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Premier league injury watch – same old story?

18 Aug, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine  a BJSM blog series

By Jonathan Shurlock (@J_Shurlock)

A new football season is upon us, with the premier league back in action alongside the lower divisions which recently kicked off. Already much of the focus is on who is going to be contending for the premier league title this year, with pundits everywhere adding their two cents. Sporting commentary is filled with often repeated; supposedly insightful phrases. One such adage, which remains true is that to win the league you need to win games. One of the most important undertakings in this process is keeping players healthy, as was nicely explored by Michael Davison recently.[1] In this vein, and inspired by the injury tracking work at the PhysioRoom website, we thought it pertinent to carry out a semi-regular review of premier league injuries. We will aim to give a brief overview of recent injury profiles, and which teams are struggling with injury burden, followed by a more in-depth look at specific injury types.

A review of the weekend’s premier league action indicates seven new injuries picked up by players from five different teams. Before reading ahead, we challenge you to have a go at predicting which injury type was most prevalent amongst these seven. Are you at all surprised that the most frequent injury type seen in the opening weekend is of the hamstring muscles? Simon Francis of Bournemouth, Isaiah Brown of Brighton & Hove Albion, and Paul Dummet of Newcastle all picked up new hamstring injuries; the most common single injury seen in football (More on this topic in this past blog).[2] It certainly seems to be a relevant time to discuss hamstring injury, off the back of watching Usain Bolt bow out from his track career with a potential hamstring injury.

Despite increasing knowledge of the mechanism of hamstring injury, and ongoing research outputs on diagnosis, management and re-injury, the burden of hamstring injury has actually increased in recent years.[3] Perhaps this is due to increased work load, or perhaps due to clubs not utilising evidence based prevention programmes.[4] One thing appears clear, we’re still not getting it right.

The BJSM team have covered hamstring injury in almost every multi-media format, including one of their most popular podcasts with Gustaaf Reurink (http://bit.ly/1zsDDDS). It’s certainly worth checking out the various outputs from Gus’ PhD as they give some great insight into topical areas of hamstring injury including Platelet-rich-plasma use and role of MRI.

Struggling to remember useful hamstring exercises? Have a watch of the following videos for a refresher:

https://www.youtube.com/watch?v=TO47AQuYphE

https://www.youtube.com/watch?v=McvuPAInukY&feature=youtu.be

There’s plenty more BJSM hamstring to get into get stuck into via blog posts, podcasts and editorials (just click on the “Hamstring” tag to the right). We’ll revisit in a few weeks and keep an eye on which teams are struggling with injuries, and whether hamstring remains the most common injury type. Additionally we will develop a more in-depth look at the diagnosis, management and return-to-play decisions for some of these injuries.

References

  1. Davison M. Extra workload will disrupt rhythm of the champions. The Telegraph. 2017;
  2. Askling C. Types of hamstring injuries in sports. Br J Sports Med. 2011 Feb 1;45(2):e2–e2.
  3. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med. 2016 Jun;50(12):731–7.
  4. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. Br J Sports Med. 2015 Nov;49(22):1466–71.

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Jonathan Shurlock is an academic foundation year 2 doctor based in Sheffield. He coordinates the BJSM Undergraduate Perspective blog series. If you would like to contribute to the blog series please email jhshurlock@gmail.com.

One small step for a human, and a giant leap for humankind

16 Aug, 17 | by atarazia

Introducing the Physical Activity and Population Health BJSM Blog Series 

By Sonia Cheng (@soniawmcheng)

As you’ve likely read from these previous posts on the BJSM blog, the case to increase population-wide participation in physical activity is stronger than ever. And, like the unsung space heroes at NASA, who crunched the numbers and successfully launched humans into orbit and to the moon1, we as health professionals, researchers, and students play a pivotal role in developing and implementing strategies to address one of the leading risk factors for chronic disease and disability worldwide.

It is an honour to launch the new ‘Physical Activity and Population Health’  BJSM Blog Series. Throughout this series, we’ll bring to you the latest developments in physical activity research, resources, and policy in the area of public health – a small step to raise awareness, discussion, and action amongst researchers and clinicians to address a major health priority.

Some vital stats

The statistics related to physical inactivity are not new to us, but still shocking. Physical inactivity is a key risk factor for non-communicable disease (NCDs) – including cardiovascular disease, type 2 diabetes, cancers, respiratory disease, dementia, and poor mental health. This places it as the fourth leading cause of global mortality, contributing to over five million preventable deaths each year2.

However, physical inactivity is also one of the key modifiable risk factors for NCDs, and the health benefits of regular physical activityare evident across the lifespan (click here for current PA recommendations). Maintaining regular physical activity levels helps to (1) promote growth and development in children and young adults, (2) prevent weight gain in mid-life, and (3) maintain independence and quality of life in older adults and in those living with chronic disease3.

Yet, despite high-quality evidence to implement effective strategies, global efforts to reduce physical inactivity have not been sufficient. It is estimated that one in three adults and more than 80% of adolescents do not meet current physical activity recommendations4.

