You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

From population based norms to personalised medicine: Health, Fitness, Sports Performance

22 Feb, 17 | by BJSM

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. – World Health Organisation 1948

By Dr Nicky Keay

There has been criticism of this definition, arguing that the word “complete” has opened the door to today’s more medicalised society. However, this trend coincides with increased volume of “patients” seeking optimal health, together with doctors who have a more extensive repertoire of medical interventions at their disposal. In a time-pressed society there is less opportunity for either patient or doctor to explore longer term adaptive measures and prevention strategies, which facilitate taking responsibility for your health. Fortunately Sport and Exercise Medicine became a recognised medical specialty in the UK in 2006. This encompasses population-based strategies for disease prevention outlined in the global initiative founded in 2007 “Exercise is Medicine“.

What has this got to do with sports performance? There are subgroups within the population, such as athletes already taking plenty of exercise. Elite athletes differ from the general population, due to superior adaptation processes to exercise, probably with a genetic component. So are the same “normal” population-based ranges of quantified medical parameters applicable?

This is precisely the issue that arose when I was on the international medical research team investigating the development of a dope test for growth hormone (GH). Crucially, exercise is one of the major stimuli for growth hormone release from the anterior pituitary. So before we could even start investigating potential downstream markers of exogenous GH abuse, the “normal” range for elite athletes had to be established.

Father and son compete in running race: How will their endocrine markers differ across age and fitness levels?

In a similar way, are the “normal” ranges for other hormones applicable to athletes? In a fascinating lecture delivered by Dr Kristien Boelaert, Consultant Endocrinologist, it was explained that the distribution for thyroid stimulating hormone (TSH) is affected by multiple factors, including illness, age and exercise status. So “normal” for the general population is not necessarily normal for specific subgroups.

The other issue, especially with the Endocrine system is that hormones act on a variety of tissues and so produce a variety of multi-system network effects with interactions and control feedback loops. Therefore symptoms of malfunction/maladaptation and subclinical conditions can be non specific. From a doctor’s perspective this makes Endocrinology fascinating detective work, but challenging when dealing with subgroups in the population who require a more intensive work-up and individualised approach.

The vast majority of research studies involve exclusively male athletes, leaving female athletes under-represented (a recent study on heat adaptation in female athletes being a notable exception). Some areas of research, including my own, have been directed more towards female athletes in the case of female athlete triad, or Relative Energy Deficiency in sports (REDs). REDs is a more appropriate term as it really sums up the important points: male and female can both be affected and therefore should both be studied. There are subgroups within the general population who may not fit the “normal” range: REDs is not necessarily a clinically defined eating disorder from lecture by Professor J. Sundgot-Borgen (IOC working group on female athlete triad and IOC working group on body composition, health and performance).

No medical/physiological/metabolic parameter can be considered in isolation: in the case of REDs, it is not menstrual disturbance and bone health that are affected in isolation. For example, there is currently great debate about whether a low carbohydrate/high fat diet (ketogenic diet) can mobilise fat oxidation and potentially be a training strategy to enhance performance. Needless to say that a recent study contained no female athletes. Given that many female endurance athletes are already lean, potentially driving fat metabolism through diet manipulation may have an impact on Endocrine function, optimal health and hence sport performance. I understand that a forthcoming study will include female athletes.

So a continuum or distinct subgroups in the population? Clearly general medical principles apply to all, with a spectrum from optimal functioning, subclinical conditions through to recognised disease state. We now have evidence of distinct differences between subgroups in the population and even within these subgroups such as male and female athletes. We are moving into a world of personalised medicine, where recommendations for optimal health are tailored for individuals within specific subgroups.

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

Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP, Clinical and research experience in Endocrinology applied to Sport and Exercise Medicine.

Publications

“Subclinical hypothydroidism in athletes”. Lecture by Dr Kristeien Boelaert at BASEM Spring Conference 2014 on the Fatigued Athlete

Awards

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, BAEM Spring Conference 2015 on the Female Athlete

Low Carbohydrate, High Fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers

References

How should we define health?

Nobody is average but what to do about it? The challenge of individualized disease prevention based on genomics

Exercise is Medicine

Enhancing Sport Performance: part 1

Effect of adaptive responses to heat exposure on exercise performance

(USEMS) Q and A with Sam Blanchard: An insight into working in elite sport

20 Feb, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine

By Sam Blanchard, Liam Newton, and Jonathan Shurlock

Undergraduate Sports and Exercise Medicine Society (USEMS) recently hosted an online Q&A session, via Twitter with Sam Blanchard (@SJBPhysio_sport) – Academy Clinical Lead & International Women’s Lead Physiotherapist for Scottish Rugby Union (SRU). For those who missed it we’ve highlighted the key interactions, and some of our personal insight into working in elite sport. We’ve taken some of Sam’s answers directly from his replies to some of the questions he received throughout the Q&A evening.

Q: How did you make your first steps into professional sport?

SB: “Putting in the hours. Continuously wanting to learn, being open to criticism, reflecting and reacting. A key moment (of realisation) was lone working and feeling out of my depth. So I looked for supported opportunities.”

The idea of working in a supportive environment is essential for safe practice and your ability to learn from your experience. As a student or new graduate working full-time within a professional sports medicine team can be difficult to achieve, however semi-professional sport often provides a great stepping stone. As Sam mentioned, it’s important to seek out a club that has qualified staff to work under to help develop your clinical decision making and ensure your work tasks are suited to your current scope of practice.

Sam and the SRU recently advertised for 2 Junior positions to address this very issue and offer a structured development plan for those wanting to make the step into elite sport. First Aid/trauma course certification and basic insight into sports tapping and massage are essential. Having these extra skills will make you more valuable to a club. When contacting them it’s important to highlight what YOU can offer them!

Sam highlighted the importance of not working from an isolated and vulnerable position, in his answer to a later question:

Q: What do you think are the most important practical skills to learn in order to be a successful practitioner?

SB: “regardless of method, clinical reasoning underpins everything. Continually ask “why” to yourself and colleagues. Clinical reasoning for exercise rehabilitation provides you with tools not ‘answers’.”

