Guest blog by Dr Steven Cox (from CRY – Cardiac Risk in the Young

The UK’s National Health Service (NHS)  policy – that “screening should not be offered*”  is currently discouraging young people who may be at risk of sudden cardiac death from having simple, non-invasive and potentially life-saving tests.

The National Screening Committee need to review its position which is out of date

It is the view of the charity Cardiac Risk in the Young (CRY) that:

• All young people (14-35 years old) should be offered the option to have cardiac screening
• Cardiac testing should only be conducted by specialist cardiologists with the necessary skills and expertise to ensure accurate interpretation of the investigations.
• The National Screening Committee policy should widen the remit to consider all cardiac conditions that can cause young sudden cardiac death
• The National Screening Committee policy directly contradicts with the general NHS policy of “prevention”

Can anyone do these tests?

Cardiac screening needs to be overseen by a cardiologist with expertise in this specialist area of cardiology, including; athletes heart, ethnic differences in cardiac adaptation to exercise, and structural/electrical cardiac conditions. Professor Sanjay Sharma is a leading sports cardiologist and CRY’s consultant cardiologist who gives his time to oversee the CRY screening programme.

When a specialist cardiologist conducts the tests the number of false positives and false negatives significantly decrease (i.e. fewer people are told they may have a problem and are subjected to further investigations when they do not have a problem, and fewer people with a problem are given an all clear).

Could the NHS handle so many people wanting testing?

In the current economic era the answer is probably not. Moreover the NHS does not have the infrastructure, including the facilities or the expertise, to immediately implement a national screening programme for ALL young people.

However, CRY is leading the way in training specialist doctors, conducting research and providing educational resources so this will be possible in the future.

Although the implementation of nationwide screening is hampered at this point due to the economic constrains and lack of infrastructure and expertise that does not mean that screening should not be recommended. On the contrary, these limitations should prompt the development of a collaborative scheme between the Government, NHS, charity organisations such as CRY and sporting bodies to provide an initiative to offer cost effective screening.

Is there any evidence from other countries that screening is worthwhile?

In Italy where screening prior to participation in organised sport is mandatory they have reduced the incidence of young sudden cardiac death by 90%. This research has informed international policies that either mandate or recommend cardiac screening prior to participation in organised sport.

Guest blog by Professor Lars Engebretsen

Photo by Aktivioslo, Flickr CC

The recent World Championship in Snowboard in Oslo, Norway led me to the question in this blog’s title. I am a sports doc with extensive experience in treating high level athletes in almost all kinds of sports (except Aussie rules football and cricket).

Since 2000, I have been involved in studies aiming at preventing sports injuries. We have targeted football (soccer), team handball and Alpine skiing and have had some success.  Newer sports however, keep popping up. Almost like the doping hunters  - often being too late to prevent new, effective performance drugs – it seems that we are too late to prevent injuries in some of the new sports.  I was reminded of this during the recent Snowboard Championship in Oslo: new venues for cross, half pipe and slope style situated beautifully in the Oslo countryside. The first days had bad weather and difficult light and there were some serious injuries- not life threatening, but nevertheless serious.

I have noticed a similarity with the last few Olympic games: the venues get bigger, the athletes better trained and with ever increasing abilities. Unfortunately, there is also an increase in injuries. The numbers from Vancouver showed that 35% of snowboard cross and 13% of half pipers experienced injuries.

What can we do to prevent these? We can count injuries, identify risk factors, study how to reduce these and aggressively implement our knowledge. In the meantime, the sporting venues get larger and more challenging and knowledge from our studies become yesterday’s news. I know that the majority of the athletes appreciate the danger, but I am not sure that the top leaders of the sport have the same awareness.

I need ideas to help the athletes operate in a safer environment- any ideas?

Note that the BJSM publishes 4 issues a year dedicated to Injury Prevention and athletes’ Health Protection (IPHP). You can find these issues of BJSM by clicking here. The next IPHP issue will launch in June and will focus on Olympic Sports. IPHP issues are published as part of BJSM’s partnership with the International Olympic Committee.

