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Discussion continues for #clarityofmessage: Day 2, 2015 Low Carb High Fat Summit (#LCHF)

20 Feb, 15 | by BJSM

Johann Windt, Liam West (@Liam_West) and Ania Tarazi

The low carbohydrate diet discussion continues: does the LCHF diet fall better under well-researched intervention or ill-advised fad? Today the focus was on various health parameters, including metabolic syndrome, type 2 diabetes, and metabolic syndrome. Check out the Day 2 Storify here!

Dr Eric Westman – #LCHF treatment of obesity & metabolic syndrome

Launching the morning, Dr Westman described the clinical use of #LCHF diets for the treatment and prevention of obesity as well as metabolic syndrome. He presented a number of trials that demonstrated the improved efficacy of #LCHF diets in comparison to low GI diets, Mediterranean diets, and low fat diets. #KeyTheme – a conscious reduction in carbohydrate content would subsequently limit caloric intake (without deliberate restriction), and the various components of metabolic syndrome. Want some extra reading? Try these papers: 1, 2 & 3.

Dr Jay Wortman – The #LCHF diet for obesity, metabolic syndrome & T2DM

Dr Jay Wortman from Canada outlined the significant decline in the health of the aboringinal people following the introduction of western dietary foods, including processed and refined foods. Continuing the trend of many other speakers, Dr Wortman drew on the hormonal model of obesity, its associated metabolic dysregulation, and the role of insulin resistance in fat accumulation. #ModelSummary – Carbs à Insulin à Fat accumulation. His presentation concluded with data showing the most significant reductions in HbA1c levels in response to very low carbohydrate diets. (Westman et al. Nutr. Metab. 2008; Nuttall & Gannon JAN 2007).

Dr Jason Fung – Insulin toxicity & how to treat T2DM

The #LCHF theory still needs work. Dr Jason Fung addressed some “holes” in the hormonal model. Namely, he identified the repeated central cycle of insulin resistance and increased insulin levels – what comes first, the chicken or the egg ? Do high insulin levels cause insulin resistance, or is it that insulin resistance causes the increase in insulin levels. Within this model, he included 3 separate ways to impact the cycle to prevent subsequent weight gain:

  • Lower CHO intake – especially refined sources, which will lower blood insulin levels.
  • Eat #RealFood (with fiber intact) – thereby reducing insulin load of food and lowering blood insulin levels.
  • Restrict fructose intake, as it contributes more powerfully to insulin resistance than glucose.

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Dr Gary Fettke – Disease-causing effects of high carbohydrate diets

Australian orthopaedic surgeon Dr. Gary Fettke expanded his focus from strictly carbohydrate intake, and presented the inflammatory response in the context of high polyunsaturated fat intake, refined carbohydrate, and fructose content. An orthopaedic surgeon with a passion for biochemistry #Solid

Dr Andreas Eenfeldt – Weight control: calories vs insulin theory

Swedish family physician Dr Andreas Eenfeldt addressed weight control in the context of the energy balance theory of obesity and the hormonal theory of obesity. He was pro-hormonal theory as per the theme of the summit but allowed the audience time to debate his opinions #OpenDebateNeeded

Dr Ann Childers – Stone-age, space-age diet: nutrition metabolism & mental health

Moving away from the waistline & heart, Dr Ann Childers presented data linking tooth decay and dental diseases to fermentable carbohydrate intake. In elite athletes, sports drinks heavily laden with sugar can lead to suprisingly rapid, advanced, caries. You can access an expert Consensus on Oral Health and Elite Sport free here.

Dr Robert Cywes – #LCHF, hunger management and limited bariatric surgery in children with morbid obesity

Shifting gears, bariatric surgeon Dr Robert Cywes brought an #addiction approach to the discussion. Take home points included not just the removal or restriction of unhealthy foods, but replacement of those foods with other foods or other rewarding activities. Physicians were encouraged to engage in lifestyle counselling with their patients and to remain sensitive to patients’ barriers. Just as smoking is not a pathology but a driver towards it, Dr. Cywes portrayed obesity in a similar light.

Dr. Jeffry Gerber – The lipid hypothesis, diet heart hypothesis & the 2013 cholesterol guidelines. Addressing treatment & management controversies based on current guidelines

Finally, Dr. Jeffry Gerber discussed the intricacies of cholesterol, HDL, LDL, particle size, and additional advanced testing methods, as well as how different diets impacted various markers. #HomeworkReading #1 & #2

Though bound together by a common thread of carbohydrate restriction there was variation among the speakers. This included their recommendations for specific daily carbohydrate values, fiber intake, and the proportion of the population who should follow a #LCHF diet – points picked up by salient questions from audience members.

The common threads woven throughout include eating #RealFood, #SayNo2RefinedCarbs, and #Don’tFeartheFat. As a number of the speakers remarked, #LCHF diets have proven effective in clinical trials, but there is a need for more research in the field of weight loss, cardiovascular risk, and dietary interventions.

Tweet your questions or comments to @BJSMPlus (BJSM’s in-depth conference Twitter handle) as we update you on the Summit.

A SACRUM TOO FAR – Tiger withdraws from Ryder Cup. What advice would we offer one of the world’s greatest ever golfers? Guest Blog @NicolvanDyk

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, with TW aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray


“If there’s a fork in the road, take it.” Yogi Berra

Tiger Woods has officially withdrawn from the Ryder Cup – a move that makes a lot more sense than his starting the PGA last week. It seems like he is now following sound medical advice. A proper break aimed at full recovery. He is aiming to return in December for the World Challenge tournament, which seems reasonable. But what will happen beyond that. What does his future hold?

That was the question some colleagues asked me at the Aspetar Orthopaedic and Sports Medicine Hospital on Wednesday (prompted by a recent blog from Prof Karim Khan (@BJSM_BMJ). How would I advise perhaps the greatest golfer ever? Can we base it on evidence?

I am sure we can. Sports Medicine Physicians and Physiotherapists make such assessments every day, from elite level athletes to all the rest of us. Here’s a short proposal that may resonate with many Sports Medicine clinicians’ reasoning in this scenario. (And to Mr. Woods, I would hope to think your team is doing the same.)  (And of course I’m keen to learn from those more expert than I).