Regardless of your experience, expose yourself to different practitioners and schools of thought. It’s important to find ways of thinking that suit you and your personality, to back this up, where possible, with evidence based research and slowly become your own clinician. Organise continuous professional development  (CPD) visits to different organisations and even different sports, as medical care very often transposes athletic demands.

 

Q: How often does your advice conflict with that from the medic? How do you deal with that?

SB: “In my experience, very rare! Understanding of roles & level of knowledge crucial. Recognise your own limitations & others’ strengths.”

Q: How would you recommend medical students learn about the basic principles of rehabilitation?

SB: “Try the exercises before prescribing. And be prepared to steal ideas from Twitter…”

Sam has written a really interesting piece on exercise rehabilitation, which can be found here. Improving your rehabilitation skills takes time and is as much an art as a science. Thus it is important to try out ideas, reflect on what has or hasn’t worked and learn from that. Setting an identity or purpose to a rehabilitation session ensures meeting the correct physiological adaptations. There is a great paper here on bridging the gap between training and rehabilitation, here on how to apply the principles of strength and conditioning into rehabilitation as well as how optimal loading can be used in the rehabilitation process.

Q: What qualities do you look for when interviewing/shortlisting a young Physio?

SB: “awareness of own limitations, humility, social skills, work ethic… and tea making ability”

Q: What do you think about increased ACL/knee damage post ankle injury?

SB: “GRF’s feed up so loss of range or proprioception or ability to decelerate would make sense for increased risk.”

Although it’s from a few years back, there’s a great literature review on this topic, which highlights some of the clear evidence for an increased risk of re-injury, particularly with inadequate rehabilitation. You can find that review here.

Q: Any courses or conferences you’d recommend to students or new grads?

SB: “Don’t just stick to your own professional courses. Explore S&C/sports science/coaching”.

Although a light-hearted tweet to finish on, extracurricular courses and CPD are a really important consideration throughout your training and post-graduation. And they often come with a hefty price tag. There are a number of student discounts available to courses such as Isokinetic Football Medicine Conference as well as through BASEM and our very own USEMS student conference – so look out for these. As rich an education resource these courses may be, it is important that you are working with a patient population that allows you to apply the newly acquired knowledge, making the money spent, a wise investment.

***********

Sam Blanchard is Academy Clinical Lead & International Womens Lead Physiotherapist for Scottish Rugby Union. You can find him on twitter @SJBPhysio_sport

Liam Newton works as a musculoskeletal physiotherapist in the NHS as well as AFC Bournemouth Academy. You can find him on twitter @newton_liam

Jonathan Shurlock is an academic foundation year 1 doctor based in Sheffield. He coordinates the BJSM Undergraduate Perspective blog series. Please send your blog feedback and ideas to: jhshurlock@gmail.com ; or Tweet @J_Shurlock

 

 

A review of Cardiio: an app to accurately measure heart rate at rest and after exercise using imaging photoplethysmography

17 Feb, 17 | by BJSM

By Saúl Martín Rodríguez

APP REVIEW

NAME OF MOBILE APPLICATION

Cardiio – Heart Rate Monitor + 7 Minute Workout

PLATFORM

Compatible with any iOS device (iPhone, iPad, and iPod touch) with iOS 7.0 or later.

COST

Lite version – free; Pro version – $A6.99

Current version is V.3.3.3 which has support to any iPhone, iPad and iPod Touch with iOS 7.0 or later installed.

ABOUT THE APP

Heart rate (HR) monitoring is an important component in cardiovascular fitness assessment and training programmes, especially in clinical populations1. Cardiio (figure 1) measures HR (i.e., pulse) at rest and after exercise using imaging photoplethysmography (PPG), i.e., tiny changes in reflected light from either fingers or face which can be detected by the in-built rear camera.  PPG is a noninvasive optical method accepted in the clinical use2 for the measurement of arterial oxygen saturation and basically consist of detecting variations of the light absorption caused by arterial blood-volume pulsations. To correctly record HR in the finger mode (figure 2), users should make sure that their fingers are not cold and lightly cover the entire back camera without pressing too hard to avoid blood flow restriction. Additionally, to correctly record HR in the face mode, users should make sure that their face is clearly visible and take the measurement in a well-lit area so the face is well illuminated. A recent study3, using 40 healthy adults without any heart condition or pacemakers, demonstrated the Cardiio app installed on an iPhone 6S to have a very strong agreement both at rest (r = 0.99 for finger, r = 0.97 for face) and after exercise (r = 0.99 for finger, r = 0.97 for face). Moreover, the accuracy of the Cardiio app at rest was ±1.58 beats per minute (bpm) (or ±2.27%) using the finger mode and ±2.28 bpm (or ±3.17%) for the face mode, compared to a pulse oximeter. After moderate to vigorous exercise, the accuracy of the Cardiio app was ±2.97 bpm (or ±2.79%) using the finger mode and ±5.31 bpm (or ±4.50%) for the face mode, compared to the pulse oximeter. These data support the use of Cardiio to accurately measure HR at rest and after exercise, making the app an important tool for educational purposes and/or to support general health and wellness.

USE IN CLINICAL PRACTISE

Adherence to physical activity programmes clearly provides numerous health benefits, perhaps most important of which is a significant decrease in the risk for cardiovascular disease and mortality4.  The HR response at rest, after exercise and into recovery is a basic physiological measurement which clearly indicates the fitness level. There are currently several commercially available devices such as activity trackers or HR monitor watches, however, most of them are not scientifically validated or are expensive (>A$100). This easy-to-use and low cost app could be used by clinicians, researchers or in educational environments, or by users to self-monitor their HR at rest and after exercise for self-or clinician review.  Therefore, Cardiio will help users to adjust their workout to ensure that they will get favorable results from a physical activity program and/or to gauge their progress.

