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Play on Pedals: engaging preschool children in cycling to improve mental and physical health of future generations

30 Mar, 17 | by BJSM

By Polly Jarman, Play on Pedals Development Officer Cycling UK

 Suzanne Forup, @backonmybike, Play on Pedals Director Cycling UK

 Prof Chris Oliver, @CyclingSurgeon, Physical Activity for Health Research Centre, University of Edinburgh

Play on Pedals aims to give every preschool child in Glasgow the opportunity to learn to ride a bike before starting school. The project was supported by players of People’s Postcode Lottery and awarded £231,000 by the People’s Postcode Dream Trust Fund (1), the largest single award given by the fund at that time. Play on Pedals (2) was a partnership project between Cycling UK (3), Cycling Scotland (4), The Glasgow Bike Station (5) and Play Scotland (6). Play on Pedals partners recognised how cycling can provide a means of independence, an opportunity to develop new skills and a low-cost way to maintain a healthy lifestyle. It has both physical activity and mental health benefits, is sustainable, inclusive and fun; by engaging children and young families in cycling, Play on Pedals aimed to have a transformational effect on future generations in Glasgow.

Need for a project like this

Glasgow is a city with large areas of multiple deprivation and recognised health inequalities. The Glasgow Centre for Population Health (GCPH) has released data sets for Children and Young People, which highlight health and wellbeing, educational, environmental and socio-economic inequalities across neighbourhoods in Glasgow, as well as between Glasgow and the rest of Scotland (7). Evidence includes higher levels of child poverty in Glasgow than the rest of Scotland, in some areas as many as 46% of children live in poor households compared to the 29% average across the city. There is a recognised lower healthy life expectancy for both males and females in Glasgow than the rest of Scotland, and high inequality in healthy life expectancy across Glasgow’s neighbourhoods with a 21 year age gap in female healthy life expectancy at birth. Active travel to schools varies across neighbourhoods in Glasgow, with some neighbourhoods where only 15% of children walk, cycle or skate to schools, whereas as other neighbourhoods report figures as high as 79% of children. Levels of active travel can impact upon other indicators, notably levels of child obesity and physical activity in childhood. Regarding physical activity and obesity in children, the GCPH notes that the 2015 Scottish Health Survey reported that 28% of children aged 2 – 15 years old were overweight and 15% were obese; in Glasgow, during 2012 -2015 period roughly 6% of primary 1 children were found to be obese.

Recommendations argue that solutions to tackling obesity in children should be holistic; tackling living environments, access to physical activity, diet and providing long-term, cost-effective support for families and educational settings to bring about change. Play on Pedals addressed these health inequalities by providing a sustainable, accessible and engaging project for all children across Glasgow. The project was closely linked to the Scottish Government’s Early Years Framework (8) and Getting It Right For Every Child (9) approach, as well as the national Play Strategy and Glasgow City Council’s Cycling Strategy.


Play on Pedals worked with 7,148 children during the 2.5 years of the project and trained 388 Instructors and Instructor Trainers across Glasgow. 182 organisations have one or more trained Instructors, delivering Play on Pedals to preschool children on an ongoing basis, including 88% of local authority nurseries; while a total of 286 organisations have been engaged in the programme.

Small grants were given to 35 Hero Organisations (10) across Glasgow, enabling local groups including bike workshops and community organisations to train their staff, deliver training events, share resources, maintain bikes between establishments and organise community cycling activities for families. In total 240 community events have been delivered by Play on Pedals and its associated Hero Organisations. These events provide free physical activity for children, information for families about access to cycling and tips for maintenance on bikes. Equipment is provided and instructors facilitate a one-to-one instructional service, supporting children to learn to pedal; they are also trained to carry out basic bike safety checks for those bringing their own bikes.  Additionally, 550 bikes have been gifted to participating groups through Play on Pedals, to ensure ongoing access to bikes thus reducing inequalities for low income families; this available bike fleet has been increased through two city wide second-hand bike amnesties. Bike donations have also increased the bike fleet available for groups to use, with over 100 second-hand bikes being fixed and redistributed during the project. These various approaches have enabled Play on Pedals to have a wide impact on cycling and physical activity for pre-schoolers across Glasgow. From the more structured programmes delivered in early years settings, to the informal and community focused drop-in sessions, the project has facilitated the engagement of families and their children in learning new skills, having fun, gaining confidence and increasing their physical activity levels.


The project evaluation was carried out by an independent evaluator over two phases from January 2015 to December 2016. Evaluation took the form of focus groups with instructors, parents, Head Teachers and Hero Organisation representatives; tick-box observational survey measuring before and after changes to child participants’ physical and social development; online surveys for participating groups; progress forms; parental feedback forms; semi-structured interviews; group interviews; early years floor book evaluation; event evaluation; training feedback; and site visits and meetings with participating groups.

From the observational studies carried out by early year’s practitioners, some of the key findings demonstrate how Play on Pedals has supported:

  • Improved physical health of participants, including improved motor skills, balance, strength and co-ordination.
  • Improved mental health and wellbeing of participants, including noted increases in confidence, self-esteem and sense of achievement.
  • Improved relationships between peers as well as between staff and children.
  • Improved language and vocabulary, particularly for those with English as a second language as well as improved communication skills amongst children.
  • Increased focus, concentration, listening and perseverance has been observed in children, as well as resilience and working together as a group.
  • Children taking responsibility and having a sense of ownership of the programme and the equipment.

From focus group discussions with participating groups, as well as written feedback and responses to online surveys, findings show the programme has:

  • Supported learning about healthy eating, exercise and outdoor play.
  • Had a positive effect on children with behavioural issues, providing a structured outdoors activity.
  • Increased engagement in physical activities for children with additional needs and disability, including autism and hearing impairments.
  • Provided clear pathways to linking Play on Pedals to the Curriculum for Excellence (11), enabling the inclusion of topics such as maths, problem solving, technology and literacy to be integrated.
  • Encouraged practitioners to use new teaching methods, particularly using the outdoor environment for educational purposes as well as providing physical, practical demonstrations rather than verbal to encourage inclusion of those with limited language skills.

As well as supporting learning and development for child participants, the project has had positive impacts for the parents and practitioners involved, including:

  • Gaining confidence in talking and teaching about health and wellbeing
  • Providing parental training sessions and opportunities to volunteer with the programme delivery.
  • Building community links between organisations, early years settings and families.
  • Providing regular free events and activities for families.


Play on Pedals has been a hugely popular programme in Glasgow. It provided a fun and engaging way to increase physical activity, confidence and resilience amongst preschool children and families in Glasgow; as one head teacher commented, ‘There will be a generational change within the community because we have children who are leaving the nursery who can cycle and that can only add to how our environment will grow’.

