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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

2014 Paralympic School Games in Brazil: Beyond expectations for personal and professional learning as team doctor

24 Dec, 14 | by BJSM

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

By Dr Guy Evans

paralympic 1

Team GB Paralympic Squad and support staff for the Brazilian Paralympic School Games 2014

Fortunately, I was invited as team doctor for the Great Britain (GB) Paralympic team at the 2014 Paralympic School Games in Brazil. Although I have travelled to a number of international championships with the GB rowing team, this was my first experience with Paralympic sport, and it was wonderful. There were plenty of lessons learned both medically and personally – perfect for sharing on the BJSM blog!

Pre-travel preparation

As a first task prior to travel, I collected staff and athlete pre-trip medical information to ensure vaccinations were appropriate and to learn more about the athletes disabilities and medications. I am quite used to receiving pre-participation forms from able-bodied (AB) athletes, which typically consist of the occasional medication alongside a usually modest past medical history (clearly there are some exemptions to this rule!). However, I quickly realised that the medical complexity of the Parasport athletes provided a much higher medical challenge than their AB counterparts. The mixture of medical problems included: visual impairment, learning difficulties, Erb’s palsy and congenital abnormalities. There were also significant medication lists, some of which were on the WADA anti-doping prohibited list. As a consequence, I quickly clarified with the organising committee whether there would be anti-doping tests taking place at the Games and if so whether prospective Therapeutic Use Exemption (TUE) forms were required for such medications. I was assured that anti-doping officials would be present to provide information rather than in a testing role. I also had to ensure that athletes had prescription lists and doctor letters on their person during travel should they be questioned during airport security. One of the squad was taking an opiate-based medication, requiring further inquiries with Brazilian authorities to ensure that these medications would be allowed through customs. Once this was all complete and appropriate immunisations were up to date, we set off for Brazil on the 23nd November!

Environmental and procedural challenges at the games

On arrival in São Paulo, the heat was one of the first challenges the athletes faced (alongside the language barrier and the local traffic). The temperature consistently rose from around 20 degrees Celsius to 30+ Celsius during the hottest parts of the day. Sun cream application was crucial to prevent burning and required constant input from staff and medical team to help those athletes who were unable to apply cream sufficiently due to their disability. By the end of the trip, it was second nature for athletes to work together to get those hard to reach areas, and this genuinely helped the athletes bond!

My first challenge on arrival at the venue in São Paulo was unanticipated. I had to complete a medical declaration for each athlete, signed by myself along with my GMC number. After submitting the forms, I surprisingly heard that the organising committee required proof that I was in fact a REAL doctor, much to the amusement of the two GB physiotherapists! It turns out that in Brazil every REAL doctor has a ‘stamp’ which they use on official documents and that my GMC number accompanied by a screenshot of the GMC website demonstrating my current registration was no match for an official stamp! After much negotiation and providing numerous supporting documents, they eventually believed me and accredited all of the athletes….phew!

On the ground preparation for competition

The first two days of the trip included training and acclimatisation. Competition started on day three and four. This gave the athletes time to see the venues (swimming and athletics) and to adjust after the 12-hour flight. Unfortunately on day 2, an athlete who displayed symptoms of a viral gastroenteritis awoke me in the middle of the night. We effectively isolated him in a separate room and contained the outbreak without any further spread. However, the athlete was unable to compete on the first day of competition. Fortunately, he recovered well to win a silver medal later in the competition!

adapted start block

Gold medallist James Arnott (left sided Erb’s palsy) – 100m and 200m sprinter using adapted start block

The athletes (aged 14-17yrs) were all incredibly successful when competing in a number of disciplines within swimming and athletics. They were all on funded training programmes through Talented Athlete Scholarship Scheme (TASS) and had significant weekly training loads. Many of the swimmers typically covered 50-60km swimming per week. This kind of training programme coupled with the talent of the GB athletes was no match for many of the Brazilian athletes; team GB walked away with 15 gold medals, 4 silver medals and 2 bronze medals. An extremely impressive medal haul!

