BJSM Podcast

Do you want to get your athletes with an acute hamstring injury back to play as quickly as possible, without the risk of a recurrence? Should you include lengthening exercises, trunk stabilisation, Nordic curls or PRP injections? Are you searching for a comprehensive, evidence-based update? This 10-minute podcast will answer all your questions. BOOM! Eminent sports physician Johannes Tol asks the hard questions. Sports physician Haiko Pas provides answers based on his recent systematic review & meta-analysis on hamstring rehab programs and PRP injections. Time codes: Optimal treatment for a quick return to play (2.30 min), re-injury reduction (3.50min) and the added value of PRP injections (6.20min). The podcast finishes with three evidence based take home messages for the clinician dealing with acute hamstring injuries (8.20 min). Links: Pas H, Reurink G, Tol JL, Weir A, Winters M, Moen M. Br J Sports Med 2015 (BJSM issue 18) Efficacy of rehabilitation (lengthening) exercises, platelet rich plasma injections and other conservative interventions in acute hamstring injuries: An updated systematic review and meta-analysis. http://bjsm.bmj.com/content/early/2015/07/21/bjsports-2015-094879.abstract Brukner P. Hamstring injuries: prevention and treatment—an update. Br J Sports Med. 2015 Jun 23. pii: bjsports-2014-094427. doi: 10.1136/bjsports-2014-094427. [Epub ahead of print] http://bjsm.bmj.com/content/early/2015/06/23/bjsports-2014-094427.long Hamilton B, Tol JL, Almusa E, Boukarroum S, Eirale C, Farooq A, Whiteley R, Chalabi H. Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. Br J Sports Med. 2015 Jul;49(14):943-50. doi: 10.1136/bjsports-2015-094603. http://bjsm.bmj.com/content/49/14/943.long Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. Br J Sports Med. 2015 May 20. pii: bjsports-2015-094826. doi: 10.1136/bjsports-2015-094826. [online first and issue 22] http://bjsm.bmj.com/content/early/2015/05/20/bjsports-2015-094826.long Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, Maas M, Tol JL; Dutch HIT-study Investigators. Rationale, secondary outcome scores and 1-year follow-up of a randomised trial of platelet-rich plasma injections in acute hamstring muscle injury: the Dutch Hamstring Injection Therapy study. Br J Sports Med. 2015 May 4. pii: bjsports-2014-094250. doi: 10.1136/bjsports-2014-094250. [Epub ahead of print] http://bjsm.bmj.com/content/early/2015/05/03/bjsports-2014-094250.long

Consider the classic understanding that high carbohydrate intakes are necessary for optimal endurance performance. What if that failed to take into account the physiological changes that occur with adaptation to low carbohydrate diets? In this podcast, @JohannWindt interviews physician-researcher Dr. Stephen Phinney about his last 30 years of research into low-carb ketogenic diets. Highlights include the previously undocumented levels of during exercise fat oxidation seen in endurance athletes adapted to a low carbohydrate diet. He also touches on ketogenic diets’ potential benefits in other sporting contexts, addresses common criticisms, and looks ahead to future research questions in the field. Further reading and papers discussed in the podcast are included below. Vermont and MIT Study Dr. Phinney’s original two studies on low carbohydrate performance. Original two low carb performance studies. http://www.metabolismjournal.com/article/0026-0495%2883%2990105-1/abstract http://www.ncbi.nlm.nih.gov/pmc/articles/PMC371554/ Phinney SD et al. The human metabolic response to chronic ketosis without caloric restriction: physical and biochemical adaptation. Metabolism 1983;32:757-68. http://www.metabolismjournal.com/article/0026-0495%2883%2990105-1/abstract Phinney SD et al. capacity for moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet. J Clin Invest 1980;66:1152-61. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC371554/ The gymnast study mentioned in the podcast: Paoli et al. Ketogenic diet does not affect strength performance in elite artistic gymnasts. J Int Soc Sports Nutr 2012; 9: 34. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411406/ Significant decrease in inflammation shown in low carb diets by Forsythe, Phinney, et al.Comparison of low fat and low carbohydrate diets on circulating fatty acid composition and markers of inflammation. Lipids 2008;43:65-77. http://link.springer.com/article/10.1007/s11745-007-3132-7?no-access=true Prof Phinney’s recent BJSM Editorial: Noakes T, Volek JS, Phinney SD. Low-carbohydrate diet for athletes: what evidence? Br J Sports Med 2014 http://bjsm.bmj.com/content/early/2014/05/26/bjsports-2014-093824.extract Prof Phinney and Volek’s website– Art and Science of Low Carbohydrate Living/Performance http://www.artandscienceoflowcarb.com/ In the August 2015 issue of BJSM you’ll find a series of paper on weight loss and physical activity: http://bjsm.bmj.com/content/49/14.toc Dr Aseem Malhotra’s paper: It’s time to bust the myth of physical inactivity and obesity: you can’t outrun a bad diet (if you want to be thin) http://bjsm.bmj.com/content/49/15/967.full (OPEN ACCESS) Coauthors are Professor Phinney and Professor Timothy Noakes. Professor Stephen Blair’s rebuttal: Physical inactivity and obesity is not a myth: Dr Steven Blair comments on Dr Aseem Malhotra's editorial http://bjsm.bmj.com/content/49/15.toc Professor Kamal Mahtani’s editorial: Physical activity and obesity editorial: is exercise pointless or was it a pointless exercise? http://bjsm.bmj.com/content/49/15/969.extract Two relevant BJSM podcasts include: 1) Professor Tim Noakes interviewed by Professor Peter Brukner http://ow.ly/PQlld 2) Dr Aseem Malhotra discussing the debate around his editorial above http://ow.ly/PQlNL BJSM editors appreciate that nutrition is a controversial issue (not sure why, but that’s OK) so please note the Prof Phinney’s competing interests are listed in http://bjsm.bmj.com/content/49/15/967.full BJSM revels in debate and publishes quality material. Hence, you can see divergent views represented above and we have commissioned an editorial from respected scientists who feel that protein, or carbohydrate, deserves greater prominence. You submissions are welcome via the BJSM’s various channels – ‘print’, rapid response, blog, Google plus community, twitter, Facebook. Or email karim.khan@ubc.ca

