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Sport and exercise medicine discipline

Exercise physiologists and chronic disease management in North America: A role of importance

6 Feb, 13 | by Karim Khan

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

By Lisa Campkin (@LisaCampkin)

rx exercise

Recently, the term ‘Exercise is Medicine’ was copyrighted by the American College of Sports Medicine. This particular initiative in exercise medicine focuses on the role of clinicians in helping increase their patients’ physical activity levels. Exercise is Medicine has growing influence in the prevention and treatment of non-communicable “lifestyle” disease, and the movement is currently progressing up north into Canada. But a major concern remains: how can physicians follow-up with patients diagnosed with multiple chronic conditions, who need further individualization and support in their exercise programs? Referral to an exercise professional may be an option!

North American organizations as change catalysts 

The Canadian Society for Exercise Physiology (CSEP) is a professional body of exercise physiologists. It is dedicated to the promotion of health, fitness, and performance through the application of knowledge and research related to exercise. As an organization based in scientific thought, applied evidence, and up-to-date advances in exercise physiology research, CSEP and its affiliate members are trained and have a scope of clinical practice related to exercise prescription; they are specialists in the field of health, exercise and rehabilitation. Specifically, a CSEP-CEP (Certified Exercise Physiologist) is certified to evaluate and treat individuals with chronic disease through tailored, progressive physical activity and exercise programs to improve the patients’ health and function.

Both CSEP and ACSM may be considered on the brink of changing the application of medical care and symptom management for those with chronic disease and/or suffering from “exercise deficiency.” Alongside the individual benefits, a patient could experience from increased structured and / or monitored physical activity (i.e. stabilized mood, increased independent living, stronger immune function, better quality of life, etc.) there follows an implication that exercise physiologists could help to decrease national health care costs long-term, through a decreased need for symptom-related prescriptions, fewer hospitalizations and decreased morbidity & mortality due to lifestyle-related disease.

Working models and available resources

Research from New Zealand and Great Britain exemplifies working models of physician-based exercise counselling and referral through the Green Prescription and Exercise Referral Scheme health promotion programs. In Canada, official and widespread programs are not yet in place for physical referral to exercise professionals.

Until such programs are developed, engaging an accredited exercise physiologist is relatively easy from a community and health care standpoint, says Katherine MacKeigan (Director of the Provincial Fitness Unit, located in Edmonton Alberta).  Interested individuals can access the online registry of CEPs or access services through widespread fitness appraisal centers; 27 of which are in the province of Alberta alone.

Although referral is not necessary for patients with varying chronic disease or physical disability, any practicing primary care physicians who can access the referral system can send patients with extended needs and long-term exercise supervision to a CEP. Costs range from CAN $20-150+ per session. Currently the services of a CEP are not covered under the provincial health care fee schedule. Although, certain employee benefits and extended health care may cover assessments for qualified individuals (e.g. through a health spending account). Katherine MacKeigan certainly encompasses a powerful idea with the question “How much is your health worth to you?”

Knowledge transfer as a way forward

The short and long-term positive health implications for persons affected by lifestyle-related disease could be huge if exercise professionals had increased contact with at-risk populations. How can we increase knowledge and awareness of this field of exercise medicine? How can we successfully promote healthy lifestyles through physicians and exercise professionals? One possible avenue is through knowledge transfer (KT), or academic detailing. This process involves an independent organization educating the professional or a group of professionals, using evidence-based and individualized methods to most effectively reach the target audience [1]. This process can help to bypass barriers that even the most experienced clinician can face on a daily basis; a lack of time, energy or desire to self-educate directly from the literature is a common issue in research-based clinical practice. KT helps bring the newest research into the practice of the clinician in a relevant, timely, packaged manner, and it could help to bring the advantages of exercise and exercise professionals to light in the field of medicine.

What do you think? Does exercise physiology and knowledge transfer seem like an important component of the medical field? Should we be teaching those students responsible for the future promotion of physical activity these skills during their undergraduate studies? Is there another avenue or profession that we can explore to help patients with chronic disease return to function and increase their quality of life?

References

  1. Campkin L, & Doyle-Baker PK. (Spring/Summer 2012). Five Reasons for Knowledge Transfer. Fitness Informer

Lisa Campkin is a MSc Student, University of Calgary under the supervision of Dr. PK Doyle-Baker. She is interested in exercise physiology, seeing it as a gateway to a decreased incidence of chronic disease worldwide, as well as decreased symptomology and better quality of life for previously diagnosed patients. She can be contacted at lmcampki@ucalgary.ca

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.