The call to action

Increasing physical activity at a population level requires a whole-of-community approach. We need to effectively implement our knowledge through policy and practice changes in healthcare delivery, education, environment, infrastructure and media. We need to support individuals and communities to be physically active every day in ways that are enjoyable, accessible, and safe in this highly urbanised and digitalised world of ours. We need to advocate for the development, financing and implementation of evidence-informed national plans so that all countries can achieve the World Health Organisation global target to reduce physical inactivity in children and adults by 10% by 20255.These key messages have been distilled into a seven-point plan developed by the International Society for Physical Activity and Health (ISPAH) in 2012, ‘Best Investments for Physical Activity – What Works’6 and the infographic is published here7.

The Physical Activity and Population Health’ BJSM Blog series supplements the brand new BJSM Editorial articles Bright Spots, Physical Activity Investments that Work Jointly8 that feature exciting and novel physical activity programmes from around the globe. Expect both series to keep you updated on research, policy, education, and practice developments in increasing population levels of physical activity.

We invite you to share and support the Physical Activity and Population Health BJSM Blog Series. Join the conversation on ‘how change happens’ at #PAblogBJSM and #brightspotsBJSM.

If you have ideas for this series please contact: emmanuel.stamatakis@sydney.edu.au

Sonia Cheng graduated from The University of Sydney with a Bachelor of Applied Sciences (Physiotherapy) (Honours Class I) in 2014. Sonia is currently employed as a physiotherapist with Royal Prince Alfred Hospital and Westmead Hospital in Sydney. 

References

  1. The True Story of ‘Hidden Figures’ and the Women Who Crunched the Numbers for Nasa
  2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; 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):219-29. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61031-9/abstract.
  3. World Health Organisation. Interventions on Diet and Physical Activity What Works? Summary Report Geneva, Switzerland: World Health Organization; 2009.
  4. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. The Lancet 2012;380(9838):247-57.
  5. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Geneva, Switzerland: World Health Organization; 2013. http://www.who.int/nmh/publications/ncd-action-plan/en/
  6. Investments that Work for Physical Activity. Br J Sports Med. 2012;46:709-712. http://bjsm.bmj.com/content/46/10/709.full.
  7. Best Investments for Physical Activity – What Works
  8. Stamatakis E, Murray A Launch of new series: Bright Spots, Physical Activity Investments that Work Br J Sports Med Published Online First: 29 June 2017. doi: 10.1136/bjsports-2017-098096

 

Mental health of elite young athletes: spot and support them before it’s too late

14 Aug, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog series

By Johnson Pok-Him Tam (@tamph4) and Manroy Sahni (@manroysahni)

Image credit: http://www.rightbluelabs.com/blog/mental-health/who-is-the-most-vulnerable-group-to-mental-illness/

Elite sport is results driven. Each generation of new athletes is pushing themselves to new limits, to reach new heights and eclipse records set by their predecessors. But what impact can this constant cauldron of pressure and expectation have on the mental health of a young athlete? Are young athletes speaking out when they need help? And what help is available?

Elite young athletes have daily gruelling training regimes to help reach the potential suggested by their outstanding natural talent. To achieve these goals, they are usually guided by an expert coach, medical team and close family and friends[i]. This network is intended to be a support system in both a sporting and an emotional sense. However, at times it can contribute to a high level of expectation placed on the shoulders of young sports stars.

Determining the burden of mental health issues in sport can be difficult. Especially considering the (1) stigma associated with speaking out given the sporting culture in which professional athletes are enmeshed (read past blog in link for more), as well as (2) the research suggesting a positive association of physical activity on the prevention and treatment of mental health issues.[ii]An American study found 21.4% of elite athletes, compared to 29.2% of the general public of the same age (18-25 years old) reported clinical symptoms of depression[iii]. This is in stark contrast to other reports indicating similar or higher levels of mental health issues in young elite athletes when compared to the general population[iv]. To help shed light on the important issue of young athletes and mental health, this blog identifies:

  • common risk factors for young athletes developing mental health issues,
  • coping strategies, and;
  • potential barriers when seeking professional help.

Common risk factors

Common risk factors for developing mental health problems can be categorised into intrinsic and extrinsic factors. Some elite young athletes have an exclusively athletic identity of self-worth, which is often dependent on their performance. If they perform below expectation, their perception of self-worth and esteem can decrease and lead to potential mental health issues[v]. It is common for an elite young athlete to develop a perfectionist personality due to the constant pursuit of superior performance both at training and competition, which often leads to extra anxiety, stress, depression and fatigue[vi],[vii]. These “optimum” levels of physical activity can improve mental health, however, at an elite level can also compromise mental health due to overtraining, injuries and excessive pressure on the athlete[viii].

Parents and coaches have a fundamental impact on a young athlete’s well-being[ix]. Dunn et al.[x] concludes that parental pressure increased negative stress and decreased motivation for their child athlete. Almost one-third of parents reported to give negative verbal comments to their young athletes, thus increasing the possibility of psychological stress and burnout[xi],[xii]. Alexander et al.[xiii] found that more than one third of young elite athletes reported emotional harm due to their coaches, from actions such as shouting, negative comments about their performance and attempts to intimidate.