Nik Zoricik dcath: News story here. (added March 10th). Updated March 15th

Related Articles

Bakken A, Bere T, and Bahr R et. al. 2011. Mechanisms of injuries in World Cup Snowboard Cross: a systematic video analysis of 19 cases. Br J Sports Med. 45:1315-1322 Published Online First: 15 November 2011.

Lars Engebretsen L and  Steffen K. 2009. Warm up The importance of sports medicine for the Vancouver Olympic Games. Br J Sports Med. 43:961-962.

J Torjussen J,  and Bahr R. 2006. Injuries among elite snowboarders (FIS Snowboard World Cup). Br J Sports Med. 40:230-234 .

Engebretsen L, and Bahr R. 2005. Injury prevention – Leader An ounce of prevention? Br J Sports Med. 39:312-313.

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Lars Engebretsen MD PhD is a professor and director of research at Orthopaedic Center, Ullevål university hospital and University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center. He is also Chief Doctor for the Norwegian Federation of Sports, and headed the medical service at the Norwegian Olympic Center until the autumn of 2011. In 2007 he was appointed Head of Science and Research for the International Olympic Comittee (IOC). Professor Engebretsen is Editor of the IPHP issues of BJSM (Injury Prevention & Health Protection)

(follow Caroline Finch on Twitter — @CarolineFinch)

This relates to:

Micheli, L, Mountjoy, M, and Engebretsen, L et al. 2011. Fitness and health of children through sport: the context for action. BJSM. 45:931-936

photo: owenfinn16 via Flickr cc

I read, with great interest, the paper by Micheli et al [1]in the September Injury Prevention and Health Promotion issue of the BJSM,because it outlined  different policy contexts for action.  These contexts are generally consistent with the ecological levels of sports delivery we outlined in the Sports Setting Matrix as a framework for the implementation and evaluation of programs delivered through sport.[2]  It is also consistent with our previous argument that the sports delivery and policy contexts need to be more aligned for global sports safety.[3]

Given that injury is one of the major barriers towards participating in sport,[4] it is surprising that no international policy link for addressing this key factor in children’s sports participation was named in the article.  Many of the organisations named in the paper (e.g. the World Health Organization) have divisions that are concerned with injury prevention as well as NCD (non-communicable disease) prevention, for example. A major way forward to ensuring lifelong participation in sport would surely be to bring together the policy bodies for physical activity/sport promotion together with those concerned with reducing or removing injury risk in such activities.

Whilst there is no doubt that having global policy is a key driver of action and priority attention given to health issues, it is largely practitioners at a more local level who need to implement those policies and to translate them into appropriate acceptable and sustainable programs.  In the sports injury context, we have found a mismatch between what the policy makers want and what the practitioners or implementers need.[5] Moreover, just because there is an international policy/guideline/directive one cannot assume that the desired practice or action at the grass roots level of participation, even at a low level, is achieved.[6]  No matter how much evidence-base there is for a new policy, the end-users will have their own perspectives that will directly influence their readiness to act according to the desired policy result.[7]

Having global, national and local policy responses to fitness and health (including injury prevention) will be crucial for ensuring lifelong participation in sport well into the future.  But not less so than also ensuring both an adequate informed workforce of practitioners to deliver associated programs and end users who are fully receptive to the messages that have been appropriately targeted to reach them.

References

1.         Micheli L, Mountjoy M, Engebretsen L, et al. Fitness and health of children through sport: the context for action. Br J Sports Med. 2011;45:931-6.

2.         Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J Sports Med 2010;44:973-8.

3.         Timpka T, Finch CF, Goulet C, et al. Meeting the global demand of sports safety – the role of the science and policy intersection for sports safety. Sports Med. 2008;39:795-805.

