Guest blog by @CarolineFinch

In the recent BJSM blog Is high level snowboard too dangerous to allow your children to participate? Prof Engebretsen raises an important question, namely how to prevent injuries in a sport where pushing the extremes of physical performance in challenging and harsh environments is both an individual athlete and sporting organisation goal.[1]

Most recent advances in sports injury prevention have tended to focus directly on the athletes, themselves, with the aim of making them more resilient to the injury risks they are faced with in their chosen sport. I wonder if, for sports such as snowboarding where most injuries result from acute energy exchange beyond the body’s tolerance, it is time to go back to first principles for injury prevention and revisit the application of Haddon’s 10 countermeasure strategies.[2] In this hierarchy of injury control, “Make what is to be protected more resistant to damage from the hazard” is only the eighth strategy. There are seven higher order control strategies that could (and should) be applied to also reduce injury risks and hazards.

Engebretsen [1]also queries whether leaders of the sport really have true awareness of the risks in elite snowboarding. The fact that so little ongoing attention seems to have been given to identifying and implementing solutions meeting many of the higher-order Haddon countermeasure strategies would seem to support this. Interestingly, a recent blog by Laura Robinson at playthegame.org also queries whether “sports officials’ tendencies to put the fight for new viewers by making the sports more dangerous and exciting” are more favoured than the safety of the athletes of snow sports.[3]

We published a review of the evidence for preventing snowboarding injuries in 1999, with the main focus on recreational participants of this sport as it was still a very new activity in Australia.[4] At that time, the sport was considered similar to other snow sports and so most safety advice was derived from that for more general snow/ski safety. One of our conclusions was:

“the rapid international growth of the sport has not been matched by a detailed epidemiological evaluation of the injuries specific to snowboarding or of the countermeasures to prevent them” (page 118).

It would seem that the situation has not changed that much. All sports injuries occur within an ecological context in which multiple levels of the sports delivery system interact with the physical environments in which sports are undertaken and the specific characteristics of the athletes who participate in them.[5] This applies equally well to high performance and professional sport as it does to the more recreational forms. Future safety gains for snowboarding, as indeed other sports, will only be achieved if all stakeholder groups:

1. are engaged and united from the outset;
2. share common goals for the ongoing development of the sport;
3. prioritise the safety of their athletes; and
4. jointly invest in the development, implementation and evaluation of cost-effective injury prevention solutions according to Haddon’s hierarchy of control as translated to this sport.

References

1.         Engebretsen L. Is high level snowborrd too dangerous to allow your children to partcipate? Posted 1/03/2012.: BJSM blog – social
media’s leading SEM voice; 2012.

2.         Haddon WJ. Energy damage and the 10 countermeasure strategies. 1973;13:321-31.

3.         Robinson L. Faster, Higher … Deader. Posted 23/03/2012. playthegame.org; 2012.

4.         Finch C, Kelsall H. Preventing snowboarding injuries – what is the evidence? 1999;6:117-26.

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

*************************************************************

Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises 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

Guest blog by George Murley

There is an increasingly strident debate on the use of minimalist/barefoot versus traditional sports footwear in running, and there appear to be advocates for both sides who believe there is no need for a rational discussion.

Screen shot from: The Barefoot Professor - by Nature Video

The debate appears to have escalated following publications by Richards and colleagues (2008) ‘Is your prescription of distance running shoes evidence-based?’ and later by Lieberman and colleagues (2009) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ and McDougall’s book — ‘Born to Run.’

The main issue in this very messy debate seems to be whether ‘some’ barefoot/minimalist shoe running is beneficial. This is related to the first vertical impact force, minimalist shoes are meant encourages a forefoot strike and  decrease this force, which in turn dampens the first vertical impact force. This however has some individuals suggesting that running barefoot may lead to injuries related to loading of the Achilles and direct impact of the forefoot. A second part of the argument is that footwear is supposed to weaken foot muscles whereas barefoot running challenges muscles and presumably leads to stronger/hypertrophied muscles that in turn have a positive effect of function.

Clinically we are primarily interested in the effect on injury.  There are strong views and some limited evidence supporting arguments about the relationship between the first vertical impact force and injury.  One perspective is that first vertical impact force causes injury whereas others argue injury is related to the ‘active’ forces of push off.

There are a ton of unanswered questions:

Does athletic shod or unshod running affect injury risk?

