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Sport and exercise medicine discipline

The Premier League and the Professional Footballers Association must censure Chelsea: by Professor William Tormey

15 Aug, 15 | by Karim Khan

PLDocs

Medical ethics clashes with team priorities

Jose Mourinho’s actions in criticising Dr Eva Carneiro and physiotherapist Jon Fearn for attending an injured player on the pitch at Chelsea must be vigorously challenged. The General Medical Council’s ‘Good Medical Practice’ states that the doctor must make the care of the patient the first concern and take prompt action if the doctor thinks that patient safety, dignity or comfort is being compromised.

The treatment of Dr Eva Carneiro by Chelsea was unprofessional, carried out in public and should have consequences. Her judgement was denigrated despite her obvious concern for the injured player. Public humiliation is no way to treat any club doctor.

The attendant massive publicity demands that the British Medical Association and the professional bodies involved in sports medicine insure that medical ethics are respected. The Premier League and the Professional Footballers Association must censure Chelsea and publicly assert support for good professional standards in their medical services. There should be no equivocation.

 

Professor William Tormey

Biomedical Sciences

Ulster University

Coleraine

Northern Ireland

Phone 00353872544646

 

There are no financial associations and no conflicts of interests

4 ‘must attend’ BASEM/FSEM conference sessions on physical activity and young people

6 Sep, 14 | by BJSM

By Beth Cameron, PR & Communications, Faculty of Sport and Exercise Medicine @FSEM_UK

action schools logoThis year’s joint BASEM and FSEM Conference, Walk 500 Miles, will include four, not to be missed, sessions covering paediatric medicine. The session starts at 2pm in Edinburgh’s historic Assembly Rooms, on Thursday 2nd October, with Heather McKay, Professor of the Faculty of Medicine University of British Columbia, opening with A School-Based Physical Activity Success Story – Action Schools! a trial based in British Columbia.

The Action Schools! programme uses a comprehensive health model (socio-ecological approach) to provide children with healthier opportunities for physical activity and healthy eating at school. Professor McKay’s presentation will cover 10 years of practical lessons from school based trials and evidence from efficacy, effectiveness and implementation trials from the inception of Action Schools! in 2004 covering 10 schools, to its scale-up covering 1500 schools.

The second session brings us closer to home with Dr Nicola Crabtree, Principal Clinical Scientist and Research Physicist at Birmingham Children’s Hospital, presenting Physical Activity during Childhood. Dr Crabtree will discuss bone as a living tissue, which responds to local and environmental stimuli and howphysical activity and mechanical loading plays an important role in the development of an optimal skeleton resistant to fracture, both during childhood and later adult life.

Neil Armstrong, Professor of Paediatric Physiology and the Provost of the University of Exeter, will follow this by asking: Young People are Fit and Active – Fact or Fiction? This presentation will provide critical analysis of what we know about young people’s physical activity and aerobic fitness in relation to health and well-being. The dose-response evidence underpinning the health-related benefits of physical activity and aerobic fitness during childhood and adolescence is not as compelling as that during adulthood. How many young people are fit and active enough?

The Paediatric session closes with Dr Karl Johnson, Consultant Paediatric Radiologist at Birmingham Children’s Hospital, talking about Imaging Acute and Chronic Injuries in Children and Adolescents. This talk will highlight the imaging differences between children and adults and illustrate the various imaging modalities available. In many instances, the injuries are specific to the paediatric age group as a consequence of the inherent weakness of the growing skeleton and the different dynamics of the paediatric musculoskeletal system.

To book your place at Walk 500 miles visit the conference web page at http://www.ba-sem.co.uk/bookings

Competing interest: This page was posted directly by @FSEM_UK via the BJSM Blog Editor – it was NOT commissioned by the Editor in Chief of BJSM Karim Khan, nor was it edited in any way by him. (arm’s length)

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

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

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

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


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

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

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

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

  1. Correct Diagnosis (correction, hypothesis)

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

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

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

  1. Correct Treatment and Rehabilitation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NvD

 

Live from Glasgow’s Sports Medicine Tent – 5 tips from #Games Doctor

29 Jul, 14 | by Karim Khan

By Doctor Rebecca Robinson @RjpRobinson

In July 2014, I was fortunate enough to be offered the opportunity of a registrar’s lifetime. Working with Team England in medical headquarters for the Glasgow Commonwealth Games. Here are my Top 5 Tips:

Glasgow1. Preparation, preparation, organisation

Games time comes and goes fast, so do your homework. Arriving a week before the Opening Ceremony in Glasgow provided a great opportunity to set up an efficient medical room. Check out competition schedules, venues and transport systems now to deliver care smoothly.

