By Ann Gates

(@exerciseworks)

Giving regular exercise advice and support as part of every health care consultation is fast becoming a critical health intervention in the prevention of the ‘tsunami’ of lifestyle diseases such as obesity, diabetes and related cancers. In May 2012 the U.S. Centre for Disease Control together with the Institute of Medicine released a national report detailing recommendations to combat the ‘Weight of the Nation’. The data predicted 42 percent (or 32 million more people) of the American population would be obese by 2030, while 11 percent would be severely obese. The economic costs for the associated health care services: $550 billion. This is an unsustainable cost for most health care systems and countries. This burden of lifestyle diseases and suffering is an unacceptable outcome for 21^st  century medicine.

The ‘Weight of the Nation 2012’ report summarised the key actions as:

1. Integrating physical activity into people’s daily lives
2. Making healthy food and beverage options available everywhere
3. Transforming marketing and messages about nutrition and physical activity
4. Making schools a gateway to healthy weights
5. Galvanizing employers and health care professionals to support healthy lifestyles

Several ‘best practice’ initiatives covering both healthier diets and integrating physical activity are identified. The authors report that physical activity should be a ‘routine and integral part of daily life’.

This provides the ‘call to action’  for health professionals to lead on giving exercise advice and support to patients, relatives and caregivers on why regular exercise helps prevent and treat many lifestyle diseases or ‘non communicable diseases’ (#NCDs). 36 million people, around the world, die from lifestyle diseases each year. They are names and faces in every doctor’s waiting room, every hospital outpatient clinic and everybody’s family. This is a global health issue that needs urgent health professional intervention by every health professional around the world.

Giving physical activity advice to everyone is not as easy as it seems. We know that when doctors give exercise advice to patients that they are more likely to follow that advice (read more here).  We also know that brief intervention during doctor –patient consultations is cost effective.

Exercise advice to patients should include warm up, exercise plan and cool down instructions on how to exercise effectively and safely. A weekly, balanced exercise programme for patients with chronic diseases should include cardiovascular, strength, flexibility and balance exercises. Different diseases often respond better to different types of exercises and physical activities. For example, Nordic walking or ballet has been shown to help improve the symptoms of patients with Parkinson’s disease.

Patients deserve the choice to choose how to incorporate ‘exercise as a medicine’ into their daily lives and in the prevention and management of long term diseases. Health care professionals can use tools like the American Cancer Society’s ‘Make Time-Break Time’ infographic to help patients understand the risks of inactivity and sedentary behaviour to their health during the day. This helps patients to ‘choose’ to increase their activity levels as part of the clinical management of their health condition.

The more health professionals consult with their patients on the benefits of regular exercise and more patients start to realise the benefits to their health, the more likely health care organisations around the world can start to address the obesity and non communicable diseases epidemic in a sustainable way.

This is a call to action to change our clinical practice and implement the concept of exercise as a medicine in the prevention and treatment of chronic diseases. Exercise advice and support should be part of EVERY consultation.

It is also time for sports and exercise professionals, health care professionals and patients to work together to help improve both the weight and health of nations all around the world.

Follow this link to see ‘part 1′ of this blog. It has 292 tweets to date – a BJSM record! Thanks everyone for promoting physical activity.

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Ann Gates BPharm(Hons)  MRPharmS

Personal Trainer, Chronic Disease Exercise Specialist, BACPR Exercise Instructor.

Founder of Exercise Works!

www.exercise-works.org

@exerciseworks

email: ann@exercise-works.org

By Helen Millson (M.Phil.Sports Physio UCT)

Well-known FIFA sports physio Mario Bizzini called groin pain “The Bermuda Triangle of Sports Medicine?” (1) with good reason! There is little consensus on groin pain management. The key is the Correct Diagnosis – Easier said than done! This blog introduces key issues for more junior sports clinicians.

What is Groin Pain?

Undergraduate training often fails to emphasise the two joints in the pelvis –   the hip joint and also the pubic symphysis are at the centre of many movements. (2)  As a clinician, try to assess how the patient’s functional movement influences both the hip and the pubic symphysis. What causes pain and where?  Try to understand the entire kinetic chain with its related function to the pelvis / groin / hip. Then perform relevant clinical tests as well as sports-specific functional tests.

The cause of groin pain is a ‘million dollar question’…….

