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

By Dr James Noake

In clinic last week my orthopaedic colleague whispered to me, “So tell me more about this AposTherapy? That’s the third patient this week to quiz me about it”. Admittedly I had only ever cast a cursory (sceptical) eye over the advertisements, which seem to have become ubiquitous in the UK.

The official website claims the therapy is “clinically proven for long-lasting pain relief” in several musculoskeletal conditions including knee OA, patellofemoral syndrome and chronic lower back pain. Further investigation reveals an intervention which operates on the principal of altering gait kinematics, re-distribution of joint contact forces and improving neuromuscular control via an orthotic device – but interestingly worn on the external surface (sole) of a customised shoe.

Aesthetically it leaves a lot to be desired and the adjustable mechanism appears crude, but before we sneer, consider that clinicians probably responded in a similar fashion years ago when some bright spark suggested we insert a device into our shoes to influence the proximal kinetic chain.

The evidence base to date is comprised of retrospective, prospective and controlled (non-randomised) trials, which show significant improvement in short and long-term outcomes (WOMAC scores) and improvement in gait velocity, cadence and stride length^1,2. A biomechanical study³ demonstrates that manipulating the foot centre of pressure during gait positively alters activation patterns of the lower limb musculature, particularly knee adduction moments, lending some scientific credence to the mechanism of action.

Although one could certainly pick holes in the methodology and quality of the research, it is still enough to pique interest in this non-invasive, relatively low cost treatment. It is however very easy to dismiss this type of product as being “gimmicky”, rather than to appraise it objectively. The outcome of a rigorous RCT with greater numbers would be very interesting.

‘Time to get your feet dirty…..’

As SEM clinicians, patients and friends have asked us for expert opinion about the positive and negative effects of  ‘bare-foot’ running, and just as often, which trainer to choose out of the bewildering array of choice on the current market.

As a specialty we are starting to gain a scientific understanding of how a mid-foot strike running style might improve symptoms in patients with Chronic Exertional Compartment Syndrome (CECS) and how a holistic running re-education approach can ameliorate Exercise Induced Leg Pain (EILP), as demonstrated by ongoing work at Headley Court DMRC. However, there is no medical consensus with respect to the most suitable footwear type.

Therefore it was with interest that I read the recent BJSM biomechanical study⁴, which definitively demonstrated that running shod, including in a so-called ‘minimalist’ shoe, does not replicate true bare foot running style.  There are significant differences between the kinetic and kinematic variables at the foot and ankle during gait analysis.

Given these results, we now need to address our patients’ misconceptions about the efficacy of different shoe types, principally driven by the misleading advertising of manufacturers and reinforced by well-meaning but ultimately financially driven store assistants. It seems that if patients want to benefit from a change in running style, then they may well have to throw their trainers away completely.

‘Subtalar arthroereisis – the surgical orthotic?’

Whilst recently exploring options for a patient with (correctable) pes planus deformity with persistent pain due to chronic overload of the medial mid-foot structures and tibialis posterior tendon, I happened across this procedure, which involves insertion of a screw or self-locking wedge into the sinus tarsi. I assumed it was an experimental procedure but to my surprise it was first utilized in 1946.

The implant is intended to block anterior, inferior, and medial displacement of the talus in resting stance and gait (and consequently prevent collapse of the mid-foot) as well as preventing excessive eversion of the rear-foot.

It seems to me that this might be an end-stage option for less active patients for whom customized footwear appliances and physical therapy have failed. Certainly biomechanical studies exist that show there is significant variability in patients’ response to orthoses and that their positive effects on subtalar motion are typically small during gait analysis⁵, so would a definitive surgical block off-load the tissues under stress more effectively?

It makes sense that the implant needs to be inserted bilaterally even if symptoms were unilateral to prevent compensatory problems. My main concern is that the rigid implant would cause a ‘stress riser’ over time in the adjacent bone, leading to stress (and ultimately frank) fracture, much in the same way peri-prosthetic fractures occur. Research to date does not corroborate this however⁶.

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Dr James Noake is a Sport and Exercise Medicine trainee currently placed at Homerton Hospital, London. He is Head Doctor at London Irish RFC, works as a medical officer for England / GB Disability Football and is clinical lead in orthopaedics, SEM and musculoskeletal medicine for Herts Valleys Clinical Commissioning Group (HVCCG). He has a special interest in foot and ankle disorders in sport.