Linking closely to the Curriculum for Excellence and the Scottish Government’s Early Years Framework, the programme provides a structured way for early years’ settings to achieve within the Getting It Right For Every Child approach and SHANARRI indicators (12). It is now used as a tool to teach a wide range of topics and has motivated staff teams to think creatively and in new ways about how to engage children within the early years.

A long-term measure of increased physical activity will be captured thanks to the inclusion of the question ‘can you ride a pedal bike?’ in the National Strengths and Difficulties Questionnaire (13) delivered to children at stages through their childhood into primary school. This, along with Sustrans’ Hands Up Survey (14) will indicate any increases in children’s cycling activities in the coming years, which may be partly attributed to children who have participated in Play on Pedals.

The programme also links closely to the Glasgow City Council’s Cycling Strategy (15), with a new indicator being included in the 2016-2020 Strategy, highlighting a commitment from the Council to support partners in the provision of balance bikes to early year’s establishments.

While there is a strong enthusiasm for the programme both within the early years setting and the wider community, observations from parental interviews and focus groups indicate that a lack of safe cycling infrastructure in Glasgow remains a barrier to families using cycling as a means of transport and to access green spaces. Additional obstacles include lack of safe bike storage for families to prevent bikes being stolen and financial hardships which remain a barrier to providing bikes within individual households. In order to support the progression of young cyclists to cycle to school and continue using a bike into adulthood, both as a means of leisure and as active travel, issues such as infrastructure remain important issues to tackle. Further results from Play on Pedals are awaited but from an initial impression the project has a significant effect on physical activity and engagement and has global reach.

Correspondence to Prof Chris Oliver @CyclingSurgeon

Bringing new meaning to the “Golden Years”: making the case for Geriatric Sport and Exercise Medicine

29 Mar, 17 | by BJSM

By Jane Thornton, MD PhD

Frenchman Robert Marchand’s name has become synonymous with incredible achievement two months ago after setting a new track cycling world record… at 105 years of age. Astounding as this is, it has only served to confirm something many of us sport docs already know: the body is built for adaptation.

When French researcher Veronique Billat and colleagues put Mr. Marchand on a training plan and studied the results (1), they noticed something remarkable – Marchand was over 100 years of age and more aerobically fit than most 50-year-olds. Even more remarkable – he is still making improvements.

But if this were globally true, why do most health care practitioners see the opposite trend as a general rule? Too many older adults are sedentary, and instead of thriving during these years, they are simply surviving – with complex, chronic diseases. In Canada, for example, 14% are over the age of 65, yet account for almost half of health care costs. These numbers are only expected to rise.

We know the numbers of Masters athletes are climbing and their performances continue to amaze and inspire. Can these stories not push the limits of what we know for ageing and chronic disease as well?

In my opinion, this is one of the most interesting emerging fields to hit sport and exercise medicine in a long time.

We know that there are several positive changes in disease markers in the older adult with an increase in physical activity, but we’re still learning ways to tailor these interventions for optimal effectiveness (2), especially in light of increased hospital visits in this population.

Hospitalization can induce atrophy and profound muscle weakness throughout the course of a relatively short stay, particularly targeting the all-important hip flexors. This can lead to a drop in functional independence and increase fall risk.

A recent prospective cohort study at an academic medical centre in northern Israel (3) evaluated 177 patients over 65 years of age hospitalized in two internal medicine units. With a relatively minor and inexpensive intervention, attaching an accelerometer to a patient’s ankle, they were able to observe that walking more than 900 steps per day (approx. 500m) results in lower hospital-associated functional decline (HAFD). They observed a strong dose-response effect, and the beauty of it was that it is one of the first to link normative data to functional outcomes.

What about those too frail even too walk? Dr. Michelle Kho and colleagues at McMaster University in Hamilton, Ontario, examined in-bed cycling for frail and critically adults in the ICU (4). They found that these patients can safely pedal using a specialized exercise bike that rolls over patients’ beds. Using a built-in motor can move patients’ legs for them or allow them to cycle on their own.


Marchand’s case may help to challenge our beliefs about what is possible to achieve, regardless of how old we are. Outside of the elite older adult’s performance, however, the biggest gains will likely be observed in a growing population – the frail and hospitalized patient.

Studies like Dr Michelle Kho’s and others in the field should give us hope that physical activity earlier on in rehabilitation can reap multiple benefits.

The critical need for research and advocacy for physical activity in the older adult will only intensify as the world’s older adult population continues to grow and their health needs continue to escalate.

When caring for older adults, we physicians should not only be talking about medication, but also about what can be done as an adjunct to therapy or in some cases to replace medication altogether (5). This also means getting older adults involved in preventative measures like strength and balance training before they wind up in the emergency department with a broken hip.

Let’s move beyond counselling on just not being sedentary and encourage our patients to embrace the joys of sport and physical activity at any age.

We may yet come to see that the “Golden Years” become even brighter.


  1. Billat V, Dhonneur G, Mille-Hamard L, Le Moyec L, Momken I, Launay T, Koralsztein JP, Besse S. Case Studies in Physiology: Maximal oxygen consumption and performance in a centenarian cyclist. J Appl Physiol 2017 Mar 1;122(3):430-434. doi: 10.1152/japplphysiol.00569.2016. Epub 2016 Dec 29.
  1. Buford TW, Anton SD, Clark DJ, Higgins TJ, Cooke MB. Optimizing the benefits of exercise on physical function in older adults. PM R. 2014 Jun;6(6):528-43. doi: 10.1016/j.pmrj.2013.11.009. Epub 2013 Dec 19.
  1. Agmon M, Zisberg A, Gil E, Rand D, et al. Association Between 900 Steps a Day and Functional Decline in Older Hospitalized Patients. JAMA Intern Med. 2016 Dec 5. doi: 10.1001/jamainternmed.2016.7266.
  1. Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, et al. (2016) TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS ONE 11(12): e0167561. doi:10.1371/journal.pone.0167561
  1. Thornton, J.S., P. Fremont, K. Khan, P. Poirier, G. Wells, J. Fowles, R. Frankovich. Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med doi:10.1136/bjsports-2016-096291


Jane Thornton, MD PhD, Resident, Physician, Olympic Rower

Optimal health: including female athletes! Part 1 Bones

26 Mar, 17 | by BJSM

Part-1 of the blog mini-series on RED-S

By Dr Nicky Keay

It is hard to dispute that women are underrepresented in medical research and certainly there are not many studies that include female athletes. Does this matter? After all whatever your gender, the same physiological and metabolic processes occur. However, the Endocrine system is where there are distinct differences in sex steroid production, which in turn have different responses in multiple target cells.

