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Live from Glasgow’s Sports Medicine Tent – 5 tips from #Games Doctor

29 Jul, 14 | by Karim Khan

By Doctor Rebecca Robinson @RjpRobinson

In July 2014, I was fortunate enough to be offered the opportunity of a registrar’s lifetime. Working with Team England in medical headquarters for the Glasgow Commonwealth Games. Here are my Top 5 Tips:

Glasgow1. Preparation, preparation, organisation

Games time comes and goes fast, so do your homework. Arriving a week before the Opening Ceremony in Glasgow provided a great opportunity to set up an efficient medical room. Check out competition schedules, venues and transport systems now to deliver care smoothly.

Medically screening the majority of the 600 Team England competitors as they arrived was invaluable to avoid last-minute concerns, with additional benefits in establishing athlete-doctor relations.

Familiarise yourself with the arena and its rules: can you see the athlete in the mixed zone? Where is the defibrillator and can you switch it on? Who can treat a blood injury in a boxing ring? With a grasp of the basics, immersing yourself in the squash court, judo hall, velodrome and track adds immeasurably to theoretical knowledge.

2. Work with the best to become better

A multisport games is a unique melting pot. The world’s best athletes supported by expertise in sports medicine, physiology and management garnished by multinational cultures.

Working alongside a wealth of experience in Team England Headquarters revealed a group of individuals every bit as dedicated as the podium athletes with their indefatiguable work-ethic.

Simply existing in this environment is a unique learning experience. Be observant.

Key to Team England was a cohesive, supportive team environment across medics, physios and HQ staff, in which all members views were valued.

There will be times to take initiative, but recognise the expertise around you. With hard work, you’ll be back for future games, but your athlete may not. If in doubt or if you think you know the answer: ask. Remember there’s no such thing as a stupid question. Do not work in isolation or outside your competency.

3. Pace Yourself

It’s a marathon. And a sprint, rugby sevens, a triathlon and track cycling: and that’s just day 1!

With a 3-week stay in the Village bubble, it was imperative to sustain energy to respond safely to medical emergencies, meet last-minute needs of anxious athletes calmly and keep a ready smile for every single volunteer, physio, cleaner and policeman (yes, they really do smile at you at Games time!)

Everyone making the games happen faces challenges and will be both exhilarated and exhausted at times. Remembering to eat, sleep, communicate with loved ones outside are essentials. Turn around to make sure your colleagues do this too. A smile, a coffee run or a supportive shoulder can make a world of difference.

4. Primum non nocere

The first rule of medicine generates ethical debate in the elite sporting arena, where medals define careers.

What is your role: to help win the medals or protect the athlete’s health? Injuries in competition demand precise evaluation: how will they impact performance now and what are the longer-term health outcomes your focused athlete cannot visualise?

The depth of senior medical experience contributing to Team England meant athletes were able to make informed decisions with their team.

Sometimes dreams are shattered in the field of play. A sensitive approach to the injured athlete, with a clear team-based management plan will not lessen the pain but can help ensure healing starts in the Village.

Management in Glasgow was facilitated by good venue medical facilities and safe field-of-play retrieval, followed by accessible Polyclinic resources including 24-hour on-site clinics and onsite radiology.

5. ‘Be Kind’ (Dr Mike Loosemore, CMO Team England)

The Commonwealth ‘Friendly Games’ is a microcosm in which tiny countries can produce sporting greatness alongside larger, expectant nations. Like all major Games, it is also a hotbed of ambition, where 7000 dreams shimmer on the cusp of reality.

An 11-day Games represents the pinnacle of careers, dreams and sheer sweat, blood and determination. Be mindful that this will alter over the course of a games as winners and losers emerge. Be on hand in triumph or disaster but don’t intrude. Resist the urge to take that selfie or add pressure to the expectations of an athlete. On the flip side, you can be well-placed to advise the hurt, anxious or unwell athlete who approaches you. Be sensitive. Be kind.

With special thanks to:

Dr Mike Loosemore, Dr Pippa Bennett, Dr Paul Dijkstra, Dr Graeme Wilkes, Dr Mike Rossiter, Dr Abosede ‘GB’ Ajayi, Dr Stephen Chew, Dr Greg Whyte, Chef de Mission Jan Patterson and Team for all their support.