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

References

1. Bar-Ziv et al. A 2 year follow up study indicated AposTherapy provides lasting pain relief and long term improved function. Arthritis 2012.
2. Elbaz A, Mor A et al. APOS Therapy Improves Clinical Measurements and Gait in Patients with Knee OA. Clinical Biomechanics 2010, 25:920-5.
3. Haim A, Rozen N et al. Control of knee coronal plane moment via modulation of center of pressure: a prospective gait analysis study. Journal of Biomechanics 2008, 41: 3010–3016.
4. Bonacci J, Saunders P, Hicks A et al. Running in a minimalist and lightweight shoe is not the same as running barefoot: a biomechanical study. Br J Sports Med 2013; 47: 6. 387-392.
5. Mills K, Blanch P et al. Foot orthoses and gait: a systematic review and meta-analysis of literature pertaining to potential mechanisms. Br J Sports Med 2010; 44: 1035-1046.
6. Van Ooij B, Vos CJ, Saouti R. Arthroereisis of the subtalar joint: an uncommon complication and literature review. J Foot Ankle Surg. 2012; 51(1): 114-117.

By James Brown (@jamesbrown06)

The best houses are built on the best foundations

The contemporary field of injury prevention has broadened its focus from purely epidemiological to include social science evaluation tools over the past five years. For example, the RE-AIM framework has now become accepted as a injury prevention programme evaluation tool [1] [2]. The letters of the “RE-AIM” acronym indicate a different aspect of the programme to be assessed: Reach, Effectiveness, Adoption, Implementation and Maintenance. Finch and colleagues also described how the RE-AIM framework should be assessed within a Sports Setting Matrix [2], which looks at these aspects (Reach, Effectiveness, etc.) within different hierarchical levels. National Sports Organisations are at the top of this hierarchy due to their ability to change policy relating to sports safety, and as a result Finch and colleagues emphasise the importance of relationships between injury prevention practitioners and these NSOs.

Thus, the relationship between the South African Rugby Union (SARU) and two universities (University of Cape Town and Vrije University Medical Center) is an exemplary example of just such an NSO/injury prevention practitioner relationship. A critical ingredient to this gel was the active buy-in and confidence of the scientific process of the injury prevention practitioners (UCT/VUmc) from the SARU medical department. Without this, the work of the injury prevention practitioners may have been largely wasted.

Based on SARU’s support, they permitted UCT/VUmc access to analyse their rugby-related catastrophic injury data. Access to and publication of catastrophic injury data, in particular, can be a sticking point among NSO’s due to the assumed negative spin-off of giving the sport a negative image. Far from this attitude, SARU saw this relationship as an opportunity to improve the already extensive BokSmart nationwide injury prevention programme [3]. Based on the publications findings (full article HERE ), SARU changed scrum laws at the amateur level in order to make this phase of play safer in South Africa (more info HERE) almost immediately. The International Rugby Board (IRB) vindicated SARU in this controversial change, by declaring a similar scrum-law change internationally from 2014.

Dr Wayne Viljoen (SARU BokSmart manager) and Clint Readhead (SARU Medical manager) discussed this relationship recently at the 2013 American College of Sports Medicine conference in Indianapolis.

 References

1.     Collard D, Chinapaw M, Verhagen E, van Mechelen W. Process evaluation of a school based physical activity related injury prevention programme using the RE-AIM framework. BMC pediatrics. BioMed Central Ltd; 2010;10(1):86.

2.     Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. British Journal of Sports Medicine. 2010 Oct 4;44(13):973–8.

3.     Viljoen W, Patricios J. BokSmart – implementing a National Rugby Safety Programme. British Journal of Sports Medicine. 2012 Aug;46(10):692–3. (FREE FULL TEXT)

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James Brown is a PhD student at the University of Capetown, South Africa. His PhD is evaluating the effectiveness of BokSmart – a nationwide injury-prevention programme for catastrophic injuries in rugby. Follow him @jamesbrown06 and http://wp.me/2UGKS

News Release

Re: The King’s Fund Analysis of A&E Waiting Times

In response to The King’s Fund analysis of A&E waiting times, the Faculty of Sport and Exercise Medicine is fully supportive of a co-ordinated response to help ease the burden on our healthcare system.

John Appelby, Chief Economist, at The King’s Fund concludes in his report on pressures on accident and emergency services: “The pressures in emergency care will not be relieved by focusing on a single aspect of the problem – it requires a co-ordinated response across the whole health system.”

The Faculty of Sport and Exercise Medicine is calling for the creation of more Sport and Exercise Medicine Doctor posts within the NHS as part of a co-ordinated solution to the issues we are facing in emergency care and across the health system. Particularly after sport or occupational injury and in the prevention and treatment of common diseases.

