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Book Reviews

Moneyball: Rewarding excellent sports medicine care. But check your indemnity limit. You may need more if treating elite professional athletes.

27 Nov, 11 | by Karim Khan

UKsem was the first conference to have a ‘Moneyball’ panel session; attendees voted with their feet that this should happen again. What’s ‘Moneyball’? The unabridged term refers to Michael Lewis’ book of that name. It’s about a baseball team who performed much better than they should have by recruiting cheap players who didn’t have the ‘look’ of top draft picks but whose statistics were impeachable. The implication is that an astute statistician may help to recruit this type of player whereas a ‘sport expert’ might be fooled by intangibles – the style, the charisma, pedigree – but in the end things that don’t predict success as well as the carefully analyzed data. The concept was in the news in Australia just today.

In the sports medicine setting, Dr John Orchard raised raised the concept in 2009. He’d read the book (didn’t wait for the Brad Pitt movie) and figured that team physios and team sports physicians could augment team performance. This appreciation, literally valuing of the sports medicine / fitness team would lead to great salaries for those individuals. At the conference Moneyball session, Liverpool Football Club’s Peter Brukner estimated that many soccer/football clubs in the English Premier League have annual player salaries over 100 million GBP but pay less than 0.5% of that for ‘maintenance’ – the sports medicine team. Seems crazy and I suspect that in Formula 1 the investment in the ‘asset’ would be much higher.

Security sit - ready for action - at Liverpool vs. Chelsea, November 20, 2011

Also in the UKsem session was power lawyer Mary O’Rourke, QC, who is clearly a pre-eminent sports lawyer in the UK. She emphasized the risk that sports physicians are at when taking care of players who might be earning over 100,000 GPB per week. Is your personal liability insurance in place for the 40 million GPB or so you might be sued for?  I didn’t realize that as Dick Steadman operates in Colorado, the legislation in that stats caps any medicolegal claim at $10 million. In the UK, there is no cap. Food for thought for both players, and physicians. Lots of players have value greater than $10 million.

There was also an introduction to the idea of clincians using agents to help them get better deals in this new world. Clinicians valued more = larger contracts = need for help with negotiation and for digging out the good gigs. Makes sense.

A great idea for future conferences in the UK and beyond. I can see it traveling very well at AMSSM in Atlanta 2012, the VSG (Netherlands), Australia, Switzerland, South Africa, and among the ECOSEP member countries.

For a detailed movie review and background to Moneyball click here please.

And on the subject of Liverpool Football Club, it seems like Brad Pitt is a fan!

Guest Blog by Professor Timothy Noakes – A comment on ‘Good Calories, Bad Calories’ and ‘Why We Get Fat and What to Do About It’

1 Sep, 11 | by Karim Khan

I have been reading Gary Taubes‘ books on nutrition and health – Good Calories, Bad Calories and Why We Get Fat and What to Do About It.

It is clear to me now that carbohydrate intake is the factor driving the obesity/diabetes/ heart disease/ metabolic syndrome epidemic globally. Taubes explains how this was known up to 1970 and then was lost as the “fat causes heart disease/diabetes” message came out.

I have proved to myself that in my genetic pre-diabetic state my body fat mass is entirely regulated by my carbohydrate intake. I have lost 15kg of fat (looks like I have lost no muscle) by switching from a “healthy” high carbohydrate diet to an “unhealthy” one comprising 55-60% fat, 30% protein and 5-10% carbohydrate (about 80g CHO per day) diet.  Thus I have proved that my body fat mass is inversely related to the fat content of my diet – the less fat I eat, the fatter I become.

The explanation is that my fat cells are profoundly insulin sensitive and store fat (and according to the Taubes hypothesis cause hunger and reduced energy expenditure in voluntary exercise) whenever there is a trace of insulin around. Removing insulin removes the break, the fat cells release the stored fat and hunger disappears and the desire to be physically active increases – this is the Taubes hypothesis that was the standard theory between 1920 and 1970.

Taubes’ book suggests that the idea that dietary fat is bad for your health is another myth that is fueled by those who draw up the US Dietary Guidelines, aided and abetted by the carbohydrate industry who do not want the alternative truth to be realized.  There may also be little appetite for Big Pharma to allow it to be known that simply by reducing their carbohydrate intakes all those at risk of diabetes, heart disease and metabolic syndrome might be able to cure themselves without medication – a frightening thought for the industry.

