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Athletes with disabilities, movement is medicine, muscle imaging, tips for undergrads and more..highlights from the 2nd annual BASEM/FSEM conference

6 Apr, 16 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine a BJSM blog series

By Ted Caplan

cardaff november 2015

With BASEM’s Spring Conference less than a week away, it is an apt time to reflect on the 2nd BASEM/FSEM Annual Conference in Cardiff (12th-13th November, 2015). This two-day event offered an in-depth look into: The Disabled Athlete, The Older Athlete, The Adolescent Athlete, Exercise in Health and Contact Sports. The programme also had sessions by the Society of Sports Therapists, FSEM, USEMS, ECOSEP and UKADIS.

The conference provided an excellent opportunity to hear from some of the leaders in the field of Sports and Exercise Medicine (SEM)- what follows are a few highlights.

Athletes with Disabilities Session

Boosting in Paralympic Sport – Protecting the Clean Athlete: Challenges for Education, Policy and Procedures (Prof Nick Webborn)

  • Boosting is the intentional induction of autonomic dysreflexia (AD) in individuals with spinal cord injuries (T6 or above) to enhance athletic performance via greater release of catecholamines, larger V02 max’s and higher peak power (1)
  • International Paralympic Committee (IPC) forbids athletes to compete in an AD state due to potential adverse consequences (e.g. cerebral haemorrhage, myocardial infarction and seizures). Interestingly, no reported performance-related AD adverse events.
  • IPC Targeting testing in sports where boosting is possible, and in athletes who can become dysreflexic
  • 7% of male athletes admitted to using AD to enhance performance (2), however no athletes found in a dysreflexic state in 7 year IPC screening programme. Perhaps screening protocols are not effective enough?

Activating Paralyzed Muscles: Necessary for Optimal Health? (Christof Smit MD)

  • Muscle paralysis only tip of the iceberg for spinal cord injuries (SCI); multiple complications (e.g. spasticity, incontinence, respiratory problems, blood pressure issues etc)
  • Arm exercises are unable to achieve sufficient intensity/durations and only activate small muscle masses
  • Functional electrical stimulation (FES) improves muscle size/performance and enhances circulation
  • FES activation of paralyzed muscles benefits individuals, attenuating several problems including pressure ulcers and low cardiovascular fitness
  • FES enables individuals to raise daily energy expenditure, necessary to reduce the high prevalence of obesity in SCI. Ideally should be incorporated into the daily lives of all individuals with SCI

The Role of Upper Body Physical Activity in the Prevention of Metabolic Disease in Spinal Cord Injured Humans (Dr James Bilzon)

  • Physical activity (PA) intervention can promote function and independence, whilst reducing biomarkers of cardiovascular and metabolic disease
  • Adults with spinal cord injury (SCI):
    • 4x as likely to develop Type 2 Diabetes (3)
    • 2x more likely to suffer from Cardiovascular Disease (4)
  • SCI individuals have reduced energy expenditure in comparison to able-bodied adults in multiple exercise/sport activities (e.g. weight training and table tennis) (5)
  • Future research should determine exercise regimes that facilitate adherence and participation

Undergraduate Sports and Exercise Medicine Society (USEMS) Session

A Birds Eye View of SEM (Dr Rhodri Martin)

  • In England, currently 41 trainees nationwide; Wales training programme is ‘on hold’. The current training pathway for SEM in the NHS is illustrated below:
flow chart

http://www.jrcptb.org.uk/sites/default/files/2010%20Sport%20and%20Exercise%20Medicine.pdf

 

  • Currently, consultant level SEM physicians working for the NHS, Ministry of Defence, Institutes of Sport, Private Clinics, Professional Sport Teams and in Research
  • Top Tips for Undergraduates
    • Get involved at any level of sport (contact sport, trauma courses etc)
    • Become involved in physical activity promotion
    • Complete SSC/Research/Audits with relevance (ortho/rheum/cardio etc)

Movement is Medicine: The Bigger Picture – Movement as Medicine (Ms Ann Gates, @exerciseworks)

  • “Movement is medicine: for patients, for the public, and for nations”
  • Being aware of the big picture will enhance potential influence and leadership
  • Inequalities still exist in our communities in terms of access
  • Access to green spaces can increase physical activity for all ages, reduce health inequalities, increase levels of communal activity across different social groups and encourage active transport and community participation.
  • Work needs to be conducted with education systems and schools, to make physical activity part of the curriculum. Children can greatly benefit from school and community policy changes.