The diagnosis is mostly by exclusion not inclusion. Osteitis Pubis (OP) diagnosis is no longer an accepted term. This may be a normal response to overload and may lead to bone stress reaction, and then possibly joint and disc degeneration. Increased signal of bone marrow oedema may be a precursor to the development of groin pain. It may or may not correlate with clinical symptoms. (3) As a clinician, consider prevention and reducing load when there are early groin pain symptoms or radiological changes (MRI) of excess load.

And what of the Adductor muscles? (4)

In soccer players with groin pathology, adductor dysfunction is a more frequent MRI finding than “osteitis pubis”. Both entities are mechanically related and frequently coexist.

Specific strengthening of all Adductor muscles is one of the main goals for preventing and managing groin / hip pathologies.

However, one must not be single minded and should take into account other structures including Ligamentum Teres tears (5), Ilio Psoas (6), Greater Trochanter (7), Rectus Abdominus (8), Pelvic floor muscles (9) and Gluteus muscle function (10).

Then consider Radiologists with their preferred way of imaging.

Although radiological investigations are important, most studies tend to agree that experienced clinical judgment remains a critical element in the diagnostic pathway. (11)

A few groin / hip tests have been well documented and are valuable for diagnosis. (12)

What about the treatment options?

There is consensus in the literature that non- surgical treatment should always be applied before surgery is considered. However, the time span differs in the studies.

The rehabilitation protocols show gradual progression based on objective functional and clinical markers over a reasonable time frame.

In my experience, it is of value to always have pre-season specific baseline tests (Musculo-Skeletal evaluation).

The rehabilitation can take anything from 3 – 12 weeks depending on the actual diagnosis e.g. if it is an overload problem, one would “actively rest” the athlete until they are able to fully function symptom free in their respective sport.

One should address the local strength first, followed by functional strength with the entire global perspective taken into account.

Reassessment criteria to judge progress and assess next level of activity with objective markers are essential in order to increase the rehabilitation appropriately.

Of course, at an elite sports level, one is mostly not given this time-frame to do conservative rehabilitation!

Post-operative rehabilitation programmes varies from 10 days – 12 weeks.

This depends on the type of surgery, the specific demands  and………the very different requirements of the Surgeon involved!

And surgery:

•   No consensus as to an ideal operating technique

•   Serial patient outcome measurements are needed to base intervention success on factors other than return to sports activity.

• Operate on asymptomatic side, as it has been suggested that 40% progress to bilateral?

There is also on-going controversy regarding the prevalence of a True Hernia, with many different surgical implications. (13)

Then on to the discussion regarding hips…….

The prevalence of radiographic hip abnormalities in elite soccer players is considerable. (15)

One must identify the relationship between these radiographic abnormalities and the clinically symptomatic pathologies.

A battery of tests should be utilised to improve the accuracy of the clinical reasoning.

Hip joint restriction often precedes the development of chronic groin injury and may be a risk factor for this condition.

One must also remember that the Acetabular Labrum and Ilio-Femoral Ligament are vital for normal hip mechanics and excessive removal of either in surgery can be detrimental.  (16)

As our understanding of FAI and chondral injuries and their causes grows, future efforts will focus on prevention.

Future research is required to determine the extent to which physio intervention aimed at improving hip kinematics would be effective in treating individuals with labral injuries

CONCLUSION

•   The challenge lies between ascertaining the Anatomical diagnosis vs. Pathological diagnosis vs. Functional diagnosis – the interaction of the three will influence prognosis and management, whereas identification of one alone will give a bias in one direction.

SOLUTION?

•     In spite of minimal EBM, it seems the most pertinent point is that many of the groin /hip pathologies can be averted by thorough and specific pre-habilitation, bearing in mind the entire kinetic chain and addressing total function around the pelvis above and below.

References

1)    Bizzini M. “Warm: Up the Bermuda Triangle of Sports Medicine?” in BJSM 2011.

2) William Meyer, FA Conference London Dec 2011

3)  Paajanen H. 2009. “Sports hernia” and osteitis pubis in an athlete. Duodecim. 125(3):261-6.

4)  Wiktorsson-Möller, Oberg , Ekstrand , Gillquist,1983. AJSM; Lynch SA, Renström PA.1999. Sports Med; Orchard et al., 2005. Clin J Sport Med; Cunningham et al. 2007; Phillipon 2009; Lloyd 2009; Thorborg 200; Crow 2010; Gilmore 2011; Davis et al, 2011; Connell 2011; Schilders 2012 and many others.

