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Tennis: Field-based fitness tests – the 7 domains every coach needs to test

2 Sep, 14 | by BJSM

By Dr. Babette Pluim (@DocPluim)

tennis ball and racketAt the start of the indoor tennis season, many fitness trainers and coaches use a set of ‘fitness tests’ to evaluate their junior player. What they really want to know is whether they have a new Federer amongst their pupils (talent identification), what strengths and weaknesses the player has (injury prevention), and their basic fitness level (periodisation).

Which tests do I recommend? There is no simple answer. Test choice depends on availability of facilities, time, finances, and the ultimate purpose of testing.

Do you want to know if your player has a good basic fitness level? Do you want to see how fast and strong they are in comparison to other players? Or is your primary goal just injury prevention?

This video gives an impression of a testing day of the junior players at the Dutch Tennis Federation (KNLTB):

https://www.youtube.com/watch?v=HPdQQP16D7g&feature=youtu.be

In a BJSM open-access overview article, Jaime Fernandez-Fernandez and colleagues describe all the existing physical tests for tennis and discuss their advantages and disadvantages. They also include a summary table of recommended tests. The full article and table are available HERE.

Tennis involves short bursts of intense effort (rallies last 2-10 seconds), followed by breaks of 10-25 s (between rallies) and longer breaks of 60-90s during the change of ends. A typical 3 set match lasts about 1.5 hours, but this varies depending on playing style, level of competition and court surface. A player must cover a mean distance of 3 meters to reach the ball, runs 8-15 m with 3 to 4 directional changes per point, hits the ball 4 to 5 times per rally and covers 2.5-3.5 km per hour of play. During singles matches, the mean heart rate is 70-80% of maximum with peaks of 100% and the mean oxygen uptake 50-60% of VO2 max, peaking at 80%.

Thus, for optimal tennis performance and a rapid recovery, a player needs speed, strength, agility, power and, a good level of basic fitness. Below I discuss the commonly used field tests for a high level, tennis performance program. These are generally cheaper than those used for indoor or laboratory-based testing and are more suitable for large groups of players. If you are interested in laboratory based testing, please refer to the original article.

1. Aerobic endurance

Most tennis federations choose the shuttle run, the Yo-Yo Intermittent Recovery Test or the 30-15 Intermittent Fitness Test. Unfortunately, relatively little normative data is available for young tennis players and the tests are not quite equivalent to the loads in tennis.

Several researchers have tried to develop tests, which mimic the game itself by using the dimensions of a tennis court, and involve tennis strokes in addition to running ability. Weber has developed a test using a ball serving machine in which the ball is hit alternately to the left and right corner of the court and the player must run faster and faster to hit the ball back. However, the quality of the stroke is rapidly lost, you can test only one player at the time, it is not very realistic in tennis terms – and you need a ball machine to perform the test!

There are two other field tests that involve simulated tennis strokes – the Girard test (2006) and the hit-and-run test but I would opt for one of the simple tests (Shuttle run or Yo-Yo IR test). These have the additional advantage that if you measure heart rate, you can monitor progress without having to perform a maximal exercise test.

2. Anaerobic endurance

Anaerobic endurance can be measured relatively easily in the laboratory using a 30 second Wingate test and, in the field, you can use a repeated sprint test. Since there is a high correlation between the speed of a single sprint test (20 meters) and repeated sprint tests (e.g. 10 x 20 m.), a single sprint test is usually sufficient.

3. Strength

Using gym-based equipment, dynamic strength can be measured with a 1 Repetition Maximum (1RM, the maximum weight that can be lifted with one repeat) but this is associated with a high rate of injury so I would recommend using multiple repetitions at the start of the season (e.g. 3RM, 5RM or 10RM).

4. Power

In the field, jumping height measures lower extremity power, and throw distance of the medicine ball measures upper body power. These tests are widely used by tennis nations, so there is plenty of normative data available for these tests.

Radar speed gun measures speed of service and ground-strokes and this has a reasonably good correlation with the tennis ranking.

5. Speed ​​

Electronic interval timing equipment measures speed in the field – a stopwatch is simply not accurate enough. The 20m sprint (with split timing at 5m and 10m) has a high reliability and, because most tennis nations use it, has adequate normative data for the various age groups.

6. Agility

Agility is the ability to change speed or direction quickly and research shows that this is clearly different from pure sprint speed. Agility is usually tested using a noise (acoustic) or light signal as seen in the hexagon test, the spider test, and the Illinois agility test .

7. Musculoskeletal system

A general assessment of the musculoskeletal system is normally included in any screening protocol and a physiotherapist often conducts this. The United States Tennis Association (USTA) have developed a dynamic examination protocol specifically for tennis (High Performance Profile), but unfortunately they do not provide normative data (read more HERE ).

7. The Functional Movement Screen (FMS) is probably the most popular tool internationally and is used by physiotherapists to detect weaknesses and asymmetries of the musculoskeletal system with a view to implementing injury prevention strategies.

If you choose one or two simple tests from every domain, you and your player(s) will have more than enough to work with during the upcoming tennis season.

Useful link:
The test protocol guide of the German Tennis Federation can be found HERE

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Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer, KNLTB,Netherlands). She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

Brilliant, engaging, relevant! 2013/14 BJSM Systematic Review Award Winners

24 Aug, 14 | by BJSM

Systematic reviews provide critical high-level evidence to influence practice. BJSM prioritises publication of quality SRs.

systematic review awardThe winning papers are enjoyable to read and their messages easily incorporated into clinical practice. The selected papers adhered carefully to PRISMA guidelines. The results were skilfully analysed and synthesised into a clinically relevant discussion which links well to the study objectives. A reviewer independent of BJSM editors chose the winners after an iterative evaluation of BJSM systematic reviews published between July 2013-June 2014.

1st equal (£500) prize winners:

  • Christian Barton, Vivek Balachandar, Simon Lack, Dylan Morrissey

Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms Br J Sports Med 2014;48:6 417-424 

  •   Jeppe Bo Lauersen, Ditte Marie Bertelsen, Lars Bo Andersen

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials Br J Sports Med 2014;48:871-877

3rd prize:    

  • Lot Verburgh, Marsh Königs, Erik J A Scherder, Jaap Oosterlaan

Physical exercise and executive functions in preadolescent children, adolescents and young adults: a meta-analysis Br J Sports Med 2014;48:12 973-979

Congratulations to all the BJSM Systematic Review Award recipients.

Congratulations to all authors who had systematic reviews published in BJSM (which has an acceptance rate of 23%).

For last year’s award winners, and the judging criteria - CLICK HERE.

To MSc or not to MSc; a doctor’s perspective

22 Aug, 14 | by BJSM

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

Part 1 of a 2 part series on making your post-graduate plans. Read part 1 HERE

By Liam West (@Liam_West)

weight liftign in chairRather than waiting for my specialist training in Sport & Exercise Medicine (SEM), I  undertook the SEM Masters (MSc) as a Foundation Year One Doc (UK version of a resident). Below are some of the questions that junior doctors should consider when thinking about whether to attempt the same challenge…

Is it worth it for a Doctor?

After graduating from medical school, junior doctors rotate through various jobs for a few years before specialization and even more years of training and exams. In line with the advice given by Prof. Khan in his “Career Development – #DreamJob”blog, I believe students should ‘differentiate’ themselves from their peers and ‘add value’ by undertaking post-graduate studies in Sport & Exercise Medicine (SEM) during these rotations years. Whilst the SEM specialist training pathway covers content taught within a SEM MSc, embarking upon an MSc also gives you the chance to ‘network’ with like-minded individuals whilst also improving research and literature based skills – this experience could reveal a hidden passion for research…

When in your training?

If you are serious about an SEM career, I must ask – why wait? I made the decision to study whilst in my first year as a junior doctor as I would have less commitments (i.e. family or elite sport) and I wanted the knowledge before entering the clinical aspect of SEM.

Part-time or Full-time Student?

So let’s say that you want to do the SEM Masters, over what duration should you complete it? Students need to be realistic – the commitments of a junior doctor with long days, on-call, weekend and night shifts are not ideal when you have strict coursework deadlines. I believe that to achieve high marks (you have chosen to do this degree so you no longer want to ‘just pass!’) you must either consider taking a year out to do the course or do it part time. I went for the part time route as this gives me five years to complete the degree and therefore if for one year the degree does not fit my schedule, I can postpone exams till the following year. I will also get to meet and network with more people and it will give me time to think what I’d like to complete a dissertation upon as currently I have no idea!

These are just a few questions you should ask yourself when considering whether to undertake postgraduate studies in SEM. I would suggest you plan well ahead, research the different courses and speak to former students.