  1. Correct Diagnosis (correction, hypothesis)

Let’s open the box and look inside. No, unfortunately no rabbit. It is rare for a single diagnosis to capture the full spectrum of what has transpired for an injury to happen. And no doubt, without any knowledge of the specific medical condition or advice Tiger Woods has received to this point, what we need to do first (or at least redo again) is work through some hypotheses, to  make a proper clinical diagnosis.

Unfortunately another MRI scan would most likely not help us (see reference here). Imaging is useful, and there are a couple of things we want to exclude, but what we see must make sense in light of the whole clinical picture. As a suggestion, let’s call it a holistic assessment. We need to look at all the aspects influencing current pain experience, playing performance, and then do a full musculoskeletal examination looking at movement patterns and muscle recruitment, to understand the current condition. It needs to include history, both past and present, classification based cognitive functional therapy (CB-CFT), pain science education, nutrition and conditioning.

Our diagnosis will perhaps not be catchy, or sexy like “sacrum out” or “disc popped”, but it will be as accurate and inclusive as possible, (maybe something like “intervertebral joint dysfunction with movement restriction into flexion”) which will guide us in our treatment and rehabilitation. This sort of thinking allows different information to be taken into account, it creates the opportunity to evolve if needed (conditions change over time) and allow us to adapt whatever treatment we choose to utilize. This is necessary for achieving our goal. And yes, then do need to identify the goal, but hang on, we’ll get to that. We need to have something to test ourselves again, and some objective signs we can measure – other than eyeballing the sacrum.

  1. Correct Treatment and Rehabilitation

Unlike our colleagues in the 70s, 80s and 90s, we do not have to rely on expert opinion anymore. Not that expert opinion is not important, or valuable, but in the context of modern sports medicine, we have a growing body of evidence to support what we do, and why we do it.

And in this scenario, here is the key message – exercise works.

It is a proven therapy that has been found in most cases to trump the quick manipulation, magic tape or the odd bit of dry needling (or a hug). The scientific search here would lead you to mechanotherapy, or mechanotransduction, but let’s not be distracted by the details right now.

Research (see here a great editorial by Prof Peter O’Sullivan (@PeteOSullivanPT) on how we manage back pain) tells us to strengthen and rehabilitate the correct movement patterns (for the individual, no recipe’s needed, thanks) rather than spend hours rubbing lotion on your back, or cracking things into place. Firstly, perhaps most importantly, we need to ensure that you understand and comprehend the condition, the pain and what it means to you as a person. And then, perhaps as important, we need you to move, and move as well as you can. (Note to TW, the writer is a qualified manual therapist). Next, a gradual return-to-play programme where you build up the necessary strength, endurance and loading of the structures in your back so that when you get back, you really are “good to go.”

  1. Finding the TEAM that works towards injury free* peak performance
    (*injury free = minimal risk of injury with maximum benefit from performance parameters)

Sports Medicine requires a team approach. And a good team will help you to integrate the evidence into a quality clinical decision. Of course I am not attempting to take away the complexities of these decisions in any way. But we have certainly come a long way from “the doctor said I shouldn’t play.”

Instead, we need to develop better algorithms to help make these decisions. Dr. Paul Dijkstra (@drpauldijkstra) has captured these difficulties in his open access BJSM article “Managing the health of the elite athlete: a new integrated performance health management and coaching model” highlights the difference when practicing integrated care medicine, and this article develops a health and performance grading system (see Table 3). This kind of system assists not only the Sports Medicine team, but it creates better understanding for the athlete of what all the information means.

Because related to rehabilitation that is (and should be) the main focus now, is performance. And having gone through 4 swing changes with 3 coaches in his career, Mr. Woods is hardly the same player as when he started. So has it backfired? And having the advantage of retrospection, was it worth it? Could these changes have influenced or played a part in the multiple knee injuries (and surgery) and ultimately the back injury leading to surgery this year?

Of course, the other question with any child prodigy who turns professional (and has a long, successful career) is load management. Prof Roald Bahr (@roaldbahr) from Norway suggests in a recent editorial for BJSM that “We now have the evidence to show that extra caution is needed when managing the gifted athlete.” Did we also fail Tiger Woods in this regard? Seeking to make the near perfect player even more perfect, asking too much of his gifted body?
Perhaps, although I am weary of the hindsight trap. We have to assess where we are now, and if we change anything again, it must be an integrated decision that allows ultimate performance with minimizing injury risk. Which brings us to perhaps the most pertinent question:

  1. The Risk-Reward Ratio – Will life after golf still allow playing some golf?

In 2008, aged 32, Tiger Woods had won 14 majors. It seemed likely (in an incredible fantastic way) that he would surpass Jack Nicklaus’ record of 18 majors. In December, when Tiger Wood plans to return, he turns 39. Is there still time? Jack Nicklaus was 46 when he won number 18, and a few other greats (Phil Mickelson, Ernie Els, Gary Player, Ben Hogan) have won majors in their 40s. But will he win another 5, with the rise of the young guns and the trail of injuries behind him? Mr. Woods wants to win majors, of that I am sure. But what will it take to win another four? What would be left? So here we have to ask, is the REWARD worth the RISK?

To really answer that question, we need to know from the athlete what the perceived reward is, versus the perceived risk. REWARD would be to hold the record number of major wins, to be the unchallenged greatest golfer that ever lived (if we classify greatest by number of major wins, although many might view Tiger Woods as the greatest already). REWARD would be to continue competing, and continue being the guy that everyone wants to beat (not sure if that’s true, but Jack Nicklaus still thinks so). REWARD could simply be to keep doing the thing you love to do, at the highest level. Yes, the rewards will be great. If this is indeed how TW sees the REWARD as well. So what then of the RISK?
There is a continuous effort among sports medicine researchers to identify risk factors for athletes, (e.g. IOC Injury Prevention Conference 2014). So when Sports Medicine Clinicians explain risk to an athlete, we try (or at least should attempt) to present all the information, and make the decision with all the components weighted. In this case, we have to consider the RISK of re-injury, of developing persistent pain, and dare I say, the RISK of not being able to continue playing golf at all? Have we even considered presenting out athlete with these scenarios? And more importantly, how we present this information, in a non-threatening and easy digestible way, might be crucial to the outcome

It’s a complex decision. But this needs thought, and all the possibilities considered. And I am not suggesting the answer is simple. Playing golf with the kids on a Saturday afternoon 20 years from now versus surpassing Jack’s record? (Oversimplification, I confess). It needs a sports medical team that is honest and clear, without seeking yes/no scenarios. (I would suggest this podcast by Prof Peter O’Sullivan here. He deals with the temptation to overdiagnose and overtreat brilliantly) And it would likely not be an “either/or” , but a “yes, and” answer that will allow the best outcome for the athlete.