5)  Botser IB, Martin DE, Stout CE, Domb BG. 2011. Tears of the ligamentum teres: prevalence in hip arthroscopy using 2 classification systems. Am J Sports Med. Jul;39 Suppl:117S-25S.

6)   Hölmich P. 2007. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. BJSM. Apr;41(4):247-52; discussion 252. Epub 2007 Jan 29.

7)  Steinbrueck A, Hocke S, Heimkes B. 2011.Apophyseolysis of the greater trochanter through excessive sports: a case report. Am J Sports Med. Jan;39(1):195-8.

8)  Connell D, Ali K, Javid M, Bell P, Batt M, Kemp S. 2006. Sonography and MRI of rectus abdominis muscle strain in elite tennis players. Roentgenol. AJR Am J. Dec;187(6):1457-61.

9)  Ruth C. Lovegrove Jones, Qiyu Peng, Maria Stokes, Victor F. Humphrey, Christopher Payne, Christos E. Constantinou. Mechanisms of pelvic floor muscle function and the effect on the urethra during a cough. Eur Urol 2010;57:1101-10.

10)  Graham RB, Costigan PA, Sadler EM, Stevenson JM. 2011. Local dynamic stability of the lifting kinematic chain. Gait Posture. Oct;34(4):561-3; Philippon MJ, Decker MJ, Giphart JE, et al.2011. Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis: an in vivo electromyography study. Am J Sports Med. Aug;39(8):1777-85. Epub 2011 May 12.

11) Garvey JF. 2011. Computed tomography scan diagnosis of occult groin hernia. Hernia. 2011 Dec 14.

12)  Delahunt  et al. Man Ther. 2011; Anthony Hogan, FA Conference London 2008; Pers Holmlich, BJSM 2004, BJSM 2007; Mallarias, Hogan et al BJSM 2009; James Moore Rehabilitation Chapter in Prof Haddad Book -  “The Young Adult Hip in Sport”. To be published 2012.

13)  Connell DG…. Patient care – crunch time. Br J Gen Pract. 2009

14) Gerhardt et al, AJSM 2011

15) Myers AJSM 2011

By  Drs. Zachary J. Schlader &  Toby Mündel 

In response to:  Barwood MJ, Corbett J, White D, et al. Early change in thermal perception is not a driver of anticipatory exercise pacing in the heat. Br J Sports Med 2011

Dear Editor,

We read with great interest the study by Barwood and colleagues published recently within BJSM  [1].  In this study, the authors aimed to explore the relationships between body temperature(s), thermal perception, and the voluntary control of exercise intensity in the heat.  For this they should be commended for although this area is quite topical, our understanding of these relationships remains virtually unknown.  By chemically activating peripheral cold thermo-sensors with menthol, Barwood et al. [1] have demonstrated that improvements in thermal comfort and reductions in sensations of warmth, independent of changes in skin temperature, both prior to, and during, the initial stages of self-paced exercise in the heat did not influence the selection of exercise intensity.  Although the conclusions drawn appear appropriate, we would like to further discuss their results in the context of others to explore this topic and perhaps allow a better understanding of our current base of knowledge.

As part of the rationale for conducting their study, Barwood et al. [1] state “It is presently unknown whether altered pacing strategy is regulated as part of behavioral thermoregulation driven by a conscious awareness of thermal state or if a central and subconscious homeostatic mechanism is activated when skin temperature rises above a threshold rate”. Furthermore, Barwood et al. [1] conclude that “This study addresses an as-yet unanswered question of whether the fatiguing mechanisms during exercise in the heat are primarily consciously or subconsciously mediated”.  Firstly, we would like to draw the authors’ attention to our recent work testing the hypothesis that voluntary reductions in exercise intensity in the heat are thermoregulatory behaviors [2].  Our results demonstrated that the observed reductions in power output during exercise in ~40°C compared to ~20°C were, at least in part, due to a conscious action that was inversely related to total heat body storage and thermal discomfort, and improved heat exchange [2].  Secondly, it is unfortunate that it was not possible to discuss two of our recent studies demonstrating that skin temperature and/or the perceptions of this temperature play a large role in the initial selection of [3] or sustained decrease in [4] exercise intensity.  Perhaps in “addressing [only] two current viewpoints on how exercise pacing is driven in hot conditions” Barwood et al. have unintentionally overlooked this recent evidence?