Dr. Liam West, BSc (Hons) MBBCh ECOSEP(ac) PG-Cert SEM, is a junior doctor at the John Radcliffe Hospital, Oxford. He is a founder and current President of USEMS and is also the founder of Cardiff Sports & Exercise Medicine Society (CSEMS). In addition to his role as an associate editor for BJSM he also 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 and on the Educational Advisory Board for the British Association of Sport and Exercise Medicine (BASEM). 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.

Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus

22 Aug, 14 | by BJSM

PeteOSBy Dr Peter O’Sullivan, Curtin University, West Australia @PeteOSullivanPT

The enormous media interest over the demise of Tiger Woods’ golf game because of his back pain disorder highlights that current approaches to management are fuelling rather than reducing the burden of back pain (Deyo, Mirza et al. 2009).  (PS: You can listen to the related podcast here).

Tiger’s story demonstrates common underlying beliefs about back pain often reinforced by well meaning health care providers, which in turn leads to the quest for ‘magic bullet’ treatments to ‘fix’ the disorder. Although an isolated case, Tiger’s situation highlights clinicians’ common diagnostic and management dilemma regarding the mechanisms for, and the management of, recurrent and disabling back pain disorders.

Tiger’s quotes and their associated media scrums raise 5 themes for discussion:

  1. “Tiger has a pinched nerve in his back causing his pain” What is the role of imaging for the diagnosis of back pain?

Commonly in clinical practice, back pain is considered from a purely biomedical perspective, where radiological imaging is the basis for diagnosis. Athough MRI and other imaging has an important role in the triage of people with back pain to identify fractures, cancer and nerve root compression in 1-2% of people, it also puts the spotlight on many patho-anatomical findings that are not related to back pain (O’Sullivan and Lin 2014). Disc degeneration, disc bulges, annular tears and prolapses are highly prevalent in pain free populations, are not strongly predictive of future low back pain and correlate poorly with levels of pain and disability (Deyo 2002, Jarvik JG 2005).

The adverse effects of early MRI imaging for LBP, highlight the risk of iatrogenic (caused by the health system) disability if spinal imaging is not communicated carefully and matched to the presenting disorder (Webster BS 2010, McCullough, Johnson et al. 2012). Even when specific pathologies exist, it is crucial to consider all relevant bio-psycho-social domains of the examination, clinical reasoning and management process (O’Sullivan and Lin 2014).

  1. Tiger had a micro-discectomy for a pinched nerve which had lasted for several months.” What is the role of microdiscectomy for the management of back pain?

In disc prolapse, the natural history is good; the majority of cases recover and the prolapse reduces in size over time. Long term outcomes for surgical intervention are no different to usual care (Benson, Tavares et al. 2010). For those who don’t recover, levels of pain and disability are not predicted by the size of the prolapse and degree of nerve compression; this suggests other pain mechanisms are involved (Benson, Tavares et al. 2010). The role of decompressive surgery (micro-discectomy) should be limited to nerve root pain associated with progressive neurological loss (e.g., leg weakness) and cauda equina symptoms (O’Sullivan and Lin 2014). Surgery for radiculopathy is unlikely to be useful in the absence of neurological compromise because the pain mechanism is associated with inflammatory mediators in the perineural fat (Genevay, Finckh et al. 2008) rather than nerve compression. Micro-discectomy is not a treatment for back pain.

  1. “My sacrum was out of place and was put back in by the physio.” What role do manual therapies play to treat back pain?

Passive manual therapies do not prevent nor change the natural history of back pain; they have a limited role in the management of persistent back pain disorders (Rubinstein, Middelkoop et al. 2009). Passive manual therapies can provide short-term pain relief. Beliefs such as ‘your sacrum, pelvis or back is out place’ are common among many clinicians.

These beliefs can increase fear, anxiety and hypervigilance that the person has something structurally wrong that they have no control over, resulting in dependence on passive therapies for pain relief (possibly good for business, but not for health). These clinical beliefs are often based on highly complex clinical algorithms associated with the use of poorly validated and unreliable clinical tests (O’Sullivan and Beales 2007). Apparent ‘asymmetries’ and associated clinical signs relate to motor control changes secondary to sensitised lumbo-pelvic structures, not to bones being out of place (Palsson, Hirata et al. 2014). In contrast, there is strong evidence that movements of the sacroiliac joint is associated with minute movements, which are barely measurable with the best imaging techniques let alone manual palpation (Kibsgård, Røise et al. 2014).

  1. “I need to strengthen my core to get back to golf pain again.”  What is the role of core stability training?

“Working the core” has become a huge focus of rehabilitation of athletes and non athletes in recent years. The belief that the spines stabilising muscles become inhibited with back pain rendering the spine ‘unstable’ and ‘vulnerable’ drives this. Yet  growing evidence tells us that disabling persistent back pain disorders are often associated with increased trunk muscle co-contraction, earlier activation of the transverse abdominal wall and an inability to relax the spines stabilising muscles such as lumbar multifidus (Geisser, Haig et al. 2004, Dankaerts, O’Sullivan et al. 2009, Gubler, Mannion et al. 2010). This increase in co-contraction can increase spine stiffness and alter biomechanical loading reinforcing pain.

A number of high quality randomised controlled trials have compared stabilisation training to various forms of exercise, manual therapy and placebo. These studies highlight that this approach is not superior to the other active therapies and only marginally superior to a poor placebo, with only minimal changes in pain and moderate reductions in disability (Ferreira, Ferreira et al. 2006, Ferreira, Ferreira et al. 2007, Costa, Maher et al. 2009). Recent studies have also demonstrated that positive outcomes associated with stabilisation training are best predicted by reductions in catastrophising rather than changes in muscle patterning (Mannion, Caporaso et al. 2012 ), highlighting that non-specific factors such as therapeutic alliance and therapist confidence may be the active ingredient in the treatment – rather than the desired change in muscle.

  1. What should clinicians do? The paradigm shift required for managing a complex multidimensional problem like back pain.

So where does this leave us as clinicians – and people like Tiger – when managing persistent and recurrent back pain? Firstly, clinicians need to realise that back pain does not mean that spinal structures are damaged – it means that the structures are sensitised. It the clinician’s job to determine what the mechanisms are that underlie this process. While for some athletes there maybe patho-anatomical and biomechanical explanations to pain, for many others it is far more complex. There is growing evidence that low back pain is associated with a combination of genetic, pathoanatomical, physical, neurophysiological, lifestyle, cognitive and psychosocial factors for each domain. The presence and dominance of these factors varies for each person, leading to a vicious cycle of tissue sensitisation, abnormal movement patterns, distress and disability (O’Sullivan 2012, Rabey, Beales et al. 2014).

The examination of an athlete involves;

  • careful history taking,
  • understanding the person’s pain experience in relation to their levels of disability and patterns of provocation,
  • the level and type of impairments,
  • the sport demands,
  • the person’s beliefs and expectations
  • other lifestyle and relevant psychosocial stressors.

When reviewing imaging, keep the clinical history and examination at the forefront of your mind. The physical examination seeks to identify the pain sensitive structures and associated pain features. Where pain is mechanically provoked, ask about and observe pain provoking movement patterns specific to the sport (golf swing) and activities of daily life. For example, observe carefully whether the golf swing is associated with increased lumbar flexion or extension, coupled with side bending and rotation, increased trunk muscle co-contraction, breath holding and as well as guarded movement of the hips and thorax, which can increase lumbar spine loading. A video analysis of the swing may well assist this process (and help you explain it to the patient). If you identify motor control impairments, then test strategies to normalise these movement patterns to determine if the pain can be reduced, modified and controlled. Also assess levels of conditioning (O’Sullivan 2012, Vibe-Fersum, O’Sullivan et al. 2013).

Based on these findings, consider whether there are likely to be bio-psycho-social drivers for the disorder. Devise a graduated rehabilitation plan in agreement with the coaching staff with clearly defined goals.

For effective management of persistent pain,  provide a clear understanding of the factors that drives pain, develop graduated strategies to normalise and optimise movement patterns while controlling pain, and couple these steps by prescribing sports specific conditioning and a graduated return to sport. Addressing psycho-social stressors and unhealthy lifestyle factors is part of this process, especially where ‘central’ pain features are dominant (O’Sullivan 2012, Vibe-Fersum, O’Sullivan et al. 2013). Magic bullets don’t exist, so don’t promise them.

To adopt this new approach clinicians require at least two things:

  • Change of mindset: Abandon old unhelpful biomedical beliefs, and embrace the evidence to change the narrative to help people with pain understand the underlying mechanisms linked to their disorder.
  • New and broader skills for examining the multiple dimensions known to drive pain, disability and distress. These assessment skills need to be complemented by the skill of developing innovative interventions that enhance self management, allow the patient to engage in relaxed normal movement. The clinician also needs to encourage the patient to adopt healthy lifestyles and positive thinking about backs (O’Sullivan 2012).