PROS

  • Demonstrated validity compared to a finger pulse oximeter
  • Ability to save unlimited participants and trials
  • Ability to export data as .csv file
  • Ability to synchronize data with Apple Health and RunKeeper (https://runkeeper.com/)
  • Integration with social media (Facebook and Twitter) to share data
  • Includes the “7-minute workout” which is a high-intensity circuit training program based on a scientific study published in the American College of Sport Medicine´s Health and Fitness Journal
  • Multiple language support (English, Dutch, French, German, Italian, Japanese, Korean, Portuguese, Russian, Simplified Chinese, Spanish, Swedish, and Traditional Chinese)

CONS

  • iOS only, not available on Android or Windows smartphones
  • Validated just in healthy adults
  • Validated just with the iPhone 6S
  • Need to upgrade to the Pro version to obtain new features (fitness level, potencial life expectancy, endurance score, target heart rate, waveform/graph representation, caloric burn, and calorie-burn estimator) which use validated equations based on scientific publications

REFERENCES

  1. Arnold JM, Fitchett DH, Howlett JG, et al. Resting heart rate: a modifiable prognostic indicator of cardiovascular risk and outcomes? Can J Cardiol 2008;24 Suppl A:3A-8A.
  2. Kamshilin AA, Nippolainen E, Sidorov IS, et al. A new look at the essence of the imaging photoplethysmography. Sci Rep 2015;5:10494. doi: 10.1038/srep10494
  3. Poh MZ, Poh YC. Validation of a Standalone Smartphone Application for Measuring Heart Rate Using Imaging Photoplethysmography. Telemed J E Health 2017 doi: 10.1089/tmj.2016.0230
  4. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ 2006;174(6):801-9. doi: 10.1503/cmaj.051351

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

Saúl Martín Rodríguez,  @smrodguezDepartment of Physical Education, University of Las Palmas de Gran Canaria, Gran Canaria, Spain

BJSM has no commercial conflict of interest the posting of this blog. 

Heading for trouble: is dementia a game changer for football?

15 Feb, 17 | by Karim Khan

 by  A Rutherford1, W. Stewart2 & D. Bruno3

1 School of Psychology, Faculty of Natural Sciences, Keele University

2 Queen Elizabeth University Hospital & Institute of Neuroscience & Psychology, University of Glasgow

3 School of Natural Sciences & Psychology, Liverpool John Moores University

Correspondence:    Dr Andrew Rutherford (arutherford@keele.ac.uk)

Introduction

2016 marked the 50-year anniversary of England’s 1966 World Cup win.  However, celebrations were tempered by commentaries on the number of players in the winning squad with dementia, and questions whether football (soccer) heading damaged long-term brain health [1].  This theme continued through 2016, culminating with the Professional Footballers Association calling for a review of the game, specifically whether to follow the lead of United States Soccer and ban heading for younger players [2].

Given these rising concerns, and over 150 years since their introduction, is it indeed time for change in the rules of association football – is there evidence to support current anxieties that football increases risk of dementia, and heading is to blame?

(No) Data on dementia risk in football

Remarkably, despite phenomenal football participation rates globally and centuries of participation, there is little evidence regarding its impact on brain health, beyond anxiogenic anecdotes.  Multiple reviews of the available research literature in this field have drawn the same conclusion: evidence for an association between football and long-term neurological or cognitive deficits is weak, to non-existent [3, 4].  However, a common feature of most research on this topic in football so far has been the recruitment and study of young active footballers; arguably too young to show late cognitive effects.

This limitation was addressed to an extent by a small self-assessment study conducted with former UK professional footballers aged 55 and over, in which 10 of 92 (11%) respondents screened positive for possible mild cognitive impairment, while 2 (2%) met the criteria for possible dementia [5]; figures the authors suggested as consistent with general population expectations.  However, with such a limited sample, absence of a matched control group, and a study methodology open to case selection bias, beyond “more work is required”, no meaningful conclusion can be drawn.

 

(Confounding) Data on consequences of heading

Research on the specific consequences of football heading is sparse, with one recent small study reporting evidence of short-lived impairment in cognitive and electrophysiological assessments after a single session of heading in young footballers [6].  However, here again, no controls were included and the effects normalised within 24h.  As such, while intriguing, the data provide no insight into long-term consequences of heading.  Indeed, whether this is a consequence of heading, per se, or arises through some other mechanism, remains unanswered.

Regarding late consequences of heading, the data are mixed and limited.  No correlation between heading frequency and performance in neurocognitive assessments is reported in a majority of studies, while the remainder report only a minor influence of heading [4].  However, surprisingly few studies control for the confounding effect of increased numbers of head injuries sustained by those who head more frequently [3].  Intriguingly, an inverse correlation between degree of exposure to heading and MRI measures of cortical thickness in former professional footballers has been reported and, in turn, associated with cognitive performance [7].  However, here again, data are mixed in the few imaging studies to date, with no direct correlation reported in others [3, 4].

Do footballers’ brains look like boxers’?

There is increased recognition of chronic traumatic encephalopathy (CTE) in non-boxer athletes in a growing list of sports [8], including isolated exemplar cases in former footballers [9].  However, while isolated cases capture headlines, they provide no insight into risk of CTE in a sport, let alone enlightenment on causality.  Notably, there are no validated operational diagnostic criteria for CTE, which still requires autopsy for confirmation [8].  As a consequence, clinical awareness remains low, with exceptionally few suspected cases undergoing autopsy evaluation.  Nevertheless, it remains premature, if not inappropriate, to equate the neuropathological consequences of football to a lifetime of boxing based on isolated cases.

Work to do before rule change is informed

By current evidence, therefore, it would seem concerns and anxieties around participation in football, specifically the act of heading the ball, and risk of dementia may be premature, if not misplaced.  Nevertheless, it must be acknowledged there is growing public anxiety around the consequences of exposure to brain injury in sport, in part fuelled by increasing recognition of CTE in former athletes, including former footballers.

However, in reality, there are remarkably few robust and enlightening data on the long term neuropsychological health of former footballers, or on the lasting consequences of football heading, with much of the research to date beset by methodological deficiencies.  So, while current evidence does not demand rule change, neither does it provide football with a clean bill of health.  Instead, to inform discussions and assuage anxieties, there is a pressing need for appropriately designed and powered research studies to address questions over dementia risk in former footballers and any long-term consequences of heading.  Until then, recommendations on heading in association football can be driven only by opinion, not by scientific evidence.

 

References

1  Wilson, J. (2016a).  Football’s silent shame: Dementia ‘conspiracy’ is a stain on the game.  Downloaded on 10 January 2017 from, www.telegraph.co.uk/football/2016/05/30/footballs-silent-shame-dementia-conspiracy-is-a-stain-on-the-gam/.