You, Mr Editor, are lean whilst eating a high CHO diet because:

  1. You have muscles that are not insulin resistant so that you store most of the CHO in muscle and;
  2. Your fat cells do not respond to the insulin effect by storing fat. Probably you have a signalling defect on a genetic basis in your fat cells.

Your genetic abnormality allows you to eat as much CHO as you wish whereas my insulin intolerant muscles and hypersensitive fat cells causes the opposite effect.

I am also running faster than I have for 20 years and my body shape looks identical to pictures I have of myself when rowing for my University 40 years ago at age 22.  I am looking to break 50 minutes for 10km running in the next 3 months – an improvement of about 25 minutes on times I was running when eating the high carbohydrate diet that I (used to) and others still do advice for athletes.

Anyone who has unsuccessfully tried to lose weight in the past by cutting fat and calories and trying to eat less should know that that approach is utterly ineffective since, in a homeostatically regulated system, all this produces is hunger.  For those who are predisposed as am I, the key is to keep circulating insulin concentrations as low as possible.

If Taubes is correct, then the advice that we should reduce the fat in our diet and replace it with carbohydrate might just be the single greatest public health disaster of the past century (since it has led to the global obesity epidemic).

Rather than dismissing this blog as random mutterings may I suggest that readers either (i) read Taubes’ books or (ii) experiment on yourself or (iii) better still as I have done, do both.  You might just be astonished and angry that something considered to be so complex and inexplicable is actually really so very, very simple.

Dr. Timothy Noakes is a Sports Physician, Exercise Physiologist and Discovery Health Professor of Exercise and Sports Science at the University of Cape Town and Sports Science Institute of South Africa, Cape Town, South Africa

Deflating the Genomic Bubble (in Science!)** Big news

18 Feb, 11 | by Karim Khan

This paper in today’s issue of Science is going to get a lot of attention because it has multibillion (yes, billion, of not trillion) dollar implications.  The thoughtful, balanced perspective should influence health policy from the WHO through to the NIH and lead public health agencies the world over.

The international authors are not alone in making the point that we need to beware of the line between hype and hope. Brilliant scientific discoveries should be respected even if they do not cure cancer tomorrow.  The paper is very balanced – the authors assert that ‘recent methodological progress in genomics has been breathtaking’ but they warn against claims of immediate therapeutic solutions that are ‘too often unrealistic and counterproductive’.

They draw the comparison with the dot-com bubble and the housing market crisis — ‘the world has seen its share of inflated expectations and attendant dangers. Science is immune to neither’.

I see an increasing wave of ‘genome skeptics’. We are far from Gladwell’s tipping point but consider the intellectual heavyweights who have gone bearish on Magic Genome Bullet shares.  James Le Fanu was ahead of the wave with his 1999 best-seller – The Rise and Fall of Modern Medicine. Last year he anchored BMJ’s Head to Head with Is modern genetics a blind alley. Yes.  Just 8 weeks ago Jonah Lehrer had a fantastic piece in The New Yorker that kept academics the world over from their fascinating Departmental Meetings.

UBC’s Kaczorowski responded to a Lancet report of genetic risk factors for cardiovascular disease with an important counterpoint. ‘…it was very disappointing to see that, after millions, and perhaps billions, of dollars invested in genomic research over the past few years, there is so little to show for it.  Although the [genetic risk] score was associated with incident disease, it failed to improve risk discrimination. …Non-invasive, easily available, and often inexpensive traditional risk factors for CHD such as age, gender, or blood pressure outperform by a large margin a genetic risk score’.

Tim Caulfield, an author of the Science paper, interviewed on Canadian radio (CBC) also said that a measuring tape (waist circumference) and a blood pressure cuff provided more clinically-useful information than he got from his personal genomic risk factor screen.

When surgeons advocate against surgery it’s time to listen. When genetics epidemiologists and mathematicians are saying ‘promise should not drive policy’, ‘rethink priorities’, ‘real personalized medicine comes from your primary care practitioner’, its time to act.