Coping strategies

Methods do exist to potentially reduce mental health problems in elite young athletes. For example, athletes should develop a coping mechanism for stress with their coaches and parents. This can include (1) thought control, (2) relaxation, (3) mental development and (4) help seeking— all of which positively improve objective and subjective achievement, whilst decreasing the risk of mental health injury[xiv],[xv]. Parents and coaches are encouraged to comment on the athlete’s attitude and effort, rather than performance[xvi].

Barriers to seeking help

Negative attitude and stigma are two of the biggest barriers faced by young athletes when looking for help. Young people in general are reluctant to admit their mental health issues and studies have shown young athletes have a bigger reluctance than non-athletes when seeking help[xvii],[xviii]. In a survey[xix] of top college athletes, the most common reason for not seeking help was to avoid any ‘personal discomfort’ and others felt there was ‘no need’ for professional help.

In conclusion, mental health issues in elite young athletes are common. Maintaining an athlete’s “super human” identity as well as pressure from parents and coaches are all contributing factors. Steps for the future are to ensure that all young athletes have personalised coping mechanisms to deal with stress and feel confident and comfortable to ask for help.

References

[i] Caine DJ. Are kids having a rough time of it in sports? Br J Sports Med. 2010;44:1-3.

[ii] Rosenbaum S, Tiedemann A, Sherrington C. Physical Activity Interventions for People with Mental Illness: A Systematic Review and Meta-Analysis. Journal of Clinical Psychiatry. 2014;75(9): 964-974

[iii] Biddle SJ, Asare M. Physical activity and mental health in children and adolescents: a review of reviews. Br J Sports Med. 2011

[iv] Junge A, Feddermann-Demont N Prevalence of depression and anxiety in top-level male and female football players BMJ Open Sport & Exercise Medicine 2016;2:e000087.

[v] Maffulli N, Longo UG, Gougoulias N, Loppini M, Denaro V. Long-term health outcomes of youth sports injuries. Br J Sports Med. 2010;44(1):21–25.

[vi] Appleton PR, Hill AP. Perfectionism and athlete burnout in junior elite athletes: the mediating role of motivation regulations. J Clin Sport Psychol. 2012;6(2):129–145.

[vii] Putukian M. The psychological response to injury in student athletes: a narrative review with a focus on mental health. Br J Sports Med. 2016 Feb 1;50(3):145-8.

[viii] Hamer M, Stamatakis E, Steptoe A. Dose-response relationship between physical activity and mental health: the Scottish health survey. Br J Sports Med. 2009:43(14):1111–1114.

[ix] Mountjoy M, Rhind DJ, Tilvas A, Leglise M. Safeguarding the child athlete in sport: a review, a framework and recommendations for the IOC youth athlete development model. Br J Sports Med. 2015;49(13):883–886.

[x] Dunn JGH, Dunn JC, Gotwals JK, et al. Establishing construct validity evidence for the Sport Multidimensional Perfectionism Scale. Psychol Sport Exerc. 2006;7:57–59.

[xi] Shields DL, Bredemeir BL, LaVoi NM, Power FC. The sport behaviour of youth, parents, and coaches: the good, the bad, and the ugly. J Res Character Educ. 2007;3(1):43–59.

[xii] Gould D, Lauer L, Rolo C, Jannes C, Pennisi N. Understanding the role parents play in tennis success: a national survey of junior tennis coaches. Br J Sports Med. 2006;40(7):632–636.

[xiii] Alexander K, Stafford A, Lewis R. The experiences of children participating in organized sport in the UK, Edinburgh: University of Edinburgh/NSPCC. 2011.

[xiv] Nicolas M, Gaudreau P, Franche V. Perception of coaching behaviors, coping, and achievement in a sport competition. J Sport Exerc Psychol. 2011;33(3):460–468.

[xv] Emery CA, Roy TO, Whittaker JL, Nettel-Aquirre A, van Mechelen W. Neuromuscular training injury prevention strategies in youth sport: a systematic review and meta-analysis. Br J Sports Med. 2015;49:865–870

[xvi] Carter CW, Micheli LJ. Training the child athlete: physical fitness, health and injury. Br J Sports Med.. 2011 Sep 1;45(11):880-5.

[xvii] Schwenk TL. The stigmatisation and denial of mental illness in athletes. Br J Sports Med. 2000 Feb 1;34(1):4-5.

[xviii] Ekeland E, Heian F, Hagen KB. Can exercise improve self-esteem in children and young people? A systematic review of randomised controlled trials. Br J Sports Med. 2005 Nov 1;39(11):792-8.

[xix] Watson J: Student-athletes and counseling: factors influencing the decision to seek counseling services. Coll Stud J 2006, 40(1):35–42.

Johnson Pok-Him Tam (@tamph4) is a Foundation Year 1 Doctor in the West Midlands with an interest in Orthopaedics Surgery and SEM. He was previously the President for University of Bristol Sports & Exercise Medicine society and has written articles for the student BMJ.