Although studies on changes in exercise performance in response to various dietary interventions and training regimes are often very interesting and well described, I am left feeling slightly uneasy when the subjects are all males. The cause for my concern is that the female hypothalamus-pituitary-ovarian axis is a particularly sensitive system with complex feedback loops and interacting networks.

Menstrual disturbance is not unusual amongst women in sport/dance where low body weight is an advantage. When a ballet dancer performs pointe work, putting full body weight through the big toe is hard enough, without extra load! Some women might consider it a convenience to be spared the hassle of menstruation. At age 24, I was perfectly fine never having had a period (primary amenorrhoea), or so I thought, being no more tired than other hospital medical colleagues working full time, studying for postgraduate medical exams and also involved in exercise training.

While working as a SHO at Northwick Park Hospital, I volunteered to be included in a study at the British Olympic Medical Association. The study was of female lightweight rowers and ballet dancers to look at VO2 max, percentage body fat and bone mineral density (BMD). I had been doing Ballet intensively (and obsessively) from a very young age, together with restricted fat and carbohydrate intake. Sounds a familiar scenario? Although I looked perfectly healthy (and I did not fit into a clinical condition requiring treatment), worked and danced well, my bone density was worryingly low. So if you are a female doing weight-bearing exercise or resistance training which loads the skeleton, these activities promoting osteogenesis will be negated if you are not ovulating and producing adequate oestrogens. The female athlete triad composed of disordered eating, amenorrhoea and low BMD was originally described by Drinkwater in 1984. However, once pathological states causing amenorrhoea have been excluded, in medical terms the female athlete triad did not necessarily constitute a disease state requiring intervention, rather subset of the “normal population”.

How significant is having low BMD compared to the age-matched population during your 20s? Could this even be viewed as a reversible adaptation to training, reflected in site specific differences in BMD according to sport? After all, when female athletes retire with decreased training “stress” and more “relaxed” diet, menses often resume and therefore does BMD also improve? This was the question I sought to answer in my study on 57 premenopausal retired professional dancers. Even with return of menses, if these athletes had experienced previous amenorrhoea of more than 6 month duration, then bone loss was irrecoverable. Current low BMD was also correlated to lowest body weight (independent of amenorrhoea) during dance career and later age of menarche. There did not appear to be any protective effect of being on the oral contraceptive pill. Constructing a model of BMD using multiple regression 33.6% of total variation in z (age matched) score for BMD at lumbar spine was accounted for by duration of amenorrhea, age at menarche and lowest body weight during dance career. So “athletic” hypothalamic amenorrhea rather than being a reversible, adaptive response has long term, irreversible effects on BMD.

Apart from bone metabolism, what other systems are impacted by mismatch of energy intake and expenditure in overtly healthy athletes? Are the endocrine and metabolic systems in male athletes also affected by subtle imbalances in training energy expenditure and dietary intake? What about young athletes? In my next blog I will explore the rationale behind the original female athlete triad now being described as part of Relative Energy Deficiency in sports (REDs). The implications for current health and sports performance, as well as long term health in both adult men and women and young athletes.


Keay N, Fogelman I, Blake G. Bone mineral density in professional female dancers. British Journal of Sports Medicine, vol 31 no2, 143-7, June 1997.

Keay N. Bone mineral density in professional female dancers. IOC World Congress on Sports Sciences. October 1997.

Keay N, Bone Mineral Density in Professional Female Dancers, Journal of Endocrinology, November 1996, volume 151, supplement p5.

Keay N, Bone Mineral Density in Female Dancers, abstract Clinical Science, Volume 91, no1, July 1996, 20p.

Keay N, Dancers, Periods and Osteoporosis, Dancing Times, September 1995, 1187-1189

Keay N, A study of Dancers, Periods and Osteoporosis, Dance Gazette, Issue 3, 1996, 47

Fit to Dance? Report of National inquiry into dancers’ health

Fit but fragile. National Osteoporosis Society

Your body your risk. Dance UK

From population based norms to personalised medicine: Health, Fitness, Sports Performance

Ankle Sprains & Lower Limb Injury: Can we identify those at risk?

21 Mar, 17 | by BJSM

By Mick Hughes

During the late 90’s and early 2000’s in the USA, the cost of treating ankle sprains was estimated to be $US2 billion dollars per year (1). Here in Australia (specifically the state of Victoria), the cost of all sporting injuries and lower limb sporting injuries rose 24% and 26% respectively between 2004 and 2010, equating to an accumulated economic burden of $265million and $110million (2).

Such concerning trends in injury incidence and associated financial cost, has led research efforts into trying to identify potential injury risk factors that leads to future injury. Unfortunately not one musculoskeletal screening test to date has been able to predict injury 100% of the time and screening has become polarising amongst some researchers and physiotherapists.

Personally, I perform pre-season screening on all of the athletes in the club I work for, However, I completely understand why some people do not see the value in it, especially if 1) the screening process is done just for the sake of “screening”, 2) it is very lengthy in time and 3) involves expensive equipment. My feeling on the topic however is, 1) if a screening test can be performed in a quick and low cost manner, 2) it has been shown in the literature to identify those people at risk of future injury, and 3) an intervention to reduce the risk can be implemented, then there is no harm done.

Now, I am not smart enough to weigh into the “should we screen/shouldn’t we screen” debate, however what I am going to do is shed some light on some recent research regarding 2 common pre-season screening tools that some practitioners use in attempting to identify those at risk of future lower limb injury, in particular lateral ankle sprains: The Star Excursion Balance Test (SEBT) and the the Y-Balance Test (YBT).

If you are unfamiliar with the SEBT or the YBT, they are tests whereby the subject is asked to stand and balance on 1 leg whilst reaching with the other leg as far as possible in many different planes – With the most common planes looked at in studies being the Anterior reach (ANT), Posterior-Medial reach (PM) and Posterior-Lateral reach (PL). When the tests are complete, the performance score is calculated using the following simple equations (reference:

  • Average distance in each direction (cm) = Reach 1 + Reach 2 + Reach 3 / 3
  • Relative (normalised) distance in each direction (%) = Average distance in each direction / leg length x 100

Information on both tests can be found in the links provided here and here and here.

From my review of literature, I found 7 studies that showed that the SEBT or the YBT was useful in identifying subjects across many different sports that were likely to sustain either a future lateral ankle sprain or other lower limb injury.