In response to Kaczorowski’s letter (above) Finlands’s Samuli Ripatti, the preeminent genetic epidemiologist from the Institute of Molecular Medicine, spelled it out…”We suggest that the key promise of investigating the genetic causes of CHD lies not in risk prediction but in finding new causal biological pathways for CHD in human beings.” Really? I wouldn’t mind a buck for every grant that links genomics with ‘risk prediction’. Go to Pubmed ID paper 20468069 for example #1. Here’s #2 in Lancet.  Despite Ripatti’s concession, risk prediction has been a cornerstone for genomics advocates as discussed, and disputed, in this paper in Science.

I’m stopping there as this is a BJSM blog post, not a polemic. Congratulations to the authors for the courage of honesty, to Science for publishing a paper challenging dogma.

As I am not to a therapeutic nihilst, what thoughts do I have to seek health? Digest the fact that physical activity is the closest we have to a magic bullet (twice as powerful as stopping smoking for health) and it comes with proven adverse events like improved mood, cognitive function — adding life to years.

You don’t need lycra – walk, take the stairs. 150 minutes a week of accumulated physical activity will provide you more benefits than the richest person on the earth can gain from any dream team of physicians and knowldege of his or her SNP variants. And my genomics friends know it – they play tennis for health!

Let me know where I am off track in the comment box below or via Twitter @BJSM_BMJ

PS: As I wrote this, I found one of my favourite quotes on James Le Fanu’s home page – apt in the circumstances. ‘For every complex problem there is a solution: neat, plausible and wrong’. HL Mencken.

Book Review: “Triathlete’s Training Bible”

25 Oct, 09 | by Karim Khan

The Triathlete’s Training Bible will make triathletes smarter, stronger and faster

Review by Ross Tucker

Joe Friel’s Triathlete’s Training Bible, now in its 3rd edition, has become an indispensable tool for triathletes of all levels wishing to improve their performance using evidence-based methods and principles. Of most credit to the book is that it is very obviously a sound theoretical treatise, heavily based on scientific truths, as well as Friel’s own experience of having worked with triathletes for many years. Yet it does not overplay its hand, forcing technical scientific information on the reader and aspirant improver. Rather, it guides decision-making for all situations, covering topics ranging from motivation (the art) to metabolism (the science), always in a very clear, concise and practical manner. As for scientists who work with athletes, the value is in appreciating how Friel balances the complexity of the science of performance, with the requirement to give athletes tangible, easily implementable advice, and this is something all sports scientists can borrow from.

[Also, click here for a link to Joe Friel’s bloged.]

Book review: Martindale’s Drugs in Sport Companion 2009

21 Jun, 09 | by Karim Khan

This is a useful guide on drugs banned in sport and is particularly helpful when
travelling as it lists generic and trade names of drugs from 40 countries worldwide. Its
main disadvantages are that it does not list permitted drugs (unlike websites such as
100percentme) and it is only valid until the next WADA revision is released.

It can also be unclear at times, for instance oxymetazoline “used… to relieve nasal
and conjunctival congestion” is listed as “banned in competition”. It mentions later
that “topical use” is permitted. This led to momentary panic in a team sports situation
before it was clarified that oxymetazoline nasal spray is safe to use!

By Mark E Batt
Consultant Sport & Exercise Medicine
Fellow NHS Institute
President-elect Faculty of Sport & Exercise Medicine
Centre for Sports Medicine
Queens Medical Centre
Nottingham University Hospitals
Nottingham, UK

Book Review: Essential Sports Medicine

7 Nov, 08 | by Karim Khan


Essential Sports Medicine
Edited by Richard Higgins, Peter Brukner and Bryan English.
Published by Blackwell, pp 160, £24.99.
ISBN: 9-78140-5114387

This is primarily a UK written sports medicine book whose primary audience is intended to be at an undergraduate level. With the expansion of the speciality as a whole it is always a difficult task to be comprehensive, but the major fundamentals have been covered in a very clear and concise manner. The book is well laid out and presented with a generous number of illustrations. Colour would have been nice but I guess budget constraints did not permit this or is it meant to reflect the murky British weather?

There is a good balance between musculoskeletal injuries and medical based problems. Basic nutrition and exercise physiology have also been included.

The book has been well researched, as you would expect from the quality of the contributors, and each chapter finishes with a short list of further reference material for those interested. I found the information to be very current and up-to-date. Even an ageing sports physician such as myself was able to learn an extra thing or two!

I was particularly interested in the sports specific injury section; secretly I was hoping that there may have been a medical explanation or two in there from one of the co-editors as to why Chelsea had a trophyless season—never mind!