2  Wilson, J. (2016b).  PFA urges FA to consider ban on heading for children under 10.  Downloaded on 10 January 2017 from, www.telegraph.co.uk/football/2016/12/29/pfa-urges-fa-consider-ban-heading-children-10/.

3  Rutherford, A., Stephens, R. & Potter, D. (2003).  The neuropsychology of heading and head trauma in association football (soccer): a review. Neuropsychology Review, 13, 153–179.

4  Tarnutzer, A.A., Straumann, D., Brugger, P. & Feddermann-Demont, N. (2016).  Persistent effects of playing football and associated (subconcussive) head trauma on brain structure and function: a systematic review of the literature.  British Journal of Sports Medicine, Published Online First: 4 November, 2016.  doi: 10.1136/bjsports-2016-096593.

5  Vann Jones, A.S, Breakey, R.W. & Evans, P.J. (2014).  Heading in football, long-term cognitive decline and dementia: evidence from screening retired professional footballers.  British Journal of Sports Medicine, 48, 159-161.  doi: 10.1136/bjsports-2013-092758.

6  Di Virgilio, T.G., Hunter, A., Wilson, L., Stewart, W., Goodall, S., Howatson, G., Donaldson, D.I. & Ietswaart, M.  (2016).  Evidence for acute electrophysiological and cognitive changes following routine soccer heading.  EBioMedicine, 13, 66-71.

7  Koerte, I.K. et al (2016).  Cortical thinning in former professional soccer players.  Brain Imaging Behavior, 10, 792-798.

8  Smith, D. H., Johnson, V. E. & Stewart, W.  (2013).  Chronic neuropathologies of single and repetitive TBI: substrates of dementia?  Nature Reviews Neurology, 9, 211-221.

9  Hales, C. et al, (2014).  Late-stage CTE pathology in a retired soccer player with dementia.  Neurology, 83, 2307-2309.

Professional Recognition in Sport and Exercise Medicine Now Available to all UK Doctors

14 Feb, 17 | by BJSM

News Release

13 February 2017

The Faculty of Sport and Exercise Medicine UK (FSEM) is opening its doors by enabling all medical doctors with skills in Sport and Exercise Medicine (SEM) to sit a new Membership Exam and apply for membership of the FSEM; the recognised, professional organisation which sets standards in SEM.

The skills base included in SEM; musculoskeletal (MSK) medicine, exercise medicine, physical activity assessment and team care are being increasingly recognised by the NHS and can provide much needed knowledge to help prevent and manage many of the common conditions and diseases seen today.

Dr Paul D Jackson, President of the Faculty of Sport and Exercise Medicine, comments: “We are pleased to be able to offer all doctors working across the spectrum of Sport and Exercise Medicine, the chance to be part of our specialty via a skills and knowledge based qualification.

“It is important that the FSEM supports the development of doctors working in musculoskeletal medicine, exercise medicine and team care at all levels. This will maintain standards of excellence and best practice for patients, which range from elite athletes to people recovering from illness and injury or managing a long term condition.”

The FSEM’s new Membership Exam will provide a national standard for those working in Sport and Exercise Medicine. This will allow those who appoint team doctors, or commission care, to identify those doctors with an appropriate level of training.

SEM has an application across both primary and secondary care. MSK Medicine and Exercise Medicine have the skills to help deliver ‘a radical upgrade in prevention and public health’[i]. The FSEM supports the ongoing skills, development and standards of SEM practitioners across the UK and sets the curriculum for higher specialty training.

The FSEM Membership Exam parts 1 and 2 will be available from September 2017. Further details can be found on the FSEM’s Membership Exam webpage.

[i] NHS Five Year Forward View 2014

Sleep for health and sports performance

7 Feb, 17 | by BJSM

 “Sleep.. chief nourisher in life’s feast,” Macbeth.

By Dr Nicky Keay

A recovery strategy vital to support both health and sport performance, during all stages of the training cycle is sleep. In this blog I outline the importance of sleep for athletes of all ages and calibres.

Young athletes

Sufficient sleep is especially important in young athletes for growth and development and in order to support adaptive changes stimulated by training and to prevent injury[1]. Amongst teenage athletes studies show that a lack of sleep is associated with higher incidence of injury[2]. This may be partly due to impaired proprioception associated with reduced sleep. Sleep is vital for consolidating neurological function and protein synthesis, for example in skeletal muscle and in the longer term bone mineral density[3]. Sleep and exercise are both stimuli for growth hormone release from the anterior pituitary, which mediates some of these adaptive effects[4].

Sufficient sleep quality and quantity

Sufficient sleep is especially important for athletes in heavy training. Lack of sleep can interfere with functioning of the immune system due to disruption of the circadian rhythm of secretion in key areas of the Endocrine system[5]. Athletes in heavy training, with high “stress” loads and associated elevated cortisol can also experience functional immunosuppression. So a combination of high training load and insufficient sleep can compound to disrupt efficient functioning of the immune system and render athletes more susceptible to illness and so inability to train, adapt and recover effectively.  In overreaching training, lack of sleep could be either a cause or a symptom of insufficient recovery. Certainly sleep deprivation impairs exercise performance capacity (especially aerobic exercise) although whether this is due to a psychological, physical or combination effect is not certain[6].

Sufficient sleep quality and quantity is required for cognitive function, motor learning, and memory consolidation. All skills that are important for sport performance, especially in young people where there is greater degree of neuroplasticity with potential to develop neuromuscular skills[7]. In a fascinating recorded lecture delivered by Professor Jim Horne at the Royal Society of Medicine[8], the effects of prolonged wakefulness were described. Apart from slowing reaction time, the executive function of the prefrontal cortex involved in critical decision making is impaired. Important consequences not only for athletes, but for doctors, especially for those of us familiar with the on call system in hospitals back in the bad old days. Sleep pattern pre and post concussive events in teenage athletes[9] is found to be related to degree and duration of concussive symptoms post injury. The explanation of how sleep deprivation can cause these functional effects on the brain has been suggested in a study where subtle changes in cerebral structural neuronal structure[10] were recorded. It is not known whether these changes have long term effects.