Manroy Sahni (@manroysahni) is an Academic Foundation Year 1 Doctor in the West Midlands with a passion for SEM. He also co-coordinates the BJSM Undergraduate Perspective blog series. Please send your blog feedback and ideas to: manroysahni@gmail.com

 

Hamstring virtual conference 2.1 Encore edition from 2015…

12 Aug, 17 | by Karim Khan

Because the first few podcast clusters went down a treat – this time we’re back with even more BJSM resources focusing on the hammy, featuring the same podcasts alongside papers from the likes of Reurink, Orchard and Whiteley. So without further ado – here is your one-stop shop for everything hamstring-related, enjoy!

  1. Hamstring Injuries with Carl Askling: http://bit.ly/1bcDzBi

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

Biceps femoris and semitendinosus—teammates or competitors? This study assessed how the different hamstring muscle bellies work together in synergistic coordination patterns and whether changes in neuromuscular coordination patterns are associated with hamstring injuries.

  1. Hamstring Injuries – the American perspective: http://bit.ly/1bcE7ah

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

  • *New* Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial: http://bit.ly/1MXwRPN

We couldn’t talk about muscle injuries without mentioning the ‘magic bullet.’ Turns out in regard to hamstring injuries, PRP is only indicated if wanting to make a quick buck, with intensive physiotherapy still the gold-standard. #BeautyInTheBasics

  1. Hamstring Injuries in football with Jan Ekstrand: http://bit.ly/1uzu9q7

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

  • *New* MRI does not add value over and above patient history and clinical examination in predicting time to return to sport after acute hamstring injuries: a prospective cohort of 180 male athletes: http://bit.ly/1XoziOq

Does MRI aid in the prediction of return-to-sport, or should we be more reliant (and trusting) in clinical judgement? Wangensteen and colleagues would argue the latter!

  1. Diagnosing and treating acute hamstring injuries: http://bit.ly/1zsDDDS

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

In this brilliant editorial, the authors (you may have heard about them…) ask if it is the right moment to say ‘bye–bye MRI’ to the device as a prognostic tool for predicting RTP after hamstring injuries in the individual athlete. A fantastic overview of the evidence.

  1. Eccentric hamstring exercise – they work in practice but not in theory? http://bit.ly/1H4ubNL

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

Want to learn more?!

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

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

Isaac Makwala and some thoughts on the challenge of Norovirus at major games.

10 Aug, 17 | by Karim Khan

By Dr Juan-Manuel Alonso  @DrJuanMAlonso

So, what initially looked like a food poisoning turned out to be a Gastroenteritis / Norovirus outbreak . The big evil all sport events medical cover organisers tried to avoid at all costs. Really bad luck! For one reason or another, the Botswana team leader and doctor did not inform the athlete of the measures, or Makwala ignored the instructions, or both, and Makwala, in a classical and predictable attitude, came himself to try to run the 400 m final.

This whole Makwala issue & Norovirus outbreak is terribly unfortunate. An outbreak is difficult to avoid. And any medical organiser needs to take urgent and stringent measures when it happens. I was wondering whether isolation/quarantine is needed or evidence-based for Norovirus outbreak. In the context of a Norovirus outbreak: is stopping a runner from running (or a worker from doing his/her job) appropriate?

I can understand the need to minimize /stop the spread of the virus and isolation /quarantine could have been considered in other settings like a school training camp or a ship’s cruise. I value the debate on the balance of protecting the majority versus individual rights of just one. Still I tend to respectfully disagree with the extreme decision to keep Makwala from racing.

An intermediate, compromise position may have been to allow Makwala to run but to ensure he avoided hand shaking or giving hugs to others. He could have worn a mask and had specific and separate call room procedures (bringing athletes to the track from their room under the stands). Right now the internet does not answer the key questions: no systematic reviews, no metanalysis, no RCT with evidence level A to support the IAAF decision as far as I am awere. In my humble opinion (IMHO) isolation /quarantine is based in level C evidence: expert opinion.

Below are more links to scientific literature.

The communication strategy of the IAAF and Local Organisers was criticised for not providing the facts, but that is difficult to do due to confidential nature of the medical data.

http://www.nhs.uk/conditions/Norovirus/Pages/Introduction.aspx …

Norovirus control measures based on general infection control principles treatment mainly supportive & non-specific https://www.ncbi.nlm.nih.gov/pubmed/25726433 

How to prevent the spread of norovirus: Stringent hygiene measures are vital to contain the virus https://www.ncbi.nlm.nih.gov/pubmed/2136600 

https://www.cdc.gov/vitalsigns/norovirus/infographic.html#infographic

 

 

Faculty of Sports and Exercise Medicine Annual Scientific Conference, September 2017 “Exercise Medicine and Physical Activity for Health”

9 Aug, 17 | by BJSM

 

This years Faculty of Sports and Exercise Medicine Annual Scientific Conference promises yet again to be a highlight of the international sports medicine calendar. The conference will focus on “Exercise Medicine and Physical Activity for Health” and takes place on the 15th and 16th of September in the Royal College of Surgeons in Ireland (RCSI), Dublin.

Delegates are welcomed from all healthcare backgrounds to this multidisciplinary conference where the Faculty of Sports and Exercise Medicine teams up with colleagues from the Irish Society of Chartered Physiotherapists (ISCP) and Athletic Rehabilitation Therapy Ireland (ARTI).