American Football athletes:

1) 606 American Football athletes (high school and college) were screened in the pre-season, which included the SEBT. Those that went on to sustain a future lateral ankle sprain were nearly 3x more likely to perform poorly on the SEBT-ANT (67% or less leg length). Furthermore, those that had a higher BMI (>27) AND who had poor performance on SEBT-ANT were 1.7x more likely to sustain a future lateral ankle sprain (4).

2) 59 American Football athletes (college) were screened in the pre-season using the YBT. Those that went on to sustain a lower limb injury during the season, were 3.5x more likely to do so if their composite YBT score (normalised score) was <89% of their leg length (5).

Various American College athletes:

3) 125 healthy recreational college athletes performed a series of screening tests, which included the YBT. The study found that there was a 48% increased risk of sustaining a future lateral ankle sprain with those who scored <80% leg length in the PL direction (6).

4) 184 college athletes were assessed on the YBT prior to their sporting season. It was found that players with an ANT asymmetry greater than or equal to 4 cm had a 2.2x greater odds of sustaining a lower limb injury compared to those that less than 4cm asymmetry on the ANT reach (10).


5) 235 high school basketball players were assessed on the SEBT prior to the start of the season. It was found that all players who had a greater than 4cm difference between limbs on the SEBT-ANT had a 2.7x greater risk of lower limb injury than those with a reach distance of 4cm or less. Furthermore for females, a composite reach score (normalised score) of less than 94% of their limb length, had a 6.5x increased risk of lower limb injury (7).


6) 94 amateur female netball players were screened in the pre-season, which included the YBT. It was found that a score of 77% leg length or less in the PM direction was associated with a 4x greater risk of sustaining a future lateral ankle sprain (8).


7) 74 male soccer players were screened in the preseason on the YBT. It was found that those with a greater than 4cm reach difference between limbs in the PM direction had a 3.86x greater risk of sustaining a non-contact soft tissue injury, Furthermore those that had a total YBT composite score (normalised score) <99% of leg length, were 2.25x more likely to sustain a future lower limb injury (9).

In summary, the SEBT and the YBT appear to be valuable pre-season screening tools to try and predict those at risk of lateral ankle sprains and lower limb injury. However, they aren’t perfect, and to assume that all your athletes will be 100% safe from all lateral ankle sprains in the future is setting yourself and your athlete up for disappointment. Furthermore the application and the generalisation of the SEBT/YBT should be carefully considered for each sport and sex, as there is a huge variance in SEBT/YBT performance and injury risk between sports and sexes.

In closing up my blog today, my take home message is this:

If you choose to screen your athletes, regardless of what screening process you undertake, identifying a player at risk of injury is only half the battle. Implementing an intervention to evoke a desired change to reduce the risk of injury (ie. improving ankle ROM, lower limb strength and neuromuscular control) is what really counts!!


Mick Hughes is the Head Physiotherapist Collingwood Magpies Netball / Physiotherapist at Melbourne Sports Medicine Centre


1.           Dallinga JM, Benjaminse A, Lemmink KA. Which screening tools can predict injury to the lower extremities in team sports?: a systematic review. Sports medicine (Auckland, NZ). 2012 Sep 01;42(9):791-815. PubMed PMID: 22909185. Epub 2012/08/23. eng.

2.           Finch CF, Kemp JL, Clapperton AJ. The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004-2010: a future epidemic of osteoarthritis? Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2015 Jul;23(7):1138-43. PubMed PMID: 25749009. Epub 2015/03/10. eng.

4.           Gribble PA, Terada M, Beard MQ, Kosik KB, Lepley AS, McCann RS, et al. Prediction of Lateral Ankle Sprains in Football Players Based on Clinical Tests and Body Mass Index. The American journal of sports medicine. 2016 Feb;44(2):460-7. PubMed PMID: 26646517. Epub 2015/12/10. eng.

5.           Butler RJ, Lehr ME, Fink ML, Kiesel KB, Plisky PJ. Dynamic balance performance and noncontact lower extremity injury in college football players: an initial study. Sports health. 2013 Sep;5(5):417-22. PubMed PMID: 24427412. Pubmed Central PMCID: PMC3752196. Epub 2014/01/16. eng.

6.           de Noronha M, Franca LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: a prospective study. Scandinavian journal of medicine & science in sports. 2013 Oct;23(5):541-7. PubMed PMID: 22260485. Epub 2012/01/21. eng.

7.           Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. The Journal of orthopaedic and sports physical therapy. 2006 Dec;36(12):911-9. PubMed PMID: 17193868. Epub 2006/12/30. eng.

8.           Attenborough AS, Sinclair PJ, Sharp T, Greene A, Stuelcken M, Smith RM, et al. The identification of risk factors for ankle sprains sustained during netball participation. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2017 Jan;23:31-6. PubMed PMID: 27665248. Epub 2016/09/26. eng.

9.           Gonell AC, Romero JA, Soler LM. RELATIONSHIP BETWEEN THE Y BALANCE TEST SCORES AND SOFT TISSUE INJURY INCIDENCE IN A SOCCER TEAM. Int J Sports Phys Ther. 2015 Dec;10(7):955-66. PubMed PMID: 26673848. Pubmed Central PMCID: PMC4675196. Epub 2015/12/18. eng.

10.         Smith CA, Chimera NJ, Warren M. Association of y balance test reach asymmetry and injury in division I athletes. Medicine and science in sports and exercise. 2015 Jan;47(1):136-41. PubMed PMID: 24870573. Epub 2014/05/30. eng.

11.         Hooper TL, James CR, Brismee JM, Rogers TJ, Gilbert KK, Browne KL, et al. Dynamic balance as measured by the Y-Balance Test is reduced in individuals with low back pain: A cross-sectional comparative study. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2016 Nov;22:29-34. PubMed PMID: 27579805. Epub 2016/09/01. eng.

Originally posted:

Highlights from The Barefoot Medicine Clinic

19 Mar, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine

By Rory Heath, Bethany Koh, Vera Wong and Anant Shah.

Two expert speakers were recently in session at the Barefoot Running Clinic, hosted by the London Sports and Exercise Medicine Society (LSEMS):

  • Mr Ioan Tudur-Jones, consultant foot and ankle surgeon at the Fortius Clinic, and;
  • Mr Ben Le Vesconte, a running technique specialist.

‘Barefoot’, or ‘minimalist’ running describes a step away from heavily padded conventional sports shoes, to wearing either a minimally supportive shoe, or no shoe at all!

It was a true multidisciplinary meeting, with medical students, doctors, physiotherapists and podiatrists from all universities London-wide. The fantastic talks were followed by diverse and lively discussion. Here are the learning points that we took away!