Dr Rod Jaques, President of the Faculty of Sport and Exercise Medicine Comments: “We would like to see a co-ordinated approach to improving the long-term health of the public by increasing the specialty of sport and exercise medicine in General Practice, therefore easing the burden on our A&E departments and health services.  Part of the solution also lies in the creation of sport and exercise medicine specialists who can work alongside emergency medicine, musculoskeletal clinics and physiotherapists to deliver activity based care and reduce unnecessary referrals and overall expenditure. 

Sport and Exercise Medicine specialists have been part of a pilot study that has improved care and cut waiting times for patients with muscular and joint pain, saving the NHS tens of thousands of pounds. The pilot enabled the partnership to deliver 62% more patient care in 2012 than was delivered in 2010, whilst still reducing overall expenditure.

For further information contact:

Beth Cameron, PR & Communications at the Faculty of Sport and Exercise Medicine

email: pr@fsem.ac.uk, Tel: 0131 527 3498 or 07551903702        Twitter: @FSEM_UK

Faculty of Sports and Exercise Medicine, 1a Hill Square Edinburgh, EH8 9DR

Association of Chartered Physiotherapists in Sports and Exercise Medicine monthly blog series

By Tom Curran MCSP (@physiotom) and Lorraine Tomeldan MCSP (@LTGolfphysio)

Sporting Balance Physiotherapy and physiotherapists to a number of touring golf professionals

Pre 1996, there was a perception amongst the public that golf was more of a game than a sport. Amongst the professional ranks there was a somewhat ambivalent attitude to fitness, which still permeates facets of the elite ranks even today. Although Gary Player was, and still is, remarkable in terms of his unwavering commitment to physical conditioning, for years he was seen as an outlier amongst the pro ranks. However, in 1996 one event radicalised all that and transformed the perception of golf, the fitness element, and of course the pay packets. Tiger Woods turned professional.

In the aftermath of the European Tour’s flagship event at Wentworth, UK, won in dramatic style by Matteo Manassero, attention is now focussed on a new generation of golfers who grew up idolising Woods. Their attitudes to fitness, conditioning and levels of athleticism send out a foreboding message to their competitors; get busy training or get left behind. Golf is a hugely technical pursuit, and golf skills (whether it is shot making, course management or ball striking) will always remain the central tenant of performance. However, maximising one’s physical ability to build power, speed and distance around such golf skills is becoming increasingly necessary to compete and challenge for victories. Of course, outliers will always exist, and science and medicine is littered with anecdotes of the healthy 90 year old chain-smoker. In high performance sport, the days are numbered for those who ignore the realm of physical conditioning.

Explosive Rotational Power

Many sports require rotational power. Thus, golf fitness and training share many similarities at a conceptual level with track and field, martial arts, baseball and other throwing sports. Ultimately, form and function are inextricably linked and training should always replicate where possible, the mechanics and sequencing of the requisite task. Golf is a rotational game, ostensibly aiming to get the club head to make contact with the ball consistently, accurately and as fast as possible without sacrificing movement efficiency. Some of the top touring professionals can generate club head speeds of over 120 miles per hour, which is phenomenal. To consistently hit a small target the size of a golf-ball with predictable accuracy at such speeds requires extraordinary timing and sequencing in the golf swing. Some are blessed with preternatural timing (look at videos of Rory McIIroy or Tiger Woods swinging a club as toddlers) whereas others have had to work harder to develop the neuromuscular control. Ultimately, timing and sequencing are required to generate power from the ground up, rotating the trunk around a stable pelvis with hips fully loaded and then, like a whipping action, the downswing is initiated by the hips, followed by the trunk and finally the arms and club head being ‘bull-whipped’ towards the golf-ball. This requires appropriate timing in the back-swing to load the kinetic chain with ‘elastic potential energy’ and the correct sequence of acceleration/deceleration in the downswing to generate controlled explosive rotational power.

The Perfect Swing

There is no perfect swing! Compare the swing patterns of Jim Furyk, Eamonn D’arcy, Bubba Watson, Ernie Els and Tiger Woods. Each will have their idiosyncratic stance position, backswing and how they initiate the downswing but what most top professionals will share is the impact position and the segmental sequencing of the downswing to impact. Ultimately the best swing is the one that is best suited to an individual’s own physical capabilities. However, this can be a grey area and is where a collaborative approach between a golf coach, a physiotherapist and fitness trainer can be utilised for maximum effect with their collective understanding of biomechanics and physiology.

Greg Brodie (Performance Coach and PGA Advanced Professional, Surrey County Coach), believes that, “putting your body in an optimal state for golf performance with the aid of physiotherapists and conditioning experts who specialise in golf is a major facilitator in skill development”.  He adds that, “So many golfers have a good understanding technically of where they need to be and are desperately trying to change their movement patterns without actually looking at the raw materials they are working with. Sadly many just try to change movement via drills or tuition which can be a futile exercise”.

