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Not all steps are equal: Changing algorithms in wearable trackers changes outcomes

20 Jan, 17 | by BJSM

By Muaddi Alharbi, Robyn Gallagher, Lis Neubeck, Adrian Bauman, Patrick Gallagher

This blog discusses JM, a female patient recovering from a heart attack. She is just one example of many patients I have encountered who monitor and track their activity using a wearable tracker. JM shared her experiences and her disappointment that her normal walk had less activity recorded from one day to the next. Her friends at cardiac rehabilitation all noticed the same thing and had the same concerns. Fortunately, I was able to let them know that Fitbit had changed its algorithm for tracking minutes of moderate to vigorous activity and that this was the reason for the lower recorded activity levels.

What does this change in algorithm mean?

The algorithm for activity trackers has changed so that increments of moderate to vigorous activity are no longer recorded in single minutes, but in 10-minute bouts. Previously, Fitbit just counted very active minutes when calculating a user’s overall minutes, but from now on it will only count active minutes if a wearer engages in an activity for over 10 minutes. So, in practical terms this doesn’t mean much to an athlete (who believes more in the ‘no pain no gain’ approach), but to someone starting a recovery activity program the sudden change could be the difference between achieving goals and giving up. A patient exercising for 39 minutes for example would now see their activity recorded as three 10-minute bouts, not as four 10-minute bouts. Thus, the 10-minute bout threshold would need to be met with each separate exercise or physical activity session. More importantly, the change to the algorithm is more likely to affect how the device tracks the length of time the wearer spends sitting down (sedentary time). Not standing is linked to many chronic health problems, as is sitting for up to 7 or 8 hours a day – which can increase the risk of death by 5%1, 2.

Wearable activity tracking devices have sparked interest worldwide and provide a novel approach to monitoring physical activity. Data generated by these devices can be used by consumers, researchers, clinicians, and insurers to improve health and wellness. They can also help people to have better discussions with their doctor about their health. These benefits are so valuable that the National Health Service NHS (https://www.theguardian.com/society/2016/jun/17/nhs-to-offer-free-devices-and-apps-to-help-people-manage-illnesses) in the United Kingdom has even announced that it will provide trackers and apps upon prescription to people with heart disease. Given their important role in managing health and wellbeing, it is not surprising that global wearable tracker sales have dramatically increased. A report showed (http://www.thetimes.co.uk/article/unfit-for-purpose-exercise-trackers-40-off-the-mark-7jltssgxn?shareToken=7aba357d23d8f831e348429bd79 5a47b) Fitbit, the most popular brand of tracker, has sold almost 21.5 million devices worldwide with the Apple Smartwatch hot on its heels with 12 million sales.

How precise do we need activity trackers to be? This is debatable. Manufacturers can change the algorithm they are using to calculate activity at any time, and from time to time, they have made such changes. But they don’t need to tell users – and that is the problem. This can have marked effects on activity outcomes and monitoring.

Every minute matters

Wearable activity trackers provide innovative ways to monitor your physical activity in real time, with little inconvenience. Importantly activity trackers may also be an activity motivator.  Indeed, they have the potential to motivate wearers to achieve their activity goals through a combination of elements such as self-monitoring, continuous feedback on progress, the ability to set reasonable goals, access to social support, and enhanced self-confidence. But how important is the device’s tracking accuracy and encouragement for the wearer to achieve personal activity goals (e.g. number of step counts or active minutes)? This is the issue we need to debate.

A change in the algorithm will change the results. So, when Fitbit™ announced it was changing the algorithm used to track active minutes it was understandable that the wearer was left feeling very confused about what the new readings may mean. Fitbit™ explained that the new10-minute rule meant that from now on, the wearers’ active minutes may sometimes appear lower than what they were used to.  Highly active people who do a lot of physical activity over the day may regard this as only a small change that requires a relatively simple adjustment in how they monitor their daily activity. For other less active wearers, changing the algorithm may motivate them to set small goals – that is to encourage them to complete the 10-minute bout of activity.

Yet, things are not so simple for researchers and for patients recovering from a disease, where every minute of activity matters for monitoring or motivational purposes. For instance, the severity of disease for patients with heart failure is different than for patients who have not experienced heart damage such as occurs with elective coronary interventions. This can affect the patient’s personal goals for achieving the recommended accumulation of active minutes. It appears the manufacturers are not fully clear about the different ways the devices are used, or can be used. Contributing to the confusion is the fact that the manufacturers are very secretive about the algorithms they use to calculate the active minutes.

Can we trust our trackers?

Before we can trust our trackers we need research that shows the algorithms are good for accurately calculating cumulative moderate/vigorous minutes of activity and steps over the day. This will help to sharpen the accuracy of the trackers, build credibility, and to make sure the tracker algorithm supports the health experts’ recommendations for physical activity.

Studies lose precious time

Research is being undertaken and the evidence is building on the accuracy of the algorithms being used in activity trackers. Some studies have even recommended the use of Fitbit devices in specific clinical settings to measure physical activity. For instance, Alharbi et al.3 revealed Fitbit-Flex is an accurate monitor to measure free living physical activity (i.e., step counts and minutes of moderate to vigorous physical activity) in phase III cardiac rehabilitation participants. This study clearly demonstrated Fitbit-Flex being within 20% of the acceptable validity criteria for clinical purposes to measure step counts and minutes of moderate to vigorous physical activity. However, Fitbit-Flex exceeded the acceptable validity criteria for research purposes which is within 3%3. Similarly, a study conducted in a laboratory setting showed Fitbit-One has high accuracy to measure step counts in healthy young adults, with percent relative error below 1.3% for all tested treadmill walking speeds and for multiple placements (e.g. on the hip or in the pocket)4. Therefore, when manufacturers make changes to the algorithm the evidence from these studies becomes outdated, and so reopens the question of their reliability.