  • Humans evolved as “hunter-gatherers” who spent a lot of time on their feet, moving about. Mr Ben Le Vesconte suggested that standing, walking, running, and squatting are natural movement patterns of Homo Sapiens. Today’s society places us in unnatural habitats that encourage sedentary lifestyles, far removing us from these natural movements. We were not made to sit around on our bums all day!


  • We commonly promote the myriad health benefits of physical activity, however, it is important to consider that exercise may incur injury risk. Running is popular, but is associated with high rates of lower limb injury – 70% of runners are injured each year1!
  • One study of 54 competitive cross country runners at Harvard who ran a weekly average of 40-15 miles reported that runners who “heel strike” (land on their heels) were shown to have over double the amount of lower limb mild-moderate repetitive stress injuries vs runners who landed on their forefoot2.
  • Despite attempts by the running shoe industry to reduce injury, rates remain high. Daroud’s paper suggests cushioned shoes alter the biomechanics in the ankle, knee and hip joints, as well as encourage a heel-strike, therefore encouraging injury2.

Is it technique, footwear and improper loading that contributes to our large injury burden? We should be wary of this when prescribing activity to patients.

  • Leonardo da Vinci said ‘The human foot is a masterpiece of engineering and a work of art’. There are 200,000 nerve endings, and lots of muscles in the foot. Our curriculums rarely encourage us to learn the intricacies of our pedal anatomy. We think that to appreciate its complexity and function, we must look at it as a whole (as we do with any other part of the body!).
  • Most people only notice the long ‘extrinsic’ muscles because they provide power, propelling the foot forwards. Although it is easy to overlook the smaller ‘intrinsic’ muscles, they control the fine motor movements of the toes and joints. A small study of 20 experienced runners suggested that runners with plantar fasciitis have significantly smaller muscles in the rear of their feet in comparison to runners without the same pathology3.

Both speakers suggested actively training the intrinsic muscles for optimum function and performance.

  • Some research has shown that barefoot running may actually increase the incidence of injury4. Our event speculated this is due to poor transition from a rear-foot to fore-foot strike, due to inadequate education, improper technique or excessive and rapid loading of deconditioned tissues.

Coaching and follow up is key to ensuring a smooth transition.

Although both talks supported barefoot running, the discussion included varied opinions from both sides of the argument. Our main take-away is that the heart of barefoot running respects the ‘intended’ biomechanics and anatomy of the foot. It can offer benefits to individuals who are appropriately conditioned or can safely transition to a new running technique. It might not be for everyone; our sedentary modern world has shaped our bodies, making a switch to barefoot running difficult for some, and possibly dangerous if done rapidly. It is, however, an option to consider for those wishing to explore how to return their feet to their natural form, and run the way we were meant to run.

To hear more on this topic from Mr Ioan Tudur-Jones and learn more about the Fortius Clinic have a listen to this fantastic podcast conducted by Anant Shah (LSEMS Secretary)!


Written by Rory Heath (@roryjheath), Bethany Koh (@bethanykoh) and Vera Wong. Podcast recorded by Anant Shah and Mr Ioan Tudur Jones, at the Fortius Clinic, London.

Find the London Sports and Exercise Medicine on Facebook and Twitter!

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee and Co-President of Birmingham University Sports and Exercise Medicine Society (BUSEMS).



  1. Van Gent RN, Siem D, Van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sport Med. 2007;41:469-480. doi:10.1136/bjsm.2006.033548.
  2. DAOUD AI, GEISSLER GJ, WANG F, SARETSKY J, DAOUD YA, LIEBERMAN DE. Foot Strike and Injury Rates in Endurance Runners. Med Sci Sport Exerc. 2012;44(7):1325-1334. doi:10.1249/MSS.0b013e3182465115.
  3. Cheung RTH, Sze LKY, Mok NW, Ng GYF. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport. 2016;19(9):713-715. doi:10.1016/j.jsams.2015.11.004.
  4. Ryan M, Elashi M, Newsham-West R, Taunton J. Examining injury risk and pain perception in runners using minimalist footwear. Br J Sports Med. 2014;48(16):1257-1262. doi:10.1136/bjsports-2012-092061.

Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences

17 Mar, 17 | by BJSM

By Dr Nicky Keay

The Holy Grail of any training program is to improve performance and achieve goals.

Periodisation of training is essential in order to maximise beneficial adaptations for improved performance. Physiological adaptations occur after exercise during the rest period, with repeated exercise/rest cycles leading to “super adaptation”. Adaptations occur at the system level, for example cardiovascular system, and at the cellular level in mitochondria. An increase in mitochondria biogenesis in skeletal muscle occurs in response to exercise training, as described by Dr Andrew Philip at a recent conference at the Royal Society of Medicine (RSM). This cellular level adaptation translates to improved performance with a right shift of the lactate tolerance curve.

The degree of this response is probably genetically determined, though further research would be required to establish causal links, bearing in mind the ethical considerations laid out in the recent position statement from the Australian Institute of Sport (AIS) on genetic testing in sport. Dr David Hughes, Chief Medical Officer of the AIS, explored this ethical stance at a fascinating seminar in London. Genetic testing in sport may be a potentially useful tool for supporting athletes, for example to predict risk of tendon injury or response to exercise and therefore guide training. However, genetic testing should not be used to exclude or include athletes in talent programmes. Although there are polymorphisms associated with currently successful endurance and power athletes, these do not have predictive power. There are many other aspects associated with becoming a successful athlete such as psychology. There is no place for gene doping to improve performance as this is both unethical and unsafe.

To facilitate adaptation, exercise should be combined with periodised rest and nutrition appropriate for the type of sport, as described by Dr Kevin Currell at the conference on “Innovations in sport and exercise nutrition”. Marginal gains have a cumulative effect. However, as discussed by Professor Asker Jeukendrup, performance is more than physiology. Any recommendations to improve performance should be given in context of the situation and the individual. In my opinion women are often underrepresented in studies on athletes and therefore further research is needed in order to be in a position to recommend personalised plans that take into account both gender and individual variability. As suggested by Dr Courtney Kipps at the Sport and Exercise Conference (SEM) in London, generic recommendations to amateur athletes, whether male or female, taking in part in marathons could contribute to women being at risk of developing exercise associated hyponatraemia.

For innovation in sport to occur, complex problems approached with an open mind are more likely to facilitate improvement as described by Dr Scott Drawer at the RSM. Nevertheless, there tends to be a diffusion from the innovators and early adapters through to the laggards.

