It 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.

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

HEADLINE FOR THE TIME-POOR: Here is the link to the slides for your presentations, but please don’t alter them without the permission of the Consensus Statement authors.

During the 4th International Conference on Concussion in Sport (Zurich 2012) attendees revised and updated the Consensus Statement. The new 2012 Zurich Consensus Statement builds on previously outlined principles and furthers conceptual understandings. Using a formal consensus-based approach, contributors developed this document primarily for use by a spectrum of Sports Medicine (recreational, elite or professional) physicians and healthcare professionals.

Remember that BJSM is the only place to find the 12 systematic reviews that support the consensus statement. We also have 5 podcasts by Co-leads Paul McCory and Winne Meeuwisse on our podcast page.

An informative PowerPoint presentation, and the main outcomes of the 2012 Conference on Concussion in Sport, is now freely available on the BJSM Education website.

The PowerPoint presentation contains:

• An outline of the consensus process
• A description of the definitions used for concussion and traumatic brain injury
• The evaluation of an athlete suspected of suffering a concussion
• The management of a concussed athlete
• The modifying factors that might influence evaluation and management
• Special populations
• Prevention
• And an overview of the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and the Child SCAT3

You are free to use these slides (link here) for your own presentations, but please don’t alter them without the permission of the Consensus Statement authors.

If you wish to insert your own slides to create a customized presentation, please use a different theme, or colour, to distinguish your slides from the ones prepared by the Concussion in Sport Group.

Sincerely,

Babette Pluim, Deputy Editor BJSM

@DocPluim

Interesting take on the Consensus statement from the Zurich 2012 Conference on Concussion In Sport. This paper is Open Access on BJSM and BJSM is the exclusive publisher of the 12 systematic reviews that underpin the Consensus statement. This special issue of BJSM is an Injury Prevention and Health Protection (IPHP) issue of BJSM – supported by the International Olympic Committee.

Click here for the full AFL blog:

By Ann Gates (@exerciseworks), Dr Mike Evans (@docmikeevans) and

Dr SalihAlAnsari (@SaudiHPC)

The World Health Organisation describes physical activity promotion to mass populations as one of its top 5 ‘Best Buys’. We collaborated to develop an Arabic version of the viral social media success 23 ½ hours to promote the importance of regular exercise to Arab countries. Particularly, those countries at high risk of inactivity associated with the non-communicable diseases epidemic of obesity, diabetes, cancer and heart disease. The Co-operation Council for Arab States (CCG) has identified that non communicable diseases (NCDs) cause more than 60% of all deaths in the region. In addition to video development, we conducted a ‘best buy’ research study to evaluate its effectiveness in reaching this audience. Our aims were to:

• Monitor and analyse the uptake of the video via Twitter, Facebook and YouTube
• Compare the success of the original English video with the Arabic version
• Understand the different viewing patterns of men and women in the English and Arabic speaking countries

The results were amazing!

There are 1.6 million views of the Arabic version to date (viewing statistics represented 92% coverage of the Arab States). This video was the fifth most viewed YouTube video (covering ALL YouTube video releases) during the second week of the launch.

Other study highlights include:

• Significant viewing differences in sex and age range by country (available by country on request); overall, 76% of the viewers were male and 24% female
• The viral spread of the Arabic version was significantly faster over 6 months than the English version
• The relative audience retention data (when compared to YouTube’s average statistical data) showed slightly below average for the full 9.21 minutes.
• The release of the Arabic version caused a significant spike in viewing figures for the English version.

• 64% of viewers shared the link via Facebook compared with 88% for the English version.

Our results show that health professionals are able to successfully promote key health messages using social media. The translated 23.5 hrs communicated the benefit of simply walking for 30 minutes each day, to a large audience (in a short timeframe) in a region where greater physical activity promotion is of key importance.

This clearly demonstrates how social media may be used as a powerful tool for targeted messaging about regular exercise and physical activity interventions to communities at risk of NCDs.