Where to from here?

Change is constant in the world of health and fitness. One such change is that people are gaining more control over their lifestyles, health, and future well-being by using wearable activity monitoring devices. There is no doubt that these trackers help to achieve better health outcomes and disease reduction. But tracker manufacturers need to keep users and researchers up to date about any changes they make to the algorithms. Being informed fosters trust and strengthens connections between users and manufacturers. It also helps researchers, physicians, clinicians, healthcare systems and insurance providers to properly respond the changes and assist people to achieve their health goals.

Take home messages

  • Clinicians, patients and researchers are eager to have accurate trackers to monitor and motivate physical activity. Therefore, tracker manufacturers should ensure that the device algorithm provides a high level of accuracy similar to those of known devices such as a research-grade accelerometer (the Acti-Graph)
  • System developers and designers need to ensure open lines of communication with researchers and consumers when changing algorithms to gain their trust
  • Researchers should be mindful of the possibility that tracker manufactures may change their algorithms in the middle of a longitudinal research study without any notification. Thus, supplementary evidence of field-based performance is crucial to ensure data safety

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Muaddi Alharbi is doing his PhD in activity tracking and has worked extensively with cardiac patients. You can find out more on Twitter @muad11

References:

  1. Chau JY, Grunseit AC, Chey T, et al. Daily sitting time and all-cause mortality: a meta-analysis. PLoS One. 2013; 8: 1-14.
  2. Ekelund U, Steene-Johannessen J, Brown WJ, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. The Lancet. 2016; 388: 1302-10.
  3. Alharbi M, Bauman A, Neubeck L and Gallagher R. Validation of Fitbit-Flex as a measure of free-living physical activity in a community-based phase III cardiac rehabilitation population. Eur J Prev Cardiol. 2016; 23: 1476-85.
  4. Takacs J, Pollock CL, Guenther JR, Bahar M, Napier C and Hunt MA. Validation of the Fitbit One activity monitor device during treadmill walking. J Sci Med Sport. 2014; 17: 496-500.

And the award for the best 2015 BJSM PHYSICAL ACTIVITY Systematic Review goes to…

18 Jan, 17 | by BJSM

By Angela Spontelli Gisselman  (@ASGPhysio) and Christina Le (@yegphysio)

Systematic reviews are the gold standard for critically appraising clinically relevant literature. Twice yearly, BJSM hosts a competition to award the authors of the “best” systematic review(s). Based on prior BJSM competitions, the “best” systematic reviews are determined following an objective, systematic appraisal process (see the end of this blog for details).

Because of the quantity and high quality of systematic reviews submitted to BJSM, we divided this semi-annual contest into two categories – 1) Physical Activity Systematic Reviews, and 2) Sports Injury and Illness Systematic Reviews. In this blog, we highlight the systematic reviews that fall into the physical activity category.

(Follow this link to read about the Sports Injury and Illness Systematic Review finalists)

The top 4 Physical Activity Systematic Review finalists published between July and December 2015 were:

  • Costigan et al (2015). High-intensity interval training for improving health-related fitness in adolescents: a systematic review and meta-analysis
  • Franco et al (2015). Older people’s perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature
  • Hupin et al (2015). Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: a systematic review and meta-analysis
  • Martin et al (2015). Interventions with potential to reduce sedentary time in adults: systematic review and meta-analysis

And, the winner for the Best Injury and Illness Systematic review for July-December 2015 is:

Hupin et al (2015). Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: a systematic review and meta-analysis

Dr. David Hupin and his colleagues targeted a growing area of concern: low physical activity participation in the aging population. With the majority of older adults (aged >60 years) failing to reach the current physical activity recommendations of 150 minutes per week of moderate-to-vigorous physical activity (MVPA), Hupin et al set out to determine if a lower dose of MVPA was effective in reducing mortality. The results of their meta-analysis revealed a reduction in all-cause mortality even in those who recorded a dose of MVPA below the recommendations. Older adults who performed less than 150 minutes per week still had a 22% reduction in mortality compared to those performing no activity. The valuable take-home message here is that even a small amount of MVPA can go a long way. Hupin et al advised to change physical activity standards to 15 minutes of MVPA, 5 days per week, as a more reasonable target for older adults to obtain. The jury applauds the authors for their rigorous methodological approach in selecting high quality studies which produced large sample sizes, extended follow-up periods, and strong homogeneity between studies.

All systematic reviews published between July 2015 and December 2015 were evaluated by two independent reviewers with the following criteria:

  1. PRISMA Guidelines (Methods): How well did the authors adhere to the internationally recommended report guidelines for systematic reviews?
  1. Clinical Relevance: Is the review’s topic highly relevant to the BJSM community of clinicians? Do the content and results have the potential to significantly impact clinical reasoning and practice?
  1. Introduction: Intriguing and Informative? Does the introduction provide a succinct description of the background literature and establish a distinct need for the systematic review?
  1. Results & Discussion: Comprehensive and well contextualized? How well did the authors critically evaluate and synthesize their results in the context of existing research? Did the authors address their study objectives and provide a thorough discussion of their findings?
  1. Conclusion: Clear and concise? Did the authors effectively communicate a concise take-home message that readers can feasibly incorporate into clinical practice? Was the conclusion accurate while acknowledging study limitations and guiding future research?