Medically screening the majority of the 600 Team England competitors as they arrived was invaluable to avoid last-minute concerns, with additional benefits in establishing athlete-doctor relations.

Familiarise yourself with the arena and its rules: can you see the athlete in the mixed zone? Where is the defibrillator and can you switch it on? Who can treat a blood injury in a boxing ring? With a grasp of the basics, immersing yourself in the squash court, judo hall, velodrome and track adds immeasurably to theoretical knowledge.

2. Work with the best to become better

A multisport games is a unique melting pot. The world’s best athletes supported by expertise in sports medicine, physiology and management garnished by multinational cultures.

Working alongside a wealth of experience in Team England Headquarters revealed a group of individuals every bit as dedicated as the podium athletes with their indefatiguable work-ethic.

Simply existing in this environment is a unique learning experience. Be observant.

Key to Team England was a cohesive, supportive team environment across medics, physios and HQ staff, in which all members views were valued.

There will be times to take initiative, but recognise the expertise around you. With hard work, you’ll be back for future games, but your athlete may not. If in doubt or if you think you know the answer: ask. Remember there’s no such thing as a stupid question. Do not work in isolation or outside your competency.

3. Pace Yourself

It’s a marathon. And a sprint, rugby sevens, a triathlon and track cycling: and that’s just day 1!

With a 3-week stay in the Village bubble, it was imperative to sustain energy to respond safely to medical emergencies, meet last-minute needs of anxious athletes calmly and keep a ready smile for every single volunteer, physio, cleaner and policeman (yes, they really do smile at you at Games time!)

Everyone making the games happen faces challenges and will be both exhilarated and exhausted at times. Remembering to eat, sleep, communicate with loved ones outside are essentials. Turn around to make sure your colleagues do this too. A smile, a coffee run or a supportive shoulder can make a world of difference.

4. Primum non nocere

The first rule of medicine generates ethical debate in the elite sporting arena, where medals define careers.

What is your role: to help win the medals or protect the athlete’s health? Injuries in competition demand precise evaluation: how will they impact performance now and what are the longer-term health outcomes your focused athlete cannot visualise?

The depth of senior medical experience contributing to Team England meant athletes were able to make informed decisions with their team.

Sometimes dreams are shattered in the field of play. A sensitive approach to the injured athlete, with a clear team-based management plan will not lessen the pain but can help ensure healing starts in the Village.

Management in Glasgow was facilitated by good venue medical facilities and safe field-of-play retrieval, followed by accessible Polyclinic resources including 24-hour on-site clinics and onsite radiology.

5. ‘Be Kind’ (Dr Mike Loosemore, CMO Team England)

The Commonwealth ‘Friendly Games’ is a microcosm in which tiny countries can produce sporting greatness alongside larger, expectant nations. Like all major Games, it is also a hotbed of ambition, where 7000 dreams shimmer on the cusp of reality.

An 11-day Games represents the pinnacle of careers, dreams and sheer sweat, blood and determination. Be mindful that this will alter over the course of a games as winners and losers emerge. Be on hand in triumph or disaster but don’t intrude. Resist the urge to take that selfie or add pressure to the expectations of an athlete. On the flip side, you can be well-placed to advise the hurt, anxious or unwell athlete who approaches you. Be sensitive. Be kind.

With special thanks to:

Dr Mike Loosemore, Dr Pippa Bennett, Dr Paul Dijkstra, Dr Graeme Wilkes, Dr Mike Rossiter, Dr Abosede ‘GB’ Ajayi, Dr Stephen Chew, Dr Greg Whyte, Chef de Mission Jan Patterson and Team for all their support.

Editor’s question: Is Chessboxing in the Commonwealth Games?

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Exercises to prevent sports injuries – lots of talk, but do they work?

20 Jul, 14 | by BJSM

Letter to the Editor

By Dr. Babette Pluim (@DocPluim)

In response to: Jeppe Bo LauersenDitte Marie Bertelsen, Lars Bo Andersen.

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trialsBJSM. 201448:11 871877 .