This notwithstanding, the results put forward by Barwood and colleagues [1] appear to be in stark contrast to those we obtained utilizing a similar methodology whereby menthol and skin cooling was used to independently alter thermal perception and skin temperature during exercise at a fixed rating of perceived exertion (RPE) [5]. These results showed that an improved thermal comfort and reduced sensations of warmth with menthol enhanced the capacity to maintain exercise intensity.  Thus, we concluded that thermal perception is a capable modulator of exercise intensity independent of any change in skin temperature [5]; so why, then, such opposing views?

As supported by Barwood et al. [1], it is becoming increasingly clear that RPE is perhaps the most dependable criterion dictating the voluntary selection of exercise intensity [6].  In such circumstances, it appears as though, independent of perturbation (e.g. hypoxia, heating, cooling etc.), the exerciser compares how they feel to how they expect themselves to feel at that moment in time and adjust their exercise intensity accordingly [6].  Thus, although the RPE response during self-paced exercise appears to be tightly controlled, the effect of a given perturbation is found in changes in the selection of exercise intensity (or pacing strategy).  Therefore, the sole manner in which pacing strategy can be altered is if the perturbation is large enough in magnitude to alter RPE.  Herein lies the difference between our studies.  It is unlikely that the cooling modalities (either skin cooling or menthol) utilized by Barwood et al. [1] were sufficiently sustained or large enough in magnitude to alter RPE.  In contrast, by utilizing a significantly different experimental design to address the same question, we were successful in altering RPE.

The reason for this is likely four-fold, but certainly other rationale cannot be discounted.  Firstly, in contrast to the entire skin surface we chose to manipulate the skin of the face, an area that is both of high thermal sensitivity during heat stress [7] and an area that has been directly demonstrated to modulate exercise duration [8].   Secondarily, we used a greater concentration of menthol (8% vs. 0.05%) which, together with the facial manipulation, likely elicited a larger change in thermal perception.  Thirdly, we chose to use fit but untrained subjects, as trained individuals have an altered perception of their physiological thermal strain during exercise [9].   Thus, our subjects were likely more sensitive to changes in thermal perception.  The fourth, and perhaps final reason for the observed differences between these two studies likely stems from the exercise protocols used, i.e. fixed-RPE vs. time trial.  For instance, anecdotal observations from our laboratory suggest that the fixed-RPE protocol may be more sensitive to a given thermal stimulus than a time trial; although to our knowledge there is no formal data suggesting this arrangement.  Other rationale that should probably also be considered include the heat stress compensability and modality, exercise duration, and suitable subject blinding to the experimental conditions, amongst others.

In conclusion, we would like to commend Barwood and colleagues for their study and the data it adds to the literature.  However, we would urge caution before readers draw conclusions based on this study alone.  As it currently stands, the relationships between temperature, thermal perception, and exercise intensity remain uncertain and further research is required before conclusions can and should be drawn.  The differences between our study [5] and that of Barwood et al. [1] further highlight that the choice of experimental methodology may greatly influence a study’s outcome(s).  Issues pertaining to methodology are not specific to perception and exercise.  For instance, this journal recently highlighted another (equally debated) area, i.e. exercise and fluid replacement, which suffers from similar methodological concerns [10, 11].  Nevertheless, these studies [1, 5] endorse (and encourage) the use of menthol and other chemicals capable of affecting thermal perception without changing skin temperature in providing a useful paradigm to study the interactions between thermal perception and the voluntary control of exercise intensity.  Finally, as is the case with nearly all areas of research, we would encourage further studies in this area to ensure a better understanding and therefore, perhaps, a resolution to this interesting and topical area.

REFERENCES

1.         Barwood MJ, Corbett J, White D, et al. Early change in thermal perception is not a driver of anticipatory exercise pacing in the heat. Br J Sports Med 2011.

2.         Schlader ZJ, Stannard SR, Mundel T. Evidence for thermoregulatory behavior during self-paced exercise in the heat. J Therm Biol 2011;36:390-6.

3.         Schlader ZJ, Simmons SE, Stannard SR, et al. Skin temperature as a thermal controller of exercise intensity. Eur J Appl Physiol 2011;11:1631-9.

4.         Schlader ZJ, Stannard SR, Mundel T. Is peak oxygen uptake a determinant of moderate-duration self-paced exercise performance in the heat? Appl Physiol Nutr Metab 2011;36:863-72.

