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

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.

 By Dr Stan Baltsezak

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

February, March and April are the months when British Universities & Colleges Sport (BUCS) championships take place. Students from all over the UK compete in numerous contact and non-contact sports.

The Championships and Games provide a unique opportunity for budding SEM doctors to learn the rules of the sports, observe elements of coach-athlete interaction and gain experience looking after different sports as an event doctor. All necessary equipment is provided by BUCS so all you need to bring is your skills and a keen interest in sport.

Being a doctor at the pitch side, pool side or ring side allows you to observe the mechanism of injury and assess the injury minutes after it’s happened. It is somewhat different to when we see patients in emergency departments or trauma clinics.

I was a ring side doctor at the Boxing competition in February 2012. A boxing doctor’s job is very hands on and can be divided into two parts:

1) Providing pre-bout medical examination (that may mean performing around 60 examinations before competition starts); within a limited timeframe you need to assess most of the important organ systems to make sure that the boxer is fit to fight

2) Being at the ring side, ready to respond to any knock out (KO) that may happen during the fight.

Knowledge of Amateur Boxing Association (ABA) rules is crucial during pre-fight medicals e.g. boxers cannot wear soft/hard contact lenses during the fight.  I came across 3 students who were going to box with lenses on. Restrictions limit the competition of boxers whose visual acuity falls below 6/12 in their best eye. The question that had to be answered is: can you convert contact lens prescription into visual acuity?

Knowing rules and regulations is also important during bouts since a doctor can and may need to stop the fight on medical grounds.

All junior docs and medical students who want to experience sports medicine will be welcomed to volunteer and/or shadow other doctors during BUCS competitions. Those who are interested to take part in future events should contact BUCS Chief Medical Officer.

Useful web sites:

1. http://www.bucs.org.uk
2. http://www.abae.co.uk

Dr Stan Baltsezak is a Specialty Registrar in Sport and Exercise Medicine. He works with GB men’s water polo squad, Paralympic Archery, and Manchester City FC reserve and academy teams.

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

Guest Blog by Dr Pria Krishnasamy

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

As I edge closer to the crossroads of my own career, I muse aloud as to where Sport and Exercise Medicine (SEM) is heading?  Is the majority of our workload going to involve musculoskeletal medicine or should the young generation coming through break free from the current mould and realize the vision of Exercise Medicine that the Faculty (FSEM) have fought so hard to promote and to what our specialty owes its existence?  I feel the urge to answer the call of cynics …

It is hard to believe bygone statements like these (in the caption) in current times.  However, I should say that Sir William Arbuthnot Lane started promoting exercise, fruit and vegetables and bran cereal as an answer to bowel problems in 1925, a good 40 years ahead of his time.  We now know that exercise should be undertaken at a sufficient intensity to make one at least moderately breathless.  Those who have gradually built endurance over time can be encouraged to perform vigorous intensity activity.  My mission is to spread the word of exercise and share a way in which SEM will develop.

“My Best Move” is a pilot project to encourage exercise prescription in primary care for long-term conditions.  The project was initiated to help Department of Health (DoH) recommendations to be translated into primary care practice.  General guidance is sometimes just not enough and physical inactivity remains one of the five big risk factors for long-term conditions equal in importance to smoking, obesity and hypertension.  Since its introduction, the project has been greeted with much enthusiasm in the primary care sector and the extra boost and guidance in the form of training is being welcomed.  It is hoped that this will start a new wave in the community that will lead to more active lifestyles despite any chronic conditions that individuals may have, without them feeling hindered by their conditions.

Taking this vision forward, an Exercise Center of Excellence is needed.  A place where both able bodied and persons with disabilities, no matter what long term conditions they have, are able to be seen and given specialist care to enable them to live life to the fullest.  By tailoring individual exercise prescription and rehabilitation according to patients needs, the aim is to enhance quality of life, improve absenteeism and return individuals to work, which will reap significant economic gains.

Everyone needs to start taking ownership of their own health and start making small gains rather than relying on the policymakers, the health service or their doctor.  The gains, after all, are to one’s own health and well-being.