A golf coach can try to teach a player a certain swing, but if the player cannot physically get into the position required for that swing, then the coaching may be stymied by such physical restrictions. A physiotherapist can help to identify reversible movement deficits (both in terms of limitations in range of movement or faulty motor-control patterns) or in the case of an injured player can help with swing analysis to identify potential causes for the pain or injury and how it may relate to the cause or effect of poor swing mechanics.

Golf Injuries

The most common injury amongst amateur and professional golfers is low back pain and often it can manifest as a result of limited trunk rotation. For right handed golfers, right sided low back pain tends to predominate. As an example, when a golfer attempts to rotate into the backswing, to compensate for the rotational deficit to get the club head to the top of the backswing, they may begin to extend and side-flex through the lumbar spine putting increased stress across the facet joints and other structures. From that extended and side-flexed position at the top of the backswing, the player then begins to flex and rotate as they transition into the downswing, and it is this repeated extension/flexion/rotary movement of the lumbar spine that can lead to biomechanical overload of the lumbar region. This classic swing characteristic is called a ‘reverse spine angle’ (although this can happen for reasons other than limited trunk rotation) and is suggested as a primary reason for Colin Montgomerie’s recurrent spinal dysfunction.

A less common injury, but absolutely devastating for a professional golfer, is an injury to the triangular fibrocartilage complex (TFCC) of the wrist (usually of the lead arm). One possible reason this may occur is due to the swing characteristic called ‘early extension’. In this instance, as the player moves through the downswing towards impact, instead of maintaining a stable pelvis, the player begins to extend both hips (and pushes the pelvis forwards closer towards the ball, away from the red line as seen in the accompanying photograph). As a consequence of this, in order to keep the clubhead on swing plane to make contact with the ball, the player has to make a compensatory movement, such as excessive ulnar deviation at the wrists. This overloading of the wrists may cause a TFCC injury

The Team 

Whether in rehabilitation from injury, working on swing mechanics or overall fitness, team-work and the multidisciplinary approach are central to the players’ performance. Good communication between the medical team and the golf coach is essential and it is important that the medical team can speak and understand the language of golf terminology, both when liaising with the coach and when imparting advice or diagnostics to the player. For elites and amateurs alike, in assessing a player with a variety of golf specific screens and other standard musculoskeletal/orthopaedic tests, the findings must always relate back to how it affects the golf swing. And more importantly, the success or failure of any corrective intervention will coalesce around ‘player buy-in’ and how clearly the interventions are linked to performance improvement with obvious specificity to the golf swing or on-course performance.

One of our interesting cases over the past year related to the South African player Anton Haig. Anton is a multiple winner on tour, with his most notable victory coming at the 2007 Johnnie Walker Classic as a precocious 21 year old. However, due to a debilitating neck injury sustained in 2011, Anton retired from professional golf aged 25. In 2012, he set about making a comeback and as part of his coaching team, we were involved in modifying his swing and changing his physicality to ameliorate the effects of the neck injury. It has been a fascinating challenge helping guide Anton back from retirement, culminating with him securing his Asian tour card for 2013.

Final Thoughts

Golf is an explosive sport with tremendous club head speeds that can stress the body in myriad ways. Consistency in timing and sequencing is fundamental for consistency in scoring and accuracy. A variety of injuries can be the cause and effect of poor swing mechanics but a coaching team with physiotherapists with golf specific understanding can complement a player’s development and longevity. The concept of golf fitness and being fit for golf is an idea that is increasingly permeating through the ranks of the hackers, amateurs and elites. Employing the use of a coach or physiotherapist is not for everyone of course, but for those with ambitions to improve performance (whether it is to get a handicap into single figures or more lofty tour ambitions), a multidisciplinary coaching team can make a significant difference.

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

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.

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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 3^rd 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.

We are happy to announce 3 different winners today.

First off, for the second year in a row the issue associated with the South African Sports Medicine Association (SASMA) (with guest Editors Jon Patricios and Wayne Viljoen) was victorious. Coincidence (or maybe it was the cute giraffe)? By coincidence, the current issue of BJSM celebrates SASMA again – and their conference in October 2013.

Secondly, the contest winners of either

1. The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr.

 or

2.Brukner and Khan’s Clinical Sports Medicine, 4th Edition, 2012.

are:

1. Xabat Casado

Xabat has been a physical therapist since 2005 and currently works in private practice in San Sebastian, Spain. He is passionate about the science and practice of manual therapy and looks forward to reading his new book to access updated information on sports medicine. When asked what about his favourite thing on the BJSM blog, he stated: “ The quality of the information published. Without a doubt, a reference blog.”