4.         Siesmaa E, Blitvich J, Finch CF. Chapter 1. A systematic review of the factors that are most influential in children’s decisions to drop out of organised sport.  In: Farelli A, editor. Sport participation: health benefits, injuries, and psychological effects: Nova Science Publishers Ltd; 2011. p. 1-45.

5.         Poulos R, Donaldson A, Finch C. Towards evidence informed sports safety policy for NSW, Australia: assessing the readiness of the sector. Inj Prev. 2010;16:127-31.

6.         Hollis S, Stevenson M, McIntosh A, et al. Compliance with return-to-play regulations following mild traumatic brain injury in Australian schoolboy and community rugby union players. 2011;On line First, published on June 24, 2011 as 10.1136/bjsm.2011.085332.

7.         Donaldson A, Leggett S, Finch CF. Community perceptions of a draft policy and training structure for Australian football sports trainers at the community level: a qualitative analysis. 2011;In press. Published online 16 September 2011 as DOI: 10.1177/1012690211422009.

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Caroline Finch is an injury prevention researcher specialising in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

This Guest Blog is the first in a series of blogs highlighting success stories – where exercise was implemented and made a difference. As part of the BJSM initiative in ‘implementation’ we invite readers to submit success stories – and we will solicit them too!

Cardiorespiratory fitness and cardiovascular disease risk factors in children: effects of a two-year school-based daily physical activity intervention was my PhD study – at the Norwegian School of Sport Sciences, Department of Sports Medicine, Oslo, Norway.

Professors Lars Bo Andersen and Sigmund Anderssen were my mentors for this 2-year, school-based,  controlled intervention carried out in two towns in the western parts of Norway.

Here is a brief overview of our investigation:

AIM

• To investigate the effects of a school-based intervention, involving 60 minutes of daily physical activity over two school years, on CRF and CVD risk factors in nine-year-old children.
• To describe CRF levels and CVD risk factor levels in rural nine-year old children
• To examine the association between CRF and clustering of CVD risk factors in these children.

METHODS

A total of 256 rural Norwegian children participated in this controlled intervention study. Intervention-school children carried out 60-minute physical activity over two school years. Control-school children had the regular curriculum-defined amount of physical activity in school, i.e. 45 minutes twice weekly. Peak oxygen uptake was directly measured during a continuous progressive treadmill protocol where the children ran until exhaustion. A blood sample was taken from each child for analyses of glucose, insulin, total cholesterol, high-density-lipoprotein cholesterol and triglyceride. Also body mass, height, systolic and diastolic blood pressure and waist and hip circumference were measured.

MAIN RESULTS

The intervention resulted in a significant greater beneficial development in peak oxygen uptake, systolic and diastolic blood pressure, total cholesterol to high-density lipoprotein cholesterol ratio and triglyceride in intervention-school children than in control-school children. No significant differences in changes were observed in waist circumference, body mass index and the homeostasis model assessment for insulin resistance between the two groups. Furthermore, the intervention, primarily carried out at moderate intensity, showed that those children in the I-school with the least favorable starting point experienced the most beneficial effect of the intervention. The cross-sectional data suggested that low CRF, and low CRF and high fatness combined were highly associated with clustered CVD risk.

MAIN CONCLUSION

This two-year school-based teacher-led 60-minute daily PA intervention resulted in a significant greater beneficial development in SBP, DBP, TC:HDL ratio, TG and VO2peak in the I-school children than in the C-school children. No significant differences in changes were observed in WC, BMI and HOMA-IR between the two groups.

PERSPECTIVES

A daily school-based physical activity intervention can significantly increase children’s CRF levels and beneficially modify their CVD risk profile if the intervention is sufficiently long, includes substantial daily physical activity, and if the physical activity is planned and organized by expert physical education teachers. Therefore, daily physical activity should be given due consideration in the design of school policies.

EPILOGUE (what happened after the intervention period was over in 2007 ?)

The daily physical activity intervention program was established as part of the school curriculum for all participating children from the I-school, thus the physical activity was mandatory.