A sum of take home messages are:

• The viral social media spread of important health messages can reach specific ‘at-risk’ populations
• Specific targeted viral media campaigns need further study and evaluation. A simple ‘thumbs up’ vote system at the end of the video saying ‘has this video changed your views and behaviour on regular exercise’ may suffice.
• Creative dissemination strategies, and the use of multiple web based platforms, may be more effective to reach large audiences and thus, combat public health problems, than traditional methods.
• YouTube, Facebook and Twitter may revolutionise the way we deliver and implement key health messages around the world on physical activity. The 23 ½ hours video translations (covering 5 languages and including the Arabic version) has been viewed by 4.8 MILLION people. This represents a significant ‘best buy’ initiative in terms of audience access through social media and extensive international reach. For the Arabic translation to reach the fifth most viewed video on YouTube demonstrates that targeted health messages can compete effectively with audience interest, and may be in fact be as interesting to the general public as cat videos!

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Ann Gates BPharm(Hons) MRPharmS, Founder of Exercise Works!

Dr Mike Evans Family physician at St. Michael’s Hospital and an Associate Professor of Family Medicine and Public Health at the University of Toronto and My Favourite Medicine

Dr Salih AlAnsari Saudi Health Promotion Centre, Riyadh, Saudi Arabia.

By Liam West (@Liam_West)

We all know regular physical activity is good for our health. So good in fact that it is often regarded as the equivalent of medicine’s ‘wonder drug.’  Exercise prescription is steadily increasing in practice and there might even be medico-legal implications if we don’t encourage patients to get physically active to reduce their risk factors for morbidity. But how can you enthuse patients to get off the sofa and get moving?

A possible answer – lead by example and propose a challenge!

The www.5×50.co.uk campaign is an effort to raise awareness of the benefits of exercise & physical activity. I am currently helping to promote this campaign across the UK, especially in Wales, so that the message spreads – regular physical activity helps keep you healthy; it helps keep you free of disease; it is effective.

Physical Inactivity kills 9% of the world’s population.

The next stage of the campaign is the ‘Run the World’ challenge. It asks people to walk, cycle or run 5kms (3.1 miles) a day for a week from 23rd November, and involve friends, family, and patients as a taster to get fit. Challenge yourself and your community to be active and share in the experience of the benefits of physical activity. Sign up now!

Andrew Murray wins 2012 North Pole Marathon

Dr. Andrew Murray is making a documentary film about his commitment to the challenge . He is personally going to complete an ice marathon in Antarctica followed by 50kms on 7 different continents in 7 days. We applaud Dr. Murray’s commitment to both being physically activite and promoting its importance!

In comparison to this, 5kms a day from you is a drop in the ocean. But, nonetheless, it is an important drop.

Scotland’s Chief Medical Officer Harry Burns, their NHS executive team & Sports Minister Shona Robison have all signed up to www.5×50.co.uk. Here in Wales both Cardiff & Swansea medical schools, Cardiff City Football Club, the Welsh Rugby Union doctor and some players have signed up along with Public Health Wales – If they can do it, so can you! We all need to be in this together!

We really want UK / world wide doctors, lecturers & students involved as a priority. However, we also want to engage the broader public, so that everyone thinks about how they might become more physically active. We need your help to make a difference:

• Join the challenge and become a physical activity ambassador;
•  Encourage all your friends, families or patients to get more active;
•  Use http://5×50.co.uk/challenges to do so.

‘Run the World’ starts soon (November 23^rd); sign up now and share with your networks!

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Liam West

Founder and President of Cardiff Sports & Exercise Medicine Society (CSEMS); Organiser of the Cardiff SEM Conference 2012; BJSM Associate Editor; Coordinator of the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM; Student Representative for the Council of Sport Medicine for the Royal Society of Medicine; Founder of Undergraduate Sports & Exercise Medicine Society (USEMS)

 Dr. Andrew Murray

Scottish Government Physical Activity Champion; @docandrewmurray – Twitter; www.docandrewmurray.com ; General Practitioner, Sport & Exercise Medicine Registrar; Author – Running Beyond Limits

By Dr David White

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

Participate in a new and interesting opportunity to help embed physical activity for health within medical undergraduate training. Drive this initiative forward by taking a few simple steps — outlined at the end of this blog.

