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The delegate view of 6th London School of SEM Conference– What lessons were learnt?

1 Apr, 15 | by BJSM

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

By Jonathan Shurlock (@J_Shurlock)

Reading the recent BJSM blog on the 6th annual London Deanery Sports and Exercise Medicine (SEM) Conference written by the event organisers, inspired me to give the delegate view of the important lessons learnt by those in attendance, and add in some links to related BJSM material.

Tales from the ballet: common problems encountered with performing athletes and dancers – Dr Roger Wolman

  • Dancers are often lumped as a single group, however movement patterns vary significantly between forms of dance
  • Injury risk factors – Poor nutrition. The movements desired by dance coaches require demanding biomechanics. Aesthetic requirements of low body weight and knee hyper-flexion
  • Demands – Highly competitive environment means that dancers do not reveal injuries for fear of being held back. Tours are often long, with inadequate rest
  • Support - Limited financial resources, therefore there is inadequate medical and scientific support. The first NHS specialist dance injury clinics were set up in 2012. There is often an on-going battle between dance teachers and sports therapists and a balance must be met to ensure protection of athlete’s health and performance capability

Mental health in sport – Dr Justin Yeoh

  • The true incidence of depression in sport is uncertain, due to limited research. There is a higher incidence in aesthetic sports (e.g. dance, gymnastics)
  • If exercise is effective in the treatment of depression, so why do athletes get depressed? à Athletes are perceived to be superhuman. However, they have the same risk factors as the general population, and a long list of additional risk factors (e.g. recurrent injuries)
  • Athletes will not necessarily discuss their symptoms, so awareness is needed of the common signs, including:
  • Consistent poor or inconsistent performance (reduced work rate, poor motivation)
  • Increased apathy or irritability
  • Medical issues (recurrent illness or injury, excessive fatigue)
  • Stigma and lack of education are still prevalent issues. Good examples of schemes to improve awareness and reduce stigma from PFA, Rugby Union, and Rugby League
  • See recent BJSM blog

Rehabilitation considerations in the older athlete – Mr Bruce Paton

  • Increasing age impacts on oxygen transfer (reduced V02 max), maximum heart rate and muscle physiology (reduced number and size of muscle fibres, and change in muscle fibre types)
  • The V02 max requirement to retain independence is thought to be above 15-18 litres/min/kg
  • A substantial drop in performance is seen with most sports at around 70 years of age, event with chronic exercise
  • Eccentric or isometric loading is very useful for older athletes
  • See previous BJSM blog

The challenges of managing an athlete with a disability – Dr Richard Weiler

  • The general level of evidence for the implementation and effectiveness of prevention strategies and treatments in disability sport is poor
  • “You must unlearn what you have learned” à observe and understand the different abilities that these athletes possess
  • Humour can be critical when working with individuals in disability sport

Keynote; How to increase exercise in sedentary people – Dr William Bird

  • Low cardiorespiratory fitness has a much greater impact on all cause mortality than obesity. (See evidence here)
  • A huge number of deaths from disease such as breast and bowel cancer are attributable to physical inactivity (See evidence here)
  • You cannot isolate physical activity and throw it on top of a busy, stressful life. To promote physical activity, we need to identify patient values and end goals, to provide a gateway to a better life
  • Promotion of physical activity requires changes to infrastructure and strong partnerships and leadership from the health sector
  • See open access article and BJSM podcast

To delivery and beyond: Exercise in pregnancy – Dr Eleanor Tillet

  • Physical activity guidelines are modified during pregnancy (See here)
  • Exercise in pregnancy should be encouraged, as long as you ensure your patient is aware of the following:

–   Contraindications to physical activity during pregnancy

–   Injury risk with increased ROM

–   Avoidance of exercise where there is risk of abdominal trauma

–   The aim during pregnancy is not to gain fitness, but to maintain

Paediatric sports medicine: Top tips for managing the child and adolescent athlete – Dr GB Ajayi

  • Children are not little adults! Their injury risks are not the same as the adult population
  • Increasing height = modified centre of mass = reduced muscular control = increased injury risk (Testosterone mitigates against this)
  • Ossification centres are areas of weakness therefore children can get injuries not often seen in adults (e.g. supracondylar fractures)
  • You need to be aware of the increased risk of acute avulsion injuries and chronic overuse osteochondroses
  • See these systematic reviews (1 & 2) for a good summary of injury considerations in children

How the medical team prepares for an international tournament – Dr Ian Beasley

  • The multidisciplinary team (MDT) is central in tournament preparation. The team must agree realistic aims and plan logistics
  • An emergency action plan is needed at every stage
  • Where is your defibrillator? This should always be immediately accessible, not ‘under the bus’
  • When traveling for competition endemic problems need to be assessed, such as local communicable disease, temperature and humidity
  • During international competition, the host country hosts a meeting of all team medical officers to discuss specifics. This is vital to ensure effective medical care throughout the competition


Jonathan ShurlockBSc (Hons), is a fourth year medical student. He sits on the european College of Sport & Exercise Physicians (ECOSEP) student committee, in addition to the London Sports and Exercise Medicine Committee. He has a passion for clean sport, and as such works as a research assistant at The Centre for Sport and Exercise Science and Medicine (SESAME) in Eastbourne, working on various WADA funded anti-doping projects. His twitter handle is @J_Shurlock.

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.

Highlights from the Sixth London School of Sport and Exercise Medicine Conference – Sport and Exercise for All

31 Mar, 15 | by BJSM

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

By Florence Newton and Katy Hornby

sport and exercise for all
The 6th annual London School of Sport and Exercise Medicine conference, “Sport and Exercise for All” (Hosted by Holborn Bars, March 11, 2015) certainly lived up to high expectations. 145 candidates from diverse backgrounds attended the expert presentations on key issues including: physical activity for the old, young, elite and the less athletic. Below, we summarize highlights from the day.

Tales from the Ballet: common problems encountered with performing athletes and dancers

In the morning, we heard from Dr Roger Wolman, Consultant Rheumatologist and Sports Physician, about ‘Tales from the Ballet’. Dr Wolman has been involved with Dance Medicine at a high level since the late 1980s, and has a great wealth of experience in the field. He highlighted the injury pattern and predisposing factors that are specific to an aesthetic athlete such as a dancer.

Mental health in sport

Dr Justin Yeoh, an ST6 in SEM who is an experienced physician in the world of football, delivered perspectives from his own experience on mental health in sport, with a particular emphasis on depression. He highlighted how common yet underreported mental health issues are in sport and how difficult they can be to manage.