However, an important question is: What will happen to the physical activity in the I-school after the physical activity-project is completed? The I-school, Trudvang School in Sogndal, Norway, based on their experience in the Sogndal school-intervention study, has decided to continue its commitment to the physical activity program, and expand the program to all students.

The program consists of 30 minutes of daily teacher-led physical activity. Trudvang School considers the 30 minutes of daily physical activity as a subject with the same status and financial resources as the traditional subjects. Additionally, the children are given the possibility of a minimum of 30 minutes of daily free play in recess. At Trudvang School, there is no conflict between PE and physical activity. The former is a subject with defined goals which teachers and pupils work together to accomplish, while the latter has a public health perspective. For both PE and physical activity, trained PE teachers are responsible for the planning and organizing of lessons, and they also lead the physical activity lessons together with classroom teachers when appropriate. In this way, the students receive physical activity lessons of high quality. According to Trudvang School, all obstacles have now been overcome, and daily physical activity is a natural part of the school day. According to the principal (Bjarte Ramstad), Trudvang school will never return to the “traditional” weekly 2 X 45 minutes PE ! Schools are coming from different parts of Norway to learn from Trudvang school. This week 8 schools from the Hardanger area (close to Bergen) came to visit (and learn).

CONCLUSION

I believe that the school setting is an ideal environment for population-based physical activity interventions. In most countries, schools exist in all municipalities, and most children and adolescents, from the age of six to 16, spend most of their day in school. Hence, the school setting may be the only means in society to reach a large number of children from all socio-economic backgrounds. In my opinion, the two best school interventions carried out so far is:

1)      Reed et al. Action Schools! BC: A school-based physical activity intervention designed to decrease cardiovascular disease risk factors in children. Prev Med. 2008: 46(6): 525–531.

2)      Kriemler et al. Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. BMJ. 2010: 340(c785).

Related BJSM Articles

Nettlefold, L, McKay HA,  Warburton DER, McGuire KA, Bredin SSD, and Naylor PJ. 2011. The challenge of low physical activity during the school day: at recess, lunch and inphysical education. BJSM ;45:813-819 Published Online First: 9 March 2010.

Nicola D Ridgers, ND, Timperio, A, Crawford D, and Salmon J. 2011. Five-year changes in school recess and lunchtime and the contribution to children’s dailyphysical activity. BJSM, Published Online First: 19 May 2011

“Prevention is better than a cure, no matter what disease we look at…football is an ideal platform to promote a healthy lifestyle and prevent disease.”       – Professor Jiri Dvorak, FIFA’s Chief Medical Officer

This month’s BJSM Editor’s Choice (free online) highlights an innovative approach to health and exercise promotion in Africa. Authors Colin Fuller, Astrid Junge, Cadrivel Dorasami, Jeff DeCelles, and Jiri Dvorak investigated how FIFA’s 11 for Health programme (watch promo video) impacted 10 to 15 year old children’s health knowledge in Mauritius and Zimbabwe. They conclude that the collaborative implementation model was successful and that post-programme analyses showed significant increases in most of the participants’ health knowledge.

Photo courtesy of: StephenandMelanie, Flickr Creative Commons

As an outcome of these successful pilot projects and the 2011 nationwide implementation of the programme in Mauritius, over the last 2 months Dr Junge and Dr Fuller worked with Dr. Dvorak on a four-week programme expansion initiative. This involved ‘training the trainers’ in Nairobi (Kenya), and Windhoek (Namibia), and making presentations to Football Associations in Botswana and Malawi. (Read more about the nationwide implementation initiative here).

Dr. Dvorak also presented the results of successful nationwide implementation of the programme to the 61st FIFA Congress on June 1st, 2011 in Zurich. This congress received global media attention. Following the presentation, officials from many countries around the world approached FIFA’s medical team (F-MARC) to express their desire to partner in this initiative.