2. Loryn Turnock

Loryn recently graduated in Sports Therapy at the University of Hertfordshire. She aspires to work with a sporting team and also gain clinical experience (in Australia where she wants to live out her dreams). She is excited to have won either book as she views them as key resources for her career. Her favorite thing about the BJSM blog is that it keeps her up to date on current literature.

Seems like these book prizes will be put to good use.

Thanks to everybody who participated!

We know that case-based learning is the most effective and fun way to improve clinical skills. So BJSM provides opportunities!

Under the “Education” tab on the home page, click on Image Quiz. You’ll find real-life cases – ideal for medical students and junior doctors. (We tested our EIC on two and are pleased to report he got them right!).

Our newest cases are of (i) a triathlete with unusual calf/Achilles region pain and (ii) a water-skier who came to grief while attempting his start.

These cases will help you recognize clinical scenarios and help you gain confidence in interpreting imaging. These new case include a lateral x-ray of the ankle/ultrasound scan of the lower leg and an MRI of the hamstring region. As a side teaching note, remember that precise localisation of hamstring injuries is important as the location of injury affects prognosis. (Carl Askling’s work – listen to his podcast here).

Thanks to Arthur Kievit (PhD fellow) and Gino Kerkhoffs (orthopedic surgeon) from the Department of Orthopaedic Surgery at the Academic Medical Centre, Amsterdam, Netherlands for the hamstring quiz. The Dutch Sports Medicine Society (VSG in Dutch) is a BJSM member society – all VSG members have full access to BJSM and the VSG guides one issue of BJSM annually.

Thanks also to Dr James Thing (Sports Physician in training), Dr James Sarkodieh (Radiology in training) and Dr Muaaze Ahmad (Consultant Radiologist) from the Royal London Hospital for the case about the calf/Achilles pain.

Follow this link to the newest quizzes

Keep an eye out for future quizes – they’ll be flagged on BJSM’s Facebook and Twitter channels. Drs Kievit, Kerkhoffs and Thing will keep the Image Quizes coming and feel free to submit cases yourself! Please contact me on bpluim@euronet.nl and I’ll make it easy for you. Best Image Quiz for the Year gets a free copy of a best-selling sports medicine book!

Yours in sport,

Babette Pluim, Deputy Editor BJSM

@DocPluim

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

By Lucinda Poulton¹, Paul Kelly², Justin Richards², Moiz Moghal³, Wilby Williamson^2,3

Affiliations

1. University of Oxford Medical School (4^th Year Medical Student)

2. British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford

3. OxSport, Nuffield Orthopaedic Centre, Oxford.

Lack of physical activity is a major risk factor for mortality, yet 25% of students at Oxford medical school are unaware of the World Health Organization global guidelines for physical activity¹. There is concern that this gap in awareness and understanding is not limited to our medical students.  With the arrival of Public Health England, there is an increasing responsibility for all doctors to consider the challenges of preventive medicine. Understanding the problems patients face and having the confidence to tackle them is critical. Weiler and colleagues highlighted a UK nationwide deficit in the provision of medical student teaching on physical activity and have championed a call for reform². A survey of 4-6^th year medical students at the University of Oxford aimed to identify where gaps in local education could be improved. The results identified three hurdles to changing patient behaviour – students’ education, knowledge and attitudes to physical activity.

First, searching for physical activity in the Oxford curriculum drew a blank. Whilst other leading risk factors for global mortality such as smoking cessation and dietary changes, were covered, physical activity was not mentioned in the core curriculum. Perhaps this explains why, when asked to rank risk factors for global mortality, physical activity was ranked bottom of the pile by the majority of students.

Should we describe the lack of curriculum as a false start? It certainly appears to leave the students struggling at the next hurdle: grasping the basic knowledge of the role physical activity plays in prevention and treatment of non-communicable diseases. More than 60% of students believed there was no evidence to support promoting physical activity as a preventive approach to bowel and breast cancers ³.  More worryingly, 16% of students said the same for cardiovascular health. Overall, 85% of students felt they had inadequate knowledge of the role of physical activity in preventing and treating chronic disease.

Encouraging behaviour change in patients requires more than just knowledge of guidelines. The ability to motivate, promote patient’s capabilities and identify opportunities for change requires medical professionals to take ownership of this problem, and to have the confidence to do so.