Rehabilitation considerations for the older athlete

Rehabilitation considerations in the older athlete were then discussed by Mr Bruce Paton, an extended scope physiotherapist at UCLH. We were introduced to key physiological aspects that affect training in an older person. He showed us how muscle physiology and aerobic capacity changes with aging. However, we were reassured by his example of Olga, a 90-year-old masters athletics champion with 7 world age-group records!

‘Extreme Sports Medicine’ – Disability in sport

After a short break to encourage some physical activity, Dr Richard Weiler inspired us all with ‘Extreme Sports Medicine’. Dr Weiler is an expert within disability sport. He taught us to think not about an athletes’ disability, but rather about their extraordinary ability, grit, and determination, and what they can do against all odds. He described how amputees playing football on crutches use 8 times more energy than conventional football. This definitely requires a ‘can do’ rather than ‘can’t do’ mind-set.

Sedentary behaviour

On the other end of the spectrum, we are faced with the public health concern of widespread high levels of sedentary behaviour. Dr William Bird sits on the Physical Activity Programme Board for Public Heath England. He showed us how explaining some of the basic physiology of obesity and inflammation to patients can help their understanding of their condition and enforce behaviour change. The main emphasis should be on physical activity and how even without demonstrable weight loss, the resulting decrease in visceral adiposity has massive implications on a persons’ health.

To delivery and beyond: Exercise in pregnancy

After a lunch of indulgence, the best dessert selection you have ever seen and some networking, the afternoon session kicked off with a very educational lecture by Dr Eleanor Tillett on exercise prescription in pregnancy. Dr Tillett is an SEM consultant with vast experience in women’s elite sport. She explained how exercise is beneficial for both mother and foetus at all stages of gestation and provided examples of special considerations to take when faced with pregnant ladies of all pre-partum athletic ability. It is not just about the pelvic floor!

Paediatric Sports Medicine – top tips for managing the child and adolescent athlete

Dr Abosede Ajayi demonstrated how child and adolescent athletes are not just small adults. Their growth velocity, bone mineralisation and adolescent awkwardness to mention just a few all play a part in adding to injury risk and patterns. Whilst younger children may be more precise with localising sites of pain, which can help the doctor, the hormonal adolescent may require different history taking skills to gather any information!

Dr Ian Beasley, Head of Medical Services to the Football Association (FA)

Dr Ian Beasley, Head of Medical Services to the FA and team doctor to the England’s men team, gave the final talk of the day. Through many anecdotes and great pictures he described the eclectic mix of facilities you might find at worldwide venues and how the medical team prepares for international tournaments. He taught us how to make the most of the equipment we have at hand. For example, spin classes in a laundry room are a great way to acclimatise to hot environments!

Closing remarks

Dr James Thing provided an excellent closing summary for the day. As a newly qualified SEM consultant, he discussed the changing face of sports medicine and the challenges ahead for our speciality. However, all that attended may agree, the conference also demonstrated how SEM offers diverse and exciting personal and professional opportunities.

Overall the conference was a great success. Many thanks and congratulations go to Farrah Jawad and Jonathan Korgaonkar, both SEM ST4s, for organising an enjoyable and informative day.


Florence Newton and Katy Hornby are both ST3 Sports and Exercise Medicine trainees in London. Florence came into SEM after Core Medical training and is an academy doctor at Arsenal FC. Katy has a background of A+E training and works with the England Womens Rugby team.


Authors of “”Load me up Scotty”: Mechanotherapy for plantar fasciopathy…” respond to Letter to the Editor by Dr. Nick Webborn and colleagues

27 Mar, 15 | by BJSM

Thank you for your interest in our editorial in the British Journal of Sports Medicine: ”Load me up Scotty”: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis)”. However, we find your letter to the editor (published in this recent blog) somewhat hit-and-miss with regards to the main “swings” (critique points) provided by you and your colleagues.

  • Your main critique was not related to our editorial, but more so to the original study published in Scandinavian Journal of Medicine & Science in Sports (SJMSS )(Read it HERE )
  • We were criticised for promoting our own work in an unbalanced way, and in an incomplete form.

In reverse order, our response to these 2 main “swings” are:

Yes, you can rightfully claim that we highlight some of our own work, but as this was an important part of the task given by the BJSM (in a requested editorial), your criticism seems a little off target. Point taken, although, we do not share you and your colleagues concern, as we believe that most BJSM readers will know that editorials are narratives (Expert opinion, Level 5), and therefore not high-level evidence, in itself. The BJSM editorial format limits of 800 words and 8-10 references, also plays a role as to why the comprehensiveness of most subjects is usually limited in some way, shape or form.

We therefore urge people to read the original study in SJMSS, as an a priori justification and rationale for the primary outcome and endpoint (including sample size justification) is provided in the methods section of this study, and the relevance of this is discussed in detail in the manuscript. Furthermore, this specific study has been referred to in this blog in BJSM, where the methodological issues are more thoroughly discussed.

We chose 3 months as the primary endpoint because the exercise protocol lasted three months, and therefore the effects of exercise were most relevant to that time point — when there is no wash-out of the exercise effect. We agree that most patients do not only care about their status at 3 months, but also at other time points. However, patients in both groups were better at 6 and 12 months (and not different as your blog suggests), than before initiating treatment, with no differences between the groups. So, if you your patients prefer to wait till 6 months, instead of 3 months, before a substantial improvement kicks in, then the traditional approach with stretching and inserts seems equally effective, as suggested by the secondary analyses of the study.

With this answer we have addressed the main points in your blog/letter. We agree that our work is only the first indication that high-load strength training is an effective treatment for plantar fasciopathy, and that replication studies should follow. We have no interest in panaceas, and have therefore extensively studied different musculoskeletal conditions and specific exercise interventions in several RCTs, during the past 5 years, and we will be the first ones to abandon interventions that show no clinically meaningful promise.

Finally, we are also admittedly very enthusiastic and passionate people, especially with regards to our clinical research and work, but the intention was never to offend you and your colleagues, only to promote a novel and interesting modality for people to consider to include in their clinical tool box. As previously stated in the blog post on the BJSM website “The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis.”

Who knows, maybe future randomised trials within fasciopathy or other tendinopathies will be initiated from an interest sparkled by this enthusiastic editorial on the importance of loading. If so, we believe ”Load me up, Scotty….” has certainly done it’s job, as the current level of evidence for the modalities often used in treating plantar fasciopathy is still low, and therefore often based upon low-level evidence, as documented in a recent Clinical Practice Guideline (Read it HERE).

Kind Regards,

Michael Skovdal Rathleff & Kristian Thorborg

On tour with elite golf: Seasoned tips for the travelling physiotherapist

25 Mar, 15 | by BJSM

Association of Chartered Physiotherapists in Sports & Exercise Medicine blog series @PhysiosinSport

By Nigel Tilley

golf ballIn my 8th season as a Physiotherapist with The European Tour Performance Institute (ETPI), I have worked at over 180 golf tournaments. In this blog, I share some of my experiences, including practitioner and athlete tips for life on the road of elite sport.