This project team exemplifies commitment to combining scientific rigour with social responsibility to create an exercise-based tool for health promotion. The potential for scaling up this programme means is has tremendous public health significance. BJSM will highlight ‘success stories’ from around the world as part of the journal’s promotion of ‘implementation’ as a key issue for sports medicine in the 2010s.

Would you like to share successful implementation stories?

Leave a comment below, or send an email: karim.khan@ubc.ca

Concussion, concussion, concussion – has dominated the media over the past months. Major injuries to kids, research suggesting long-term problems, even the American Neurology Association updating their guidelines, now Sidney Crosby sits on the sidelines at millions of dollars a day.

BJSM afficionados will be aware but as we get new readers and blog followers daily, I don’t apologize for reminding you of free value in the following links:

The special issue of BJSM that followed the Zurich Concussion Consensus Meeting – this is the meeting that is driving the science – this was the evidence behind all the current change.

Particularly useful is Paul McCrory’s explanation of how to interpret the guidelines – via BJSM’s masterclass podcast.

Here’s the intro that goes with that podcast…

Part 3: You are the expert – you teach concussion to fellows and you can recite the SCAT2 even if you have profound headache and retrograde amnesia. Professor McCrory provides tips from the Consensus Statement that have you on the same page as the 27 experts in Zurich. And maybe you were one of them. Listen anyway, send any additional tips to the BJSM blog (http://blogs.bmj.com/bjsm/) and share the news of this practical podcast.

And then there is consensus statement itself – copublished in about 14 journals – a remarkable achievement in turning knowledge to action or ‘knowledge exchange’

As well as the practical forms to use on the sideline – the unfortunately named ‘SCAT2′ and ‘Pocket SCAT2′

The 2007-2009 Canadian Health Measures Survey indicated that only 15% of adult Canadians were active for a recommended 60 minutes of moderate to vigorous activity per day. Younger Canadians were even less active with 9% of boys and 4% of girls aged 5 to 17 meeting the health-benefit informed goals of 60 to 90 minutes of physical activity per day.

That the majority of Canadians failed to meet the minimum standards to experience health benefits suggests the need for further actions to encourage exercise uptake and decrease environmental barriers to physical activity.

(see related BJSM publications:

• Prevention in the first place: schools a setting for action on physical inactivity. Naylor PJ, McKay HA, 2009.
• The challenge of low physical activity during the school day: at recess, lunch and in physical education. Nettlefold L, McKay HA, Warburton DE, McGuire KA, Bredin SS, Naylor PJ, 2010.
• Contribution of free play towards physical activity guidelines for New Zealand primary school children aged 7-9 years. McGall SE, McGuigan MR, Nottle C, 2011)

Remarkably, the Canadian Society of Exercise Physiology’s (CSEP) response to the survey outcomes was to lower the Canadian Physical Activity Guidelines. Adults are now only recommended to exercise 150 minutes per week, and children are recommended to exercise 30 minutes a day with a gradual progression to 90 minutes. The CSEP legitimizes these changes by stating that the new guidelines are in-line with the World Health Organization standards.

Mark Trembley, chair of the CSEP, stresses that these new targets are the minimum recommendations. He states that due to the progressive nature of benefits from physical activity “more is better.” The changes are also designed to be less intimidating to Canadians that may “give up before they start” if they think they can’t meet recommended guidelines.

Despite the well-meaning intentions of the CESP, I am concerned that lowering our recommendation for physical activity sends completely the wrong signal to the community. Clearly 150 minutes per week makes enormous health differences compared with nothing but to change the message when a survey has shown abject failure seems like changing the ‘obesity’ cut-off in BMI to 50 so that Canada becomes a thinner nation.

So the practical challenge is — how can we (on a local, national, and global level) create more enabling environments that encourage physical activity and promote healthy behaviour changes?

What do you think about this?  Please respond in the boxes below the blog. Or write to the BJSM editor to have your own comments posted in this main blog page (attributed to you).