There is growing evidence and momentum to support this process (Hill, Whitehurst et al. 2011, Vibe-Fersum, O’Sullivan et al. 2013) but large sections of the health industry have a vested interest in the status quo. For substantial and sustained improvement (as in anti-smorking), all levels of the socioecological framework must contribute/be engaged. Consumers will need to advocate for change by demanding better outcomes. Political will and legislation is needed to prevent expensive ineffective interventions (such as discectomy for back pain). Critically, a large and growing body of clinicians and educators must be committed to evidence based practice with an emphasis on the P for practice. The media reports related to Tiger Woods’ 2014 problems suggest we have some way still to go.

LISTEN HERE – BJSM PODCAST: Professor Peter O’Sullivan on Tiger Woods’ back and ‘core strength’

NB: Peter O’Sullivan has 3 BJSM podcasts altogether. (1) The link above relates to Tiger Woods of course. (August 2014)

(2) Prior to that one he discussed managing acute and chronic back pain - click here please (July 2014)

(3) And he also comments on the issue of ‘overdiagnosis’ – ordering too many MRIs, creating fear of pathology in people – ‘pathologising’ and ‘catastrophising’ in this podcast – click here please (also July 2014)

Peter O’Sullivan is a Professor of Musculoskeletal Physiotherapy at Curtin University, Western Australia, and a Specialist Musculoskeletal Physiotherapist. For more info: www.pain-ed.com 

 References

Benson, R., S. Tavares, S. Robertson, R. Sharp and R. Marshall (2010). “Conservatively treated massive prolapsed discs: a 7-year follow-up.” Ann R Coll Surg Engl 92: 147–153.

Costa, L., C. Maher, J. Latimer, P. Hodges, R. Herbert, K. Refshauge, J. McAuley and M. Jennings (2009). “Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial.” Physical therapy reviews 89(12): 1275-1286.

Dankaerts, W., P. O’Sullivan, A. Burnett and L. Straker (2009). “Dankaerts W, O’Sullivan P, Burnett A, et al. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.” Spine 34: 1610-1618.

Deyo, R. (2002). “Diagnostic Evalution of LBP. Reaching a Specific Diagnosis Is Often Impossible.” Archives of Internal Medicine 162: 1444-1447.

Deyo, R., S. Mirza and J. Turner (2009). “Over treating chronic back pain: time to back off? .” J Am Board Fam Med 22: 62 – 68.

Ferreira, M., P. Ferreira, J. Latimer, R. Herbert, P. Hodges, M. Jennings, C. Maher and K. Refshauge (2007). “Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial.” Pain 131(1-2): 31-37.

Ferreira, P., M. Ferreira, C. Maher, R. Herbert and K. Refshauge (2006). “Specific stabilisation exercise for spinal and pelvic pain: a systematic review.” Aust J Physiother. 52(2): 79-88.

Geisser, M., A. Haig, A. Wallbom and E. Wiggert (2004). “Pain related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain.” Clin J Pain 20: 61 – 69.

Genevay, S., A. Finckh, M. Payer, F. Mezin, E. Tessitore, C. Gabay and P. Guerne (2008). “Elevated Levels of Tumor Necrosis Factor-Alpha in Periradicular Fat Tissue in Patients With Radiculopathy From Herniated Disc.” Spine 33 (19): 2041–2046.

Gubler, D., A. Mannion, P. Schenk, M. Gorelick, D. Helbling, H. Gerber, V. Toma and H. Sprott (2010). “Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain.” Spine 35: 1506 – 1513.

Hill, J., D. Whitehurst, M. Lewis, S. Bryan, K. Dunn, NE, K. Konstantinou, C. Main, E. Mason, S. Somerville, G. Sowden, K. Vohora and E. Hay (2011). “Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial.” Lancet Oct 29(378): 1560-1571.

Jarvik JG, H. W., Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. (2005). “Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors.” Spine 30: 1541-1548.

Kibsgård, T., O. Røise, B. Sturesson, S. Röhrl and B. Stuge (2014). “Radiosteriometric analysis of movement in the sacroiliac joint during a single-leg stance in patients with long-lasting pelvic girdle pain.” Clin Biomech Apr;29(4): 406-411.

Mannion, A., F. Caporaso, N. Pulkovski and H. Sprott (2012 ). “Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function.” Eur Spine J 21: 1301–1310.

McCullough, B., G. Johnson, B. Martin and J. Jarvik (2012). “Lumbar MR imaging and reporting epidemiology: Do epidemiologic data in reports affect clinical management?” Radiology 262: 941-946.

O’Sullivan, P. (2012). “It’s time for change with the management of non-specific chronic low back pain.” British Journal of Sports Medicine 46: 224-227.

O’Sullivan, P. and D. Beales (2007). “Classification of pelvic girdle pain disorders – within a mechanism based bio-psycho-social framework. .” Manual Therapy 12: 86-97.

O’Sullivan, P. and I. Lin (2014). “Acute low back pain: beyond drug therapy.” Pain management Today 1(1): 1-13.

Palsson, T., R. Hirata and T. Graven-Nielsen (2014). “Experimental pelvic pain impairs the performance during the active straight leg raise test and causes excessive muscle stabilization.” The Clinical Journal of Pain in press.

Rabey, M., D. Beales, H. Slater and P. O’Sullivan (2014). “Multidimensional Pain Profiles in Four Cases of Chronic Non-Specific Axial Low Back Pain: An Examination of the Limitations of Contemporary Classification Systems.” Manual Therapy In press.

Rubinstein, S., M. Middelkoop, W. Assendelft, M. d. Boer and M. v. Tulder (2009). “Spinal manipulative therapy for chronic low-back pain.” The Cochane Library.

Vibe-Fersum, K., P. O’Sullivan, A. Kvale, A. Smith and J. Skouen (2013). “Efficacy of classification based ‘cognitive functional therapy’ in patients with Non Specific Chronic Low Back Pain – A randomized controlled trial.” European Pain Journal 17(6): 916-928.

Webster BS, C. M. (2010). ” Relationship of Early Magnetic Resonance Imaging for Work-Related Acute Low Back Pain With Disability and Medical Utilization Outcomes.” J Occ Environ Med 52: 900 – 907.

The Role of the Tunnel Doctor in Football: An experience in the Premier League

20 Aug, 14 | by BJSM

 

By Raj Subbu, Clinical Research Fellow in Trauma and Orthopaedics/ Sports Medicine /Tunnel Doctor Fulham FC

The role of the tunnel doctor is to provide extra medical assistance in managing acute medical or surgical emergencies and injuries for the home and away medical staff on match-days. This ensures a high standard of medical care is maintained for all players throughout the football season.’

football-on-the-stadium-4565The tunnel doctor will be mandatory for all clubs competing in the 2014/15 Barclays Premier Football League. In previous seasons, certain clubs have employed ‘pilot tunnel doctors’ to assess their role and responsibilities on match-days.

This is a review of my experience as the tunnel doctor during the 2013/14 Premier League season at Fulham Football Club.

Background and Preparation

I first completed Core Surgical Training, and clinical training including General Medicine, General Surgery, Plastic Surgery, Trauma and Orthopaedics, Critical Care and Emergency Medicine rotations. I then explored my true passion in sports medicine and the treatment of elite athletes. I accepted a clinical research post in London focusing on clinical sports medicine, lower limb injuries and sports related research. In addition to clinical and research commitments, I carried out the role as tunnel doctor at Fulham Football Club for the 2013/14 season. In these varied fields, I managed both medical and surgical emergencies. Also, my previous pitch-side experience involved amateur football clubs at local and university level, providing basic first aid care.

Resuscitation and surgical courses required and beneficial to carry out role effectively

The FA Resuscitation and Emergency Aid is a mandatory life support course for all medical professionals working in football at pitch-side. This is essentially a combination of the ATLS and ALS course specifically designed for football related injuries, cardiac arrest scenarios and concussion management in particular. It is a two-day course (£450) consisting of pre and post course MCQ’s with simulation-based sessions throughout and a common scenario moulage set-up for final assessment. For the duration of the course, knowledge, communication, and teamwork are monitored and assessed in each a group. Students must pass both the written and practical parts of the course for successful completion.

Summary of essential courses

  • FA Resuscitation and Emergency Aid Course (AREA)
  • Advanced Trauma Life Support (ATLS)
  • Advanced Life Support (ALS)
  • Basic Surgical Skills (BSS)

Matchday 

All home Premier League, FA Cup and League Cup matches required tunnel doctor cover. The day consists of arriving approximately three hours before kick off to meet the head of medical services and club doctor to discuss the Emergency Action Plan (EAP). All equipment required for match-days is reviewed and signed by the two home team doctors and the away team doctor. Meetings with the local paramedic and ambulance services take place two hours before kick-off to outline logistics and the destination of local hospitals, including the major trauma centres.