At the recent Faculty of Sport and Exercise Medicine (FSEM) Annual Meeting in Edinburgh there were confirmations of progress across the UK in the promotion of physical activity for health. However, one recurring issue throughout the FSEM programme was the pressing need for an update of undergraduate education. Several studies convincingly suggest that current inclusion in undergraduate curricula is inadequate. [1,2]

Our current challenge is how to promptly improve undergraduate medical curricula, to place appropriate emphasis on physical activity for health. One or two medical schools have made progress, owing largely to enthusiastic individuals lobbying for amendments to that curriculum (e.g. Drs. Rhodri Martin, Liam West and John Brooks at Cardiff and King’s College, respectively). Vigour and persistence over prolonged periods were required in each of these cases. We can ill-afford to wait for this approach across each of the UK’s 32 medical schools.

The ultimate responsibility for undergraduate curricula across all medical schools lies with the General Medical Council (GMC). Their document ‘Tomorrow’s Doctors’, published in 2009, regulates what medical schools are expected to teach their students [3]. There is not a single mention of physical activity for health in this key document.
Opportunely, the GMC recently published another paper entitled:

            “The state of medical education and practice in the UK: 2012”. [4]

GMC’s aim in compiling this document is:

“To promote discussion and debate on issues and trends that require attention or further analysis, to improve standards of medical practice.”

Accordingly, the GMC have invited responses to this paper. These can easily be submitted online, and via Twitter, Facebook, or LinkedIn. Herein lies the opportunity to make the GMC sit up and take note of the current shortcomings in undergraduate education.

Here is a link to the report, and a brief feedback form.

Please complete the 4 simple questions, and forward the link to others who may support this cause.

The GMC have committed to log all comments detailing ‘Tomorrow’s Doctors’ for when the document is next revised.

In order to truly promote Good Medical Practice, the GMC must now set appropriate, up-to-date standards for our future medical workforce. Medical training needs to be altered to reflect changing patterns of healthcare and support a disinvestment in costly medications. Inclusion of physical activity across each of the relevant specialties is imperative. I believe this will inevitably happen. Seizing this current opportunity to offer feedback, however, could save many years lobbying individual medical schools and promote the more widespread application of curricula improvement.

References:

[1] Oluwajana F, Rufford C,Morrissey D. Exercise, sports and musculoskeletal medicine in UK medical school curricula: a survey. Br J Sports Med 2011;45:2 e1 doi:10.1136/bjsm.2010.081554.26

[2] Weiler R, Chew S, Coombs N, et al Physical activity education in the undergraduate curricula of all UK medical schools. Are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med doi:10.1136/bjsports-2012-091380

[3] General Medical Council. Tomorrow’s Doctors. 2009. Available online.

[4] General Medical Council. The state of medical education and practice in the UK: 2012. 2012. Available online.

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Dr David White is a Sport and Exercise Medicine Registrar based in Scotland, currently working with the Scottish Government and within the CMO Directorate. He is also a Medical Officer with the Irish Football Association and an IPC Classifier.

Email correspondance: david.white@scotland.gsi.gov.uk

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

17 fantastic articles from leading experts comprise BJSM’s Advances in Sports Cardiology supplement. From:

…Hot debates in US vs European approaches…

Ventricular arrhythmias, stress, and adaptations associated with endurance sports athletes …

To… Peripheral vascular structure and function in hypertrophic cardiomyopathy…

This supplement is packed with variety and quality.

What’s more — all articles are open access (thanks to Aspetar Hospital, Doha, Qatar).

and they are available online now.

Check it out here, or via the links below.