A special theme issue of BJSM guest edited by Jon Drezner and Babette Pluim on the topic of sudden cardiac death in young athletes is scheduled for June 2009.

A letter from Dr. Thamindu Wedatilake, Hope Hospital, Salford, UK, related to this serious sports medicine condition:

I have read in interest the article by Wilson et al regarding their support for using an ECG in screening for sudden cardiac death in the young. Furthermore I note that there is considerable support from many sporting governing bodies for the above recommendation.

I note the comments of Dr Richard Page where he argued that in the USA alone, mass ECG screening of young athletes would exclude 2000 children from sport for every life saved.

Dr. Page’s comments have concerned me. By trying to save one life in an issue that is highly media motivated for the obvious dramatic nature of sudden cardiac death, we prison a further 2000 children to a potentially life threatening sedentary life style. Hence, ironically we may increase their risk of death from a cardiac cause later in life.

Are we really doing whats best for these children or are we dancing to the tune of the media? Have we thought about the long term repercussions that such a screening programme may have on our childrens’ physical and psychological wellbeing?

Yours/your colleagues thoughts are appreciated.

Jon Drezner replies:

Dr. Wedatilake,

You make an excellent point which was also raised by Dr. Page. Interestingly, I just gave a pro/con ECG screening Grand Rounds with Dr. Page and we looked at this question together.

The number of disqualifications and the downstream effect of limiting exercise in a subset of kids (with identified cardiovascular disease) but who may never suffer SCA is a question that needs to be investigated. I would agree that disqualifying 2000 to save 1 life may not be acceptable. What number of disqualifications is acceptable? 1000? 100? 10? I think the number of disqualifications calculated to save one life is hugely affected by 3 things: the incidence of SCD, prevalence of asymptomatic disease, and total positive (and false positive) rate of ECG screening. If you begin with traditional reported estimates (1:200,000 incidence and 15% false positive) you get about 2000 disqualifications. If you use statistics from more recent studies (1:50,000 incidence and 2-5% total positive rate), you get about 30-50 disqualifications to save a life. Unfortunately, these are all just calculations and until we have large scale studies with follow-up of those disqualified, the long-term effects will just be speculative.

Sudden cardiac death has always been at the apex of ‘serious’ sports medicine conditions. We all agree that one death is one too many. Sports physicians with expertise in cardiac issues — Jon Drezner and Babette Pluim — will guest edit a 2009 Themed Issue that will include, but not be limited to, original data and commentary on the use of automated external defibrillators (AEDs) in the athletic setting, emergency preparedness for sudden cardiac arrest, and the secondary prevention of sudden cardiac death in young athletes.

We look forward to the opportunity to work with authors, groups convening to provide consensus statements, and partner journals to contribute to minimizing sudden cardiac death in the sporting setting.

This special issue will form the June 2009 Issue of BJSM. More details will follow and the deadline for submissions is 11:00 pm, Dec 31. 2008.

One of the questions that is always asked of sports medicine clinicians is how much training kids should be doing. At a time where physical inactivity is the major childhood disease, we also have the paradox of parents encouraging 3-yr old golfers and 4 yr-old tennis players. After all, the earning potential of those children exceeds the annual salary of all but the most successful CEOs.

Until now, there has been very little to guide training the elite athlete. The IOC Medical Commissionhas a goal of protecting the health of the athlete and to this end, it convened a group to develop a Consensus Statement on the training of the elite child athlete. The paper provides a holistic approach to training the elite child athlete, including exercise prescription, psychological training, nutritional guidelines and special considerations.

It is now available in the March issue of BJSM (Br J Sports Med 2008;42:163–164). The expert committee members were: M Mountjoy, N Armstrong, L Bizzini, C Blimkie, J Evans, D Gerrard, J Hangen, K Knoll, L Micheli, P Sangenis, W Van Mechelen.

What are your thoughts? Is this helpful? How could it be improved? What is your experience with the elite child athlete. Please leave any feedback in the comment section below.