Although the GB athletes all performed phenomenally well, one performance from a Brazilian athlete has stuck in my mind. This was a swimmer named Eli. She won gold in the 200m breaststroke, a commendable result for any athlete. However, Eli was the only athlete with no arms as a result of a congenital defect in the 200m final. It was inspiring to watch her win her gold with such a significant ‘disability’. At the start of the race she used a towel clinched by her teeth to get set in to the start position as she was not able to grasp the start blocks with her arms. Once the race began, she released the towel. The stamina of her leg kick through 200m was incredible, ‘bouncing’ herself of the kick boards at each end of the pool to turn. Eli’s performance in the pool was a perfect example of what one our GB athletes said to me during the trip: ‘I have learned to know my ability, not my disability’ It certainly made me reflect on the ‘limiters’ in my life and how these faded in to insignificance after watching Eli’s enabling performance.

eli technique to post

Eli demonstrating her technique for the start of the breaststroke 200m during her gold medal winning performance

eli w coach

Physiotherapist Mike Chello with Eli before competition (complete with new goggles that he kindly donated to her!)

Myself and the two physiotherapists did our best to provide a ‘professional experience ‘ for the athletes, many of whom had never before been abroad for a competition. Fortunately we did not experience any major medical issues outside the realms of a normal competition. We did however instigate morning monitoring and gave tips of how an athlete might optimise performance and recovery. This improved their understanding of how to create the best environment for success in competition and may help sow seeds for even more medal winning performances in Rio 2016!

We flew back the day after the closing ceremony, although my duties were not done, as I was called into action on the plane as a passenger collapsed just down the aisle from me! Never a dull moment! Fortunately it was a mere vasovagal and my upgrade to first class disappeared with the discovery of such an unexciting diagnosis.

w mascot

An opportune meeting with the newly unveiled Paralympic mascot (yet to be formally named)

Reflecting back on the trip, I genuinely found the whole experience very enlightening, personally and professionally and I gained a lot of medical insight for working and traveling as a team. Overall, the attitude of the athletes combined with the inspiration of the coaching staff really was fantastic. On a personal level, it reappraised my attitude to the words ‘I can’t’.

I encourage anyone working in the field of Sport and Exercise Medicine to get involved with Parasport, and I thank TASS for providing the opportunity to be part of such a great team.




Dr Guy Evans is a Sport and Exercise Medicine Registrar in the West Midlands. He is currently the Great Britain U23 rowing team doctor, match day Doctor for Worcester Warriors Rugby and works as a British Boxing Board of Control Medical Officer. He is a competitive triathlete and has represented GB at the ITU Long Distance World Championships.

Dr Farrah Jawad is a Sport and Exercise Medicine Registrar in London and coordinates the BJSM Trainee Perspective Blog.

A Global Fail? International Comparisons of Physical Activity of Children and Youth Report Cards

24 Jun, 14 | by BJSM

By Dr. Christine Voss (@DrChristineVoss)

Originally posted on the Active Streets Active People blog:


The 2014 Global Summit on the Physical Activity of Children recently brought together researchers, practitioners and policy makers to address the growing childhood physical inactivity crisis. There was an impressive agenda of scientific communications, workshops, debates, networking opportunities, and key note addresses. Notably including health knowledge translation phenomenon Doc Mike Evans (Watch his latest viral video: Let’s Make our Day Harder).

The Physical Activity Report Cards

One of the key highlights of the summit was the release of the 10th Report Card on the Physical Activity of Children and Youth (1), an important knowledge translation tool to inform policy and practice relating to Canadian children’s low physical activity levels. Alongside overall physical activity, supportive indicators that are scored in the report card include: Organized Sport Participation, Active Play, Active Transportation, Sedentary Behavior, Family and Peers, School, Community and Built Environment, and Government Strategies and Investments.

This year for the first time, 14 additional countries, from 5 continents, collaborated to publish their individual, yet similar, physical activity report cards (see Figure 2). Most countries scored relatively poorly for overall physical activity levels; however substantial differences in countries’ individual indicators exist. The international comparison of grades shocked mainstream media and produced headlines such as “Canadian kids near bottom of international physical activity survey” (The Globe and Mail, 20 May 2014; (3)).

Whilst the report fuels further, and necessary, debate over the global physical inactivity crisis, one must still take the findings with a grain of salt. For example, the report compares only 15 countries; 3 out of the 4 participating European countries were from the British Isles. There is disparity between each country’s gathering of information to grade each indicator; this depended on the available type of nationally representative datasets. Full methodologies for each country are available in an open access edition of the Journal of Physical Activity and Health (4).