Along the path to attaining the Holy Grail of improved performance there are potential stumbling blocks. For example, overreaching in the short term and overtraining in the longer term can result in underperformance. The underlying issue is a mismatch between periodisation of training and recovery resulting in maladapataion. This situation is magnified in the case of athletes with relative energy deficiency in sport (RED-S). Due to a mismatch of energy intake and expenditure, any attempt at increase in training load will not produce the expected adaptations and improvement in performance. Nutritional supplements will not fix the underlying problem. Nor will treatments for recurrent injuries. As described by Dr Roger Wolman at the London SEM conference, short term bisphosphonante treatment can improve healing in selected athletes with stress fractures or bone marrow lesions.  However if the underlying cause of drop in performance or recurrent injury is RED-S, then tackling the fundamental cause is the only long term solution for both health and sport performance.

Network effects of interactions lead to sport underperformance. Amongst underperforming athletes there will be clusters of athletes displaying certain behaviours and symptoms, which will be discussed in more detail in my next blog. In the case of RED-S as the underlying cause for underperformance, the most effective way to address this multi-system issue is to raise awareness to the potential risk factors in order to support athletes in attaining their full potential.


Teaching module RED-S British Association Sport and Exercise Medicine

From population based norms to personalised medicine: Health, Fitness, Sports Performance BJSM 22/2/17

Balance of recovery and adaptation for sports performance 21/1/17 BASEM

Sleep for health and sports performance BJSM 7/7/17

Annual Sport and Exercise Medicine Conference, London 8/3/17

Bisphosphonates in the athlete. Dr Roger Wolman, Consultant in Rheumatology and Sport and Exercise Medicine, Royal National Orthopaedic Hospital

Collapse during endurance training. Dr Courtney Kipps, Consultant in Sport and Exercise Medicine. Consultant to Institute of Sport, medical director of London and Blenheim Triathlons

Innovations in Sport and Exercise Nutrition. Royal Society of Medicine 7/3/17

Identifying the challenges: managing research and innovations programme. Dr Scott Drawer, Head of Performance, Sky Hub

Exercise and nutritional approaches to maximise mitochondrial adaptation to endurance exercise. Dr Andrew Philip, Senior Lecturer, University of Birmingham

Making technical nutrition data consumer friendly. Professor Asker Jeukendrup, Professor of Exercise Metabolism, Loughborough University

Innovation and elite athletes: what’s important to the applied sport nutritionists? Dr Kevin Currell, Director of Science and Technical Development, The English Institute of Sport

Genetic Testing and Research in Sport. Dr David Hughes, Chief Medical Officer Australian Institute of Sport. Seminar 10/3/17

Effects of adaptive responses to heat exposure on exercise performance

Over Training Syndrome, Ian Craig, Webinar Human Kinetics 8/3/17

The Fatigued Athlete BASEM Spring Conference 2014

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S).Br J Sports Med. 2014 Apr;48(7):491-7.


Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP, Clinical and research experience in Endocrinology applied to Sport and Exercise Medicine.

Maximising Opportunities for the use of ‘new’ social media in Sports Medicine

15 Mar, 17 | by BJSM

By Sean Carmody and Nirmala Perera

Sport and Exercise Medicine has a lot to thank Jack Dorsey and Mark Zuckerberg for. Their brainchildren – Twitter and Facebook, respectively – have transformed how information is shared among those interested in the specialty. These platforms provide ‘all access, backstage passes’ that foster conversation and networking opportunities with peers across the globe – geographical, hierarchical and time constraints are removed.

While Facebook and Twitter dominate social media in #SEM, Instagram and Snapchat are increasingly popular among the tech/SoMe savvy, many of whom are undergraduates. These ‘millennials’ are often accustomed to list-based articles beginning ‘10 things you need to know about..’ and ‘snaps’ lasting less than ten seconds. It is therefore crucial for sport and exercise medicine to embrace this ‘new’ social media to appeal to the next generation. Here, we make the case for integrating the words ‘snap’ and ‘insta’ into the sport and exercise medicine vernacular, and using these platforms for dissemination.

Social media is an established platform for knowledge transfer and dissemination of research in sports medicine (1). With 80,000+ followers across Twitter and Facebook (as of February 2017), the BJSM effectively uses social media to promote open scientific discourse, providing 24/7 connectivity and propagating interdisciplinary conversations. Their presence is complimented by many others including Yann Le Meur and his pioneering infographics that have inspired a renewed emphasis on improving data visualisation (2).

But social media’s contribution to sports medicine isn’t just limited to promoting the latest research in the field. Its impact runs deeper. It can provide professional guidance in otherwise challenging circumstances (3). Also, in recent years we have seen how it can influence a change in health policy (4), raise awareness of the recognition and management of concussion (5) (6) and measure the response to emerging sports medicine interventions in real time (7).

These aren’t isolated achievements – there are numerous examples of effective social media that furthers our specialty’s ultimate goal; to promote the health and well-being of all who participate in sport and exercise.

The Rise of ‘new’ Social Media

Rumour of Facebook and Twitter’s demise among teenagers is likely greatly exaggerated. Nevertheless, there are persistent press reports indicating a trend among younger people towards the more frequent use of social media applications such as Snapchat and Instagram versus older platforms (8). With this in mind, sports medicine must position itself strongly within these communities to inspire and engage the next wave of undergraduates to advance our specialty. A brief glance at the hashtag #sportsmedicine on Instagram (there are nearly 70,000 posts indicating the movement is well underway) demonstrates many effective uses of the medium in the context of sports medicine. While its function is likely to develop and evolve over time, we have identified three examples of organisations or individuals using Instagram effectively in a sports medicine context at present:

BJSM- Infographics

The British Journal of Sports Medicine has extended their prolific social media presence to Instagram, featuring a wealth of resources including key conference slides, information regarding BJSM podcasts and infographics. Infographics + Instagram = High Impact, with salient points easily summarised in an engaging manner:



Johnny Wilson – Head of Sport Science and Medicine at Notts County FC

It’s refreshing to see such openness and transparency from a football club’s medical department. Johnny Wilson, head of the medical department at Notts County FC, shares rehabilitation protocols via regular video updates of exercises used by professional players on their path to returning to play. The two-part video series of a simulation undertaken by the medical department on the Evaluation and Management of Anaphylaxis in Professional Football was informative to junior doctors. A recent post outlining the club’s match day medical emergency action plan was another example of how senior practitioners can impart knowledge onto emerging clinicians:


Dr John Sykes – Promoting Exercise as Medicine

Social media is congested with individuals offering lifestyle advice, with the quality of advice often highly variable. However, it is welcoming to see a general practitioner taking a lead on promoting proactive healthcare online. John Sykes, a GP based in Bath, shares key health messages online and uses the text box to provide greater detail on his messages:


Twitter and Facebook have revolutionised how information is shared among sport and exercise medicine practitioners. However, with the popularity of applications such as Instagram and Snapchat soaring, particularly among the younger generation, it is important to incorporate these habits into SEM social media strategy. By doing so, SEM can position itself strongly to inspire the emerging generation of undergraduates interested in sports medicine. The effective use of ‘new’ #SoMe platforms offers a range of opportunities to communicate, connect and network which may ultimately contribute to improving athlete health and welfare.