Strategies to maximize positive benefits of sleep

So given that sleep is essential not only for health and fitness, but to support sports performance, what strategies maximise this vital recovery process? Use of electronic devices shortly before bedtime suppresses secretion of melatonin (neurotransmitter and hormone), which is not conducive for sleep. Tryptophan is an amino acid precursor in the synthesis of melatonin and serotonin (neurotransmitter) both of which promote sleep[11]. Recent research demonstrates that protein intake before bed can support skeletal and muscle adaptation from exercise and also recovery from tendon injury [12] . Conversely there is recent report that low levels of serotonin synthesis may contribute to the pathogenesis of autoimmune inflammatory disease[13] such as rheumatoid arthritis. This highlights the subtle balance between degree of change required for positive adaptation and a negative over-response, as in inflammatory conditions. This balance is different for each individual, depending on the clinical setting. So maybe time to revisit the warm milky drink before bed? Like any recovery strategy, sleep can also be periodised to support exercise training, with well structured napping during the day as described by Dr Hannah Macleod, member of gold winning Olympic Hockey team[14].

In conclusion, when you are planning your training cycle, don’t forget that periodised recovery to compliment your schedule should be factored in, with sleep a priority recovery and adaptation strategy.

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

If you want to read more about short and long term strategies to improve sport performance read my blog (on my personal page): Balance of recovery and adaptation for sports performance

 Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP, Clinical and research experience in Endocrinology applied to Sport and Exercise Medicine

[1] Milewski MD, Skaggs DL, Bishop GA, Pace JL, Ibrahim DA, Wren TA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of pediatric orthopedics. 2014 Mar;34(2):129-33

[2] Luke A, Lazaro RM, Bergeron MF, Keyser L, Benjamin H, Brenner J, et al. Sports-related injuries in youth athletes: is overscheduling a risk factor? Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2011 Jul;21(4):307-14

[3] Keay N, Dancing through adolescence. Editorial, British Journal of Sports Medicine, vol 32 no 3 196-7, September 1998.

[4] Keay N, Logobardi S, Ehrnborg C, Cittadini A, Rosen T, Healy ML, Dall R, Bassett E, Pentecost C, Powrie J, Boroujerdi M, Jorgensen JOL, Sacca L. Growth hormone (GH) effects on bone and collagen turnover in healthy adults and its potential as a marker of GH abuse in sport: a double blind, placebo controlled study. Journal of Endocrinology and Metabolism. 85 (4) 1505-1512. 2000

[5] Lange T, Dimitrov S, Born J. Effects of sleep and circadian rhythm on the human immune system. Annals of the New York Academy of Sciences. 2010 Apr;1193:48-59.

[6] Hausswirth C, Louis J, Aubry A, Bonnet G, Duffield R, Le Meur Y. Evidence of Disturbed Sleep and Increased Illness in Overreached Endurance Athletes. Medicine and science in sports and exercise. 2013 Oct 1.

[7] Myer GDFaigenbaum ADFord KRBest TMBergeron MFHewett TE When to initiate integrative meuromuscular training to reduce sports-related injuries and enhance health in youth? Curr Sports Med Rep 2011 May-June:10(3):155-66

[8] “Sleepiness and critical decision making”. Recorded lecture Professor Jim Horne, Royal Society of Medicine 16/11/16

[9]  Sufrinko A, Pearce K, Elbin RJ, Covassin T, Johnson E, Collins M, et al. The effect of preinjury sleep difficulties on neurocognitive impairment and symptoms after sport-related concussion. The American journal of sports medicine. 2015 Apr;43(4):830-8.

[10] Bellesi M, Pfister-Genskow M, Maret S, Keles S, Tononi G, Cirelli C.
Effects of sleep and wake on oligodendrocytes and their precursors.
J Neurosci. 2013 33: 14288–14300. DOI: 10.1523/JNEUROSCI.5102-12.2013

[11]  Hartmann E. Effects of L-tryptophan on sleepiness and on sleep. Journal of psychiatric research. 1982;17(2):107-13.

[12] Jorn Trommelen, Luc J. C. van Loon Pre-Sleep Protein Ingestion to Improve the Skeletal Muscle Adaptive Response to Exercise Nutrients 2016, 8(12), 763

[13] Yasmine Chabbi-Achengli, Tereza Coman, Corinne Collet, Jacques Callebert, Michelangelo Corcelli, Hilène Lin, Rachel Rignault, Michel Dy, Marie-Christine de Vernejoul, Francine Côté
Serotonin Is Involved in Autoimmune Arthritis through Th17 Immunity and Bone Resorption
The American Journal of Pathology, 2016; DOI: 10.1016/j.ajpath.2015.11.018

[14] “Science in Elite Sport” Dr Hannah Macleod, University of Roehampton, 6/12/16

 

Anti-doping and the physician’s role: how do we overcome the challenges in elite sport?

3 Feb, 17 | by BJSM

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

By Roman Gaehwiler

Since the introduction of the World Anti-doping Agency (WADA) in November 1999, antidoping efforts have become much more organized and professional. However, illegal doping practices have also become more embedded and complex…

Contemporary elite sports are characterized by a prohibition of doping with strict rules and elaborate procedures. Nevertheless, the prevalence of doping and illicit drug use in elite sports (members of national teams) estimated on behalf of a randomised response interrogation technique (RRT), accounted for 6.8%. Whereas official doping examination procedures reveal 0.81% of positive test in all elite athletes (1). This mismatch cannot be neglected. How do we address these grievances? Within the course of this blog we will work out three key elements that comprise the challenges of an early-career sports physician’s daily work. Finally, we recommend the implementation of principles in future efforts towards a stringent antidoping policy, one where medical doctors take over a predominant role in its prevention.

Challenge 1: The Universe of Elite Sports has its own laws

If an adequate protection of athletes is the goal, as WADA states, it is important to acknowledge and critically evaluate the specific context of professional sports rather than simply insisting on ever-stricter doping controls. Whereas sports as a leisure activity emphasizes intrinsic satisfaction (in the sense of an “autotelic play” (2), social interaction) and health promotion, the purpose of professional sports in modern society could be reduced to entertainment and willingness to take risks as an essential feature of every protagonist. Consequently, the borderline of “wrong and right” becomes blurry, especially for athletes themselves. This might be what former Irish cyclist Paul Kimmage had in mind when he stated: “And yet one thing is becoming clear to me: as soon as you started playing, as soon as you accepted the taking of medication, the line between what was legal and what was illegal, between taking care of yourself and doping grew very, very thin” (3).