As a sports physiotherapist, I wish Tiger Woods all the best with his rehabilitation and return to play. And I hope that he (and every elite professional athlete) will have the opportunity to make these decisions with the support of a good team and the value of current research and best practice guidelines driving the process.

Nicol van Dyk is a sports physiotherapist with special training in manual therapy. He is writing this in his personal capacity as a physiotherapist.

NvD

 

Australian Open – Hot Tennis. To play or not to play? That is the question!

18 Jan, 14 | by Karim Khan

By tennis physician, Dr Babette Pluim (@DocPluim)

RodLaverThe scorching Australian Open has stirred up debate as to how safe it is to play tennis under extreme conditions. Some claim that it is part of the game, just like wind, rain, and playing late at night and that you just have to deal with it. Prepare, and try to beat the heat!

Others find the conditions to be unacceptable and too dangerous for health, and argue that play should be stopped when drinking bottles start melting on the court surface. Their main concern is that the extreme heat may lead to severe heat illness and possibly even the death of an athlete.

Emotions run high in these heated conditions, so let us try to separate fact and fiction by using available science.

Facts:

A number of studies have investigated the thermoregulatory response of tennis players to heat stress.[1-3] These show that core temperature can be maintained at a safe level across a wide range of environmental conditions and is determined mainly by the intensity of the exercise and the resulting metabolic rate. The cooling mechanisms of the body (sweating and cutaneous vasodilatation) work in optima forma under normal environmental conditions and thermal equilibrium is reached and maintained after approximately 40 minutes of tennis match play.

However, in hot ambient conditions, core body temperature (CBT) is determined not only by the metabolic rate, but also by the environmental heat load.[3] The body’s cooling system has to work hard to reduce excessive heat when both the metabolic rate and environment heat load are high, causing extra strain on the heart. Work by Périard et al, who studied male tennis players during tennis match play in cool (~19°C WBGT, 22ºC) and hot weather (~34°C WBGT, 37ºC), showed  mean CBTs of ~38.7ºC under cool and ~39.4ºC under hot conditions, respectively.[3]  In addition, adverse environmental conditions (e.g. high air temperature, high humidity, solar radiation and no wind) will result in a high skin temperature and increased thermal discomfort (irrespective of the actual CBT).

As thermal discomfort increases, players decrease the pace of the match, which results in a drop in metabolic rate: an excellent example of autoregulation.[1,3] Players will generally take additional measures to cool their bodies and may use fans, ventilators, parasols, ice vests, ice towels, and cold water. BJSM’s ‘Online First’ includes a systematic review on the effect of cooling by Professor Christopher Tyler (UK). Currently the heat rules in tennis allow juniors, women and seniors to have a ten-minute break – and 15 minutes for wheelchair tennis players – between the second and third set to allow some extra time for cooling the body when the WBGT hits 30.1°C. This can reduce the CBT by 0.25°C.[4]

When must play stop?

But is there an air temperature or a WBGT when CBT will continue to rise over 40°C up to 42°C, because the environmental heat load is so high and the metabolic heat production so great that equilibrium cannot be reached? When are tennis players at risk of developing hyperthermia and possibly heat stroke and multi-organ failure? When do we need to stop play?

Cooling is easier in tennis than in some sports. American Football is requires players to wear protective clothing and running requires high intensity continuous work. In those sports, heat illness is more common than in tennis.

However, even the tennis player may be at risk if he/she is ill (cytokines raise the temperature set point), is severely dehydrated (less circulating blood to the skin and less cooling), has an underlying heart condition (increased strain on the heart) or has autonomic dysfunction (high spinal cord injury, less sweating). In these situations, great care must be taken to protect the players from potentially life threatening heat illness or heart problems.

This year’s Australian Open has illustrated that there should be an upper limit above which play should be suspended, even for healthy athletes. This upper limit seems to be around an air temperature of 42°C-43°C or a WBGT of 32°C; if not for the players, at least for the long-suffering spectators!

 References

1. Morante SM, Brotherhood JR. Air temperature and physiological responses during competitive singles tennis. Br J Sports Med 2007;41:773-8.

2. Hornery D, Farrow D, Mujika L, et al, An integrated physiological and performance profile of professional tennis. Br J Sports Med 2007; 41:531-536

3. Thermal, physiological and perceptual strain mediate alterations in match-play tennis under heat stress. Périard J, Racinais S, Knez W, Herrera C, Christian R, Girard O. Br J Sports Med 2014  (accepted)

4. Tippet M, Stofan J, Lacambra M, et al, Core temperature and sweat responses in professional women’s tennis players during tournament play in the heat.  J Athletic Training 2011, 46:55-60

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Babette Pluim  is a Sports Physician KNLTB and Deputy Editor BJSM. Tennis, healthy lifestyle, injury prevention, sports medicine education. Follow her on twitter:  @DocPluim

 

 

 

 

Introduction to Long QT Syndrome: A Cause of Sudden Cardiac Death in Athletes

4 Jan, 14 | by Karim Khan

By Lauren Forsyth, Kevin Booker, Adam Nathani, Karyn Kraemer,  & Lisa Kirby

Athletes are bigger, faster, and stronger than ever; yet, they are still vulnerable to fatal injury.  Complications from Sudden Cardiac Death (SCD) can ultimately lead an otherwise healthy athlete to a tragic fate. As misconceptions, and grey areas surrounding SCD continue, it is worthwhile to shed light on factors associated with this “silent killer.”

The aim of this blog is to promote awareness of Long-QT Syndrome and the risk of SCD in high performance athletes and to shed light on the possibility of inclusion if training is monitored and symptoms are controlled.  Although it is a potentially fatal disorder, if detected, athletes may still be able to safely compete at the sports they love.