A unique responsibility of the tunnel doctor is to liaise with the away team doctor. This involves informing and discussing the facilities available and facilitating support for any injuries or emergencies. With regards to head injuries, the players are continually assessed (if substituted during the match) with any deterioration of clinical symptoms relayed to the medical team pitch. If a player is taken to hospital during the match, the tunnel doctor will remain at the home stadium ensuring two doctors remain present. This also provides the opportunity to address any appropriate medical history of concern, in particular any cardiac/respiratory history to be aware of in the event of an on pitch cardiac arrest.

At the stadium, we take positions for the match at kick-off. I alternate between the medical office (with a live TV feed) and the players tunnel. The live feed helps us assess mechanisms of injury or any loss of consciousness in head injuries. We then effectively communicate this information to the medical team at the bench/pitch side to inform appropriate decisions, including immediate substitutions, or close monitoring scenarios. Under the new guidelines, if there is a confirmed or suspected period of loss of consciousness, the player will be prevented from returning. This set-up allows for quick and repeated review of the live feed, reducing any uncertainty when making decisions. This worked effectively throughout the season for both home and away teams.

At full-time, the medical team assesses all wounds and performs appropriate treatments. We also make decisions on further imaging and investigations. We discuss any necessary issues with the travelling medical team and/or offer further medical assistance until situations are resolved safely. 

Summary of number of games covered

  • 19 Home Premier League matches
  • Home FA Cup matches
  • Home League Cup matches

Summary of common injuries encountered

  •  Lower limb musculoskeletal injuries and assessments at half time and full-time
  • Head injuries/Concussion
  • Wound treatment and management
  • General medical treatment and advice

Communication and player interaction

The match day in the Premier League is highly pressurised and can be a stressful environment for the players and staff. Meticulous planning and organization ensure that all aspects of preparation are covered and run smoothly. Outlining the EAP early on match days gives each person a specific role and responsibility to carry out during the day. From the tunnel doctor perspective, a key skill is effective and clear communication. A number of different situations and scenarios test this skill throughout the day: discussions with team doctor and physiotherapists, describing and relaying mechanisms of injury information pitch-side or to the bench, discussions with local emergency departments and consultants regarding immanent transfers and admissions. Keeping calm under pressure along with confident decision-making are medical staff characteristics that provide high levels of care consistently.

Player interaction is also very important, as a tunnel doctor you are only present on match-days; player interaction is limited and there will be situations where you are leading their medical care and treatment. It is imperative, like any other clinical situation, to build rapport and trust with the players to ease anxiety during these situations, for example suturing a wound quickly at half time or assessing a head injury. Each player has certain pre-match assessments, medications and supplements that can be administered to develop a better rapport and doctor-player relationship. It is therefore important to consistently arrive with sufficient time before kick-off to allow for certain interactions. In my experience, building a relationship whenever possible makes treating the injured player more comfortable and reduces the initial stress levels of being treated by someone they don’t know.

Summary

Tunnel Doctor is a challenging and rewarding role and is a valuable experience for those doctors working in sports medicine. It provides the opportunity to deliver treatment and assessment for head injuries and manage a range of acute conditions in the professional football environment. It requires enthusiasm and dedication, testing a range of attributes including clinical skills, decision-making and communication.

A sound knowledge of common sports injuries, musculoskeletal anatomy combined with experience in managing both medical and surgical emergencies are required to provide the highest standard of care in this environment.

References

1.THE FA GUIDELINES ON HEAD INJURY AND CONCUSSION MANAGEMENT IN FOOTBALL. www.thefa.com/my-football/head-injuries-in-football

Acknowledgements

Professor Fares Haddad: Research/Clinical Supervisor

Dr Steve Lewis: Fulham FC Club doctor

Mark Taylor: Head of Medical Services Fulham FC

All have provided support, guidance and mentorship and have encouraged further participation in this field of sports medicine.

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Mr. Raj Subbu is a Clinical Research Fellow in Trauma and Orthopaedics/Sports Medicine, University College London Hospitals, and Tunnel Doctor Fulham FC University College 

Correspondence

rajsubbu1@hotmail.com

A SACRUM TOO FAR – Tiger withdraws from Ryder Cup. What advice would we offer one of the world’s greatest ever golfers? Guest Blog @NicolvanDyk

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, with TW aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray


“If there’s a fork in the road, take it.” Yogi Berra

Tiger Woods has officially withdrawn from the Ryder Cup – a move that makes a lot more sense than his starting the PGA last week. It seems like he is now following sound medical advice. A proper break aimed at full recovery. He is aiming to return in December for the World Challenge tournament, which seems reasonable. But what will happen beyond that. What does his future hold?

That was the question some colleagues asked me at the Aspetar Orthopaedic and Sports Medicine Hospital on Wednesday (prompted by a recent blog from Prof Karim Khan (@BJSM_BMJ). How would I advise perhaps the greatest golfer ever? Can we base it on evidence?

I am sure we can. Sports Medicine Physicians and Physiotherapists make such assessments every day, from elite level athletes to all the rest of us. Here’s a short proposal that may resonate with many Sports Medicine clinicians’ reasoning in this scenario. (And to Mr. Woods, I would hope to think your team is doing the same.)  (And of course I’m keen to learn from those more expert than I).

  1. Correct Diagnosis (correction, hypothesis)

Let’s open the box and look inside. No, unfortunately no rabbit. It is rare for a single diagnosis to capture the full spectrum of what has transpired for an injury to happen. And no doubt, without any knowledge of the specific medical condition or advice Tiger Woods has received to this point, what we need to do first (or at least redo again) is work through some hypotheses, to  make a proper clinical diagnosis.

Unfortunately another MRI scan would most likely not help us (see reference here). Imaging is useful, and there are a couple of things we want to exclude, but what we see must make sense in light of the whole clinical picture. As a suggestion, let’s call it a holistic assessment. We need to look at all the aspects influencing current pain experience, playing performance, and then do a full musculoskeletal examination looking at movement patterns and muscle recruitment, to understand the current condition. It needs to include history, both past and present, classification based cognitive functional therapy (CB-CFT), pain science education, nutrition and conditioning.

Our diagnosis will perhaps not be catchy, or sexy like “sacrum out” or “disc popped”, but it will be as accurate and inclusive as possible, (maybe something like “intervertebral joint dysfunction with movement restriction into flexion”) which will guide us in our treatment and rehabilitation. This sort of thinking allows different information to be taken into account, it creates the opportunity to evolve if needed (conditions change over time) and allow us to adapt whatever treatment we choose to utilize. This is necessary for achieving our goal. And yes, then do need to identify the goal, but hang on, we’ll get to that. We need to have something to test ourselves again, and some objective signs we can measure – other than eyeballing the sacrum.

  1. Correct Treatment and Rehabilitation

Unlike our colleagues in the 70s, 80s and 90s, we do not have to rely on expert opinion anymore. Not that expert opinion is not important, or valuable, but in the context of modern sports medicine, we have a growing body of evidence to support what we do, and why we do it.

And in this scenario, here is the key message – exercise works.

It is a proven therapy that has been found in most cases to trump the quick manipulation, magic tape or the odd bit of dry needling (or a hug). The scientific search here would lead you to mechanotherapy, or mechanotransduction, but let’s not be distracted by the details right now.

Research (see here a great editorial by Prof Peter O’Sullivan (@PeteOSullivanPT) on how we manage back pain) tells us to strengthen and rehabilitate the correct movement patterns (for the individual, no recipe’s needed, thanks) rather than spend hours rubbing lotion on your back, or cracking things into place. Firstly, perhaps most importantly, we need to ensure that you understand and comprehend the condition, the pain and what it means to you as a person. And then, perhaps as important, we need you to move, and move as well as you can. (Note to TW, the writer is a qualified manual therapist). Next, a gradual return-to-play programme where you build up the necessary strength, endurance and loading of the structures in your back so that when you get back, you really are “good to go.”

  1. Finding the TEAM that works towards injury free* peak performance
    (*injury free = minimal risk of injury with maximum benefit from performance parameters)

Sports Medicine requires a team approach. And a good team will help you to integrate the evidence into a quality clinical decision. Of course I am not attempting to take away the complexities of these decisions in any way. But we have certainly come a long way from “the doctor said I shouldn’t play.”

Instead, we need to develop better algorithms to help make these decisions. Dr. Paul Dijkstra (@drpauldijkstra) has captured these difficulties in his open access BJSM article “Managing the health of the elite athlete: a new integrated performance health management and coaching model” highlights the difference when practicing integrated care medicine, and this article develops a health and performance grading system (see Table 3). This kind of system assists not only the Sports Medicine team, but it creates better understanding for the athlete of what all the information means.

