By Ann Gates

(@exerciseworks)

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

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

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

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

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

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

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

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

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

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

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

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

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Ann Gates BPharm(Hons)  MRPharmS

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

Founder of Exercise Works!

www.exercise-works.org

@exerciseworks

email: ann@exercise-works.org

 Guest blog by @CarolineFinch

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

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

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

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

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

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

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

References

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

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

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

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

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

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are
published by the BMJ Group.

Caroline can be followed on Twitter @CarolineFinch

Guest blog by Dr Steven Cox (from CRY – Cardiac Risk in the Young

The UK’s National Health Service (NHS)  policy – that “screening should not be offered*”  is currently discouraging young people who may be at risk of sudden cardiac death from having simple, non-invasive and potentially life-saving tests.

The National Screening Committee need to review its position which is out of date

It is the view of the charity Cardiac Risk in the Young (CRY) that:

• All young people (14-35 years old) should be offered the option to have cardiac screening
• Cardiac testing should only be conducted by specialist cardiologists with the necessary skills and expertise to ensure accurate interpretation of the investigations.
• The National Screening Committee policy should widen the remit to consider all cardiac conditions that can cause young sudden cardiac death
• The National Screening Committee policy directly contradicts with the general NHS policy of “prevention”

Can anyone do these tests?

Cardiac screening needs to be overseen by a cardiologist with expertise in this specialist area of cardiology, including; athletes heart, ethnic differences in cardiac adaptation to exercise, and structural/electrical cardiac conditions. Professor Sanjay Sharma is a leading sports cardiologist and CRY’s consultant cardiologist who gives his time to oversee the CRY screening programme.

When a specialist cardiologist conducts the tests the number of false positives and false negatives significantly decrease (i.e. fewer people are told they may have a problem and are subjected to further investigations when they do not have a problem, and fewer people with a problem are given an all clear).

Could the NHS handle so many people wanting testing?

In the current economic era the answer is probably not. Moreover the NHS does not have the infrastructure, including the facilities or the expertise, to immediately implement a national screening programme for ALL young people.

However, CRY is leading the way in training specialist doctors, conducting research and providing educational resources so this will be possible in the future.

Although the implementation of nationwide screening is hampered at this point due to the economic constrains and lack of infrastructure and expertise that does not mean that screening should not be recommended. On the contrary, these limitations should prompt the development of a collaborative scheme between the Government, NHS, charity organisations such as CRY and sporting bodies to provide an initiative to offer cost effective screening.

Is there any evidence from other countries that screening is worthwhile?

In Italy where screening prior to participation in organised sport is mandatory they have reduced the incidence of young sudden cardiac death by 90%. This research has informed international policies that either mandate or recommend cardiac screening prior to participation in organised sport.

 Guest Blog by @CarolineFinch

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

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

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

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

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

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

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

Success stories:

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

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

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

Photo by Serge Melki, Flickr CC

Exercise  during pregnancy provides many benefits to the mother and baby. Fortunately, clinicians and mothers have moved well beyond the view that women should be confined, or cannot initiate activity and be active at any stage of pregnancy. Here are 10 ‘take home messages’ for both clinicians and mums from a recent BMJ podcast with Dr. Browyn Bell.

1. Consider type, frequency and duration; a combination of different types of exercise is important to:

• Reap the different rewards of different types of exercise (pre, during, and post-partum)
• Prepare women for the physical demands of pregnancy and motherhood
• Maintain a healthy bodyweight which decreases likelihood of pregnancy complications

2. There are multiple benefits to exercise during pregnancy such as:

• Prevention of Gestational Diabetes
• Reduction of stress and fatigue

3. Keep core body temperature below 38.5 degrees Celsius (especially in the first trimester)

4. Avoid contact sports, scuba diving, and supine exercises during later pregnancy (listen to the podcast for specifics/details)

5. Consider pre-existing health conditions that may become more pronounced during pregnancy

6. For sedentary pregnant woman who want to start exercising, guidelines are the same as for non-pregnant women (gradual increase in activity)

7. One way to ensure a safe exercise intensity is by maintaining a conversation during exercise

8. Women are encouraged to continue exercise during all stages of pregnancy (even if performance ability is reduced)

9. As always, make healthy food choices

10. Everyone has different (pre-existing and unique) health and physical needs. Common sense activities such as walking are always a good idea. Consult a physician or physiotherapist to develop an individualized approach to exercise.

Follow this link to listen to the complete podcast

Related Articles

Artal, R and O’Toole, M. 2003. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med 2003;37:6-12 . (FREE ONLINE!)

Ruben Barakat, R, Cordero Y, and CoteronJ et al. 2011. Exercise during pregnancy improves maternal glucose screen at 24–28 weeks: a randomised controlled trial. Br J Sports Med Published Online First: 26 September 2011.