Intense competitions such as the Tour de France require weeks of top performance that promote doping activities. During the Tour – a race of approximately 3600 kilometres within 23 days – cyclists sometimes get infusions for nutrition and hydration (4), as the human body is physiologically unable to restore its stock until the subsequent stage. When critics ask – in the light of doping scandals – why the race is not being adjusted to a more humane level? The reply is usually that spectators would lose interest. Break-downs, accidents, and doping scandals have become part of the Tour de France as a show event. Under such circumstances, it seems somewhat cynical to insist on a prohibition of doping by appealing to concern for athletes’ well-being (5).

As physicians we are obliged to protect, preserve and promote the health and physical integrity of our athletes! Especially within the parallel universe of elite sports where pharmaceutical agents are ubiquitous in order to reach or maintain the expected top-level performance and serve the commercial interests at stake.

Challenge 2: Professional Athletes are Susceptible for Doping

Protecting athletes from professional sports’ negative long term health consequences cannot be limited to restricting access to certain substances. As sports physicians, we have to keep in mind that elite athletes do represent a vulnerable and manipulable cohort (6). In 1994 Goldman interviewed several professional athletes in order to find out how far they are willing to go for a guaranteed success in their sport. More than 50% of them were willing to take a substance in order to win the gold medal although the substance would cause death within 5 years (7). Not surprisingly, these results could not be reproduced within a cohort of leisure athletes (8). As doctors, we have to be aware of this psychological feature in order to identify and prevent drug abuse in athletes.

Challenge 3: Medical Ethics is underrated in Sports Medicine

As physicians, we are not immune to the temptations of the spotlight. Thus, criminal medical experts have facilitated subtle artificial performance enhancement within a controlled anti-doping framework. In the past, various medical experts have instrumentalized and suggested athletes as human test organisms for performance enhancing substances or even genetic enhancement. In 1958 John Bosley Ziegler (team physician of US-weightlifters) was heavily involved in the development of an androgenic anabolic steroid called Methandrostenolon (Dianabol), which has been distributed by Ciba Pharmaceuticals and abused by several athletes. During 1960-1970, the department of Sports Medicine at Albert-Ludwigs University in Freiburg (Germany) performed systematic research in artificial performance enhancement. In 2003, Victor Conte, founder of Bay-Laboratory-Co-Operative (BALCO), was pleading guilty to distribute steroids to professional American sprinters (9). Grigori Rodschenkow, 2006-2015 head of the WADA antidoping laboratory in Moscow, has been a key player in Russia’s national doping program described in the McLaren-Report 2016 (10). Concerning this, philosopher Torbjörn Tännsjö argues: “In elite sport we can test out the results of such enhancements and see, not where the limits are of the (given) human nature, but how far we can push them. And we can thank the athletes for taking the inconvenience to test them out before us”(11). It sounds like a fantastic service rendered to humanity, but it also means simply exploiting the vulnerability of those keen to become or remain professional athletes. Regarding this, basic knowledge in medical ethics must be an essential component within the education of the next generation of (sports) physicians.

Conclusion

In order to create a credible and sustainable anti-doping practice that protects, preserves, and promotes athletes’ health, future sports physicians need to assume the role of ‘independent counsellor’ of athletes’ physical integrity. It also requires attention to the explicit and implicit norms which govern the elite sporting world, and make its protagonists as susceptible to dependence. Politics and spectators must provide the policy and cultural infrastructure to implement such efforts.

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

Acknowledgements: Thanks to Professors Nikola Biller-Andorno (Director Institute for Biomedical Ethics, University of Zuerich, Switzerland) and Perikles Simon (Chief of Department of Sports Medicine, University of Mainz, Germany) who critically reviewed parts of this text.

Roman Gaehwiler, MD, is a PhD student in the field of artificial performance enhancement in sports at Institute of Biomedical Ethics at the University of Zurich. Currently, he works as a clinical physician in a hospital in Zurich (Switzerland) and is part of the medical team of Women’s Swiss National Ice-Hockey team.

Email: Roman.Gaehwiler@usz.ch

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 for further information.

References:

  1. Striegel H, Ulrich R, Simon P. Randomized response estimates for doping and illicit drug use in elite athletes. Drug Alcohol Depend. 2010;106(2-3):230-2.
  2. Schmid SE. Reconsidering Autotelic Play. Journal of the Philosophy of Sport 2009;36:238-57.
  3. Kimmage P. Rough Ride: Behind the wheel with a pro cyclist. London: Yellow Jersey Press 2001:94.
  4. Lenk H. Denkperlen 06 “Dopium fürs Volk?”: Werte des Sports in Gefahr. Hamburg: merus verlag, Hamburg 2007:24 (comment of Jörg Jaksche).
  5. Schneider AJ, Rupert JL. Constructing Winners: The Science and Ethics of Genetically Manipulating Athletes. Journal of the Philosophy of Sport 2009;36:182-206, originally in Hanson, RW, Hakimi, P. “Born to run; the story of the PEPCK-Cmus mouse.” Biochimie 2008;90(6):838-42.
  6. Connor J, Woolf J, Mazanov J. Would they dope? Revisiting the Goldman dilemma. Br J Sports Med. 2013;47(11):697-700.
  7. Goldman B, Bush P, Klatz R. Death in the locker room. London: Century; 1984.
  8. Connor JM, Mazanov J. Would you dope? A general population test of the Goldman dilemma. Br J Sports Med. 2009;43(11):871-2.
  9. Fainaru-Wada M, Williams L. Game of Shadows: Barry Bonds, BALCO, and the Steroids Scandal that Rocked Professional Sports  Gotham Books; 2006.
  10. https://www.wada-ama.org/en/resources/doping-control-process/mclaren-independent-investigations-report-into-sochi-allegations.
  11. Tännsjö T. Medical Enhancement and the Ethos of Elite Sport. In: Savulescu J, Bostrom N, eds. Human Enhancement. Oxford University Press 2009: 315-26.