Strength training was the big winner in a recent BJSM systematic review and meta-analysis of Lauersen et al.1 The authors carefully quantified the preventive effect of several different forms of physical activity programs. They differentiated between the effect on acute and overuse injuries. Previous studies on musculoskeletal injuries, have focused on one particular intervention, one injury type or location, one specific sport, or were narrative reviews. This is a quantum step forward.

The field is relatively mature with 25 RCTs to study, including 26 610 participants with 3464 injuries. The studies were grouped into strength exercises, stretching exercises, proprioception exercises and multiple exposure studies.

Strength training was the most effective intervention and reduced sports injuries to less than one third (RR 0.315 (0.207-0.480). Proprioception exercises were also effective and reduced the number to almost half (RR 0.550 (0.347-0.869). Contrary to my expectations multiple exposure interventions were less effective (RR 0.655 (0.520-0.286) and stretching had no beneficial effect at all (RR 0.963 (0.846-1.095). Outcome analysis showed that both acute (RR 0.647 (0.502-0.836) and overuse injuries (RR 0.527 (0.373-0.746) could be reduced by preventative exercise programs.

exposure plot

Clinical implications

1. There is great potential in strength training — we should utilize this more. The results from the strength training studies were consistent, despite different programmes being used and despite different outcomes of interest, which points towards a strong generalisability of results. This means that many types of strength exercise have the potential to prevent many types of injuries.

2. Was it a nail in the coffin for stretching exercises? Stretching did not prevent injuries, whether done before or after training. However, this analysis included only two studies on army recruits and one internet-based study on the general population, so more data are badly wanted.2-4 Stretching may serve other purposes, and it may still be relevant for the upper extremity, but NOT for injury prevention of lower extremity exercises. It may be helpful in specific cases if there has been a previous injury. But today, there is no evidence supporting stretching for injury prevention.

It makes intuitive sense to combine several interventions to prevent all injuries, and I was therefore surprised that see that multiple intervention studies had smaller effect size that strength training or proprioception alone. However, the authors point out that each component may be reduced quantitatively or qualitatively by designing a program with an array of exposures (the proportion of effective interventions may be smaller, compliance may suffer etc). They therefore suggest these type of programs should be built from well-proven single exposures and they stress the importance of further research into single exposures.

The take home message for me as a sports physician is that I will take strengthening exercises to prevent injuries even more seriously than I already did:

– hip abduction, lunges, squats, step ups and step downs to prevent ACL injuries and anterior knee pain
– leg curls and Nordic hamstring exercise to prevent hamstring injuries
– proprioception exercises for the ankle (the ankle app!)5 to prevent ankle injuries

The recent data of Clarsen et al. on the shoulder are promising,6 and as a tennis doctor, I would love to see an RCT on the effect of external rotator cuff strengthening as a follow up to their cohort study :-).

*********************************************************

Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer – Netherlands. She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

References

1. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2014:48:871-7.

2. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sports Med 2010;44:1002–9. LaBella CR, Huxford

3. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 1998;44:65–72.

4. Pope RP, Herbert RD, Kirwan JD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000;32:271–7.

5. Verhagen E. Easy to use mobile app for ankle sprains prevention and rehabilitation. http://blogs.bmj.com/bjsm/2014/04/07/easy-to-use-mobile-app-for-ankle-sprains-prevention-and-rehabilitation/

6. Clarsen B, Bahr R, Andersson SH, et al. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med 2014. Published Online First 19 June 2014.

 

 

Top blogs of 2013 – Career Development – How to get the #DreamJob?

19 Mar, 14 | by Karim Khan

conc3 aussieYou know the job you’d love to have, sports physio or sports physician for a team of your choice. And/or working in a private clinic where you respect the clinical leaders and they provide terrific opportunities for developing your skills through working with teams, attending conferences, ensuring continuing professional development on site including workshops. How do you get such a job? Why would the Australian Cricket Team choose you as their physio? Why would Barcelona FC choose you as the head of sports medicine & sports science?

Leading sports clinicians have shared these 5 elements:

1. Differentiate This should be on every student/trainee’s mind. We often call it ‘specialisation’ in our disciplines but that word has specific meanings (e.g. Titled Sports Physio); the concept of ‘differentiation’ is a broader one. Being a ‘sports physio’ is not enough if you want to be considered for a cricket job. You’ll need to get experience in cricket of course. Or, even as a Titled Sports Physio, you might differentiate further into shoulder injuries. Sounds simple!