Staring into the Crystal Ball of SEM (Dr Rod Jaques)

Dr Jaques spoke about the future of SEM from personal experiences and reflected on the following:

  • The requirements of the SEM physician are ever-changing – learn to deal with uncertainty and adapt. “Be a chameleon”
  • SEM challenges for the future:
    • Look after your patients, not the sport
    • Learn to sell yourselves and your services
    • Inward-facing changes ahead – SEM curriculum, lack of jobs and training?
    • Outward facing challenges – wellness has been construed as an individual’s own responsibility (i.e. not the government’s); less need for SEM specialty?
  • Did the London 2012 Olympics help SEM? One positive outcome is that it has led to SEM specialty recognition 

Imaging Muscle Injuries – A Clear Picture (Dr Steve James)

  • Grading systems for injury determine the extent and severity of muscular injury, provide the clinician with prognostic information and guide therapeutic intervention (if required)
  • British Athletics has introduced a new muscle injury grading system (see http://bjsm.bmj.com/content/48/18/1347)
  • Poor prognostic factors for muscular injury on MRI:
    • Higher cross-sectional area involvement
    • Longer cranio-caudal length of injury
    • Intratendinous involvement of injury
  • Dr James’ approach to identifying and grading muscle injuries:
  1. Where is the injury? – Use axial fat suppressed/stir then axial T1
  2. Longitudinal extent of injury? – Use coronal/sagittal fat suppressed/stir
  3. Tendon rupture/ laxity? – Use coronal/sagittal T1

Top-,  in Ten Minutes (Dr Bryn Savill)

  1. Make Your Own Way – What are your goals? Tailor your time to your goals.
  2. Be Unique – How can you stand out? Highlight your strengths
  3. Find the Balance – Enjoy what you do; however, think about the here and now; make sure you pass all of your exams
  4. Absorb SEM – Undertake a wide variety of experiences, the more the better. Immerse yourself
  5. Find a Mentor and Make Contacts – The best way to do this is to Network. Network. Network

References

Ted Caplan BSc (Hons) Sport Science in Relation to Medicine is a 4th year medical student at the University of Bristol, UK.

Dr. Liam West BSc (Hons) MBBCh PG Dip SEM is originally from the UK and now is a Resident Medical Officer in Melbourne, Australia. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

If you would like to contribute to the Undergraduate Perspective on SEM BJSM Blog, please contact Dr. West at liamwestsem@hotmail.co.uk

Professor Karim Khan Awarded Honorary Fellowship of the Faculty of Sport and Exercise Medicine UK

6 Nov, 14 | by BJSM

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

Prof Karim Khan and Dr Roderick JaquesProfessor Karim Khan was awarded Honorary Fellowship of the Faculty of Sport and Exercise Medicine at the BASEM/FSEM joint Annual Conference, Walk 500 Miles, on Thursday 2 October 2014. Professor Khan received the award in recognition of his international career in Sport and Exercise Medicine.

Professor Khan is a truly international sports physician. He was educated in Australia, and studied Medicine and Medical Research at the University of Melbourne. He was awarded a PhD in Medicine by the University of Melbourne with a thesis titled “The effect of mechanical loading on the musculoskeletal system: clinical and laboratory studies”.  More recently he has studied and completed an MBA from the University of British Columbia, Canada.

His career spans the globe. Starting in Australia, he moved to Canada and is currently working in Qatar as the Director of Research and Education at Aspetar Orthopaedic and Sports Medicine Hospital. He is in his 7th year as Editor in Chief of the British Journal of Sports Medicine, which has become the leading international academic journal and digital media hub for the speciality.

Professor Khan is authorised as a Sports Medicine Physician by the Canadian Academy of Sports Medicine (CASEM) and the Australasian College of Sports Physicians (ACSP). He is a Fellow of the American College of Sports Medicine and Sports Medicine Australia. He served as Sports Physician to several teams, from a range of disciplines from Ballet to Basketball. His main research areas are in exercise promotion for health (including bone health and falls prevention) and pathogenesis and imaging of tendinopathies. He has published over 250 original research articles in addition to 3 books. He is a co-author of Brukner and Khan’s Clinical Sports Medicine, which has been published in three languages and is in its 4th edition. In 2001, Professor Khan was awarded the Australian Prime Minister’s Medal for service to sports medicine. In 2012, he was profiled in ‘The Lancet” with a biography titled ‘Good Sports’.

The FSEM awards up to two Honorary Fellows per year via its Members and Fellows Committee. The award of Honorary Fellow is made where there is an outstanding contribution to the specialty of Sport and Exercise Medicine throughout an individual’s professional career.