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

Angela Spontelli Gisselman (@ASGPhysio) is in her third and final year as a PhD candidate in Physiotherapy at the University of Otago in Dunedin, New Zealand. Angela received her Doctor of Physical Therapy from Duke University in 2011 and completed residency training at University of North Carolina to become a ABPTS board-certified orthopedic clinical specialist (OCS) in 2014. For her PhD research, she is investigating the role of monitoring the autonomic nervous system in the presence of musculoskeletal overuse injuries. Alongside her husband, she enjoys mountain biking, hiking, photography, and stargazing during her PhD study breaks.

Christina Le (@yegphysio) is a graduate of the MScPT program at the University of Alberta. Christina works as a physiotherapist at the Glen Sather Sports Medicine Clinic (GSSMC) in Edmonton, Canada. In addition to being a clinician, she serves as the GSSMC interdisciplinary knee team lead and FC Edmonton physiotherapist. She is currently pursuing a PhD with a focus on knee injury rehabilitation.

Vote now! Round 3 of the 2016 BJSM cover competition

13 Jan, 17 | by BJSM

Vote now, in the second last preliminary round, for your favourite cover of 2016.

Win a prize! We will reveal this year’s prizes (voters in the final round get entered in a draw, and profiled on the blog) next round. See last year’s winners HERE. One of whom flew across the Atlantic from Canada, to redeem her prize of free entry to the Football Medicine Conference, in London, April 2016. We guarantee that this year’s prizes are just as (if not more) exciting. So stay tuned.

Vote for your favourite cover out of the group below.

 

July-50-13: The 13th Scandinavian Congress of Medicine and Science in Sports

July-50-13: The 13th Scandinavian Congress of Medicine and Science in Sport

 

July 50 14: 2nd World Congress of Sports Physical Therapy, Belfast

July 50 14: 2nd World Congress of Sports Physical Therapy, Belfast

August-50-15: Rugby ACL re-injury

August-50-15: Rugby ACL re-injury

August-50-16 2016: Sports Medicine Australia Conference

August-50-16 2016: Sports Medicine Australia Conference

September-50-17: Getting to grips with golf hip and wrist issues in a new olympic sport

September-50-17: Getting to grips with golf hip and wrist issues in a new olympic sport

September 50 18 Swiss Sports Medicine national conference

September 50 18: Swiss Sports Medicine national conference

 

 

 

 

 

 

And the award for the best 2015 BJSM ‘Sports Injury and Illness’ Systematic Review goes to…

10 Jan, 17 | by BJSM

By Angela Spontelli Gisselman  (@ASGPhysio) and Christina Le (@yegphysio)

Systematic reviews are the gold standard for critically appraising clinically relevant literature. Twice yearly, BJSM hosts a competition to award the authors of the “best” systematic review(s). Based on prior BJSM competitions, the “best” systematic reviews are determined following an objective, systematic appraisal process (see the end of this blog for details).

Because of the quantity and high quality of systematic reviews submitted to BJSM, we divided this semi-annual contest into two categories – 1) Physical Activity Systematic Reviews, and 2) Sports Injury and Illness Systematic Reviews. In this blog, we highlight the systematic reviews that fall into the Sports Injury and Illness category.

michael-jordon-ice-kneesThe top 4 Sports Injury and Illness Systematic Review finalists published between July and December 2015 were:

  • Filbay et al (2015). Quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis
  • van Meer et al (2015). Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review
  • Lack et al (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis
  • OIds et al (2015). Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis
  • Pas et al (2015). Efficacy of rehabilitation (lengthening) exercises, platelet-rich plasma injections, and other conservative interventions in acute hamstring injuries: an update systematic review and meta-analysis

And, the winner for the Best Injury and Illness Systematic review is:

Lack et al (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis

Mr. Simon Lack and his colleagues produced a comprehensive systematic review with meta-analysis on the topic of proximal muscle rehabilitation for patients with patellofemoral pain (PFP). A timely follow-up to the 2014 BJSM winner of the best risk factor-based systematic review (Rathleff et al (2014)), Lack et al identify a well-defined literature gap and effectively communicate new findings regarding the effects and possible mechanisms of proximal muscle intervention for PFP. Through their meta-analysis and pooling of data across short, medium, and long term time points, they conclude the greatest effects on pain and improvements in function for patients with PFP are achieved when proximal muscle rehabilitation is combined with quadriceps strengthening. Of particular clinical interest were the results that closed kinetic chain quadriceps rehabilitation is equally as effective as open kinetic chain proximal muscle rehabilitation for increasing proximal muscle strength. These findings are encouraging for clinicians who appreciate the diverse clinical and pain presentations of patients with PFP. We commend the authors for their careful design and organization of their systematic review which was clearly written with the BJSM community in mind.

All systematic reviews published between July 2015 and December 2015 were evaluated by two independent reviewers with the following criteria:

  1. PRISMA Guidelines (Methods): How well did the authors adhere to the internationally recommended report guidelines for systematic reviews?
  1. Clinical Relevance: Is the review’s topic highly relevant to the BJSM community of clinicians? Do the content and results have the potential to significantly impact clinical reasoning and practice?
  1. Introduction: Intriguing and Informative? Does the introduction provide a succinct description of the background literature and establish a distinct need for the systematic review?
  1. Results & Discussion: Comprehensive and well contextualized? How well did the authors critically evaluate and synthesize their results in the context of existing research? Did the authors address their study objectives and provide a thorough discussion of their findings?
  1. Conclusion: Clear and concise? Did the authors effectively communicate a concise take-home message that readers can feasibly incorporate into clinical practice? Was the conclusion accurate while acknowledging study limitations and guiding future research?