SCD Background

SCD is characterized as a non-traumatic, unexpected event that occurs due to sudden cardiac arrest.  In order to be clinically considered SCD, the event must occur within 6 hours of previously witnessed typical health (Pugh, Bourke, & Kundian, 2011).  Although SCD is still rare, “[it] is the leading cause of mortality among young athletes with an incidence of 1-2 per 100,000 athletes per [year]” (Pugh et al., 2011).

HKIN 3 Figure 1Long QT Syndrome and SCD

Numerous conditions are associated with SCD (figure 1); the focus for this article is the Long QT Syndrome (LQTS) — a disorder of the heart’s electrical system.  The prolonged Q-T interval that can be detected via an electrocardiograph (ECG).  This prolonged Q-T interval represents the slower than normal passing of the electrical signal through the ventricles of the heart.  This congenital syndrome is often asymptomatic.  In some cases people with LQTS experience unexplained faints, seizures, or arrhythmias. Sudden death can be the first clinical manifestation.  According to Pugh et al. (2011), genetic testing is available for people with prolonged QT on ECG and those with a family history of SCD. This test is particularly useful for patients who do not exhibit any of the symptoms that are typically associated with the condition.  The diagnosis of LQTS should be considered for any athlete with a history of losing consciousness.

Once it has been determined that an athlete has LQTS, lifestyle adjustments must be made with respect to their athletic participation. If an athlete has LQTS, he or she must be excluded from participating in all competitive sports.  This ruling is consistent with the guidelines of the two main governing bodies regarding competitive sports participation for patients with LQTS, which are the 36th Bethesda Conference and the 2005 European Society of Cardiology (ESC) guidelines (Johnson and Ackerman, 2012).  Although support for exclusion is extensive, opponents state restrictions placed on these athletes are too strict and the removal from sport can actually result in future debilitating effects on the athlete. According to Johnson and Ackerman’s article, a more formal structure with a pre-screening evaluation is needed that has acceptable sensitivity and specificity for those at risk of SCD. This multilevel pre-screening evaluation is an accurate way of determining the athlete’s exact magnitude of risk when competing in sport. When completed, it will highlight the patients that should not be participating in most sports, as indicated by “either (1) symptoms, or (2) a corrected QT interval (QTc) greater than 470 milliseconds (males) or 480 milliseconds (females)” (Johnson & Ackerman, 2012).  If the corrected QT interval is less than the 470 or 480 milliseconds standard for males and females, respectively, the athlete can qualify for participation contingent upon an appropriately tailored therapy regiment including “β-blockers, …electrolyte and hydration replenishment, and minimization of core body temperature elevations” (Johnson & Ackerman, 2012). Athletes will also be advised to purchase an automatic external defibrillator as part of their sports equipment.

Despite being one of the main causes of SCD in competitive sport, “the estimated prevalence of this disorder is in the range of 1:5000 in the general population…with LQTS account[ing] for approximately 0.8% of the total deaths in young athletes” (Weaver-Pinson et al., 2009). The low prevalence rate suggests that considering alternatives for athletes is appropriate. Above all, recommendations should be individualized, “to assure that the specific recommendations as to type and intensity of athletic involvement are well understood and adequately discussed” (Weaver-Pinson et al., 2009). For minors, parental discussion is also vital.

Dana VollmerTo further support the participation of patients with controlled LQTS, there are well known cases of athletes who have decided to continue to play at a highly competitive level. One famous case is of Olympic swimmer Dana Vollmer who competed at the London Olympic Games in 2012. At the age of 15, Dana was diagnosed with LQTS after experiencing a dizzy spell while training. Vollmer and her family decided to implant a defibrillator in her chest, and closely monitor her training regimen so she could continue to swim. Dana is an inspiration to all athletes living with LQTS as her perseverance and bravery earned her a gold medal at the 2012 London Olympic Games. Although Dana now appears to have outgrown her LQTS symptoms, her decision to continue to swim “illustrates that some athletes can still participate in competitive sports despite cardiac defect” (O’Conner, 2012).

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Lauren Forsythe, Kevin Booker, Adam Nathani, Karyn Kraemer, and Lisa Kirby are undergraduate students in the School of Kinesiology at University of British Columbia. They are all avid sport and exercise enthusiasts that share a keen interest in chronic sports related injuries that plague the collegiate level.

 

References

Heart and Stroke Foundation. 2012. Web. 20 Oct. 2012. Retrieved from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484075/k.F8EF/Heart_disease__What_is_Long_QT_Syndrome.htm

Johnson J, & Ackerman J, (2012). Competitive sports participation in athletes with   congenital long qt syndrome. The Journal of the American Medical Association. 308(8):764-765. doi:10.1001/jama.2012.9334.

O’Conner A, (2012). Overcoming a heart condition to win olympic gold. The New York Times. Received from http://well.blogs.nytimes.com/2012/07/31/overcoming-a- heart-condition-to-win-olympic-gold/?_r=0

Pugh, Andrew, John P. Bourke, and Vijay Kunadian. Sudden cardiac death among competitive adult athletes: a review. Postgraduate medical journal 88.1041 (2012): 382-390.

Wever-Pinzon O, Myerson M, & Sherrid M, (2009). Sudden cardiac death in young    competitive athletes due to genetic cardiac abnormalities. Roosevelt Hospital Center Columbia University. 2; 17-23. Received from            http://www.anakarder.com/sayilar/76/buyuk/17-23.pdf

Guest post by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands

18 Dec, 13 | by Karim Khan

 

A month is a long time in football

OrchardPICOn November 21st, I was one of three sports physicians who wrote a Blog at BJSM on the topic of concussions in football & managerial interference in medical decisions. I tried to assess the risks involved for all of the participants in the Hugo Lloris concussion incident. Perhaps controversially, I estimated that the (then) Tottenham manager, Andre Villas-Boas, had between a 1 in 3 and 1 in 5 chance of being sacked this season. Well as it turns out if I had have offered to hold bets at these apparently meagre odds I would have been taken to the cleaners, as he didn’t survive the calendar year, let alone the remainder of the football season.