The conference which takes place over 2 days will include national and international keynote speakers:

  • Prof Donal O’Shea, Consultant Endocinologist and leading clinican and researcher on obesity will discuss the role of exercise in contemporary medicine and population health.
  • Prof Ulf Ekelund, Professor in Physical Activity Epidemiology from the Norwegian School of Sports Science will discuss if sitting is the new smoking.
  • Prof Paul Thompson, Chief of Cardiology and The Athletes’ Heart Program at Hartford Hospital, professor of medicine at the University of Connecticut (USA) and past president of the American College of Sports Medicine, will debate how we prevent sudden cardiac death in athletes and also if there are deleterious effects of too much exercise.

Experts in the field will lead thematic sessions over the two days. On day 1 themes include exercise in chronic, cardiac and respiratory disease as well as mental health. On day 2, topics include the role of exercise in prehabilitation and rehabilitation as well as innovations in exercise science.

Delegates will also be able to attend a number of dedicated delegate scentific sessions under the following themes:

  • Exercise Medicine
  • Exercise and Population Health
  • Exercise in Rehabilitation and Treatment
  • Sports and Exercise Science

Register online for the conference with discounted rates for full-time post graduate students. The conference is approved by FSEM for 12 external CPD credits.

Log on for further information and registration details: www.fsem2017.com

We look forward to seeing you there!

Dr Nick Mahony (FSEM Vice-Dean), Prof Niall Moyna (FSEM Board Member) and Dr Ronan Kearney (FSEM Associate Member)

Running (more!) randomised controlled trials in sport and exercise medicine – Tips for clinical research

6 Aug, 17 | by BJSM

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

By Dr Robert M Barker-Davies

Have you ever considered running a randomised control trial (RCT)? Or at least perhaps wondered why there aren’t more of them in sports medicine? RCTs along with systematic review and meta-analysis are the gold standard for evidence-based medicine. Just 3% of articles in the BJSM between 1991-1995 were RCTs, increasing to 7% from 1996-2000 compared to over 16% in the BMJ1. More recently across sports medicine literature, that figure has been reported as 6% by systematic review2.

Most readers will be familiar with how quickly autologous blood/platelet rich plasma injections rose to fame. Early on in the process of putting my PhD research proposal together, a PubMed search on this topic found 3 out of 62 papers to be RCTs. As the quality of the research improved, the justification for administering this treatment disappeared.

A challenge in sports medicine research is that most patients have a thirst for a winning new (medical) formula and they rarely want to be in the control group. Yet do we really adhere to the principle primum non nocere if we don’t have evidence for a new treatment? In the UK Military, we have a clear duty of care to our personnel that tips the balance away from the untried and untested.

The case of High Volume Injection

High Volume Image Guided Injection (HVIGI) has promise as an adjuvant therapy3. At Headley Court Rehabilitation Hospital, we appraised the evidence and decided to practice HVIGI within the framework of an RCT before rolling out its use more widely. With the support of the Higher Education Funding Council for England’s catalyst fund in collaboration with Loughborough University, the National Centre for Sport and Exercise Medicine and Defence Medical Services, I am now studying as a full time PhD student to run this project. This has meant taking 3 years out of SEM registrar training.

Running an RCT poses many challenges and requires a committed team. Processes such as blinding, randomisation, unblinding, safety reporting and data monitoring all require additional staff members outside of the traditional multidisciplinary team. Much of this relies on the good-natured professionalism of those involved.

Getting off to the right start is key to avoid later pitfalls and delays re-submitting applications for regulatory and ethical approval. Dr Ben Goldacre’s book, Bad Pharma, brings to life the all too common problems with clinical trials. The cornerstone of his text relates to publication bias and missing data both well illustrated by the case of TGN1412 in 2006. Six participants suffered multiple organ failure; all were possibly avoidable had the results of an unsuccessful trial 10 years earlier been made public4. A key recommendation here is that trials are registered. We have taken the additional step of publishing our High Volume injection protocol in a peer-reviewed journal5.

Once you have your funding, academic, institutional, ethical and regulatory approvals in place, comes the next challenge: recruitment. The excellent resources from the NIHR website highlight the danger of overestimating the ease with which you will recruit the study population6. Much of sports medicine is practiced away from a large institutional setting making this a constant challenge for the specialty. Pooling results in multi-centre trials is one way around this but presents organisational challenges.

Increasing engagement with research as part of SEM training perhaps offers us an opportunity here. Universal understanding makes collaboration easier. Good Clinical Practice (GCP) training is a short course covering the international governance standards for research. I would highly recommend Sports Medicine as a specialty engages with GCP’s language and processes to help bring the evidence we really need within our grasp.

**********

Robert Barker-Davies is Sport and Exercise Medicine (SEM) and Rehabilitation Medicine Registrar and Clinical Research Fellow with the Academic Department of Military Rehabilitation and Loughborough University. He joined the RAF on a medical cadetship whilst at the University of Nottingham in 2004, attained MRCGP in 2012 and served in the Falkland Islands, RAF Waddington and RAF Scampton as a station GP. He represented the RAF, Coventry Godiva Harries and Wales U23s as a sprinter and hurdler. He holds UK Athletics qualifications in coaching and has sought to bring together his knowledge of the sport with his professional training and experience. He commenced dual specialist training in Sport and Exercise Medicine and Rehabilitation Medicine at DMRC Headley Court in 2014.