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Dr Pria Krishnasamy is a Sport and Exercise Medicine Registrar in London and enjoys long walks in the countryside, martial arts, playing tennis, and dinners with good friends.

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

Guest blog By Dr Matthew Stride

The UK trainee perspective (A monthly BJSM blog feature)*

The year 2012 represents a pivotal time for the speciality of Sport and Exercise Medicine. Time will tell whether the Olympic and Paralympic Games will leave any significant lasting ‘legacy’ on the health of our nation.¹ However there is no doubt that the subsequent months after the Games will represent the strongest test for the integrity and future of the speciality.

Consultant SEM Physicians were envisaged, when the training program was inaugurated in 2007, to be instrumental in delivering the legacy. Now five years on, if this is going to come to fruition, there has to be a greater shift towards health promotion and a greater acceptance of exercise medicine than there is currently. As it is primarily through this role that SEM consultants are likely to be (and arguably should be) employed in the not too distant future.²

The SEM curriculum has a greater emphasis on the role of regular exercise for health and chronic disease management than in other countries.³ This includes public health training, knowledge and experience of exercise physiology, exercise testing and exercise prescription in health and disease states, in both the primary and secondary care setting. It is this training and expertise in exercise medicine that is unique to the SEM curriculum and separates us from any other speciality. Musculoskeletal medicine and sport injuries are a comparatively smaller part of the curriculum, yet continue to be by far the largest focus of interest and expertise (the ‘traditional’ Sports physician.) There seems to be a marked, noticeable disparity between curriculum content and SEM physicians who currently specialise in exercise medicine. This imbalance may be largely driven by the historical context of the speciality development. However if this continues then deliverance of the post games legacy may not happen and the speciality training program may not last for much longer.

Exercise medicine needs greater emphasis and acceptance if more SEM Consultants are to be employed in the NHS.⁴ Exercise medicine is an integral part of the training and cannot be dismissed. After all, its inclusion helped the speciality to gain recognition and led to the supposed governmental promise that SEM physicians will be trained to ensure the games leaves a lasting legacy on the health of our nation.

References

1. London 2012: Legacy. A Position Paper from the Faculty of Sport and Exercise Medicine. Available at
2. Sport and Exercise Medicine. A Fresh Approach.
3. Cullen M.  Crossroads or threshold? Sport and exercise medicine as a specialty in the UK. Br J Sports Med 2009;43:1083-1084.
4. O’Halloran P, Tzortziou Brown V, Morgan K et al.The role of the sports and exercise medicine physician in the National Health Service: a questionnaire-based survey. Br J Sports Med. 2009;43(14):1143-8.

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Dr Matthew Stride is a Specialist Registrar in Sport and Exercise Medicine. He is now in the final year of the training program in the London Deanery. He is currently based at Homerton University hospital and has been made an honorary research fellow at Imperial College. He is also a football club doctor.

Guest Blog by Dr Kate Jackson

The UK trainee perspective (A monthly BJSM blog feature)*

This morning I was walking through woods on one of those glorious crisp days. I stopped in a patch of sunlight, with my North Face hat pulled down over my ears, and I felt a physical upsurge of pure, simple, unadulterated bliss. And a thought floated in my head… “If I can still do this when I’m 80, I’d be happy.”

Photo courtesy of Florian Seiffert (Flickr CC)

So as we enter 2012, it’s worth pointing out that alongside the London Olympics, the UK is also hosting the World Congress on Active Ageing for the first time and it got me thinking about ‘active ageing’.  What does it mean? How can we help as sport and exercise doctors? What might an active ageing programme look like?

I’m not suggesting for a minute that every person should be instructed to walk in woods (although I’d bet they would enjoy it). The approach needs to avoid being patronising or generic, but instead allow for an individual’s personal circumstances and preference. It needs to encourage inactive people to start fun, low-cost activities that suit them. But it also needs to guide already-active people who develop co-morbidities and give them the confidence to exercise safely despite their illness.  It needs to work in partnership in the community with exercise programmes for older people that already exist. The approach should encourage a lasting change in behaviour and in the long-term should not require high levels of external organisation. So can we do this?