The ETPI and Mobile Physio Unit provide physiotherapy, sports medicine and performance services to tour golfers across the world. We work on site at golf tournaments and have permanent facilities in France and Dubai. The original service was set up in 1990 and now has 6 full- and 8 part-time staff members across the 3 main golf tours; we travel over 30,000 miles and work in over 30 countries annually.

The blend of practitioners from various backgrounds and countries makes for a great learning environment: physiotherapists, sports therapists, chiropractors and osteopaths as well as sports medicine doctors and upper limb surgeons and radiologists. We aim to deliver a world class, integrated service, that provides a single point of access on tour for all professional golfers regarding injury, assessment, diagnosis, treatment, screening, performance enhancement, rehabilitation, strength & conditioning and biomechanics.

The road to elite sport

My first taste of working in elite sport was as a student in 1999 during a 6-week placement at Ipswich Town Football Club. I worked alongside inspiring physios, and I then knew I wanted to work in the field of physiotherapy. (See BJSM blog on career development here).

Soon after qualifying and finishing junior rotations, I travelled abroad and worked as the physio for the Bahamas FA. This built my knowledge and competencies and provided skills required to work in high level sport: strong communication, organisation, preparation, planning and dedication. After that I worked with other professional football teams, built up private practice work and started a master’s degree (see BJSM blog on MSc or not to MSc here). This created opportunities to work with amateur and professional golfers and become involved with the European Tour Physio Unit.

Life on the road

In my job, you never know who or what problem may come through the door. This really tests you daily. I enjoy the immediate, substantial effect you can have on a player, their performance and achievements. Many times we have had players about to pull out with an acute injury who have gone on to win the event that week — this is an extremely rewarding part of the job. For me, the apotheosis of my physio career was working with the triumphant European Ryder Cup Team in Medinah in 2012 when they made an incredible final day comeback. To be in the locker room listening to Jose Maria Olazabal’s team talk before, and victory speech after, was something I will never forget.

The last 5-10 years in golf physiotherapy has seen much greater emphasis on exercise and strength & conditioning work in treating injuries and maximizing performance. The new breed of much stronger, fitter golfers can generate higher forces and swing speeds and hit the ball further. We have a well equipped gym in the Mobile Physio Unit and are able to spend a good amount of our time with players, working on both general fitness and conditioning, as well as golf specific exercises.

Life on tour means long hours. In summer we regularly start at 5 am and finish at 9 pm. We open an hour before first tee and stay until every player has finished playing. Early parts of the week often involve dealing with more acute injuries and working on strength and conditioning and rehab programmes. Moving through the week, we do more preparation, recovery and maintenance work with the players and less strength & conditioning.

Practitioners and players share some similar problems: having to perform week after week when moving across large time zones and taking multiple long flights. I manage this by getting sufficient sleep, eating & drinking well and staying fit. This year I will travel to over 25 events across the world – it’s lucky I have got my packing and travel logistics down to a fine art! (This part was sponsored by TARDIS*)

Biomechanics and injuries

Golf is very demanding. It requires strength, explosive power, flexibility and athletic ability to perform a movement which produces some of the fastest club head and ball speeds of any sport.

The effect of repeated large forces, often over decades, can lead to numerous injuries, particularly in the lower back, wrist, shoulder and elbow. The biomechanical requirements of an asymmetrical swing is a risk factor for injury. For instance, right handed golfers, who lead with the left side, are more likely to suffer from Extensor Carpi Ulnaris (ECU) injuries on the left wrist and Dorsal Rim Impaction Syndrome (DRIS) injuries on the right wrist. Open Access BJSM paper on wrist injuries here.

The physical requirements to execute these most complex athletic skills are enormous. Human anatomy and biomechanics are poorly suited to perform the high-torque rotational movement of the golf swing, which creates and must resist many high forces. The modern swing uses a large shoulder turn but restricts the hip turn to build torque in the muscles of the lower back and shoulders.  This places larger stresses on the back and shoulder complexes, leaving them susceptible to injury.

From the pro circuit to your clinic

When working with golfers and sportspeople in general, my plan is to make them strong, robust (resilient, strong over repeated events) and stable. When working with golfers in clinic, a good strength and conditioning programme is vital to helping them perform better and reducing injury potential.   Try to get them to always perform a warm up before swinging a club and structure their practice and play so they start to build up tolerance and ability to withstand the relevant forces through vulnerable structures.

Poor technique is a massive contributor to injury in amateur golfers. Going with a golfer to their golf coach or golf specialist is a great way to understand problems with their swing and the effect that could be having on their injury. Settle in to watch the 2015 Masters in Augusta this April to see great technique and watch how it is done by the pros.


Nigel Tilley is a Consultant Physiotherapist on the European Golf Tour & ETPI.

@nigel_tilley @ETPI_Physiounit

If you are a UK physio and not already a member of UK Physios in Sport, check our website for member benefits. Tremendous value on your CPD events, opportunities to network with the leaders in UK sports physio as well as valuable access to 4 sports physio journals including BJSM and JOSPT.  Benefits begin at £21 pounds for students and <£5 per month for all Chartered Physiotherapists.

See also Young Athlete conference – Brighton, October 9 and 10, 2015. Just £221 for UK Physio in Sport Members (early bird, sign up now) and £133 for students! Great value!


‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy – “It may be science Jim, but not as we know it!” (Letter to the Editor)

24 Mar, 15 | by BJSM

Letter to the Editor by BJSM Associate Editor Dr Nick Webborn and colleagues

In response to: MS Rathleff and K Thorborg (2015) ‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis)

feet tiptoesAlthough it’s good to see researchers putting forward hypotheses for improving rehabilitation protocols, I believe there needs to be a balance of promoting their own work published in another journal  (Scandinavian Journal of Medicine & Science in Sports) with incomplete presentation of the data in a BJSM editorial.

The original paper was titled High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Keep in mind the key point in the editorial was a significant difference between groups after THREE months of loading intervention – mechanotherapy.(Open Access Paper with 66,000 views here)

The authors found no differences between groups at 1, 6, and 12 months. There was no mention of this failure to find a difference at those time points in the editorial. At 12 months, the Foot Function Index score was actually worse in the stretch group. So if all our patients were just interested in how they functioned after 3 months of treatment the study findings are exciting. But there could be numerous reasons for this transient difference at 3 months including chance. There may have been no difference at 4 months and it was a transient blip in the data. Perhaps an explanation of reported improvements at 3 months but not at 1,6 & 12 should have been hypothesised in relation to the high-load’ model.