BASEM/FSEM Conference ‘Walk 500 Miles’, October 2014: Reflections on the Top 5 Themes

21 Oct, 14 | by BJSM

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

By Dr Rebecca Robinson @rjprobinson

Reg OCtEdinburgh October 2014

1) Before we walk 500 more…

2014 marked the first year of a joint BASEM/FSEM annual conference with the Faculty of Sport and Exercise Medicine. Held in Edinburgh’s Assembly Rooms, the conference was a hub of energy, with attendees ranging from highly experienced sport and exercise physicians to proactive medical students sharing ideas in a strongly supportive atmosphere.

Dr John Maclean’s poignant eulogy for the late Dr Stuart Hillis was a fitting reminder to celebrate excellent mentors. Dr Hillis, a founding father of SEM was posthumously awarded the Sir Roger Bannister Award for outstanding contribution to Sport and Exercise Medicine. Additionally, the award of Honorary Faculty fellowship to Professor Karim Khan reflected his continuing and invaluable contribution to Sports and Exercise Medicine. We are fortunate to have a wealth of experienced and supportive senior physicians in our specialty. As a still-young specialty we are often reminded of the challenges ahead. We may have 500 miles to walk but it was a moment to reflect and thank those who have trail blazed the first 500.

2) Are Elite Athletes any different from the rest of us?

To what degree can we credit genetics in sprint performance, enhance and interpret physiological factors from VO2 max to red cell mass, and just how strong are the upper bodies of world class cyclists compared to weightlifters? Presentations from Professor Yannis Pitsalidis, Dr Barry Fudge, and Calvin Morris provided compelling evidence and raised further questions for research, with one certainty: that world-leading scientific knowledge is providing a performance-enhancing stimulus to elite programmes.

Insights into injuries incurred in golf drew expertise from the medical team attendant at the recent Ryder Cup, led by Dr Roger Hawkes and explained the principles of biomechanics and profiling to an attentive audience. Across the conference, BOSTA (British Orthopaedic Sports Trauma Association and Arthroscopy Association) and BIMM (British Institute of Musculoskeletal Medicine) brought theory behind practice to the table with opportunities for practical sessions.

3) Careers in Sports Medicine

The range of speakers and perspectives in this stream included: NHS, Private and Military Sport and Exercise Physicians. It was valuable for trainees and new consultants at all stages, as they addressed important issues about the scope of future practice from their own depth of experience.

Whilst elite sport offers great opportunities for team involvement, experience, and travel, Dr Phil Batty’s salient advice was a reminder that our foremost duty of care is always to the patient. Align conduct as a Team Physician with your regulatory body’s rules and do not be afraid to stand up for your principles despite perceived pressures.

The mantra to remember was: “You cannot talk yourself out of a situation you’ve behaved yourself into.”

REg OCtBallet demonstration BASEM October 20144) ‘Be More Dancer’

It was a privilege to be treated to the Royal Ballet School’s performances both at the Gala Dinner and demonstrations during the fascinating insights into ballet medicine on Friday morning. Appreciating perhaps one of the most graceful forms of human performance was coupled with insight into the unique challenges of injury, as reported by Drs Ian McCurdie and Philippa Woodward.

The dancers on stage brought to life the focus of the morning session; perhaps if we can be ‘more dancer’ in our approach to our own work and in our perceptions of patients’ potential, we can surpass expectation.

5) ‘Exercise-The Way Forward’

The mandate for physical activity as medicine has never been greater. There is strong evidence that cardiorespiratory fitness reduces mortality in chronic disease, benefits health independent of BMI, and enhances surgical recovery. In the final day session, Dr Harry Burns urged delegates to work together to ‘join the dots’ on promoting and implementing ’physical activity as medicine’. Collaboration between CCGs and hospital specialties are essential, as is work within the wider community to ensure integrated environmental and social policy – vital to supporting wellbeing. It is time to incorporate physical activity into every consultation. Investment in lifelong physical activity promotion for patients from early childhood should involve the whole family and continue through to active ageing. Programmes for community-wide education and engagement are necessary to empower, integrate, and mobilise everybody, everyday.