Three groups of 5^th year students were asked to list everything they had, or had not done, in the past week that was a threat to their health. They all keenly acknowledged the risks they took in not eating enough fruits and vegetables, riding bikes without helmets or over indulging in some other vice. But of the 50 students surveyed, none identified a lack of physical activity as a personal risk they had taken. Yet when specifically questioned approximately 90% did not meet physical activity guidelines (150 minutes per week)⁴. How can tomorrow’s doctors encourage physical activity behaviour change when they don’t see it as a problem in themselves?   With the rising burden of non-communicable diseases it is increasingly important for medical students to be prepared and to feel motivated to gain the knowledge and expertise needed to promote physical activity. However, over three-quarters of students felt they hadn’t received enough training, and a majority lacked the confidence to provide advice to patients on physical activity.

Oxford currently leads the world in medical student education⁵. Now they are taking steps to guarantee students receive appropriate training in physical activity and preventive medicine. However, this is a global issue, and our fear is that we are joining a small minority of institutions where educational reform is being driven by passionate physical activity researchers and clinicians. Nationally and internationally, are others taking up the call to champion undergraduate physical activity education? Will the gap in curriculums be filled?

References

1. http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html

2. Weiler R. 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, 46, 1024-6 (2012)

3.http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/lifestyle/physicalactivity/physical-activity-and-risk-of-cancer

4. https://www.gov.uk/government/publications/uk-physical-activity-guidelines

5. http://www.timeshighereducation.co.uk/world-university-rankings/2012-13/subject-ranking/subject/clinical-pre-clinical-health

Acknowledgement

Dr Natasha Jones and Dr Julia Newton

Oxsport, Nuffield Orthopaedic Centre, Oxford.

Contact

Wilby Williamson, Academic Clinical Fellow, Oxford

wilby.williamson@dph.ox.ac.uk

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

By Dr. Fred H. Brennan, Jr.

Born in Boston in 1965 and having run the race twice, the Boston Marathon has always been a special event for me. I returned in 2013 for my fifth year as a medical volunteer.

This time would be special. My 18-year old daughter would be working and shadowing me as part of her senior year high school project. She had been contemplating her career choice; an emergency department nurse or an athletic trainer. This day, Patriot’s Day in Massachusetts, would be a day that would shape her career choice and forever bind us together.

We arrived in Boston a little after 6 am. Plenty of time for us to get a coffee and bite to eat at the Starbucks just 75 yards shy of the finish line on Boylston Street. We made our way down to the finish line and took a few pictures of Alyssa standing under the media bridge. It was quiet at 6:30 am except for a few media personnel setting up their cameras in preparation for one of the world’s greatest marathons. The Grand Stands were empty but would be packed with family members, fans, men, women and children in just a few short hours -all excited to watch their runners finish the grueling 26.2 mile event. We could never have imagined that the very spot where I was taking photos would later be littered with bomb blast debris, human flesh, and bones.

Arriving at the pre-race meeting Alyssa was impressed with the abundance of volunteers, smiling faces, camaraderie, and organization of this massive event. The meeting introduced the new and prior volunteers to the logistics of the medical support structure at the Boston Marathon. Chris Troyanos, the medical coordinator, thanked and praised last year’s volunteers for their incredible efforts caring for over 2000 athletes suffering the effects of record breaking heat. This day was expected to be cool with a bit of a breeze. Cramps, nausea, post-race collapse, and mild hypothermia were anticipated….the usual marathon ailments. We broke from the meeting and dispersed to our respective medical treatment areas along the race course and near the finish line.  Alyssa and I went to Med Tent B, approximately 1-2 blocks from the finish line, where I would spend the next two hours coordinating my team of approximately two hundred volunteers.  Our volunteers were excited, motivated, and anxiously awaiting our first potential patients. We were able to view the finish line area on two large flat screens monitors set up in the tent. Approximately 3 hours into the race we began to get a slow trickle of patients who were cold and cramping. At 4 hours we were approximately 75% full of patients who were cold, exhausted, and worn out from the trek from Hopkinton to Boston.

At 4 hours and 9 minutes into the marathon, our lives would change forever. I will never forget the look on Alyssa’s face when the first bomb went off…then the second one. We heard and felt the blasts.  Everyone in the medical tent froze in place. The flat screen monitors went dead, cell phones stopped working, and we lost all communications with the rest of the medical command. I stood on a milk crate and got on the tent intercom system. “We all need to stay calm. We don’t know what has happened yet but there is a good chance that we will receive causalities. Stay in the tent, take care and stabilize your current athletes, and let’s get the tent ready to receive trauma casualties.” The response from the volunteers was incredible. No panic, no hesitation, and a total team effort. During this time the first responders at the finish line, including Tent A marathon medical personnel, heroically triaged and stabilized the casualties. We were told to stay put in Med Tent B as the blast area was not secured and more explosive devices were possible. We received 3 minor shrapnel injured patients and saw the psychological effect on the spectators. People were running frantically trying to either get away from the blast area or looking in horror for their loved ones in our medical tent.  Runners were diverted to the Boston Commons as the course finish area was secured and evacuated. Amazingly most of the casualties were evacuated from the finish area within 30 minutes.  It was an incredulous response to a tragic event.