Which begs the question, why should someone (an EPL manager) with a job expectancy of roughly a year – give or take – have any role in decisions which may have an impact on the health of the player 20 years down the track? The answer is that of course they shouldn’t, but of course they do. If there was one thing that AVB made very clear in his short tenure, it was that he and he alone decided when players were substituted off the field. Other managers have said that they respect the opinion of their medical staff, but those at the coalface know of pressure to not be “too conservative” in a cut-throat world with limited substitutions.

It’s not surprising that a manager would put ‘team performance’ ahead of ‘long-term player welfare’. (We are not pointing any fingers – we are just drawing a logical conclusion).

Did AVB’s stance on concussion have a role in his downfall? I suspect not; my experience in professional sport is that managers are judged primarily on (poor) results. If Tottenham were leading the EPL then he would have been getting praised for being a strong leader who made tough decisions. Since my November blog, the Australian cricket coach Darren Lehmann has talked about batting on after being knocked unconscious by a ball the first time he batted at the WACA. No one talked about this being an inappropriate thing to say, possibly because cricket has fewer incidences of concussion but – more pragmatically – because coaches are fair game for criticism when they are losing but almost immune to criticism when they are winning. Darren Lehmann has just presided over a 3-0 Ashes win for Australia that – like AVB getting the sack – would have seemed impossible a month ago.

The ‘must win’ culture for coaches is unfair

The deal which coaches get – “win or else” – is unfair, but all in sport need to understand this deal and then question whether those under such ridiculous pressure to win should have the health and welfare of players in their hands? How can AVB be asked to think about Hugo Lloris’ health 20 years hence when the coach might only be in the job another month? Given the manager is NOT well placed to consider a player’s long-term health, how are sports administrators redressing the imbalance of power on match day between the coaching and medical staff? Note that the NFL paid out close to 800 million $US to football players who felt their long-term health was not a club priority during their playing years. NHL players are now seeking a similar payout. (Of course the NFL did not acknowledge ‘guilt’ of any kind).

Is there time for doctors to make an accurate concussion diagnosis pitchside?

A further development from my Blog, but relating to a different game (i.e. NOT the Tottenham doctors) is that a team doctor who has been accused – by the press – of allowing a concussed player to stay on the field wrote to say that in the incident in question he didn’t believe the player to have been concussed (despite what the press wrote). He admitted that the rules of football meant that his assessment was unfortunately a brief one on the pitch and that he supported a rule where he could more thoroughly assess the player on the sideline. Rugby Union has introduced Pitchside Concussion Medical Assessment. Doctors are thus under conflicting pressure from their teams (to err on the side of leaving the player on the field) and their medical colleagues (to err on the side of taking the player off, permanently if this is all the rules allow). It is a hard time to be a team doctor.

Legislate to be allow doctors to make additional concussion assessments and require player substitution as needed.

The bottom line is that in almost every professional sport the decisions on which players to substitute are primarily controlled by coaching staff who are forced by the nature of the job to think in the short term. Witness AVB’s sacking. Doctors are in a position to think longer term with respect to a player’s health later in life. The rules of sport need to change to allow doctors to have the power to make (additional) assessments and substitutes in the case of potentially concussed players.

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Dr. John Orchard @DrJohnOrchard is an Australian sports physician, injury prevention researcher, Cricket NSW doctor, and BJSM Associate Editor.

Guest Blog @PeterBrukner SOME FURTHER THOUGHTS ON THE HUGO LLORIS CONCUSSION INCIDENT

7 Nov, 13 | by Karim Khan

(A full version of the Daily Mail publication, page 75, November 7). The Daily Mail @DailyMailUK is doing a tremendous service to improve concussion awareness and player management. Kudos Daily Mail.

Now that the dust (if not Hugo Lloris’ scrambled brain) has settled on the Spurs keeper’s knock to the head on Sunday, let’s review the situation and ask what we can learn. Let’s remember that the focus must be on what is best for this player, and sportsmen and women the world over

THE STORY SO FAR

  • Lloris was clearly concussed. He was knocked out, was wobbly on his feet and in his manager’s own words after the game “Hugo still doesn’t recall everything about the incident”
  • The Spurs doctor (who is highly regarded and was commended for his work on resuscitating Fabrice Muamba) wanted the player removed from the pitch. I have looked at the TV coverage numerous times and he clearly signals that the player should go off. In fact Villas-Boas admitted as much after the match when he said “the medical department was giving me signs that the player couldn’t carry on because he couldn’t remember where he was” and that “he went against medical guidelines to keep the goalkeeper on the pitch”.
  • The decision to keep the player on the pitch was solely the Managers. He admitted that after the game “’It was my call to delay the substitution, you have to make a decision in situations like this”
  • Loris had a CT scan performed after the game and the club’s website said “The Club can confirm that Hugo Lloris underwent a precautionary CT scan and was given the all-clear and travelled back to London last night”
  • A CT scan is performed to rule out more serious head injury. It cannot exclude concussion which probably explains why the Spurs statement said given “the all-clear” which in reality was from serious head injury but the media interpreted as from concussion
  • Despite the clear cut evidence of concussion and the Manager’s admission that he was responsible for the decision, Spurs changed their tune the following day presumably on advice from the club’s PR department (otherwise known as the “Protect the manager at all cost department”)
  • Their Head of Sports Medicine, physiotherapist Wayne Diesel was quoted as saying “Once the relevant tests and assessments were carried out we were totally satisfied that he was fit to continue playing.”
  • Spurs have a Europa League game on Thursday, 5 days after the Everton game
  • The most recent World Concussion meeting was co-sponsored by FIFA and held at the FIFA headquarters in Zurich last November. The Consensus Statement from that conference published in March this year is quite clear on management guidelines for concussion
  • Regarding return to play (RTP) on the same day, it states it was unanimously agreed that no RTP on the day of concussive injury should occur”.
  • Regarding a graduated RTP following concussion “RTP protocol following a concussion follows a stepwise process as outlined in table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed”.