Overall this book has very few weaknesses, certainly nothing worth mentioning. I feel it has more than achieved its aim of reaching the intended target audience and I can see this material becoming a good source reference book in the years to come, with further revisions, especially when sports medicine finally becomes a part of the undergraduate UK medical curriculum. No doubt it will encourage a few undergraduate physiotherapy and medical students to enter a sports medicine career path.

Objective details

  • Targeted to an undergraduate audience.
  • Peter Bruckner is a well known author and has written arguably one of the finest books in sports medicine, Clinical sports medicine, with Karim Khan (McGraw Hill Publications).

Subjective details

  • The easy reading style along with the illustrations was appealing although JK Rowling need not worry about the competition!
  • Not useful to me at this point in my career; certainly would have been valuable when I was starting out.

Arjun Rao
Maylands, Washington State, USA

Presentation 16
Comprehensiveness 15
Readability 16
Relevance 15
Evidence basis 15

Book review: Oxygen uptake kinetics in sport, exercise and medicine

17 Oct, 08 | by Karim Khan


Oxygen uptake kinetics in sport, exercise and medicine
Edited by A M Jones, D C Poole
ISBN: 978-0-415-30561-7
Published by: Routledge
Publication Date: 2nd December 2004
Pages: 432

This book provides a comprehensive review of the field of oxygen uptake kinetics. Written in a text book format, this multi-authored effort is a useful reference for scientists and students interested in clinical and research aspects of oxygen uptake kinetics. The book has contributions from experts in each of the areas presented and provides an evidence-based approach to our understanding of oxygen uptake kinetics and its importance to health, disease and improving elite athletes’ performance.

The book is aimed at researchers, practitioners, teachers and students and broadly meets the demand of this market. The book serves as an invaluable resource for recent graduates embarking on a career in exercise physiology with a key focus on the kinetics of oxygen uptake during exercise. The book’s strength lies in its comprehensiveness, collating a large body of information which might ordinarily require several different sources. The book is divided into four distinct sections: Introduction; Theory and practice of measuring VO2 kinetics; Mechanistic bases of VO2 kinetics; and Practical applications to the study of VO2 kinetics. The main theme of Oxygen Uptake Kinetics in Sport, Exercise and Medicine is that pulmonary oxygen uptake measurement, using a metabolic cart, can provide valuable insight into metabolic control processes within the exercising muscle. The format of the book provides readers the opportunity to read the text as a whole, or more likely, given the density of material, to access specific material as required.

The introduction to this book provides a nice summary of oxygen kinetics. The historical timeline is very interesting and provides readers with some useful background material on the progression of this buoyant field of research. The following chapters have a wealth of information describing oxygen uptake kinetics, how oxygen uptake is measured, limitations in measuring oxygen uptake at the mouth, and deconstructing oxygen uptake into its constituent phases from rest to exercise. The book also links oxygen uptake kinetics measured at the mouth and actual oxygen uptake kinetics at the muscle, and the underlying assumptions in this process. The mechanisms and regulation are described in detail and the book is extremely well referenced for further reading in particular areas of interest. Chapter 12 provides a very nice summary of the complex and detailed information, and is a good overview for readers to consolidate the key aspects of the book. Experienced researchers and graduate students alike certainly love easy-to-read and accessible summary material. The practical applications put some of the more esoteric details on ageing, disease states and training for high-level athletic performance into perspective.

There is some variability in breadth and depth between chapters but this is understandable given the large number of contributors involved. The book can be quite hard going with the large volume of detailed information presented on underlying physiological processes and metabolic calculations. However, for readers with an interest in this field the book provides a comprehensive treatise on oxygen uptake kinetics.

Presentation: 17/20
Comprehensiveness: 19/20
Readability: 17/20
Relevance: 17/20
Evidence basis: 19/20

Review by Philo Saunders
Department of Physiology,
Australian Institute of Sport, Australia

Book Review: Handbook of Sports Medicine and Science: Running

16 Oct, 08 | by Karim Khan


Handbook of Sports Medicine and Science: Running
Editor(s): John A. Hawley
Print ISBN: 9780632053919 Online ISBN: 9780470757116
Copyright © 2000 Blackwell Science Ltd

This book is a wonderful handbook for all those actively involved in the management of runners, including doctors, physiotherapists, podiatrists, physiologists and coaches.