5.         Schlader ZJ, Simmons SE, Stannard SR, et al. The independent roles of temperature and thermal perception in the control of human thermoregulatory behavior. Physiol Behav 2011;103:217-24.

6.         Schlader ZJ, Stannard SR, Mundel T. Human thermoregulatory behavior during rest and exercise – a prospective review. Physiol Behav 2010;99:269-75.

7.         Cotter JD, Taylor NA. The distribution of cutaneous sudomotor and alliesthesial thermosensitivity in mildly heat-stressed humans: an open-loop approach. J Physiol 2005;565:335-45.

8.         Ansley L, Marvin G, Sharma A, et al. The effects of head cooling on endurance and neuroendocrine reponses to exericse in warm conditions. Physiol Res 2008;57:863-72.

9.         Tikuisis P, McLellan TM, Selkirk G. Perceptual versus physiological heat strain during exercise-heat stress. Med Sci Sports Exerc 2002;34:1454-61.

10.       Mundel T. To drink or not to drink? Explaining “contradictory findings” in fluid replacement and exercise performance: evidence from a more valid model for real-life competition. Br J Sports Med 2011;45:2.

11.       Goulet ED. Effect of exercise-induced dehydration on time-trial exercise performance: a meta-analysis. Br J Sports Med 2011;45:1149-56.

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Zachary J. Schlader, PhD, Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA

 Toby Mündel, PhD, School of Sport and Exercise, Massey University, Palmerston North, New Zealand

Guest blog by Prof @EvertVerhagen

It is well known that ankle sprains are the most common sports and physical activity (PA) related injury. It has also been clearly documented that athletes who experience an ankle sprain have a higher risk of re-injury within 1 to 2 years post-injury. This increased injury risk after an initial ankle sprain is generally thought to be caused by a proprioceptive impairment in the ankle due to trauma to mechanoreceptors of the ankle ligaments after an ankle sprain. Partly based on this rationale, neuromuscular training (NT) is widely used for rehabilitation after an ankle sprain, and is thought to improve proprioception by re-establishing and strengthening the protective reflexes of the ankle. However, despite a vast number of studies pointing towards the preventive effectiveness of NT, use of NT in practice does not seem to pick up. This leaves a high rate of ankle sprain recurrences that potentially can be prevented.

Consider the research cycle as postulated by Tugwell et al. [1] (Figure 1). In general this cycle states that effective prevention of injuries is the result from a sequence of seven translational steps, ranging in content form fundamental to practical. The first step is identifying the burden of disease and the seventh is evaluating a program that provides, by implementation, health benefits in the real world. If one substitutes ‘disease’ with ‘ankle sprains’, gaps arise in this translational research cycle. With regards to ankle sprains and NT there is an abundance of knowledge of step 1 (burden of disease) [e.g. 2-4] and  a vast knowledge base on steps 4 (effectiveness) and 5 (cost-effectiveness) [5]. However, etiological (causation) and efficacy evidence is lagging behind, and implementation knowledge and program evaluation is completely lacking.

Figure 1 The research cycle of Tugwell et al.[17] In this model, there are seven distinct steps. The first is identifying the burden of disease and the seventh is evaluating the implementation of a program that provides health benefits in the real world (e.g. a prevention program for ankle sprains).

In my opinion, to push preventive in practice forward we require a more integrated and translational approach to bridge the gaps between on the one side effective preventive measures and the underlying working mechanisms, and on the other side between effective preventive measures and true injury prevention in every day practice (Figure 2). We need to take one step backwards in order to jump forward.

Recently we finished the 2BFit study, a RCT on the effectiveness of an 8 week unsupervised NT program for the prevention of recurrent ankle sprains [6,7]. This particular program was a further elaboration from a previous study we conducted [8,9]. In two studies this neuromuscular training program has now been proven (cost)effective for the prevention of ankle sprain recurrences. I dare to state that based on available evidence we now have an epidemiologically sound effective preventive NT program that can be used to unravel preventive pathways as well as effective prevention in practice.

Figure 2 A schematic description of the proposed translational approach with a (cost) effective preventive measure as the starting point of fundamental and implementation goals.

Therefore, in a laboratory setting we can specifically study changes induced by the program in recently injured athletes, as compared to healthy athletes. This will provide information on which etiological factors are positively affected, which specific exercises of the program induce this effect, and the required frequency and duration of exercises for the NT program to be effective. The latter is required as the current effective NT program is a container of different exercises targeting strength, proprioception and agility in an 8 week program prescribing 3 exercise sets per week. Not surprisingly full compliance to prescribed program was low, even in controlled studies. Through this approach, fundamental knowledge will provide guidance to specify the NT program to it’s bare essentials and decrease user-burden while retaining full effectiveness. This will give us an effective and useable intervention message to be implemented.