Editor’s question: Is Chessboxing in the Commonwealth Games?

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7 key attributes of Sports Doctors and Physiotherapists at The Commonwealth Games

24 Jul, 14 | by Karim Khan

PhotobombHow can young doctors and physiotherapists get involved?

Paul Dijkstra (@DrPaulDijkstra)

I’m passionate about high performance medical teams and how they work. I used the lead-up to yesterday’s opening ceremony of the 20th Commonwealth Games in Glasgow, Scotland, to chat with participants from different countries here with me in the Village. The excellent sports clinicians are very busy, running around and working long hours to plan and deliver world class medical services to thousands of elite athletes and officials (6500 from 71 nations competing in 17 sports over 11 days!).

I asked “What are the key attributes of Sports Doctors and Physiotherapists working at a major event?”. I asked clinicians and also asked the coaches and management what they expect from good medical teams. Here are top attributes:

  1. Be comfortable to work in an open and collaborative clinical environment (a flat hierarchy) amongst a group of medical, science and coaching professionals where good people do what they’re good at’: Dr Mike Loosemore, Chief Medical Officer of Team England. (@DoctorLoosemore)
  1. Make sure you’re well qualified and experienced for the job’. Easier said than done… It takes 10-12 years of hard work and study to become a specialist Sport and Exercise Medicine Physician and good jobs don’t fall into your lap! Medical students and young doctors in training should not hesitate to get out there and volunteer. ‘Chase knowledge’ said one coach. ‘Build relations with colleagues, physiotherapists, teams, coaches, athletes and sporting officials’. Angela George, Team England physiotherapist agrees: ‘Be prepared to volunteer for every opportunity, get your name known and gain experience in lots of different sports. We all started out in community sport and now have the opportunity to work at the pinnacle of elite sport.’ Really good advice – offer to shadow and assist senior clinicians in the policlinics or next to the fields in smaller local clubs or school events. Be willing to work hard for little or no pay. (@PhysioAnge)

Kudos to Mike Loosemore and Team England management who’ve allowed British marathon runner and Specialty Registrar in Sport and Exercise Medicine (ST5 SEM), Rebecca Robinson to work as part of the Team England medical staff. Market yourself: ‘Blog, write and tweet…’ watch this space: Rebecca will share her experience in a BJSM blog soon! (rjpRobinson)

 

  1. Connect with the athlete’ says Paul Treu, Head Coach to the Kenyan Rugby Sevens team. ‘It is so important for the Team Physician to be able to really understand and appreciate the expectations of each individual athlete’.Dr Stephen Chew, Team England doctor agrees: ‘Attention to detail is important – know the athlete, know the venue and know the sport’. (@paultreu)

 

  1. Be able to adapt to the different environments without compromising on your standards of clinical care’ says Dr Karen Schwabe, here with the South African Team. She added: ‘Be ready to give energy – know how to pace yourself, do some exercise and get down time’. Karen has vast experience in rugby and endurance sport having just published three landmark papers in the BJSM – the SAFER studies.

 

  1. Know your place – the athletes are here to perform. When you’ve seen an injured athlete, don’t keep focusing on that injury or illness by constantly asking the athlete how he / she is doing. They will tell you!’ A valuable lesson I think; our instinct as doctors is to be caring, empathetic and protective. These are all good attributes but should be applied in a sensitive way in a performance focused environment.

 

  1. Laura Hanna is a very experienced physiotherapist and leading Team England’s physiotherapy team: ‘Experience, sound clinical knowledge, flexibility and ability to deal with whatever comes through the door gives physiotherapists working in a multi-sport an advantage. Long hours and putting your hand to anything will help and importantly having a great sense of humor and fun makes anything seem possible.’li>

 

  1. You have to be able to enjoy working in a complex and challenging environment and be passionate about working in sport’, wise words to end this short blog from Dr Bruce Hamilton, leading the New Zealand medical team here.

 

Enjoy the Commonwealth Games!

PS: BJSM Editor’s comment – Follow @DrPaulDijkstra and when he get clearances he’ll keep us informed. Health professionals are part of the TEAM at the Commonwealth Games so they need media clearance of course. He’ll be contributing to the @weRengland twitter feed (Who comes up with those nAmes?)

