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Exercise oncology part 2/3: Let’s put it into practice!

31 Jul, 17 | by BJSM

Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series

By Anne Cornevin @anne_cornevin and Justin Carrard @Carrard.Justin

The first part of this series reviewed the scientific evidence to prescribe exercise in order to prevent and treat cancers [read it HERE]. This second part “gives”  the floor to a family, whose daughter was diagnosed with acute lymphoblastic leukaemia at the age of two. She was then treated until the age of four and got a relapse at six. At that time, she integrated the program PASTEC (French acronym for Promotion of Therapeutic Sports Activity for Children with Cancer).

PASTEC is an out-of-hospital exercise training program initiated in Lausanne (Switzerland) for children suffering from cancer. It was born out of a joint effort between the paediatric-haematology-oncology unit of the CHUV (French acronym for Lausanne University Hospital) and the Health and Sport Centre (which is attached to both the University of Lausanne and the Swiss Federal Institute of Technology of Lausanne).


Can you explain how you discovered PASTEC and what it involves?

Parents: “When our daughter got her relapse, doctors suggested to enrol her in the program. We were told that the first studies just got published, showing that showing that physical activity improves chemotherapy induced neurological deficits as well as concentration.

She has been taking part in PASTEC for 2 years. In the first year, it took place every Saturday and they did alternatively fine motor skills and endurance/strength training. Now, it is fortnightly, and the main emphasis is on discovering new activities.”

What was your reaction?

Daugther: “First, I did not agree at all. I didn’t want it, I wasn’t motivated.”

Parents: “She was tired and scared of not being able to make it through, not being able to keep up the pace and achieve the proposed exercises. Because of her leukaemia, she had to stop the dancing lessons she just started. She couldn’t catch up the sports program at school either, because she had to spend most of the time in the hospital. We then noticed that her physical capacity was fluctuating all the time according to the therapy schedule. For that reason, it wouldn’t have been impossible for her to do sport in a usual non-adapted sporting club.

However, as sportsmen, we had the conviction that sport could help her feel better especially if the program was well adapted. From a general point of view, although we got a lot of support since her diagnosis of leukaemia, we had the feeling that physical activity was lacking in the proposed care process.”

What are the differences between PASTEC and scholar sports teaching?

Daughter: “At school there is no sports teacher, but a school teacher who gives us sports lessons. I can’t do everything like other children, but I can do a lot.”

Parents: “Her muscle and endurance are very different from the ones of other kids. For her it is an opportunity to be in a group where she isn’t judged on her physical abilities.  In PASTEC, there is a lot of tolerance because all children are sick. They support and encourage each other far more than at school.

Moreover, it allows her to say “I have my own sport and I am able to realise the given exercises”. It totally changed the way she perceived her physical difficulties. Instead of saying “I can’t do this”, she tries it and most of the time she succeeds. This made physical activities much more accessible for her.”

Lastly, they take part in popular sporting events, which helps integrating them into the society. For example, all children did the 2km running race as part of the 20km of Lausanne. We would have never dared trying this alone with her.  Doing it with PASTEC allowed them to do it proudly, without fear and with a common goal. It was a real challenge and at the end, they all received a prize. She was very happy that she did it!

What did PASTEC change for you?

Parents: “Chemotherapy brought her really down. With PASTEC, in one year, we noticed that she gained muscle, that everything related to gesture or coordination, and self-confidence had clearly improved. We realized that she was able to ride a bike again, simply because she regained her confidence. It is the whole program that kept her away from falling lower, and that allowed her to keep the course and to improve.

Furthermore, as parents it is also a relaxing moment when we go to the centre. We can exchange with other parents facing similar challenges without having to justify what is going on with her. This is a very nice feeling.”

If you are told that the latest scientific findings show that regular physical activity has an impact on cancer treatment AND prognostic, would you believe it based on your experience?

Parents: “Yes, we definitely would. We saw that exercise had a huge positive impact on our daughter.”

Do you have any tips for our readers wanting to implement such program in their home country?

Parents: “We believe that exercise should be part of cancer therapy and such be proposed to all children suffering from cancer. To enable this, such programs need more recognition and financial support. For example, PASTEC is supported mainly by “Zoé for life” (an association for children with cancer) through donation.

Secondly, we were disappointed that the fine motor skills exercises disappeared the second year. Neuropathy is one of the most important impact of chemotherapy and it is essential to integrate those motor skills.