Because related to rehabilitation that is (and should be) the main focus now, is performance. And having gone through 4 swing changes with 3 coaches in his career, Mr. Woods is hardly the same player as when he started. So has it backfired? And having the advantage of retrospection, was it worth it? Could these changes have influenced or played a part in the multiple knee injuries (and surgery) and ultimately the back injury leading to surgery this year?

Of course, the other question with any child prodigy who turns professional (and has a long, successful career) is load management. Prof Roald Bahr (@roaldbahr) from Norway suggests in a recent editorial for BJSM that “We now have the evidence to show that extra caution is needed when managing the gifted athlete.” Did we also fail Tiger Woods in this regard? Seeking to make the near perfect player even more perfect, asking too much of his gifted body?
Perhaps, although I am weary of the hindsight trap. We have to assess where we are now, and if we change anything again, it must be an integrated decision that allows ultimate performance with minimizing injury risk. Which brings us to perhaps the most pertinent question:

  1. The Risk-Reward Ratio – Will life after golf still allow playing some golf?

In 2008, aged 32, Tiger Woods had won 14 majors. It seemed likely (in an incredible fantastic way) that he would surpass Jack Nicklaus’ record of 18 majors. In December, when Tiger Wood plans to return, he turns 39. Is there still time? Jack Nicklaus was 46 when he won number 18, and a few other greats (Phil Mickelson, Ernie Els, Gary Player, Ben Hogan) have won majors in their 40s. But will he win another 5, with the rise of the young guns and the trail of injuries behind him? Mr. Woods wants to win majors, of that I am sure. But what will it take to win another four? What would be left? So here we have to ask, is the REWARD worth the RISK?

To really answer that question, we need to know from the athlete what the perceived reward is, versus the perceived risk. REWARD would be to hold the record number of major wins, to be the unchallenged greatest golfer that ever lived (if we classify greatest by number of major wins, although many might view Tiger Woods as the greatest already). REWARD would be to continue competing, and continue being the guy that everyone wants to beat (not sure if that’s true, but Jack Nicklaus still thinks so). REWARD could simply be to keep doing the thing you love to do, at the highest level. Yes, the rewards will be great. If this is indeed how TW sees the REWARD as well. So what then of the RISK?
There is a continuous effort among sports medicine researchers to identify risk factors for athletes, (e.g. IOC Injury Prevention Conference 2014). So when Sports Medicine Clinicians explain risk to an athlete, we try (or at least should attempt) to present all the information, and make the decision with all the components weighted. In this case, we have to consider the RISK of re-injury, of developing persistent pain, and dare I say, the RISK of not being able to continue playing golf at all? Have we even considered presenting out athlete with these scenarios? And more importantly, how we present this information, in a non-threatening and easy digestible way, might be crucial to the outcome

It’s a complex decision. But this needs thought, and all the possibilities considered. And I am not suggesting the answer is simple. Playing golf with the kids on a Saturday afternoon 20 years from now versus surpassing Jack’s record? (Oversimplification, I confess). It needs a sports medical team that is honest and clear, without seeking yes/no scenarios. (I would suggest this podcast by Prof Peter O’Sullivan here. He deals with the temptation to overdiagnose and overtreat brilliantly) And it would likely not be an “either/or” , but a “yes, and” answer that will allow the best outcome for the athlete.

As a sports physiotherapist, I wish Tiger Woods all the best with his rehabilitation and return to play. And I hope that he (and every elite professional athlete) will have the opportunity to make these decisions with the support of a good team and the value of current research and best practice guidelines driving the process.

Nicol van Dyk is a sports physiotherapist with special training in manual therapy. He is writing this in his personal capacity as a physiotherapist.

NvD

 

“Thank-You” to the pioneering clinicians who paved the way for SEM specialist training

15 Aug, 14 | by BJSM

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

In 2005, the Department of Health formally recognized Sports and Exercise Medicine (SEM) as a medical speciality. One year later the Faculty of Sports and Exercise Medicine (FSEM) was born and with it the specialist training program. Since its inception, the program has produced a number of consultants who have taken-on leading roles in sport and healthcare.

thank youMy own adventure in SEM began in August 2010, six months after completing my GP training. In accepting the offer of a training rotation in London, I was taking a significant gamble compared to the relative security of Primary Care. Nevertheless, like my predecessors, I could never have predicted the positive impact of this challenge on my career.

Beginning with Exercise Physiology, I was introduced to the complex pathways of our body and how we adapt during illness and physical activity. To watch it broken down into its essential elements not only provided a steep learning curve, but also brought an understanding of how physiological parameters can enhance performance.

With my time in Public Health, I became acutely aware of the challenges we face from a physical (in-) activity perspective. With expanding waistlines and ever-increasing demands on the NHS, I came to appreciate the importance of upstream prevention, motivating me to promote SEM to RCGP conference delegates as a new alternative.

The two final years were my musculoskeletal (MSK) and rehabilitation components. Spending time in orthopaedics, sports injury clinics and the Defence Medical Rehabilitation Centre (DMRC) at Headley Court helped develop the skills necessary to confidently manage musculoskeletal conditions and sports injuries. It also provided the opportunity to develop diagnostic and interventional MSK skills using ultrasound.

In addition to providing excellent training, the SEM rotation has opened many doors to work in sport. This aspect of SEM can be difficult to experience unless you are in the field. Its includes taking on lead medical roles within professional football or rugby teams, providing medical cover at multi-sport events, travelling to international tournaments, and working with the wide range of professionals who comprise the medical team. As a trainee, I have been privileged to work with a huge variety of athletes and professionals.

However, with all the additional experiences that SEM training can provide, the main caveat is that these tend to happen in the evenings or over weekends. Often one must sacrifice time spent with family and friends to accommodate this aspect of your career. Nevertheless, when compared to on-calls in other medical specialities, the job satisfaction and maintenance of interest when working in sport is incomparable.

As the end of the training program draws to a close for the current cohort of ST6s, let us take this opportunity to thank the pioneering clinicians who helped establish this field. Without their effort and sacrifice, the NHS recognition, FSEM and training programmes would not have been established. Equally, we must thank the interview panel of 2010 for accepting us onto the rotation and allowing us to embark on this journey. Finally, we must thank our respective families for their patience with our time spent away on training camps or competitions.

If any of the previous trainees were asked whether the SEM rotation positively impacted on their career, the answer would most certainly be a resounding “yes”. Not only is it a new and exciting speciality, but also holds much potential for the future. With leadership and foresight from the FSEM, SEM can be guided to new horizons and further its impact on conventional healthcare.

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Dr Dinesh Sirisena is a Sport and Exercise Medicine Consultant who lives and works in London. He is the club doctor for AFC Wimbledon, team doctor for FA Women’s Under 19 and Partially Sighted Squads and Northampton Saints Rugby team.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

In response to: “Challenging beliefs in sports nutrition: are two ‘core principles’ proving to be myths ripe for busting?”

13 Aug, 14 | by BJSM

Letter to the Editor by Javier T. Gonzalez, Research Fellow, Department for Sport, Health & Rehabilitation, Northumbria University, Newcastle-upon-Tyne, UK

IN RESPONSE TO: Brukner P. Challenging beliefs in sports nutrition: are two ‘core principles’ proving to be myths ripe for busting? British Journal of Sports Medicine, 2013;47(11):663-64.

The editorial by Brukner [1] provokes an interesting debate around two nutrition-related principles that are certainly worth of discussion. There are however, some points that may be misleading to some readers, particularly regarding the second point. The major problem is the oversimplification of complex issues, which begins in the description of the “principle”: “The optimum diet for weight control, general health and athletic performance consists of low fat, high carbohydrate” [1]. The diet for athletic performance is clearly possible to differ from a diet optimized for weight control and/or general health.

Carbohydrate restricted diets are certainly efficacious in weight control and for improving some markers of metabolic health such as triacylglycerol and high-density lipoprotein concentrations [2]. With regards to primary end points, a Mediterranean-style diet including high intakes of extra-virgin olive oil and nuts reduced the incidence of cardiovascular events by ~30% compared to a low fat diet (which as a result was relatively high-carbohydrate) [3]. Changing the focus from reducing fat intake to focusing on evidence-based diet patterns such as the Mediterranean diet would be a positive step, however, this does not support a role for a very-low-carbohydrate diet.

Dr Brukner refers to the appetite effects of macronutrients and intriguingly states that: “advocates of the high fat diet emphasise that fats (and to a lesser extent protein) are satiating” [1]. This statement is not supported by a reference. In fact, evidence points to the contrary. Protein is generally found to be the most satiating macronutrient, with spontaneous energy intake falling when protein replaced with fat or carbohydrate in the diet [4 5]. High fat intake, can lead to overconsumption due to the high energy density of fat [6 7]. Another erroneous point is that insulin is only stimulated by carbohydrate. Protein is well-known to produce an insulin response [8]. It is unfortunate that this evidence has been neglected.

