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Referring patients for exercise from the emergency department: A pilot study

4 Apr, 13 | by Karim Khan

By James R Griffiths



In 2006 NICE concluded that there was insufficient evidence to recommend the use of exercise referral schemes (ERS) to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. Despite this, there are approximately 600 ERS in the UK that primary care have access to. We looked at referring patients into the ERS in Barnsley (run by Barnsley Premier Leisure) from the Emergency Department.


Patients who attended the Emergency Department over a six-month period were screened for the exercise referral scheme. Posters were placed in the department advertising the scheme and encouraging patients to get more detail from a member of staff. Patients who met the inclusion criteria had a referral form faxed to their GP or practice nurse asking them to refer the patient on to the scheme.


Over the six-month period, 26 patients were referred to their GP or practice nurse. Of these only 10 were subsequently referred on to Barnsley Premier Leisure and only 3 patients attended for an initial assessment. No patients completed the 24 gym or swim sessions.


The results of this pilot study are obviously disappointing. We have tried to identify the barriers preventing patients from completing the scheme and have made changes to the way patients are referred onto the scheme.

We are hopeful that with better engagement from patients and GPs, we will be able to recruit patients on to the exercise referral scheme from the ED.



Hamstring injury mini-symposium (BJSM papers that will help you manage hamstring injuries).

16 Oct, 12 | by Karim Khan

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. 


Feasibility and efficiency of an under-desk exercise device: a pilot study

24 Sep, 12 | by Karim Khan

By Drs  Vadim N. Dedov and Irina V. Dedova


Background/Aim – Sedentary behaviour is associated with a variety of chronic diseases and considered as a health hazard. Worksite interventions, which decrease sedentary time and increase physical activity during working hours, may improve health of sedentary workers.

Methods – In this study we tested a specially designed exercise device, which allowed linear feet movements at the horizontal plane and hence the under-desk use. The device had friction resistance mechanism, which was equipped with a temperature sensor for objective monitoring of exercise intensity, duration and amount of exercise. Four healthy volunteers were provided with continuous access to the device during their normal activities at the desk.

Results – It was shown that the amount of exercise achieved during 30-minute dedicated device usage at moderate intensity was 131.0 kC⁰, as measured by the heat production in the device. According to the current exercise guidelines, this amount of exercise could be considered as the recommended daily amount of physical activity. Exercise concurrent with the use of computer resulted in the device usage equal to 251.6 kC⁰. The concurrent exercise was of lower intensity than dedicated exercise, but longer duration of device usage, which was achieved in several bouts, resulted in accumulation of significant total amounts of exercise.

Conclusion This study suggested for the first time that under desk exercise could complement the use of computer and result in accumulation of amounts of exercise exceeding the recommended daily amounts of physical activity. Larger studies are warranted for evaluation of under desk exercise in various sedentary occupations.



Physical inactivity is considered as an important health hazard and reduction of sedentary behaviour could improve population health by preventing the development of chronic diseases.1 However, the levels of physical activity at work are continuously declining2 and full-time workers in sedentary occupations remains immobile for approximately 11 hours per day and don’t have enough leisure time for sufficient exercise.3 Unfortunately, modern megatrends in information and communication technology may negate the effects of planned physical activity interventions.4 Conversely, regular physical activity in the workplace would result in decrease of sedentary time and hence in improvement of employees’ health. A variety of worksite exercise programmes were tested to increase employees’ physical activity.5 However, it might be argued that short bouts of exercise (e.g. use of stairs) are not lengthy enough for substantial reduction of sedentary time, whereas dedicated exercise bouts require allocation of extra time during working hours.

Exercise devices facilitate regular physical activity and three major types of conventional fitness machines were tested in the workplace. The use of treadmill was shown to be compatible with the worksite activities of medical transcriptionists6 and it was calculated that replacement of sitting with walking-and-working computer time for 2-3 hours/day would result in a weight loss of 20-30 kg/year in obese workers.7 However, treadmill walking caused decrease in the measures of fine motor skills and math problem as compared with seated conditions.8 A miniature bike installed in the office was used for 23.4 minutes a day on 3 out of 5 working days.9 A miniature stepping device increased the energy expenditure over sitting condition and it was calculated that, if it used to replace sitting by 2 hours per day, weight loss of 20 kg/year could occur.10

The under desk exercise device would have the advantage of convenience and accessibility for prolonged use during working hours. In this study we tested feasibility and efficiency of specially designed under-desk exercise device.