Paul was too humble to put this in his Blog but his BJSM paper “Managing the Health of the Elite Athlete” has taken off – it’s gone viral as far as journal articles go.  You can read it free tonight here once you turn the TV off.

Top blogs of 2013 – Career Development – How to get the #DreamJob?

19 Mar, 14 | by Karim Khan

conc3 aussieYou know the job you’d love to have, sports physio or sports physician for a team of your choice. And/or working in a private clinic where you respect the clinical leaders and they provide terrific opportunities for developing your skills through working with teams, attending conferences, ensuring continuing professional development on site including workshops. How do you get such a job? Why would the Australian Cricket Team choose you as their physio? Why would Barcelona FC choose you as the head of sports medicine & sports science?

Leading sports clinicians have shared these 5 elements:

1. Differentiate This should be on every student/trainee’s mind. We often call it ‘specialisation’ in our disciplines but that word has specific meanings (e.g. Titled Sports Physio); the concept of ‘differentiation’ is a broader one. Being a ‘sports physio’ is not enough if you want to be considered for a cricket job. You’ll need to get experience in cricket of course. Or, even as a Titled Sports Physio, you might differentiate further into shoulder injuries. Sounds simple!

2. Add value I almost bundled this in with ‘differentiation’ because ultimately the point of differentiation is to provide special value. Extending the cricket example, you’ll get the cricket job not just because you have ‘experience’ in cricket but because you are better at treating backs, shoulders, and finger injuries.  By recognising this need, you might chase experience in treating shoulders and fingers by spending time with specialists in those roles – even if those clinicians are not expert in cricket. Gaining experience may not be a straightforward path but if you are clear on the goal, you know HOW your will ‘add value’, you can at least go after those skills.

3. Volunteer strategically The first job is the hardest and that is particularly the case in 2013. The Baby Boomers have the #DreamJobs and they aren’t marching away from them yet. Also, national unemployment is high the world over; youth unemployment – yes, that means new graduates — is at a record high. So, if you ever thought that after your final exams or graduation, you would be able so scan a long list of advertisements offering you and your peers full time work…. I’m sorry to be a bearer of bad news. But don’t be disheartened  – you have a valuable, practical, degree in hand or coming, so please adjust to the fact that you need to volunteer and network the way many graduates have done in many disciplines for decades.

Be patient, take care of the process and the outcome will take care of itself. You‘ll often have to start with part-time opportunities. As a volunteer, if you are confident of ‘adding value’ (see above) you may have some leverage – you are bright, prepared to work hard and you have acquired some skills. And nothing is ‘below you’. Need the water bottles? That’s OK. Fetching balls? OK too. Remember that the top team clinicians will also do a bit of that where needed. It’s a team. No-one is suggesting a trainee sports physician or physio agree to serve as a bowling machine as 100% of a volunteer experience. But it is invaluable to experience a 3-day training camp where you meet the key coaches and officials, see the sport first hand, and at least watch assessment, treatment and prevention programs first hand. This will definitely provide you skills you didn’t learn about at Uni.

4. Network This word has negative connotations for some young people – who may be confusing networking with nepotism. The words are very different and carry very different implications. Networking means you try to connect with people you think are influential in the field and who may be able to guide you. If you can have an appropriate ‘mentor’ agree to guide your career that will be invaluable. But mentors are busy and you may not have things to offer the mentor (money, time at your ski chalet, a drive in your Porsche) so it makes sense to have a few different mentors – so you don’t burden ‘one mentor’ too much. Sports Medicine events such as educational programs run by your local and national sports medicine organization can be excellent networking events. In Australia, Sports Medicine Australia, (one of BJSM’s 13 member societies) runs excellent networking events for members and non-members. In the US, the AMSSM conference is terrific for sports medicine fellows; there are specific ‘networking events’ within the program. Network young, network early. In many prestigious Business Schools they start the students networking in the first weeks. In sports, now you’ll need to network just to get your volunteer opportunity!