References

1. Tugwell P, Bennett KJ, Sackett DL et al. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis 1985;38:339–51.
2. J Hootman, R Dick, J Agel Epidemiology of Collegiate Injuries for 15 Sports: Summary and Recommendations for Injury Prevention J Athl Tr 2007;42(2):311–319.
3. Le Gall F, Carling C, Reilly T. Injuries in young elite female soccer players: an 8-season prospective study. Am J Sports Med 2008;36(2):276-84.
4. William GF, Yard EE, Dawn C. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emer Med 2007;14(7): 641-5.
5. Verhagen E, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082–1088.
6. Hupperets M, Verhagen E, Van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 2009;339:b2684.
7. Hupperets M, Verhagen E, Heymans M, et al. Potential savings of a program to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial. Am J Sports Med 2010;38(11):2194–2200.
8. Verhagen EALM, Van Tulder M, Van der Beek AJ, et al. An Economical Evaluation of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains in Volleyball. Br J Sports Med 2005:39(2);111-115.
9. EALM Verhagen, AJ van der Beek, JWR Twisk, LM Bouter, R Bahr, W van Mechelen. The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains. Am J Sports Med 2004:32;1385-1393.

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Evert Verhagen is an Assistant Professor at the EMGO Institute for Health and Care Research at the VU University Medical Center, Amsterdam, the Netherlands.  You can follow him on Twitter @EvertVerhagen

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

By Dr Ciaran Cosgrave

To gain more experience at providing medical cover at mass-participation endurance events I volunteered my services at a local marathon. It was the first time that the city had hosted a marathon in over a decade so there was a lot of excitement surrounding the event. A local volunteer organisation had been afforded the responsibility of providing medical cover for the marathon. However their task was made difficult by the fact that some vital information was only provided at the last minute (route, participant numbers etc.). Three days before the race was due to be run the organisation providing medical cover were seriously considering pulling out of the event because of poor communication from the event organisers and a safety concern for the runners.

Despite this, the marathon went ahead as planned. When I arrived on the morning of the event it quickly became clear that we were seriously under prepared to deal with many of the potential illnesses and conditions encountered in such a race. There were approximately 10,000 entrants and only 3 doctors (a second year doctor, an orthopaedic surgeon and myself). Neither of my colleagues had any experience of working at endurance events. We had ample first aid staff, ambulances and paramedics, however we were lacking some essential equipment; we had dozens of intravenous fluid giving-sets but no fluids or cannulae. I was laughed at when I enquired about the rectal thermometers (luckily I’d brought my own), and when I asked where the ice was they thought I wanted it for my drink. At the finish line there was only an 8-bed ‘field hospital’.

At this point I seriously considered going home. What had I let myself in for? It was ironic that I had actually volunteered for this role. I had genuine concerns for the safety of the runners and doubted that we would be able to cope with the demand of expected injuries and illness.

Luckily we had a couple of hours before the race commenced. We borrowed whatever additional equipment we needed from the local hospital and erected an additional 20-bed marquee at the finish line.  This was allocated for ‘minors’, leaving the 8-bed unit for ‘majors’. I gave a brief teaching session to all available volunteers about the types of conditions that may be encountered and how these should be managed. Finally, we put a system in place whereby all runners needing medical attention would be triaged at the first point of contact to either ‘majors’ or ‘minors’.  Anyone sent to ‘majors’ would have a set of observations done on arrival, with any ‘red-flags’ being brought to the attention of a doctor.

Thankfully we made it through the race without any fatalities. Both the 8-bed and 20-bed units were full for 3-6 hours after the start of the race. We encountered severe hyperthermia, hypoglycaemia, hypothermia and acute asthma, as well as the usual cramps, injuries and exhaustion.

In hind-sight I think we did an excellent job on the day. Everyone in the team worked extremely hard all day and I do believe a serious incident was avoided as a result. It was also a learning experience for myself; I will never again presume an organisation is prepared to deal with the job they have signed up to, and I will always endeavour to make contact with the CMO of any such event in advance to establish that everything that needs to be in place is in place.

