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Fit to Live? Genotype-positive Phenotype-negative Hypertrophic Cardiomyopathy

3 Jul, 15 | by BJSM

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

By Dr Christopher Speers

At a recent Cardiac Conditions Clinic with Dr William Bradlow (Consultant Cardiologist) at the Queen Elizabeth Hospital Birmingham, we reviewed a number of patients with Hypertrophic Cardiomyopathy (HCM) and Dilated Cardiomyopathy (DCM).

genesThese consultations produced numerous patient-centered exercise-related discussions, but one case in particular raised a challenging and novel exercise medicine dilemma; genotype positive-phenotype negative HCM.

This is seen in patients who have a family history of HCM, and have tested positive for a genetic mutation attributed to causing HCM.  However, they have normal ECGs and echocardiograms with no evidence of cardiac hypertrophy or left ventricular outflow tract obstruction. Therefore they are diagnosed as having ‘genotype positive-phenotype negative HCM’.

Are genotype positive-phenotype negative individuals at increased risk of Sudden Cardiac Death?

We know that HCM is phenotypically heterogeneous; with the age of onset, severity of symptoms, and relative risk of Sudden Cardiac Death (SCD) showing inter-patient variability even within family members with the same genetic mutation (1, 2).

Some studies have shown that particular genotype sub-groups, for example mutations of Troponin TNNT2 correlate with a higher risk of SCD.  There is also evidence that some genotype positive-phenotype negative individuals have impaired relaxation of myocardium, altered energy metabolism, and phenotypic changes such as crypts. This inherently abnormal cardiac tissue may predispose to adverse events (2, 4).

However there are only a very small number of cases of SCD in genotype positive-phenotype negative individuals described in the literature, making deductions challenging (2, 3, 4).

At present the clinical implications of these pre-hypertrophy cardiac changes are not known, and the real risk of SCD is thought to be significantly lower than that in clinical HCM (2, 4).

So what exercise advice should we give?

The governing bodies are clear on competitive sport exemption in individuals with clinical HCM. However the genotype positive-phenotype negative sub-group poses both an ethical and practical dilemma; it is not known if individuals will develop left ventricular hypertrophy or when this may occur. Developing clinical HCM would increase the risk of SCD, becoming particularly dangerous if undiagnosed in those engaged in competitive sport. At present there is no agreed international consensus on management.

The 36th Bethesda Conference 2005 states; ‘Although the clinical significance and natural history of genotype positive-phenotype negative individuals remains unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.’ (5)

However the European Society of Cardiology (ESC) 2006 position paper states; Based on the level of present knowledge, the decision for participation in competitive sport should be individualized. However, prudent recommendation suggests restriction of these individuals from participation in competitive sports, especially those with high cardiac demand (i.e. high dynamic, high static sports), and to recommend prudently amateur and leisure time sport activities.’ (6)

2014 ESC guidelines on HCM management have since relaxed this approach to some degree; ‘In definite mutation carriers who have no evidence of disease expression, sports activity may be allowed after taking into account the underlying mutation and the type of sport activity, and the results of regular and repeated cardiac examinations.’ (4)

It is clear that this subgroup of genotype positive-phenotype negative individuals need long-term regular follow-up with 12-lead ECG, echocardiogram, exercise stress testing and cardiac MRI, particularly if engaging in regular sporting activity. The adjunct of genetic profiling may aid with risk stratification in the future.

The implications of this diagnosis and potential restriction from sporting activity are far reaching for the individual, having both negative psychological and physiological effects.

An individualised risk stratified exercise prescription with careful specialist follow-up must form the basis of current and future management. However further research is essential to enable us to understand the natural history of genotype-positive phenotype-negative HCM and the real risk of SCD in this sub-group.

What did we recommend?

In line with the ESC recommendations we worked with our patients, exploring the potential risks and current evidence, and together formulated an exercise prescription. We agreed upon maintaining a healthy level of fitness through regular exercise at an intensity level where one can still hold a conversation, with the stipulation of regular cardiology follow-up.