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Editorials

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Advancing sports cardiology: blue sky thinking in Qatar. Bruce Hamilton, Mathew G Wilson, Hakim Chalabi. Br J Sports Med 2012;46 i1 Open Access

Sports cardiology: current updates and new directions. Mathew G Wilson, Jonathan A Drezner. Br J Sports Med 2012;46 i2-i4 Open Access

Cardiac screening: time to move forward! Mats Borjesson, Jonathan Drezner. Br J Sports Med 2012;46 i4-i6 Open Access

Standardised criteria for ECG interpretation in athletes: a practical tool. Jonathan A Drezner. Br J Sports Med 2012;46 i6-i8 Open Access

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Current updates

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Debate: challenges in sports cardiology; US versus European approaches. Bruce Hamilton, Benjamin D Levine, Paul D Thompson, Gregory P Whyte, Mathew G Wilson Br J Sports Med 2012;46 i9-i14 Open Access

Aetiology of sudden cardiac death in sport: a histopathologist’s perspective. Mary N Sheppard Br J Sports Med 2012;46 i15-i21 Open Access

Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Michael Papadakis, Mathew G Wilson, Saqib Ghani, Gaelle Kervio, Francois Carre, Sanjay Sharma. Br J Sports Med 2012;46 i22-i28 Open Access

The endurance athletes heart: acute stress and chronic adaptation. Keith George, Greg P Whyte, Danny J Green, David Oxborough, Rob E Shave, David Gaze, John Somauroo Br J Sports Med 2012;46 i29-i36 Open Access

Atrial fibrillation and atrial flutter in athletes. Naiara Calvo, Josep Brugada, Marta Sitges, Lluis Mont. Br J Sports Med 2012;46 i37-i43 Open Access

Ventricular arrhythmias associated with long-term endurance sports: what is the evidence? Hein Heidbuchel, David L Prior, Andre La Gerche. Br J Sports Med 2012;46 i44-i50 Open Access

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New directions

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Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum. M G Wilson, S Sharma, F Carre, P Charron, P Richard, R O’Hanlon, S KPrasad, H Heidbuchel, J Brugada, O Salah, M Sheppard, K P George, G Whyte, B Hamilton, H Chalabi. Br J Sports Med 2012;46 i51-i58 Open Access

Advising a cardiac disease gene positive yet phenotype negative or borderline abnormal athlete: Is sporting disqualification really necessary? Pascale Richard, Isabelle Denjoy, Veronique Fressart, Mathew G. Wilson, Francois Carre, Philippe Charron Br J Sports Med 2012;46 i59-i68 Open Access

Imaging focal and interstitial fibrosis with cardiovascular magnetic resonance in athletes with left ventricular hypertrophy: implications for sporting participation. Deirdre F Waterhouse, Tevfik F Ismail, Sanjay K Prasad, Mathew G Wilson, Rory O’Hanlon. Br J Sports Med 2012;46 i69-i77 Open Access

Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. Peter J Angell, Neil Chester, Nick Sculthorpe, Greg Whyte, Keith George, John Somauroo. Br J Sports Med 2012;46 i78-i84 Open Access

Emergency cardiac care in the athletic setting: from schools to the Olympics. Brett Toresdahl, Ron Courson, Mats Borjesson, Sanjay Sharma, Jonathan Drezner. Br J Sports Med 2012;46 i85-i89 Open Access

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Original articles

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Do big athletes have big hearts? Impact of extreme anthropometry upon cardiac hypertrophy in professional male athletes. Nathan R Riding, Othman Salah, Sanjay Sharma, Francois Carre, Rory O’Hanlon, Keith P George, Bruce Hamilton, Hakim Chalabi, Gregory P Whyte, Mathew G Wilson. Br J Sports Med 2012;46 i90-i97 Open Access

Peripheral vascular structure and function in hypertrophic cardiomyopathy. Nicola Jayne Rowley, Daniel J Green, Keith George, Dick H J Thijssen, David Oxborough, Sanjay Sharma, John D Somauroo, Julia Jones, Nabeel Sheikh, Greg Whyte Br J Sports Med 2012;46 i98-i103 Open Access

Bruce Hamilton’s article (Hamstring muscle strain injuries: what can we learn from history? 2012;46: 900-903) is receiving a lot of attention. Current in this month’s BJSM print edition, >6,000 people have already downloaded and digested it (free full text!). This October issue has been shaped by the Australasian College of Sports Physicians, one of BJSM’s 8 member societies (and more to be announced shortly!).