 Related Blogs

2012 Olympic test events: encouraging medical preparedness and camaraderie – Guest blog by Dr Kate Hutchings

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)

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Dr Ciaran Cosgrave is a Specialist Registrar in Sport and Exercise Medicine.

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

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 @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Compared to many other health issues, it seems that it is not hard to get media stories about sports injury into our daily newspapers.  What seems to be hard, is the coupling of such stories with positive injury prevention messages.

An interesting paper in the February 2012 18(1) issue of Injury Prevention reports an analysis of US new stories and their use of the phrase “freak accident” in the reporting of injury events. The Editor’s Choice paper by Smith et al identified 250 human injury stories over a 5-year period that used this phrase. The vast majority of stories (61%) related to injuries sustained by professional athletes and these mainly focussed on the nature or impact/outcome of the injury. Only 9% of the professional athlete injury news stories contained any clear prevention content.

This study is consistent with the findings from an Honours student project I supervised in 2009 (Sarah Hester, University of Ballarat).  We undertook a daily hand check of three Victorian (Australian) newspapers and identified 3215 media stories mentioning injury or injury-death and recorded the context in which those injuries occurred.  We also found the majority of stories to relate to injuries in sport (64% of the total) and hardly any of these mentioned injury prevention at all (<1%) (unpublished data).

There is ample anecdotal evidence that many people believe sports injuries to be an inevitable consequence of participation in sport.  It is not surprising that this view is common if the popular media fails to mention prevention, either directly or indirectly, in their stories.  The term “freak accident” just reinforces any belief that injuries in sport cannot be prevented and further implies that they are the result of just bad luck.  Public health orientated injury experts have long argued against the use of the term “accidents” because of the connotations of this word, and its use has been banned in BMJ journals since 2001.  Readers of the British Journal of Sports Medicine (BJSM) also well know that sports injuries in result from a combination of factors, and are certainly not freak events with no aspect of predictability or preventability.

Perhaps it is time for sports injury prevention researchers and sports medicine practitioners to actively work towards also have the word “accident” banned from all popular media coverage of sports injuries in both professional and recreational athletes. 

As long as major attitudinal barriers to sports injury prevention such as “there is nothing I can do to reduce my risk of injury in sport” and “of course everyone who plays sports get injured” prevail, all of our broad-based population efforts to implement injury prevention programs will largely fail.  Rather than just talking about the impact of injuries in terms of a need for ongoing medical treatment and time away from sport, we should also be routinely providing journalists and the media with simple messages about how the same sorts of injuries could be prevented in the future. What a better situation it would be for a future media analysis to find a strong reporting theme relating to guaranteeing lifelong participation in sport precisely because injury prevention is inevitable.

Success stories:

The AMSSM Annual Meeting (April 21, 2012) opens with a keynote session on Injury Prevention. It includes international sports injury prevention stars including Roald Bahr (Norway), Per Holmich (Denmark), Mark Saffron (US) and Martin Schwellnus (SA)

BJSM publishes 4 Sports Injury Prevention Themed issues annually. These are called the ‘IPHP’ issue of BJSM – Injury Prevention and Health Protection. You can find the archive of IPHP issues here

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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 @JosephLightfoot

The State Of Our Health

Britain is facing a health crisis and the statistics paint a bleak picture for the future.

Why Is This Happening?

Humans are evolved to be highly active and to consume natural, unrefined food. However, our lifestyles have changed radically. As a population, we are now largely sedentary and consume more refined food. Our lives are out of step with our genetic heritage resulting in obesity and chronic disease.

Healthcare professionals do an incredible job in challenging conditions. However, our training lacks emphasis on how to use lifestyle advice to empower people to live healthy lives.

My Personal Experience

If I had to sum up my time at medical school in one sentence, I’d do so like this:

I have learnt about disease, but I haven’t learnt about health.

Whilst there are many contributing factors to the current state of our nation’s health, I think the lack of education for healthcare professionals on lifestyle advice is a particularly important area.

The lack of education and training has resulted in many professionals who are unable to effectively help their patients stay healthy, and a healthcare system, which focuses almost entirely on reactive measures and only steps in when patients are already ill.

I don’t think this is good enough.

The Future

My vision for healthcare can be summed up by this fantastic quote from Thomas Edison.

“The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.”