A novel resistance exercise device MedExercise ST (MDXD Pty Ltd, Australia) was used in this study (Figure 1A). Changes of temperature in the resistance unit were measured with a temperature sensor connected to the industrial multimeter IP57 (Digitech, Australia). Data was collected using respective software Multimeter V1.0 from Digitech and then converted into Excel databases (Microsoft, U.S.A.) for analysis. The average exercise-induced rise in temperature was calculated after subtraction of ambient temperature values. The heat production during usage of the device was expressed in kCo (average + SD), which was the average exercise-induced rise of temperature multiplied by the duration of recording in seconds. Fingertip pulse-oximeter CMS-50E (Contec, China) and corresponding SpO2 Review software were used for the continuous measurement of heart rates during the exercise. Overall, four healthy volunteers, aged between 36 and 49 years, participated in this study. Respective informed concerns were obtained. Statistical analysis was performed using the Student’s t-test.



Figure 1A shows the user sitting in the stationary chair, such as a standard visitor chair. During the exercise user’s feet were moving in horizontal plane without rising of the knee that allowed leg movements under the desk. Repeated leg flexion-extension cycles resulted in physical efforts of the user and respective heat production in the resistance mechanism of the device due to friction. Figure 1B shows that the usage of device installed under the desk caused a fast rise of temperature to the plateau level, whereas stopping of exercise resulted in a drop of temperature to the pre-exercise values.

The current physical activity guidelines suggest that all healthy adults aged 18 to 65 years need moderate intensity aerobic physical activity for a minimum of 30 min on 5 days each week’.11 Therefore, 30-minute usage of under-desk exercise device in moderate intensity could be considered as the recommended daily amount of exercise. Accordingly, the device was used for 30 minutes (Fig. 1B, pattern filled area) with no other activities involved (dedicated exercise). At this intensity of device usage, a pulse rate of the participant was around 100 bpm (Fig. 1C), which indicated a moderate intensity of exercise in healthy adults.12

The amount of device usage and hence the amount of exercise were calculated as the average exercise-induced temperature rise multiplied by the duration of recording expressed in seconds (Fig. 1B, double sided arrow). Overall, dedicated under desk exercise for 30 minutes resulted in the average temperature rise of 43.4+6.6 C⁰ and the corresponding total amount of device usage of 131.0+15.7 kC⁰ (n=5) (Fig. 1E and 1G, respectively). According to the current exercise guidelines,11 this amount of exercise might be considered as the recommended daily amount of physical activity, which was achieved solely by using of under-desk exercise device.

For the next set of experiments, the under-desk exercise device was used, while working with desk computer (concurrent exercise). A typical recording of exercise intensities during the concurrent exercise is presented at Fig. 1D. In this example a total duration of recording was 232 minutes (double sided arrow), which included the actual using of the device at various intensities for 146 minutes (pattern filled areas), breaks and time away from the desk. In contrast to the uniform intensity of device usage in dedicated exercise (Fig. 1B), the concurrent exercise pattern demonstrated significant variability in exercise intensity (Fig. 1D). Overall, the recording time was 221.6+67.5 minutes (n=7), including 128.5+25.1 minutes of actual exercise, which constituted 58% of the total recording time (Fig.1F). The average intensity of concurrent exercise was 18.9+4.7 C⁰ and a total amount of device usage amounted to 251.6+55.5 kC⁰.

Therefore, the average intensity of concurrent exercise was 2.3 times lower than in dedicated exercise (Fig. 1E). However, the longer total duration of device usage (Fig. 1F), which was accumulated during several exercise bouts separated by breaks, resulted in 1.9-fold larger amount of exercise than in 30-minute dedicated exercise (Fig. 1G). It could be calculated that on average 68.7 minutes of concurrent usage of the device was required to equal the recommended daily amount of physical activity achieved by the 30-minute dedicated exercise using the same exercise device.



Significant evidence is presented for the benefits of worksite exercise in sustaining employee health, whereas the technical features of conventional fitness machines may limit their use in the workplace. For example, installation of  ‘walk-and-work’ desk, which is based on treadmill, requires a significant modification of the workplace.13 In contrast, MedExercise ST was designed for use under the desk and hence can be used seated with the standard desks and chairs with no modifications.