RTP

 

 

 

  • Following the recommended protocol, the minimum time before returning to play is 6 days assuming that the player is totally asymptomatic (no headaches, nausea, “foggy” feeling etc) the day after the incident and right through the rehabilitation
  • Most Premier League clubs would also perform a computerised neuropychological test at the end of the rehabilitation process to confirm full recovery
  • The Spurs Manager explained his decision to over-rule the club doctor on this basis “I made the call to keep him on the pitch because of the signs he was giving. When you see this kind of assertiveness from the player it means that he is able to carry on. He was determined to continue and looked concentrated, driven and focused enough for me not to make the call to replace him. The saves he made after the incident proved that right”.
  • The Manager was overly influenced by the player, rather than the expert medical opinion. The fact that Lloris made some good saves after continuing is not relevant, as it is the long term effects of playing concussed that are a concern. There are plenty of historical precedents for players playing quite effectively immediately after a concussion. It does not justify the decision.
  • To be fair to the Manager, the medical profession’s stand on the management of concussion has changed over the past few years and the Manager may not be aware of this
  • Previously concussion was thought to be a self-limiting relatively benign condition. In the past few years there is increasing evidence of long term brain problems in retired footballers. Most of the research has come from the NFL who recently settled a lawsuit form a large group of retired players for $750 million (without admitting any guilt).
  • Clearly we as a profession have not succeeded in educating football club managers as to the change of attitude and the new protocols
  • Football in the UK would be wise to follow the lead of the English Rugby Union who have summoned all their coaches to Twickenham this Thursday to hear the latest on the management of concussion.
  • When a player is suspected of being concussed, he should be immediately removed from the field of play and assessed to determine whether he indeed has concussion. This assessment, which should ideally be done in the medical room, takes approximately 5 minutes. See SCAT3 (Free). As a result the other football codes have introduced a temporary substitution which can be made while the player is being assessed. In rugby this is a 5 minute period, in Aussie Rules football it is 20 minutes. Soccer needs to consider something similar.

What now?

The short term dilemma for Spurs is whether Lloris plays tonight (Thursday night). They have put themselves in a difficult position. If he plays, then in addition to their breach of concussion protocol on Sunday, they will be breaching the RTP protocol which requires a minimum of 6 days graduated rehabilitation

  • If they rule him out, then they are admitting that he was concussed and that they were wrong to allow him to continue playing
  • If that PR department had been doing its job they would have said that they had always planned to play their No 2 goalkeeper on Thursday and got out of it that way!!
  • The team doctor has the expert knowledge and is the one person who has the player’s health as his/her primary responsibility and therefore should be the sole arbiter of whether a player is concussed.

[BJSM Editor’s note: Credit to Tottenham for clearly following the Zurich Concussion Guidelines here: The Manager is quoted as resting Lloris as a result of Sunday’s concussion. For non-expert readers, when Lloris returns to play should depend on his symptoms (and potentially neuropsychological tests, not a specific ‘time’ . One week is a minimum to progress through the stages (above) but it can take longer if symptoms (headache, unusual tiredness, dizziness) persist. ] Posted on Thursday Nov 7th after the Europa Cup game.

How should this have been handled?

  • It would have been nice yesterday instead of Spurs trying to shift the blame to their (absolutely innocent) medical staff, to hear the Manager publicly state that he had made a mistake, that he was not up-to-date regarding the changes in guidelines for the management of concussion, state his total support for the club’s medical team, and state clearly that he will not interfere in the future.
  • That would have made a positive out of a negative.
  • Instead Villas-Boas has come out and abused those of us who have expressed concern calling us “incompetent”.
  • Sadly he had missed a wonderful opportunity to get the message out there that concussion must be taken seriously.

 

 

Academic performance improves at age 11-16 thanks to physical activity: mainstream media broadcasts BJSM OnlineFirst paper

24 Oct, 13 | by Karim Khan

It’s no secret we are exercise advocates. And we love media coverage that provides the general public with even more incentive to be active. One profiled study on social media and language links sports with greater emotional stability. Even more notable, are the numerous international news outlets (including articles from Australia, India, the US, and the UK) covering the work of Dr. Booth and colleagues. Dr. Booth et al.’s research suggests that moderate-vigorous intensity physical activity predicts higher academic achievements in adolescence, or in the words of Australian reporters: “exercise is brainfood for teens.”

girls soccerBooth’s research team base their findings on a representative sample of almost 5000 children who were all part of the Children of the 90s study, also known as the Avon Longitudinal Study of Parents and Children (ALSPAC). This is tracking the long term health of around 14,000 children born in the UK between 1991 and 1992 in the South West of England. They conclude: “If moderate to vigorous physical activity does influence academic attainment this has implications for public health and education policy by providing schools and parents with a potentially important stake in meaningful and sustained increases in physical activity.”

Read Booth et al’s (open access) article, Associations between objectively measured physical activity and academic attainment in adolescents from a UK cohort (2013), HERE.

Valerie Adams – Greatest shot putter ever talks about her physio & sports medicine team / And you can get the Aspetar Journal (96 pages) hard copy for free!

22 Oct, 13 | by Karim Khan

This interview was published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Qatar Orthopaedic and Sports Medicine Hospital.

Just email journal@aspetar.com with the address you want the excellent Aspetar Sports Medicine Journal sent to and you’ll join 1000+ on the subscriber list. No junk mail, no selling your details – just this excellent high-quality content journal that has emerged from Qatar (now in Volume 2).

Valerie Adams Aspetar coverINTERVIEW WITH VALERIE ADAMS

Her career speaks for itself: two Olympic Games gold medals, two Commonwealth Games gold medals, two World Indoor Championship gold medals and four World Championship gold medals. In 7 years, there has been only one time when New Zealand shot putter Valerie Adams didn’t take home gold, and even then it was a silver. In the world of track and field, she was the first woman to win four back-to-back individual world championships. When it comes to shot put, she is the most successful shot putter (man or woman) of all time.

How did she get there? A combination of discipline, pain and very little downtime. Here the 29-year-old tells Nick Cowan about her love of competition and great support team.

Tell us about some of your career highlights.

Highlights for me have been the 2008 Beijing Olympic Games where I won a gold medal, the 2001 World Youth Championships which was my first big win, 2011 World Championships in Daegu where I equalled the championship record with a personal best throw of 21.24 m and the London Olympics last year – eventually!

What is your current training programme?

My training programme consists of two sessions a day. I do a lot of weight lifting, throwing, plyometrics, medicine ball work, a lot of specific training for throwing the shot and recovery and rehab on top of that.