Lastly, it would be great to delocalise such program in smaller centres in order to make it available to families who are living further away.”

Lastly, how does the future look like for you?

Parents: “She should be in remission in August and hopefully for good. We wish she could then integrate a sporting club. In fact, we really see PASTEC as a springboard to her integration into the society.”

For more information:



N.B. This blog article does not distinguish the study PASTEC (which took place during the first year of PASTEC) from the program PASTEC (which is the legacy of the study and is still taking place). Thus, the study PASTEC was supported by “Zoé for life”.

Read part 1 of the series: Exercise oncology part 1/3: Let’s get moving, exercise helps in preventing AND treating cancers!


Anne Cornevin is a 4th year medical student at the University of Geneva (Switzerland) and also a member of Students and Junior Doctors SSGSM/SSMS. As a sport lover and previous artistic gymnast, she aspires to contribute to the promotion of Sports & Exercise Medicine as a medical speciality.

Email:                                            Twitter : @anne_cornevin

Justin Carrard is a second year internal medicine resident based in Biel/Bienne (Switzerland). He coordinates the BJSM Swiss Junior Doctors and Undergraduate Perspective Blog Series and leads the Students & Junior Doctors SGSM/SSMS movement. Justin aims to raise SEM awareness among medical students and modern solutions it provides to big public health issues like non-communicable diseases. As an ex-competitive swimmer, he has a keen interest for endurance sports and regularly practices them with passion.

Email:                              Twitter: @Carrard.Justin

Young people: Neuromuscular skills for Sport Performance

24 Jul, 17 | by BJSM

 Part-3 (of 3) of the blog mini-series on youth

Dr Nicky Keay nickykeay

Many publications report concerns over low exercise levels in young people. At the other end of the spectrum there are potential pitfalls to be avoided for young athletes. Some aspects have been discussed in my previous blogs: health and fitness in young people and optimising health and fitness for young people, below are some updates.

Supporting previous publications that exercise in young people improves cognitive and academic performance, research found that in boys, delay in reading skills was associated with high levels of sedentary time combined with low levels of exercise. Low muscle tone, associated with lack of exercise is also proposed as potential inhibitor of learning in children. Lack of physical activity, coupled with unfavourable body composition in young people is linked with adverse outcomes for bone development and cardio-metabolic disease in adults. Now there also appears to be long term consequences for cognitive ability and neuromuscular skills.

For young people already involved in sport training, the same principles apply in that this represents the optimal time in life for development of not only physical fitness such as CV fitness, muscular strength and endurance, but also neuromuscular skills. All these factors are important to enhance sport performance and to avoid injury. The risk of injury is more prevalent in early sport specialisation, so any strategies to minimise injury risk is important. For example, periodised strength and conditioning with neuromuscular training to reinforce the acquisition of a diverse range of motor skills. In other words to combine both health related physical fitness (eg. CV fitness) with skill related fitness (eg. co-ordination). The Pilates style body conditioning which I teach for young people, includes developing flexibility, proprioception, core stability, balance and co-ordination which are applicable for all sports.

Collaboration with coaches, sports clubs, physiotherapists and other health care professionals is required to support young people and their families in optimising health and fitness.


Health and fitness in Young People

Optimising Health and Fitness for Young People

Reading skills in sedentary boys

Muscle tone and leaning in children

Factors impacting bone development

Optimal Heath especially for Young athletes! British Association of Sport and Exercise Medicine

The role of Pilates in facilitating sports performance


Exercise and fitness in young people – what factors contribute to long term health?

14 Jul, 17 | by BJSM

Part-2 of the blog mini-series on youth

By Dr Nicky Keay

Recent reports reveal that children in Britain are amongst the least active in the world. At the other end of the spectrum there have been a cluster of articles outlining the pitfalls of early specialisation in a single sport.

Regarding the reports of lack of physical activity amongst young people in Britain, this is of concern not only for their current physical and cognitive ability, but has repercussions for health in adult life. Research demonstrates that young people with low cardiovascular fitness have an increased risk of developing cardiovascular disease in adult life. Conversely, the beneficial effects of weight bearing exercise in prepubescent girls has been shown to enhance bone mineral density accumulation, which will have beneficial impact on peak bone mass. However, as I found in my longitudinal studies, the level of exercise has to be in conjunction with an appropriate, well-balanced diet to avoid relative energy deficiency deficiency in sport (RED-S), which can compromise bone mineral density accumulation.