Too often we are told of the next great step in treatment based on limited science and then have to readjust it and confuse our patients yet again. If we are going to tell people “to boldly go where no one has gone before” we need to be clear, and honest, as to why. The authors need to temper their enthusiasm for their theory and accept the limitations of the study. There were only 24 subjects per group. We need to consider this before we all jump on the bandwagon that this is the next new panacea.

We all acknowledge that some form of loading is important during rehabilitation of injured structures but the evidence of this type of loading over other forms is still conjectural based on the current evidence. Maybe we need Dr ‘Bones’ McCoy’s medical tricorder device to assess it?

Aspiring to get ahead? Sports Physio tips from the UK to Qatar

20 Mar, 15 | by BJSM

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

By Johnathon King (@Jonny_King_PT) & Liam West (@Liam_West)

You need mentors and role models to get ahead in your career. From this perspective, I Liam West (LW) interviewed Jonny King (JK), (a successful physiotherapist from the UK now based in Aspetar, Doha) to find out what aspiring physios can do to get ahead!

LW: Hi Jonny, great to have you on board for the blog. Can you kick us off by giving the students a quick overview as to your undergraduate career and if you were involved in any Sport & Exercise Medicine (SEM) activities at this stage.

JK: I trained in Sheffield, graduating with a BSc (Hons) in Physiotherapy in 2009. During my time as an undergrad, I always had a special interest in musculoskeletal (MSK) medicine, in particular, SEM.  During my time as a student, I volunteered as much as my uni workload allowed me to; providing soft tissue work at athletic events and marathons, providing assistance to local rugby and football semi-pro clubs under the supervision of a senior physiotherapist etc. I kept an eye out for open SEM lectures, as these were great for not only learning but networking also.

LW: Great tips. So after you graduated how did you get involved with SEM? Did you work within the NHS at all or did you go straight into your posts in Elite Football?

JK: My first post was a junior physio in the NHS, completing my rotations in a variety of clinical fields over nearly 2 years. Alongside this job, I continued my interest in SEM by working part-time at a professional football academy. As my experience accumulated, I stepped up to working full time with elite athletes in a football academy. However, I feel very strongly that my time in the NHS was an invaluable experience, as not every presentation you see in the sporting world musculoskeletal related.

LW: How did you build upon your enthusiasm for SEM? Is there anything you would advise aspiring sports physios to do whilst still an undergraduate?

JK: I continued to attend lectures, conferences and CPD courses in my interest areas. My career pathway to date has taken me into football, and The FA provides excellent workshops and events for CPD work, but saying this, there are also many other great courses out there. Staying on top of current research is very important for keeping up to date with the most effective practices. So I also suggest subscribing to various SEM journals/podcasts.

Before starting my degree, I asked various clinicians already working in professional sport about how to pursue a career in elite sport. They all offered the same advice – volunteer, volunteer, volunteer! So this is my best advice also, as it helped me considerably. I provided soft tissue work at various athletic competitions and marathons as well as assisted senior clinicians at local semi-professional football and rugby clubs. Most semi-pro clubs and certainly professional clubs with a lower medical budget will always welcome volunteers, so send a letter or e-mail enquiring of voluntary (or even observational) work. Don’t be afraid to ask!

LW: After your hard work in the UK, you were rewarded with a fantastic opportunity to work at Aspetar, Doha. Could you tell the readers what it is like there and what you are getting involved in? Has it influenced your interests in any particular areas of SEM?

JK: Working at Aspetar has been a great experience to date.  The quality of facilities and resources are up there with the best, but the best thing about the job is the level of expertise here. I am surrounded by Doctors, Physiotherapists, Physiologists and Sport Scientists with an unbelievable amount of experience and for someone at a relatively early stage in their career, it is a great opportunity to be ‘a sponge’ – to learn and develop my knowledge and skill base as much as possible.

There are also fantastic opportunities to get involved in research. We are looking at collaborating with some big European Football clubs to collect injury data. There are also opportunities to attend some great conferences – Aspetar recently held the 1st World Hip and Groin conference. Attending sessions led by international leaders in the field was a definite highlight since moving out here.

In terms of developing a special interest, working in football has developed my interest in the obvious – the hip, knee and ankle. But I’m also looking into researching the management of lower back injuries in young athletes. This is an area where the literature is relatively inconclusive at present, so hopefully you will see some research in this area coming out of Doha soon. We are also interested in the hip and groin, and if we can reduce the complexity of issues professional adult athletes face, by addressing certain factors during the maturation process.

LW: Finally, are there any tips from your experiences that you could give to students wanting to follow a similar path?

JK: As previously stated, I would aim to volunteer and seek observational opportunities as much as possible. Stay away from paying for expensive CPD courses – I feel as a student it is difficult to benefit from the skills you learn on a course as you do not have the client base to practice them on – they are of much greater value once qualified. I would rather spend the money on a conference, even look out for free evening lectures as they are quite frequent. This is only personally speaking, obviously, to each their own.


Jonny King BSc MCSP HCPC is a sports physiotherapist from the United Kingdom that is now working at the Aspire Academy in Doha, Qatar. He has a specialist interest in injuries and rehabilitations of MSK injuries sustained around the hip, knee, ankle and lower back in junior athletes.

Dr. Liam West, BSc (Hons) MBBCh ECOSEP(ac) PG-Cert SEM, is a junior doctor in the Oxfordshire Deanery In addition to his role as a Senior Associate Editor for BJSM he coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series. He has a passion for developing the SEM movement amongst undergraduates and sits on the Council of Sports Medicine for the Royal Society of Medicine as Editorial Representative, founder, and is the founder & current President of USEMS. He has also now been elected as the President of the Junior Doctor’s Committee for the European College of Sport & Exercise Physicians (ECOSEP). His Twitter handle (as above) is @Liam_West.

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.

Winner announcement: BJSM 2014 cover competition

18 Mar, 15 | by BJSM

The Dutch Association of Sports Medicine theme issue that focused on muscle injuries won the Oscar for BJSM’s 2014 cover.  The clear winner broke the The South African Sports Medicine Association’s  3-year stranglehold on the coveted trophy; no other nation had captured this ultimate among sports awards. Congratulations to all 17 BJSM member societies and particularly to those who created BJSM’s September 2014 issue 18 that focused on muscle injuries.

Canadian sidenote: there are no ‘loser’ covers at BJSM – excellent quality all-round for 2014.

We shared the good news with Drs Babette Pluim and Robert-Jan de Vos, the issue’s Editors, and here’s what they said during the crazy all-night celebration in Amsterdam’s Vondelpark which was orange-bedecked in anticipation of this announcement.