The Move Eat Treat Campaign

In order to achieve this vision, I founded a campaign called Move. Eat. Treat. Along with the rest of the campaign team, I am working to promote the importance of preventative medicine with the aim of eventually developing a healthcare system, which doesn’t wait until patients become ill before it acts, but works to keep the population healthy – a true health service that is proactive rather than reactive.

We believe that the best way to achieve this is to educate healthcare professionals on how to deliver effective lifestyle advice. We hope that this will lead to a sea-change in culture within the healthcare system to one that assertively seeks prevention instead of cure. Then this will be followed by policy and organisational changes to prioritise prevention via promotion of healthy lifestyles.

Lifestyle should be a core theme of healthcare education, alongside other key pillars such as anatomy, physiology, and pathology. This campaign wants to pave the way for updated curriculums and provide education to both undergraduates and current healthcare professionals.

We Need Your Help

However, we need your help. The most successful campaigns have all had significant public backing. The first goal of the Move Eat Treat campaign is to gain 100 000 signatures on our petition.

With support, we have a voice and we can lobby the people and organisations that can bring about the changes in the healthcare and education systems that are so desperately needed.

You can sign that petition HERE .

We hope you’ll also consider sharing the campaign with friends and colleagues via email and social media. The infographics used above which illustrate the problems we face can be freely downloaded HERE.

A Final Word

The Move. Eat. Treat. vision is a lofty one, but with your help we believe we can make a positive change to healthcare philosophy and help keep people healthy.

Move. Eat. Treat isn’t the same old drone from your doctor about losing weight. It’s about creating innovative solutions, tools and guidance to really equip people to be, and more importantly, stay healthy.

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Joseph Lightfoot BSc(Hons) is a final year medical student at the University of Manchester.  He is also currently the strength and conditioning coach to England Under 19 Lacrosse team. Along with the other members of the Move Eat Treat team he is campaigning for a proactive healthcare system.

For more information about the campaign and our goals visit www.moveeattreat.org

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)

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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.

The UK trainee perspective (The BJSM blog features the trainee perspective every two weeks)*

Guest blog by Dr Dee Clark

Over the time I have worked with Rugby Union teams, I have come across a number of methods for players dealing with their own skin “wounds”.  These have ranged from use of safety pins, sewing needles (“sterilised” in a flame or just “off the shelf”) through to complicated use of homemade vacuum devices to draw out pus.  Whilst this has been an educational experience (!), in my role as a team medic, and particularly as an ex nurse, it fills my heart with dread when presented with the aftermath of the self-treated or ignored wound.  What often starts off as a relatively innocuous complaint, can lead to loss of training time, game time and even hospital admission.

Rugby is played on dirty surfaces.  Training facilities can hide potential for infection disaster. The sharing of washing and drying areas and materials as well as the constant comings and goings of those being treated in physio and medical rooms have the potential to wipe out a team.  Despite this, basic hygiene and common sense are often not employed in a strategy aimed at keeping players fit and healthy to play.

In one season we carried out an audit after noticing recurrent skin infections.  It was shown that in the first half of the season 11 players from the squad needed formal treatment (antibiotics/ minor surgical procedures), with 6 losing training days and 3 losing game time.  Further investigation led us to link the rise with a change in training facility where cleanliness had been an issue. After changing this facility, our infection rate decreased dramatically.

What we did to change things!

We reviewed facility cleaning arrangements, talked to the players about general hygiene including towel sharing, reporting of wounds, covering abrasions etc, installed more hand gel dispensers and instigated more stringent cleaning processes for physio and medical rooms.

Staff and players were encouraged to use hand gel and to wash their hands with greater frequency. Players were encouraged to report skin breaks at an early stage and were discouraged from self-treatment.

Sometimes, being swept up in the search for that extra 1% to make us bigger, better, stronger and faster than the others, can cause us to forget the basics.  After all, an ounce of prevention is worth a pound of cure.

 Articles of interest

Hayton MJ, Stevenson HI and Jones CD et al.  (2004) The management of facial injuries in rugby union, Br J Sports Med;38:314-317 

Stacey A and Atkins B (2000) Infectious diseases in rugby players: incidence, treatment and prevention, Sports Med Mar; 29 (3) 211-220

Horgan M and Bergin C,  IRB Policy on Hygiene, Infection control and Prevention of infection

 Goodman R et al (1994), Infectious diseases in competitive sport, JAMA Mar; 271 (11) 862-867

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Dr Dee Clark is a Sport and Exercise Medicine Registrar and GP in the North West.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK Trainee Perspective” which runs every two weeks.