Using this device, we have demonstrated for the first time the feasibility of effective under desk exercise at sufficient intensity and duration to be considered as the recommended daily amount of physical activity.11 This pilot study also suggested that the under-desk exercise machine could be used concurrent with computer and hence in the workplace. Therefore, it might be an effective tool for reducing time spent sedentary while at work and for achieving the recommended daily amount of exercise. Since the lower average intensity of concurrent exercise, it required longer duration of device usage (e.g. 68.7 minutes) to equal the recommended 30-minute daily exercise of moderate intensity.11 Nonetheless, 68.7 minutes constitutes only ~10.4% of daily sedentary time of working population.3

Importantly, the concurrent exercise does not require significant modifications of the lifestyle in order to allocate dedicated time for exercise. It might result in better adherence to regular physical activity regime and provide better health outcomes when used in combination with other modes of physical activity. Limitations of our study include a small number of participants and types of sedentary activities that warrants further studies. Future research is also needed to evaluate effect of the under desk exercise on employee productivity, health and weight loss.


Competing interests

Dr Vadim Dedov has a stake in MDXD Pty Ltd, which designed and produced the equipment used in this study.


This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Contributorship Statement

Both authors contributed equally in experimental design, data collection and analysis, and preparation of manuscript, which has been read and approved by them.


1.    Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012;380:219-29.

2.    Castillo-Retamal M, Hinckson EA. Measuring physical activity and sedentary behaviour at work: a review. Work 2011;40:345-57.

3.    Tudor-Locke C, Leonardi C, Johnson WD, et al. Time spent in physical activity and sedentary behaviors on the working day: the American time use survey. J Occup Environ Med 2011;53:1382-7.

4.    Pratt M, Sarmiento OL, Montes F, et al. The implications of megatrends in information and communication technology and transportation for changes in global physical activity. Lancet 2012;380:282-93.

5.    Archer WR, Batan MC, Buchanan LR, et al. Promising practices for the prevention and control of obesity in the worksite. Am J Health Promot 2011;25:12-26.

6.    Thompson WG, Levine JA. Productivity of transcriptionists using a treadmill desk. Work 2011;40:473-7.

7.    Levine JA, Miller JM. The energy expenditure of using a “walk-and-work” desk for office workers with obesity. Br J Sports Med 2007;41:558-61.

8.    John D, Bassett D, Thompson D, et al. Effect of using a treadmill workstation on performance of simulated office work tasks. J Phys Act Health 2009;6:617-24.

9.    Carr LJ, Walaska KA, Marcus BH. Feasibility of a portable pedal exercise machine for reducing sedentary time in the workplace. Br. J. Sports. Med. 2012;46:430-5.

10.  McAlpine DA, Manohar CU, McCrady SK, et al. An office-place stepping device to promote workplace physical activity. Br J Sports Med 2007;41:903-7.

11.  Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports. Exerc. 2007;39:1423-34.

12.  Norton K, Norton L, Sadgrove D. Position statement on physical activity and exercise intensity terminology. J Sci Med Sport 2010;13:496-502.

13.  Thompson WG, Foster RC, Eide DS, et al. Feasibility of a walking workstation to increase daily walking. Br. J. Sports Med. 2008;42:225-8.

Figure caption

Figure 1. (A) Position of the participant in stationary chair during exercise, using MedExercie ST device; (B) An example of exercise-induced temperature rise during 30-minute dedicated under desk exercise; (C) An example of the exercise-induced changes of participant’s pulse rate during 30-minute dedicated under desk exercise (bmp – beats per minute); (D) An example of exercise-induced temperature changes during under desk exercise concurrent with the use of computer; B-D: Pattern filled areas are periods of the actual using of the device. Double sided arrows show the duration of exercise intensity recordings. (E) Average intensity of device usage during the dedicated (DE) and concurrent (CE) under desk exercise, *P<0.01. (F) Average recording time of the dedicated (DR) and concurrent (CR) under desk exercise, and average duration of the actual device usage during concurrent exercise (CE); (G) A total amount of exercise achieved during dedicated (DE) and concurrent (CE) under desk exercise, *P<0.01.