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

Dr Rebecca Robinson is currently an ST6 in Sports and Exercise Medicine Based in Sheffield, working with GB Boxing, Swimming and Team England at the 2014 Commonwealth Games. She is currently competing for GB in Mountain Running. Twitter: @rjprobinson

Are high performing athletes any different from the rest of us? Find out on October 1st, 2014

29 Sep, 14 | by BJSM

edinburgh-mileThe Secrets Behind High Performing Athletes

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

 

‘Walk 500 Miles’ Sport and Exercise Medicine Conference 2014, co-hosted by BASEM and the FSEM, will reveal some secrets behind elite performance in sport.

An October 1st conference session will address the question: Are high performing athletes any different from the rest of us?

Yannis Pitsiladis, Professor of Sport and Exercise Science and Director of the Centre for Sport and Exercise Science and Medicine (SESAME) at the University of Brighton, has an established track record of research into the phenomenal success of east African distance runners and sprinters from Jamaica. Professor Pitsiladis will be presenting ‘what we know’ about the Jamaican sprint phenomenon in one of the opening sessions of the conference. The biological mechanisms versus socio-economic and cultural factors affecting the Jamaican athlete’s performance will be a key part of the discussion.

This session is swiftly followed by Dr Calvin Morriss, Head of Speed and Power Sports for the English Institute of Sport, speaking about the upper body requirements of athletes and how detailed biochemical analyses can help provide coaches and athletes with the means to develop highly specific training methods. Dr Morriss will also explore sports where the upper body contribution might appear of a secondary importance to that of the lower body, yet can have a profound effects on performance.

Closing Wednesday’s session will be Dr Mark Gillette, Head of Athletic Performance British Basketball, talking about high performance in Basketball and the strategy British Basketball used to implement a high performance model for its senior squads, in preparation for the London Olympics.

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

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

6 Sep, 14 | by BJSM

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

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

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

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

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

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

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

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

‘The fatigued athlete’ and RED-S: Lessons from the field and the BASEM spring conference

16 Apr, 14 | by Karim Khan

Sport and Exercise Medicine: The UK trainee perspective, a monthly blog series

athlete fatigue

By Dr Khine Swe Win

I recently attended the British Association of Sport and Exercise Medicine (BASEM) spring conference, “The fatigued athlete” in Manchester. It provided the latest evidence in diagnosis, prevention and management of underperformance syndromes.

Unsurprisingly, the new IOC consensus statement on Relative Energy Deficiency in Sport (RED-S) was a discussion topic of interest at the conference. The RED-S replaces the previous term “female athletes triad” (a medical condition often observed in physically active girls and women, that involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density, (Mary Jane De Souza et al 2013)).

The new term recognizes the complexity of the condition’s pathophysiology and multisystem involvement, affecting both men and women. The background theory of RED-S is the imbalance in the energy availability and the energy expenditure, or misbalance between training load and recovery. Low energy availability can have serious implications for many body systems such as nutrient deficiencies, low immunity, risk of infections and illnesses, and chronic fatigue, resulting in short-term and long-term compromise of optimal health and performance.

Multiple monitoring tools have been used to detect early signs of fatigue and health decline in athletes. A good monitoring tool should be reliable, reproducible, standardized, sport-specific and provide immediate feedback. Of the many monitoring models, here are some examples that I have come across:

  • Daily monitoring of rated perception of exertion (RPE), sleep hygiene, muscle soreness, fatigue level, readiness to train, attractiveness of training day, general health, mental wellbeing (POMS).
  • Physical tests and examination such as range of movement, adductor squeeze test, FABER test, Functional movement assessment (SFMA), counter movement jump (CMJ).
  • GPS data on duration, covered distance, speed, acceleration, total work, metabolic power.
  • Physiological markers such as heart rate, heart rate recovery, heart rate variability.
  • Monitoring by blood tests and biochemical markers.

The key is to effectively analyze data and utilize it to boost performance. Multiple factors enhance team performance. The sum of many little improvements or marginal gains can provide a big leap in performance.

Further points to highlight from the conference discussion include:

  • Load can influence performance and hence, appropriate load management is crucial. Athletes should be exposed to different stimuli on a day-to-day basic and should avoid monotony of training.
  • Establishment of recovery strategies within the team is important.
  • It is essential that athletes have a balanced nutritious intake with a mixture of macro and micronutrients.
  • Nutritional interventions can be considered for low immune athletes, such as Vitamin D
level, high carbohydrate, whey protein, open window theory (post exercise recovery shakes),
probiotics (illness prone athletes)
and Colostrum (influencing the gut barrier).
  • Sleep efficiency is slowly gaining its popularity in maximizing performance. The issue of sleep and its impact on performance was discussed recently by Dr Andy Franklyn-Miller in his research review blog (HERE)
  • Athletes’ personal, environmental and emotional issues should be addressed efficiently.
  • Dr John Roger discussed that the athletes should be “Happy, Healthy (heart rates normal), Hungry (appetite excellent)
and Horny (libido in good working order) (4Hs)
  • There are also other multiple factors that can influence performance, such as time zone transition, jetlag and altitude exposure.