2. Add value I almost bundled this in with ‘differentiation’ because ultimately the point of differentiation is to provide special value. Extending the cricket example, you’ll get the cricket job not just because you have ‘experience’ in cricket but because you are better at treating backs, shoulders, and finger injuries.  By recognising this need, you might chase experience in treating shoulders and fingers by spending time with specialists in those roles – even if those clinicians are not expert in cricket. Gaining experience may not be a straightforward path but if you are clear on the goal, you know HOW your will ‘add value’, you can at least go after those skills.

3. Volunteer strategically The first job is the hardest and that is particularly the case in 2013. The Baby Boomers have the #DreamJobs and they aren’t marching away from them yet. Also, national unemployment is high the world over; youth unemployment – yes, that means new graduates — is at a record high. So, if you ever thought that after your final exams or graduation, you would be able so scan a long list of advertisements offering you and your peers full time work…. I’m sorry to be a bearer of bad news. But don’t be disheartened  – you have a valuable, practical, degree in hand or coming, so please adjust to the fact that you need to volunteer and network the way many graduates have done in many disciplines for decades.

Be patient, take care of the process and the outcome will take care of itself. You‘ll often have to start with part-time opportunities. As a volunteer, if you are confident of ‘adding value’ (see above) you may have some leverage – you are bright, prepared to work hard and you have acquired some skills. And nothing is ‘below you’. Need the water bottles? That’s OK. Fetching balls? OK too. Remember that the top team clinicians will also do a bit of that where needed. It’s a team. No-one is suggesting a trainee sports physician or physio agree to serve as a bowling machine as 100% of a volunteer experience. But it is invaluable to experience a 3-day training camp where you meet the key coaches and officials, see the sport first hand, and at least watch assessment, treatment and prevention programs first hand. This will definitely provide you skills you didn’t learn about at Uni.

4. Network This word has negative connotations for some young people – who may be confusing networking with nepotism. The words are very different and carry very different implications. Networking means you try to connect with people you think are influential in the field and who may be able to guide you. If you can have an appropriate ‘mentor’ agree to guide your career that will be invaluable. But mentors are busy and you may not have things to offer the mentor (money, time at your ski chalet, a drive in your Porsche) so it makes sense to have a few different mentors – so you don’t burden ‘one mentor’ too much. Sports Medicine events such as educational programs run by your local and national sports medicine organization can be excellent networking events. In Australia, Sports Medicine Australia, (one of BJSM’s 13 member societies) runs excellent networking events for members and non-members. In the US, the AMSSM conference is terrific for sports medicine fellows; there are specific ‘networking events’ within the program. Network young, network early. In many prestigious Business Schools they start the students networking in the first weeks. In sports, now you’ll need to network just to get your volunteer opportunity!

5. Be prepared to travel – live in a different environment for a while. Finally for this short blog, remember that many folks have to travel beyond the backyard to make their dreams come true. Read biographies of your heroes on Wikipedia and see if they did everything they needed to do to become great in their birth city. Russell Crowe  (@RussellCrowe) famously had to move to make his career as a Rabbitoh’s spruiker. Think of folks like Roald Bahr (@RoaldBahr, Norway) and Timothy Noakes (@ProfTimNoakes, South Africa) who may seem the archetypal home grown talents and proud ambassadors for their country; both report pivotal years away which changed their lives. Concussion expert Prof Winne Meeuwisse moved from Vancouver to Calgary for better opportunities. The list is long. To share a personal story for illustration, I moved to Canada for love (without thinking about work, I am not as strategic as I am advocating in this blog!) yet it proved to be a boon for my development as a sports physician. (This principle of moving to a fertile environment is a key message in one of my favourite books – Outliers by Malcolm Gladwell but let’s not go there today.)   ******************************************************************

If you feel we have missed something about how to improve your career chances, just email me (Karim.Khan@ubc.ca) your comments or a blog post and we’ll add it to the conversation. If you want to make a point in <140 characters, tweet to @BJSM_BMJ. #TopJobs  Or suggest someone you’d like to hear share their thoughts on a BJSM podcast.

Guest Blog: What if Nelson Mandela was a Sports Medicine Physician? by @DrPaulDijkstra

7 Dec, 13 | by Karim Khan

 

mandela

Nelson Mandela died on the 5th December 2013.

How will we remember this man of immense stature? This man who truly loved his people, his country – and sport! How did he change my life and career and how will his legacy continue to do so for me and many others?