“We are delighted to win this cover competition with the Dutch Sports Medicine (VSG) special issue. Sports medicine was recognized as a medical specialty in the Netherlands last year, and we are now gaining a permanent position in the Dutch healthcare system. Our partnership with BJSM is a positive stimulus for Dutch sports medicine, and the support for our 2014 issue adds to our momentum.”

Cover art by Vicky Scott; Cover athlete: Sven Kramer, Dutch speed skater winner of an all-time record seven World Allround Champion,  record holder of seven European All round Championships and Olympic Champion of the 5000 meters and the current world record holder in the 5000 m, 10,000 m, and the team pursuits

Cover art by award winning medical illustrator Vicky Earle Cover athlete: Sven Kramer, Dutch speed skater winner of an all-time record seven World Allround Championships, record holder of seven European All round Championships and 3 x Olympic Champion. Current world record holder in the 5000 m, 10,000 m, and team pursuits

BJSM is grateful for Vicky Earle’s cover designs and here the depiction of Dutch great Sven Kramer You can contact Vicky for that special powerpoint slide or paper/book illustration at

To read articles from this issue, please click HERE. And you can check all BJSM content conveniently via the free BJSM mobile app (Android/AppStore)

The Warm-up (Free) for the issue is called, Knowledge is only rumour until it is in the muscle by Robert-Jan de Vos.

The most downloaded article from the issue is by Noel Pollock and the team from UK athletics: British Athletics Muscle Injury Classification: A injury grading system  This Open Access paper moves us past the historic Grades 1, 2 and 3 muscle strain classification to take more account of the extent of damage that can now be assessed by MRI.

A great complementary piece in that issue (also Open Access, as Editors’ Choice) is from the Dutch group (Maarten Moen, Gustaaf Reurink, Adam Weir et al) who found that passive straight leg raise deficit, and the player’s own estimate of time to return to play, were both better predictors of ultimate return to sport than MRI appearance at the time of injury! Food for thought. Predicting Return to Play after Hamstring Injuries – click here

On the subject of Return To Play, remember the first World Sports Physical Therapy Congress that will focus on Return To Play – Bern, Switzerland, November 21-22, 2015

Stay tuned to the blog (and your emails) for our announcement of the book prize winners. And share news of the free BJSM mobile app with your friends.


















PART 2: To #LCHF or not to #LCHF; That’s the dietary question!

15 Mar, 15 | by BJSM

By @JohannWindt, @Liam_West & Ania Tarazi

This is part 2 of the’ To #LCHF or not to #LCHF’ Summit summary. Read part 1 HERE

In this post, we focus on the low carb high fat diet (LCHF) and performance, and finish off with the pros and cons of the #LCHF2015 summit. We hope you enjoyed BJSM Editorial team’s coverage from the summit in Cape Town! Follow the #TeamBJSM on @BJSMPlus for future SEM event coverage!


#LCHF and #EndurancePerformanceruntrackcrop

#RunOnFat – More than the name of the exclusive screening of the new documentary featuring Dr. Stephen Phinney and Prof. Tim Noakes, this describes how adaptation to a #LCHF diet may impact endurance performance. Professor Tim Noakes, Dr. James Smith, and Dr. Stephen Phinney all demonstrated that fat oxidation rates are significantly higher in athletes adapted to a #LCHF diet than any other athletes. They identify that an adaptation period is necessary for performance to return to performance levels with higher carbohydrate content. This may explain the significant portion of the research supporting high carbohydrate diets, as the athletes with lower carbohydrate content in their diets were not on the diet long enough to adapt. The increased fat oxidation level as a result of a high fat diet corresponds to slower rates of glycogen depletion, thereby offering a theoretical benefit to improved endurance performance, and less dependence on exogenous carbohydrate intake during prolonged activity. At this point, data is mixed between beneficial effects and no documented effects on endurance performance on LCHF diets. More research is necessary to determine whether athletes adapted to the diet are capable of maintaining/improving sprint performance and peak power outputs, since sprint performance appears to decrease under carbohydrate restricted conditions.

#LCHF and #Strength/Power Sports

Most of the discussion at the conference focused on #LCHF diets and endurance performance, with little addressing strength/power sporting contexts. With the exception of a study in gymnasts, showing stable performance in the presence of fat and weight loss, no literature has examined this area in depth. In addition to their potential use in helping these athletes lose fat, further research is needed as to whether this diet contributes to  significant performance benefits.

As identified by Noakes, Phinney and Volek in their recent editorial, many research questions remain in this field. Namely, the effects of #LCHF adaptation on recovery ability and total training volume, their immune function and overtraining risk, sports requiring high levels of hand-eye coordination and mental acuity (i.e. Golf & Cricket), and their efficacy in allowing for weight control. While #LCHF adaptation can significantly increase rates of fat oxidation, it remains to be seen if this translates to improved performance in endurance events.


#LCHF2015 Summit summary and final considerations 


  • The conference included a global speaker line-up and addressed #LCHF diets from a variety of perspectives, including weight, CVD risk, glycemic control, mental health, anthropology, history, psychology and more.
  • The speakers consistently voiced that low carbohydrate diets are not the only way to success/health, but that they should be considered as an effective, healthy option.
  • The conference itself ran very smoothly and was very well-organized seeing over 400+ each day register.


  • Certain portions of the conference were heavier in anecdotes/case studies than scientific data. On occasion, unsubstantiated claims without supporting data were made. During the first 3-day medical part of the conference, it is vital to remain consistently evidence-based.
  • #LCHF can cause some confusion. The demonization of “carbohydrates” can lend to the misunderstanding that all carbohydrate sources, from fruits and vegetables to refined, sugary breakfast cereals and pastries are the same. The recommendations to consume unprocessed, nutrient dense foods must be emphasized, after which point the restriction of certain carbohydrate sources may be warranted.
  • Many speakers failed to elaborate beyond the carbs à insulin à fat model, which fails to account for other factors associated with weight gain. Acknowledgement of other factors, and more thorough explanations are warranted.

Far from a simple fad, #LCHF diets have a growing body of evidence in their favour. #LCHF diets are extremely effective for weight loss, glycemic control, and improve a large number of CVD risk factors. Adaptation to this diet also significantly increases rates of fat oxidation during exercise. It is true that no long-term trials have demonstrated their efficacy beyond two years. However, the significantly positive effects from RCT evidence should validate their use, especially since the long term effects of the low-fat diet have not proven to be beneficial beyond a control diet after 8 years. To demonize them as a ‘fad diet’ fails to honestly examine the evidence, which indicates both their efficacy and safety. #LCHF diets may not the only way to eat, but they should be considered as a viable option.

