sevens, the local and international media interest created from the return to Singapore meant the medical room, pitch-side team (doctor, physiotherapist and ambulance crew) and head injury spotters needed to be on our toes.

A key element in developing the medical team was the regular cohort of clinicians chosen from Singapore Rugby. Also, limiting numbers meant that we better understood each other’s patterns of working and were very familiar with various protocols.  Our continual increase in pitch-side efficiency reflected this approach.

Equally, with World Rugby leading the way in concussion management internationally, the medical team was well versed in Head Injury Assessment (HIA) protocols: what to look out for during games and when to request assessments.  The CSx Headguard app (http://csx.co.nz/hub/), with its electronic record of the HIA and previous data for comparison, made the assessments more efficient.

Match Day Arrives

The weekend finally arrived coupled with plenty of Twitter and Facebook updates.  The number and frequency of matches kept us busy and made for two long days. Fatigue particularly set in on the second day when there were higher-stake matches. Teamwork and daily essentials such as readying equipment, performing run-throughs and ensuring there was a regular supply of coffee, were key components to a successful weekend for the medical team.

One of the significant differences compared to domestic matches was the constant media presence.  For the tournament organisers, entry of teams onto the field of play and half-time footage were important times for filming and it was essential that players were the focus.  Equally, with free-flowing social media in the stands, it was essential that we maintained our professionalism and integrity.  Often, there would be calls from the spectators to take photographs or retrieve something from the field of play, but fortunately this did not faze the team.

Removals from play due to concussion risked excluding a player from the remainder of the tournament, so ensuring we made a correct diagnosis was essential.  To ease the decision-making responsibility extra steps were taken; in addition to the pitch-side HIA/Match Day Doctor, a HIA spotter was made available to provide feedback and replay footage from the stands.  It meant that HIA assessments become a shared decision after careful analysis.

The heightened awareness of on-field events brought with it another challenge to maintain focus!  With the high turn-around of matches, there was little time to “switch off” and enjoy the event.  Often, even when away from pitch-side or the spotter location, we found ourselves analysing games from the medical room, assessing movements and looking out for potential injuries. This relentless monitoring of events was draining, even if we witnessed no injuries.  To ease this pressure and keep refreshed, we constantly cycled roles.

Despite the challenges of working in this environment, the event was a fantastic experience. It was humbling to work amongst a close-knit group of colleagues, who maintained team spirit and supported each another fully.  In situations where we were called upon to help athletes on field, the team worked seamlessly and feedback on social media and organisers was overwhelmingly positive.

As a side benefit, being part of the medical team also meant that you had the best seats in the stadium when your favourite team came on!

What Next?

The HSBC Rugby Sevens will be returning to Singapore next year and will hopefully become a permanent fixture on the sporting calendar.  While the medical team reflects on the event and plans for 2017, the significant interest generated following Kenya’s surprise win will no doubt fuel the excitement further.  It seems Singapore may be the event where teams and organisers do not know what to expect, other than excellent medical care!

Take Home Messages

  1. Develop a strong rapport with organisers to identify their expectations.
  2. Identify key roles, select the medical team early and provide opportunities to work together prior to the main event.
  3. Ensure emergency protocols are in place and have been taken through rigorous practices.
  4. Maintain professional integrity when working under the spotlight of social and mainstream media.
  5. Make sure the team feels valued with treats, coffee and a celebratory drink at the end of the event.

Please do let us know what your experiences of Sevens Rugby or other event medical coverage have been – hopefully we can learn from each other!

Bio:

Dr Dinesh Sirisena is an Associate Consultant in Sports Medicine at Khoo Teck Puat Hospital and was both Field of Lead and Match Day Doctor at the event.

Dr Joanne Probert is a Consultant in Emergency Medicine at Khoo Teck Puat Hospital and was the Medical Director for the event.

Sudden cardiac death in sport: time to simplify the guidelines to base them on mechanism and collapse – not breathing assessment.

7 Jun, 16 | by BJSM

By Dr Jonathan Hanson (@SportsDocSkye)

Another on field cardiac death in sport. Another debate about screening and medical care.

The successful resuscitation of Premier League football player Fabrice Muamba in 2012, in stark contrast to the tragic death of Marc Vivian Foe 9 years earlier, broadcast the role of basic life support and early defibrillation is to all with an interest in sport.

Media scrutiny of the recent on field death of Patrick Ekeng in Bucharest focused on the medical care provided during the incident. Professionals and the public expect high standards.

The majority of first responders in sport are either physiotherapists or from a primary care background – a population without frequent exposure to critically unwell patients. Although an accepted standard of training in sports pre-hospital care exists through a number of worldwide courses (including under the auspices of FIFA and UEFA), the ability to act appropriately still requires situation awareness, pattern recognition and appropraite decision making and excellent technical skills in a time of crisis.

Are we overcomplicating the challenge in the sport setting? 

By adhering to guidelines designed to treat a person on the street or in hospitals do we make it harder for those who assume the responsibility of first responder in sport?

Drills, checks, and sound clinical governance will help minimise the practical skill loss (often quoted at 90% skill loss at 1 year). But how can we assist in making the decision making easier?

As an emergency medicine doctor and sports physician I have seen quite a lot of cardiac arrests. I cannot recall any of the cases I have seen in hospital looking like the patient in the Mark Vivian Foe video, Fabrice Muamba, or this week’s Patrick Ekeng case.