Public Health experience in SEM training – why is it important?

21 Jan, 13 | by Karim Khan

Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)

By Dr Jim Kerss

the diffusion of innovation

Why public health? Was a surprisingly common question asked of me when I explained to my friends, family and colleagues that I was working in Public Health as part of my Sport & Exercise Medicine training. Thus, my aim of this blog post is to share reflections and inform anyone interested or involved in SEM training of the benefits and opportunities of working in Public Health.

Local experience

SEM enthusiasts are well aware of both the mounting global public health crisis of physical inactivity and the evidence base behind physical activity as a preventative and treatment intervention for a range of diseases. I was keen to learn the extent to which these messages were filtering through to other medical specialities and if there was evidence of the development of local services to tackle the problem.

Under the brand of ‘Liverpool Active City’, work done by the Public Health department has contributed to a 3% increase in city residents being sufficiently active between 2005 & 2011, with an aim to achieve a 1% yearly rise until 2017. I have been involved in work to develop a physical activity treatment pathway for women with Breast Cancer and to improve the existing GP exercise referral scheme which will hopefully help to achieve these targets.

Clearly there is a great deal being done but we are still probably in the ‘Early Adopters’ phase of the law of diffusion of innovations meaning there is still more to do before physical activity becomes a cornerstone of healthcare in the UK. See TED talk by Simon Sinek on the subject.

National experience

I attended a NICE Public Health Interventions Advisory Committee meeting on Physical Activity advice in Primary Care. The analysis of evidence and cost-effectiveness was very robust but there was a lack of clinical input into the discussions which I feel could have been provided by a specialist in SEM. NICE accepts applications to join these committees to provide such expert guidance and are shortly due to commence the update of advice on exercise referral schemes.

In 2012 NICE also discussed adding indicators on recording physical activity levels in patients with hypertension to the QOF but these were rejected. I believe financial incentives could be a useful way of encouraging the recording of physical activity as a ‘vital sign’ in primary care. SEM specialists could use their expertise, and skills learnt in public health, in helping to develop national guidance that would encourage healthcare staff to discuss physical activity with their patients.  An example of this already occurring is the RCP document ‘Exercise for life: physical activity in health and disease’.

NHS management

Given the current organisational changes in the NHS, and particularly as SEM is a new and developing speciality the exposure to NHS management, funding issues and experience of developing new services that can be gained through working in public health is invaluable.

Education

Working in public health has highlighted the importance of continuing to spread the messages behind physical activity through education of different groups – medical students, doctors in various stages of training and differing specialities, other allied healthcare staff as well as the general public. Public Health provides a good platform to be able to do this.

Final thoughts

Starting work in public health was actually quite daunting, with a sense of being out of my comfort zone in clinical medicine. Overall, it was a rewarding experience, that furthered my enthusiasm for SEM and my understanding of where the speciality will exist in the NHS in the future.

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Dr Jim Kerss is a Speciality Trainee in Sport and Exercise Medicine in Liverpool

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

Images wanted for BJSM clinical quizzes!

2 Jan, 13 | by Karim Khan

Images wanted!

x-rayHave you ever come across a patient’s condition that looks so interesting, you want to share it with your colleagues?

From now on: please do (with consent of course)!

We have the perfect platform for sharing noteworthy cases and conditions. And, good news — it’s not much work for you to contribute. You can find it on the BJSM Education home page. It is called the Image Quiz.

Image Quizzes are based on a clinical image which relates to a patient’s case that is educational for students and junior doctors.

The requirements are as follows:

1.        Image in JPEG/GIF format with maximum dimensions of  400 x 400 pixels, minimum resolution of 300 DPI.
2.        Categorical description
3.        Question with background information (as per the examples currently online).
4.        Six possible answers to choose from (including an indication of the correct answer)
5.        An explanation and a discussion section – which may include a more detailed description of the condition (max 700 words)
6.       A further reading list of up to three sources, for example, articles (clinical reviews published in the BJSM, Student BMJ or other publications) or relevant textbooks.

However, one thing is important: you need to obtain the patient’s informed consent to publication

Please send you case to bpluim@euronet.nl  and feel free to contact me if you have any further questions.

We look forward to your submissions!