What have we missed?

Are you aware of other individuals or organisations sharing useful sports medicine content on Instagram or Snapchat? We’d love to hear – tweet us (excuse the irony!) @Nim_Perera and @seancarmody1.

The IOC World Conference on Prevention of Injury & Illness in Sport

The sports medicine world will be making a familiar pilgrimage to Monte Carlo this week for the IOC World Conference on Prevention of Injury and Illness in Sport. As ever, social media will play an important role during the conference – join the conversation by using #IOCprev2017.


Sean Carmody is a junior doctor working in London. He tweets regularly on topics related to sports medicine and performance @seancarmody1.

Nirmala Perera (@Nim_Perera) is a researcher at the Australian Centre for Research into Injury in Sport and its Prevention (@ACRISPFedUni). She is the @IOCprev2017 #SoMe campaign coordinator.


  1. Verhagen E, Bower C, Khan KM., How BJSM embraces the power of social media to disseminate research. Br J Sports Med 2014;48:680-681.
  1. Scott H, Fawkner S, Oliver CW, et al. How to make an engaging infographic? Br J Sports Med Published Online First: 30 December 2016. doi: 10.1136/bjsports-2016-097023
  1. Ahmed OH, Weiler R, Schneiders AG, et al. Top tips for social media use in sports and exercise medicine: doing the right thing in the digital age. Br J Sports Med 2015;49:909–910.
  1. Weiler R, Neyndorff C. BJSM social media contributes to health policy rethink: a physical activity success story in Hertfordshire. Br J Sports Med 2013;47:593-594.
  1. Provvidenza C, Engebretsen L, Tator C, et al. From consensus to action: knowledge transfer, education and influencing policy on sports concussion. Br J Sports Med 2013;47:332-338.
  1. Sullivan SJ, Schneiders AG, Cheang C, et al. ‘What’s happening?’ A content analysis of concussion-related traffic on Twitter. Br J Sports Med 2012;46:258-263.
  1. McKay C, Stokes K. The crowd goes wild: The dissemination of concussion risk information on Twitter in response to the removal of headgear in men’s boxing at the Olympic Games. Br J Sports Med 2017;51:361-362.
  1. Hoelzel M., New Study Shows Instagram and Snapchat beating Twitter Among Teens and Young Adults. Business Insider March 2014.

2016 cover competition: Prize announcement and last preliminary round, vote now!

13 Mar, 17 | by BJSM

Here’s the final preliminary round for the best BJSM cover of 2016. After this we move on to the sudden death grand final.

We have some exciting new prize announcements. All ‘top-shelf’ books to add to your #sportsmed knowledge, and the utility of your professional text collection.

Brukner and Khan’s Clinical Sports Medicine, 5th Edition, 2017


Grieve’s Modern Musculoskeletal Physiotherapy, 4th edition, 2015.

The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr, 2012.

In the final round we will explain how you enter to win one of three of these masterclass books (you get to choose which one!). For now, please vote to move one of these covers into the final (polls close in one week):

October 50 – 19: International Consensus Warwick agreement on FAI Syndrome

October 50-20: ACSEP GOLD COAST 2017

November 50 – 21: Focus on spine

November 50 – 22: Annual Conference Umeå

December 50 – 23: IOC World Conference on Prevention of Injury & Illness in Sport Monaco, 16-18 March 2017

December 50 – 24: 5th ECOSEP Congress and F-MARK Update Dubai-UAE 25-26 November 2017


Competing interest: Karim Khan, editor in chief of BJSM is an author of one of the prize books and receives royalties on sales. BJSM is open to donations of books in the field and arms’ length editors decide whether the book is appropriate as a BJSM prize or not. The prize for this competition has been donated (i.e. the prize is not billed to the BJSM). BJSM has a history of promoting leading texts in this manner since 2002. Please email [confidential] if you feel the inclusion of Brukner & Khan’s book in this competition is inappropriate.


International Criteria for ECG Interpretation in Athletes- Top Ranked Journals Publish Consensus Guidelines

9 Mar, 17 | by BJSM

The new “International Criteria for ECG Interpretation in Athletes” consensus guidelines have been published by the British Journal of Sports Medicine and co-published in two prestigious cardiology journals, the Journal of the American College of Cardiology and the European Heart Journal.

“This consensus guideline is a major milestone in the cardiovascular care of athletes,” said lead author and AMSSM past-president Jonathan Drezner, MD. The statement is the product of the 2nd Summit on ECG Interpretation in Athletes held in Seattle, WA, in February 2015. The event was made possible by support from AMSSM, FIFA and the NCAA. This unique collaboration among world leaders in sports cardiology provides updated standards for ECG interpretation in athletes and a clear guide to the secondary evaluation of ECG abnormalities.

The guideline is freely accessible at:

Sudden cardiac death remains the leading cause of mortality in athletes during sport. In the U.S. and most countries, a shortage of physician expertise limits wider application of the ECG in the care of the athlete. Thus, a critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology.

The statement is endorsed by 16 international sports medicine and cardiology societies including:

American Medical Society for Sports Medicine (AMSSM), Austrian Society of Sports Medicine and Prevention, Brazilian Society of Cardiology – Department of Exercise and Rehabilitation (SBC – DERC), British Association for Sports and Exercise Medicine (BASEM), Canadian Academy of Sport and Exercise Medicine (CASEM), European College of Sports and Exercise Physicians (ECOSEP), European Federation of Sports Medicine Associations (EFSMA), European Society of Cardiology (ESC) Section of Sports Cardiology, Fédération Internationale de Football Association (FIFA), German Society of Sports Medicine and Prevention, International Olympic Committee (IOC), Norwegian Association of Sports Medicine and Physical Activity (NIMF), South African Sports Medicine Association (SASMA), Spanish Society of Cardiology (SEC) Sports Cardiology Group, Sports Doctors Australia, and the Swedish Society of Exercise and Sports Medicine (SFAIM). The American College of Cardiology (ACC) affirms the value of this document (ACC supports the general principles in the document and believes it is of general benefit to its membership).