Is it all about active transportation?

The international comparisons of different countries report cards sparked my curiosity for identifying significant patterns. I wondered whether a good grade in any of the supporting/hindering indicators relates to a good grade for overall physical activity. I assessed these relationships and found that only two of the indicators were meaningfully related to overall physical activity: ‘Active Transportation’ and ‘Community and Built Environment’ (Figure 2).

We already know from a wealth of scientific research that children and youth who walk or cycle to school are more physically active (5), so this finding is not all that surprising. We also know that a supportive neighbourhood environment is related to more physical activity in children and youth (6), so it was unexpected to learn that countries with a better community design score also scored lower for overall physical activity. It is of note that it is predominantly high-income countries that scored well on community design, which highlights that maybe we are comparing apples with oranges in the international report card: what matters a lot in some places, matters little – if at all – in other places. Regardless of methodological shortcomings, international comparisons carry great potential for identifying underlying CULTURAL differences that may be culprit or cure for the global physical inactivity pandemic.


Figure 2

All conference abstracts are accessible in an open access edition of the Journal of Physical Activity and Health (HERE) (7).


Want more on this topic? Read BJSM’s recently published (open access) article:  Is the lack of physical activity strategy for children complicit mass child neglect? By Richard Weiler.


  1. 2014 Report Card on the Physical Activity of Children and Youth: Is Canada in the Running?
  1. Tremblay et al. Physical Activity of Children: A Global Matrix of Grades Comparing 15 Countries. 2014, J Phys Act Health, 11(Supp 1), S113 – S125;
  1. Global Summit on the Physical Activity of Children 2014 Special Issue. 2014, J Phys Act Health. 11(Supp 1), S1-S207.
  1. Larouche et al. Associations between active school transport and physical activity, body composition, and cardiovascular fitness: a systematic review of 68 studies. 2014, J Phys Act Health. 11(1):206-27. doi: 10.1123/jpah.2011-0345
  1. Ding et al. Neighborhood environment and physical activity among youth a review. 2011. Am J Prev Med. 41(4):442-55. doi: 10.1016/j.amepre.2011.06.036
  1. 2014 Global Summit on the Physical Activity of Children: Abstracts. 2014, J Phys Act Health, 11(Supp 1), S126 – S198;


Dr Christine Voss (@DrChristineVoss) is a post-doctoral research fellow at the Centre for Hip Health and Mobility, University of British Columbia in Vancouver, Canada. Her research interests centre around the interplay between active travel to school, the built environment, and health in children and youth.

Seeing patients today? “Heart healthy” exercise advice can be a life saver for men, women and children via @exerciseworks

26 Feb, 14 | by BJSM

@exerciseworks guest blog series on physical activity and cardiovascular health: Part 2

Heart disease is the leading cause of death for both men and women.

exercise works 2Reduction of heart disease risk in patients is significantly linked to modifiable factors (such as tobacco use, poor diet, physical inactivity, obesity, alcohol use) or factors that can be changed to reduce the risk of further ill health and heart disease (such as appropriate blood pressure control, lipid management and the availability of essential medicines and technologies to treat cardiovascular disease). More than half of the deaths worldwide (due to heart disease) are in men.

Physical inactivity is a major contributor to all types of cardiovascular disease risk- yet regular physical activity can help maintain a healthy weight, lower cholesterol and blood pressure, and help reduce the risks associated with an inactive lifestyle. Children who are inactive are also at risk of developing heart disease and stroke risks earlier in life. A simple solution, you would think, such as helping each of your patients to exercise more, would and should work!

Providing physical activity advice and support to every patient, is an essential part in the prevention and treatment of all aspects of heart disease and stroke health care.  The World Health Organisation is clear on the physical activity message:

Every adult needs to enjoy physical activity for at least 150 mins a week:

  • Adults aged 19–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.
  • Aerobic activity should be performed in bouts of at least 10 minutes duration.
  • For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.
  • Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

An exercise prescription can include walking, hiking, swimming, dancing, running, jogging, sports and gym activities, or physical activities in leisure time also help to promote heart health!

Every child and teenager needs to enjoy active play and opportunities to exercise:

  • Children and youth aged 5–17 should accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity daily.
  • Amounts of physical activity greater than 60 minutes provide additional health benefits.
  • Most of the daily physical activity should be aerobic. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone*, at least 3 times per week.
  • *For this age group, bone-loading activities can be performed as part of playing games, running, turning or jumping.