Babette Pluim,
Deputy Editor BJSM, Education

Suicide, sport and medicine: more education and awareness needed for athletes’ mental health

10 Dec, 12 | by Karim Khan

By Dr. Kerry Lang

I was very interested to read Dominic Malcolm and Andrea Scott’s BJSM editorial on suicide, sport and medicine (2012) and agree that more attention should be paid to the psychological welfare of athletes.

I am a doctor, albeit not a psychiatrist, and have also been part of the British triathlon team since 2005. On several occasions I was acutely aware of depression in athletes that has gone apparently undetected. In one particular case, a female athlete was deliberately self-harming in response to her perceived poor performance in training. She had inflicted substantial lacerations to her forearms, which were obviously visible when swimming. I felt a duty of care to report this to her coaches and challenged them on whether or not they had noticed the wounds. The response from the first coach was they had not noticed and from the other coach was that they had noticed but felt inadequately qualified to address the issue.

This is just one example of where education is needed to identify warning signs and hopefully prevent catastrophic consequences. Not only the sports physician, but the whole support team needs to be aware of signs and symptoms for mental health issues.

Treatment for athletes is available. Education in what services are available is the key to providing mental health resources. There are sports psychologists who work closely with teams and individual athletes, general practitioners and team doctors with mental health training may also be useful and in more serious cases tertiary referral to a psychiatrist. Cognitive behavioral therapy and antidepressants are currently used with good effect. There is also an important role for preventative medicine in identifying “at risk” individuals and implementing early intervention.

Screening may be useful. Some simple signs for the performance team to look out for are: changes in appetite and weight, withdrawal from other team members or friends, crying, tiredness, indecision, anxiety, moodiness, loss of enthusiasm, feelings of sadness, lack of concentration and anger.

Formal screening can be done with the Beck Depression Inventory, the Hamilton Rating Scale for Depression (Ham-D), or the Montgomery-Asberg Depression Rating Scale.

A simple tool that, as far as I know, is not widely used but may be helpful in a coach-athlete setting is a self reported “vigor” score. Ask athletes to rate their level of vigor from 1-10 on any particular day. Scores consistently of less than 5 may merit further investigation.

In the case I describe in this blog, a sports psychologist became involved and with counseling the individual went on to perform internationally at a high level. Good mental health will ultimately lead to better athletic performance and is as important as good physical health.

References

1. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (June 1961). “An inventory for measuring depression”. Arch. Gen. Psychiatry 4 (6): 561–71. doi:10.1001/archpsyc.1961.01710120031004. PMID 13688369
2. Hedlund JL, Viewig BW (1979) The Hamilton rating scale for depression: a comprehensive review. Journal of Operational Psychiatry 10:149-165
3. Williams, J. B. W.; Kobak, K. A. (2008). “Development and reliability of a structured interview guide for the Montgomery-Asberg Depression Rating Scale (SIGMA)”. The British Journal of Psychiatry 192 (1): 52–58. doi:10.1192/bjp.bp.106.032532. PMID 18174510

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Kerry Lang MBChB, MRCS (Glas)

Medical students and sports medicine – The desperate need for improved access to mentors

5 Dec, 12 | by Karim Khan

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

By Matthew Gray

You may well have read the recent blog post or listened to the even more recent podcast featuring Cardiff medical student and Sport and Exercise Medicine (SEM) enthusiast Liam West. Although heavily summarising, Liam’s overarching conclusion was that students interested in SEM should be enthusiastic and proactive in gaining exposure in the speciality. Liam also puts forward a number of the many “challenges” that undergraduates face in their struggle for SEM success. These included the topic to which this post relates – the lack of mentors and shadowing experience available to students.

Why does it matter?

It’s pretty clear that in order to attract the very best students, SEM must come across as a speciality that is enthusiastic and inclusive. The part to be played by positive role models for students in achieving this cannot be overstated. It’s interesting that both enthusiasm and approachability have been shown to rank amongst the highest of the characteristics sought by undergraduate students in a role model, albeit in a surgical context [1]. Positive role models also have a significant impact on student decisions regarding future careers [1, 2].

Although there is an impression amongst students of a lack of SEM mentors, the widespread enthusiasm projected by the BJSM community in general potentially suggests the opposite. It seems quite likely that there are many SEM clinicians out there keen to offer their invaluable advice and mentorship to undergraduates; it’s just that at the moment, there is no foolproof way of connecting the two.