A related point is that circulating ketone body concentrations, which rise in response to low carbohydrate availability (achieved by carbohydrate restriction and/or exercise, in the presence or absence of high-fat intake), suppress appetite [9]. A potential concern however, with diets that severely restrict carbohydrate is the limited fibre intake. This likely has broad implications for gut microbiome [10], the consequences of which may include immune, appetite, inflammatory and metabolic effects that are not likely to be conducive to health.

Brukner also makes that statement: “glycogen, the storage form of carbohydrate, was thought to be a more efficient fuel than fat. This has also been challenged of late by scientists who argue that fat provides more calories per gram and also has much larger body stores” [1]. Each individual point made in this statement is correct and, although Brukner proposes that they conflict with one another, they do not. Almost 100 y ago carbohydrate was shown to be a more efficient fuel during exercising humans [11], that is, less oxygen is consumed per kJ of work done. This is a separate point to the fat providing more energy per unit mass or that humans’ capacity to store energy as fat is greater that carbohydrate. These points are not debated against, however, this statement manufactures otherwise preventable confusion.

The statement that: “Noakes argues that after a week or two of carbohydrate deprivation, our bodies change from a carbohydrate metabolism to a fat metabolism with health and performance improvements” [1] sounds as if this is a novel concept. It has been known for almost a century that manipulation of carbohydrate and fat in the diet influences fuel metabolism during exercise [11]. What has never been shown, to the authors knowledge however, is that a high-fat diet improves performance in a performance trial that mimics “real-world” conditions with high pre- exercise glycogen concentrations. In fact, when fat metabolism is upregulated with a high-fat diet, this suppresses pyruvate dehydrogenase activity [12] and thus carbohydrate metabolism is downregulated along with decrements in the capacity to perform high-intensity exercise [13].

A major issue with high-fat vs. high-carbohydrate diets is the unnecessary polarization and oversimplification of an complex issue. Periodisation of macronutrient intake may be a useful strategy for endurance athletes [14] and carbohydrate/food intake can be restricted at certain times of the day to manipulate metabolism and appetite [15 16]. Whilst the public may benefit from reducing their carbohydrate intake (particularly refined and processed carbohydrates and sugars), a focus on changing dietary patterns (such as the Mediterranean diet) can achieve this along with other effects that are likely beneficial including intakes of beneficial compounds consumed in the food matrix and context that is most suitable for health. Very low carbohydrate intakes are not likely beneficial for all aspects of health and many athletes would certainly benefit from a high-carbohydrate diet for prolonged periods of their season. Perhaps we should remember that the athlete and the general population are very different models with different goals and that we should consider carbohydrate and fat availability (ie. intake and expenditure) as an excess of either is detrimental. A further degree of complexity is apparent upon consideration of lifestyle of the individual. A high energy turnover offers some protection of metabolic health over low energy turnover even in the presence of similar degrees of energy surplus [17].

References

1. Brukner P. Challenging beliefs in sports nutrition: are two ‘core principles’ proving to be myths ripe for busting? British Journal of Sports Medicine, 2013;47(11):663-64.

2. Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta- analysis of randomized controlled trials. Archives of internal medicine 2006;166(3):285-93 doi: 10.1001/archinte.166.3.285[published Online First: Epub Date]|.

3. Estruch R, Ros E, Salas-Salvado J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368(14):1279-90 doi: 10.1056/NEJMoa1200303[published Online First: Epub Date]|.

4. Martens EA, Lemmens SG, Westerterp-Plantenga MS. Protein leverage affects energy intake of high-protein diets in humans. Am J Clin Nutr 2013;97(1):86-93 doi: 10.3945/ajcn.112.046540[published Online First: Epub Date]|.

5. Weigle DS, Breen PA, Matthys CC, et al. A high-protein diet induces sustained reductions in appetite, ad libitum caloric intake, and body weight despite compensatory changes in diurnal plasma leptin and ghrelin concentrations. Am J Clin Nutr 2005;82(1):41-8.

6. Lissner L, Levitsky DA, Strupp BJ, et al. Dietary fat and the regulation of energy intake in human subjects. American Journal of Clinical Nutrition 1987;46(6):886-92.

7. Stubbs RJ, Harbron CG, Murgatroyd PR, et al. Covert manipulation of dietary fat and energy density: effect on substrate flux and food intake in men eating ad libitum. American Journal of Clinical Nutrition 1995;62(2):316-29.

8. Nilsson M, Stenberg M, Frid AH, et al. Glycemia and insulinemia in healthy subjects after lactose-equivalent meals of milk and other food proteins: the role of plasma amino acids and incretins. Am J Clin Nutr 2004;80(5):1246-53.

9. Johnstone AM, Horgan GW, Murison SD, et al. Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum. Am J Clin Nutr 2008;87(1):44-55.

10. David LA, Maurice CF, Carmody RN, et al. Diet rapidly and reproducibly alters the human gut microbiome. Nature 2013 doi: 10.1038/nature12820[published Online First: Epub Date]|.

11. Krogh A, Lindhard J. The Relative Value of Fat and Carbohydrate as Sources of Muscular Energy: With Appendices on the Correlation between Standard Metabolism and the Respiratory Quotient during Rest and Work. The Biochemical journal 1920;14(3-4):290-363

12. Stellingwerff T, Spriet LL, Watt MJ, et al. Decreased PDH activation and glycogenolysis during exercise following fat adaptation with carbohydrate restoration. Am J Physiol Endocrinol Metab 2006;290(2):E380-8 doi: 10.1152/ajpendo.00268.2005[published Online First: Epub Date]|.

13. Havemann L, West SJ, Goedecke JH, et al. Fat adaptation followed by carbohydrate loading compromises high-intensity sprint performance. J Appl Physiol (1985) 2006;100(1):194-202 doi: 10.1152/japplphysiol.00813.2005[published Online First: Epub Date]|.

14. Stellingwerff T. Case study: nutrition and training periodization in three elite marathon runners. Int J Sport Nutr Exerc Metab 2012;22(5):392- 400.

15. Yeo WK, Paton CD, Garnham AP, et al. Skeletal muscle adaptation and performance responses to once a day versus twice every second day endurance training regimens. J Appl Physiol (1985) 2008;105(5):1462-70 doi: 10.1152/japplphysiol.90882.2008[published Online First: Epub Date]|.

16. Gonzalez JT, Veasey RC, Rumbold PL, et al. Breakfast and exercise contingently affect postprandial metabolism and energy balance in physically active males. British Journal of Nutrition 2013;110(4):721-32 doi: 10.1017/S0007114512005582[published Online First: Epub Date]|.

17. Walhin JP, Richardson JD, Betts JA, et al. Exercise counteracts the effects of short-term overfeeding and reduced physical activity independent of energy imbalance in healthy young men. J Physiol 2013;591(Pt 24):6231-43 doi: 10.1113/jphysiol.2013.262709[published Online First: Epub Date]|.

Fighting (Physical) Inactivity (3 important conference dates!): Committee of the European College of Sports and Exercise Physicians

10 Aug, 14 | by BJSM

By Dr Amir Pakravan

Physical inactivity is the fourth risk factor for mortality in the world and responsible for 6% of deaths globally.

globe_diversityHealthcare costs of physical inactivity are immense. Inactive adults spend up to 38% more days in hospital and it is estimated that physical inactivity is the main cause for up to 25% of colon and breast cancer burden, 27% of diabetes burden, and 30% of Ischaemic Heart Disease burden.

There are very well documented health benefits of physical activity in prevention and effective management of more than 20 different specific  medical conditions.

The fighting Inactivity Committee (FIC) of the European College of Sports and Exercise Physicians (ECOSEP) has the mission of promoting physical activity across Europe at the population level and among healthcare professionals.

We believe physical activity is most effective when incorporated into daily life. We have the long term aim to promote, support, and contribute to relevant research, guidelines, and policies across Europe by proactive involvement with such activities and acting as a European hub for information exchange.

ECOSEP-FIC recently achieved Observer Membership of the WHO European network for the promotion of health-enhancing physical activity (HEPA Europe) which in addition to significantly raising the FIC status, would enable ECOSEP to officially associate with HEPA Europe and participate in its annual meetings and other activities.

The FIC Chair will be representing ECOSEP in the HEPA Europe 2014 Conference in August in Zurich where he will also present on a study of Exercise Referral Schemes delivery in Suffolk, England.

ECOSEP-FIC is proactively looking for educational opportunities where it can help promote the role of physical activity in healthcare.

“Wales Exercise Medicine Symposium,” September 2014 in Swansea is a high profile event endorsed by ECOSEP and organised by FIC member, Dr Bryn Savill. The event follows on the success of the first Symposium in 2013, and aims to display the best talent in the “Exercise is Medicine” field in Europe. This will be of interest to a large contingent of sport and exercise, and healthcare professionals.