  • Ho CY. Genetics and clinical destiny: improving care in hypertrophic cardiomyopathy. Circulation. 2010; 122:2430Y40.
  • Sylvester, J. et al. The Dilemma of Genotype Positive-Phenotype Negative Hypertrophic Cardiomyopathy. Current Sports Medicine Reports. Volume 13 & Number 2 & March/April 2014.
  • Richard, P. et al. Advising a cardiac disease gene positive yet phenotype negative or borderline abnormal athlete: Is sporting disqualification really necessary? Br J Sports Med 2012;46(Suppl I):i59–i68.
  • 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. European Heart Journal. (2014) 35, 2733–2779.
  • 36th Bethesda Conference. Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology. Vol. 45, No. 8, 2005
  • Pelliccia A, et al. Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis and pericarditis. European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:876–885.

Dr Christopher Speers BSc(Hons) MBChB MRCP(UK) is a ST3 Sport and Exercise Trainee in the West Midlands Deanery. He works with Bristol Rugby, British Universities and Colleges Sport, and is an Amateur Boxing Association Medical Officer. 

Dr Farrah Jawad is an ST4 Sport and Exercise Trainee and co-ordinates the BJSM Trainee Perspective blog.

FSEM Supports Concussion Guidelines for the Education Sector

30 Jun, 15 | by BJSM

fsem_v_Variation_1The Faculty of Sport and Exercise Medicine UK (FSEM) is supporting new Concussion Guidelines for the Education Sector, produced by the Forum on Concussion in Sport and Physical Education in conjunction with the Sport and Recreational Alliance.

The guidelines have been created in order to alleviate parental concerns around the safety of school sport and to ensure a consistent and suitable management protocol is available to those working with children in the education sector.

Endorsed by an independent expert panel of Sport and Exercise Medicine, Neurology and Health specialists, the guidelines have a clear message on how to handle a suspected concussion in school aged-children and above, including the dangers of returning to play too soon. Concussion can occur during any physical activity and these simple guidelines will help those working in education to follow the four principles of concussion management:


Dr Mike England, Fellow of the FSEM, Community Rugby Medical Director of the Rugby Football Union and Facilitator of the guidelines comments: This has been a ground breaking initiative, with sport, education and health coming together to address a very important issue. We hope teachers will find these guidelines useful, as it is imperative that those working in the education sector know how to recognise concussion and take action. If I had to pick out one key message it would be if in doubt sit them out.”

Dr Roderick Jaques, President of the FSEM comments: “We identified the education sector as a priority area through our call for a national consensus on the prevention, assessment and management of concussion. We are now delighted to see the launch of concussion guidelines to help teachers, school staff, coaches, parents and carers to be aware of the danger signs and how a suspected concussion should be managed in the absence of a trained medical professional.”

The FSEM called for a national best practice consensus on concussion, for all sectors where concussion is encountered, last year and has been working with the UK National Sporting Bodies and Medical Royal Colleges. Easy to follow guidelines, like this, could be developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.

View the Concussion Guidelines for the Education Sector at

Also see related BJSM material:

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Full text free online. (downloaded >100 k times)

Guest blog by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands



The sedentary office: the need for more pragmatic guidelines

26 Jun, 15 | by BJSM

Letter to the Editor by: Dr Kelly Mackenzie, Specialty Registrar in Public Health / Academic Public Health Fellow

In response to:  JP Buckley & A Hedge et al (2015). The sedentary office: a growing case for change towards better health and productivity. Expert statement commissioned by Public Health England and the Active Working Community Interest Company

To the Editor,

We welcome the development of quantifiable targets relating to workplace sedentary.  However, given the low quality evidence, it was expected that the recommendations would have been more pragmatic.