Why can’t students take steps to contact clinicians under their own steam?

There is no doubt that students should definitely be using their initiative to get in touch with clinicians, but there are often a number of challenges:

  • Firstly, students showing an interest in gaining initial experiences in SEM will inevitably have a limited idea of what the speciality entails. For example, who exactly comes under the umbrella of the term ‘sports medic’? Guidance in who to approach in this circumstance would be priceless.
  • Secondly, there is a problem that contact details for a given clinician, whether it be postal or e-mail address, are rarely available online. This simple fact alone limits access to SEM mentors for students almost before a student has started looking!
  • Finally, taking this approach is inefficient: there is no guarantee that a single clinician contacted for advice would be willing to offer it. Students are often forced to contact a number of individuals. In the process, this inconveniences those clinicians who do not want to be involved and, in the case of receiving multiple offers of mentorship, puts the student in an awkward position.

Although getting in touch with mentors ‘under your own steam’ is great, it is surely not the best approach. There must be a better way of linking students with SEM mentors. It seems that the root of the problem lies in a lack of established infrastructure to pair mentor and ‘mentee’ – something that could so easily be improved.

What can be done? – A suggestion

The introduction of an SEM mentor network (for the sake of this blog post, let’s call it SEMnet) where willing SEM professionals sign up to offer a point of e-mail contact for interested students in a given geographical area could be the simple solution.

For students, this would serve as a straight-forward but invaluable ‘foot in the SEM door’ allowing questions to be answered and serving as a platform to organise future SEM experiences.

In the UK, for example, SEMnet could be incorporated into the Faculty of Sport and Exercise Medicine (FSEM) as a benefit of (free) student affiliation. In turn, this would protect the privacy of clinician’s details, only allowing access to ratified, affiliated medical students. Promotion of SEMnet by BASEM, BJSM and within medical schools would also be key

in order to spread the message of this opportunity as widely as possible.

Consequences

By not improving access to mentors/SEM experiences to students, there is a real danger that talented students (who may well have become those championing the speciality in the future) may just pass by SEM. Ignorance of this issue is not really an option, especially if we hope to maintain the strength and quality of the speciality into the future.

References

  1. Ravindra P, Fitzgerald JE. Defining surgical role models and their influence on career choice. World J Surg 2011;35(4):704-9.
  1. Wright S, Wong A, Newill C. The impact of role models in medical education. J Gen Intern Med 1997;12:53-6.

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Matthew Gray is a fourth year medical student at Newcastle University, UK, with an avid interest in SEM. He is now a contributor to the BJSM ‘undergraduate perspective on SEM’ blog and amateur but enthusiastic triathlete!

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.

Sports Medicine: Inspiring the next generation (Part 2 of 2)

23 Nov, 12 | by Karim Khan

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

 By Liam West (@Liam_West) & Dr. Peter Brukner (@PeterBrukner)

The second of this two part interview series exploring the field of Sport & Exercise Medicine (SEM) is with Dr. Peter Brukner (PB). He is a world renowned name in SEM, co-authors Clinical Sports Medicine (for many the “SEM Bible”), hosts a fantastic SEM website and helped set up the prestigious Olympic Park Sports Medicine Centre in Australia.

LW: Hi Dr. Brukner. Could you start by describing what is involved in sports medicine for the undergraduate readers?

PB: It is a very broad field. The core is musculoskeletal medicine concerning injuries categorised into acute, chronic or acute-on-chronic injuries. As a sports medicine physician you need be able to diagnose these conditions from a comprehensive history, clinical examination and often imaging techniques. Then you must decide the management plan which may be physiotherapy rehabilitation, injections, surgery etc. You should have a good understanding of all these areas, even ones you may not be directly overseeing such as the rehab, as ultimately you will be running the show! At the end of the day, the patient is your responsibility.

LW: A great overview. What other skills do students need to acquire to be successful in sports medicine?

PB: Competency with clinical skills and underlying knowledge of radiological skills, rehabilitation protocols, recovery and available treatments is fundamental to success in sports medicine. Increasing performance, rehabilitation and prevention is at the heart of everything we do. Good research is out there with which we can reduce the risk of certain injuries – you will need a good understanding of this. As well as all these medical factors you must have an understanding of training, sport and biomechanics, nutrition and psychology which are all components of sports medicine.