My coach, Jean-Pierre, designed an eccentric-concentric machine that we use for base training in Switzerland. There are no machines like this in New Zealand and so we travel to Switzerland to start new phases. This type of training enables me to get maximal strength and get a real base under me, in contrast to normal training in the gym.

With the athletic schedule the way it is, do you ever get any downtime?

I get about 4 weeks off in October when the season’s done, that’s it.

My holiday period is basically just the month of October and, thankfully, it’s a good month for me. I get to party because it’s my birthday and I try and be a ‘normal’ citizen for that month.

You spend most of the year living outside of New Zealand. What’s it like to live away from your home?

It’s just part of life and it’s something that I’ve chosen to do. My career as an athlete won’t last for the rest of my life so I’m giving it my best shot while I can. It’s good to be away from New Zealand because there are no distractions, meaning there’s more time to train and recover.

And Europe this is where the competitions are, so it makes more sense to be based here instead of New Zealand.

What would you say is the toughest part about the sport of shot put throwing?

Every aspect of it is challenging.

Have you ever had an injury that threatened your career?

In 2006 I had shoulder surgery. I had two cm cut from my clavicle because of overuse. It didn’t stop my career as such, fortunately, because it happened in the off season and I was able to get without it interfering in any competitions.

I’ve been quite lucky in that I haven’t had to skip a season through injury so far. That’s down to having a great physio and also the support team who have been able to manage me.

Then again, I’m not the kind of athlete to stop for anything. My pain threshold is very high, I’m an animal like that and I love to compete very much. I’ll do anything to compete, pain or no pain. But pain is just part of an athlete’s life.

How do you treat an acute injury?

Basically I call my physio, Louise Johnson. She’s been working with me since day one; we’ve worked together for 14 years. She assesses the situation from near or far and we try and get the help we need immediately. It can be hard if I’m overseas but she runs the show and gets help to me as soon as possible.

I am pretty good at self-managing but she calls the shots on doctors and scans and I just have to listen to her.

Who makes up your medical support team?

I work on a day-to-day basis with my physio, Lou. She’s my right-hand man, the person who is on my phone’s speed dial. It’s very important to have a good relationship with someone like that.

I don’t travel with a doctor. Because my physio knows me so well, she knows what I need and what to do when things come up. But I do have a doctor, chiropractor and massage therapist and as far as ay medical conditions are concerned, those are the people that look after me.

Who makes the decisions around your health?

It’s a team approach but I basically have the last choice. The doctor’s opinion will usually have the biggest impact but then again I have both a sports doctor and a general practitioner who I see.

What is your relationship like with your coach?

My coach is awesome! He’s saved my career and made me a better athlete than ever. With his training and planning I’ve been able to save my back from injury. It’s very important that he is kept in the loop on everything. If you’re a team, there’s nobody kept in the dark.

He’s a very hands-on coach. He likes to know what’s going on and will adapt things accordingly – which is very important – as opposed to shutting down on you. I’ve been lucky to work with my coach, Jean-Pierre.

Do you follow any injury prevention programmes?

No, not at the moment.

Do you follow a nutritional strategy?

I don’t follow any nutritional programme but do have supplements to take. I work with High Performance Sport New Zealand who help me figure out what to take pre- and post-competition. As far as eating is concerned I look after myself.

Do you find much difference in the medical treatment you receive when you travel, compared to back home in New Zealand?

This is only my personal experience, but I have found that European physios are not as hands on. In Europe they tend to give you a lot of stretching and exercise and ask you to come back in a few days. I prefer to feel like I’m getting more benefit from hands on work.

What do you think the athletic world can learn from New Zealand?

I think it goes both ways. In New Zealand, we have to fight all our own battles because we’re stuck at the bottom of the world – we have to research what the rest of the world is doing. We do well for a small country but I think we have our own strategies which work for us. Of course, there are things in Europe that we could benefit from. For example, their technology tends to be slightly better.

 

Creation of sport and exercise medicine posts would help ease the burden on A&E

7 Jun, 13 | by Karim Khan

sealNews Release

Re: The King’s Fund Analysis of A&E Waiting Times

In response to The King’s Fund analysis of A&E waiting times, the Faculty of Sport and Exercise Medicine is fully supportive of a co-ordinated response to help ease the burden on our healthcare system.

John Appelby, Chief Economist, at The King’s Fund concludes in his report on pressures on accident and emergency services: “The pressures in emergency care will not be relieved by focusing on a single aspect of the problem – it requires a co-ordinated response across the whole health system.”

The Faculty of Sport and Exercise Medicine is calling for the creation of more Sport and Exercise Medicine Doctor posts within the NHS as part of a co-ordinated solution to the issues we are facing in emergency care and across the health system. Particularly after sport or occupational injury and in the prevention and treatment of common diseases.

Dr Rod Jaques, President of the Faculty of Sport and Exercise Medicine Comments: “We would like to see a co-ordinated approach to improving the long-term health of the public by increasing the specialty of sport and exercise medicine in General Practice, therefore easing the burden on our A&E departments and health services.  Part of the solution also lies in the creation of sport and exercise medicine specialists who can work alongside emergency medicine, musculoskeletal clinics and physiotherapists to deliver activity based care and reduce unnecessary referrals and overall expenditure. 

Sport and Exercise Medicine specialists have been part of a pilot study that has improved care and cut waiting times for patients with muscular and joint pain, saving the NHS tens of thousands of pounds. The pilot enabled the partnership to deliver 62% more patient care in 2012 than was delivered in 2010, whilst still reducing overall expenditure.

For further information contact:

Beth Cameron, PR & Communications at the Faculty of Sport and Exercise Medicine

email: pr@fsem.ac.uk, Tel: 0131 527 3498 or 07551903702        Twitter: @FSEM_UK

Faculty of Sports and Exercise Medicine, 1a Hill Square Edinburgh, EH8 9DR

@PeterBrukner discusses today’s major headline: Successful antibiotic treatment in a subset of people with chronic low back pain

8 May, 13 | by Karim Khan

PB picIt is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). I had that feeling today when, after an article in this morning’s Guardian newspaper, I read two recent papers published by a Danish group of researchers led by Hanne Albert in the European Spine Journal (links below).