Dr Natasha Jones and Dr Julia Newton will be putting theory into practice this year.  In December, Nuffield Orthopaedic Centre Sport and Exercise Medicine Department won the Oxfordshire Active Ageing Service bid in an exciting collaboration with Age UK.  The service, launching in May, is called ‘Generation Games’.

It will involve an interactive website that will help individuals improve their fitness and health awareness by addressing individual barriers. To help those with chronic disease, there will be a progressive exercise pathway, integrated with current level 1-4 exercise schemes and established specialist rehabilitation schemes. A key piece of work will be the development of pathways for specialist departments not yet providing exercise rehabilitation schemes e.g. diabetes, cancer care, mental health, all of whom would benefit from improved physical activity levels.

The service will be launched through media, online, poster and leaflet-based information systems and promoted through peers, the media, primary care, secondary care, rehabilitation services, community care and Active Ageing partners in the community.

The over-arching ethos of the Generation Games service is self-efficacy and a user-centred approach that has to be the way forward. I wish them every luck in setting up this service, particularly as I may just be needing it in another decade or two…

Related BJSM Publications

J C Davis, M C Robertson, M C Ashe, et. al. 2010. Does a home-based strength and balance programme in people aged ≥80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. BJSM. 44: 80-89. {Short answer is yes! Good evidence to take to your health policy folks to instigate strength and balance training for seniors}. See also Otago Exercise Program (OEP) for detailed instructions on the program. Thanks Prof John Campbell and Clare Robertson for this internationally-adopted program.

X Liu,Y D Miller, N W Burton, and W J Brown. 2010. A preliminary study of the effects of Tai Chi and Qigong medical exercise on indicators of metabolic syndrome, glycaemic control, health-related quality of life, and psychological health in adults with elevated blood glucose. BJSM. 44: 704-709.

Wondering whether it is safe to encourage a senior to be active? See John Campbell’s helpful guide here.

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Dr Kate Jackson is an ST5 Sport and Exercise top-up trainee in the Oxford Deanery. She is interested in good walking, good food and good company

Guest Blog by Dr Sarah Davies

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

“The function of protecting and developing health must rank even above that of restoring it when it is impaired.” Hippocrates

It’s that time of year when the ghosts of Christmas past, present and future are looming, but the present fiscal climate brings little promise to the future legacy of the Olympics that we’re all hoping for, in terms of healthcare benefit.

Musculoskeletal conditions are the most common cause of chronic pain and disability.¹ The prevalence of many of these increases with age and many are affected by lifestyle factors, such as obesity and physical inactivity. Increasing numbers of older people and changes in lifestyle means that the problem is set to spiral out of control in the UK.

Last week, my father turned 71. Having swam all his life, in the last 6 months he has swapped the pool for the gym in order to avoid waterlogging his new hearing aids. He has studied the theory of what, when, where and how much he should be doing in the gym (alongside chats to said SEM daughter) but he is missing the physical awareness of specific muscle groups when carrying it out.

Despite his programme at the gym, my father remains posturally challenged in a computer-hunched sort of a way, attacking the rowing machine with all the vigour of a bull in a china shop.  Suffice to say, I’m somewhat alarmed that it may be only be a matter of time before this over-enthusiasm tears his rotator cuff apart at the seams.

In today’s bleak economic landscape, employers cannot afford to treat illness rather than prevent it. If we want to improve both quality and cost-benefit of health care in this country – if we truly believe that SEM can make a difference – we must use the power of prevention.

We know the leading causes of death in our society – Hypertension, smoking, obesity, and physical inactivity – but what about the causes of preventable musculoskeletal injury and the consequent preventable pain and preventable inactivity?

This week, whilst working with the GB B1 football squad on their training camp, I noted that once a person has learned certain postural habits that are associated with being blind, they are very difficult to shake off. In contrast, if these children develop awareness at an early age, they are able to learn better physical awareness and counteract these habits.