At the other end of the scale, early specialisation in a single sport does not necessarily guarantee long term success. Rather, this can increase the risk of overuse injury in developing bodies, which in turn has long term consequences. Ensuring that all elements of fitness are considered may be an injury prevention strategy. I agree that injury prevention can be viewed as part of optimising sports performance, especially in young athletes for both the present and in the long term.

Sleep is a vital element in optimising health and fitness, especially in young people who may be tempted to look at mobiles or screens of other mobile devices which delays falling asleep by decreasing melatonin production. Sleep promotes mental freshness and physical elements such as boosting immunity and endogenous release of growth hormone. As Macbeth put it, sleep is the “chief nourisher in life’s great feast”.

A balanced approach to health and fitness should be promoted, with young people encouraged to take part in a range of sporting activities.


Young athletes’ optimal health: Part 3 Consequences of Relative Energy Deficiency in sports Dr N. Keay, British Association Sport and Exercise Medicine, 13/4/17

Sleep for health and sports performance Dr N. Keay, British Journal Sport Medicine, 7/2/17

Optimising health, fitness and sports performance for young people

Telegraph article

Active Healthy Kids global alliance

Poor cardiovascular fitness in young people risk for developing cardiovascular disease 

Sports Specialization in Young Athletes

IOC consensus statement on youth athletic development British Journal Sport Medicine






Optimising Health, Fitness and Sports Performance for young people

30 Jun, 17 | by BJSM

Part-1 of the blog mini-series on youth

By Dr Nicky Keay

Young people need information in order to make life decisions on their health, fitness and sport training with the support of their families, teachers and coaches.

As discussed in my previous blog anima sana in corpore sano, exercise has a positive effect on all aspects of health: physical, mental and social. The beneficial impact of exercise is particularly important during adolescence where bodies and minds are changing. This time period presents a window of opportunity for young people to optimise health and fitness, both in the short term and long term.

The physical benefits of exercise for young people include development of peak bone mass, body composition and enhanced cardio-metabolic health. Exercise in young people has also been shown to support cognitive ability and psychological wellbeing.

Optimising health and all aspects of fitness in young athletes is especially important in order to train and compete successfully. During this phase of growth and development, any imbalances in training, combined with changes in proportions and unfused growth plates can render young athletes more susceptible to overuse injuries. A training strategy for injury prevention in this age group includes development of neuromuscular skills when neuroplasticity is available. Pilates is an excellent form of exercise to support sport performance.

In athletes where low body weight is an advantage for aesthetic reasons or where this confers a competitive advantage, this can lead to relative energy deficiency in sport (RED-S). Previously known as the female athlete triad, this was renamed as male athletes can also be effected. The consequences of this relative energy deficiency state are negative effects on metabolic rate, menstrual function, bone health, protein synthesis and immunity. If this situation arises in young athletes, then this is of concern for current health and may have consequences for health moving into adulthood.

A well informed young person can make decisions to optimise health, fitness and sports performance.

Link to Workshops


Optimal Health: Especially Young Athletes! Part 3 – Consequences of Relative Energy Deficiency in Sports Dr N. Keay, British Association Sport and Exercise Medicine 13/4/17

Report from Chief Medical Officer

Cognitive benefits of exercise

Injuries in young athletes

Young people: neuromuscular skills for sports performance

IOC consensus statement

Health and fitness in young people



Are we destroying junior talent? 25% reinjury rate among children who have ACL reconstructions!

16 Jun, 17 | by BJSM

By Lars Engebretsen

The number of ACL injuries in children is rising.  Many of us see this daily in our clinics, however, each one of us have just a few–perhaps 10-20 a year.  These are active children. In my country, Norway, the majority of these children are injured while skiing. On other continents, other sports dominate. What we have in common that these are often the best child athletes and the most daring ones.

Across the globe, many of these children do not see an orthopaedic surgeon and the injury goes undetected. However, in the developed world, many are referred to orthopaedics and they often undergo surgery. More than 50 different procedures have been published for this setting.  All publications have only short-term followup; there are none with follow up > 10 years.

At the June 2017 International Society for Arthroscopy, Knee Surgery and Orthopaedic  Sports Medicine (ISAKOS) meeting in Shanghai, an expert group agreed that the paediatric ACL reinjury rate after the various surgical procedures was about 25%.  What does this mean?  In short, we do not know what happens to children who rupture their ACL. Do they grow up like their friends, doing sports or prioritizing education and going on with their life? Or does the injury and treatment change their lives?