The “PRACTICE SEM Conference” in October 2014 in Lisbon, Portugal, is another high profile event endorsed by ECOSEP and organised by Dr Jorge A Ruivo, also a member of FIC, which aims to promote discussion around therapeutic effects of physical activity, exercise, and sport on a wide range of public health issues. This year will focus on the latest trends in innovative training methodologies and physical activity interventions applied to patients with or at risk of chronic disease.

The “2014 ECOSEP Sport and Exercise Medicine Student Congress” in association with Queen Mary, University of London, in November also includes dedicated sessions on the role of Exercise Medicine component of SEM practice.

For further information about these and other ECOSEP-FIC activities please visit the relevant websites below.

FIC welcomes ideas and collaboration proposals from sport and exercise advocates, interested health professionals, and academics. To further support and expand our range of activities, we invite sponsorship offers that fit with the ECOSEP mandate.

References and weblinks:

1) Global Recommendations on Physical Activity for Health. World Health Organization 2010

2) 10 Facts on Physical Activity. World Health Organization website accessed Jul 2014. http://www.who.int/features/factfiles/physical_activity/facts/en/

3) Lee IM, Shiroma EJ, Lobelo F, et al; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012 Jul 21;380(9838):219-29.

4) ECOSEP website accessed Aug 2014. http://www.ecosep.eu/Fighting-Inactivity-Committee

5) WHO-HEPA Europe website accessed Aug 2014. http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/activities/hepa-europe

6) University of Zurich, Institute of Social and Preventive Medicine – HEPA Europe 2014. Website accessed Aug 2014. http://www.ispm.uzh.ch/arbeitsbereiche/panh/hepaeurope2014/overview_en.html

7) Eventbrite, Wales Exercise Medicine Symposium. Website accessed Aug 2014. http://www.eventbrite.com.au/e/wales-exercise-medicine-symposium-tickets-12075434951

8) PRACTICE website accessed Aug 2014. http://practice.pt/en/

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Dr Amir Pakravan is a Sport and Exercise Physician and the Chair of ECOSEP Fighting Inactivity Committee.   

‘Sacrum went out’…what went wrong? Tiger Woods, media doctors, and collective responsibility

8 Aug, 14 | by Karim Khan

Is there a responsibility for professional bodies such as UK Physios in Sport or the BJSM to comment on sportsmedicine / #sportsphysio media?

I don’t know Tiger Woods although I suspect he is probably an avid BJSM follower. So, everything I mention here is in the public domain. 1. Mr Woods has had back symptoms for some time. 2. On May 5, 2014, he blogged in detail about his progress from microdiscectomy surgery (March 31, 2014). 3. He withdrew from the WGC Bridgestone tournament on Sunday 3rd August. 4. He started in the US PGA on Thursday, August 7th.

When Mr Woods reported on his recovery between the Bridgestone withdrawal and his PGA start, the television coverage cited Mr Wood as saying “My sacrum went out, it pinched the nerve and hence the spasms. Once the bone was put back, it was all good. The spasms went away and I started to get some range of motion. I’m not in any pain. That is the good part”

Photo credit: @RichNorris00 (zero zero - weird number font in word press)

Photo credit: @RichNorris00 (zero zero – weird number font in word press)

Athletes are entitled to their belief systems; no clinician fixes everything/everybody. Humility has to be a foundation of health care. We would laugh if our colleagues in 1914 had the arrogance to say they knew everything; our colleagues in 2114 would laugh would we claim that. However, the scientific method means that we have current ‘best-practice’ and ‘evidence’.

1. When an athlete says ‘sacrum went out’ should we grin and bear it?

From that perspective, ‘sacrum went out’ is not evidence-based. Mr Woods is not a health professional and does not need to be an expert on health care or back pain. He does not need to read Hodges, Vicenzino or O’Sullivan. No need to define central sensitization. So any comments about ‘sacrum went out’ are not criticisms of Mr Woods, they are just comments for naïve readers who may wonder ‘sacrum goes out?’.

Twitter discussion was quick to point out that the health professional may not have said ‘sacrum goes out’. And no-one suggested a health professional had said that. We have all played Chinese whispers. ‘You may have irritated your annulus fibrosis, your facet joints may have jammed up on a drive, or when you fell in that bunker, you have muscle spasm’ can easily turn into ‘sacrum went out’. [And before the back experts put this on Twitter, I appreciate that one is unlikely to make a 'tissue diagnosis' here and that management requires a careful history, assessment of movement patterns, special physical examination, some trial treatments and expert explanation etc. - and I am not an expert]. [And of course this clinical scenario will not be solved by an MRI miracle - MR imaging post-surgery is even less helpful than it is pre-surgery]. But those clinical issues are a distraction in this blog. The point is to share issues related to the public discourse when a prominent player shares health opinions that run counter to evidence.

I argue that professional bodies have a responsibility to alert the public that ‘sacrum went out’ is an unlikely diagnosis. No value judgement of the athlete, not impugning the health care provider’s skill. Just facts. “Dear member of the public – if you saw TW’s quote that ‘sacrum went out’…please imagine you didn’t. If you have back pain, we suggest you see someone you trust or one of our specialists.

2. When a health professional explains that sacrum can ‘easily come of place’ should we grimace and bear it?

I’m not going to put the links to a video clip from a TV show because the specifics are not important – it’s not personal. A prominent (i.e., comes up near top on Google) golf television show interviewed a medical doctor (‘affiliations and board certifications’ from the American Medical Association and others) about Tiger Woods’ dramatic recovery between the withdrawal (an inability to bend to take shoes off) at Bridgestone and clearing himself for the PGA 72 hours later. (NB: Not Tiger Woods’ MD – a ‘golf’ MD and ‘specialist sports physician’ (among other attributes))

The MD indicated that he had walked some of the PGA holes with Tiger Woods, observed the 2008 US PGA winner moving freely, bending over fully and swinging freely. The MD had spoken to TW’s coach. Great for television. #Credible. The MD explained (with a lovely anatomical drawing) that the sacrum can ‘easily come out of place’ and that one ‘sees it very often in golfers’. In the same clip, he explained that ‘sacrum out’ (1) has a 20-minute fix, (2) benefits from nonsteroidal anti-inflammatory medications (3) has a benign course (my interpretation of ‘good to go’). The MD expressed full confidence that Tiger Woods was cured – sacrum out, sacrum in. ‘Good to go’.

Really? ‘Good to go’? Go where? On which planet? Many real sports physicians and real sports physios were surprised that TW was ‘good to go’. They committed on Twitter ahead of the PGA starting that TW was likely ‘BAD to go’. Imagine it is a final year medical or physio exam…”You are consulted by a 38-year old former World Number 1 who has not won a tournament since 2008. He has had 4 surgeries included microdiscectomy most recently (March 31st, 2014). On his blog on May 5 (3 months ago) he reported filling in the holes on his private golf course so he doesn’t have to bend.

I’ve worked with [son] Charlie on [baseball] hitting and fielding drills and showing him slowly what to do; I can’t do it quickly. We watch a lot of sports on TV, and we try and copy that. We have a lot of putting contests. I can’t bend down to pick up the ball out of the hole, so we sand-filled all the holes so you can still putt to a hole.

…(exam question still going….) The player withdrew on the final day of the most recent tournament on August 3rd. He was reported as being unable to pick up balls, take his shoes off. Today is August 5 and you are assessing and providing advice about his management and specifically playing in the US PGA starting on Thursday August 7. (phew, end of background to question!). Question: What is your advice?”

There are many ways to pass but as a UBC Professor (sticking to scope, shocking at golf), I’d say in my course (KIN 461) ‘sacrum out’ as diagnosis, and ‘sacrum in, good to go’ as treatment, would be a fail.

A first year sports physiotherapist is taught about ‘progression’ of exercises and return to play. You have to pass one level to get the text. Example answer might list progressions like this…Putting with kids. Short irons, longer irons. Drivers (easy swing, not too many). More of above…greater volume, greater intensity. 9 holes. 18 holes. Days on, days off of 18 holes. Two days in a row and then an easy day. Three days in a row. Four days in a row, but taking it easy. Later tournament but not hitting for maximum length (many options, just an example). //

Breaking down in Bridgestone is not how you pass the ‘return to tournaments at lower pressure than Majors’ level. That’s why the media was awash with predictions (just one of many snips, below) that TW’s PGA would be the train wreck that it proved to be. No need for Nostradamus.