How does shod and unshod running interact with comfort and performance?

Which biomechanical parameters are related to injury risk?

Does footwear or unshod running reverse biomechanics parameters related to injury risk?

What is important is that clinicians and scientists approach this debate in a reasoned and calm way as there may be merit in both sides of the argument. Having only one perspective and fighting amongst ourselves is not necessarily going to help answer the questions or help the sportspeople make informed decisions about their footwear.

References:

Podiatry Arena (extensive blogging on this issue)

Simon Bartold’s presentation

Lieberman et al (2010) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ published in Nature’s International Weekly Journal of Science

The Barefoot Professor: by Nature Video

Author Chris McDougall’s book — ‘Born to Run’

Richards et al (2008) ‘Is your prescription of distance running shoes evidence-based?’ published in the British Journal of Sports Medicine

Related BJSM Blog

To Strike or Not to Strike? That’s not the only question (for running and injury prevention)

***********************************************

Dr George Murley is a Podiatrist who graduated from La Trobe University with Honours in 2002. He then commenced teaching at La Trobe and completed his PhD related to the effect of foot posture and foot orthoses on lower limb muscle activity. Dr Murley was awarded the Stephen Duckett Higher Degree Research Prize for best PhD thesis in the Faculty of Health Sciences in 2010.

BJSM reader poll results

By Tim Noakes

Only 12% of the BJSM readers who answered the poll were correct – this speaks to the power of the prevailing dogma and marketing messages.

Readers have clearly been influenced by the “Science of Hydration.” This mythical concept developed by the sports drink industry during the late 1980s was designed to increase the consumption of sports drinks.

Heatstroke and indeed all heat illnesses are unrelated to measures of fluid balance. Weight loss during exercise includes the weight lost due to the irreversible oxidation of fuels. Moreover, fluid loss during exercise has only a marginal effect on the core body temperature during exercise.  Thus the third answer,  is the only correct answer.

Interestingly, the small rise in body temperature that occurs with “dehydration” is a biological adaptation found in many desert dwelling mammals. Two to three million years ago our evolutionary ancestors developed this adaptation on the arid plains of South and East Africa. When there is inadequate fluid for ingestion, slightly raising the body temperature during exercise in the heat increases these mammals capacity to lose heat without requiring increased sweating. Hence, it is a water-conserving adaptation.  All these mammals could increase their sweat rates to lower their body temperatures, but their brains’ chose not to do this. This shows that this adaptation is:

1. A biological adaptation of value and;
2. Is not simply due to a “failure of sweating” caused by “dehydration”.

The latter was naturally the interpretation used by advocates of the “Science of Hydration” further to advance the commercial success of the sports drink industry.
These ideas are covered in my two books, Challenging Beliefs (Struik/Random House, 2nd Edition, 2012) and Waterlogged (Human Kinetics, 2012).

*November’s BJSM carried this key review by well known US primary care physicians Chad Asplund and Professor Fran O’Connor along with Tim Noakes.

Related BJSM Blogs

EVIDENCE-BASED considerations for the Prevention of Heat related illness in Marathon Training (part 1)

EVIDENCE-BASED considerations for the Prevention of Heat related illness in Marathon Training (part 2)

**************************************************************

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.

By Dr. Bert Fields

Photo of Daniela Hantuchova by Sasho

As a busy sports medicine physician I see an increasing number of patients pursuing unproven and often expensive treatments before they have tried established therapies with stronger evidence.  One example of this is a recent patient who saw advertising for a cold laser that they purchased from an internet site. The patient showed no progress with his tennis elbow until we saw him in the office and gave him a series of eccentric exercises and other standard treatment which quickly started a reversal of his problem.

In my opinion marketing and news stories which exaggerate the benefits of unproven therapies are leading patients to make bad choices.  Particularly for tendon injuries, patients are purchasing unproven devices or seeking injections with substances like platelet rich plasma or stem cells before they have done any established treatment.

Related BJSM Articles

Lotta Willberg, Kerstin Sunding, Magnus Forssblad, Martin Fahlström, Håkan Alfredson. 2011. Sclerosing polidocanol injections or arthroscopic shaving to treat patellartendinopathy/jumper’s knee? A randomised controlled study . Br J Sports Med 2011;45:411-415.

A van der Plas, S de Jonge,  R J de Vos, H J L van der Heide, J A N Verhaar, A Weir,  J L Tol. 2011. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2012;46:214-218 Published Online First: 10 November 2011. (FREE ONLINE!)