Farrah Jawad is a Sport and Exercise Medicine Registrar and co-ordinates the BJSM Trainee Perspective blog.

References

  1. Bleakley C, MacAuley D. The quality of research in sports journals. British journal of sports medicine 2002;36(2):124-5.
  2. Harris JD, Cvetanovich G, Erickson BJ, et al. Current status of evidence-based sports medicine. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2014;30(3):362-71. doi: 10.1016/j.arthro.2013.11.015
  3. Wheeler PC, Mahadevan D, Bhatt R, et al. A Comparison of Two Different High-Volume Image-Guided Injection Procedures for Patients With Chronic Noninsertional Achilles Tendinopathy: A Pragmatic Retrospective Cohort Study. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 2016 doi: 10.1053/j.jfas.2016.04.017
  4. Goldacre B. Bad Pharma. London, UK: Fourth Estate 2012.
  5. Barker-Davies RM, Nicol A, McCurdie I, et al. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC musculoskeletal disorders 2017;18(1):204. doi: 10.1186/s12891-017-1564-7
  6. Research NIfH. Clinical Trials Guide for Trainees https://www.nihr.ac.uk/funding-and-support/documents/Clinical-Trials-Guide.pdf2017 [accessed 26 May 2017.

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction?

3 Aug, 17 | by BJSM

By Dr Nicky Keay nickykeay

Health is not just the absence of illness, but rather the optimisation of all components of health: physical, mental and social. Exercise has numerous benefits on all these aspects. However, a recent article in the British Medical Journal described how exercise addiction can have detrimental physical, mental and social effects.

Dedication and determination are valuable qualities required to be successful in life, including achieving sporting prowess. Yet, there is a fine line between dedication and addiction.

To improve sports performance, cumulative training load has to be increased in a quantified fashion, to produce an overload and hence the desired physiological and Endocrine adaptive responses. Integrated periodisation of training, recovery and nutrition is required to ensure effective adaptation. Sufficient energy availability and quality of nutrition are essential to support health and desired adaptations. On the graph above the solid blue line represents a situation of energy balance, where the demands of increased training load are matched by a corresponding rise in energy availability. This can be challenging in sports where low body weight confers a performance or aesthetic advantage, where the risk of developing relative energy deficiency in sport (RED-S) has implications for Endocrine dysfunction, impacting all aspects of health and sports performance.

Among those participating in high volumes of exercise, what distinguishes a healthy level of commitment from exercise addiction? Physical factors alone are insufficient: all those engaging in high levels of training can experience overuse injuries and disruption in Endocrine, metabolic and immune systems. Equally, in all these exercising individuals, overtraining can result in underperformance.

Psychological factors are the key distinguishing features between the motivated athlete and the exercise addict. In exercise addiction unhealthy motivators and emotional connection to exercise can be identified as risk factors. In exercise addiction the motivation to exercise is driven by the obsession to comply with an exercise schedule, above all else. This can result in negative effects and conflict in social interactions, as well as negative emotional manifestations, such as anxiety and irritability if unable to exercise, including the perceived necessity to exercise even if fatigued or injured.

Two categories of exercise addiction have been described. Primary exercise addiction is the compulsion to follow an excessive training schedule. Without balancing energy intake, the physical consequence may be a relative energy deficiency, as indicated on the graph by the dashed blue line. In secondary exercise addiction, the situation is compounded by a desire specifically to control body weight. These individuals consciously limit energy intake, almost inevitably developing the full clinical syndrome described in RED-S, dragging them down to the position indicated by the dotted blue line on the chart. These situations of exercise addiction can lead to varying risk categories of RED-S.

As described at the start of this blog, there is a blurred boundary between the dedicated athlete and the exercise addict. In practice there is most likely a cross over. For example, an athlete may start with healthy motivators and positive emotional connection to exercise, which can become a primary addiction to adhere rigidly to a training schedule, rather than putting the emphasis on the outcome of such training. In the case of an athlete where low body weight is an advantage, it is easy to appreciate how this could become a secondary exercise addiction, where the motivation for exercising becomes more driven by the desire to control weight, rather than performance.

In order to support those with exercise addiction, discussion needs to focus on adopting a more flexible approach to exercise, by recognising that exercise addiction has detrimental effects on all aspects of current and long term health. Furthermore, in the case of athletes, a multi-disciplinary approach is desirable to help the individual refocus on the primary objective of training: to improve performance. In all situations, discussion should explore modifications to exercise and nutrition, in order to prevent the negative effects of RED-S on health and performance.

Exercise has numerous health benefits and is usually viewed as positive behaviour. However, the outcome of exercise is related to the amount of training, appropriate nutrition and motivation for exercising.