 

Note date stamp (prior to PGA tee-offs): Contrasting with GolfTV doc 'good to go', back experts such as @PeteOSullivanPT and even aged, out-of -touch editors (i.e. not expert) predicted TW back would not hold out for 72 holes (to say nothing of likely poor scoring which will precede frank pain)

Note date stamp (Aug 7, prior to PGA tee-offs): Contrasting with GolfTV doc ‘good to go’, back experts such as @PeteOSullivanPT and even aged, out-of-touch editors (i.e. not expert) predicted TW back would not hold out for 72 holes (to say nothing of likely poor scoring which will precede frank pain)

 

3. What to do? On the one hand we don’t like to be critical of colleagues.

It’s not easy being interviewed on TV. As a viewer, I don’t have the clinical information about Tiger Woods. On the other hand, the interview can be analysed merely on the facts. Analysis is not personal. NONE of the discussion from commentators related to Tiger Woods’ actual condition.

We were discussing (i) Tiger Woods’ public explanation of his understanding of what is going on and (ii) an MD’s TV (and web clip) explanation. The MD’s website lists ‘Golf Medicine’ under an ‘Expertise’ tag. The MD’s website says he is ‘…sports medicine physician and doctor to some of the top golfers in the world….and a pioneer in the field of golf medicine’. Humbly, he shares that he learns from every patient including from ‘one of my golfers with a major tournament on the line.’ His website includes golfers describing the MD as eminent – ‘the best in the business’.

An MD going on TV with those ‘credentials’ also carries responsibility. A responsibility to fellow MDs, fellow sports physicians and to golf medicine experts. If the TV interview says that the sacrum ‘easily comes out of place‘, this will reflect badly on MDs, real sports physicians and golf medicine experts who base their practice on evidence. If, on surfing the MD’s website one finds claims of ‘4 simple saliva tests’ that allow this MD to quantify the patient’s level of inflammation it raises flags. Immunology expert as well as golf, sports medicine, emergency medicine and surgery…oops I digress… [Editor's note - take that out]

Des Spence has already labelled ‘sports medicine’ as ‘Bad Medicine’ in theBMJ. As sports physicians, we don’t want to provide a chapter for Ben Goldacre’s BAD SCIENCE. @BenGoldacre

4. Don’t top players like Tiger Woods have the best clinicians caring for them?

First, I am not commenting on TW’s medical team. That’s way out of my scope. But speaking of elite athletes generally, some make better choices than others. That’s my opinion (level V evidence). Top players, particularly in individual sports, can have a very sheltered life. They might need a GP from time to time. How can they know who the best golf doctor is!

You know how tournament doctors are chosen! Did you see ‘Sportsmedicine Team’ advertised for the US Open in the BJSM, AJSM, JOSPT and other reputable journals? Did you hear that a committee recommended by the AMSSM (@TheAMSSM) reviewed applications? Did you hear PGA organisers commit an appropriate budget for Tournament Physician, Physiotherapist, Massage therapist etc? [How could the PGA possibly pay expert health professionals properly? Its 2009 tax form (#990) revealed the revenue for this non-profit organization was only $973,000,000].* And the players being taken care of by those health professionals share $10 million.

Or do you imagine that a friend of the tournament organizer with an MD degree might have picked up the odd tournament gig? Can you imagine that the price was right? ($0.00? + 3 autographs + one photo). That’s why saying you were the doctor for James Dean, Marlon Brando, Elvis Presley (OK, maybe not a great example) shouldn’t carry weight. #RightPlaceRightTime.

In short…(??really!!)

1) Tiger – we all wish you the best. Real sports physicians hate giving advice that a player needs to miss any tournament, let alone a Major. We became sports physicians to allow folks like you to share your talents. And folks like my neighbor, Dr Targett who hacks around. And to promote exercise in 86-year olds like my Mum before she died. Unfortunately Tiger, pathologies exist, rehabilitation can take time. Things may not look good for you at the very top level.  Your PGA wins may be done at 14; a writer way more expert at golf than me has suggested.

Sports physiotherapists and sports physicians are big on exercise for rehabilitation. Exercise is a proven therapy. It works via the process of mechanotherapy. But the compression forces alone (not to mention shear etc.) on your lumbar discs from top golf are 6 times bodyweight (see below). That’s a serious Bear you are carrying (!, sorry). Body structures have remarkable capacity to repair with appropriate loading (=rehab exercises and progression) but at the very top you also need high volume practice (not an expert on golf, just guessing).

So, the combination of forces you create, and volume you need to sustain to be competitive on weekends, may not be compatible with another PGA win. This link provides a useful starting place on the biology. Noteworthy, it includes scientific data – ‘studies’. No financial competing interest for surgery or implants. There’s no way to tell your future precisely, you need to work at rehab progressively. I’m just painting a ‘worst-case’ scenario that I hope you have discussed with your expert team. Understand that microdiscectomy is not a guarantee of return to sport at the previous level (i.e., in your case winning Majors, not just showing up). Your player colleagues also need to know that in randomized trials, outcome of surgery has not bettered outcome of physio rehabilitation. As Adam Meakins @TheSportsPhysio tweeted “The best don’t have any miracle fixes”

2) Discussion of Tiger’s public explanation of his problem are just discussions – they are not meant to reflect any insider knowledge. They are like a ‘theoretical case’ or a movie where they say ‘any likeness to real people is accidental’. Because of the media focus on top athletes, authorities need to discuss comments such as ‘sacrum went out’. To help the public and to help athletes who want to be part of the discussion.

3) Collegial responsibility and self-promotion on TV. If you find a website that seems rather ‘self-aggrandising’ it might be worth adding a pinch of salt. I’m not referring to any specific website here – so no-one should take offence. And media doctors are important – consider the excellent educational work of Dr Peter Larkins (@DocLarkins), a fully certified real specialist in sports medicine. His expertise is based on formal external certification (Australasian College of Sports Physicians) (not ‘self-certification’ or ‘cereal packet certification’).

Speaking of real sportsmedicine/#sportsphysio experts, I see that Roald Bahr (@RoaldBahr) doesn’t have a personal website telling the world he’s a pioneer or leader in anything. Neither does Jill Cook (@ProfJillCook). They don’t have a *6-part miracle cure for everything*. Their universities, their hospitals, and the IOC may refer to them but they don’t self-market. Remember that the very best don’t need make self-promoting videos with guarantees and background music of a certain genre. And if a physician’s greatest claim to fame is ‘who I’ve treated’ there is reason to think twice. Medicine can be treated as a business.

4) Players – are you sure you have a quality physician and physiotherapist? How do you tell? Don’t ask other folks in the same industry – there is likely to be ‘group think’ in your sport. Speak with folks from different sports who are experienced and who don’t have a commercial interest in being your doctor. I’m not convinced that a golfer (lumbar compression force = 6 times bodyweight per swing x 72 swings per round x 4 rounds) can compare his loads with that of a Cowboys’ quarterback but that’s an aside.

I can see the challenge though. In the US, the American Medical Society for Sports Medicine (@theAMSSM) is an internationally recognized accrediting body for real sports medicine physicians. Has your doctor done an accredited AMSSM fellowship (specialist training)? Who were your doctor’s mentors? Does your doctor encourage you to get different opinions as needed? Does your doctor work closely with sports physiotherapist or experienced athletic therapist? Does your doctor use the word ‘evidence’ (not watertight but a start!)?

In closing, I offer this blogpost with humility.  I know there are flaws in BJSM articles. I am open to correcting them and to highlighting that I have made mistakes. My personal scientific articles have wrongs, please let me know. Not all my patients got better. I made clinical errors.

But our compelling goal as real sports physicians and athletes and active people is to share accurate information. To acknowledge what we don’t know, and to be athlete focused in an evidence-based manner. Marketing voodoo/snakeoil/funky treatments has no place among real sports physicians and real sports physiotherapists who are working hard to master the art.

There has be room to point out, and draw attention to, statements that don’t have evidence.

And Tiger, if you can’t get through the PGA tournament because of your back (as I suspect you won’t) I’d respectfully suggest you listen to Dr Peter O’Sullivan’s podcast (link here). He’s a physiotherapist with specialised training in back assessment and treatment, a ton of experience with ‘difficult backs’. And a PhD. Just like a top golfer will have a range of qualities, those qualities belong to a top back clinician. There are a few like him around the world – just as there are a top 10 in golf. Encourage your sportsmedicine/#sportsphysio team to be honest with you – not to tell you what they think you want to hear. Reward those who have courage – to make it part of your team’s culture.

Which brings me to my last book recommendation – The 5 dysfunctions of a team. Patrick Lencioni emphasises that ‘artificial harmony — fear of conflict is cancer in a team. (A similar theme to the ‘GroupThink’ point above). Disagreement is not disloyalty, it’s evidence of loyalty. Your on-course team, your Tiger Jam team, your golf design project teams – encourage them to be honest. An honest, even remotely qualified, itsy bitsy teeny weenie experienced #sportsphysio would have suggested you were not ready on Thursday. You failed the progression (Bridgestone).

I wish you every success, as I do every player. And every 86-year old who knows what’s best for her.

*Above – PGA donate $130 million to charity (much directly from sponsors).

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