There are also the challenges of looking after a team on a day to day basis. Screening, travel and its associated issues (jetlag effects etc), doping and dealing with the media can all prove difficult. You must be source of education for players as to the dangers of certain performance enhancing practices. It is much broader than running on to the football pitch with the magic sponge! I think this is what people don’t understand about sports medicine.

LW: If you could only say one thing to a student that is trying to weigh up a potential career in sports medicine with a more traditional medical speciality what would it be?

PB: One of the big differences with sports medicine and other medical specialities is the multi-disciplinary approach. Once students start clinical attachments they will soon realise that consultants often treat their physiotherapists like third rate citizens! We really must work as equals in a team. If you think you know a whole load more than physios, don’t get into sports medicine! Be an orthopaedic surgeon, sounds like you have the right personality for that! I have learnt more sports medicine from physiotherapists than from doctors.

LW: That sounds very appealing. So what jobs can we get into in sports medicine?

PB: A huge range is on offer. You can become a consultant in the NHS or private practise managing musculoskeletal injuries or exercise related problems. You could be working at one of the multi-disciplinary sports medicine centres popping up around the UK. You can get involved with university jobs based in research or teaching. Then there is obviously involvement with team sports or professional sporting organisations. Most do a combination of these.

Sports physicians also have to become the world leaders in exercise prescription and dealing with the effects of exercise on patients with various chronic health problems. Something you have spoken to Dr. Mike Loosemore about.

LW: Any advice for medical students wanting to get involved in sports medicine?

PB: Go and look after your local sports team. Most amateur or semi-professional teams are dying to get people that can come and help them. You obviously need some simple skills and to act under proper guided supervision. Completing sports strapping / taping, first aid or pitch side trauma management courses can make you a valuable member of the medical team. Look to cover sports that guarantee carnage! Rugby, football or hockey are perfect and you will learn lots just from being around acute pathology and their subsequent management.

Get your foot in the door with sports medicine by volunteering. As well as your local sports team, marathons and triathlons are always looking for volunteers to help out with the medical teams. These are great opportunities to gain experience and this is what you need to do as an undergraduate. When I interview people for sports medicine jobs I always ask about their relevant volunteer experience. If they say they have only just come across the field, I immediately think “so you failed your application for orthopaedics then…” The genuine sports medicine enthusiast normally has longstanding interest.

Once you graduate, carefully pick your clinical rotations. Emergency medicine, orthopaedics, rheumatology, cardiology and respiratory medicine are all very helpful for a future sports medicine career. Then you might like to undertake a masters degree to further your interest.

You have got to love sport. You have got to appreciate sportsmen and women. You must understand that your regular Sunday league footballer wants to get back to playing after an injury just as much as Wayne Rooney does. You can’t just tell him to rest for 6 weeks and expect him to listen to you! You may think you are pretty hot stuff as you are a medical student but you quickly need to swallow a big slice of humble pie and not be too proud to learn off any member of the sports medical team. You need to be a sponge.

LW: There are some great take home messages for students in there. Can you finally comment on the role that the media plays in sports medicine?

PB: The public know very little about sports injuries and what we as sports medicine doctors actually do. The media can be used as a very powerful vehicle to educate the public on sports medicine. In Australia, sports injuries are openly discussed in the media and in quite a lot of detail, so the average sports fan is quite knowledgeable on the subject. That doesn’t happen here in the UK. I think we should get out there and talk more to the media and break down this culture of secrecy in sport regarding injuries. The average punter knows what an orthopaedic consultant or cardiologist does but they have no idea what a sports physician does. We need to sell our profession.

A perfect example is the case of Fabrice Muamba. Two club doctors did an absolutely sterling job of keeping this guy alive but the sole media attention was that the cardiologist jumped the fence and played no role in the immediate resuscitation. We need to ensure credit is given where credit is due!

LW: I think we will leave it there with that powerful success story. Thanks for your insights into sports medicine Dr. Brukner.

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Dr Peter Brukner (@PeterBrukner) is an Associate Editor of BJSM and an Australian sports medicine physician, author and media commentator living in Liverpool, UK. Currently working with Sky Sports News and one of the sports physicians working with the Australian cricket team. He runs his own website,www.peterbrukner.com which is a site for provocative and insightful sport & exercise medicine columns.

 

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.