Vadim N. Dedov, M.D., Ph.DFaculty of Medicine, University of New South Wales, NSW, Australia

Irina V. Dedova, M.D., Ph.DSchool of Medical Sciences, University of New South Wales, NSW, Australia


CT scans and X-rays increase risk of cancer – changing the goal posts in sports medicine

19 Sep, 12 | by Karim Khan

By John Orchard and Jessica Orchard

Two jaw-dropping papers from The Lancet 1 and BMJ 2 published in the past month should have a major effect on the practice of sports medicine.  They have clearly demonstrated that radiating scans in young people actually do lead to an increased risk of cancer later in life. Perhaps until 2012 this was a theoretical risk, but as of the publication of these landmark papers 1-3 we can be certain that the increased risk is not zero. There will be much more to come in this field over the next few years and it will dramatically change the landscape of radiology and all medical practice.

Pearce and colleagues’ study in The Lancet looked at the excess risk of leukaemia and brain tumours for children and young people exposed to CT scans. They found that children exposed to cumulative doses of 50mGy in CT scans may have triple the risk of leukaemia, and doses of 60mGy may have almost triple the risk of brain tumours1. Though this appears to be a massive increase in risk, the authors point out that these cancers are still relatively rare, causing an estimated one excess case of leukaemia and one excess brain tumour per 10,000 head CT scans. They are clearly cause for concern, as indicated by the fact that 12 other groups from 15 countries are studying the risk of scans on children3.

These Lancet findings are more striking when combined with the findings of Pijpe and colleagues’ GEN-RAD-RISK paper published last week in the BMJ2. This study showed that when women who carry a specific mutation associated with breast cancer (BRCA1/2), and who  were exposed to diagnostic radiation before the age of 30, had almost twice the risk of breast cancer (with a dose-response pattern). This study involved lower doses which we have previously considered fairly ‘safe’ (e.g. 4mGy from a single mammogram or shoulder x-ray). Therefore, BRCA1/2 carriers, with an already increased risk of a very common cancer, would be particularly at risk from exposure from radiating scans at a young age.

Why does this matter for sports and exercise medicine?

Sports and exercise medicine is a field in which most patients have many years of life expectancy remaining; it is also a field in which diagnostic imaging is very common. Imaging is often confined to the limbs but also involves the spine.  Importantly,  the GEN-RAD-RISK paper showed, for example, that shoulder X-rays in women with the BRCA1/2 mutation can increase the risk of breast cancer. This does not prove that a shoulder X-ray is unsafe for the entire female population, but because it is quite plausible, we need to reassess the use of radiating scans. The authors of this study have already recommended that women with the BRCA1/2 mutations should not get mammograms and it is hard to see how this recommendation will not soon be extended to all younger women, as mammograms are meant to be preventing deaths from cancer, not causing them.

Studies have not been published to look at, for example, the risk of  cancers in the abdominal cavity (e.g. bowel, ovarian) after lumbar spine CT scan, but again we have to presume from the existing knowledge that the increased cancer risk is not zero. In this case,  the unknown is the size of the increase in cancer risk (and not whether there actually is one). All tests (and treatments) in medicine need to consider benefits, risks and costs. On the benefit side, the test which gives the best information relevant to management needs to be identified. This can’t be done in isolation of the increased cancer risk of radiating scans, particularly in young or middle aged patients.

There will still be cases where a test that involves radiation is going to give preferred information to a non-radiating one – a classic example being in the knee of a 70 year old, where X-ray will tell what needs to be known in 95% of cases and MRI scan is generally an excessive use of imaging. However in scenarios where we used to recommend radiating tests (e.g. CT and bone scan to investigate for suspected pars stress fracture in an adolescent) we may need to quickly change to a recommendation of first line MRI scan to avoid increasing the risk of cancer. Health systems are going to need to change in scenarios where radiating tests are funded but non-radiating tests aren’t, because clearly it would raise ethical questions for a health system to be funding (offering a financial incentive) to have a test which can increase a patient’s risk of cancer when a non-risky test is available but unfunded.

Up to fifty years ago, some shoe stores used to perform X-rays on the spot to show whether a kid’s shoe was fitting well4 – this practice is now considered archaic.  Sensibly there is now an attitude in medicine that a pregnant woman should not receive an X-ray or CT scan if the information could be obtained in any other fashion. We are probably heading into an era where the same attitude needs to apply to all children and young people, for CT scan and even X-ray. Modalities such as MRI and ultrasound (and good old-fashioned clinical examination) will need to become more prominent in sports and exercise medicine, at the expense of radiating examinations. These studies highlighted in the blog will generate a demand for consensus meetings involving sports physicians, radiologists, radiation physicists, and epidemiologists among others to provide guidance for clinicians, professional bodies and patients. Depending on the recommendations made at consensus meetings, there should ideally also be a review of government/insurance funding arrangements to remove any financial incentives towards the inappropriate use of radiating scans.