So what lessons were learned and how does this change the future of endurance event medical coverage? I will shed some light on this from my year in the 28^th Combat Support Hospital in Iraq where we frequently responded to tragic events like this.

1.  We must now be prepared to be first responders for mass trauma. A team or teams of volunteer medical personnel with trauma training and/or experience should be pre-determined. They should meet with local EMS supporting the event to discuss available assets and how the volunteers can augment the EMS system.
2. A trauma bag (s) should be assembled and include basic oral airways, tourniquets, curlex bandages, ACE wraps, SAM or other extremity splinting materials, some IV starter kits with normal saline. This list is certainly not all inclusive.  These bags should be at the race start, the race finish, and at aid stations along the course.
3. Think before jumping into the scene. Make sure the scene is safe and secured. Terrorists will wait for first responders to act then set off a second explosive device to wipe out those responders.  “Dirty bombs” laced with chemical agents are also a real possibility.  First responders can quickly become casualties if they are exposed to chemical agents. And contaminated patients brought back to your medical tent will quickly contaminate your medical treatment area.
4. When triaging casualties think about those interventions that can quickly save a life. Firm pressure on a bleeding wound, a tourniquet, an oral airway, quick stabilization of a long bone or pelvic fracture.  You may have to walk away from someone who you could save in an emergency department so that you can tend to a greater number of injured who will survive with your simpler but more timely intervention, such as an application of a tourniquet.
5. If ever in an event like this remember to talk it out. Share your feelings and experience with anyone you trust or who wants to listen. It is therapeutic and will help minimize the chances of the “unseen” injuries that can haunt those injured (Post Traumatic Stress Disorder) and those who helped them.

I could not be more proud of the Boston Marathon medical volunteers who responded to this tragic event.  As with the tragedies of 9/11 this event once again made us all realize the important things in life; family, friends, freedom, and faith. Thankfully my daughter Alyssa is fine. She will be a terrific ED nurse someday. And she now wants to run the Boston marathon as a tribute to those who were killed and injured. Maybe we’ll cross the finish line together…Boston Strong!

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Fred H. Brennan, Jr is currently the medical director at Seacoast Orthopedics and Sports Medicine in New Hampshire and a team physician for the University of New Hampshire. Dr. Brennan studied at the University of New England College of Osteopathic Medicine, completed his family medicine residency at Albany Medical Center and a sports medicine fellowship at the University of Toledo.  A member of the American Medical Society for Sports Medicine (@TheAMSSM), he chairs the musculoskeletal ultrasound committee.   Previously he was an active duty physician for the US Army with service during Operation Iraqi Freedom as a trauma physician. An avid endurance athlete, he is a Hawaii Ironman finisher and a two-time Boston Marathon finisher.

The AMSSM is one of BJSM’s 13 member societies – clinical societies who partner with BJSM to advance the missions of the organizations. The January 2013 issue of BJSM was guest edited by the AMSSM.

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

By Bryn Savill (@BrynSavill) 

The evidence behind exercise as medicine is substantial and it can no longer be ignored.¹ Prof. Blair (2009) named physical inactivity the “Biggest public health issue of the 21^st Century” after discovering that physical inactivity was killing more Americans than smoking, diabetes and obesity combined.² Cardiff Exercise Medicine Symposium hopes to explore the wealth of evidence about physical activity, and inspire us all to be more active and proactive in promoting physical activity both at an individual and policy level.

Symposium Rationale

Physical activity promotion in the UK is limited. This is not unexpected given the reality that healthcare is influenced heavily by the drug, devices and diagnostic trades with the aim of boosting their share price³. Further, the NHS has a strong track record of favoring interventions that involve something to swallow, breathe in and/or a syringe. We need to develop the skills, tools, and collective capacity to not only prescribe exercise as medicine but also move it to the front lines of government healthcare agendas. Of the four key adjustable risk factors to health: alcohol, smoking, food and physical activity – only physical activity seems to lack champions in the higher echelons of government.  We must act now and thrust this physical inactivity plague into the limelight. Physical activity is the polypill that we have been searching for; a moderate level of fitness causes a 44% reduction in mortality ⁴ – how many drugs are that effective?