This blog is to challenge clinician and researcher readers to initiate studies on not only the short-term technical aspects of the treatment of the ACL injury. We already have data on meniscal and cartilage injury as well as additional ligament tears. Although disagreements between groups exist, it appears there are as many meniscal tears in children who have surgical reconstruction as there are in children who choose nonoperative treatment of the injury.  Growth disturbances occur after surgical treatment, but these are rare.  The irony is that we seem to have good technical capability to deal with these challenges, but the injury still seems to have a major impact of the child. Very few, if any of the children become high level athletes in pivoting sports. We lack information on their quality of life and premature OA development when they turn 25.

These issues can only be solved by long-term follow up in multicenter collaborations across universities and nations. This needs a long-term commitment by those of us who have the children’s interests close at heart.  In October 2017, the international Olympic Committee will host an expert group from all parts of the world with leaders from AOSSM, ESSKA, ISAKOS, SLARD and expert PTs who also specialize in treating and researching these patients. The group will prepare ahead of time and spend three days drilling into the literature and discussing the clinical issues. The meeting will result in an international consensus statement that should set the stage for future research.  What I learned at ISAKOS was that the high number of reinjuires mean we need to improve our game!


Professor Lars Engebretsen has published over 400 articles and book chapters, with a citation index (H-index) of 56. He is among the world’s most productive researchers. He uses clinical, epidemiological and basic science methods to address questions in the areas of general sports medicine, knee ligaments, cartilage as well as the prevention of sports injuries and illnesses.

He was inducted into the AOSSM Hall of Fame in July 2015 and became an ESSKA Honorary member in 2016 and an ISAKOS Honorary member in June 2017 . He received the Nordic Prize in Medicine in 2016.

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

22 Feb, 17 | by BJSM

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. – World Health Organisation 1948

By Dr Nicky Keay

There has been criticism of this definition, arguing that the word “complete” has opened the door to today’s more medicalised society. However, this trend coincides with increased volume of “patients” seeking optimal health, together with doctors who have a more extensive repertoire of medical interventions at their disposal. In a time-pressed society there is less opportunity for either patient or doctor to explore longer term adaptive measures and prevention strategies, which facilitate taking responsibility for your health. Fortunately Sport and Exercise Medicine became a recognised medical specialty in the UK in 2006. This encompasses population-based strategies for disease prevention outlined in the global initiative founded in 2007 “Exercise is Medicine“.

What has this got to do with sports performance? There are subgroups within the population, such as athletes already taking plenty of exercise. Elite athletes differ from the general population, due to superior adaptation processes to exercise, probably with a genetic component. So are the same “normal” population-based ranges of quantified medical parameters applicable?

This is precisely the issue that arose when I was on the international medical research team investigating the development of a dope test for growth hormone (GH). Crucially, exercise is one of the major stimuli for growth hormone release from the anterior pituitary. So before we could even start investigating potential downstream markers of exogenous GH abuse, the “normal” range for elite athletes had to be established.

Father and son compete in running race: How will their endocrine markers differ across age and fitness levels?

In a similar way, are the “normal” ranges for other hormones applicable to athletes? In a fascinating lecture delivered by Dr Kristien Boelaert, Consultant Endocrinologist, it was explained that the distribution for thyroid stimulating hormone (TSH) is affected by multiple factors, including illness, age and exercise status. So “normal” for the general population is not necessarily normal for specific subgroups.

The other issue, especially with the Endocrine system is that hormones act on a variety of tissues and so produce a variety of multi-system network effects with interactions and control feedback loops. Therefore symptoms of malfunction/maladaptation and subclinical conditions can be non specific. From a doctor’s perspective this makes Endocrinology fascinating detective work, but challenging when dealing with subgroups in the population who require a more intensive work-up and individualised approach.

The vast majority of research studies involve exclusively male athletes, leaving female athletes under-represented (a recent study on heat adaptation in female athletes being a notable exception). Some areas of research, including my own, have been directed more towards female athletes in the case of female athlete triad, or Relative Energy Deficiency in sports (REDs). REDs is a more appropriate term as it really sums up the important points: male and female can both be affected and therefore should both be studied. There are subgroups within the general population who may not fit the “normal” range: REDs is not necessarily a clinically defined eating disorder from lecture by Professor J. Sundgot-Borgen (IOC working group on female athlete triad and IOC working group on body composition, health and performance).