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

Angela Spontelli Gisselman (@ASGPhysio) is in her third and final year as a PhD candidate in Physiotherapy at the University of Otago in Dunedin, New Zealand. Angela received her Doctor of Physical Therapy from Duke University in 2011 and completed residency training at University of North Carolina to become a ABPTS board-certified orthopedic clinical specialist (OCS) in 2014. For her PhD research, she is investigating the role of monitoring the autonomic nervous system in the presence of musculoskeletal overuse injuries. Alongside her husband, she enjoys mountain biking, hiking, photography, and stargazing during her PhD study breaks.

Christina Le (@yegphysio) is a graduate of the MScPT program at the University of Alberta. Christina works as a physiotherapist at the Glen Sather Sports Medicine Clinic (GSSMC) in Edmonton, Canada. In addition to being a clinician, she serves as the GSSMC interdisciplinary knee team lead and FC Edmonton physiotherapist. She is currently pursuing a PhD with a focus on knee injury rehabilitation.

Inside the Refugee Olympic Team with Team Doctor, Carlo Bagutti

7 Jan, 17 | by BJSM

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

By Artiom Ganchine, @ArtiomGanchine

With the contribution of Justin Carrard, @Carrard.Justin

The world is facing the biggest refugee crisis since World War II. In 2015 and according to the office of the United Nations High Commissioner for Refugees (UNHCR), about 63 million people across the world were forced from their homes1 .They are fleeing war, famine, and other man-made and natural disasters2. Consequently, the International Olympic Committee (IOC) created a Refugee Olympic Team (ROT) to “raise awareness of the magnitude of the refugee crisis”. The IOC President, Thomas Bach, said: “These great athletes will show everyone that, despite the unimaginable tragedies that they have faced, anyone can contribute to society through their talent, and most importantly, through the strength of the human spirit”2. The IOC, together with National Olympic Committees, International Federations and the UNHCR selected athletes with refugee status and Olympic level skill. Ten athletes were chosen (two swimmers, one marathoner, five middle-distance runners and two judokas) to take part in the 2016 Olympic Games in Rio3.

Refugee Olympic Team

Refugee Olympic Team

I recently met up with Dr Carlo Bagutti4, who was the elected ROT (Refugee Olympic Team) Chief Medical Officer. He is also a Sports Physician in Lausanne (Switzerland), a team doctor for Swiss Athletics and a member of the IOC Athletes’ entourage commission5.  I had the great pleasure of interviewing him. You can see from his responses how diverse and humanly enriching Sports and Exercise Medicine can be.

Dr Bagutti, first thank you for accepting the interview. Could you explain to us – how, if at all, was it different to work with the refugee athletes in comparison to the athletes you usually work with?

The first difference was a psychological one. The medical team has to help the ROT athletes to keep focused on the competition despite the breadth and richness of the new experiences they faced during the Games. To understand this point, you should try to imagine the life and training conditions of South Soudan athletes in a closed camp in Kenya or those of the two Congolese judokas in one of Rio Favelas. Most of the athletes were not familiar with all the facilities and material wealth you can enjoy for free in the Olympic Village. Others had never seen an athletic track before. In such a situation, you can easily imagine, that it is not simple to keep focused on the competition.

Secondly, the marginalized social status of these athletes transformed to a beacon of hope for all refugees across the world. The Syrian refugee Yusra Mardini said it very well at the 129th IOC session: “We still are humans. We are not only refugees. We are like everyone in the world. We can do something. We can achieve something”2.

On a clinical angle, did you have to deal with atypical pathologies?

They came with two kinds of problems, which I usually do not treat in big competitions. Firstly, some of them had dental health issues. Secondly and more interestingly, most of them suffered from overuse injuries (mainly tendinopathies). Only having 6 months to train for the Olympics, all of them trained hard in order to proudly represent all the refugees around the world. Additionally, some of them presented uncorrected basic biomechanic issues, as they did not have the opportunity to follow high quality training and lacked adequate sporting material.

What in particular, left an impression on you?

I was really pleased by the interest that other athletes and the media showed for the ROT. A lot of athletes and journalists visited us, mainly because the ROT spread a positive message in a more complicated political context such as the Russian doping scandal, the ticketing corruption issue, and the Brazilian internal political crisis.

If you had the opportunity to repeat this experience, would you go for it?

Yes, without any hesitation. I wish that all my colleagues could have such a rewarding human and clinical experience.

In that way, would you recommend to a medical student to shadow a sport physician on the sporting field? If yes, which postgraduate rotations would you counsel in that case?

Firstly, I encourage all SEM interested medical students to embrace a SEM career because it is a varied and very stimulating specialty, which offers a lot of intellectual and human challenges.

Secondly, I would definitely recommend shadowing. In my opinion, academic training is not enough to become a sports physician. One should know the sport in which they are practicing in order to better understand and treat the pathologies. In that way, I advise to both practice the sport in question and to go on the field.

Concerning the postgraduate training, I recommend a broad clinical training including internal general medicine and physical medicine and rehabilitation rotations. This is because athletes see us for a large variety of issues. Even having a background in psychiatry could be very useful.