Physical Inactivity vs Obesity

Everyday the newspapers, TV, and media are full with stories about the obesity crisis whilst we see little press on physical inactivity: yet which is the bigger public health issue – obesity or physical inactivity? Prof. Steven Blair has shown in a number of papers that being fit can alleviate the risks of being fat,^5,6,7,8 and Weiler et al. (2010) argue that health policy should focus on physical inactivity not obesity.⁹

Prof. Blair will be presenting his latest research in the field at the symposium, whilst Prof. Terence Wilkin will be discussing the link between physical activity, genetics and childhood obesity. 

Sedentary behaviour

High levels of sedentary behaviour are damaging to our health, and sitting forms part of our everyday life so it’s an issue which we must address although I’m not in any way saying we should ban sitting; that’s mad! Indeed, sedentary behaviour is now included in the UK physical activity guidelines with the general advice to “minimise the amount of time spent sitting”.

Dr Emmanuel Stamatakis will discuss realigning are public health priorities with sedentary behaviour on the afternoon of Cardiff Exercise Medicine Symposium. 

National exercise guidelines – evidence or opinion?

There is growing confusion over how we should become active, perhaps stoked by programs such as the BBC documentary, “The Truth about Exercise” and Andrew Marr’s recent appearance on the BBC. Whilst providing mixed messages to the public can only serve to negatively impact physical activity levels, we need the debate and research between exercise professionals to continue so we can formulate clear evidence-based guidelines.

At the Symposium, Prof. Jamie Timmons will clear up the confusion by identifying if high intensity interval training has a role to play in the national exercise guidelines. 

Final Thoughts

It’s our responsibility, students and healthcare professionals alike,  to lobby for change, and form a voice to create a compelling fight for the role of physical activity in the health of the nation. Have you ever spoken to anybody who didn’t deem exercise as beneficial for your health? The response is most likely an emphatic “no.” However, do you have the expertise to lead by example and rally for change? Are you up to date with the latest developments in the exercise medicine field? Why not come to Cardiff Exercise Medicine Symposium to learn more about how we can construct effective models of physical activity intervention, the role of sedentary behaviour, the genetics of physical activity, and the interface between obesity and physical activity.

Remember we as emerging and seasoned healthcare practitioners can provide one of the seven “best investments” to combat this public health disaster¹⁰ – Listen to Fiona Bull’s podcast on the “Seven Best Investments”

Cardiff Exercise Medicine Symposium 2013 will be held on the 15^th June at the University Hospital of Wales. For more information on Cardiff Exercise Medicine Symposium & to register CLICK HERE 

References

1 Department of Health (2012). Let’s Get Moving – A Physical Activity Care Pathway. 

2.Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009;43:1–2.

3. Stamatakis E, Weiler E, and Ioannidis JPA. Undue industry influences that distort healthcare research, strategy, expenditure and practice: a review. Eur J Clin Invest 2013. Article first published online: 25 MAR 2013

4.Lee DC, Sui X, Ortega FB, et al. Comparisons of leisure-time physical activity and cardiorespiratory fitness as predictors of all-cause mortality in men and women. Br J Sports Med 2011;45:504–10.

5. Ortega FB, Lee DC, Katzmarzyk PT, Ruiz JR, Sui X, Church TS, Blair SN. The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness. Eur Heart J. 2013 Feb;34(5):389-97.

6. McAuley PA, Artero EG, Sui X, Lee DC, Church TS, Lavie CJ, Myers JN, España-Romero V, Blair SN. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc. 2012 May;87(5):443-51

7. Lee DC, Sui X, Church TS, Lavie CJ, Jackson AS, Blair SN. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol. 2012 Feb 14;59(7):665-72.

8. Lee DC, Park I, Jun TW, Nam BH, Cho SI, Blair SN, Kim YS. Physical activity and body mass index and their associations with the development of type 2 diabetes in korean men. Am J Epidemiol. 2012 Jul 1;176(1):43-51.

9.Weiler R, Stamatakis E, Blair S. Should health policy focus on physical activity rather than obesity? Yes. BMJ 2010;340:c2603.

10. Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD prevention: investments that work for physical activity. Br J Sports Med 2012;46:709–12.

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Bryn Savill BSc (Hons) is a fourth year medical student at Cardiff University, Wales, having undertaken an intercalated BSc in Sports and Exercise Science at Loughborough University. He sits on the undergraduate committee of the European College of Sports and Exercise Physicians (ECOSEP) and is a Move. Eat. Treat. Ambassador.

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.