For desk-based workers, an initial target of two hours per day of standing/light activity eventually progressing to four hours per day, would be difficult to accumulate without the use of environmental and/or ergonomic adaptations such as adjustable-height desks.  As these interventions have a relatively high initial cost (around £300-1000 for an adjustable-height desk1), this recommendation is unlikely to be achievable in most workplaces.  Financial gains due to increased productivity and decreased absenteeism can be made to offset these costs, but tend to only be realised in the longer-term, so will not provide a viable justification for many organisations.

Instead, initial recommendations need to provide realistic targets that involve no/low cost changes that can be accumulated incidentally throughout the working day e.g. by encouraging standing/walking meetings.  The recommendations could then be taken up by a range of organisations, hence promoting maximal public health benefits.


  1. Height Adjustable, (Accessed on 16th June 2015)

2015 Women’s Ice Hockey World Championships: An SEM trainee’s perspective

24 Jun, 15 | by BJSM

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

As part of my Sport and Exercise Medicine training I attended the 2015 International Ice Hockey Federation Women’s World Championships, Division II A, held in Dumfries this April. This was my first experience both of travelling with a national team and working with a female winter sports squad. It certainly lived up to my expectations and more!

hockey1Women’s Ice hockey is an amateur sport in this country; our Great Britain squad ranged in playing experiences, providing me both with the biggest challenge and greatest opportunity to learn. A handful of players had moved abroad with their university studies to experience playing in Sweden and Canada, whilst the majority are based in the UK normally training and playing only once a week, for clubs with no to very basic medical support.

Strategy for Injury Prevention

The World Championships are a round robin tournament, formed of six teams including Great Britain, who won silver in 2014, Kazakhstan. They had been relegated from the division above while Croatia, South Korea, Poland and New Zealand, had been promoted from the division below. This format presented both a physical and mental test to the squad, and it was our aim as the medical team to ensure as many of the players remained fit to play across all five matches in seven days. In order to combat this we introduced ice baths post heavy practice sessions and matches from the outset of the tournament. For most this was a completely new concept and although we were not liked by the squad at first, within days the players recognized the benefits and by the end of the week I think we had converted them all!

“Off the ice” health challenges

Unfortunately, it was sickness off the ice which kept me most busy during the tournament. As many team doctors have experienced I’m sure, gastroenteritis can spread like wild fire! We faced the added challenge that squad members sharing hotel rooms, but we also shared the hotel with one of the other countries in the competition and the tournament officials.  So not only were squad members sharing bathroom facilities and changing rooms, they were also exposed in the self-service restaurant and transportation to and from the hotel. I highlighted basic hygiene techniques within the team meeting setting at the first sign of gastroenteritis affecting a player and was able to source multiple single isolation rooms at the hotel. Given that the tournament was being held in Scotland, I had sufficient access to a well-stocked medical bag in order to manage each patient’s symptoms appropriately.

Giving back to sport for women and girls

During one of the rest days, a ‘Learn To Play’ event had been organized where local school girls attended a one hour session full of basic ice hockey skills stations. Members of the Great Britain squad instructed the girls as they went around the stations. It was clearly a successful event with the children leaving full of memories and the players feeling good having given something back to both the local community and sport itself.

Success and lessons learned

The squad were successful in winning a silver medal at the championships. Their disappointment at the time, may serve to further fuel proactive  changes and development in the sport. I would encourage anyone working in the field of Sport and Exercise Medicine to get involved with winter sports, particularly women’s ice hockey: it is an exciting, high impact, highly skilled game where women’s participation is on the increase; there is the need and demand for medical team support within the club structure. It provides additional challenges to pitch-side care when the field of play is an ice rink – I managed not to be an additional casualty!

See related BJSM publications:

Injury rates, types, mechanisms and risk factors in female youth ice hockey

Seasonal variation in fitness in a women’s National League hockey squad

A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what?


Dr Philippa Turner, a Sport and Exercise Medicine Registrar in the East Midlands. I am currently working as the Aston Villa Women’s team Match Day Doctor, FA Super League Division 2. I’m a keen netball player, having previously played at the British University Games, and I am running the 2015 Virgin London Marathon for Asthma UK.