No medical/physiological/metabolic parameter can be considered in isolation: in the case of REDs, it is not menstrual disturbance and bone health that are affected in isolation. For example, there is currently great debate about whether a low carbohydrate/high fat diet (ketogenic diet) can mobilise fat oxidation and potentially be a training strategy to enhance performance. Needless to say that a recent study contained no female athletes. Given that many female endurance athletes are already lean, potentially driving fat metabolism through diet manipulation may have an impact on Endocrine function, optimal health and hence sport performance. I understand that a forthcoming study will include female athletes.

So a continuum or distinct subgroups in the population? Clearly general medical principles apply to all, with a spectrum from optimal functioning, subclinical conditions through to recognised disease state. We now have evidence of distinct differences between subgroups in the population and even within these subgroups such as male and female athletes. We are moving into a world of personalised medicine, where recommendations for optimal health are tailored for individuals within specific subgroups.


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


“Subclinical hypothydroidism in athletes”. Lecture by Dr Kristeien Boelaert at BASEM Spring Conference 2014 on the Fatigued Athlete


Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, BAEM Spring Conference 2015 on the Female Athlete

Low Carbohydrate, High Fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers


How should we define health?

Nobody is average but what to do about it? The challenge of individualized disease prevention based on genomics

Exercise is Medicine

Enhancing Sport Performance: part 1

Effect of adaptive responses to heat exposure on exercise performance

School Games: great introduction to a multi-sport experience

24 Sep, 16 | by BJSM

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

By Dr Philippa Turner

If anyone is looking for an introduction to the multi-sport experience, look no further than the School Games! Previous medical team alumni (and athletes, of course) have gone on to World University Games, Commonwealth Games, Olympic and Paralympic Games success.

About the games

Developed and organised by the Youth Sport Trust, Sport England and the Department of Culture, Media and Sport, the School Games creates an inspirational and motivational setting. It provides elite young sports people with the opportunity to perform at the highest level. It also encourages more young people to take part in sport. Over 1,600 young athletes competed across three days this September at Loughborough University, England.

The Games currently includes twelve sports: Fencing, Rugby Sevens, Gymnastics, Hockey, Athletics, Cycling, Judo, Swimming, Table Tennis, Volleyball, Wheelchair Basketball and Wheelchair Tennis; disability athletes compete in seven sports: Athletics, Fencing, Swimming, Table Tennis, Cycling, Wheelchair Basketball and Wheelchair Tennis.

Organisers make the School Games as similar to the Olympics and Paralympics as possible. This includes an Opening and Closing Ceremony to participate in and enjoy, shared flats as accommodation, communal food halls, accreditation procedures, volunteer support staff, and a central medical clinic alongside pitch-side support.

SEM takeaways – ‘court-side’ lessons learned

This was my first experience of working at the School Games. It made me realise the massive logistical planning which goes into providing medical cover at such an event compared to a single one off fixture. A day of introduction and CPD was put on prior to the competitions’ start. This included sessions on safeguarding, anti-doping, dental injuries and venue familiarisation. It also allowed the medical team to get to know each other and practise moulages. This was a great opportunity to learn from both more experienced colleagues in a supervised setting, and other health professionals who work in a wide range of sporting environments.


I was placed at Volleyball with three physiotherapists, a paramedic and technician. I had no prior experience of covering Volleyball. It was quickly evident that the crowd was enthusiastic and loud! The competition was tight at the top of the tables in both the girls’ and boys’ groups. This made for some aggressive warm ups causing bloody noses, but also some great games to watch.

The main issues we saw included shoulder, knee and lower back pain. The athletes’ long levers with little muscle bulk to control movement patterns were clearly causing issues. Many of the boys were over 6’5” tall and did not fit on our examination plinths. Many also appeared to rely on K-Tape to get them through matches. So as a medical team, we tried to educate our patients as much as possible about activation and strengthening exercises they could perform in order to improve their performance both in the short and long term.

I also became more aware that, when working with young athletes, their overall wellbeing is paramount. We were not there simply to treat an injury or illness. When the competition started the pressure from coaches, parents and the athletes themselves was also a critical thing to manage. This was further intensified by the fact that this was many of the athletes’ first time away from home, and/or their first experience with a team of professional medical support.

A great opportunity


Philippa Turner, Phillip Harris, Jude Coe, and Leanne Simoncelli

I thoroughly enjoyed getting to know and learning from the medical team.  Working at the School Games lets you see first-hand young athletes gaining invaluable multi-sport experience. They performed at their best even if the results didn’t go their way. I would certainly encourage any doctor or physiotherapist who is interested in Sport and Exercise Medicine to look out for the job adverts on the UK Sport website early next year and do their homework before the interviews! You never know – you might look after the next Max Whitlock, Ellie Simmonds or Adam Peaty!