Many athletic events, such as the current Wimbledon Tennis Championships, are staged in hot to very hot environmental conditions. Clinicians should be aware of the risks posed to athletes competing under heat stress and how to mitigate them. Dr. Julien Périard is a former successful triathlete and now works at Aspetar, Qatar, as a senior research scientist investigating athletic performance under heat stress conditions. BJSM’s Liam West (@Liam_West) poses questions about what heat illness encompasses, what signs and symptoms to look for and how to take care of athletes. See the 2015 Consensus Statement on Training and Competing in the Heat via BJSM’s Online First http://bit.ly/1CfQLCj The Consensus Statement will be published in BJSM issue 15 which goes live on July 16, 2015 (http://bjsm.bmj.com/) Primary Link; Racinais S, ..., & Périard J. (2015). Consensus recommendations on training and competing in the heat (Online First) - http://bjsm.bmj.com/content/early/2015/06/11/bjsports-2015-094915.abstract?sid=4f2f6068-8857-4c4b-ba0e-143084d62ff0 Other reading: April 2014, Volume 48, Supp 1 – Heat Stress & Tennis Performance - http://bjsm.bmj.com/content/48/Suppl_1.tocBergeron MF. (2008). Muscle cramps during exercise - Is it fatigue or electrolyte deficit? Curr Sports Med Rep7, S50-S55. Périard JD, Racinais S & Sawka MN. (2015). Adaptations and mechanisms of human heat acclimation:- Applications for competitive athletes and sports. Scand J Med Sci Sports25, 20-38. Girard O, Brocherie F & Bishop DJ. (2015). Sprint performance under heat stress: A review. Scand J Med Sci Sports25, 79-89. Sawka MN, Leon LR, Montain SJ & Sonna LA. (2011). Integrated physiological mechanisms of exercise performance, adaptation, and maladaptation to heat stress. Compr Physiol1, 1883-1928. Book chapter: Leon, LR and Kenefick, RW (2011). Pathophysiology of Heat-Related Illnesses. In: Wilderness Medicine. Ch 10. Auerbach, PS (Ed) http://www.dtic.mil/dtic/tr/fulltext/u2/a559070.pdf Blogs: Thermal perception as a controller of exercise intensity - http://blogs.bmj.com/bjsm/2012/04/28/cool-it-so-is-thermal-perception-a-controller-of-exercise-intensity-during-heat-stress/ Prevention of heat illness – part one - http://blogs.bmj.com/bjsm/2011/03/24/evidence-based-considerations-for-the-prevention-of-heat-related-illness-in-marathon-training-part-1/ Prevention of heat illness – part two - http://blogs.bmj.com/bjsm/2011/03/25/evidence-based-considerations-for-the-prevention-of-heat-related-illness-in-marathon-training-part-2/

Dr Mike Bergeron, Chair of the IOC Consensus Committee on Youth Athletic Development discusses hot topics. Here’s the link to the Consensus Statement (Open Access): http://bjsm.bmj.com/content/49/13/843.full

How can we modify the environment we live in to increase physical activity? Steffan Griffin, junior doctor, BJSM editorial team, talks to Simon Allford, one of the UK's most celebrated architects, and the man behind the design of Google's HQ in London, about how buildings can improve health and activity.