Mathijs van Ark, Johannes Zwerver,  Inge van den Akker-Scheek. 2011. Injection treatments for patellar tendinopathy. Br J Sports Med 2011;45:1068-1076 Published Online First: 3 May 2011. 

R J de Vos, A Weir, J L Tol, J A N Verhaar, H Weinans, H T M van Schie. 2011. No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med 2011;45:387-392 Published Online First: 3 November 2010

Bert Fields, MD is a professor for the UNC School of Medicine and directs the sports medicine fellowship at Cone Health system in Greensboro, NC.  He is a past president of AMSSM.

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.

************************************************************

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)

Photo courtesy of Andrew Malone, Flickr CC

Running biomechanics and footwear’s (from bare feet to orthotics) relationship to injury generates lively debate.  And not just among sports clincians. A recent NY times article boldly asked – Does Foot Form Explain Running Injuries? The article profile’s the running professor, Daniel Lieberman’s (Evolutionary Biologist, Harvard) and Mr. Daoud’s (Medical Student, Stanford) research on 4 years worth of data gathered from Harvard’s cross-country running team. The researchers investigated footstrike (heel vs. toe) and rate of injury.

Beyond running style, Lieberman advocates for daily physical activity. In the BMJ podcast, Evolved to Run (that also features Steven Blair and Karim Khan), you’ll hear Lieberman say:  “we live in an abnormal world where people sit all day long.” What Lieberman positions as ‘normal,’ from an evolutionary perspective, is human bodies adaptation to having physical activity integrated into daily activities. In short – ‘the abnormality’ results from the dissonance between being ‘built to run’ and the post-industrial epidemic of sedentary behavior. You’ll hear more on the impacts of physical inactivity and the ‘ physical activity dose’ required’ to increase health from Blair and Khan on that  podcast.

Lieberman and Daoud concluded that “runners who landed on their heels were considerably more likely to get hurt,” but a forefoot running strike did not neccessarily prevent injury. Also, the researchers caution against changing your running style if you are injury-free.

And BJSM readers will know that ground/foot impact is not the only factor to take into account. What about knee and hip control? Also from Harvard, PT Professor Irene Davis illustrated that gait retraining – providing runners with feedback about landing forces – swiftly reduced anterior knee pain. Read the (free) Editor’s Choice article here.

So, while it may be premature to (run or) jump to conclusions about any one ‘superior’ approach to running, it’s clear  that 30-60 minutes of forefoot and/or heel striking is better than no strike at all.

Related BJSM Articles

RF Pinto, TR Souza, and CG Maher. 2012. External devices (including orthotics) to control excessive foot pronation. Br J Sports Med. 46:110-111.

K Mills,  P Blanch,  P Dev,  M Martin,  and B Vicenzino. 2011. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility . Br J Sports Med. Published Online First: 18 September 2011

A Hirschmüller,  H Baur,  S Müller,  P Helwig, H-H Dickhuth,  F Mayer. 2011. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med. 45:959-965 Published Online First: 12 August 2009

RTH Cheung, RCK Chung,  GYF Ng. 2011. Efficacies of different external controls for excessive foot pronation: a meta-analysis. Br J Sports Med 2011;45:743-751 Published Online First: 18 April 2011

Figures often beguile me, especially when I have the arranging of them myself; in which case….’There are three kinds of lies: lies, damned lies and statistics’.  - Mark Twain

A beguiling and artful video promoting exercise went viral: a good thing, right? Delighted tweets and emails came at me from people whose judgment I respect. They keep coming. But each time I see more praise and still no criticism, my heart sinks.

Is this reception happening because literacy about risk of bias in research is far too low? Or don’t enough people oppose the use of framing techniques that magnify effects rather than putting them in realistic proportions? Or is it because people condone biased data being used to exaggerate effects if it’s for a cause they believe in? Or do people only see bias very selectively? All are a cause for concern.

People’s alarms should always go off when faced with a slew of relative risks without any absolute measures to place it in context. It is the classic “go to” framing technique for exaggeration, be it researchers, journalists, manufacturers or anyone else wanting to make benefits or harms sound as big as possible. On its own, a relative risk is actually uninformative: from what to what? is what we need to know. Reducing or increasing a tiny effect remains a tiny change, even if it is by a huge relative margin. In this video, claims based only on relative risks were made for 11 specific conditions, plus death and quality of life.