For more information about the 2016 School Games you can visit

Dr Philippa Turner, ST5 in the East Midlands Deanery. She works as the match day doctor for Aston Villa Ladies Football Team, Team Physician to England Cricket Disability Squads and the Women’s Performance Programme. She is also the Trainee Representative on the SEM Speciality Advisory Committee (SAC).

Dr Farrah Jawad is a registrar in London and co-ordinates the BJSM Trainee Perspective blog.



Safety in youth rugby: education is not the answer to the concussion crisis

19 Sep, 16 | by BJSM

By Adam White @AdJWhite, Dr. Tim Gamble, and John Batten @JBatz85 

Injury worries

Despite the potential health benefits from participating in the sport, rugby is under increasing scrutiny as a result of the high number of injuries experienced by youth participants. We know, for example, that injury rates in rugby union for participants under 21 years of age can be as high as 128.9 injuries per 1000 playing hours, with a mean injury incidence rate of 26.7 per 1000 playing hours. The tackle is often to blame, causing sixty-three per cent of all injuries in one study on school rugby.


Concussion has received particular attention due to the potential long-term impacts (e.g., chronic traumatic encephalopathy) it may have upon brain functioning. Indeed, a systematic review of concussion in youth sport, stated that rugby had the highest risk of concussion compared to sports such as Field Hockey and American Football. In fact, one recently published study in Sweden shows many of the damaging social outcomes of concussion. Concerned about the potential damage the tackle may be having on children, we and the Sport Collision Injury Collective recently wrote to the British government urging them to ban tackling in rugby in school sport.

The HEADCASE programme

The Rugby Football Union’s response to safety concerns in their sport is through the delivery of educational initiatives. Specifically, the online HEADCASE programme provides key stakeholders with information about recognising concussion and managing injured players (i.e., secondary prevention). Delivered through an online, interactive web platform, it is freely available for players, coaches, officials, parents, teachers, first-aiders and spectators to complete. This potentially represents an improvement to player-safety, with the rugby authorities (the Rugby Football Union, World Rugby etc.) leaders in the management of brain trauma in sport. However, the following sections highlight some concerns about the effectiveness and delivery of this health-focused educational programme.

Voluntary participation

Globally, some rugby authorities require their coaches and teachers take either annual or biannual training to coach the sport. The Rugby Football Union, however, has no mandate for coaches to have undertaken HEADCASE training – although any individuals seeking to undertake a new coaching or refereeing qualification (which is also not mandatory to coach or officiate) are required to complete the programme before attending a course. Yet, this neglects the vast population of coaches who have completed their qualifications before the introduction of the HEADCASE programme, or those coaches and officials who do not seek qualifications at all. Furthermore, coaches and officials in England who have completed the training will only have to do so once, with no immediate plans to make it a yearly requirement like rugby governing bodies in the southern hemisphere.

Lack of evaluation

There is poor evaluation of educational initiatives aimed at reducing injury in sport. Only two rugby programmes (BokSmart and RugbySmart) complete all four elements of Van Mechelen’s Model of Injury Prevention (i.e., establishing the extent of the injury problem, establishing the aetiology and mechanisms of sports injury, introducing a preventative measure, assessing its effectiveness by repeating the process) to establish intervention effectiveness. Subsequently, researchers have asserted: ‘There is a dearth of evidence to support the effectiveness of such programmes’. Additionally, a recent BJSM systematic review found the concussion prevention benefits of technique training and practice time restrictions may be limited to a specific sub-set (i.e., 11-15 year olds) of the at-risk athletic population.

Education and injury prevention

Unless sporting bodies evaluate the effectiveness of their training, the impact upon injury prevention is unknown. However, evidence from the health and safety literature suggests that when implementing controls to manage risk, educational interventions are somewhat limited in effectiveness. Specifically, the Hierarchy of Control asserts that elimination of a risk is the most effective way of management, with personal protective equipment being the least effective, and administrative controls (i.e. education) the second least effective. Thus, altering the structure of an activity (substitution) or eliminating the mechanism – in this case tackling –  are likely to be much more effective interventions for the prevention of injuries than educational initiatives. Exemplifying this, law amendments in youth Ice Hockey (i.e., removing the body check) resulted in a reduction of injuries and concussions.