Dr Farrah Jawad is a ST4 doctor in Sport and Exercise Medicine and coordinates the BJSM Trainee Perspective blog.

BJSM Virtual Conference – Tendons

20 Jun, 15 | by BJSM

A monthly round-up of podcasts and articles 

By Steffan Griffin (@lifestylemedic)

If you were hoping for further additions to the cluster series (previously on hamstring and shoulder injuries), fear not, here it is. We have simply changed the (now-monthly) series’ name from “cluster” to “virtual conference” to better reflect its provision of sleek and sexy resources.

Whether you fancy becoming a 24-hour expert or need to stay awake on your commute to & from work, enjoy these great contributors to BJSM podcasts and publications.

Tennis Player Preparing to Serve --- Image by © Royalty-Free/Corbis

Tennis Player preparing to serve

This month’s focus is on the key academic and clinical entity of tendons, featuring some of the world’s most respected authorities on the matter.

1. “Mechanotherapy” and why it’s important for clinicians, with Karim Khan

A podcast centred on the “the most important fundamental concept that underpins rehabilitation exercises” – containing nuggets of information including why ‘rest doesn’t work’ and the evidence-base underpinning the theory. For best results, combine listening to reading the paper

2. The continuum model of tendinopathy, with Jill Cook

Is tendon pathology a continuum? Prof Jill Cook explains and answers questions relating to this famous pathology model to explain the clinical presentation of load-induced tendinopathy (Accompanying paper can be found at

3.Tendons: Where does pain fit in the continuum model? with Chris Littlewood

So now you’re familiar/brushed up on the tendinopathy continuum, do you have any questions about the connection between pain and pathology in tendons? Chris Littlewood, who has expertise as a clinician and researcher in the rotator cuff, asks questions of Craig Purdam and Ebonie Rio in this fantastic podcast.

4. Time to revisit inflammation in tendons, with Jon Rees

So inflammation is completely out of the window, right? Although widely accepted that chronic tendinopathy is caused by a degenerative process devoid of inflammation, the evidence for non-inflammatory degenerative processes alone as the cause of tendinopathy is surprisingly weak. In this podcast, Jon Rees tells Jill Cook why the role of inflammation offers potential opportunities in treating chronic tendinopathies and should be explored further.

5. Managing tendinopathies, with Jill Cook and Hakan Alfredson

Cook and Alfredson focus on the management aspect of tendinopathy, with practical pointers and a tip to consider the time-course of tendon injury when making treatment decisions. It fits nicely with Hakan Alfredson’s ‘treating tendinopathy’ podcast; here they discuss the clinical challenge of whether to opt for exercise treatment, new ‘biological therapies’ like platelet-rich plasma (PRP), or surgery.

 6. The pathogenesis of tendinopathy and tendon healing, with Michael Kjaer

This great podcast discusses seven models of tendinopathy, and the important difference between mid-tendon and insertional tendinopathy. We also hear about the healing capacity of tendons, the (absence of a) link between tendinopathy and tendon rupture, and various interventions that are used in an attempt to promote tendon healing – a real one-stop shop for those short on time!

7. The brain and mind in chronic pain, with Lorimer Moseley

A man needing no introduction, this podcast discusses the important difference between pain and nociception, with thoughts on how pain science can help clinicians working in sports medicine. You’ll hear him share the best, and worst, ways to explain pain to patients, with thoughtful reflections along with a big dob of humour and humility.

So there we go, the first official virtual conference, all for free! As always, let us know your thoughts via our various social media channels – Twitter (@BJSM_BMJ), Facebook and Google+. Feedback is appreciated and valued!