John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at www.johnorchard.comand/or follow @DrJohnOrchard on Twitter

Jessica Orchard is an Australian lawyer with qualifications in economics and public health, currently employed at the NSW Cancer Council. Her views in blogs are also personal and not necessarily representative of her affiliated organisations.


  1. Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505.
  2. Pijpe A at al. Exposure to diagnostic radiation and risk of breast cancer among carriers of BRCA1/2 mutations:  retrospective cohort study (GENE-RAD-RISK).BMJ. 2012 Sep 6;345:e5660.
  3. Einstein AJ. Beyond the bombs: cancer risks of low-dose medical radiation. Lancet. 2012 Aug 4;380(9840):455-7.
  4. Bowden T. Frying one’s gonads for shoes.

Designer Bodies: Anabolic steroid use in high schools

2 Aug, 12 | by Karim Khan

By Dr Glen Hagemann

Sports Physician and President of the South African Sports Medicine Association (SASMA)


Last year Discovery Sharksmart  anonymously surveyed 9824 male pupils attending 20 high schools in South Africa regarding various lifestyle behaviours.  One section of the questionnaire related to the use of anabolic steroids, the results of which proved both interesting and somewhat surprising. The response rate to the survey was in excess of 85% meaning that the results could be seen as representative of the high school population surveyed. In the survey approximately 5% of the respondents acknowledged having tried steroids at some stage in their lives – this figure was lowest for grade 8’s (1.2%), as expected, and highest for grade 12’s (9.5%). It is possible that these figures are indeed an underestimation of the real situation as a result of under-reporting.

The results of the survey are not only surprising in that they reveal the relatively frequent use of anabolic steroids, but also because the main reason reported for steroid use is for self-image reasons, and not for enhancing sporting performance, as is the common perception. Two thirds of the pupils who had used steroids stated that they did so primarily to “look good”, while only a third did so to perform better on the sports field. Incidentally, the main source for obtaining steroids by schoolboys was reported to be from gyms.

We then looked at the association between steroid use and other lifestyle factors, using a statistical measure called “the odds ratio”. This ratio measures the strength of the association between two behaviours; the higher the odds ratio, the stronger the association.  We found that steroid use and a perceived excessive pressure to perform on the sports field had an odds ratio of 2.5. Other associations with steroid use in order of increasing strength are: physical violence (odds ratio = 4.2), suicidal thoughts (odds ratio = 4.4), recreational drug use (odds ratio = 5.5) and hard drug use (7.2).

The finding that steroid use has the strongest association with recreational and hard drug use, and the weakest association with sports performance, suggests that steroid use in our schools is a “lifestyle” or social problem; it is more of a social behaviour undertaken for social reasons, similar to the use and abuse of mind altering drugs like marijuana, ecstasy and cocaine. With this in mind then, it was easier to understand why half of the nearly 10,000 respondents indicated in the survey that they did not consider the use of steroids as “cheating”; the notion of cheating is only relevant to a sporting context.

In this material world of designer clothes, shoes, accessories and electronics, have some of our youth reached a point where the use of body altering drugs like anabolic steroids to produce designer bodies is just an extension of this culture?

The South African Sports Medicine Association (SASMA) is one of 8 international member societies that partners with BJSM. See the South Africa focussed issue of BJSM (June 2012) by clicking here.


Mechanisms, persistence, and prevention of airway dysfunction in swimmers

25 Jul, 12 | by Karim Khan

Swimming is consistently one of the most popular Olympic sports.

However, at BJSM we don’t care about Twitter gossip on Australian swimmer Stephanie Rice, nor are we particularly concerned if US Champion Michael Phelps wins more medals. We, of course, are interested in noteworthy research on swimmers’ health.


We focus today on Valérie Bougault and Louis-Philippe Boulet’s BJSM publication: Airway dysfunction in swimmers (May 2012). The authors discuss “upper and lower airway disorders in swimmers, underlying mechanisms of development and persistence, their general management and the future research needed to help understand their clinical significance in order to prevent potential long term damage to the airways.” Over 5,000 readers have accessed this paper – it’s on the way to being a landmark in the field.