I grew up and completed my medical studies in the privileged, white South Africa of the 1970s and 1980s, while political prisoner number 46664, Nelson Rolihlahla Mandela was in solitary confinement on Robben Island, just off the west coast of Cape Town. He was found guilty of high treason and jailed for life in 1962, before I was born. This was after he launched Umkhonto we Sizwe, the military wing of the African National Congress (ANC) in response to the banning of this organization by the South African white minority government at the time. I remember his name mentioned on television, mainly in the context of terrorism, protests, anti-apartheid activists and a growing chorus of international leaders calling for his release. But I never saw a photo of him – it was illegal to print or possess any image of ‘Mandela’ at the time. There were separate hospitals, clinics, churches, libraries and public building entrances for whites and ‘non-whites’ at the time – a morally corrupt and divided society with a massive white sheet covering the mountains of hatred, nepotism, racism, self-enrichment, pride, vanity, deception and self-righteousness. (Sadly still the case in many parts of the world…)

I remember the day when South African President FW De Klerk announced the end of Apartheid and the imminent release from prison of Nelson Mandela. It was early 1990 and I was in 5th year medical school.

Then the big day, 11th February 1990 when, after serving 27 years, Nelson Mandela was released from the Victor Verster prison in Paarl near Cape Town, a short drive from my first primary school.

The 1992 Barcelona Olympics was South Africa’s first Games since 1960. On Friday evening 7th August 1992 Ethiopian, Derartu Tulu became the first black African woman to win Olympic Gold, finishing ahead of white South African Elana Meyer in the 10,000m event.  The images of these two sporting heroes completing a lap of honor hand in hand, symbolising the true nature of sport and new hope for Africa, captured the imagination of the world. I remember huge crowds gathering and celebrating on the streets of South Africa. There was hope…

Many innocent people, however, continued to lose their lives. One of them was Chris Hani, the South African Communist Party leader who was assassinated on the 10th April 1993 outside his home in Dawn Park, Johannesburg. The country was on the brink of civil war. Mandela, not yet president went on national television delivering an incredible message to the nation and I remember listening in awe: “Tonight I’m reaching out to every single South African, black and white, from the very depths of my being,” he began. “The cold-blooded murder of Chris Hani has sent shock waves throughout the country and the world. Our grief and anger is tearing us apart.” He urged against violence and retaliation. “Our decisions and actions will determine whether we use our pain, our grief, and our outrage to move forward to what is the only lasting solution for our country – an elected government of the people, by the people, and for the people.”

Nelson Mandela and FW De Klerk were jointly awarded the Nobel Peace Prize later that year and the Nobel Committee hailed them for “looking ahead to South African reconciliation instead of back at the deep wounds of the past.”  De Klerk, a deeply religious man and a remarkable statesman in own right, sacrificed his career; Nelson Mandela sacrificed his life and he had forgiven his jailers.

I have very clear memories of the 27th April 1994: following years of liberation struggle and 3 years of intense negotiations, millions of South Africans voted in the first democratic elections. I lived and voted in Potchefstroom, a small University town that many international Olympic athletes, including double Olympic champion in Athens, Kelly Holmes, would later use as warm weather training base. In 2010 Spain used Potchefstroom as the base for their successful FIFA World Cup campaign.

I was at the Union Buildings in Pretoria on the 10th May 1994 to witness one of the most important events in the history of South Africa: the inauguration of Nelson Mandela as President.  I was a young doctor and part of a small team of military medical officers responsible for the medical care of the attending local and world leaders. I stood no more than 30 meters from the podium listening to Nelson Mandela’s inauguration speech – not far from where Benazir Bhutto was sitting. After delivering his speech and following the inauguration ceremony, Mandela and De Klerk both turned to the huge crowd, Mandela raising the hand of the former president saying: “We have to do this together.”

I will never forget the 24th June 1995, the final of the South African Rugby World Cup. Just before kick-off, in probably one of the greatest political gambles of his career, Nelson Mandela appeared before the mostly white crowd of more than 60000 wearing a green and gold Springbok jersey to shake the players’ hands. The crowd erupted and of course we won! Nelson Mandela and Francois Pienaar together on the podium in green and gold holding the Webb Ellis Trophy marked the emergence of the ‘Rainbow Nation’.

“Sport has the power to change the world. It has the power to inspire, it has the power to unite people in a way that little else does.”