Athletes who suffer from illness are more likely to get injured and they are likely to underperform. It’s messy (vomiting, diarrhoea) but there are guidelines for physios and docs in these roles. Professor. Martin Schwellnus talks to Liam West (@Liam_West) and offers practical tips useful for all members of the medical team. Prof. Schwellnus is director to one of only 8 IOC Research Centres worldwide. He has recently been appointed as Professor Sports & Exercise Medicine by the University of Pretoria, South Africa. Recorded at the IOC Team Physician Course in Doha, Qatar, so you’ll hear a few sounds in the background. #NotBMJStudio Practical tips from an international icon in sports & exercise medicine, who is a member of the Scientific Committee for the 2016 IOC Team Physician Course in Cape Town, (November). Further Links: Prospective monitoring of illness and injury - http://bit.ly/1C2PXLp Sports Injury & Illness at the Sochi 2014 Games- http://bit.ly/1Fd1aJj Injury & Illness for Team GB at Sochi 2014 - http://bit.ly/1GyuRKb Health protection of the Olympic Athlete - http://bit.ly/1BaUhgC Illness in Super 14 Rugby - http://bit.ly/1SazEp7 Injuries & Illness at the FIFA 2010 World Cup - http://bit.ly/1cPTdmB Prevention against illness & Injury in Athletics - http://bit.ly/1Iz7hfP Injuries & Illness at the London 2012 Olympic Games - http://bit.ly/1MvxXyL Factors associated with illness at London 2012 Games - http://bit.ly/1SazEp7 BJSM App iTunes - itunes.apple.com/us/app/bjsm/id943071687?mt=8 Google Play - play.google.com/store/apps/detail…m.goodbarber.bjsm

23 international experts in groin pain were sent two specific cases – one on inguinal region pain, the other – you guessed it – adductor region pain. The heavyweights in groin pain including Holmich, Muschaweck, Ekstrand, Meyers, Tyler, Silvers, Schilders, Thoborg, Brukner, Paajanen, Philippon, Weir, Griffen, Orchard +++. Physiotherapists, sports physicians, surgeons – unique for the diversity of opinions sought. The experts were asked to (i) write down their diagnosis and (ii) suggest initial treatment. How many diagnoses were presented? (Really? 22!! You are kidding, surely). These folks were also invited to work on focused systematic reviews and share their thoughts in person in Doha, Qatar. So far so good. But there’s always a catch! They were then locked in a room with just #LCHF not to come out until there was useful product for clinicians. Adam Weir, MD, PhD, was the driving force behind this effort and he shares what was achieved and how this can help your practice. He also guides you to hours of additional resource material including the Aspetar YouTube channel for the entire World Conference (some links below). If you see patients with groin pain this is a must! Key resources include: BJSM Issue 12, 2015 – Groin pain in athletes: http://bjsm.bmj.com/content/49/12.toc Consensus Statement: Doha Agreement Meeting: http://bjsm.bmj.com/content/49/12/768.full (Weir et al - 23 authors, Open Access) Aspetar YouTube Channel (Google Aspetar, Groin Pain, YouTube for a full list) Adam Weir BJSM podcast part 1 on BJSM (and follow @AdamWeirSports). You are encouraged to tweet your podcast questions to @AdamWeirSports or post on the Google + Sports & Exercise Medicine Community page – a great place to write more than a tweet. All you need is a gmail account.