Read the full article to learn more about the diagnosis, treatment and prevention of: the effects of chlorine, mechanisms of rhinitis, pulmonary/airway function changes, and their impact on athletic performance.


Bougault and Boulet’s insightful article is (free!) online here.


Want more on respiratory health in elite and amateur athletes?



BJSM special issue on intensive exercise and respiratory health (May 2012). Including:

Bicycling opportunities and injury risk–both are about exposure

8 Mar, 12 | by Caroline Finch

Guest blog by @CarolineFinch

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

One of the most researched areas in road safety and injury prevention is that of bicyclist safety. In fact, my own initial foray into injury prevention research in the early 1990s was as a member of the team that evaluated the population-level impact of the first mandatory bicycle helmet wearing law (1). The topic of bicycle helmet effectiveness remains a topic of much debate despite much evidence that they are effective if worn correctly. Bicycling is also a major focus of current active transportation and physical activity research.

The February 2011 issue of Injury Prevention includes several papers relating to bicycling injury that are of relevance to anyone interested in increasing this form of physical activity. The first paper, by Poulos et al. presents the protocol of study that aims to describe the incidence of crashes, near-misses and injury rates in relation to bicyclist exposure factors including the time and distance travelled and the type of road infrastructure used. As the authors point out it is not fully obvious which type of bicycling infrastructure provides overall best safety gains and this needs further research. They cite the example that paths that are designed to protect bicyclists from road traffic, but which enable sharing by bicyclists and pedestrians, may in fact increase total injury rates due to collisions with pedestrians in which either type of oath user is injured. The study plans to recruit people who self-identify as active bicyclists and then to conduct two-monthly follow-up surveys with them to collect information about their bicycling habits and injury experiences.

Another paper in the same issue, by Ackery and colleagues, describes a case-control study of bicyclist deaths in the USA e documented as part of the well-established national Fatality Analysis Reporting System. This system includes all fatal crashes involving a motor vehicle on public roadways and so the bicyclist injuries were all the result of a collision with a motor vehicle. The study explored a range of exposure factors such as travel time of day, posted speed limits, and the type of vehicle collided with in both fatal cases and controls who were non-bicyclist road deaths. The most significant finding was that a disproportionately high proportion of the bicyclist deaths, compared to controls, involved larger and more expensive vehicles. The authors concluded that transportation policy should consider strategies to separate bicyclists from other very large road users.

The first French case-control study of helmet wearing and bicyclist injuries is described in a paper by Amoros et al. All study participants were recruited from a road trauma registry, with cases being bicyclists with a head injury and the control being bicyclists without head or neck injuries. Exposure to particular road infrastructure at the time of injury was collected in terms of the crash setting being on an urban or rural road and the type of road (as being major, local, or “off”). Evidence from this study is in support of the protective benefits of helmets.

As with all areas of physical activity promotion, there is a very clear and strong overlap with injury prevention. The bicycling context provides a graphic example of how increased exposure to a given ideal behaviour (e.g. in terms of duration of activity), can also increase the risk of adverse outcomes such as injury. Injury researchers have long known this and have a history of well-developed robust methods for measuring bicyclist exposure (e.g. in (1)). The success of active transportation as a physical activity will depend on there being suitable safe infrastructure and environments for the bicycling to occur in and the amount of bicycling (or exposure to positive physical activity) that ensues will be directly related to this. Conversely, increased exposure to hazards within those same environments, whether due to longer amounts of accumulated time spent bicycling or bicycling in settings with particularly high traffic volumes or poor road conditions, can lead to increased risk of bicycling injury. Active transportation policy developments will need to consider the provision of infrastructure to protect and support the needs of all road users, including those who wish to use it for their physical activity benefits, rather than just as a means of getting from a to b.

Additional reference
(1) Cameron MH, Vulcan PA, Finch CF, Newstead SV. Mandatory bicycle helmet use following a decade of helmet promotion in Victoria, Australia – an evaluation. Accident Analysis and Prevention. 1994, 26:325-337.

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.


Injury surveillance on young elite athletes participating in the 1st Winter Youth Olympic Games in Innsbruck/Austria

27 Dec, 11 | by Karim Khan

BJSM e-letter by:

Gerhard Ruedl and Wolfgang Schobersberger

E-letter for: Kathrin Steffen, Lars Engebretsen. The Youth Olympic Games and a new awakening for sports and exercise medicine. BJSM. 2011; 45: 1251-1252 (Warm up)

Photo courtesy of IYOGOC

Do we really want to see our young promising talents go through a major injury at one stage into their career?