Guest blog by George Murley

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

Screen shot from: The Barefoot Professor - by Nature Video

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

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

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

There are a ton of unanswered questions:

Does athletic shod or unshod running affect injury risk?

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

Which biomechanical parameters are related to injury risk?

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

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

References:

Podiatry Arena (extensive blogging on this issue)

Simon Bartold’s presentation

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

The Barefoot Professor: by Nature Video

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

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

Related BJSM Blog

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

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

BJSM reader poll results

By Tim Noakes

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

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

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

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

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

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

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

Related BJSM Blogs

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

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

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Dr. Timothy Noakes is a Sports Physician, Exercise Physiologist and Discovery Health Professor of Exercise and Sports Science at the University of Cape Town and Sports Science Institute of South Africa.

By Dr. Bert Fields

Photo of Daniela Hantuchova by Sasho

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

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

Related BJSM Articles

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

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

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

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

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

By @DrJohnOrchard

I have just started working in my 15^th season as a professional NRL (National Rugby League, Australia) team doctor but with respect to one injury feel as uneasy as I ever have at any stage of working in sports medicine. In theory I should be more experienced and therefore more relaxed at being able to cope with what the game can throw up at me. I am worried about one of my players suffering a minor concussion in a game, which is almost certainly going to happen in the next 6-8 weeks.

I’m not worried about one of my players suffering a significant concussion, which probably also will happen. By significant, I mean either than he is knocked out (for, say, >=10 seconds) or he is disoriented and reports are coming through that he doesn’t know where he is or what he is doing in the match. In this situation, the management will be simple – the player will come off the ground, I’ll recommend that he doesn’t come back on and the coaching staff for my team (who have a very responsible attitude towards injured players) will take my advice, with the player done for the day.

Why am I more worried about the so-called ‘minor’ concussion than the more serious one? Because the NRL has just brought in a rule that if a doctor assesses a player as having had a concussion (irrespective of whether he has been deemed to have recovered), then the player must not be allowed to return to play in that game. In bringing this zero-tolerance rule in, the NRL are following international trends and appearing to be doing the right thing by players. The problem is that the NRL haven’t really properly defined concussion (which doesn’t distinguish them too badly as even the consensus panels struggle to give a good definition) and, more importantly, haven’t defined a severity cut-off. I’ve seen players in the NRL before get knocked out cold for 60 seconds, come off on a Medicab, and 20 minutes later return to the field. I agree that this is not a good look and in the current climate we need to stop it happening with rule changes. So there is a part of me that is happy that the regulators are trying to stamp this sort of practice out.

The part of me that isn’t comfortable came out at an internal club meeting we had the other day. I told the coaching and training staff that the new official rule was that if I examined a player and determined that he had been concussed that day that, under the new rules, I couldn’t let him return to the field and the club couldn’t overrule me. However, it was quickly pointed out, if I didn’t examine the player, then the rules would allow him to continue. I think everyone can see where this is heading. An anonymous NRL player has blatantly recorded in the Sydney papers that players will avoid doctors and lie to them to make sure they aren’t removed from the field under the new rules.

Thus, I am either going to be put in one of the 3 uncomfortable positions very soon:

1. That I am going to be pulling players out of the game who I have been comfortable letting continue for many years, and possibly hurting our team’s chances of winning games.
2. That I am going to turn a blind eye and not examine or fully assess a player who looks as though he is fit to continue.
3.  That I am going to re-name something I used to call “mild transient concussion” something different like “traumatic migraine” so the player can be allowed to continue, even though deep down I think that the player has probably had a very mild concussion that has quickly recovered.

Over the past 14 years I have overseen about 10000 player games and have recorded approximately 250 concussions (about one in every 40 player games). I would also expect that maybe even second incident that could count as a concussion I wouldn’t even see/record (i.e. a player wouldn’t necessarily report symptoms to me). Of the 250 I did record, about 100 (less than half) left the field on the day, with 68 coming off for good and the other 32 being allowed to return to the game at some stage with a careful eye being kept on them by me and the on-field trainers. I am not aware of any of these players coming to long-term harm as a result of the concussions they have suffered – certainly none seemed to in the time that they were with the team.

I am aware that there is now a massive question mark over the long term effects of concussion, in that ex-footballers seem to have a higher rate than normal of erratic behaviour, including depression and suicide. The problem is whether you can pin these characteristics on concussion or simply playing professional team sport which attracts risk-taking, mood-swinging behaviour types. Cricketers are also renowned for having psychological issues post-retirement, yet the rate of concussion is very low. We obviously need some well conducted case-control studies (by well-conducted I mean where players with depression aren’t prompted to remember their previous concussions any more than players who are living happily). Sadly we aren’t going to get much further high quality research before we get the hysteria associated with the NFL concussion lawsuits, where retired players who have managed to blow their post-football life are going to have a crack at arguing that the concussions they received in the NFL were responsible. I’m not suggesting that they have no right to take action, but I think everyone can understand that in the absence of definitive scientific evidence that such a case will be decided by emotive arguments to a judge rather than a proven scientific link being established.

