Domhnall MacAuley: Top ten sports medicine publications in the last year

Domhnall MacauleyThe top ten publications of the last year in sport and exercise medicine? It is inevitably, a personal choice and I selected these papers because they challenge, educate, and question current practice.

Some papers—great papers—that didn’t quite make my top ten: Sudden deaths among competitors in big city marathons always prompt media soul searching. It is reassuring, therefore, that a paper in the New England Journal of Medicine found the incidence rate of cardiac arrest to be 0.54 per 100,000 participants. I enjoyed another paper in a later issue of the same journal showing that Tai Chi (which in his blog Richard Lehman compares to slow disco dancing) helps patients with Parkinson’s Disease. I am interested in the application of the principles of sport and exercise medicine into mainstream medicine and found a meta analysis in Circulation:Heart Failure showing that testosterone supplementation might improve functional capacity in heart failure patients particularly intriguing.

And the top ten:

10. Those with an interest in young people’s sport will take heart from a systematic review from the Netherlands in Archives of Paediatrics and Adolescent Medicine that suggests that sport may improve academic performance.  The methodological quality of the studies was not ideal but they found a significant longitudinal positive relationship between physical activity and academic performance.

9. Anterior cruciate injuries are a major problem in football; is there any way to reduce injury? An RCT of a preventive neuromuscular warm-up programme (targeting core stability, balance, and proper knee alignment), published in the BMJ, might give us cause for optimism. There was a reduction but, due to the overall small numbers of injuries, the results were not statistically significant. But, what is remarkable about this paper was that they were able to bring 230 football clubs into the trial and follow them for an entire season. Do other countries have this level of cooperation with sports clubs?

8. Rapid return to sport is the goal of rehabilitation. But, could we be allowing patients to return too soon? A letter in the American Journal of Sports Medicine should, perhaps, make us stop and ask ourselves if we are allowing athletes, under pressure from the media and coaches, family members and patients, to return to sport before adequate tissue healing. “Tissue healing takes time” they say “and surgeons must learn to be patient.”

7. The Olympics pushed even mainstream medical journals to focus on exercise. The Lancet published a series on the benefits of physical activity prompting UK media horror that perhaps Britons may take even less exercise that Americans. I liked their conclusion that to increase global physical activity we need a systems approach that focuses on populations and the complex interactions among the correlates of physical inactivity, rather than solely a behavioural science approach focusing on individuals. This leads nicely into the next paper.

6. How do we encourage people to take exercise? One of my personal concerns is the apparent push to make exercise a medical problem. While inactivity undoubtedly creates many health problems, health may not offer a solution. Exercise prescription seemed to offer an easy answer, but two papers in the BMJ show that physical activity promotion through primary care is relatively ineffective. The first, a meta analysis of eight randomised controlled trials of exercise referral schemes and the second, a meta analysis of fifteen randomised controlled trials of physical activity promotion in primary care. Thirty years ago I wrote a passionate piece in favour of exercise promotion in general practice. I am no longer as certain.

5. It seems you are never too old to train. A BMJ paper from Australia showed that, of three home based interventions, a lifestyle integrated approach to balance and strength training was effective in reducing the rate of falls in older, high risk people living at home. There was a significant reduction of 31% in the rate of falls, with improvement in static balance, ankle strength, function, and improvement in dynamic balance. The lifestyle intervention was compared to standard structured exercises and a sham programme. While the study targeted patients aged 70 or older, the mean age of participants was more than 82 years.

4. Epidemiologists have long been interested in the benefits of physical activity in cancer prevention but there is now a body of research on the benefits of physical activity in cancer survivors.  A meta analysis published in the BMJ, included 34 RCTs, of which those 22 that focused on breast cancer identified improvements in, bench press, leg press, fatigue, depression, insulin-like growth factor-I, and quality of life. Looking at combined studies on different types of cancer, there were significant improvements in body mass index (BMI), body weight, peak oxygen consumption, peak power output, distance walked in six minutes, right handgrip strength, and quality of life.

3. A RCT of  facilitated physical activity as a treatment for depressed adults provoked widespread international media attention and a remarkable reaction from our readers of the BMJ. When I looked at the metrics this week there had been 31 rapid responses with an unprecedented number of downloads and full paper accesses. It was a negative trial but, there was considerable debate as to what the study actually tested. It was advice to increase activity that was ineffective rather than exercise itself.

2. The rehabilitation after myocardial infarction trial (RAMIT) and accompanying editorial challenged my views on cardiac rehabilitation.  Comprehensive rehabilitation following MI had no important effect on mortality, cardiac or psychological morbidity, risk factors, health-related quality of life or activity and questioned the value of cardiac rehabilitation as practised in the UK. David Wood, in his linked editorial, asked if cardiac rehabilitation in the UK was fit for purpose? Not everyone agreed and the correspondence is fascinating.

1. With my interest in evidence based sports medicine, you will understand why I chose the BMJ of July 21st , the combined series of papers in BMJ Open, the analysis piece by Deborah Cohen and the BMJ– Panorama collaboration as my number one. More than any contribution to the sports medicine media it challenged athletes, coaches, sports science, and industry. These linked publications and television documentary ask about the value of sports drinks, and the evidence underpinning many products  promoted to help sports performance, really made you think. In sports medicine, perhaps more than any other aspect of healthcare we need to ask: How good is the evidence?

This blog forms the basis of an address to the Faculty of Sport and Exercise Medicine at the Royal College of Surgeons in Ireland on 28 Sept.

Acknowledgements: Richard Lehman’s weekly blog, together with Research News and Minerva from the BMJ, were very helpful. I also wish to thank Leon Creaney for his suggestions and regular research update on twitter.

Domhnall MacAuley is primary care editor, BMJ