To learn more about ROT, as well as the projects the IOC is currently conducting to help refugee through the practice of sport, we highly recommend you the following links:

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Artiom Ganchine (@ArtiomGanchine) is a third year Swiss medical student (Geneva, Switzerland) with a keen interest for SEM. Outside of medicine, he enjoys cycling, running, trail running and participates in competitions in all of these disciplines. Contact: ganchine.artiom@gmail.com; Twitter: @ArtiomGanchine

Justin Carrard (@Carrard.Justin) is a first year internal medicine resident based in Biel/Bienne (Switzerland). He is the newly appointed Swiss Correspondent for the brand new BJSM Swiss Junior Doctors and Undergraduate Perspective Blog Series. If you would like to contribute to the “Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercice Medicine” Blog Series please email justin.carrard@gmail.com, or tweet @Carrard.Justin for further information.

References

  1. http://www.unhcr.org/figures-at-a-glance.html
  2. https://www.olympic.org/news/refugee-olympic-athletes-deliver-message-of-hope-for-displaced-people
  3. http://blogs.bmj.com/bjsm/2016/06/01/counting-down-to-rio-2016-with-the-olympics-special-edition-a-bjsm-treat/
  4. http://www.vidysport.ch/equipe-bagutti.html
  5. https://www.olympic.org/athletes-entourage-commission

 

 

Introducing the Sports and Exercise Medicine Students Association (SEMSA) in Australia

5 Jan, 17 | by BJSM

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

By Jacob Jewson (@jacobjewson, @SEMSA_Vic )

Co-authored by Mitchell Simpson and Jack Cookson (@JackCCookson)

semsa-logo

Why do we need a student association for sports and exercise medicine in Australia?

Sport and exercise medicine is a growing health field across the world, particularly in Australia. Important for elite athletes, and your everyday sports enthusiast, this area of health is vital for maximising player performance and enhancing quality of life through the benefits of exercise [1, 2].

Despite these benefits, some health degrees do not provide enough teaching on sports and exercise medicine. Often it is up to students to search far and wide to find appropriate teaching and to hopefully stumble upon some career guidance. This has been the driving factor behind an exciting new students association founded in March 2016.

What is SEMSA?

The Sports and Exercise Medicine Students’ Association (SEMSA) is an Australian organisation that facilitates education and career development in the field of sport and exercise medicine.

SEMSA aims to promote SEM as a speciality field, covering both the management of exercise related injuries and the promotion of health through increased use of exercise and physical activity. Member education across multiple disciplines is also a key focus. The association is consistently sharing journal and news articles about advances in SEM. To further facilitate this education and development SEMSA will host a number of events and workshops to introduce members to influential sports and exercise medicine clinicians, and key aspects of the profession.

Who is SEMSA?

SEMSA was founded by a group of like-minded students and recent graduates. We saw the need for further specialized instruction in sports and exercise medicine. The committee is comprised of medical and physiotherapy students, as well as recent graduates in the medical and physiotherapy field.

We all have a passion to expose students to key concepts and practitioners in SEM, and facilitate the education of practical skills. This common interest has enabled us to work well together as a multi-disciplinary unit to provide opportunities for students from various fields.

What type of events and workshops does SEMSA host?

SEMSA’s first event, Careers in Sports and Exercise Medicine, saw over 110 SEMSA members learn from leading clinicians about their journey in sports and exercise medicine.  Dr Peter Brukner (Australian Cricket Team doctor), Dr Rohan Price (orthopaedic surgeon (OrthoSport Victoria)), Mr David Francis (Collingwood Football Club head physiotherapist) and Dr Andrew Aldous (Australasian College of Sport and Exercise Physicians registrar) inspired our members with stories of the starts of their careers in sports medicine and their ongoing passion for the speciality. Our members also gained some practical tips on concussion management from leading expert, Dr Michael Makdissi, and Williamstown club doctor, Dr Liam West.

SEMSA will continue to hold events and workshops in conjunction with Sports Medicine Australia and the Australasian College of Sport and Exercise Physicians. The next events will include tendinopathy, women in sport and the journey of an injured player through treatment and recovery.

SEMSA was established in Melbourne, with its early membership base primarily comprised of students from Victorian universities studying medicine and allied health degrees. 2017 will see the expansion of SEMSA into NSW, and by 2018, the association aims to be recognised nationwide, with subcommittees in each state.

In doing this, SEMSA hopes to form relationships with various universities and their student societies, to promote sport and exercise medicine as an important subject in health science degrees. It is our goal to have sport and exercise medicine taught as part of university curricula, through lectures, workshops and placements, because that’s what students want [3]!

The committee is very excited to be part of a student organisation dedicated to sport and exercise medicine in Australia. We hope that it will encourage students and clinicians to consider it as a career, and understand the importance and scope of this emerging health field.

Further information about SEMSA

 Please visit our website

http://semsa.org.au

Connect on social media
Facebook: https://www.facebook.com/semsavic/

Twitter: @SEMSA_Vic

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Jacob Jewson, a medical intern, has learned a lot about Sport and Exercise Medicine over the last two years. He has longstanding passion for sport, particularly cricket and Aussie rules football, and found that sports medicine is a perfect fit. During his degree, he undertook research in Achilles tendinopathy. He also worked with amateur and professional football clubs around Melbourne. Now, as secretary of SEMSA, he oversees meetings and decisions to facilitate growth of the association and member events. Jacob is extremely excited about what SEMSA can offer its members in the future, and the growing global community of SEM practitioners.