The wide staring eyes, the very rapid but inefficient respiratory effort from arresting in a state of hyper adrenergic exercise and lactate debt, and the small degrees of twitching or movement do not make up what I typically see in my cardiac arrest experience in hospitals in the unwell, elderly or in patients who have arrested a few minutes before I arrive. My cardiac arrest experience does not cover folks like Patrick Ekeng either.

 

Current basic life support guidelines rely upon either a 10 second assessment for “normal” breathing (European guidelines) or simple “scan for breathing” (American Heart Association guidelines) as the decision making step to commence basic life support. We are advised not to confuse normal breathing with “agonal breathing” which is defined as slow, irregular and inefficient breaths of a dying patient. This description does match not the rapid regular agonal breathing initially witnessed in Muamba, Foe or Ekeng.

Is it any wonder that inexperienced but trained pitch side medical staff find it difficult to recognise the unusual rapid variant of agonal breathing of cardiac arrest in athletes? Our niche patient group and speed of response point toward the need for customised guidelines. It’s easy to mistake agonal breathing for normal breathing if it looks slightly atypical and you’ve never seen it before with the additional pressures of the stadium environment TV coverage.

Our aim should be to make it easier for the responder to recognise the diagnosis and commence CPR/AED. Thus increasing the chance of survival from 6% (no CPR) to 35% (CPR plus AED). A survival rate of 35% still sounds poor – but it is a six times increase as compared to the survival rate with no CPR/ AED.

 

Resuscitation guidelines do evolve. Concerns over disrupting a pelvic haematoma through “springing the pelvis” on examination in the primary survey of trauma patients led to a revision of the approach to pelvic fracture diagnosis. Now the decision is based on mechanism rather than the examination. If the mechanism is suspicious, the pelvis is treated as fractured and a binder applied without any springing until imaging suggests otherwise.
In spinal immobilisation in sport, although guidelines support minimal handling and the use of split devices to minimise logrolling, we often deal with much larger and wider body shapes than the general public body shape. More often than not we face a moving and handling safety issue in addition to concerns about spinal injury. Only a tiny minority of spinally packaged athletes need to go onto hospital and they are generally not multiply injured. The majority are removed from the device at the medical room and so don’t need to worry about pressure areas etc. Hence we work around the guidelines to fit our situation, sometimes using out of vogue long spine boards to accommodate the additional size and moving and handling challenge, rather than carrying directly on split devices designed for “normal” heights and widths.

 

Why can’t we adjust the resuscitation guidelines?

The morbidity from inappropriate CPR is very small and the AED will not give a shock to someone who does not need it.

The decision around whether to begin CPR could be made purely on the mechanism of off-the-ball collapse, thus simplifying the first responder’s decision, increasing the likelihood of high quality compressions with minimal interruptions and prompt use of a defibrillator.

It’s time to make the change and move to a mechanism based decision on commencing CPR.

A sudden off-the-ball collapse in sport should always be regarded as a cardiac arrest and receive a response with CPR and AED. We should adjust our training accordingly and educate on agonal breathing in the post exercise state.

This is in keeping with FIFA’s 11 steps to prevent cardiac death – but this needs to be adopted more widely.

“Performance of the emergency medical plan

  • Immediate recognition of collapsed player
    1. Assume SCA if collapsed and unresponsive
    2. Seizure activity and/or agonal respirations—SCA”

This would benefit of the rescuer and thus benefit the athlete.

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Dr Jonathan Hanson is a Sport and Emergency physician for the Sportscotland institute of sport and World Rugby Immediate care training management group.

Tackle injury mechanisms in sport: How different is past, present and future research?

4 Jun, 16 | by BJSM

By Sharief Hendricks

My colleagues and I are currently working on a couple of reviews in rugby, and like most reviews, we went back as far as 1980. As we illustrated last year, the majority of rugby research has been published in the last ten years and a relatively small proportion has been produced before the year 2000.

rugby lions-1971

As I scroll titles of articles before the year 2000 to review, I notice how the purpose of studies hasn’t changed much over the last 15 years. For example, in 1999 Garraway et al. published an article titled Factors influencing tackle injuries in rugby union football. Recently, we published a paper titled Tackle technique and tackle-related injuries in high-level South African Rugby Union under-18 players: real-match video analysis. Although the aims of the studies seem similar, after a peruse of both articles, the difference between the two studies soon become evident. Let’s call this difference…progress?

I think Garraway et al.’s paper in combination with other around the same time were essential for the subsequent work on analysing tackle injuries in rugby union. The same can probably be said for the New Zealand’s RugbySmart outputs in the 90s, and the more recent South African BokSmart outputs.

The point of all of this is, what will the next 15 years bring? Knowing the progress we’ve made over the last 15 years, will we still be looking into tackle injury mechanisms 15 years from now? Probably yes. But I think with the advancement of technologies and more exposure to other fields, the way we approach the problem and frame the question will be different.

How has your research focus changed over the last 15 years? And how will it look 15 years from now?

References

Garraway, W. M., Lee, A. J., Macleod, D. A., Telfer, J. W., Deary, I. J., & Murray, G. D. (1999). Factors influencing tackle injuries in rugby union football. British Journal of Sports Medicine, 33(1), 37-41.

Burger, N., Lambert, M. I., Viljoen, W., Brown, J. C., Readhead, C., & Hendricks, S. (2016). Tackle technique and tackle-related injuries in high-level South African Rugby Union under-18 players: real-match video analysis. British journal of sports medicine, bjsports-2015.

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Sharief Hendricks Twitter @Sharief_H is a Research Fellow, LeedsBeckett University and University of Cape Town, rugbyscientists.com

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