It gives a profound coverage of the science behind sprinting, middle and long distance running. Early chapters go into detail about the biochemistry of muscular contraction in sprinters versus distance runners and look at body morphology. Power output relative to muscle fibre type is discussed. The role of glycogen and fat as energy substrates is analysed along with aerobic and anaerobic thresholds. There is an interesting review covering recovery after exercise and insights into back-to-back training sessions.

All these factors lead into a discussion as to whether human performance can continue to improve. The age-old desire to break records is challenged by science and potential training techniques. It leaves one wondering whether we will reach a point where we will have to measure performances down to 1/10♥000th of a second, just to be able to “break” existing records!

An understanding of the biomechanics of running is vital to those practitioners who spend many hours trying to optimise foot and limb mechanics to aid in injury recovery or in injury prevention. The chapter on this topic is well presented and easy to understand. Some of the force curves go beyond what is needed to justify shoe selection but will be helpful to podiatrists and physiologists and coaches looking to modify running styles in their athletes.

As a runner myself, I am always interested in training techniques, so the chapter on this appealed. It gives a wide view of the training techniques required to optimise sprinting or distance running. The specific tables relating to runners across the ages give a fabulous historical perspective to training diaries over the last 50♣years. There is useful information in athlete selection about predictive run times for events based on sprint times. This section provides great background but would not give enough practical information for an individual athlete to write his or her own training programme. Other publications probably aim at this more specifically.

The final two chapters cover injuries and nutrition for runners. The beauty of these chapters is that they are entirely specific to runners. The injuries discussed are those which occur commonly in runners. There is a well-rounded set of facts about why these injuries occur and how to manage them. These chapter include information about runner’s diarrhoea, iron deficiencies and common overuse injuries such as stress fractures and muscle strains. Sections covering heat stress, dehydration, hyperthermia and possible fluid overload in races are succinct but very accurate. These sections would be essential to any practitioner who may be involved in event coverage.

Overall, this book gives a very specific overview of the science and medical considerations of runners. Being fewer than 100 pages long, it is practical to read, and as each section is a standalone chapter one can read them all, or only those sections of particular interest personally. It would be a good handbook to have in your medical library.

Objective details
This book is targeted at all those practitioners who look after runners, particularly elite runners. Doctors, sports physicians, podiatrists, physiotherapists, dieticians and physiologists would all enjoy aspects of it. Some coaches may find it of interest.

Each chapter is written by an expert in that field, and all of these people are well-known professionally in runners’ circles. For example, Dr Tim Noakes wrote the injury chapter and Louise Burke the chapter on nutrition.

Subjective details
The book is simply organised and is easy to read a section at a time. It is possible to read only those sections which interest you, as they are all written independently – you do not rely on information from one chapter to understand the next! It includes only information relevant to running, so it is well confined to its subject. Some sections contain more details on scientific premises than the average person may require, but it is possible to skip over these and not lose continuity.

I found the book useful and informative. I would like to have it on my shelf as a reference to go back to from time to time and would encourage those who deal with runners to buy a copy.

1. Presentation: 15 – More pictures would be great
2. Comprehensiveness: 19
3. Readability: 15
4. Relevance: 20
5. Evidence Basis: 17

Review by Jane Fitzpatrick
Fellow Australasian College of Sports Physicians (FACSP),
Bachelor Medicine and Surgery Melbourne University (MB.BS Melb)

Book Review: Clinical anatomy of the lumbar spine and sacrum

16 Oct, 08 | by Karim Khan


Clinical anatomy of the lumbar spine and sacrum (2005)
By Nikolai Bogduk
Published by Churchill Livingstone
pp 324, US$90. ISBN: 0-443-10119-1

This publication can be considered a classic for those clinicians involved in the care of patients with lower back problems. The purpose of the book is given in the foreword and the first paragraph of the author’s preface to the 4th edition: “There have been no changes in the anatomy of the lumbar spine in the past 20 years, but our understanding of some of the controversial issues has. Among them the presence of new data on zygoapophyseal joint pain, suggesting that it is not as frequent as once thought, whereas discogenic pain seems to be on the up once more, with better knowledge of the process of internal disc disruption.”