The way forward

Injury prevention must be the priority when considering the current concussion crisis in sport.  However, if the Rugby Football Union is committed to education about tertiary care of brain trauma at this stage, programmes should specify mandatory annual participation for the rugby workforce, with comprehensive evaluations of their effectiveness simultaneously undertaken. Although unlikely to be as effective as altering the structure of the sport (e.g., moving from contact rugby to touch rugby in schools), such changes may help to reduce the risk of concussion in youth rugby, while maintaining the cardiovascular and psychosocial health benefits offered by participation.

Conflicts of interest: None to be declared.


Adam White [] @AdJWhite, is a doctoral researcher at the University of Winchester and founding member of the Sport Collision Injury Collective. He also sits on the committee of the England Rugby Football Schools Union.

Dr. Tim Gamble [] is a Senior Lecturer in Psychology at the University of Winchester. His main research interest is investigating risk and protective equipment, specifically the unintended consequences of safety equipment provision.

John Batten [] @JBatz85 is a senior lecturer in the Department of Sport and Exercise at The University of Winchester where he is currently programme leader for the BSc/MSci (Hons) Sport and Exercise Science.

Cutting sporting Australians to their knees: time for more investment in sports injury prevention

29 Jun, 16 | by BJSM

By David Hunter, Florance and Cope Professor of Rheumatology

Australia flagAustralians’ passion for their favourite sporting pursuits is almost unmatched by any other country throughout the world. We pride ourselves on our sporting heritage and the records that our minnow sized population has been able to achieve in an ever expanding sporting world. Not detracting from the importance of physical activity, our love for sport is counterposed by the risks inherent in not practising sport safely.

How common is this problem?

Every year approximately 20,000 Australians tear the main ligament in their knee and about half of those require reconstruction. The major burden of these injuries is amongst our young adults (15 to 25-year-olds) and this appears to be rising at about 5 to 6% each year. These injuries appear to be more common in females potentially as a consequence of anatomical and physiological differences. They are so common they now lead to five times more hospital admissions than road injuries.

What are the consequences?

Separate from the pain and diminished sports participation, knee injuries can also lead to reconstructive surgery, osteoarthritis and potentially, joint replacement. Thirty to forty per cent of participants experiencing a major sports-related injury will discontinue playing sport and/or will significantly reduce their physical activity levels. Approximately 60% of young persons who sustain a knee injury will develop osteoarthritis within 10 to 15 years.

This can be prevented

Robust evidence supports that over half of these injuries could be prevented if young people received appropriate balance and agility training. This training teaches them how to land properly on their knee and move so that the potential for injury is not sustained. A preventive training program should include exercises that are done 2-3 times a week over the course of the entire season, take no more than 15 minutes to complete, and can be incorporated by coaches into regular training sessions. Many forward thinking countries around the world have implemented such training programs with great success. An Australian sports injury prevention program targeting all 12 to 17-year-olds and high risk 17 to 25 – year -olds would cost $1 million per year and cut future public health costs by $120 million over four years.

An effective response to sports injury prevention is now needed in order to make sport safe for all participants and reduce the later community burden of osteoarthritis. Sport has many salutary benefits and we strongly encourage increased “safe” participation in sport. The major sporting codes are all on board and we need funding to ensure the Australian sports commission can train coaches and trainers properly in implementing these sports injury prevention programs. Discussions have been had with the respective federal sports/health ministers of successive Labor and conservative governments without success. Will Smith’s recent movie appropriately highlighted concerns related to concussion and the threat of litigation for the NFL. Young sporting Australians deserve the right to practice sport safely-our mutual love for sport supports that wish.


Physiotherapy’s role in an adolescent multi-sports environment: what’s tape got to do with it?

24 Sep, 15 | by BJSM

Association of Chartered Physiotherapists in Sports & Exercise Medicine blog series @PhysiosinSport

By James Boyd

physio 2 2015 Well, what a fantastic few days I’ve had recently. I’ve not long returned from working at the 2015 Sainsbury’s School Games, and am proud to have shared company with a wonderful plethora of athletes, coaches, doctors and physiotherapists. This was my second year at the games and this time around, I found myself working with fellow physio and frequent blogger for the BJSM, Sam Blanchard (@sjbphysio_sport). Whilst there isn’t much down time in this environment, there is always time for discussion. One such chat between Sam, myself and the rest of the team got me thinking: what is the physiotherapist’s role in an environment such as the School Games?

physio sep 2015The annual School Games event sees approximately 1600 athletes aged 13-18 years of age, competing across various sporting disciplines, over a three-day period. For the medical team this is a busy 72 hours, with plenty of assessments being undertaken and lots of new faces, each with their own complex histories and idiosyncrasies. So how can we be the most effective?