With that said, many questions remain. Long-term trials are still called for to examine the effects of long-term adherence to a #LCHF dietary plan. What factors help to explain individual variability in response to #LCHF diets? What are the long-term effects of nutritional ketosis? In terms of performance, further investigation into different performance parameters, sporting contexts, recovery rates, and weight control remains necessary.

Overarching the whole #LCHF summit was an insistence on nutrient dense #RealFood, thereby #AvoidProcessedFood stripped of fiber and containing additional sugar. Thus, we conclude by insisting a focus on eating #RealFood, and if desired to try a #LCHF approach to nutrition.


Johann Windt BHK CSCS (@JohannWindt) is a graduate student at the University of British Columbia in the Department of Experimental Medicine. His research currently focuses on physical activity prescription and lifestyle counseling in family medicine settings. A certified strength and conditioning coach, Johann is passionate about improving health, body composition, and performance through evidence-based application of nutrition and physical activity. 

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a Cardiff Medical School graduate and now a junior doctor at the John Radcliffe Hospital, Oxford. He is an Associate Editor for BJSM and also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

Ania Tarazi BSc (Hons)  (@AniaTarazi) coordinates the Aspetar Sports Medicine Journal in Doha, Qatar. Ania graduated from Royal Holloway University of London with an International Business degree in 2013. Her interests lie in social media engagement to promote physical activity and healthy eating in children.

PART 1: To #LCHF or not to #LCHF – that’s the dietary question!  

12 Mar, 15 | by BJSM

By @JohannWindt, @Liam_West@AniaTarazi

Cape Town International Convention Centre

Cape Town International Convention Centre

Attendees of the 2015 Old Mutual Health Convention were fattened with four full days of low-carb, high fat (#LCHF) information #PunIntended. For brief summaries, see daily blogs of Day 1, Day 2, and Day 3. Combining our notes, conference speaker interviews, and your questions, #TeamBJSM hope this blog captures and summarizes the main scientific research presented at the summit. We have hyperlinked relevant papers in green for you to make up your own mind about the diet – #NoBias. There will be two parts: “#LCHF and #Health” and the second, “#LCHF and Performance”. Here, in part 1, we look at LCHF in respect to weight loss, cardiovascular risk and glycemic control and answered the common misconceptions about the diet.


#LCHF for weight loss:

Physiological Basis – Hormonal Model Adopted – The central basis of the low-carbohydrate diet is adoption of the hormonal model of obesity, as opposed to a strictly energy balance model. They suggest that a purely calorie-based model (energy in vs. energy out) is insufficient, and the interplay of dietary intake, hormonal and physiological responses is key to understanding weight control. Most speakers highlighted the role of dietary carbohydrates in raising insulin levels, thereby encouraging the body to store fat (de novo lipogenesis), and block fat breakdown (lipolysis). Support for this model includes differential weight loss in isocaloric conditions, and different weight loss in low-carbohydrate vs. low fat diets, dependent upon insulin resistance. Bonus reading here & here.

Trial Evidence – Low Carbohydrate Diets vs. Other Diets – A number of speakers presented evidence that low carb diets have outperformed low-fat diets (related reading; one, two, three)  and low glycemic index diets  in randomized trials of weight loss. This observation has been picked up in a number of systematic reviews regarding the efficacy of low carbohydrate diets – links to read here; one, two & three. Notably, it was identified the low-fat diets were deliberately energy controlled (with prescribed kcal to induce weight loss), while the low-carbohydrate diets were unrestricted in energy intake, yet still outperformed low-fat counterparts.

Caveats and Misconceptions – First a calorie is a calorie. It’s a unit of energy, it measures the potential energy food can release. Therefore #CaloriesStillCount. But, it must be emphasised, two equal calories can produce different biological effects to body fat or body weight, i.e. a calorie of protein vs a calorie of refined carb. Second, carb intake leading to fat storage is an oversimplification. Dr. Jason Fung aptly presented that the “carbs leading to insulin leading to fat” hormonal model is a part of the puzzle, but fails to take into account all aspects. With the cycle of increased serum insulin, leading to insulin resistance, causing higher serum insulin, etc. at the center of the model, he identified three central players that all link to Insulin:

  • Carbohydrates – As often identified in the hormonal model above, cause increased insulin levels and can if consumed in too high quantities and frequencies, contribute to insulin resistance.
  • Fiber – Helps reduce insulin levels #Protective – see papers here – one & two
  • Fructose – Unique capacity to induce insulin resistance, thereby exacerbating the problems.

Since the refining/processing of foods often strip the fiber from foods, and add additional fructose, they are especially harmful in inducing weight gain. #CheckFoodLabels

Therefore, the consistent take-home messages from the conference in terms of weight control included #RestrictCarbs, #EatRealFood, & #AvoidProcessedFoods.

#LCHF and cardiovascular risk:

Conventional wisdom states that too much fat increases fat and cholesterol in the bloodstream, and contributes to cardiovascular risk – commonly called the diet-heart hypothesis. If true, a LCHF diet is a tremendous risk, and will predispose people to heart attacks and CVD. However, these fears must be reconsidered in light more recent data.

Systematic reviews – click on one, two & three to view – examining the LCHF diet and cardiovascular risk factors, showed significantly:

  • Improved weight, BMI and waist circumference
  • Increased HDL, which serves as protective against heart disease
  • Decreased triglyceride levels
  • Decreased systolic and diastolic blood pressure
  • Decreased fasting plasma glucose
  • Decreased Insulin levels
  • Decreased HbA1c levels

Further evidence also suggests:

  • Reduced levels of saturated fats in the bloodstream
  • Reduced inflammatory biomarkers

The ‘red-flags’ to patients on a LCHF diet is the variable response of LDL levels, and average increase in total cholesterol levels. In terms of total cholesterol increases, this is predominantly or exclusively due to HDL increases, serves as protective to CVD, and is not seen as a major concern. Though the average LDL level is usually unaltered, it must be taken into account with a LCHF diet and CVD. It was pointed out that LDL levels are only one component of CVD risk, the rest of which all improve on LCHF. In addition to this, the particle sub-fractions of LDL change positively in response to LCHF, not negatively – check out two interesting papers here & here. Nonetheless, total cholesterol and LDL responses on a LCHF diet are variable, and more research will have to investigate these parameters.

To wrap up, cardiologist Dr. Aseem Malholtra identified that the best evidence to date for primary prevention of CVD is for the Mediterranean diet from the PREDIMED study; with the supplementation of EVOO and raw nuts and total of 41% fat content. He recently highlighted that saturated fat is not the major issue, and data on LCHF diets and CVD risk factors lend support to their safety from a CVD standpoint.