Will team doctors become the meat in the sandwich? Collision sports have rules which encourage a limited amount of violence and you win games by dominating the opposition players. If players are injured and come off the park, teams lose games. Perhaps there will be a trend for the leagues to pin the responsibility for player safety on the team doctors, yet the doctors get paid by the teams whose primary responsibility is to try to win games. One thing that the leagues can do, and which the NRL did very well last week, is crack down on high contact and increase penalties and suspensions to give a disincentive for players to tackle in such a way that concussions could result.

I was previously comfortable with a middle-ground approach to concussion – removing those who had moderate to severe symptoms from the game and watching those with mild symptoms which recovered quickly to make sure they didn’t get worse or become recurrent. It is probably a responsibility of the collision sports to ensure that players with moderate or severe concussions do not return to play on the same day (but to allow for enough substitutions so that teams aren’t disadvantaged by medically doing the right thing). A further dilemma for the contact sports is on how to handle the so-called ‘minor’ concussions where a player doesn’t get knocked unconscious but has transient symptoms lasting for less than a minute. Removing all of these players for the day is very problematic (and if it is mandated it becomes very difficult to police). No doubt it will be a major topic of discussion in the 4^th concussion in sport consensus statement conference  in Zurich this November.

Related BJSM Publications

International Olympic Committee’s special BJSM issue – Injury Prevention and Health Protection (IPHP): Read about that here.

BJSM publication of the proceedings of the 3rd International Conference on Concussion in Sport (Zurich 2008).

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John Orchard BA, MD, PhD, FACSP, FACSM, FFSEM (UK), is a Sports Physician, and an Adjunct Associate Professor at the University of Sydney, School of Public Health.

Guest blog by Professor Lars Engebretsen

Photo by Aktivioslo, Flickr CC

The recent World Championship in Snowboard in Oslo, Norway led me to the question in this blog’s title. I am a sports doc with extensive experience in treating high level athletes in almost all kinds of sports (except Aussie rules football and cricket).

Since 2000, I have been involved in studies aiming at preventing sports injuries. We have targeted football (soccer), team handball and Alpine skiing and have had some success.  Newer sports however, keep popping up. Almost like the doping hunters  - often being too late to prevent new, effective performance drugs – it seems that we are too late to prevent injuries in some of the new sports.  I was reminded of this during the recent Snowboard Championship in Oslo: new venues for cross, half pipe and slope style situated beautifully in the Oslo countryside. The first days had bad weather and difficult light and there were some serious injuries- not life threatening, but nevertheless serious.

I have noticed a similarity with the last few Olympic games: the venues get bigger, the athletes better trained and with ever increasing abilities. Unfortunately, there is also an increase in injuries. The numbers from Vancouver showed that 35% of snowboard cross and 13% of half pipers experienced injuries.

What can we do to prevent these? We can count injuries, identify risk factors, study how to reduce these and aggressively implement our knowledge. In the meantime, the sporting venues get larger and more challenging and knowledge from our studies become yesterday’s news. I know that the majority of the athletes appreciate the danger, but I am not sure that the top leaders of the sport have the same awareness.

I need ideas to help the athletes operate in a safer environment- any ideas?

Note that the BJSM publishes 4 issues a year dedicated to Injury Prevention and athletes’ Health Protection (IPHP). You can find these issues of BJSM by clicking here. The next IPHP issue will launch in June and will focus on Olympic Sports. IPHP issues are published as part of BJSM’s partnership with the International Olympic Committee.

Nik Zoricik dcath: News story here. (added March 10th). Updated March 15th

Related Articles

Bakken A, Bere T, and Bahr R et. al. 2011. Mechanisms of injuries in World Cup Snowboard Cross: a systematic video analysis of 19 cases. Br J Sports Med. 45:1315-1322 Published Online First: 15 November 2011.

Lars Engebretsen L and  Steffen K. 2009. Warm up The importance of sports medicine for the Vancouver Olympic Games. Br J Sports Med. 43:961-962.

J Torjussen J,  and Bahr R. 2006. Injuries among elite snowboarders (FIS Snowboard World Cup). Br J Sports Med. 40:230-234 .

Engebretsen L, and Bahr R. 2005. Injury prevention – Leader An ounce of prevention? Br J Sports Med. 39:312-313.

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Lars Engebretsen MD PhD is a professor and director of research at Orthopaedic Center, Ullevål university hospital and University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center. He is also Chief Doctor for the Norwegian Federation of Sports, and headed the medical service at the Norwegian Olympic Center until the autumn of 2011. In 2007 he was appointed Head of Science and Research for the International Olympic Comittee (IOC). Professor Engebretsen is Editor of the IPHP issues of BJSM (Injury Prevention & Health Protection)