Jonathan Shurlock is an academic foundation year doctor based in Sheffield, UK. He co-coordinates the BJSM Undergraduate Perspective blog series. Please send your blog feedback and ideas to: jhshurlock@gmail.com; or Tweet @J_Shurlock

References

  1. Pina IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: A statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation 2003;107(8):1210-25
  2. Myers VH, McVay MA, Brashear MM, et al. Exercise training and quality of life in individuals with type 2 diabetes: a randomized controlled trial. Diabetes care 2013;36(7):1884-90
  3. Osborne SA, Adams JM, Fawkner S, Kelly P, Murray AD, Oliver CW. Tomorrow’s doctors want more teaching and training on physical activity for health. British journal of sports medicine 2016

 

Cardiovascular screening in athletes: time to refocus!

3 Jan, 17 | by BJSM

By Dave Siebert, MD, @DaveMSiebert

focus

When medical students learn about hypertrophic cardiomyopathy (HCM), one fact often resonates as a shocking and tragic reality: it frequently first presents as sudden death. Yet HCM is just one of a heterogeneous list of pathologic structural and electrical cardiac disorders that can cause sudden death in athletes without prior warning. This troubling fact presents many challenges to clinicians striving to protect athletes from catastrophic incidents on the field of play.

The decision to screen an asymptomatic patient for disease is not always clear cut. The scientific literature is constantly in flux, requiring those that make medical recommendations to continually re-evaluate the best available evidence. When that evidence starts to conflict with historical practices, controversy often results.

Screening athletes for silent cardiovascular disease – such as HCM, long QT syndrome (LQTS), and arrhythmogenic right ventricular cardiomyopathy to name a few – is no different. However, the evidential landscape is in the midst of a dramatic shift.

In their recent BJSM manuscript1, Drs. Jonathan Drezner, Kimberly Harmon, Irfan Asif, and Joseph Marek present a critical review of cardiovascular screening in young athletes. They discuss a number of factors to consider when deciding whether or not to add an electrocardiogram (ECG) to the standard athlete pre-participation physical exam. Those factors include: (1) the consistent, strong evidence suggesting sudden cardiac arrest and death (SCA/D) are much more common in certain athlete subgroups2,3; (2) evidence-based methods to risk stratify and manage patients found to have a cardiovascular condition, such as Wolff-Parkinson-White4, HCM5, or LQTS6 exist; and (3) when implemented by physicians experienced in athlete ECG interpretation using modern criteria, many conditions associated with a higher risk of SCA/D can be detected with a false-positive rate of less than 2.5%7,8.

The authors also address the very concept of cardiovascular screening itself: “The premise of CV screening in athletes is that early detection of cardiac disorders associated with SCD can reduce morbidity and mortality through individualized and evidence-driven disease-specific management. Without believing in the benefit of early detection, then screening by any strategy is called into question. If one believes in early detection, screening by history and physical examination alone is inadequate.”

In September 2016, the American Medical Society for Sports Medicine (AMSSM) brought widespread attention to this dilemma with the publication of its Position Statement on Cardiovascular Preparticipation Screening in Athletes9. The consensus panel concludes that “the current (Preparticipation Physical Evaluation), while pragmatic and widely practiced, is limited in its ability to identify athletes with conditions at risk for SCA/D.” Moreover, the group discusses their concern that standardized symptom and family history questionnaires demonstrate a high false positive rate, sometimes surpassing 30%. Ironically, a high false positive rate is frequently cited as a potential pitfall of ECG screening, but the numbers aren’t comparable.

Where does the most recent evidence truly lie?

In two independent studies7,8, standard pre-participation history and physical exams failed to identify each of eight college athletes found to have potentially lethal cardiac disorders detected by screening ECG. At the same time, in one of these studies8, 37.2% of athletes reported one or more positive responses on a history questionnaire, and 3.5% had abnormal physical exam findings. The false-positive rate for an abnormal ECG, on the other hand, was just 2.2%.

Said another way, standard history or physical exam data were positive in over one-third of athletes but did not yield a single meaningful cardiac diagnosis. Conversely, each diagnosis that was made was done so solely by ECG during an otherwise negative screen.

Importantly, proponents for more intensive cardiovascular screening state that national mandates for ECG screening are not appropriate1,9. Rather, they call for the development of a trained physician infrastructure to conduct more effective screening for targeted athlete populations.

One of the most important characteristics of a screening tool is its ability to detect the disease in question in its pre-clinical state. However, many of the cardiovascular conditions relevant to young athletes often first present as sudden death in an otherwise asymptomatic patient. As such, the practice of relying on a symptom questionnaire is inherently called into question.

When deciding whether or not to add an ECG to the standard history and physical exam to screen for silent, potentially lethal cardiovascular diseases, a clinician must remember to ask themselves one simple question: What am I really looking for? After all, widespread agreement about the purpose of cardiovascular screening, achieving early detection of athletes with at-risk disorders, already exists. However, the standard history and physical exam just isn’t enough.

It’s time to refocus.

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

Dave Siebert, MD, @DaveMSiebert is a Primary Care Sports Medicine Fellow, University of Washington. Contact: siebert@uw.edu

References

1Drezner JA, Harmon KG, Asif IM, Marek JC. Why cardiovascular screening in young athletes can save lives: a critical review. Br J Sports Med. 2016 Nov;50(22):1376-1378.

2Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence and etiology of sudden cardiac arrest and death in high school athletes in the United States. Mayo Clin Proc. 2016 Nov;91(11):1493-1502.

3Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation. 2015 Jul 7;132(1):10-9.

4Rao AL, Salerno JC, Asif IM, Drezner JA. Evaluation and management of Wolff-Parkinson-White in athletes. Sports Health. 2014 Jul;6(4):326-32.

5Maron BJ, Rowin EJ, Casey SA, Lesser JR, Garberich RF, McGriff DM, Maron MS. Hypertrophic cardiomyopathy in children, adolescents, and young adults associated with low cardiovascular mortality with contemporary management strategies. Circulation. 2016 Jan 5;133(1):62-73.

6Johnson JN, Ackerman MJ. Return to play? Athletes with congenital long QT syndrome. Br J Sports Med. 2013 Jan;47(1):28-33.

7Fuller C, Scott C, Hug-English C, Yang W, Pasternak A. Five-year experience with screening electrocardiograms in National Collegiate Athletic Association Division I athletes. Clin J Sport Med. 2016 Sep;26(5):369-75.

8Drezner JA, Prutkin JM, Harmon KG, O’Kane JW, Pelto HF, Rao AL, Hassebrock JD, Petek BJ, Teteak C, Timonen M, Zigman M, Owens DS. Cardiovascular screening in college athletes. J Am Coll Cardiol. 2015 June 2;65(21):2353-5.

9Drezner JA, O’Connor FG, Harmon KG, Fields KB, Asplund CA, Asif IM, Price DE, Dimeff RJ, Bernhardt DT, Roberts WO. AMSSM position statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2016 Sep 22.

An Open Letter to Tim Gabbett: Thank-you, I’m running harder and smarter.

27 Dec, 16 | by BJSM

By James Montgomery

RE: The training-injury prevention paradox: should athletes be training smarter and harder (Open access) Br J Sports Med doi:10.1136/bjsports-2015-095788

Dear Dr. Gabbett,

Thank you. Since reading your January 2016 article I can sincerely say I am running smarter and harder! You may ask ‘why did I decide to write a thank-you letter?’ Well there’s a story to that answer.

We (that is, my cobber and I) decided that we needed an adventure for 2016. As two dedicated fathers, the idea of a weekend run seemed as good a Father’s Day present as you’d ever get. We settled on one of NZ’s Great Walks – The Rakiura Track, Stewart Island, New Zealand.

silversea-cruises-australia-stewart-island-new-zealand-468x270

Stewart Island, NZ

Stewart Island had me sold on the idealistic idea of running 30km through dense and ancient NZ bush, along rugged and majestic coast lines and finishing with a fine plate of fresh caught Blue Cod. However, the reality was much more daunting. I hadn’t completed anything longer than 5 km for months and nothing longer than 20 km for years. How am I going to get fit enough in 14 weeks to run that far and still walk from the accommodation to the restaurant and back? As a mid-40’s recreational runner the prospect of sore hips, knees, and ankles are at an even balance compared to the picturesque beauty of NZ’s deep south.

Luckily, the chance to manifest the ‘acute:chronic workload ratio’ sweet spot was possible. And so, training commenced.

Rooted with the knowledge that under training and overtraining were real possibilities, I began the intriguing prospect of building a steady base without overloading (figure 1). I have been able to use details of your article to educate patients on load management and planning. But sometimes there is a need for experience, either in the clinic or in life, to help with the hard sell of change (figure 2). How many experienced runners train using volume + volume + volume until they break – any then keep running on anyway hoping it comes right? Sometimes convincing an old dog about new tricks requires some fundamental facts. Hence, I am using the acute: chronic loading ratio to evaluate the progress of my own training plan for this pending Rakiura 30km delight.

I have included a couple of graphs to illustrate progress so far, I am currently at week 13.

Figure 1 – Acute loading per week (km) – currently training in week 13.

Figure 1 – Acute loading per week (km) – currently training in week 13.

Figure 2 – Chronic loading – the four-week average. Currently training in week 13.

Figure 2 – Chronic loading – the four-week average. Currently training in week 13.

I’m not going to introduce an intensity variable here Tim as speed is not an issue – I don’t want to miss any photo opportunities by running too quickly! But I think using an RPE factor may be adequate for the future.

At week 8 it was too early to decide if I was near an overuse risk. At week 11 things were still on track. By week 13 I had two unplanned missed trainings but my data below indicates I’m in a training sweet spot (figure 3).

acute-chronig

Figure 3 – Acute:Chronic ratio – the sweet spot. Currently training in mid-week 13.

So, I say again – thank you Tim – I’m certainly running smarter and harder than before. There is a confidence in quantifying the process but now I’ll need to brush up on my exercise physiology because if this gets published the athletic trainers, strength and conditioning coaches and running coaches will be up in arms – where are the intervals, the Fartlek’s, the tempo’s and the recovery sessions? Maybe there’s an art to this smarter and harder stuff too?

Yours sincerely,

James Montgomery @gardensphysio

PS Don’t worry Tim, the recovery and strength work is being done too.

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

James Montgomery is the Director and Principal Physiotherapist at Gardens Physiotherapy, an independent musculoskeletal physiotherapy and sport medicine practice in Dunedin, New Zealand. James has worked in professional cricket for over six years, both nationally and internationally. He recently started his Masters in Sports Physiotherapy, is a keen recreational mountain runner and has two young daughters with a passion for the outdoors.