Football Medicine Strategies for Player Care Conference – Take home messages

17 Jun, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine a BJSM blog series

By Zachary Spargo (@ZachSpargo)

After attending the Football Medicine Strategies (#FMS2015) Conference in London, I was inspired to put together a brief, yet hopefully informative overview of the streams I attended. It was a fantastic opportunity to learn, first hand, from some of the world leaders in Sport and Exercise Medicine (SEM).

football med

What was on offer? Introduction to the conference:

The conference focused on strategies for player care and in that sense, it didn’t disappoint. After the official welcome from Dr. Peter Brukner and Dr. Stefano Della Villa, Dr. Dvorak explained the Fifa 11+ initiative and how it has led to reduced injury risk in football. This was followed by Dr Philip Batty who highlighted some current issues within sport medical teams including:

  • Pressures to diagnose quickly from coaches and players
  • Over reliance on scans
  • Under reliance on clinical judgement
  • Treat the player not the scan
  • Glamour of surgery over exercise rehab

And perhaps most aptly for BJSM readers, the notion of ‘ignore exercise rehab at your peril’.

Strategies for hamstring, tendon and groin injuries:

Hamstring Injuries (P Brukner, K Thorborg, W Diesel, C Askling & M Stride)

A key message for hamstring injuries was the need for knowledge of mechanism of injury.  Know the mechanism, tailor the rehab #Simple. Whether during maximal sprinting (long head of biceps femoris commonly involved), or stretching (semimembranosus involvement), this has an effect injury duration and re-injury potential. The success of the Munich consensus statement for classification of injury was highlighted. Diego Costa was hot topic also, with his recent hamstring re-injury (after only 12 days side-lined), highlighting the medical teams need to consider risk vs reward. Interestingly, hamstring injuries were shown to be on the increase. However, the research suggests an 83% non-compliance with Nordic eccentric strengthening programmes in top-level clubs, despite their proven efficacy. Food for thought!

Tendon injuries (N Maffulli, H Alfredson, K Khan, J Cook & B Knowles)

Key messages included:

  • Imaging should only be used to either confirm clinical diagnosis or rule out differentials
  • Little evidence for alignment issues associated with tendon injuries
  • PRP has no place in rehabilitation (check @BJSM_BMJ for numerous tweets on this!)
  • Mechanotransduction: the use of exercise to produce beneficial effects in tendon
  • Train tendon to upper limit without pain – too much protection causes dysfunction


Groin Injuries (A Weir, M Gimpel, A Franklin-Miller, P Holmich & H Silvers)

The overall message was that the use of a dedicated prevention strategy of hip strengthening exercises could have major effects on player availability. Mo Gimpel, sports medicine and science manager at Southampton football club demonstrated just this with phenomenal player availability rates of more than 90% for past two seasons. Although this may be overemphasised with a large sized squad. You can see more of Mo Gimpel’s groin strategies at this years ACPSEM conference in October.

Functional Movement & Communication around the Player

Functional rehabilitation was the focus of the second day’s agenda. Attendees discussed deceleration, with the key points including:

  • No running to be commenced before patient confident controlling fast deceleration exercises – you have to be able to slow down before you can speed up!
  • ‘Stiffness’ training using a trampoline or gym bands is beneficial
  • Train at 100%, not 80% in order to replicate competition

Following this there was a fantastic round table discussion which included the likes of Dr Gary O’Driscoll (Arsenal FC) and Tony Strudwick (Manchester United FC). The discussion was of high quality with regard to player confidentially and the transfer of medical notes from club to the next. Consent was stressed to be an extremely important factor – what if a player will not allow you to send details of his chronic injury to his new club for fear of contractual issues? Dr O’Driscoll highlighted the fact that there can be no excuse for not making complete and thorough medical notes even for things such as drugs administered during a busy half time period. BJSM’s very own Dr Liam West made a valid point to the discussion on the subject of player medical preference and the role of a third party medical representative to the media.  Specifically, he bought up the need for us as clinicians to consider and educate ourselves on why some players wish to receive treatment from their native countries instead of using their current clubs services. One to consider there!