The fact is, learning a new physical skill, especially the more ingrained the old behaviour patterns, requires repeated feedback to instil new habits.²

With SEM doctors at the interface of primary care, we are well placed in the community to identify potential musculoskeletal pathology and advise individuals how to prevent this from occurring.

It is in the prevention of illness that SEM can make a difference to the healthcare economy. SEM has the edge in diagnosing and managing musculoskeletal injuries, but SEM clout also lies in assisting the well to stay well.

Wishing you a Happy Christmas and a Healthy New Year.

References:

1. Woolf AD, Akesson K. Understanding the burden of musculoskeletal conditions. The burden is huge and not reflected in national health priorities. BMJ 2001;322:1079-80.

2. Nilsen P, Bourne M, Verplanken B. Accounting for the role of habit in behavioural strategies for injury prevention. Int J Inj Contr Saf Promot. 2008 Mar;15(1):33-40.

Related Article

Dvořák, J. Give Hippocrates a jersey: promoting health through football/sport. BJSM 2009;43:317-322 Published Online First: 22 March 2009

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Dr Sarah Davies is an ST6 Sport and Exercise Medicine Registrar in the London Deanery, currently on a Rehabilitation and Complex Trauma placement at Headley Court Military Hospital. She also covers disability football for the FA and holds an honorary research fellow post at CXH, where she is looking into causes of pain in patients with hypermobility syndrome.

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

With the countdown to the 2012 Olympic and Paralympic Games, ‘Test Events’ have started to take place throughout the UK. These are an integral and essential part of the preparation for any games — the London Prepares Series is a comprehensive programme that tests each sporting event.

These test events occur periodically throughout the year and have been in place since May 2011, testing the operational aspects of each venue, whilst at the same time promoting the already established venues around the UK and introducing the public to the new Olympic Park.

The London organising committee for the Olympic Games (LOCOG) has designed and implemented procedures for testing the organisation of the field of play, results and scoring systems, and medical and emergency procedures.

As a Sports and Exercise Medicine Registrar, I have worked at a number of different test venues throughout the summer. These events have provided hands-on experience of the medical preparation needed for major sporting events and engendered camaraderie among new colleagues from around the country.

The medical teams include physiotherapists, emergency practitioners, doctors, paramedics and sports masseurs, bringing together specialised skills and drawing upon individual expertise. At each test event, medical volunteers worked in teams and were prepared, with briefings at the start of each day, with protocols regarding acute on-site medical care, transportation of patients, and communication procedures. In keeping with the International Olympic Committee injury surveillance approach (1) medical documentation protocols were reviewed for ease of use by personnel and each team member was allocated medical responsibilities for both major and minor events.

Trauma scenarios were replicated on a daily basis, enabling medical teams to practise emergency response procedures and familiarise themselves with the safe transportation of patients and communication protocols. The additional logistics of trauma management at water venues highlighted situations many of us are unaccustomed to in our normal working environment.

From athletics to cycling, rowing to equestrian, the venues were spectacular; with the crowds supporting the test events, we got a sense of what was to come for 2012. The opportunity for Sports and Exercise doctors to be part of the home Games is a very rare experience and one, as a new specialist in SEM, I am very much looking forward to.

Richard Budgett, the Chief Medical Officer (CMO) for the Games, recorded a podcast for BJSM and this will be on the podcast site (see home page adjacent to Blog) shortly. (Before November 1st with any luck!). (It is currently being edited and approved by the IOC for release).

References

1. Injury surveillance in multi-sport events – the IOC approach, Astrid Junge, Lars Engebretsen, Juan Manuel Alonso, Per Renström, Margo L, Mountjoy, Mark Aubry and Jiri Dvorak. Br. J. Sports Med. published online 7 Apr 2008

2. Mass Participation Event Management for the Team Physician: A consensus Statement, American College Sports Medicine, 2004

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Dr Kate Hutchings is a specialist registrar in Sport and Exercise Medicine and a General Practitioner. Her interests include working in professional ballet and rugby.