Exercise Medicine: Inspiring the next generation, an interview with Dr. Mike Loosemore (Part 1 of 2)

14 Nov, 12 | by Karim Khan

By Liam West (@Liam_West) & Dr. Mike Loosemore

Undergraduate perspective on Sports & Exercise Medicine (a BJSM blog series)

The field of Sport & Exercise Medicine has two distinct areas. Namely, Exercise Medicine and Sports Medicine. To gain insights and get tips for students looking to follow in their footsteps, I interviewed two influential figures pushing the boundaries of each field.

The first of this two part interview series is with Dr. Mike Loosemore (ML) who is leading the “Exercise Is Medicine” initiative in the UK.

LW: Hi Dr. Loosemore. Could you describe to the undergraduate readers what Exercise Medicine entails?

ML: Exercise Medicine, or ‘Exercise Is Medicine’ as it’s promoted by the American College of Sports Medicine (ACSM), is the idea that exercise is important in preventing chronic non-communicable diseases (NCD) such as Type 2 diabetes mellitus, heart disease & cancer. Exercise can also be prescribed as a treatment for a NCD allowing the patient to simultaneously reap the additional benefits of regular moderate activity such as reducing co-morbidities and improving the patient’s sense of well being.

LW: So essentially undergraduates can view exercise as a more powerful treatment than handing out a single pill in many circumstances?

ML: Yes. Medical school essentially teaches students how to poison patients as that’s what you do by giving small doses of drugs; although obviously if you give them too much of the drug you poison them properly! It’s completely different with exercise. Using exercise we re-establish a natural process which allows the body to heal itself, returning it to the homeostatic state & often improving health considerable. Humans are exercising monkeys, we need to be active and if you don’t exercise enough important functions of your body start to degenerate!

LW: Powerful stuff! Would you be able to share with the readers some of the data surrounding exercise as a treatment for various NCDs?

ML: Here are some basic facts and figures for the undergraduates from the ACSM website. Regular physical activity reduces the;

  • Risk of heart disease by 40%
  • Incidence of diabetes by roughly 50%
  • Risk of developing Alzheimer’s disease by 30%
  • Incidence of high blood pressure by nearly 50%
  • Risk of stroke by 27%
  • Recurrence of breast cancer by almost 50%
  • Risk of colon cancer by approximately 60%
  • Depression as effectively as Prozac or Behavioural therapy

A pretty impressive intervention that has no medical equivalent that can do one of those things, never mind all of them! If you consider that medical inflation is going up significantly quicker than normal inflation and the population is ageing, we are reaching the edge of a financial cliff as far as healthcare costs are concerned. Currently the vast proportion of the NHS budget is spent on treating disease. Instead we should concentrate on preventing disease occurring in the first place which is relatively cheap! We cannot continue to be a disease service. It is called the National HEALTH Service not the National Disease Service!!!

LW: Hopefully that is a quote that will stick in the mind of many undergraduates! You have briefly touched upon some of the research, but are there any other resources students could use to find out about exercise medicine?

ML: I suggest they go to the ‘Exercise Is Medicine’ website where they can access lots of relevant resources & facts from evidence based research, read the BJSM blog and attend Sport & Exercise Medicine conferences, such as the Cardiff SEMS Olympic Conference 2012 on 15th December which is aimed primarily at undergraduates.

LW: Finally, if there was only one thing that we could do during our undergraduate career to spread the message of Exercise Medicine what would it be?

ML: Include it in your history paradigm. Every time you take history from a patient, ask about exercise. Two reasons for that;

  1. You will find out their individual activities levels and then can encourage them to do more. Any increase in exercise, no matter how small, will start to reduce the risks of chronic NCDs.
  2. A doctor asking about exercise sends a very powerful message to the patient and they clearly see that exercise is important.

LW: Thanks Dr. Loosemore for your expert opinion on Exercise Medicine and how undergraduate students can get involved.

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Dr. Mike Loosemore MBBS DCH MRCGP MSc FFSEM(UK) is a Consultant in Sport & Exercise Medicine at the Institute of Sport, Exercise and Health, University College London. He is the lead Sports Physician (South of England) for the English Institute of Sport and currently the doctor to British Boxing. He is currently president of the Sports and Exercise Medicine section at the Royal Society of Medicine and leads the ‘Exercise is Medicine’ task force in the UK.

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.

Undergraduate curricula: An opportunity for progress (requires your help!)