The exercise ‘prescription’ for children and young adults should emphasise active play, fun, inclusivity and less sitting.

Health professionals are skilled at supporting patients to make the right choices for their best health outcomes. There is no better preventative medicine that you can prescribe than to help encourage and support your patients to exercise daily!

The clinical benefits of regular physical activity on cardiovascular risk factors for patients have been well reviewed but you can summarise for patients as:

  • able to exercise more: regular exercise increases exercise tolerance and stamina
  • reducing body weight: a loss of just 5 to 10 percent of weight can lower your patient’s risk of coronary heart disease. Regular exercise advice together with a healthy eating programme can help your patients achieve this. Many people may need more than 150 minutes/week of moderate intensity activity a week to stay at a stable weight, as well as to lose weight or keep off weight they have lost. (U.S. Dept. of Health and Human Services. 2008 Physical Activity Guidelines for Americans, 2008)
  • a lowering in blood pressure: the average reduction in blood pressure ranges from 7.4mm to 5.8mm Hg in hypertensive study patients
  • reduction in ‘bad’ (LDL and total) cholesterol
  • increase in good (HDL) cholesterol
  • increase in insulin sensitivity: both aerobic and resistance training improve insulin action, blood glucose control, and fat oxidation and storage in muscle. This means that the risks of developing metabolic disorders and type 2 diabetes are significantly reduced with regular physical activity

And finally, as I’m a British Association Cardiac Pulmonary Rehabilitation exercise instructor….

Cardiac or stroke rehabilitation programmes (cardiac rehab) reduce the risks of a further cardiac event by stabilizing, slowing or even reversing the progression of cardiovascular disease. In the USA, only 14-35% of heart attack survivors and only 31% of coronary artery bypass surgery participate in a cardiac rehab programme. In the UK, the average attendance rate post cardiac event is 43%.

Please support, advise, engage, signpost, enable, encourage, prescribe, refer and educate patients as to the benefits of attending their local cardiac rehabilitation programme- it is life-saving medicine after a cardiac event and continuing as a lifelong prescription. Every patient should be able to access cardiac rehabilitation programmes locally, and bespoke to their cultural needs.

In summary: heart healthy exercise prescriptions are critical care medicine at their finest. Let’s start prescribing exercise and fun, physical activities and monitoring our patients at risk of heart disease, every consult they attend, and at every opportunity in their health care pathway!

And remember….. refills and repeat prescriptions of this life saving prescription are on a weekly basis of 150 minutes/week, but review as a ‘vital sign’, every consult!


Ann Gates BPharm(Hons) MRPharmS

Founder of Exercise Works! in celebration of World Heart Month February.

Member of the WHF Champion Advocates Programme – Emerging Leaders Programme.

Info graphics courtesy of the World Heart Federation Champion Advocates Programme.


Bizarre breaking news: Government finally releases a strategy for childhood physical activity using it as punishment. Early April fool, ignorant Olympic legacy or plain clueless?

8 Feb, 14 | by BJSM

By Richard Weiler, Sam Allardyce, Greg Whyte, Emmanuel Stamatakis

This week the UK government Department of Education has released a new strategy to improve school discipline, including the alarming strategy that physical activity should be used as punishment, recommended (on page 8) as running laps around school playing fields (READ FULL STRATEGY HERE).

Another defining moment from Mr Michael Gove’s Department of Education. Especially as he himself has continued the path of previous governments by approving the selling off of these same school playing fields, so that even fewer children now have playing fields to be punished with. Even Her Majesty’s Prisons have a better understanding of the use of physical activity for health and mental well-being.

We urge Mr Gove, his advisors and colleagues at the Department of Education to read our recent report in BJSM to help them understand the gravity and dire need for a national physical activity, physical literacy and physical education strategy for children, which involves greater access, options for participation and crucially enjoyment of a variety of forms of physical activity (not just sport) for school children. The protection of safe environments for children to enjoy active play is also critical, including playing fields at schools, where children spend most of their week in state care. Using physical activity as a form of enforced negative punishment will not help these children develop a positive and fun relationship with physical activity to maintain into adulthood.

Please let us know what you think:





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