References

Addiction to Exercise British Medical Journal 2017

Clusters of Athletes

Sport performance and relative energy deficiency in sport British Journal of Sport Medicine 2017

Balance of recovery and adaptation for sports performance British Association of Sport and Exercise Medicine 2017

Optimal Health for all athletes Part 4 Mechanisms of RED-S British Journal of Sport Medicine 2017

Sports Endocrinology – what does it have to do with performance? British Journal of Sport Medicine 2017

Inflammation: Why and How Much? British Association of Sport and Exercise Medicine 2017

Exercise oncology part 2/3: Let’s put it into practice!

31 Jul, 17 | by BJSM

Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series

By Anne Cornevin @anne_cornevin and Justin Carrard @Carrard.Justin

The first part of this series reviewed the scientific evidence to prescribe exercise in order to prevent and treat cancers [read it HERE]. This second part “gives”  the floor to a family, whose daughter was diagnosed with acute lymphoblastic leukaemia at the age of two. She was then treated until the age of four and got a relapse at six. At that time, she integrated the program PASTEC (French acronym for Promotion of Therapeutic Sports Activity for Children with Cancer).

PASTEC is an out-of-hospital exercise training program initiated in Lausanne (Switzerland) for children suffering from cancer. It was born out of a joint effort between the paediatric-haematology-oncology unit of the CHUV (French acronym for Lausanne University Hospital) and the Health and Sport Centre of the University of Lausanne.

INTERVIEW

Can you explain how you discovered PASTEC and what it involves?

Parents: “When our daughter got her relapse, doctors suggested to enrol her in the program. We were told that the first studies just got published, showing that showing that physical activity improves chemotherapy induced neurological deficits as well as concentration.

She has been taking part in PASTEC for 2 years. In the first year, it took place every Saturday and they did alternatively fine motor skills and endurance/strength training. Now, it is fortnightly, and the main emphasis is on discovering new activities.”

What was your reaction?

Daugther: “First, I did not agree at all. I didn’t want it, I wasn’t motivated.”

Parents: “She was tired and scared of not being able to make it through, not being able to keep up the pace and achieve the proposed exercises. Because of her leukaemia, she had to stop the dancing lessons she just started. She couldn’t catch up the sports program at school either, because she had to spend most of the time in the hospital. We then noticed that her physical capacity was fluctuating all the time according to the therapy schedule. For that reason, it wouldn’t have been impossible for her to do sport in a usual non-adapted sporting club.

However, as sportsmen, we had the conviction that sport could help her feel better especially if the program was well adapted. From a general point of view, although we got a lot of support since her diagnosis of leukaemia, we had the feeling that physical activity was lacking in the proposed care process.”

What are the differences between PASTEC and scholar sports teaching?

Daughter: “At school there is no sports teacher, but a school teacher who gives us sports lessons. I can’t do everything like other children, but I can do a lot.”

Parents: “Her muscle and endurance are very different from the ones of other kids. For her it is an opportunity to be in a group where she isn’t judged on her physical abilities.  In PASTEC, there is a lot of tolerance because all children are sick. They support and encourage each other far more than at school.

Moreover, it allows her to say “I have my own sport and I am able to realise the given exercises”. It totally changed the way she perceived her physical difficulties. Instead of saying “I can’t do this”, she tries it and most of the time she succeeds. This made physical activities much more accessible for her.”

Lastly, they take part in popular sporting events, which helps integrating them into the society. For example, all children did the 2km running race as part of the 20km of Lausanne. We would have never dared trying this alone with her.  Doing it with PASTEC allowed them to do it proudly, without fear and with a common goal. It was a real challenge and at the end, they all received a prize. She was very happy that she did it!

What did PASTEC change for you?

Parents: “Chemotherapy brought her really down. With PASTEC, in one year, we noticed that she gained muscle, that everything related to gesture or coordination, and self-confidence had clearly improved. We realized that she was able to ride a bike again, simply because she regained her confidence. It is the whole program that kept her away from falling lower, and that allowed her to keep the course and to improve.

Furthermore, as parents it is also a relaxing moment when we go to the centre. We can exchange with other parents facing similar challenges without having to justify what is going on with her. This is a very nice feeling.”

If you are told that the latest scientific findings show that regular physical activity has an impact on cancer treatment AND prognostic, would you believe it based on your experience?

Parents: “Yes, we definitely would. We saw that exercise had a huge positive impact on our daughter.”

Do you have any tips for our readers wanting to implement such program in their home country?

Parents: “We believe that exercise should be part of cancer therapy and such be proposed to all children suffering from cancer. To enable this, such programs need more recognition and financial support. For example, PASTEC is supported mainly by “Zoé for life” (an association for children with cancer) through donation.

Secondly, we were disappointed that the fine motor skills exercises disappeared the second year. Neuropathy is one of the most important impact of chemotherapy and it is essential to integrate those motor skills.

Lastly, it would be great to delocalise such program in smaller centres in order to make it available to families who are living further away.”

Lastly, how does the future look like for you?

Parents: “She should be in remission in August and hopefully for good. We wish she could then integrate a sporting club. In fact, we really see PASTEC as a springboard to her integration into the society.”