Definitely no!

However, in competitive alpine skiing, snowboarding and freestyle, the risk to get major head and anterior cruciate ligament injuries is indeed high [1-4]. Therefore, training focussing on injury prevention should start at an early age and should go along with the athletes’ career. To implement evidence based preventive measures, however, it is of utmost importance to investigate first of all data on occurrence and severity of injuries according to the 4-step model of injury prevention research [5].

At this point of time, there is little data available concerning the injury risk of youth elite athletes competing in winter sports [6, 7]. Therefore, we will conduct a systematic injury and illness surveillance on young elite athletes participating in the 1st Winter Youth Olympic Games in Innsbruck/Austria in January 2012.  Let us work together to get meaningful data as a basis for further research on injury risk factors and injury mechanisms and finally on injury prevention strategies among young elite winter sport athletes.

We are glad to welcome you in Innsbruck!

(1) Pujol N, Blanchi MP, Chambat P. The incidence of anterior cruciate ligament injuries among competitive alpine skiers.  Am J Sports Med 2007; 35: 1070-4.
(2) Florenes TW, Bere T, Nordsletten L et al. Injuries among male and female World Cup alpine skiers. Br J Sports Med 2009; 43: 973-8.
(3) Florenes TW, Nordsletten L, Heir S et al. Injuries among World Cup freestyle skiers. Br J Sports Med 2010; 44: 803-8.
(4) Florenes TW, Nordsletten L, Heir S et al. Injuries among World Cup ski and snowboard atlethes. Scand J Med Sci Sports. 2010 Jun 18 [Epub ahead of print].
(5) Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 2005; 39: 324-9.
(6) Steffen K, Engebretsen L. The Youth Olympic Games and a new awakening for sports and exercise medicine. Br J Sports Med 2011; 45: 1251-52.
(7) Steffen K, Engebretsen L. More data needed on injury risk among young elite athletes. Br J Sports Med 2010; 44: 485-9.


Gerhard Ruedl is a Senior Researcher at the Department of Sport Science, University of Innsbruck, Austria

Wolfgang Schobersberger is the Chief Medical Officer of Winter Youth Olympic Games in Innsbruck; Institute for Sports Medicine, Alpine Medicine &amp; Health Tourism Innsbruck/Austria

23 and a half hours video passes 2 million views!

12 Dec, 11 | by Karim Khan

Mike Evans circulated this to his hockey team of kids early in December 2011.  #1 educational video on YouTube. Remember that low fitness (<30 mins of physical activity daily) kills more Americans that smoking, diabetes, and obesity combined (smokadiabesity).

Click on this link. Watch it, share it. Do it yourself.

Encourage patients to watch it and start today! Great ‘sticky’ message capturing Steve Blair’s evidence that this treatment will save more American’s lives than a cure for smoking, diabetes and obesity put together. That’s a fact!

It passed 2 million views in February, 2012. Wow!!

No magical therapeutic benefit of PRP in Achilles tendinopathy — JAMA paper follow-up and BJSM podcast

18 Oct, 11 | by Karim Khan

My sense is that the popularity of platelet-rich plasma (PRP) is increasing independent of research in this field. BJSM has covered this with front cover attention:

Of most interest to blog readers will be the Podcast on PRP with Robert Jan de Vos and Adam Weir. These authors have arguably the highest quality study testing PRP to date. We congratulate the Dutch researchers on their quality study design and comprehensive investigations.


– No clinical benefit in 6 months:

–  No ultrasound evidence of benefit:

– and now no benefit at 12 months:

No benefit at 12 months is not a surprise given previous findings. The proposed mechanism for PRP therapy is accelerated early healing. Nevertheless, these data are important as some evangelical PRP providers may be tempted to discount the 6-month results and argue for a ‘delayed benefit’. This is not the last word on PRP and BJSM Associate Editor Kim Harmon (see: Musculoskeletal ultrasound: taking sports medicine to the next level) has pointed out reasons for this series of Dutch studies having ‘no effect’. BJSM is one of the leading venues for rational debate on PRP and we look forward to adding to your knowledge about the clinical utility of this ‘hot’ therapy that is gaining clinical popularity. Time for a quality randomized trial of PRP versus the Alfredson program for Achilles tendinopathy?

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