5 Nov, 12 | by Karim Khan

By Dr David White

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

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

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

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

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

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

GMC’s aim in compiling this document is:

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

Physical inactivity in Nigeria: A short analysis (part 2 of 2)

21 Sep, 12 | by Karim Khan

Guest blog by Damilola Alawode (@DAlawode)

 Read part 1 here

In Nigeria, government policies (e.g., policies that might influence health) can arise at three levels. There is the Federal Government, state governments, and local governments. Local governments tend to follow the policy laid down by state governments. Though there is a national health promotion draft policy, there is no legislation compelling the Federal Government to reduce or combat the scourge of NCDs through promotion of physical activity. Unfortunately, Nigeria does not have a goal of reducing physical inactivity by 10% as the government of Canada did for year 2003 or the Healthy People 2020 policy (a 10-year health agenda released by the US Department of Health and Human services in 2010), which identifies physical activity as a leading health indicator.

However, the FG through the National Sports Commission (NSC) set up a body known as the Nigeria Academicals Sports Committee (NASCOM) headed by a former Nigerian soccer star to collaborate with both state and local governments in promoting an initiative on physical activities in secondary schools (read more here). The initiative started with soccer, and it has been extended to 4 other sports (tennis, table tennis, basketball and swimming); athletics will start later in the year. The schools are required to train teams that would represent them in inter-school competitions from the local to the states up to the national level, thereby maintaining and promoting a culture of physical activity among the students. This is a good initiative that should be built upon by all levels of government as well as the private sector so as to sustain its impact.

The “Walk and Live” program

A state government in the southwest part of the country (The state of Osun) organizes what they call the “Walk and live” program. It is a once a month city walk similar to what takes place in the city of Mombasa, Kenya. It is an attempt to keep citizens of the state fit. Although this initiative can be improved, it has brought the importance of physical fitness to the forefront of more people. This should be applauded, but the message on the importance of having at least 30 minutes of physical activity everyday should be made known to all through different channels and utilising the best methods of public health education and support. This state has also made it mandatory for physical education to be taught in elementary schools, hoping it would make children enjoy the culture of daily participation in physical activities from an early age. This is a commendable policy which other states should look to implement.

The Medical and Dental Council of Nigeria regulates undergraduate medical education and, regrettably, physical activity does not feature within the undergraduate curriculum (in related news, stay tuned for the new BJSM undergraduate blog series). This is a fundamental flaw which should be rectified as patients deserve evidence based professional practice. However this is hampered in Nigeria due to the lack of training in physical activity promotion and behaviour change unlike countries such as USA, Canada and South Africa where sports and exercise medicine specialists use exercise and tailored physical activity to treat and prevent chronic diseases.

The ideal medical curriculum

This can be remedied if the Medical and Dental Council of Nigeria (MDCN) as the regulating authority for training doctors ensures that:

  1. A review of the medical curricular requirements to include emphasis and guidance for physical activity education.
  2. Refresher courses are offered on the significance and management of NCDs and reduction of physical inactivity

These two recommendations are crucial because a majority of the 32% of private facilities registered with the federal ministry of health are primary health care facilities; if we add this number to the public primary healthcare facilities and we have a very significant pool of healthcare facilities that are the first point of patient contact with probably being staffed by doctors who may not be up to date with managing physical inactivity induced illnesses.

We advocate for setting up a body (like the US National Society for Practitioners of Physical Activity and Public Health and the American College of Sports Medicine) to develop specialists in physical activity and public health. This will ensure that there is a practitioner workforce as well as academic trainers to ensure that in future, the medical curriculum includes physical activity promotion (more info here). This model is presently being used in the United States and may also be put in place in Nigeria. This involves training in competencies areas such as use of data and scientific information; planning and evaluation; intervention; organisational structure; and exercise science in public health.

Graduate training should also be created to guide the next generation of researchers in this field. Global capacity in exercise science, physical education, physical therapy, public health, architecture and planning, and environmental health should be increased. There is an urgent need for integration and comprehensive approaches to public health and physical activity.

Also more research into programmes that will increase physical activity and reduce physical inactivity are needed to help to build evidence base for our national policies and action plans.

Next steps – Olympic Legacy?

In conclusion, following the poor performance of Nigeria’s team at the 2012 London Olympics, the Federal Government has ordered a comprehensive re-organisation of the sports sector. I hope this will also have a positive effect on promotion of physical activity in the country and its people.