The Legion of Super-Heros

Elite athletes are revered for their ability to repetitively perform feats that push the human body to its physical and physiological limits. In the eyes of many they are superhuman. If we consider fictional superheroes many demonstrate the same abilities, albeit exaggerated, that we admire in athletes such as strength, speed and agility. Sports scientists are constantly looking for ways to achieve and maintain peak performance with the latest growing interest being in supplementation of vitamin D.

Vitamin D is a naturally synthesised hormone historically associated with calcium homeostasis, muscle and bone health. Apart from bone disease and muscle weakness, deficiency in vitamin D is associated with an increased risk of developing all cancers[i].

The effect of circulating vitamin D [25(OH)D3] on muscle activity has been demonstrated in several studies. Most recently a positive relationship was shown between 25(OH)D3  levels and jump height, velocity, power as well as fitness levels in adolescent girls [ii]. In a separate study Ardestani et al showed with each standard deviation increase in 25(OH)D3 VO₂ max increased by 2.6ml/kg/min (p=0.0001) for individuals with low levels of physical  activity and 1.6ml/kg/min (p<0.0004) for moderately active people.[iii]

Athletes are susceptible to infections either due to the immuno-suppressed state that accompanies their level of training or the close proximity surrounding team sports. Protective antimicrobial proteins lining epithelial surfaces are directly regulated by Vitamin D and deficiency is associated with increase incidence of infections[iv]. In a large epidemiological study Juzienne and Moan suggest that seasonal nadir in vitamin D levels may be a controlling factor in influenza epidemics.

Rapid recovery following injury is vital for any athlete and 25(OH)D3 levels, through its direct regulation of  insulin-like growth factor (IGF-1), has been shown to increase the healing speed of skeletal muscles[v].

The primary source of Vitamin D is ultraviolet-B rays from sunlight with dietary sources accounting for very little. For anyone living above the 43-degree parallel north sun exposure is only effective at generating vitamin D between the months of April and September. What this means is that irrespective of outdoor training and games players of seasonal sports such as Rugby Union, Football, or NFL, whose season falls outside of these months, may require supplementation. Ultraviolet radiation treatment is not a new concept: in 1938 Russian researchers reported a 7.4% improvement in 100m dash times of collegiate sprinters following UV treatment compared to 1.7% improvement of the control group’s times[vi].

Vitamin D deficiency is a public health issue that goes beyond the boundaries of sports and exercise medicine. By correcting the deficiency Sports Physicians look to give their athletes an advantage over others that would otherwise be affected by seasonal variation. Should health-governing bodies look to address the problem through public health initiatives, such as increased fortification of food products, perhaps this advantage would be negated. Till then I will continue to take my daily supplement and hope to be stronger, faster and aspire to leap large puddles in a single bound.

Ademola Adejuwon

MBBS, MRCS (Eng), Dip SEM (GB & I), BSc (Hons)

Registrar in Sports and Exercise Medicine

London Deanery

Dr James Thing coordinates the UK SEM Registrars Guest Blogs. Dr Thing is a Sport and Exercise Medicine Trainee and General Practitioner in London, England

[ii] Stockton KA et al. Osteoporos Int 2010 Oct 6

[iii] Alderstani et al. Relation of Vitamin D level to maximal oxygen uptake in adults. Am J Car (2011) Apr 15;107(8):1246-9.

[iv] Sabetta JR, DePetrillo P, Cipriani RJ, Smardin J, Burns LA et al (2010) Serum 25-Hydroxyvitamin D and the Incidence of Acute Viral Respiratory Tract Infections in Healthy Adults. PLoS ONE 5(6): e11088. Doi:10.1371/journal.pone.0011088.

[v] Bogazzi et al 2010

[vi] Journal of Physiologiy of the USSR 1938; 25:695-701 (In Russian)

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Related article from BJSM Archives:

Dam, BV. 1978. Vitamins and sport. BJSM ;12:74-79