About the AMSSM: AMSSM is a multi-disciplinary organization of sports medicine physicians dedicated to education, research, advocacy and the care of athletes of all ages. The majority of AMSSM members are primary care physicians with fellowship training and added qualification in sports medicine who then combine their practice of sports medicine with their primary specialty. AMSSM includes members who specialize solely in non-surgical sports medicine and serve as team physicians at the youth level, NCAA, NFL, MLB, NBA, WNBA, MLS and NHL, as well as with Olympic teams. By nature of their training and experience, sports medicine physicians are ideally suited to provide comprehensive medical care for athletes, sports teams or active individuals who are simply looking to maintain a healthy lifestyle.

Considering psychological stress alongside training load – A reflection on the “How much is too much’” IOC Consensus Statement

8 Mar, 17 | by BJSM

By Pete Garbutt

I first read about the International Olympic Committee’s 2-part ‘How much is too much’’ Consensus Statement in BJSM 50(16/17), 2016 regarding injury and illness in athletes. It highlighted common roadblocks to athletic performance, and evidence informed insights to enhance the health of our athletic community. This was a landmark paper to shine light on a diverse and cumbersome topic, however it was clear that this IOC paper was targeted towards elite athletes. (Read the open access articles: part 1 HERE, and part 2 HERE).

Below are my reflections on psychological stress, otherwise known as psychological load – one of the less monitored issues raised in the IOC paper. I discuss how these ideals can fit amongst a modern SEM framework in an elite and non-elite setting. Psychological load or psychological distress is defined as ”the end result of factors eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with ‘significant others’ ”. This may impact on functioning and is likely to affect performance.

Loading and illness/injury

In the Consensus Statement, psychological load was discussed as one of the parameters in an athlete’s training load. Whilst not an entirely new concept, it is certainly one not often discussed. This is especially true outside an elite setting where a sports psychologist is becoming a more standard part of the team. Elite sport often includes daily measurement of psychological parameters with outcome measures such as Rate of Perceived Exhaustion (RPE) or forms such as the K10 for detecting anxiety and depression. This is to assess signs of early warning. The non-elite setting does not usually provide for this. Psychological stressors were noted as coming from a variety of external areas such as negative life events, daily stressors and sports related stress. It also covered internal variables such as personality type, anxiety, stress susceptibility and maladaptive coping strategies. These areas have been implicated in increasing athlete load, impacting areas such as timing and coordination, fatigue, muscle tension and immunity.

The conversation

The conversation surrounding psychological load and training, in elite and non-elite settings is one that needs to exist between three groups of people. The coaches, the athlete and the treating practitioners: physiotherapists, doctors, and other therapists. Without an openness to this topic, we close our eyes to a potential cause of injury.

Coaches program their training based on physiological factors in and around competition needs. They are experts on the physical requirements of the athlete within their sport, the technical and skill requirements of the sport, and the competitive mindset for achievement. It is important that the coach has a conversation with the athlete that creates an awareness of these off-field psychological loads which affect their training.

Although professional practitioners are often trained in Waddell’s biopsychosocial model, in my experience they often focus on the patho-anatomical side of injuries. They need to be cognisant of the impact of psychological load as a contributor to system overload in the first place, and as a confounder for return to play. The practitioner needs to instigate this discussion and this concept as they sort through the potential points of overload and initiators of breakdown in the system that results in injury.  If there is not a multidisciplinary team, including a sports psychologist, who are communicating between each other about the athlete’s welfare, such as exists in many elite settings, practitioners in private practice need to be this front line. Thus, for the non-elite athlete the conversation of psychological load ought to be held in the treatment room. It is also a conversation that must be monitored and maintained.

The athlete is the only person in this conversation that can make it work. Although in an elite setting psychological concerns may be attended to, it is especially important that non elite athletes are also aware of the importance of psychological load. The success of their training programs hinges on it. Giving them a safe, open environment to discuss these issues, and having them prepared to come to the table with this considered as part of their overall load, is essential. Only once the athlete understands psychological load and is engaged in this process can the potential outcomes be viable and useful.

Missed training and performance

Papers by the likes of Raysmith, Drew, Blanch and Gabbett demonstrate why it is so important to monitor and manage load. They show the usefulness of training smart so that trainings aren’t missed.

This research becomes an important part of our conversation with the elite and non elite athlete regarding psychological load. Notably, how it can tip the scales on injury and illness. This evidence is useful to reason with the competitive mindset of the athlete. Non elite populations additionally need to understand how crucial it is not to miss trainings. When injuries are reduced, we ultimately create better performance, and the competitive mindset is satisfied that taking the foot off the pedal can be a step forward.

Management strategies

The IOC papers focus very much on the elite end of sport. Here we see sophisticated monitoring of athlete well-being and suggestions on implementing resilience strategies and stress management skills.

For most coaches, docs, and therapists treating elite and non-elite athletes, the strategy is to consider psychological stress assessments, referral to a sports psychologist for the above, and/or have a discussion with the athlete, educating on importance of moderating training during times of increased psychological stress.

The first step to combating this silent injury risk is being aware, and having the conversation. It’s time that we all became a part of this conversation for not only our elite athletes, but our recreational athletes. The latter are quite possibly the most at risk due to their diminished support structure.

I hope that these thoughts have helped to raise the relevance of the IOC papers beyond elite sport and into private clinics and sports medicine practices around the world. Thank you to the BJSM blog team for letting me share my thoughts.


Pete Garbutt is in private practice at Enhance Healthcare in Canberra, Australia. With over 20 years of working with sports from indoor soccer to beach volleyball, pole dancing to water polo at all levels from local to international, Pete has a wealth of experience with managing sports injury and performance.Pete is the President of the International Sports Chiropractic Federation. In 2015 Pete was awarded a Fellowship with Sports Medicine Australia and Australian Chiropractor of the Year in 2016. You can follow him on Twitter (@Pete_Garbutt).


Raysmith B, Drew M, Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study  Original Research Article. JSAMS 2016;19(10):778-783

Charlton P, Drew MK. Can we think about training loads differently? Canberra, Australia: Australian Institute of Sport; 2015

Schwellnus M, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. Br J Sports Med 2016;50:1043–1052

Soligard T, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury Br J Sports Med 2016;50:1030–1041

Definition “psychological distress”. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. URL: . Date accessed: 10/2/2017

Beyond Blue, Anxiety and depression checklist (K10). Date accessed 10/02/2016,


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