Do you see football or ice hockey players with persistent pain in the inguinal region? What about players in twisting sports with adductor region pain? Are you still making the diagnosis ‘osteitis pubis’? Are you unsure as to when to order investigations in cases of groin pain? Enough questions – time for answers. Adam Weir, MD, PhD, has more than 10 years’ experience in dedicated clinics treating groin pain in athletes. His sports medicine specialty training was in Netherlands and the past 3 years has seen him work closely with a multidisciplinary team including sports physiotherapists and groin surgeons at the Aspetar Clinic for Groin Pain in Athletes (Doha, Qatar). He discusses the management of the two patients outlined in the two questions above (longstanding pain in the inguinal region, adductor region, in turn). 14 minutes of practical tips – assessment, investigation, specific management. PRP, surgery? No holds barred. What remains unknown. You’ll get the pearls that @AdamWeirSports shared as a keynote speaker at the American Medical Society for Sports Medicine (@TheAMSSM) conference in April 2105. Key resources include: BJSM Issue 12, 2015 – Groin pain in athletes – Table of Contents: http://bjsm.bmj.com/content/49/12.toc 9 systematic reviews most of the Open Access thanks to Aspetar Orthopaedic and Sports Medicine Hosptital, Doha, Qatar – here’s the one on management of groin pain. http://bjsm.bmj.com/content/49/12/813.full (Serner et al., Open Access) Consensus Statement: Doha Agreement Meeting: http://bjsm.bmj.com/content/49/12/768.full (Weir et al - 23 authors, Open Access) Part 2 BJSM podcast with Adam Weir – https://soundcloud.com/bmjpodcasts/take-homes-from-1st-world-conference-on-groin-pain-in-athletes-doha-agreement-part-2 You are encouraged to tweet your podcast questions to @AdamWeirSports or post on the Google + Sports & Exercise Medicine Community page – a great place to write more than a tweet. All you need is a gmail account.

High performance demands heavy workloads but loading increases the risk of ‘overuse’ injury. How can clinicians and strength & conditioning (S&C) coaches find the happy medium? Or is it time to take a different view? Perhaps INCREASING training load will make tissues more resilient and injury LESS likely. Dr Tim Gabbett (www.gabbettperformance.com) bridges sports medicine and S&C as a performance consultant and a recognized applied researcher. In the BJSM spotlight he shares what physiotherapists can learn from S&C coaches and argues for the concept of the ‘performance physiotherapist’. Similarly, he translates S&C secrets for physios – insights to progressing sport specific game demands within the rehabilitation program using a rugby example. We ask him about the high-tech and low-tech equipment to gauge how much players are doing and how to titrate their training dose. The latter part of the podcast focuses on how greater training loads can make players less likely to suffer injury but match demands must be considered. “High training loads are not necessarily the problem, it is how you get there that can damage players”. The internationally-recognized Gabbett closes by outlining the concept of ‘training stress balance’ – the net difference between fitness (long-term training load) and fatigue (short-term training load). When the player is in ‘positive’ balance, (i.e, the short-term load is lower than the longer term level of load the player is adapted to) injury is very unlikely. However, when this pattern is reversed, such as when a player is attempting to rapidly ‘gain fitness’ after a layoff, injury is almost inevitable. Cricket fast bowling data provides compelling evidence for this novel concept. Link to Dr Tim Gabbett’s home page: www.gabbettperformance.com In case you don’t get to check Dr Gabbett’s bio, he is in that rare group of individuals with two PhDs – one in human physiology (2000), the other in the applied science of professional football (2011). He has worked with players in many Olympic Games cycles and published over 150 papers. http://gabbettperformance.com.au/profile/ The BJSM paper relating to ‘training stress balance’: Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Hulin BT, Gabbett TJ, ….Orchard JW. Br J Sports Med. 2014 Apr;48(8):708-12 http://www.ncbi.nlm.nih.gov/pubmed/23962877

“Just because it’s difficult doesn’t mean it’s impossible” says Norway’s Ben Clarsen (PT, PhD) (@BenClarsen). We all say the words – ‘injury prevention is important’, ‘we want to catch injuries early’ but how do you do it? What about if your nation’s athletes are spread all around the globe? Can a systematic, yet simple, process of asking athletes questions by text messaging work? Norway punch above their weight in elite sport and Ben Clarsen is one of the team at the engine room of Norwegian Sports Medicine & Sports Science ‘Olympiatoppen’ (ie. ‘EliteSport’). He shares with @Liam_West HOW Norway keeps in touch with athletes weekly, responds to early warning signals, and initiates appropriate treatment in a financially prudent manner (oil price down right now). Links include: For athletes’ health problems: http://bjsm.bmj.com/content/48/9/754.abstract - The Oslo Sports Trauma Research Center questionnaire on health problems: a new approach to prospective monitoring of illness and injury in elite athletes. By Clarsen B, Rønsen O, Myklebust G, Flørenes TW, Bahr R. Br J Sports Med. 2014 May;48(9):754-60. doi: 10.1136/bjsports-2012-092087. Epub 2013 Feb 21. For sports injury problems: http://bjsm.bmj.com/content/47/8/495.abstract Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire. By Clarsen B, Myklebust G, Bahr R. Br J Sports Med. 2013 May;47(8):495-502. doi: 10.1136/bjsports-2012-091524. Epub 2012 Oct 4.