It will also be of immense national benefit if the appropriate authorities, private organisations and individuals take steps to implement a “Call to action” message. These key actions, namely reducing inactivity and sedentary behaviour, enabling patients and the public to access regular physical activity and exercise as part of an integral part of their daily lives, are necessary to advance global health through physical activities and is something that Nigeria can deliver.

 

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Damilola  A. Alawode (MBChB ile-ife) is a Public Health resident in the Department of Community Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria, a Msc Student (Sports and Exercise Medicine, University of Bath, United Kingdom), an advocate for the promotion of physical activities and a blog writer on Sports and Exercise medicine for Naijamedics.com.

Twitter: @DAlawode  

Email:  dalawode2002@yahoo.com

Acknowledgements

Ann Gates (www.exercise-works.org); A source of inspiration and motivation; and for sharing her resources.

Dr. Dayo Osholowu (IOC certified Sport Medicine Clinician and Director Sport Medicine Program, Lagoon Hospital Lagos state, Nigeria); for his advice and contribution to the piece.

Dr. Stathi Afroditi (Director of Sudies SEM, University of Bath United Kingdom); for her comments on an earlier draft of this report.

References

  1. Abubakari AR et al, Systemic review of the prevalence of diabetes, overweight/obesity and physical inactivity in Ghanaians and Nigerians. Public Health Journal, 2008 Feb;122(2):173-182 http://www.ncbi.nim.nih.gov/pubmed/18035383
  2. Adegoke BO et al, Physical Inactivity in Nigerian young adults; Prevalence and socio-demographic correlates. Journal of Physical Activity and Health, 2011 Nov;8(8);11 35-42 http://www.ncbi.nim.nih.gov/pubmed/22039132
  3. Canadian Fitness and Lifestyle Research Institute (CFLRI) reports 2001 https://www.phecanada.ca/economic-costs-inactivity
  4. California Centre for Physical Activity (CCPA), California department of Health services; The economic costs of physical inactivity, overweight and obesity in Californian adults, 2005 report https://www.phecanada.ca/economic-costs-inactivity
  5. Cost of physical Inactivity, 2008 a publication of Physical and Health Education Canada https://www.phecanada.ca/economic-costs-inactivity
  6. Federal Ministry of Health, Nigeria Report 2010 Health promotion draft policy.   www.scribd.com/doc/43538097/Nigeria
  7. Lancet Physical Activity series: Physical Activity 5; The pandemic of physical inactivity; global action for public health. Lancet 2012, 380: 294-305 Published online July 18, 2012 http://dx.doi.org/10.1016/S0140-6736(12)60898-8
  8. National Society for Physical Activity Practitioners in Public Health. http://www.nspapph.org/new-acsm-nspapph-physical-activity-inpublic-health-specialist-paphs-certification (accessed Jan 19, 2012)
  9. Nigeria demographic and Health Survey 2008 by National Population Commission, Federal Republic of Nigeria and DHSmeasure,2009 http://www.measuredhs.com/../FR222pdf
  10. Odegbami Segun, Mission to Addis Ababa, Segun Odegbami’s Official blog, 2012 Apr 30 http://mathematical7.com/mission-to-addis-ababa/
  11. Odunaiya NA et al, Physical activity levels of Senior Secondary School Students in Ibadan, Western Nigeria. West Indian Medical Journal 2010 Oct;59(5):529-534 http://www.ncbi.nim.nih.gov/m/pubmed/21473401/
  12. Osun State Goverment report June 2012, Walk and Live. http://osunstate.gov.ng/index.php?option=com_content&view=article&id=204&catid=7&Itemid=199
  13.  Business day Newspaper August 15 2012, Poor Olympics outing: FG orders re-organization of sport sector.   www.businessdayonline.com/NG/lndex….
  14. Sallis RE, Exercise is medicine and physicians need to prescribe it. Br J Sports Med 2009 43: 3-4  bjsm.bmj.com/content/43/1.toc

 

  1. WHO Non-Communicable Diseases report, 2004   www.who.int/../ncd_report_chapter1.pdf
  2. WHO, A framework to monitor and evaluate the implementation: Global Strategy on Diet, Physical Activity and Health, 2008. http://www.who.int/dietphysicalactivity/DPASindicators/en/index.html (accessed Jan 19,2012)

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.

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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.

References

  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. http://www.abc.net.au/unleashed/37598.html
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