Football Medicine Strategies Conference 2015: In Summary

It was a brilliant event for networking, learning, and participating and one attended by many students from all over the world.

Keep your eyes out for FMS2016 in London – Definitely one for all students with a keen appetite for football medicine and SEM!

Zachary Spargo MSc Physiotherapy student (pre-registration) BSc (Hons) Sport and Exercise Science (@ZachSpargo) is currently studying at York St John University and is the Yorkshire and Humber CSP electronic communications editor for the region. He is passionate about all things Physiotherapy and SEM and is a regular footballer in his spare time.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM is a junior doctor in Oxford, England. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

If you would like to contribute to the Undergraduate Perspective on SEM BJSM Blog, please contact Dr. West at

TE(D)rrific talks (and a chance to win a prize)

13 Jun, 15 | by BJSM

tedThe internet – not only does it provide countless videos of animals doing funny things, it also contains a rich stock of fantastic educational resources, meaning that you can learn from world-experts in a variety of fields from the comfort of your home – all for absolutely free. One organisation that is universally regarded as a leader in providing high quality and reliable online teaching is TED, a non-profit committed to spreading ideas through video-recorded talks. Due to the success of the recently published blog centred around Dr Sarah Hallberg’s TED talk on tearing up the guidelines in treating Type 2 diabetes, the BJSM editorial team brainstormed to produce a list of favourite TED talks, covering issues from SEM staples on the basis of pain to the power of body language in success. Let us know if you find these helpful!

  1. Challenging Beliefs. Tim Noakes

This 15-minute talk is a whistle-stop tour of Prof Tim Noakes’ (author of the recent BJSM editorial on exercise in obesity which made headlines around the world) lifetime of research in SEM. Covering everything from exercise-induced hyponatraemia to his now infamous advocacy of a #LCHF diet, this talk is worth watching not only for the countless educational nuggets, but also to learn from someone who has never been afraid of swimming against the tide.

  1. Are athletes really getting faster, better, stronger? David Epstein

This thought-provoking talk by David Epstein questions whether human evolution is truly at the heart of athletic improvement, and suggests that we may want to lay off the self-congratulation. Great talk for anyone interested in sporting performance and it provides a view rarely considered or advocated in the public domain.

  1. Sugar – the elephant in the kitchen. Robert Lustig

A talk on sugar in relation to the obesity & diabetes pandemic by one of the world’s most respected authorities on the matter had to make the list. With nearly 200,000 views, this talk by Dr Robert Lustig reinforces the growing message regarding the dangers associated with high sugar intake, providing real food-for-thought.

  1. Why things hurt. Lorimer Moseley

This fantastic video explains the rarely-taught basis of pain, and the role of the brain in the pain response. It provides an insight into some ground-breaking experiments that demonstrate astonishing results, more of which can be found in this BJSM podcast with the same speaker!

  1. Your body language shapes who you are. Amy Cuddy

Something that although not SEM related, is infinitely useful whether you’re plucking up the courage to ask a question at a conference or whether you’re going for that dream job in SEM. It’s not about faking it ‘til you make it, fake it until you become it.

That’s just some of the fantastic resources available online – now we want to hear from you. For a chance to win a copy of Brukner & Khan’s Clinical Sports Medicine, share using the hashtag #TED4BJSM and comment on the Facebook stream (pinned post)  to let us know which TED talk you would recommend to others in SEM or one that has made an impression on you. As always, you can let us know your thoughts on Facebook, Twitter (@BJSM_BMJ) or Google +, we look forward to hearing from you!

#MakeYourDayHarder campaign launch: who, what, when, where, and why?

10 Jun, 15 | by BJSM

By Dr. Mike Evans


What: on June 11 we are launching #MakeYourDayHarder campaign where people make their day harder (get off a stop early, park at the back of lot, take stairs, have a walking meeting, ride, walk to lunch, etc..) and then share +/- pic/video on social media (twitter, FB, instagram) with the #MakeYourDayHarder hashtag.