The book covers comprehensively the expected topics: bones, joints, ligaments, muscles and fascia, blood and nerve supply in various chapters, as well as embryology and development. There is a separate chapter for the sacroiliac joint.

The book has been written as a text book for the International Spine Intervention Society (ISIS): it is required reading for students and a key reference to instructors to review before teaching the Society’s anatomy courses.

As a clinician with an interest in low back and pelvis patients (but not involved in intervention procedures) I found the “extra” chapters particularly interesting. In the chapter “Age changes in the lumbar spine” Professor Bogduk stresses in his own emphatic style that many changes observed in imaging studies are nothing more than the result of the normal ageing process, not pathological findings.

From a clinician’s point of view the last three chapters on low back pain, instability and radiographic anatomy are of particular interest. The author addresses controversial topics as is his custom: with thoroughly researched references, available clinical evidence and very definite opinions. A number of the references are obviously form the first edition (1987), but still valid. The instability chapter has an excellent biomechanical basis, and is presented in a very logical fashion, that makes understanding of the issues easier. There is no reference, however, to the available literature on the link between low back pain and changes in muscle recruitment patterns, which is clinically significant. I also would have liked to see the last chapter on the radiographic anatomy expanded to cover other imaging modalities, rather than limited to simple x ray films. In fairness to the author, he indicates that further material is covered in the instructional CD of the ISIS.

These criticisms are not sufficient to change my opinion of this book: it is an excellent resource for all those who have an interest in the lumbar spine, from surgeons to interventionists, anatomists, physiotherapists, chiropractors and osteopaths.

M F Cusi
University of Notre Dame
Sydney School of Medicine
Darlinghurst, NSW

Presentation 15
Comprehensiveness 18
Relevance 20
Evidence bass 18

Book Review: Exercise physiology: A thematic approach

12 Oct, 08 | by Karim Khan


Exercise physiology: A thematic approach

By Tudor Hale.
Published by Wiley, 2003, pp 356, £100/€135.00 (hardcover).
ISBN: 978-0-470-84682-7

This publication is the first in the Wiley SportTexts series written specifically with undergraduate students in mind. This text is structured as a series of chapters that cover the basic principles associated predominantly with oxygen uptake, transport and utilisation during exercise. The written material is easy to read and well supported by figures and diagrams. Overall the text provides extensive coverage of the historical development of several key principles that may appeal to some, but perhaps not all readers. Chapters on factors limiting maximal oxygen uptake as well as exercise, fitness and health offer insight into practical application of this material. However, the presentation of these concepts as epilogue and postscript chapters gives the feeling that these issues were included as somewhat of an after thought.

With the focus of the book clearly on concepts relating to maximal oxygen uptake, the title “Exercise physiology” could mislead some readers; other key exercise physiology concepts including training principles, thermoregulation, fluid–electrolyte balance, nutritional concepts and anthropometry are obvious in their omission. It is not clear if these issues will be addressed in future books in the series.

The book offers a thorough introduction to basic principles of cardiorespiratory physiology that are easy to follow for those with little previous exposure to these concepts. The oxygen uptake, transport and utilisation story is somewhat disrupted by chapters on circulation and contraction of skeletal muscle. However, these chapters provide useful information to the student and the background to the chapters that follow. At times further discussion of the practical application of these basic concepts in an exercise physiology setting, either recreational or elite sport, would have added an extra dimension. The chapter on aerobic and anaerobic metabolism provides a useful combination of theory and examples of practical application.

Each chapter commences with a list of learning objectives, and a short objective test to allow readers to assess their existing knowledge. The list of symbols, abbreviations and units of measures is useful for readers with little experience in this field, as is the glossary and list of references. The key points summarised at the end of each chapter should appeal to students revising for examinations. One downside of the presentation is the review questions interspersed among the text distract from the logical presentation of the information. That said, these questions and their associated answers will be popular with students looking for the take home message. Overall, this text is best suited for the level of the undergraduate student.

The conversational style of the written material, as well as the readily accessible summaries and supplementary information included in each chapter, make this an ideal text for undergraduate students, particularly those with little background in human biology. The book effectively introduces key concepts relating to oxygen uptake, transport and utilisation. The practical application of these principles in a range of sports science settings should not be overlooked by the student.

A Cox
Department of Physiology
Australian Institute of Sport

Presentation 16
Comprehensiveness 14
Readability 17
Relevance 15
Evidence basis 16

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