#LCHF and Glycemic Control:

LCHF diets effectively reduce body weight, insulin levels, fasting glucose levels, reduce insulin resistance, and significantly reduce HbA1c – evidence to back this up? Read 2 papers here & here. Hence, they are extremely effective in improving glycemic control and type 2 diabetes.

Dr. Jason Fung addressed the underlying issue of insulin resistance in T2DM, highlighting the fact that controlling blood sugar levels through intensive glucose lowering in diabetic patients has little benefit on mortality. He stated that a focus on blood sugar levels, as a chronic, progressive disease promotes learned helplessness and fails to take the current evidence into account. He highlights that both bariatric surgery  and fasting/extreme energy restriction have potent effects in reducing insulin resistance and reversing diabetes. Similarly, efforts should be made to control insulin levels and reduce the underlying insulin resistance through dietary strategies. This can best be achieved through restricting refined carbohydrates, increasing fiber intake, and removing fructose from the diet.

Challenging Guidelines

As expected, the national dietary guidelines of were touched on by a number of the speakers, including Gary Taubes and predominantly Zoe Harcombe. Presenting her recent paper, she highlighted that the randomized trial evidence at the time of the national guideline introductions in the US and UK was insufficient to prescribe a low-fat message.

An overarching theme of the conference was that ‘one-size-fits-all’ dietary guidelines that continue to restrict fat and cholesterol intake are not fair to the existing evidence. As discussed, Mediterranean diets with over 40% fat intake have continuously shown positive health outcomes. Furthermore, #LCHF diets reduce weight, cardiovascular risk, and glycemic control. This differs from the guideline recommendations.

Addressing Misconceptions:

Below we have tried to briefly address some #LCHF common misconceptions

“#LCHF treats all food as the same, as long as carbs are controlled”:

  • Consistently, all speakers presented that nutrients should come from #Unprocessed #RealFood, with high nutrient density and minimal processing.
  • All carbohydrates are the not the same, and intake should come from whole, unprocessed foods, green leafy vegetables, cruciferous vegetables, and minimal fruit.
  • Fats are not all the same. Mono and saturated fats are recommended on a #LCHF diet, while polyunsaturated sources should not be consumed in high quantities.

“What about Ketosis?”

  • Nutritional ketosis and diabetic ketoacidosis are entirely separate physiological states #Important
    • Nutritional ketosis has a blood ketone level of 0.5-2.0 mmol/L, with post-exercise ketosis up to about 3.0
      • Starvation ketosis can elevate levels up to 5.0-7.0 mmoL/L.
      • Ketoacidosis occurs with levels of 10 mmol/L or more
    • Ketones can serve as a primary fuel source for the brain during carbohydrate restriction.
    • There is emerging evidence for the benefits of ketogenic diets in various health conditions, including epilepsy, neurogenerative diseases, cancer, polycystic ovary syndrome, to name a few – see the evidence here, here & here.

“Higher saturated fat intakes on low-carb diets would cause higher saturated fats in bloodstream”

“Excess protein intake on a low-carb diet is dangerous”

  • Most low carbohydrate diets are moderate protein diets, with 15-25% of calories coming from protein.

“#LCHF insists that low-carb diets are universally the best diet”

  • Individual responses to low-carb diets vary, meaning #LCHF does not suit all! However, they should be considered as a safe, viable dietary option.
  • Insulin resistance can be reduced with a low-carb diet. Therefore, those with insulin resistance of type 2 diabetes may respond more favourably to a low-carb diet than those who have greater insulin sensitivity.

“Nutrient density is low on a low-carb diets”

  • If a #LCHF diet is followed as recommended at the conference (i.e. #RealFood, #Unprocessed), nutrient density will be attained through intake of a variety of vegetables, meat, and dairy. If attention is paid to eating whole foods from a variety of sources, all the micronutrients that would be attained on a high carb can be attained on a #LCHF diet.

Additional Considerations

Alongside a ‘well-formulated’ ketogenic diet, as described by Drs. Westman and Phinney, some additional sodium and magnesium intake may be recommended to help to prevent muscle cramps in susceptible individuals.

In Part 2 of ‘To#LCHF or not to #LCHF’ we’ll take a look at “LCHF and Performance”. Starting with the view of a LCHF diet on endurance performance and the need for an adaption period. We’ll take a look at the pros and cons of the summit and our take home message from #LCHF2015.


Johann Windt BHK CSCS (@JohannWindt) is a graduate student at the University of British Columbia in the Department of Experimental Medicine. His research currently focuses on physical activity prescription and lifestyle counseling in family medicine settings. A certified strength and conditioning coach, Johann is passionate about improving health, body composition, and performance through evidence-based application of nutrition and physical activity. 

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a Cardiff Medical School graduate and now a junior doctor at the John Radcliffe Hospital, Oxford. He is an Associate Editor for BJSM and also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

Ania Tarazi BSc (Hons)  (@AniaTarazi) coordinates the Aspetar Sports Medicine Journal in Doha, Qatar. Ania graduated from Royal Holloway University of London with an International Business degree in 2013. Her interests lie in social media engagement to promote physical activity and healthy eating in children.

For the “Body Matters” MOOC (McGill University, Prof Ian Shrier): Exercise is medicine, for the body and the brain by Nagamatsu and colleagues.

9 Mar, 15 | by Karim Khan

YourBrainLovesTheGym Each week over 23,001 folks are learning about the power of exercise via a Massive Open Online Course (MOOC).

Generously, BJSM helps out Professor Ian Shrier by answering one question each week on this blog. Prof Shrier just has to answer the other 23,ooo students’ questions.

This week’s question is:

“What are the effects of exercise on the brain’s ability for computation and memory?”

You could ‘Google it’ and you will find that the past 2o years has seen an explosion of literature on this topic. Fueled by? You guessed it – the wonder of MRI (magnetic resonance imaging) that provides structural images to complement tests of brain function (formerly pen and paper tests, now largely converted to computer/tablet tests). I don’t fully understand it yet, but MRIs can also show us changes in brain FUNCTION. So if exercise improves brain performance (which it does), some of these changes can be seen during ‘functional’ MRI of the brain. Wow!!  It used to thought that one exercised ‘for the heart’ but my feeling is that ‘exercise for the brain’ is even more important.

So, down to the nitty-gritty! “Show me the money” or, in this case – Show me the evidence!

And here I take you to a 2014 BJSM article –

LiuExerciseExercise is Medicine for the Body and the Brain


It is by Lindsay S Nagamatsu, Leon Flicker, Arthur F Kramer, Michelle W Voss, Kirk I Erickson, Chun Liang Hsu and my hero, Teresa Liu-Ambrose.