5. Be prepared to travel – live in a different environment for a while. Finally for this short blog, remember that many folks have to travel beyond the backyard to make their dreams come true. Read biographies of your heroes on Wikipedia and see if they did everything they needed to do to become great in their birth city. Russell Crowe  (@RussellCrowe) famously had to move to make his career as a Rabbitoh’s spruiker. Think of folks like Roald Bahr (@RoaldBahr, Norway) and Timothy Noakes (@ProfTimNoakes, South Africa) who may seem the archetypal home grown talents and proud ambassadors for their country; both report pivotal years away which changed their lives. Concussion expert Prof Winne Meeuwisse moved from Vancouver to Calgary for better opportunities. The list is long. To share a personal story for illustration, I moved to Canada for love (without thinking about work, I am not as strategic as I am advocating in this blog!) yet it proved to be a boon for my development as a sports physician. (This principle of moving to a fertile environment is a key message in one of my favourite books – Outliers by Malcolm Gladwell but let’s not go there today.)   ******************************************************************

If you feel we have missed something about how to improve your career chances, just email me (Karim.Khan@ubc.ca) your comments or a blog post and we’ll add it to the conversation. If you want to make a point in <140 characters, tweet to @BJSM_BMJ. #TopJobs  Or suggest someone you’d like to hear share their thoughts on a BJSM podcast.

Not everything in sport is black and white: #Addsomecolour…….Part 1 The Association of Chartered Physiotherapists in Sport and Exercise Medicine Biennial Conference

4 Dec, 13 | by Karim Khan

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series

By Charlie McCall

With a healthy dose of intrigue, I set off from Bristol for Glasgow and the Association of Chartered Physiotherapists in Sport and Exercise Medicine (ACPSEM) Biennial conference in late October.  The high calibre international speakers and diverse topics in the conference programme had sparked my enthusiasm.

The conference venue was the University of Glasgow. Delegates could be forgiven for thinking they had been transported to Hogwarts, while Glasgow’s West End provided a plethora of amazing architecture, culture and restaurants.

Alison Rose ACPSEMA conference entitled “Not everything in sport is Black & White” with the tag line ‘#add some colour’.  Surely this is why we attend conferences: to learn new ideas, to have our preconceptions challenged. The first day kicked-off with short lectures based around ‘The Profile of The Modern Day Athlete”.  Discussions covered topics including how our ability to sweat enables us to outrun our prey and why humans make lousy athletes. The question of whether champions were born or built was discussed, and our interaction with our environment explored. I wonder if, in the western world,    we have lost some of the patience we had in chasing our prey for so long.  Five minutes in a supermarket queue for convenience food seems to equate to ‘stress’ these days.

Topics were pertinent, with Dr Barry O’Driscoll speaking about concussion and current issues around the Pitchside Concussion Assessment (PSCA) in rugby. Recent events in the nation’s first sporting love, football, have highlighted the issue of concussion in sport to the masses.  Hopefully this platform will help those campaigning for better and safer procedures for decision making about return to play get their message across.  This needs to be heard: not just by medical professionals, but by coaches, trainers, players and parents of young players.

The first full conference day started with Dr Antonio Stecco talking about fascia.  The idea that up to 30% of muscle fibres do not reach the tendon or bony interfaces, instead blending into the deep fascia, means we need to rethink the traditional anatomical model.  The fascial system as a whole has a huge role in proprioception, so changes in elements of fascia, such as ‘densification’, a term Stecco used to describe increased viscosity of the fascia, is likely to impact proprioception and, ultimately how we move.

Dr Quentin Fogg further challenged ideas about anatomy basics through discussion on how muscle attachments actually work.  For example, the continuity between semitendinosus and anterior tibial fascia could have implications for anterior tibial pain. Dr Jay Shah gave really interesting lectures on the pathophysiology of myofascial pain, trigger points and the physiological findings around trigger points. With growing evidence, we can more adequately explain to patients why the problem may be somewhere other than where they feel the pain.

Coaches Frans Bosch and Vern Gambetta played their part in ‘adding colour’.  Bosch suggested that for highly skilled movement at speed, we need to move away from the idea of the hierarchical model i.e. cue the brain and it will tell everything in the body what to do.  He championed the idea of a ‘decentralised model’ with multiple ‘substations’ throughout the system that can adjust our control of movement.  Gambetta warned against confirmation bias, i.e. only seeing what you are looking for.