Infection and low back pain!?

The papers relate to the possibility of an infective cause in a sub-group of patients with chronic low back pain. This sub-group is those patients with Modic changes. Modic changes (MC) are bone oedema in the adjoining vertebra to one in which there is a disc herniation. MC are present in 46% of patents with chronic low back pain compared to 6% in the general population. MC can only be reliably detected using MR imaging. A number of previous studies have demonstrated the presence of bacteria especially Propionbacterium acnes (P. acnes) in disc nucleus tissue evacuated at surgery from patients with lumbar disc herniation.

The first paper Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? reports on 61 patients who had nuclear disc material removed while undergoing surgery for chronic low back pain. Microbiological cultures were positive in 28 (46%) patients, of which 26/28 were anaerobic cultures, 2 (3%) aerobic and 4 (7%) mixed. In the discs with a nucleus with anaerobic bacteria present, 80% developed MC in the vertebrae adjacent to the previous disc herniation, compared to none in the aerobic group and 44% with negative cultures. They concluded that the occurrence of MCs in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc.

How do intervetebral discs become infected?

Organisms such as P. acnes are commonly found in hair follicles in the skin and in the oral cavity. They frequently invade the circulatory system during tooth brushing where they do not present an immediate risk because the blood stream is an aerobic environment. When an intervertebral disc is herniated, nuclear material extrudes into the spinal canal. Within a short time, neocapillarisation begins in and around the extruded nucleus material, inflammation occurs and brings with it macrophages. So far so good – no debate about any of that.

The innovation of the authors is their proposal that avascular and thus anaerobic disc provides an ideal environment for these anaerobic bacteria to flourish. In this setting, anaerobic bacteria that are normally inconsequential (low virulent) may enter the disc and give rise to a slowly developing infection.

Local inflammation in the adjacent bone (MC Type 1) may be a secondary effect due to cytokine production or microbial metabolites (e.g. propionic acid) entering the vertebrae through normal disc nutrition. P. acnes is known from the skin to trigger an adjacent inflammatory response. P. acnes cannot multiply in the highly vascular aerobic bone and are therefore not present where the MC occur.

All good in theory but what about an RCT?

The second paper is entitled Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy.  this paper reports the efficacy of antibiotic treatment in this group of patients with MC lesions and chronic low back pain. This double blind RCT study examined 162 patients with chronic low back pain (> 6 months duration) occurring after a previous disc herniation AND who had MC changes in the vertebrae adjacent to the previous herniation. Subjects were randomised to either 100 days of antibiotic treatment (Bioclavid) of two different dosages or placebo. Outcomes were evaluated at baseline, end of treatment and at 1 year follow up.

Primary outcomes were the well accepted disease-specific disability Roland Morris Questionnaire as well as the report of lumbar pain. The antibiotic group made highly statistically significant improvements on all outcome measures; the improvement continued from 100 days follow up until 1 year follow up. For example, on the disease specific disability, the antibiotic group was 15 at baseline, 11 at 100 days and 5.7 at 1 year compared to placebo (15, 14, 14). The report of lumbar pain decreased much more in the antibiotic group who started at a score of 6.7 and improved to scores of  5.0 (100 days) and 3.7 (1 year). The placebo group mean report of lumbar pain stayed constant at 6.3 from baseline through 100 days and 1 year (lower is better, of course).

Biologically plausible time course

Patients also reported that pain relief and improvement in disability commenced gradually, for most patients 6-8 weeks after the start of the antibiotic tablets and for some at the end of the treatment period. Improvements reportedly continued long after the end of the treatment period, at least for another 6 months, and some patients reported continuing improvement at 1-year follow up. The improvement seen in the antibiotic group at 1 year follow up was approximately twice that observed at the end of the 100 day treatment period, suggesting that a biological healing process that starts only when and after the bacteria have been killed.

Half the treatment group took one Bioclavid (amoxycillin-clavulanate 500mg/125mg) tablet three times a day while the other half took two tablets. The authors state that the long duration of antibiotic treatment is commonly prescribed for post-operative discitis. There was a trend towards an improvement with double dose, but did not reach significance.

What should we make of these papers?

This treatment is certainly an exciting possibility for one of the most difficult management challenges in medicine.  At this stage all the authors are saying is that in a particular sub-group of patients with chronic (>6 months) low back pain, those with Modic changes on MRI scan after lumbar disc herniation may respond well to long term antibiotic treatment. We are reluctant to prescribe long term antibiotics for reasons of potential development of resistance but there seems to be a rationale for long term use in this situation. Further studies need to assess the efficacy of shorter terms of treatment. Because this is the BJSM blog, we can point out to readers that the group’s pilot study was not accepted by a number of famous journals but saw the light of day via BJSM’s ‘peer-review fair review’ process. That paper came out in 2008.

I would think on the basis of this research it is reasonable to prescribe the recommended antibiotic program to those who strictly meet the clinical and MR imaging criteria. Especially if the only alternative seems to be surgery which has limited efficacy in these patients and is obviously vast more expensive than a course (albeit prolonged) of antibiotic therapy. Remember if you have this infection surgery will not be treating the cause.

It took the Nobel prize winning research  on Heliobacter and its relationship to stomach ulcers of West Australians Barry Marshall and Robin Warren to alert the skeptical medical community of the potential of infective causes of common conditions. Many investigators are currently seeking infective causes for a wide variety of common and uncommon medical disorders. This research will encourage such investigation. Undoubtedly we will find more causal infective relationships. Further work needs to be done to answer a range of questions (which antibiotic, what dose, how  long etc), but these two papers are an exciting step forward in the management of a very difficult condition. If I were a sufferer of chronic low back pain I would be feeling a little more optimistic after the publication of this research.

Dr Peter Brukner (@PeterBrukner)MBBS, FACSP, Sports Physician, Melbourne, Australia, is an experienced team physician and writing in his capacity at BJSM Senior Associate Editor and regular blogger.

ModicBJSMCover

Cover of December 2008 BJSM issue that included this group’s pilot study. We congratulate the Albert group of researchers for their persistent pursuit of better outcomes for patients – well done! For their 2008 BJSM paper see this link  http://bjsm.bmj.com/content/42/12/969.full

 

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