I remember 2010 – Nelson Mandela’s public triumph of an amazing Football World Cup in Africa. I also remember his personal tragedy when he lost his granddaughter in a motor vehicle accident in Gauteng at the same time.

What is the legacy of this remarkable man?  Can we learn anything from him, his life, his words, his choices? What if Nelson Mandela was a Sports Physician?

‘In judging our progress as individuals we tend to concentrate on the external factors such as one’s social position, influence and popularity, wealth and standard of education. These are, of course, important in measuring one’s success in material matters and it is perfectly understandable if many people exert themselves mainly to achieve all these. But internal factors may be even more crucial in assessing one’s development as a human being. Honesty, sincerity, simplicity, humility, pure generosity, absence of vanity, readiness to serve others – qualities which are within easy reach of every soul –  are the foundation of one’s spiritual life. Development in matters of this nature is inconceivable without serious introspection, without knowing yourself, your weakness and mistakes.’[1]

If Nelson Mandela was a Sports Physician he would probably not have been famous. He would have been profoundly human, showing emotion, compassion and real humility. He would have acknowledged his imperfections and asked for forgiveness where he perhaps failed to diagnose a stress fracture early enough or recommended a treatment without taking into account the feelings and circumstances of the athlete: “I have made missteps…” He would have forgiven missteps against him: “resentment is like drinking poison and then hoping it will kill your enemies.”

He would have sat down with an athlete who just missed out on an Olympic medal or who failed to make the team; perhaps with comforting words or possibly just a quiet firm hand on a shoulder. He might have cried alone in his room later because he would have felt the pain of that athlete in his own heart. And in the morning they would have had breakfast or tea together and he might have said: “Difficulties break some men but make others. No axe is sharp enough to cut the soul of a sinner who keeps on trying, one armed with the hope that he will rise even in the end.”

To the young athlete and coach preparing for his first major event he might have commented: “I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.”

He would have known when to stand still and quietly observe or when to walk away and reflect. He would have known when it is not a doctors’ business; when the athlete and coach needed to be alone. He would however have known when to sprint to assist on a football pitch.

He would have known when and how to protect the vulnerable.

He would have truly acknowledged the unsung heroes: the clinic cleaners, the hospital security guards, the volunteers, the midnight nurses and paramedics, the lonely receptionist whose mother is critically ill in hospital. He would have stopped and asked about their lives, their worries, their triumphs, their ambitions… “Man’s goodness is a flame that can be hidden but never extinguished.”

He would have wept about the ongoing injustices to fellow human beings around the world; injustices based on race, religion, sex, education, wealth or class. “… to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.”

As a hospital executive or medical team leader he would have remembered that “a good head and a good heart are always a formidable combination”. He would therefore have “lead from behind and put others in front, especially when celebrating when nice things occur.” He would have “taken the front line when there was danger.” He would have loved “independent minds because they tend to make you see problems from all angles”.

He was indeed a remarkable man, touching and forever changing the lives of millions.

My privileged life was touched by his life. It is his humanity, his forgiveness that gave me wings.

I salute this man, this fellow African. I celebrate the life of a humble giant who lived the true meaning of forgiveness, generosity, sincerity and compassion.

Hamba kahle Madiba.

 

Reference:

1              Mandela N. Conversations with myself. New York: : Picador 2011.

 

You can follow Dr Paul Dijkstra on Twitter @DrPaulDijkstra

Dijkstra

 

Well-rOunded dOctOrs (!) Not necessarily a good thing in this case

18 Jun, 13 | by Karim Khan

By  Dr Rajat Chauhan,

Sports-Exercise Medicine & Musculoskeletal Medicine Physician; BJSM Associate Editor (India)@drrajatchauhan

march coverFrom the time of Hippocrates and probably even before, we have known the benefits of physical activity and exercise in health. In today’s world of evidence based medicine, it is even more important for research to back up our gut feeling. The last two decades of research show how big an impact ‘Physical activity and exercise’ have in reducing risk of non-communicable chronic disease morbidity and premature mortality.

The cover of March 2011 edition of BJSM did its bit by suggesting that every doctor consultation room needed to have a copy of the free PDF ‘Physical Activity in the Prevention and Treatment of Disease‘, (a ground breaking book by Professional Associations for Physical Activity (Sweden)) and then to use it 20-30 times daily. The editorial was so appropriately titled “Physical activity as medicine: time to translate evidence into clinical practice” (see full text here – FREE).