E-mail: james.physio@gardenshealth.co.nz

 

Should you listen to music through earphones whilst cycling?

22 Dec, 16 | by BJSM

By Chris Oliver @cyclingsurgeon

Whilst banning wearing headphones whilst cycling may seem obvious for safety reasons, this behaviour restriction could be unfounded. In the United Kingdom it is currently not illegal to wear headphones whilst cycling on public roads or cycle paths. One would think that listening to music may distract you from your surroundings. It may also prevent you from hearing other vehicles approach and thus jeopardise your own safety.

headphones-cycling

When cycling, there is a dynamic environment and a dependency on balance, speed, vision and hearing. All are required with many other factors such as wind and ice to ride safely.

Despite the common perspective that a greater ability to hear external sounds is safer and therefore better cycling practice, credible scientific evidence about cycling and wearing headphones is very limited. One Dutch paper by de Waard [2] from 2011 studied a small series of 25 subjects who wore headphones. An auditory beep was used to alert of a hazard whilst listening to music. When the headphones were worn on both ears only 68% of cyclists heard the audible stop. When just one headphone was used all audible stops were heard. The researchers also found negative effects of high volume and fast tempo on auditory perception. The problem with this study is that no consideration was given to any visual warnings. Generally cyclists will use both visual and auditory information to stay safe. Stop signals are not auditory. There are red lights, white lines, and so on. All visual. Unfortunately there is really little evidence about how cycling with headphones affects concentration.

There must also be a consideration for hearing impaired and deaf cyclists. Being deaf and driving any vehicle, being in an enclosed vehicle or riding a bicycle is also not illegal in the United Kingdom. If one was to argue that the loss of ability to hear sounds was in itself sufficient reason to prohibit cycling with headphones, one would also have to argue that deaf and partially deaf people would have to be banned from cycling. [1] Cars have music systems and therefore, logically, if one was to argue that loss of concentration through listening to music or speech was in itself sufficient reason to prohibit cycling with headphones, one would also have to argue that car stereos would have to be banned. With large numbers of pedestrians using smartphones and listening to music whilst walking one might also have to argue that this habit might have to be considered illegal?

A BBC poll conducted in 2014 resulted in almost 90 per cent questioned being in favour of a blanket ban of cycling and wearing headphones. Many respondents perceived that cyclists would be more unaware and unresponsive to dangers, and therefore more likely to be involved in incidents. One study showed that listening to your favourite artists can increase your endurance by up to 15 per cent while lowering your perception of effort [3]. Competitive cyclists often use radio earphones often just in one ear to communicate with team cars to set speed and their own power output.

Cycling and headphones causes much emotion and controversial debate, especially in the media. [4]. Victim blaming can be very upsetting in some accident situations. The facts of cycling accidents have to be absolutely established. Before anyone can come to any strong conclusions, we need further research to build up the evidence base on the use of headphones while cycling.

References

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

Professor Chris Oliver, Physical Activity for Health Research Centre, University of Edinburgh
Consultant Trauma Orthopaedic Hand Surgeon, Royal Infirmary Edinburgh

c.w.oliver@ed.ac.uk

http://tinyurl.com/ntpmtar/

Twitter: @cyclingsurgeon

International Congress on Medicine & Science in Ultra-Endurance Sports- call for submissions and funding announcement

20 Dec, 16 | by BJSM

By Martin D. Hoffman

ultra-endurance

We are pleased to announce that the 4th Annual International Congress on Medicine & Science in Ultra-Endurance Sports will be held as a 1-day pre-conference to the American College of Sports Medicine (ACSM) Annual Meeting in Denver, Colorado. The congress date is Tuesday, May 30, 2017.

With only 1 day for this Congress, we have an intense and exciting agenda.  Attendees will also find a colloquia entitled “Medical Coverage of Ultramarathons” during the ACSM meeting.  Please join us for both of these programs.  Further details on the Congress program and registration are available at: http://ultrasportsscience.us

Scientific abstract and case studies submissions for the Congress on Medicine & Science in Ultra-Endurance Sports will follow a separate process from that for the ACSM meeting.  Accepted abstracts will be published in International Journal of Sports Physiology and Performance.  Submission deadline is March 1, 2017. For process details go to: http://ultrasportsscience.us

The intent of the Congress – as the name implies-  is to bring together clinicians actively involved in providing care for ultra-endurance athletes and scientists performing research related to these activities.  The Congress has been attracting key players in this regard, particularly as related to ultramarathon running.  It’s probably fair to refer to the Congress speakers as the “rock stars” of ultramarathon science and clinical care.  Details on the programs and published abstracts from past Congresses can be found at the following site: http://ultrasportsscience.us

Introducing the Ultra Sports Science Foundation

ultra-sports-science-foundation

As in other areas of exercise and sports science research, securing proper funding for research related to ultra-endurance sports is often a challenge. This limits the number and types of studies that are undertaken.  A new non-profit foundation, the Ultra Sports Science Foundation (www.ultrasportsscience.org), will hopefully provide at least some relief in this regard. An intent of this foundation is to become a viable funding source for research related to ultra-endurance sports. The foundation also has an educational mission, and now oversees the annual Congress on Medicine & Science in Ultra-Endurance Sports.  If you are aware of individual or corporate connections who might value contributions to this organization, please contact me.

Martin D. Hoffman, MD, FACSM

Congress Program Director

Founding Member, Ultra Sports Science Foundation

m.hoffman@ultrasportsscience.org

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