Well, for starters we need to ensure that we are performing the basics to a high standard. Thorough subjective and objective assessments need to take place with our detective’s hats on, so we can wean out any possible ‘nasties’ or serious pathologies. These could range from osteosarcomas to a previously undiagnosed stress response. It is also worth taking note of the possibility of apophyseal avulsions in the adolescent athlete. But let’s assume that we’ve managed the basics well and we are left with those generalized aches and pains that any athlete will present with. Those that are not life or limb threatening, but are a day to day issue with athletes who train and compete for many hours each week.

Here’s an example from this year’s games: A 14 year old male athlete entered the make-shift medical clinic (the changing rooms), complaining of vague soreness in his knees. This had been ongoing for a couple of weeks and had been linked with an increase in training load in prep for the competition. Upon observation he was covered in tape from top-to-toe. He assured me that he was not sponsored by a leading kinesiology tape brand, but I was dubious. Three strips around each knee, lines up and down his ITBs, and some obscure technique running across his lower back. When asked who had implemented the taping he confessed that he had self-applied, but had based what he’d done on the techniques he had been shown by physios in the past.

“Do you think you need all that tape on?” I asked.

“Umm, I think so?” He replied with a questioning inclination.

“Do you think it helps?” My second line of inquisition.

“Umm, I think so” His response came with a pondering pause prior.

“Do you think it will help your pain or performance?” My third line of questioning.

“Umm, maybe” He replied.

I can’t promise that this was verbatim, but that was the gist of the conversation, and with it I aim to highlight the impact that previous physiotherapy input has had. At this stage I hasten to acknowledge that there are, of course, other contributing factors, such as the influence of peers and role-models who are seen sporting the same tapes, the effect of marketing strategies of the tape companies, and many more. But he has been shown how to perform these techniques by other physios and they have been remembered, to the point where he is applying the tape with no known knowledge as to what it does, or why he’s even using it. He just feels that he needs it, and has become reliant on wearing the tape. I am not questioning the role of taping (that’s a new blog topic altogether), neither am I questioning the quality of the previous physio input (as any athlete will come away with only a few key messages from a session and in this case, it may have been the tape that stuck – excuse the pun!). However, by contributing in such a way, are we helping to build strong, robust athletes or those reliant on external factors?

Predictably enough, this athlete was a repeat user of the physiotherapy service during the 3 days of games. Each time presenting with fatigue based aches and pains – expected after four to four and half hours of repeated jumping and landing per day. He frequently asked for rub downs and taping to help him get through the tournament and with time restraints as they are in such an environment, it would be very easy to slip into auto pilot and give him some therapeutic hands on work. However, what followed was a dose of education and reassurance that his own body and mind were resilient structures that could withstand the rigors of the sport and perform at a high level. Whilst he may have left unsatisfied without his rub down, he went on to medal with his team at the games, and I can only hope that this experience went some way to reassuring him that he could still perform, even without his taping/soft-tissue work.

As a team we pondered if there was something underlying that we were missing, but we realized that this 14 year old athlete had simply been institutionalized into the world of physiotherapy. He had become reliant on his tape and massages, with very little education as to how he can self-manage some of the rigors of training independently. I would argue that the child/adolescent athlete should be empowered to manage their own bodies, as opposed to feeling dependent on techniques that they may not always be able to access. I pose that if we are not considerate with our wording and actions as physiotherapists, we will nurture a generation of athletes (and on a bigger picture, adults) who are reliant as opposed to resilient, and may not be able to self-manage.

As elite programs for the young athletes develop and a greater number of kids are exposed to the pressures of high level sport, the medical profession must identify that we are not working with young adults. This completely different client group requires a different skill set. It is my belief that as part of our practice to the developing athlete, we need to instill good habits, educate and most importantly, empower them to become the best that they can be.

physio three

Signing out,

James Boyd


James is a Physiotherapist at the University of Bath and acts as the Lead Physiotherapist for the Southampton FC Satellite Academy and the University Badminton set-up. He is currently setting up the Team Bath Physiotherapy and Sports Science Podcast, so watch this space!! Follow him on Twitter @jimmypboyd

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