Why: see below (PA=Physical Activity). The black line is sedentary time.

sedentary time

Sitting disease has become an independent risk factor for poor health outcomes. People who are active but sit all day have worse outcomes. Read about the evidence HERE. Also, read the consensus statement and guidelines – recently published in the BJSM – geared at sedentary office workers.

What it’s not: this is not about workouts, sports etc.., its about working activity into your average day. Sidney Crosby is not our hero. The guy/gal who take the stairs while everybody else is escalating.

Who: An Olympian/Doctor (@JaneSThornton), a design agency (@pivoting), a patient engagement star (@emily_Nicholas8) and me (@docmikeevans) (and you). We don’t have any funding. We are just doing this to see if we can start to make a little social nudge towards more activity in our days. Kind of an experiment to see if we can start changing the culture of easy.

Website: Launching this week and will summarize science about both sitting disease and challenges (i have arthritis, i am too tired, too busy, etc..)

Want more info? This less than 4 minute video explains the plan:

Not enough? Here’s theWhiteboard explaining the science:

The launch: You can soft launch anytime (i.e. tweet #MakeYourDayHarder about something today) or join us virtually or in person at hard launch on june 11.  I am giving a speech that day at the YMCA on “The Better Life Experiment at 6 pm to launch.

We need you to help us spread the word, and share your pics, videos, and tweets.


Sports Medicine at the 2015 London Marathon: critical reflections from a medical and a physiotherapy student

8 Jun, 15 | by BJSM

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

By Sean Carmody & Liam Newton

Spectators watch as runners cross Tower Bridge during the Virgin London Marathon in London.

Spectators watch as runners cross Tower Bridge during the Virgin London Marathon in London.

The medical student experience – @seancarmody1:

The London Marathon is a fascinating event from a sports medicine perspective. The 38,000 participants represent nearly every category of athlete. The weekend warriors to world record-holders range in abilities and disabilities and thus, have greater potential for a wide-range of morbidities.

Pre-event injuries: why do they happen?

We all know many marathon-related injuries occur during training, before the event itself, meaning some participants may not make it to the starting line.

Reasons for this include: a (too) quick increase in mileage, previous injury and a competitive training motive. Common ailments during the race include cramping, blistering and skin chafing but these often go unreported. Although it is challenging to obtain accurate injury incidence from a marathon, by far the most frequent reported injuries appear to be musculoskeletal problems, with the knee affected the most.

What do doctors’ have to be the most alert for?

Major illnesses, such as cardiac arrest, are thankfully relatively rare occurrences, but their prevention is of paramount importance for medical organisers. Cardiac-related marathon deaths have been estimated to occur between 1 in 50-100,000 runs. Exertional heat stroke is another potentially life threatening disorder among marathon runners – important to note that there have been reports of occurrence in cool weather. In recent years, hyponatraemia due to excessive hydration has emerged as an important cause of race-related death and life-threatening illness among marathon runners – participants should be educated as to best hydration practices to prevent its onset; i.e. drink to thirst strategies!

My experience ‘on-the-ground’

This year I was fortunate to be part of the medical team supporting those running on behalf of the ‘Children with Cancer’ charity. The team consisted of 3 medical doctors, accompanied by several medical students. There were also podiatrists, massage therapists, osteopaths and physiotherapists to greet the runners once they had completed the race. The most common injuries we saw were light-headedness, nausea and chills. We managed these athletes effectively with close observation, rehydration, refuelling, and some general TLC (it’s amazing what a blanket and some Haribo can achieve!).

My take home message – do the simple things right and the rest will follow suit!

The London Marathon is an extraordinary event, and I commend those who coordinate the world-class medical care for the level of preparation they undertake.

I encourage any medical student interested in sports medicine to get involved in 2016’s edition.