For more information:

PASTEC: www.pastec.ch

Zoé4Life: https://en.zoe4life.org/

Read part 1 of the series: Exercise oncology part 1/3: Let’s get moving, exercise helps in preventing AND treating cancers!

*********************

Anne Cornevin is a 4th year medical student at the University of Geneva (Switzerland) and also a member of Students and Junior Doctors SSGSM/SSMS. As a sport lover and previous artistic gymnast, she aspires to contribute to the promotion of Sports & Exercise Medicine as a medical speciality.

Email: cornevin.anne@gmail.com                                            Twitter : @anne_cornevin

Justin Carrard is a second year internal medicine resident based in Biel/Bienne (Switzerland). He coordinates the BJSM Swiss Junior Doctors and Undergraduate Perspective Blog Series and leads the Students & Junior Doctors SGSM/SSMS movement. Justin aims to raise SEM awareness among medical students and modern solutions it provides to big public health issues like non-communicable diseases. As an ex-competitive swimmer, he has a keen interest for endurance sports and regularly practices them with passion.

Email: justin.carrard@gmail.com                              Twitter: @Carrard.Justin

Duty of care and the relevance of occupational health in professional sport

28 Jul, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine  a BJSM blog series

By Manroy Sahni (@manroysahni)

Image credit: http://www.korbuild.co.uk/csr/occupational-health/

 

Performance vs Safety

Team success, winning and performance are undoubtedly at the heart of elite sport. The concept of “marginal gains” and the pursuit of miniscule improvements that ultimately tip the balance between winning and losing mean that “performance” is a growing theme within sports medicine. However, performance and safety should never compete. Elite sport will never be 100% safe- that is an unrealistic expectation given the intrinsic risk associated with high-level physical competition. However, it is reasonable to expect that we should take steps to reduce the likelihood of harm, whether this be through modifying the playing environment, optimising technique or analysing and learning from previous incidents. This begs the question, who is responsible for the care of an athlete?

Who is responsible for the care of the athlete?

Within the hospital environment, doctors and the multidisciplinary health care team have a duty of care for patients on their wards. Things are not so clear cut within the sporting arena. Sports doctors of course still have a duty of care for their players but this duty of care is shared with the Employer. For example, football players will be employed by a club, whether that be at Premier League level or in the lower leagues, and player safety is therefore also the responsibility of the club. This is written in law under the Health and Safety at Work Act (1974). Consequently, within a sporting context the duty of care of the player falls on both the Doctor and the Employer. The Doctor must be competent and work within their “scope of practice” and the Employer must take reasonable steps to mitigate the risk to their employees through operating safely.

A Sports Physician’s Scope of Practice

It is of fundamental importance for all doctors to recognise their limitations and only work within their scope of practice. This remains true for doctors working within the dynamic and unpredictable world of professional sport. There are various routes into SEM so the training background for sports doctors can vary considerably. Typically, team doctors will have a General Practice background with a Postgraduate SEM qualification or have completed the SEM specialty pathway (http://blogs.bmj.com/bjsm/2017/04/24/postgraduate-perspective-sem-training-programme-undergraduates/).

For football, the Premier league and football league also require all team doctors to have a postgraduate qualification in SEM, up-to-date ATLS training in the form of Advanced Trauma Medical Management in Football (ATMMIF) and appropriate ultrasound accreditation if necessary. On top of this, a multitude of skills are required from the knowledge and capacity to travel with teams, the flexibility to work within a specialist MDT and the character required to cope with the very particular demands of the competitive environment . An appreciation for occupational health is often overlooked within this varied skill set.

Relevance of Occupational Health

In professional sport, the doctor is working for both an athlete and an employer. This means that the role of a sports medicine doctor has striking similarities with occupational medicine. The doctor must respect the fundamental importance of patient / athlete confidentiality whilst at the same time communicating pertinent information to the employer that may impact on an employee’s capability to work. Furthermore, sports doctors will often find themselves communicating player’s health reports to non-medical staff- whether this be members of the coaching team or club management. It is vital that in these scenarios, the team doctor understands the limits of what they can and cannot disclose.

Additionally, a team doctor may be asked to provide a medical opinion during a discussion regarding termination of a player’s contract, fitness to return to sport following serious injury or to advise on the impact of a mental or physical disability. These tasks come under the realm of occupational health and require the consent of the employee who has a right to see any report submitted.

What I hope to highlight in this short blog, is that doctors and employers have a shared interest in the wellbeing of athletes. Also, that the role of a sports doctor is evolving to fit in line with health, safety and employment law. These key messages are important to underline to an undergraduate audience, namely the representatives of the future of SEM.

For further detail and background on the points raised in this blog please read the following resources:

  1. Duty of Care in Professional Football, Dr Matt Perry, BASEM Today Issue 38, Spring 2017
  2. The Occupational Health of Sports Medicine, Dr John Ballard, BASEM Today Issue 38, Spring 2017
  3. A Doctor’s Duty of Care When Attending a Football Game, BASEM Position Statement
  4. Ethics Guidance for Occupational Health Practice; The Faculty of Occupational Medicine December 2011

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He is an academic foundation doctor in the West Midlands and serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee.

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