To support the data, the narrator mentions 1 meta-analysis, 1 definite trial, some cohort studies (at least one of which he refers to as a trial) and a survey. The one meta-analysis was for anxiety. I don’t know which one he means – there were no references – but for the two I identified (1st link here, 2nd here) in the last few years, the Centre for Reviews and Dissemination indicated reservations about the reliability of evidence in both.

Good quality trials at a low risk of bias are short in this area, but once they are done, they often reveal that effects are only modest. That’s not surprising, given what a confounder exercise is. Are very active people less depressed and ill because they exercise – or are people who are on top of the world just more likely to be getting out and about more too?

Don’t get me wrong: I’m not saying there are no proven benefits of exercise. Of course there are. But for most health outcomes, rigorous systematic reviews have conclusions like: “no strong evidence to support or refute” or “some modest short-term benefits but no evidence for long-term health effects”. (More systematic reviews here)

Figures can be beguiling, as Twain says. But when data are biased and then framed in biased ways that magnify effects, they deny people wisdom and the opportunity to make well-informed choices among options presented on a level playing field. Buttressing claims with biased (and thus likely-to-be-refuted) data might also contribute to a lack of trust in science and statistics.

The issue of bias is a matter of serious import and principle. We need to be rigorous about all health claims – even (and perhaps most especially) for those we want to believe most earnestly to be true.

***********************************************************

Hilda Bastian‘s involvement in health began with consumer advocacy in Australia. She has been working in the fields of communicating about and assessing effectiveness since the late 1980s.

Mike Evans circulated this to his hockey team of kids early in December 2011.  #1 educational video on YouTube. Remember that low fitness (<30 mins of physical activity daily) kills more Americans that smoking, diabetes, and obesity combined (smokadiabesity).

Click on this link. Watch it, share it. Do it yourself.

Encourage patients to watch it and start today! Great ‘sticky’ message capturing Steve Blair’s evidence that this treatment will save more American’s lives than a cure for smoking, diabetes and obesity put together. That’s a fact!

It passed 2 million views in February, 2012. Wow!!

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!

Reporting from UKsem 2011 – the largest Sports and Exercise Medicine and performance Conference in Europe. London’s Excel conference centre 23rd November – no downtime for the BJSM blog!

Richard Frobell opened with 3 major revelations. #1. ACL injuries are associated with arthritis – whether you have a reconstruction or not.  (citation classic, 103 citations to date).

#2. Give a piece of rehabilitation a chance! Not everyone needs a knee reconstruction. Really? New England Journal of Medicine RCTs demonstrating that = 1; disputing it = 0. (See Frobell, 2010, 53 citations already), THE hot topic of 2010/2011 and great to have Dr Frobell here himself. Audience experts included the IOC’s Lars Engebretsen so discussion was energetic. They were seen breakfasting together later so no risk of Scandinavian Spring just yet.

#3. There is limited return to sporting activity after ACL rupture. With or without surgery. This is where I was about to slash up. Depressing keynote stuff. Who chose him?

But then the good news. Prevention is key and possible. There are success stories. More of that tomorrow’s program. Sessions on prevention of football and tennis injuries, of knee and groin debacles. Hope springs eternal, no need to jump into the boxing ring that is available here for conference attendees. No need to walk up to the fencers, brandishing only the complimentary Prograin Minitub from maximuscle and say in true Homer Simpson fashion, ‘give it your best shot pal, I don’t need that poncy white protective gear, go on, try me!’.

Seriously though, I am a Frobell fan as BJSM readers and podcast listeners know. Great clinical insights, great presentation. Privilege to be in the shop at the same time as the KneeMaster.

Great day planned for Thursday 24th and BJSM Blog will be there. Blair, Dvorak, Daniel Coyle from the Talent Code, Bahr, Franklin-Miller. Track us on @BJSM_BMJ and you’ll be first with the updates. And competitions are in the wings!

Say hi to journal manager Claire Jura at the BJSM booth (ground floor, right side) and sign up for free stuff.

And do your ACL prevention exercises daily!

Teaser video – Richard Frobell kindly agreed to do a 20-second spot for the podcast of a conversation on ACL management he had with Lars Engebretsen. The discussion will be hosted on the BJSM podcasts – which are getting 4000 listens per month!