Cognitive decline is one of the most pressing healthcare issues   of the 21st century. Worldwide, one new case of major cognitive decline (ie, dementia) is detected every 4 s. Given that no effective pharmacological treatment to alter the progress of cognitive decline exists, there is much interest in lifestyle approaches for preventing or treating dementia. Ideally, such strategies should be cost-efficient and widely accessible at a societal level to have the largest benefit for older adults with varying income and functional status levels.

One attractive solution is exercise. However, despite a large and consistent pool of evidence generated over the past five decades linking exercise to improved cognitive functions in older adults, there is a reluctance among academics, healthcare practitioners and the public alike to embrace exercise as a prevention and treatment strategy for cognitive decline. For example, the National Institutes of Health (NIH) consensus statement from 2010 concedes that there appears to be preliminary data to support the efficacy of exercise in improving cognitive function. However, they caution that there is currently no strong evidence to suggest that modifiable lifestyle factors can alter the trajectory of cognitive decline.

Adding fuel to the fire are publications such as a 2013 systematic review of randomised controlled trials (RCTs) (prior to 31 October 2011) reporting ‘weak’ evidence for the effects of exercise on cognition. However, the search strategy used in that systematic review failed to capture many pertinent papers providing evidence from RCTs that exercise promotes cognitive and brain plasticity not only in healthy older adults but also in those with cognitive impairment. Animal studies that provide insight into the molecular and cellular mechanisms by which exercise promotes neuroplasticity.

In a previous commentary,(Liu-Ambrose, BJSM 2009)  we outlined studies that provided compelling evidence that exercise should undoubtedly be considered as a promising treatment strategy for cognitive decline. Our present commentary aims to provide a brief update, as well as to discuss factors that have continued to hinder the adoption of exercise as a legitimate medical strategy for the prevention of cognitive decline and dementia.

Since 2010, we have additional evidence from RCTs that exercise, both moderate-to-vigorous intensity aerobic and resistance training, promotes cognitive and brain plasticity and have gained further insight into underlying mechanisms. Notably, the behavioural and mechanistic outcomes converge and support a cohesive picture. In 2011, Erickson et al demonstrated that aerobic exercise resulted in increased hippocampal volume in healthy community-dwelling older adults. Furthermore, changes in hippocampal volume in the aerobic exercise group were significantly associated with increased levels of serum brain-derived neurotrophic factor and spatial memory performance. In the same RCT, Voss et al  demonstrated that aerobic exercise also improved the functional connectivity or temporal coherence of brain regions that are functionally related in a network known to decouple with ageing.

For resistance training, Liu-Ambrose et al  demonstrated increased functional plasticity after 12 months of training with corresponding improvement in selective attention and conflict resolution in healthy older women. Critically, the benefits of exercise extend to those with mild cognitive impairment (MCI) and dementia. Among older women with MCI, Nagamatsu et al  demonstrated that 6 months of resistance training led to improved executive functions, spatial memory and associative memory with concurring functional plasticity. In the same study, the authors also found that aerobic training improved verbal memory and learning. These findings indeed support the findings from a recent systematic review on exercise and cognition in those with dementia, although to our knowledge no such systematic reviews exist for those with MCI.

Despite these recent positive findings, scepticism remains. Enthusiasm for increased exercise as a prevention strategy is often tempered by the fact that no RCT until now has demonstrated that exercise can actually reduce the incidence of MCI or dementia. Is the absence of such a definitive trial reason enough to disregard the evidence until now? We contend that the answer to this question is a resounding ‘no’ when the following points are considered:

  • The number of individuals with dementia will exponentially increase in the next 20 years.

  • There is now a large and consistent pool of animal and human data demonstrating the cognitive benefit of exercise. Importantly, recent randomised studies show a convergence among behavioural, neuroimaging, and serum biomarker outcomes. Furthermore, large cohort studies have demonstrated significant associations between exercise and reduced risk of cognitive impairment and dementia.

  • Exercise has a multitude of established health benefits with minimal side effects and is cost-effective. Even in older adults, exercise increases the chance of survival and healthy ageing.

  • Exercise significantly reduces the key vascular risk factors (eg, hypertension, diabetes type II, hypercholesterolaemia, etc) for Alzheimer’s disease and vascular dementia—the two most common types of dementia.

In fact, exercise should be promoted as an essential component of healthy ageing given that reducing physical inactivity by 25% could prevent as many as one million cases of dementia worldwide.

Providing healthcare practitioners and seniors with specific and individualised recommendations regarding the type, intensity, and frequency of exercise for benefit is critical to successfully advocate exercise as a treatment for cognitive decline. (FOR MOOC STUDENTS, THIS IS WHAT PROF SHRIER WILL COVER NEXT WEEK – THE PRINCIPLES OF EXERCISE PRESCRIPTION)

However, we are limited by the fact that dose and type of exercise have been utilised in different studies with varying success. For example, Baker et al  found that older women with MCI who engaged in aerobic exercise four times per week exhibited improved cognitive function, whereas in a similar population, aerobic exercise twice per week did not yield the same benefits. Further, confusion centres around the type of exercise (eg, aerobic vs resistance training) and sex differences.

Evidence strongly suggests that exercise does have benefits for cognition—and critically, the magnitude of the benefit can exceed that of pharmaceutical approaches. It is estimated that if the onset and progression of dementia could be delayed by a mere 1 year, there would be nearly 9.2 million fewer cases in 2050. Given that exercise can be promoted at a population level with relatively low risks and costs, we highly recommend that older adults should be encouraged to engage in regular exercise to boost cognitive function as further research is concurrently conducted, rather than wait until all the intricacies of the relationship between exercise and cognition have been resolved.

We recognise that a large proportion of the population is sedentary and that successfully changing behaviour to a more active lifestyle is challenging. To effectively advocate exercise, we emphasise the need for a cross-disciplinary collaborative effort among researchers and healthcare workers to develop consistent standards and a united message of the multiple benefits of exercise. In light of the recent support for exercise in preventing cognitive decline, we stress that endorsing exercise as an effective strategy for improving health and well-being among older adults should be indisputable. Given that it may potentially have a high impact for mitigating multiple health concerns, including dementia, exercise should therefore be considered as a leading treatment strategy to delay or prevent dementia.

Thanks to BJSM for allowing us to reproduce the paper:

Exercise is medicine, for the body and the brain.

Nagamatsu LS, Flicker L, Kramer AF, Voss MW, Erickson KI, Hsu CL, Liu-Ambrose T.

Br J Sports Med. 2014 Jun;48(12):943-4. doi: 10.1136/bjsports-2013-093224. Epub 2014 Mar 21.

Karim Khan (@BJSM_BMJ)
One of the 3 lead editors at the BJSM – along with Babette Pluim (@DocPluim) and Jill Cook (@ProfJillCook).

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