New (free, online) course highlights the importance of physical activity in healthcare services

1 Feb, 17 | by BJSM

  • NEW Exercise and Health course by Peoples-uni, pulls together a set of presentations developed by an international team of experts, led by Ann Gates, CEO of Exercise Works
  • The program contains data from different countries and encourages students to perform interventions to increase physical activity locally and/or nationally.

Peoples-uni, the UK-based charity focused on providing affordable education in Public Health, recently debuted its new short online course, Exercise and Health: http://ooc.peoples-uni.org/course/view.php?id=22. The course is based on a set of world class presentations prepared by an international team of experts in exercise and health, led by Ann Gates, CEO of Exercise Works and a member of the World Heart Federation Emerging Leaders Programme. This organization is dedicated to leading the global fight against cardiovascular disease (CVD), including heart disease and stroke and other non-communicable diseases (NCDs) with physical activity and exercise.

The course is an inter-disciplinary educational resource designed to help global healthcare professionals and community health advocates understand four important points:

  • The size of the problem of physical inactivity in populations globally
  • The role of physical inactivity in non-communicable diseases
  • The benefits of exercise in treatments and prevention
  • To encourage students and those who access the course to perform and evaluate interventions to increase physical activity in their patients at local and/or national settings.

The course contains presentations and resources made available to all undergraduate medical and health schools to use. These have been endorsed by the United Kingdom Council of Deans of Health. Data from different recognized sources such as Global Observatory for Physical Activity and the World Health Organization are also included. At the end of the course, students can earn a certificate.

Ann Gates: “We are delighted to partner with the Peoples-uni on this exciting leadership initiative to provide low and middle income health care students with access and support to the Movement for Movement campaign and educational resources. We hope that this work inspires health care professionals to help patients, communities and nations to move more, and move well!”

Professor Richard Heller from People’s-uni affirms: “We are proud and delighted to provide access to this excellent set of resources, on a topic of major public health importance, to a global audience of health professionals.”

Professor Ged Byrne, Health Education England’s Director of Education and Quality for the North confirms: “I support this initiative and look forward to the impact it will have on educating health professionals about the importance of physical activity on health. This is very relevant to Making Every Contact Count http://www.makingeverycontactcount.co.uk “ 

Physical exercise to address cardiovascular and other diseases

The World Health Organization (WHO) and the Institute for Health Metrics and Evaluation, identifies cardiovascular diseases (CVD) such as heart disease or stroke, as the number one cause of death around the world, and 1 in 3 deaths globally are as result of CVD, yet most premature heart disease and stroke is preventable.

Many of these NCDs relate to sedentary and physically inactive lifestyles and physical inactivity is the fourth leading risk factor for global mortality. Regular moderate intensity physical activity (walking, cycling or leisure activities) is proven to provide very significant benefits for health and wellbeing as they can reduce the risk of CVD, type 2 diabetes, colon cancer, breast cancer, and depression (WHO).

That is why physical activity promotion, or the inclusion of exercise and active lifestyles in the designing of active lives is key. Therefore, training of health professionals in the benefits of exercise on their interventions and methods is an essential part in the strategy against CVD and other diseases, and Peoples-uni has joined this initiative to promote and protect individual health through regular physical activity.

How to access the course and about People’s-uni OOC courses

The program is part of People’s-uni short Online Open Courses (OOC), a range of short courses designed for self-study, available for free in an open access site, which also offers the possibility for to earn a certificate. The OOC initiative by Peoples-uni is a simple, quick, an affordable way for health professionals, or anyone interested in, in getting more specialization in certain public health related topics, or going deep into certain areas of general interest. For more information: http://ooc.peoples-uni.org/

About Peoples-uni

Peoples-uni is a UK-based charity dedicated to offer affordable education in Public Health. Its main mission is to contribute to improvements in the health of populations in low- to middle-income countries by building Public Health capacity via e-learning at very low cost. To do that, Peoples-uni initiative offers master-level educative programs and short Open Online Courses (OOC). Individual course module development and delivery teams have involved more than 250 volunteers from more than 40 different countries

For more information visit http://www.peoples-uni.org/

About Ann Gates and the team of contributors for the resources

Ann Gates ()is a health care leader, clinical pharmacist, and exercise educationalist. She started her career as a clinical pharmacist in the NHS but quickly became interested in leadership and service planning. Ann is CEO and founder of Exercise Works but has also worked as NHS Director of Strategic Planning and as Head of Health Strategy, for Trent Strategic Health Authority, UK. She is passionate about global health, action on inequalities, and exercise medicine.

The resources were curated and authored by Ann as part of an international, collaborative health project including over 60 expert authors, health care students and educational evaluators.

References

World Heart Federation, fact sheet – http://www.world-heart-federation.org/fileadmin/user_upload/documents/Fact_sheets/2016/Cardiovascular_diseases_in_the_UK.pdf

Hey undergrads, research doesn’t bite! Reflections from recent Tom Donaldson Award Winners

30 Jan, 17 | by BJSM

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

By Manroy Sahni and Esther Wright

Manroy and Esther, both final year medical students, reflect on why they were motivated to get involved in SEM research and show how far you can take your work. Manroy was the recent winner of the Tom Donaldson Research award (http://www.basem.co.uk/awards/tom-donaldson-poster-prize/) for his project “Anxiety, Depression and Perceived Sporting Performance amongst Professional Cricket Players”. Esther was runner up with her project “The Risk Factors for Patellar Tendinopathy in Adolescent Athletes: A Systematic Review”.

From left to right: Joey Fong (3rd), Manroy Sahni (1st) and Esther Wright (2nd). Tom Donaldson 2016 Prize Winners

What are some of the benefits for undergraduates that get involved in research?

To a medical student, the word ‘research’ is a daunting one. Although medical school prepares us for work within a clinical environment, the same cannot always be said for academic medicine. Despite being taught the basics of reading and appraising a paper, as students, we rarely get the chance to actively participate in research and are required to seek out our own opportunities. Those of us willing to put in a few extra hours of work will reap the rewards, even at an undergraduate level. Opportunities to explore areas of interest can help with refining career choices, whilst developing contacts and finding suitable mentors.  Publications, presentations and posters are useful additions to any portfolio, whilst demonstrating ambition and a commitment to learning.

How do you get involved with research within SEM?