You may have thought that all these efforts put together would have changed the healthcare fraternity’s attitude in recommending ‘physical activity’ to patients. In this presentation, I have put down the reasons why we, doctors, are neglecting one of our duties. I have also suggested a couple of solutions.

This presentation targets practicing doctors and medical students, so they are better informed about the role of physical activity and exercise which is often mentioned in medical schools in passing. It’s also for the public, to make them aware that it’s their right to know better. Why should they trust someone who doesn’t practice what s/he preaches!

Please view the presentation HERE, and share with your friends and colleagues.

 

Keep miling and smiling,

Dr Rajat Chauhan

Rajat Chauhan

@drrajatchauhan

Ultra Runner, Sports-Exercise & Pain physician practicing (un)common medicine. Columnist – Mint newspaper, Blogger – Forbes India, Associate Editor – BJSM

New Delhi, India · about.me/drrajatchauhan

The legacy of London 2012 – Finding a home for Sport and Exercise Medicine

31 May, 13 | by Karim Khan

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Jack Nash (@JackNash58)

Delivering a health legacy to get more people physically active was one of the London 2012 Olympic Games’ promises(1). £30 million was earmarked to build three centres and form the national sports medicine centre. A year later, work is well underway in the east midlands to ensure that this legacy translates into public health benefits and a hopefully bright future for SEM in the UK.

An artist’s impression of the finished east midlands centre Taken from: https://twitter.com/ncsemem/status/217904559631245312/photo/1

An artist’s impression of the finished east midlands centre
Taken from: https://twitter.com/ncsemem/status/217904559631245312/photo/1

Why the East Midlands?

A market town with a population of 56,000 would not be everyone’s choice for a national sports medicine centre site! However, it just so happens that this market town is Loughborough. Loughborough University is the leading UK University for sport, with a variety of elite and recreational athletes on campus every day. This coupled with the cutting-edge health and exercise research taking place make it the perfect site for one of the three centres – the others being London and Sheffield. Six university and hospital partners will be involved in running the east midlands centre – Loughborough University, the University of Nottingham, the University of Leicester, Nottingham University NHS Trust, University Hospitals of Leicester NHS Trust and Nottingham Healthcare NHS Trust.

What will the centre provide?

£10 million will be invested to produce a state of the art building, which will provide a focal point for clinical, research and educational services on the Loughborough site. Uniting all of the expertise in the area under one roof will promote knowledge transfer amongst professionals and provide a home for the SEM speciality in the region. The East Midlands hub will focus on four key areas: ‘physical activity in disease prevention’, ‘exercise in chronic disease’, ‘sports injuries and musculoskeletal health’ and ‘mental health and well-being’. Importantly for budding SEM doctors, the new centre will have a role to play in SEM training. This is where we come in…

How will this centre benefit SEM trainees?

The East Midlands deanery currently provides 2 of the 12-16 ST3 training posts nationally for those looking to work in SEM. With the new centre, SEM training and educational opportunities are set to increase. Excitingly, an Academic SEM Clinical Fellowship has been confirmed when the centre opens in 2014. This base will enable the delivery of Continued Professional Development (CPD) resources in SEM which will raise professional standards and spread the message of exercise and health.

How will this centre benefit undergraduate students interested in SEM?

Liam West has highlighted the lack of undergraduate education on sport and exercise medicine – the new centre may have a role to play in increasing this. The Sport and Exercise Science BSc intercalated programme is going from strength to strength in Loughborough and this centre will allow undergraduate students to attend clinics and shadow physicians – an important determining step in the career choice of students. Matthew Gray’s blog shows the difficulty in finding mentors in SEM. The east Midlands centre will facilitate a large number of SEM professionals to meet under one roof, providing help and support to those looking for a career in SEM. Hopefully we are turning the corner for these problems…

Much like the building work in Loughborough, the career pathways and opportunities for the budding SEM doctor are ever increasing. The east midlands are a fitting site for this up and coming speciality. As a budding SEM doctor, it is exciting to see the potential opportunities that lie ahead as a result of the London 2012 health legacy.

What are your thoughts on these three national sport medicine centres? Is this money well spent? Are these set to be the best sites nationwide? I’m keen to hear everybody’s views.

References

1)    Tew G, Copeland R, & Till S. Sport and exercise medicine and the Olympic health legacy. BMC Medicine 2012; 10: 74.

********************************************************************

Jack Nash is a medical student who is intercalating in Sports and Exercise Science at Loughborough University and will be graduating from the University of Manchester in 2014. He placed 3rd in the Tom Donaldson prize at the BASEM Congress 2012.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

 

 

Zlatan Ibrahimovic – The passionate football star on physical health and team doctors

8 Apr, 13 | by Karim Khan

This interview was published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Qatar Orthopaedic and Sports Medicine Hospital. For information about the Aspetar Journal or for a complimentary hard copy email journal@aspetar.com

INTERVIEW

With Zlatan Ibrahimovic

Zlatan

Not every athlete has had their name entered into the dictionary. Zlatan Ibrahimovic has. As of 2012, to ‘zlatan’ means ‘to dominate’, which he has consistently done on the football field for clubs like Barcelona and Paris Saint-Germain. Known for his exciting and unpredictable technical skills, he is an athlete who plays with passion.

Throughout his career he has received medical care from all over Europe, but there is one consistent experience that he takes wherever he plays: his relationship with his doctor is one of closeness and confidence – like a best friend. Here, the Swedish striker tells Dr Nebojsa Popovic about his relationship with his doctor and his growing awareness for his own physical health.

What is football to you?

Football is everything. It is made up of many small parts to make it whole. It is being healthy, being happy and something I love. For me, it is passion.

How tough is it to be a top athlete?

I think it is very tough. You have to work very very hard. You train every day to get better but in doing that, you take risks every day too. Injuries happen – you hope that they don’t but sometimes they do. Essentially, you sacrifice your body.

People think that it’s easy, but they don’t understand that football is our whole lives and it is hard. We have to stay at our best constantly, when in reality it’s easier to fluctuate, to go up and down. It’s difficult to stay on top – you have to perform well every single day to demonstrate every day that you are working hard and are at your best.

How much is talent and how much is work when it comes to making a professional athlete?

I think talent is about 30% and then the rest is hard work. Talent doesn’t mean you will win. Talent is something you are born with. You see the opportunity of somebody with talent, but if you don’t work hard, this talent is a waste of time.

What is your personal relationship with the team doctor? What kind of doctor would you like to work with?

For me, the doctor is my best friend. He is the one I give the most confidence to because he doesn’t see me as a football player. It’s different to a relationship with the coach; when the coach sees me, he only thinks about football and how he can use me to play. But when the doctor looks at me, he sees a person rather than a player. He thinks about my health and how I feel and that I have to be 100% healthy, not 99%.

If you are injured, the coach will still push you on the field, but the doctor will not. I remember when I was in Inter I got a kick to the head and a scan showed I had a lesion in my head. The coach felt I could still play but the doctor said no, I couldn’t, I had to rest. So you have two different ways of thinking: the doctor thinks about your health and the coach thinks about how you can be used to win games. It is important for me to have a doctor with a strong personality because I have to be healthy – that is the most important thing.

Every time that we players have a problem, we go to the doctor. It is important that he knows his profession and he has confidence in his knowledge but he must have a good relationship with every player because whenever there is a problem, we don’t go to anybody else. The first person we look for is the doctor, because he is the one who has to make you feel good and who can make you better and he becomes like a best friend to you.

You have played for many teams all over the world and at each new club you had a new medical staff. Tell us about the differences between them.

To start with, in Sweden we actually didn’t have a doctor with the team all the time. Instead we had a doctor at the hospital, so if we had a problem we went there. I really didn’t notice how important the doctor is for the team while I was playing in Sweden, but when I moved to Ajax it was different. There we had a full-time doctor with us.

But I was young then. When you are young you can afford injuries without the consequences of an older player. When I moved to Italy and played for Juventus I was a little bit older. Of course they had some problems with doping before my time, but the doctor I worked with there was very good and always helpful.

I think every culture has a very different way of having contact and giving medicine to the players. In Italy, doctors are very close to their players. In Holland, they keep their distance a bit more. It was similar in Spain. Of course, if I ever got sick I’d have a doctor beside me every time. I think it just comes down to culture. I have been lucky in my career and I have not had a big injury. I have met fantastic doctors wherever I have played and that is why they are there, so I haven’t had any problems. If I had to choose, I would prefer to have the doctor as my best friend and give him my full confidence but basically it’s different in every country depending on the culture.

more…

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