Bosch and Gambetta both urged us to rehabilitate  the entire movement, to go straight to the end point and move beyond just rehabing the muscle.  They also suggested that we should stop ‘over-coaching’ in rehab and allow the body to regain movement patterns independently.  Physiotherapist Dr Dylan Morrissey agreed there is a tendency to over coach, but cautioned against just allowing the body to work it out with the question ‘what if the body keeps getting it wrong?’  There was collective agreement on the need to ensure we move past low level rehab and challenge the body and movement patterns in relation to forces it will undergo.  Physiotherapist James Moore followed this idea through, suggesting that returning to running early in hamstrings rehab is important, while Johnson McEvoy discussed how the ability to resist fatigue is critical to reducing key risk factors to shoulder and upper limb injury.

To be continued (Part 1 of  the synopsis of The Association of Chartered Physiotherapists in Sport and Exercise Medicine Biennial Conference )…

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Charlie McCall is a Sport and Exercise Physiotherapist at the University of Bristol Sports Medicine Clinic. http://www.bris.ac.uk/sport/sportsmedicine

Archive: 20 min podcast re: Mechanotherapy paper (>89,000 views)

26 Oct, 13 | by Karim Khan

mechano picMany BJSM followers know about mechanotherapy – so skip this blog.

If you aren’t aware that you know about it, there is a BJSM podcast – here’s the link.

Relevant background —  I have a ‘competing interest’ – I’m blogging about a paper I coauthored. It’s my 2nd such post since we started blogging seriously at BJSM (2009). The objective measure is that the paper has been downloaded almost 90,000 times in full text and PDF. And I have been encouraged by colleagues – so here goes…

There is substantial level 1 evidence that exercise is a powerful therapy for musculoskeletal conditions – for muscle strains, joint degeneration, sciatica, tendinopathy. The historical rationale to explain the mechanism was ‘strengthening’.

‘Strengthening’ as a mechanism for tissue repair didn’t make sense to me when I was in my busy clinical phase. How did ‘strengthening’ the hip external rotators remove the pain of ITB friction syndrome? What was it about ‘strength’ that would remove the pain of a hamstring strain? There is more to tissue repair than ‘strength’.

Mechanotransduction is a well-recognized physiological principle that should have much more traction in physiotherapy/physical therapy courses and in sports medicine. This is how the body adapts to load. Why are Arnold Schwarzenegger’s muscles bigger than mine? His workouts signal his cells to hypertrophy and and multiply as needed and he gets bigger muscles. Why does an elite distance runner have  larger blood vessels than a sedentary academic about to have a cardiac arrest? Mechanotransduction is the process.

A negligent sawmiller – who has lost his distal phalanx — has a vastly smaller proximal phalanx than his or her proximal phalanges on the intact fingers. Same hand, same genetics — less loading. Mechanotherapy trumps genetics! Note examples from different tissues – mechanotherapy is a universal principle.

When clinicians prescribe exercise, the loading signals cell to repair and to function in response to load. Turning movement into repair.

Clinicians see the power of mechanotherapy daily. Mechanotherapy is when you apply the principle of mechanotransduction as a treatment – analogous to the use of ‘electotherapy’ or ‘pharmacotherapy’ (but way more powerful than either of those!). Medial ligament rehab – how does it work? Mechanotherapy. Normal physiology = mechanotransduction; Prescribing targeted exercise = mechantherapy. Simple.

Mechanotransduction has a very well-established scientific basis underpinning the success. Incontrovertible. (5077 citations in Pubmed). Stick with exercise loading– it can take time to work fully. Avoid the temptation to switch to snake-oil formulas or funky treatments. Trust in millions of year of evolution. The folks who couldn’t heal their own injuries while moving on to the next feeding grounds aren’t with us any more. Mechanotherapy provides a powerful survival benefit!

Click here for open access to the paper: Mechanotherapy–How physical therapists’ prescription of exercise promotes tissue repair

And I discuss this paper with BMJ MultiMedia editor @HarrietVickers on this podcast link: https://soundcloud.com/bmjpodcasts/bjsm-podcast-mechanotherapy

And you can upload of the graphics from the paper for free as powerpoint slides.  If you enjoy the podcast or have tips as to how we can make it better – tweet @BJSM_BMJ

Turning movement into repair!

**BJSM has over 230 podcasts on SoundCloud with over 900,000 listens** Check them out at http://bjsm.bmj.com/site/podcasts/

Professor Michael Kjaer has a great podcast on pathology and treatment options: It’s much better than this mechanotherapy one but don’t tell anyone I said that.

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