Clinicians’ interest in hamstring injury prevention, diagnosis, and management is no surprise. Elite athletes from American Football (i.e Jets’ tight end Dustin Keller who has missed four weeks – to date – with a hamstring injury), to European Football (i.e Manchester City’s Jack Rodwell who may be warming the bench for England in Tuesday’s Euro 2013 decider) suffer from hamstring injury. Rodwell has the classic ‘recurrence’ issue – six such injuries this season.

As a ‘mini-symposium’ we share 4 recent papers below. Their take-home messages include that: (i) focussed eccentric loading – in the appropriate functional range of motion is critical, (ii) that there are different types of hamstring strains with different prognosis (Type 1 ‘sprinters’; Type 2 ‘dancers’), (iii) there remains an element of art in treatment – but don’t give up the science as the first option. And don’t forget Carl Askling’s podcast – one of BJSM’s most popular of all time.

BJSM senior associate editor Roald Bahr (@RoaldBahr) vouches strongly for the ‘nordic hamstring’ exercises to prevent recurrence. He suggest that EPL teams should be ensuring the high-risk players (those with previous injury) perform the program. You can see the video of this program at the Oslo Sports Trauma Research linked web-page. (Skadefri which means ‘Injury Free’). The words are in Norwegian but the images speak for themselves. And while you are on that site check out the IOC Manual of Sports Injuries – great value and completely up to date.

In short – no-one has all the answers but progressive and functional training – with a particular focus on players who have already had a hamstring strain – is a way to go. Please do share your solutions confidentially or in public.

Related publications

Mendiguchia J, Alentorn-Geli E,Brughelli M. Hamstring strain injuries: are we heading in the right direction? Br J Sports Med 2012;46:81–5.

Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis Br J Sports Med 2012;46:2 86-87 Published Online First: 14 December 2011

Orchard JW, Best TM, Mueller-Wohlfahrt HW, et al The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. Br J Sports Med 2008;42:158–9. (Free full text)

Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 2007;35:197–206.

 Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med 2006; 40: 40-4. 

Are you an app developer? If you want to create the BJSM podcast app please ‘call me maybe’.  Granted BJSM podcasts are marginally less popular than Carly Rae Jepsen’s hit (300 million views) but I am optimistic that sports medicine will truimph over time. Right now we are only 300 million views behind (with rounding). Many in the BJSM community commented on the value of  the 5 most popular BJSM Podcasts in 2011.

Here is a 2012 update on our ‘platinum podcasts’:

5 most popular in the last 30 days (average over 1000 listens per podcast):

Acute ankle injuries, with Gino Kerkhoffs  Based on the very rigorous review of management published in the August issue of BJSM (VSG member society – theme issue).

Five clinical tips for shoulder assessment and Rx, with Professor Mark Hutchinson  Comes with linked video material – a multi-media overview that even experienced clinicians can learn from.

Darren Burgess – Head of Fitness and Conditioning at Liverpool FC   How can clinicians and fitness and conditioning professionals can work together to improve team performance. Yes they can!

Professor Mark Hutchinson’s pearls on knee examination: Do the simple things extraordinarily well  Don’t be fooled by the word ‘simple’ in this one. Later in the podcast (and you can go straight there using the timeline under the link) Hutch discusses complex management issues. He’s a great instructor. (As his >3 million YouTube views attest.)

Prof Jeremy Lewis: Rotator cuff tendinopathies You get the best of BJSM’s Deputy Ed Prof Jill Cook (interviewing) and Prof Jeremy Lewis on controversial issues topics related to the painful shoulder. Where does the pain come from? Should I succumb to SAD? (subacromial decompression). A rare opportunity to be a fly on the wall while two of the most popular clinical educators chat.

Most popular ever (all with > 2000 listens):

Biomechanical overload and lower limb injuries, with Andrew Franklyn-Miller Expert commentary on leg pain (not ‘shin splints’ but roughly in that part of the body ), barefoot running, and how to modify your running technique to reduce injury risk.