The physiotherapy student experience – @newton_liam:

On a cool overcast morning, perfect for marathon running, I met up with the team of physiotherapists and was subsequently divided into smaller teams working in medical tents, down the length of the Mall. Within these tents were a range of health professionals including the St Johns Ambulance, podiatrists, doctors and nurses. Our team leader briefed us on all of the details of the day, including: documentation protocol, recording of injury statistics and insight into likely patient presentations. Our role was not just to perform massage, but rather, to perform acute musculoskeletal assessments and injury management and offer advice/education.

The afternoon started off fairly quiet with only the elite runners passing through, some of whom looked ridiculously comfortable post marathon for my liking! However, as the afternoon progressed the tent started to get busy with runners of all abilities. I was positioned within the first medical tent past the finish line that meant we were exposed to more of the acutely unwell or more physically restricted athletes. Initially I began shadowing and assisting the qualified members of the team, however as we got busier and as my confidence grew with the support of a magnificent team of physiotherapists, I was able to treat and educate some of my own runners! What soon became apparent was the real strength of mind some of these runners possessed, a real steel-like determination to complete this grueling event. Throughout the day I was exposed to a wide range of injuries/physical presentations including; a lateral ankle sprain at the hands of a water bottle (in mile 5 and still completed it!), severe lower limb cramp, patellofemeral pain, muscle strains, shock and dehydration.

Learning point – small packets of dioralyte as well as race pack goodies proved to be invaluable tools throughout the afternoon.

Exposure to a wide multi-disciplinary team was a valuable learning tool; I gained insight into medical and podiatry clinical reasoning which enabled me to provide a more holistic injury management plan.

Overall I thoroughly enjoyed my day. I learnt a great deal of acute injury management as well as the importance of keeping cool under pressure. I’d highly recommend this experience and found it a great way to promote the benefits of physiotherapy from a rehabilitation and performance enhancement perspective for runners and exercise enthusiastic alike.


Sean Carmody (@seancarmody1) is a final year medical student at the Hull York Medical School.

Liam Newton (@newton_liam) is a final year MSc (pre-registration) physiotherapy student at the University of Birmingham.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Scotland’s concussion guidelines highlight the need for a UK wide approach

4 Jun, 15 | by BJSM

News Release – The Faculty of Sport and Exercise Medicine

sealThe Faculty of Sport and Exercise Medicine UK (FSEM) welcomes the launch of Scottish Sport Concussion Guidelines for the general public and for grassroots sports participants, where specialists in Sports and Exercise Medicine are not available to manage concussed players. The FSEM would like to see similar guidelines produced, not just for sport, but to improve recognition, assessment and management of all concussions in the UK.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine UK comments:

Concussion is recognised to be one of the most challenging of injuries to diagnose, assess and manage. Best practice clinical pathways from injury to return to play, work or school for a concussed person, outside of the elite sports setting, are not always easily accessible in the UK.

“The Faculty of Sport and Exercise Medicine fully supports the new Scottish guidelines for the recognition, assessment and management of concussion. We would like to see great initiatives like this developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.”

Sport Scotland, the Scottish National Sporting Bodies, Medical Royal Colleges and the Scottish CMO have produced the guidelines that are intended to provide information on how to recognise sports concussion and on how sports concussion should be managed from the time of injury through to a safe return to play.

The guidelines stress that, at all levels and in all sports, if an athlete is suspected of having a concussion, they must be immediately removed from play.

Any player with a second concussion within 12 months, a history of multiple concussions, player with unusual symptoms or prolonged recovery should be assessed and managed by health care providers (multidisciplinary) with experience in sports-related concussions.

The overriding message is that ALL concussions are serious and if in doubt, sit them out!

The FSEM recognised the need for a national best practice consensus on concussion last year and has been working with a group including UK National Sporting Bodies and Medical Royal Colleges. The group would like to see consistent best practice, recognition, management guidelines and care pathways adopted from ground level up, across all sectors in the UK and by all health and allied professional groups, where concussion is encountered.

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