I conclude by sharing Tom Lancashire’s thoughts, from an athlete’s perspective, that as core staff we should “know the athletes, understand the sport, and communicate and co-ordinate effectively within the team.”

Read more in BJSM:

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

Dr Khine Swe Win is a final year sport and exercise medicine registrar, undertaking her training in West Midlands deanery. 

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

BASEM Congress 2013 – St George’s Park, 31st October & 1st November

25 Jun, 13 | by Karim Khan

BASEM_2013_ConferenceProg_V10-4_Page_01

BASEM 2013 is a ‘not-to-miss’ event for clinicians interested in sport and exercise medicine & physiotherapy. A great forum for physiotherapists, sports therapists and doctors, the packed program is full of practical sessions and opportunities for networking and discussion. See full program details HERE. What’s more, it will be at the impressive new venue of St. Georges Park.

“The theme of the conference is focused on a new era for BASEM and the specialty of SEM with ‘an expanding field of practice’. The programme contains scientific evidence based material as well as empirical data, experience and anecdotes. Time keeping will be strict to ensure that the discussion sessions are respected and lead to constructive interaction and debate.”

Check out the BASEM website for more details.

Perfect time to commit to UKsem London…Nov 23 thru 26 or part thereof…

10 Nov, 11 | by Karim Khan

Looking for a world class conference bringing together sport and exercise medicine, conditioning and science with nutrition, rehabilitation and high performance coaching?. This conference will provide new knowledge for those working with elite sport and recreational athletes as well as those presenting to all clinicians for exercise prescription. See the UKsem home page including the concise video (and Andy Franklin-Miller’s very modish shirt)…Will you be there?

The UKsem site is the best place to find the conference program. Names I am looking forward to hearing from include Roald Bahr (sports injury prevention-always great value), Dan Lieberman (the ‘barefoot doctor’), Damien Comolli (the secret to Liverpool’s success), Vern Gambetta (the art and science of coaching).Vern has over 4000 followers as @coachGambetta on Twitter so you know he’s doing something right.

‘Sleepers’ for many will be Carl Askling on hamstring rehabilitation and Richard Frobell on conservative management of ACLs. The former has terrific programs for both prevention and treatment. He discovered the difference between ‘type I’ (sprinters/football players) and ‘type II’ (stretching/dancer’s) hamstring strains and their very different prognoses. Great teaching videos for both rehab and determining return to play.

Dr Frobell headed up the New England Journal of Medicine RCT which randomized ACL patients to rehab or surgery. Not every conference presenter can open up with that claim…’Thanks for coming and if you doze off during my talk you can read all about in the NEJM….’. Good one. 10 years of hard work to become the overnight sensation. BJSM comments on that paper are here in a WarmUp and here in a podcast with Dr Frobell and his research team. Do your homework and then ask him the stumper at UKsem. Or buy him beer for the great effort!

I’ll stop there as I want you to use your coffee break to go to the UKsem site, not to read this. And by ‘sleepers’ – I meant – ‘under the radar’ — not lectures to sleep in. I would reserve sleeping for Friday morning 9:35 – 10:05. Something about how Mad Men, the Marlboro Man and Freakonomics have the answer to ‘smokadiabesity‘? Weird!

The UKsem site is great but if you insist on only following BJSM pages you can see Andy Franklin-Miller’s WarmUp about the conference here and listen to two interviews with the mellifluous BBC-trained sports physician and fashionista.

July podcast – his conference highlights

October podcast – lower limb biomechanics plus a sneaky conference plug in the last 3 minutes of this 24 minute file.

Nice shirt….

CASM to include “Exercise” in their title

10 Mar, 10 | by Karim Khan

The sports medicine association formerly known as the Canadian Academy of Sport Medicine (CASM) voted to change their name to the Canadian Academy of Sport and Exercise Medicine (CASEM). This will come into effect on June 9th 2010. It is interesting that this follows the BASEM name change in the UK. Given the broad mandate of health professionals in our field, and the unfortunate association of the term ‘sports medicine’ with elite athletes in the mind of the general public, is it time for national societies of ‘sports medicine’ to follow the trend set by BASEM, CASEM, and others that preceded them.


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