Hamstring injuries with Carl Askling In a short podcast, Swedish physiotherapist Askling shares the take-home messages from over a decade of both treating hamstring strains in athletes/dancers and from completing a brilliant PhD on the subject. This is revolution – not just evolution – in managing hamstring tears. If your hamstring strain is not differentiated into Askling’s Type 1 or Type 2 you are at a disadvantage in knowing your prognosis and perhaps even optimum treatment. A hot commodity on the sports medicine conference circuit Dr Askling provides valuable guidance here.

Groin injuries, with Per Holmich One of the most challenging areas of sports medicine – from a world-renowned surgeon with rare appreciation of conservative management.  Learn how to differentiate the entities that contribute to groin pain and how that should influence management. Don’t have FAI surgery before listening to this!

Treating tendinopathy with Professor Håkan Alfredson A very practical podcast on the distinction between mid-portion and insertional Achilles problems. How to manage each condition. Current management controversies. From the clinician who invented the modern heel-drop program – one of the top 10 downloaded and cited papers of all time in the Am J Sports Med (1998).

The shoulder in sport, with Ben Kibler  Dr Scapula – Ben Kibler – is guaranteed to fill a room at any conference. Tennis doctor and BJSM deputy editor Babette Pluim (@DocPluim) poses the challenging clinical scenarios so we can all learn!

BJSM welcomes your suggestions for podcast guests. Email karim.khan@ubc.ca or Tweet to the BJSM at @BJSM_BMJ or post to our facebook page.

E-letter and update by Dr Ian Beasley (FFSEM)

In response to:

Jo Price, Peter Malliaras, Zoe Hudson. 2012. Current practices in determining return to play following head injury in professional football in the UK. Br J Sports Med 2012; 0: 201109068 (Original article). [this paper is Online First and is included in the upcoming November Print Issue of BJSM [BASEM Theme Issue].

There is no doubt that since the first consensus statement on concussion, conceived in Vienna in 2001 (read BJSM summary article here), every sport has raised its game on head injury and concussion management and reviews by the various sports over the years have resulted in updated and improved practice.

Football in this country has been similarly active.  At the behest of the FA medical committee, and as a result of collaboration between an eminent Premier League medical officer, and a Neurosurgeon working in sport, the current FA head injury guidelines were devised.  They were circulated to clubs in November 2009, and have been in use since then.

Since its inception the SCAT 2 form has been included in these guidelines, and is published as part of the head injury guidelines in the FA handbook (1), and on our website (here).

In their study Price et al (2) mention that many club medical officers ‘are not required to demonstrate any expertise in concussion management’.

Medical indemnity providers have insisted for some time that medical practitioners attending sporting events must ensure they are adequately trained to provide appropriate care for their athletes (3).  We would encourage any medical practitioner involved in sport to heed this message.

The initial questionnaires in this study (2) were sent to clubs before the availability of current guidelines. By the time the second batch of questionnaires were sent out, all clubs were in receipt of the current guidelines from the FA.  Hence, by the time conclusions were drawn in this study, they were not contemporary. They do not reflect current practice within professional football.  Nor do they represent the stance of the FA in dealing with this important issue.

In my experience, governing bodies and their medical officers will always be of help when trying to obtain up to date information regarding practice and policy within their respective sports if asked.

References
1. The FA Handbook, Rules and Regulations of The Association, season 2012-13.
2.  Current practices in determining return to play following head injury in professional football in the UK. Price, J., Malliaras, P., Hudson, Z.  Br J Sports Med 2012;0:1-5
3. MPS issues advice to doctors assisting at sporting events :  07 Jul, 2006. 

Editor’s note – link to the most current consensus document here – the Zurich (3rd) concussion guidelines (>47,00o page views as of October 8th, 2012).

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Dr Ian Beasley MBBS, MRCGP, MSc, DIP.Sports Med, FFSEM (UK) is Head of Medical Services Club England Division The FA Group Wembley Stadium, Wembley, London, HA9 0WS Ian.beasley@thefa.com