As a relatively new and rapidly advancing specialty, research within SEM provides numerous opportunities for student participation. Many hospitals will not have dedicated SEM physicians, but due to the large overlap with other specialties such as orthopaedics and general practice, finding a supervisor with an interest in SEM is surprisingly easy. To date 15 UK universities have a SEM society, providing opportunities to attend lectures and discuss research ideas with speakers. If there is no SEM society are your university, don’t fret! The National Undergraduate Sports and Exercise Medicine Society (USEMS) holds an annual conference, inviting prominent figures within the sports medicine field to discuss their job roles and research interests. Conferences such as this create a platform to approach potential mentors and gain guidance on how to go about research as an undergraduate. USEMS also has a Facebook page, making it even easier to stay up to date with events and developments within SEM.

It’s all well and good taking part in research, but where can you present your findings at an undergraduate level?

As students we have the common misconception that research is only presented at conferences. When not developed with undergraduate attendees in mind, these are often pitched at the wrong level and may be very costly to attend. There are several other platforms which are easy to access as students and much less daunting places to develop presentations skills. Grand rounds occur regularly within most teaching hospitals, these allow a more informal approach to presentation and offer good opportunities for feedback. Regional SEM meetings also encourage student presentations within a supportive environment, not to mention the opportunities for peer education and development of teaching skills. Manchester SEM society runs an annual poster competition for undergraduate SEM projects; the Tom Donaldson Prize. This is a great starting point and shortlisted applicants will present their posters at the British Association of Sport and Exercise Medicine (BASEM) annual conference.  If you’re still looking further afield, some universities and research centres will provide grants to enable students to attend international conferences, it’s always worth submitting an abstract, you never know where it may take you!

You participated in the 2016 Tom Donaldson poster competition, how did you find the experience?

Participating in the competition enabled me to present my work at the BASEM conference; a prestigious event attended by leading club and national team doctors and expert physicians within the field of SEM.  Whilst presenting my work to individuals of this calibre was challenging it allowed me to establish relationships with professionals who may vitally assist me with future research and career advice. The conference itself featured a vast number of speakers covering a variety of topics from their role in the Olympic games, to development in the treatment of particular musculoskeletal conditions. I also met a number of SEM trainees, who shed more light on the available training pathways and gave me tips to further develop my portfolio. Overall the experience was very rewarding, both educationally and as a networking opportunity. As a final year medical student, I can’t really complain about the prize money either!

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

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee and Co-President of Birmingham University Sports and Exercise Medicine Society (BUSEMS).

Esther Wright is a final year medical student at Birmingham University and a senior committee member of Birmingham University Sports and Exercise Medicine Society (BUSEMS). She has further demonstrated her interest by completing an intercalated BSc in Sport and Exercise Medicine (SEM) at Barts and the London, graduating with First Class honours. Her interest in SEM stems from her own sporting experiences, both as a competitive swimmer and horse rider. She hopes to pursue a career in orthopaedic surgery, whilst maintaining an interest in SEM.

2017 Arsenal FC SEMS Conference Presented by Vitality Screening in Elite Sport: The Search for the Panacea to Optimise Player Performance 21 March 2017

26 Jan, 17 | by BJSM

Early Bird Booking Deadline – 31 January 2017 

Senior SEMS practitioner or student – a day not to be missed!!

Building on the great success of previous Arsenal FC SEMS conferences, Dr Gary O’Driscoll, Arsenal FC Medical Director, and Mr Colin Lewin, Head of Medical Services, are delighted to confirm the 2017 high level, interdisciplinary, FSEM accredited Conference will take place at Emirates Stadium. Again this year, the speakers have international reputations that will ensure high quality, current, and interactive presentations.

Comments from 2016 conference attendees: “An excellent meeting, many new ideas and methods to implement.”; “A very enjoyable meeting and lots of information gained looking forward to the next meeting.”; “The usual high quality, well organised, interesting meeting – thank you!”

Arsenal First Team Player Alex Oxlade-Chamberlain. Arsenal Training Ground, London Colney, Hertfordshire, 4th July 2016. Credit: Stuart MacFarlane / Arsenal Football Club.

Open to all medical and scientific healthcare professionals working across sports, presentations are aimed at SEM Faculty Fellows, senior doctors, physiotherapists and professional healthcare staff working with elite sportspersons. The conference presentations will focus on various aspects of screening in elite sport with presentations on cardiac, concussion, hip, groin and knee screening.

The full schedule and on-line registration are available at: www.arsenal.com/semsconference

To access the conference app please search “Arsenal FC SEMS Conference.” This will help you find out about extra content, who is attending and details of our exhibitors. Any queries, please contact scurthoys@arsenal.co.uk

Confirmed speakers:

  • Professor Roald Bahr, Norwegian School of Sports Sciences, Chair, Oslo Sports Trauma Research Center, Norway
  • Dr Michael Collins, Director of the UPMC Sports Medicine Concussion programme at University of Pittsburgh, USA
  • Professor Fares Haddad, Consultant Orthopaedic Surgeon, UCH The Princess Grace and The Wellington Hospital, UK
  • Mr Adam Meakins, Specialist Sports physiotherapist and Strength and conditioning coach, UK
  • Andrea Mosler, Senior Sports Physiotherapist at Aspetar Orthopaedic and Sports Medicine, Qatar
  • Dr Gary O’Driscoll, Medical Director at Arsenal Football Club, UK
  • Mr Des Ryan, Head of Sports Medicine and Youth Athletic Development at Arsenal Football Club, UK
  • Professor Sanjay Sharma, Professor of clinical Cardiology at St Georges University of London, UK

A limited number of early bird SEMS PG Student discounts (£90) and full BASEM member discounts (£135) remain. The early bird delegate fee of £150 ends on 31 January 2017, followed by the standard fee of £175. This fee includes attendance at all sessions, FSEM accreditation, attendance certificate, refreshments, hot lunch, a guided tour of Emirates Stadium (subject to availability), a post event flash drive (with Speaker PowerPoint presentations sessions uploaded) and a link to video taken of all presentations and discussion.

All at Arsenal FC Medical Department look forward to seeing you at Emirates Stadium in March.

BJSM blog homepage

BJSM

A peer review journal for health professionals and researchers in sport and exercise medicine. Visit site



Creative Comms logo

Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine