F O U R T H E D I T I O N - L E S S O N S F R O M R I O : R E F L E C T I N G O N T H E O LY M P I C G A M E S
Dr Chris Tomlinson highlights the preparation process and challenges prior to Rio 2016
Interview with Dr Ella Nicholas, who represented the Cook Islands in the canoe slalom at the 2012 and 2016 Olympic Games
Dr Patrick Oâ€™Halloran reflects on his role as a Field-Of-Play Doctor for the Beach Volleyball Competition in Rio 2016.
EDITORS NOTE Welcome to the 4th edition of the Undergraduate Sport and Exercise Medicine Society (USEMS) quarterly publication. It’s now just over 12 months since we first started this venture, and we’ve learnt many lessons since. The most heartwarming aspect of this undertaking has been the willingness of the sports medicine community to engage with us and to give up their time to produce quality content - it makes the role of Editor largely redundant! Our theme this quarter is Lessons from Rio: Reflecting on the 2016 Olympic Games, and once again we are fortunate to have contributions from doctors who attended (and competed at!) The Games. Another feature of this edition is the increasing presence of undergraduate contributors - something we are very keen to encourage more of. Sprinkled throughout this edition are various notices for upcoming conferences in 2017. The locations sound like the venues for a Formula One season; London, Monaco, Barcelona etc. It’s always difficult to attend conferences as a student, between facing the cost and finding the time off from your studies. However, we’d massively encourage you to smash the piggy bank to attend the ones that interest you (all have excellent student rates) because inevitably opportunities arise from meeting people and building relationships at these events. One year into the life of the USEMS eMag, we’re not prepared to rest on our laurels. We are committed to growing, bringing you quality learning materials every 4 months, and are very open to progressing the format in which we do this. One of the highlights of 2017 will be our Golf for Health edition due for release in June/July which will be guest edited by Dr Andrew Murray who works with the European and Challenge Tours in Golf and has published extensively on the subject. Thanks for reading! Yours in Sport, Dr Sean Carmody Dr Fadi Hassan Steffan Griffin Co-Editors, USEMS eMagazine.
THE ROAD TO RIO: MEDICAL PREPARATIONS FOR THE CHALLENGE AHEAD DR CHRIS TOMLINSON
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THE ROAD TO RIO: MEDICAL PREPARATIONS FOR THE CHALLENGE AHEAD DR CHRIS TOMLINSON
As I write this in a Spanish hotel room at the European Trampoline Championships at the end of March, the Olympic Games in Rio seem both a long way off and tantalisingly close. Heaven knows what it must feel like for the athletes desperately pushing for places in the team. The heady days of October and November 2015 seem a long time ago now. It was then that we qualified Men’s and Women’s Artistic Gymnastic teams for Rio, winning an historic five World Championship Medals (including our first Men’s individual Gold), and two individual female trampoline places. These were the targets for the year, and to achieve them was immensely satisfying for all of those involved in the sport.
But as the hashtag says, ‘Better Never Stops’ and after the briefest of pauses, the final stages of this Olympic cycle swung into action. It’s fair to say that preparation for Rio actually began before the London 2012 Olympics, just as planning for Tokyo 2020 has already begun.
Screening also consists of reviews with our Sports Psychologist, Performance Lifestyle Advisor and Nutritionist. Body composition is measured with DEXA scanning three times a year. We believe that optimal body composition reduces injury risk and improves performance.
From the Sports Medicine and Sport Science perspective, the aim has been to develop strong and resilient athletes, able to cope with the rigours of intensive training regimes and to compete at their best.
With the final months of the Olympic cycle upon us, 2016 began with screening for all squad members. Medical screening consists of checking that the medical information I have on my screening spreadsheet is up to date – past medical, surgical and injury history, medications, TUEs and allergies, immunisations, family history. I check on the number of concussions they have had, that their cardiac screening (via CRY) is up to date and in female athletes, we check for any menstrual problems.
There have been twice yearly screening programmes. These involve the entire Sport Science and Medical Team (SSMT). I’ll discuss the medical screening shortly. Our physiotherapists and S&C coach screen for the physical capabilities needed for elite level gymnastics performance and injury prevention, and feedback is given to each gymnast individually, and to their coach and the national coaches. Each gymnast has an individualised S&C programme based on these findings.
I then take a current medical and musculoskeletal history, perform a physical examination, and take blood tests, including checking Vitamin D levels. I work closely with our nutritionist
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to ensure Vitamin D levels are good throughout the year – particularly important when our athletes spend so much of the year indoors. This year, for the first time, we’ve use IMPACT to provide baseline neurocognitive screening. Concussions are not uncommon in Gymnastics, and improving concussion care is high on my agenda for the following Olympic cycle. Anti-Doping education is an important aspect of my role within our sport. Our squads have antidoping education twice yearly, and this year we have worked closely with UK Anti-Doping to deliver their ‘Clean Sport’ and, prior to the Games, ‘Clean Games’ educational programmes. I have been really impressed by how involved the gymnasts have become during these sessions. Managing injury becomes much more complicated around competition time, and in Olympic year, these pressures are significantly magnified. From the beginning of March onwards, each competition is either officially or unofficially a trial for the Olympic team, and ensuring athletes have enough time to recover from injuries becomes ever more challenging. The psychological aspects of injury are also increased, and working closely as a multi-disciplinary unit becomes even more important, both as an SSMT and with the coaches. Requests for scans and ‘specialist opinions’ have also increased this year and must be managed with sensible discussions between athlete, medical and coaching staff. It is a constant learning curve for us all, and already this year the results of scans have overcomplicated what should have been really rather simple medical management.
In cases such as this, I have found getting the opinions of a number of colleagues to be useful in terms of quantifying risk. This enables fruitful discussions with the athlete, parents, personal coach, National Coach and Sports Medicine Team in planning the way forward. UK Sport has set tough Medal Targets for each Sport, and gymnastics is no different. Keeping our athletes fit and healthy so that they can train maximally and compete injury free is the aim of our team. We do, however, have to acknowledge that injuries and illness occur, and contingency planning has occupied much of our thoughts – what if our main medal hopes get injured? How do we ensure they receive speedy access to the best medical care when they train on the other side of the country to our base in Lilleshall? Each potential Olympic Team member has a contingency plan in place so that all eventualities are covered. I’m hopeful that the 2016 Olympic Games in Rio will be a professional highlight for myself, traveling with Team GB, but more importantly that they are a successful one for the Sport, and the athletes who have worked so hard over the last four years (and beyond).
Chief Medical Oﬃcer for British Gymnastics, Dr Chris Tomlinson, wrote this article back in March 2016 as he and his team prepared for the Olympic Games. Since writing, Team GB gymnasts finished the Rio Olympic Games with seven medals across all three gymnastics disciplines, making it their most successful Olympic performance in history. There can be no doubt that the hard work, diligence and organisation of Chris and his team contributed to the success of the athletes.
Discussions regarding risk once an athlete is injured are always important, but particularly so this year. A lumbar pars stress fracture in February is going to struggle to heal before the Games, never mind the trials beginning in March.
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EVALUATING THE ROLE OF OCCLUSION TRAINING IN REHABILITATION EOIN CREMEN TWITTER @EOINCREMEN. The sports medicine team values small percentages. The demands of elite sport are such that if even 1, 2, or 5% of an added benefit can be provided for your athlete then it should be made available. These small percentages can amount to a meaningful contribution in the return to play process, with regard to both the athlete’s physical capacity and the timing of recovery. There is an increasingly convincing body of evidence to suggest that blood flow restriction training (BFR) or occlusion training is one such valuable addition to the rehabilitation process. BFR/occlusion training refers to the process of using an external tool or device to limit the venous return from contracting muscles, while still enabling arterial inflow. The device, typically an inflatable cuﬀ, is wrapped around the proximal portion of a limb and inflated to a desired pressure. This pressure should be individual to the athlete using the cuﬀs and the type of cuﬀ being applied 1. Factors such as cuﬀ width, cuﬀ material, and limb circumference can all cause variations in pressure1, 2. Benefits of blood flow restriction When BFR/occlusion training, exercise loads as low as 20% of an individual’s 1-repetition maximum (1RM) can stimulate muscle morphology and strength responses. This is contrary to the commonly referenced guidelines from The American College of Sports Medicine (ACSM), which states loads of at least 70% 1RM are needed to stimulate muscle hypertrophy and 85% 1RM is recom-
Eoin Cremen is an Academy physiotherapist with Yorkshire Carnegie. He has previously worked with Loughborough Students RFC and Seapoint RFC. A key area of interest for Eoin is the use of occlusion training in the rehabilitation of athletes. Here he outlines the advantages of occlusion training, while also looking at some of the limitations of its use.
mended for muscle strengthening adaptation3. Therefore, this training method has huge potential to benefit injured athletes with restricted training loads. BFR/occlusion training, combined with lowintensity exercise, has been proven to enhance muscle h y p e r t r o p h y, m u s c l e strength, muscular endurance, as well as performance in tests of power, speed and anaerobic conditioning 4-8.
tions have been described in the literature. A key component is the creation of a local anaerobic environment, secondary to limiting muscle oxygenation during exercise9. Subsequently, type II muscle fibres become rapidly and preferentially recruited, stimulating favourable morphological and strength responses 10.
Local growth hormone levels have been recorded to increase by up to 200%11 secondary to cell swelling and lactate accumulation when BFR/occlusion training. Muscle ischaemia also Proposed mechanisms stimulates the production The exact mechanisms that of heat shock proteins, nicause these changes are tric oxide synthase-1, and still not wholly understood mTOR, which all act to and a number of explanastimulate muscle protein
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synthesis12. Furthermore, elevated mechanogrowth factor and IGF-1, in combination with an inhibition of myostatin, have been reported in the literature13. This suggests that BFR/occlusion training is advantageous over traditional exercise as a stimulus for muscle protein synthesis. Safety considerations The most conclusive evidence for the safety of BFR/occlusion training comes from a study that analysed data from 30,000 BFR/occlusion training sessions at 105 facilities14. This report found that although adverse events did occur, the incidence was lower than that reported with traditional resistance exercise.
propriate restrictive pressure. Setting the pressure to a percentage of that required to occlude arterial inflow (AOP) has been suggested as an eﬀective strategy. Other methods using limb circumference and systolic blood pressure have also been proposed18. Subjectively, a perceived rating of an individual’s maximum tolerable pressure can be used, with 7/10 being recommended as an upper limit19, 20.
One of the main concerns surrounds the possibility of haemostasis and thrombosis. However, an investigation into haemostatic markers post BFR/ occlusion training found no increase in fibrin formation or D-Dimer presence15. In fact it appeared to positively influence the production of cardioprotective markers via fibrinolytic stimulation. This has been supported by evidence from blood samples taken immediately before, 10 minutes, 1 hour, 4 hours, and 24 hours post BFR/occlusion training, which showed no increase in thrombin markers or intravascular clot formation16. This is further supported by findings that BFR/occlusion training does not negatively alter peripheral vascular stiﬀness or peripheral nerve conduction17.
There is emerging evidence suggesting that 50% AOP is the most eﬀective pressure for stimulating maximal muscle responses, while percentages of 60% and above seem to provide no additional benefit21. In addition, there is still more to learn regarding the nature of intra-exercise pressure fluctuations and how these may impact the pressure selection.
Despite this promising evidence it is still recommended that a medical history indicating increased risk of coagulation disorder, thrombo-embolism, or similar vascular dysfunction be treated as a contraindication, alongside any other cardiac pathology. Therefore, we can conclude that providing SEM staﬀ carry out a thorough medical history and apply BFR/occlusion correctly, there is no additional risk to performing this training method.
Finally, with recent reports indicating a positive influence on bone health, there is a need for comprehensive investigation into the eﬀect of BFR/occlusion training on musculoskeletal injuries, such as tendinopathy. The future directions for this training type promise to be fascinating.
Current research directions There is still a lack of agreement among researchers and clinicians regarding how to determine ap-
References 1. Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sports medicine. 2015;45(3):313-25. 2. Jessee MB, Buckner SL, Dankel SJ, Counts BR, Abe T, Loenneke JP. The influence of cuﬀ width, sex, and race on arterial occlusion: implications for blood flow restriction research. Sports Medicine. 2016:1-9. 3. American College of Sports M. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Medicine and science in sports and exercise. 2009;41(3):687. 4. Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Eﬀects of resistance exercise combined with moderate vascular occlusion on muscular function in h u m a n s . J o u r n a l o f a p p l i e d p h y s i o l o g y. 2000;88(6):2097-106. 5. Takarada Y, Sato Y, Ishii N. Eﬀects of resistance exercise combined with vascular occlusion on muscle function in athletes. European journal of applied physiology. 2002;86(4):308-14. 6. Cook CJ, Kilduﬀ LP, Beaven CM. Improving strength and power in trained athletes with 3 weeks of occlusion training. Int J Sports Physiol Perform. 2014;9(1):166-72. 7. Abe T, Kawamoto K, Yasuda T, Kearns CF, Midorikawa T, Sato Y. Eight days KAATSU-resistance training improved sprint but not jump performance in collegiate male track and field athletes. International Journal of KAATSU Training Research. 2005;1(1):19-23. 8. Manimmanakorn A, Hamlin MJ, Ross JJ, Taylor R, Manimmanakorn N. Eﬀects of low-load resistance training combined with blood flow restriction or hypoxia on muscle function and performance in netball athletes. journal of Science and Medicine in Sport. 2013;16(4):337-42. 9. Kacin A, Strazar K. Frequent low‐load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scandinavian journal of medicine & science in sports. 2011;21(6):e231-e41. 10. Loenneke JP, Fahs CA, Wilson JM, Bemben MG. Blood flow restriction: the metabolite/volume threshold theory. Medical hypotheses. 2011;77(5):748-52. 11. Takarada Y, Nakamura Y, Aruga S, Onda T, Miyazaki S, Ishii N. Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. Journal of applied physiology. 2000;88(1):61-5. 12. Loenneke JP, Wilson GJ, Wilson JM. A mechanistic approach to blood flow occlusion. International journal of sports medicine. 2010;31(01):1-4. 13. Loenneke JP, Pujol TJ. The use of occlusion training to produce muscle hypertrophy. Strength & Conditioning Journal. 2009;31(3):77-84. 14. Nakajima T, Kurano M, Iida H, Takano H, Oonuma H, Morita T, et al. Use and safety of KAATSU training: results of a national survey. International Journal of KAATSU Training Research. 2006;2(1):5-13. 15. Nakajima T, Takano H, Kurano M, Iida H, Kubota N, Yasuda T, et al. Eﬀects of KAATSU training on haemostasis in healthy subjects. International Journal of KAATSU Training Research. 2007;3(1):11-20. 16. Madarame H, Kurano M, Takano H, Iida H, Sato Y, Ohshima H, et al. Eﬀects of low‐intensity resistance exercise with blood flow restriction on coagulation system in healthy subjects. Clinical physiology and functional imaging. 2010;30(3):210-3. 17. Clark BC, Manini TM, Hoﬀman RL, Williams PS, Guiler MK, Knutson MJ, et al. Relative safety of 4 weeks of blood flow‐restricted resistance exercise in young, healthy adults. Scandinavian journal of medicine & science in sports. 2011;21(5):653-62. 18. Loenneke JP, Allen KM, Mouser JG, Thiebaud RS, Kim D, Abe T, et al. Blood flow restriction in the upper and lower limbs is predicted by limb circumference and systolic blood pressure. European journal of applied physiology. 2015;115(2):397-405. 19. Wilson JM, Lowery RP, Joy JM, Loenneke JP, Naimo MA. Practical blood flow restriction training increases acute determinants of hypertrophy without increasing indices of muscle damage. The Journal of Strength & Conditioning Research. 2013;27(11):3068-75. 20. Lowery RP, Joy JM, Loenneke JP, Souza EO, Machado M, Dudeck JE, et al. Practical blood flow restriction training increases muscle hypertrophy during a periodized resistance training programme. Clinical physiology and functional imaging. 2014;34(4):317-21. 21. Loenneke JP, Kim D, Fahs CA, Thiebaud RS, Abe T, Larson RD, et al. Eﬀects of exercise with and without diﬀerent degrees of blood flow restriction on torque and muscle activation. Muscle & nerve. 2015;51(5):713-21.
AS AN ATHLETE, WHAT DO I NEED TO KNOW ABOUT THE ZIKA VIRUS? INFOGRAPHIC BY EDDIE SMITH
1 2 1. Zika virus
Zika virus spreads mainly through bites from an infected mosquito. It can also spread from Mother to fetus and during sex with an infected male. The world health organisaIon consider Brazil to be a high risk place for the transmission of Zika
2. Symptoms 4 out of 5 people have no symptoms. Most common symptoms are a temperature, rash, red eyes and joint pain If you feel unwell, seek medical attention
5 4 4. What to do if you get Zika Plenty of Rest Drink lots of fluids There is no specific medicaIon for Zika
5. Pregnancy and Zika There is a risk of a brain defect called microcephaly in foetuses if Mum is infected. Use a condom when having sex within 8 weeks of travelling to Brazil or 6 months of being infected. Seek medical advice if you are wanIng to start a family
Protection from Mosquito bites When possible: wear long sleeves/ long trousers Stay in air-conditoned rooms with window and door screens Use EPA registered insect repellent References: www.cdc.gov/zika (accessed 25/07/16), Zika virus: management of infecIon and risk BMJ 2016;352:i1062
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THE DOCTOR WHO DARED TO DREAM AT THE OLYMPICS ELLA NICHOLAS Can you describe the build up to the 2016 Games? In particular, how you managed to balance medical school/working as a doctor with training? Balancing medical commitments with training has been a constant challenge in recent times. I have done it for years and I don't think it has ever gotten any easier. I had to become very good at time management while maintaining the capacity to be adapt to varying work and competition demands. During the build up to Rio, I was working full-time as a Doctor from the end of 2015 until 3 months before The Games started. After that, I took 3 months unpaid leave from work to focus completely on training. The 6 months where I was working were tough. Days consisted of waking at 5am, doing a gym session before work, carrying out a full day’s clinical work before heading to the Kaituna River for a white water kayaking session (about a 45min drive away) then home at 8pm in time for dinner and bed. Every day was diﬀerent. Eﬀectively every weekend was used for training camps or racing. Annual leave was reserved for a training camp in Australia. Some days I felt like just sleeping in and other days I loved the hard work and struggle. I got a lot of support from my colleagues and from the hospital which was awesome. They ensured I wasn't rostered on when I needed weekends oﬀ and were accommodating if I needed to swap shifts to fit in with my preparation. I am incredibly grateful to them. My social life was essentially non-existent. If I wasn't working with you or living with you it was unlikely I’d see you for weeks on end. I was lucky that my close friends were so understanding. I used to train with my brother who is an Orthopaedics Registrar at the same hospital as me and that helped too. Having someone going through the exact same schedule (potentially even busier) was encouraging. Have you had much experience with injury as a canoeist? How has your medical background influenced your approach to recovery and rehab?
Ella Nicholas is a medical doctor working in New Zealand. She has represented the Cook Islands in the canoe slalom at the 2012 and 2016 Olympic Games. The third smallest nation in the Olympic family with a population of less than 20,000, the Cook Islands has sent just 39 athletes to The Games since they made their debut in Seoul 1988. Ella carried the Cook Islands flag at the Opening Ceremony in Rio de Janeiro where she competed alongside her brother Bryden, an orthopaedic surgeon.
Unfortunately, yes. No major injuries thankfully, but I got pinned on a rock when I was at a training camp in Dubai a few years back and injured my shoulder. I had physiotherapy at the time but it developed in to a chronic issue which still niggles occasionally. Luckily that is the only long-term injury I have had.
and so I knew that that is exactly how my physio would feel if I slacked oﬀ my programme!
During rehabilitation, I had to be a bit open minded and try techniques that we’re sometimes skeptical of in medicine. That was a bit unnerving (i.e dry needling and osteopathy) but I made sure I was using well reputed practitioners who I trusted. Rehab is intense and I found you have to be disciplined and do your exercises daily to see improvement. This was a challenge given my congested schedule, but I understood the importance of it. Seeing patients in hospital who come back in every few weeks because they aren't compliant is disheartening
What was the highlight of The Games for you? The highlight of The Games for me was being able to enjoy it with my family. My brother was competing too, and I look back on the long days training alongside him as cherished memories. My mother and father were our
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team manager and doctor respectively, so they were there throughout. My sister, who I had spent some time training with in Europe, came out to watch too. I think being able to share such an awesome experience with the people I love was the most amazing thing. The opening ceremony was incredible. I can't describe it in a few words but carrying my nation’s flag into the Maracana was one of the most emotional experiences I have had. Again, I am so proud I got to share those moments with my family. Apart from that, the free McDonalds wasn't bad... (post race of course), and it was great to experience Brazilian culture. Rio de Janeiro was a vibrant city with so much to see, do and learn. Being able to watch and appreciate lots of other sports after our race finished was awesome - Beach Volleyball and Rugby 7s were probably the most memorable! What are your thoughts on the medical provision for athletes at The Games? There was a huge centre in The Olympic Village for medical services. There they would provide a free medical assessment, dental treatment, ophthalmology etc... I definitely didn't feel like I would be wanting for anything. It was mostly run by volunteers and there was a slight language barrier but they still managed to communicate well. Each team also had their own sports physician. Ours being a small team, we just had my Dad who is a GP but there wasn't much he needed to deal with. Coming from a smaller nation like the Cook Islands, with limited resources compared to the 'global superpowers', what do you think are the key positions that should be included in every support staﬀ? You could definitely notice the diﬀerence in The Village and at training. The big teams have got a wealth of support staﬀ compared to the smaller nations. I am sure that this much support leading up to an event and during is very beneficial, and probably contributes to improved performances.
all of the logistics, race day would be a much more stressful experience. In kayaking, a coach doesn't do much on the day of competition itself except provide encouraging words. All the major teams had a huge entourage of physios, chiropractors, sports doctors, massage therapists... We had a chiropractor and my Dad, the GP. I was fortunate to be able to utilise physiotherapists from Team Canada through a contact of mine, but some of the bigger teams weren’t as willing to share resources with the smaller nations. What are your goals going forward (in terms of medicine and competing)? Is Tokyo 2020 an ambition of yours? This is the big question... I haven't quite decided yet. After Rio, I came straight into a busy surgical job and decided to take a break from kayaking. My current job is making me wonder how I ever had any time to train!
I am sitting the first part of my surgical exams this year and hoping to apply for the Paediatric Surgical training scheme at some point. I have always loved surgery so the plan is to pursue that path and see what happens. In the meantime I have started to do a bit of kayaking training again. It’s tough to get back in the boat after a long break but I am enjoying it so far. I don’t think it will be the main focus for me this year, as I look to regather a bit of a social life and progress in surgery. I definitely haven't closed the door on Tokyo 2020, but I am increasingly aware that as I become more senior as a doctor, it is going to be come more diﬃcult to balance everything. I am just trying to enjoy every day and see where the road takes me.
For most of our training days, my brother and I are alone which can aﬀect our speed of progress and motivation levels. The most important person for me around race time is probably my manager followed closely by my coach. The manager ensures things run seamlessly (and for an event like The Olympics organisation can be a real headache!). Without someone else looking after
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A REFLECTION ON RIO. DR PATRICK O’HALLORAN
Having narrowly missed out on the opportunity to be a medical volunteer at the London Olympics, I was keen not to let the chance pass me by for Rio 2016. I wanted to volunteer for several reasons. Firstly, I had heard great things from the 2012 volunteers about their experiences both from the point of view of opportunities to learn about new sports and to develop their skills in a new and challenging environment but also from the perspective being a part of such an amazing event so close to home. I had the chance to put this to the test at the Glasgow Commonwealth Games in 2014 and felt my time as a “Clydesider” had really helped to broaden my experience both of sports medicine and the logistics and administrative challenges of supporting high performance athletes. However, by far and away the biggest reason I wanted to volunteer was because, as you will have guessed from my name, my mother is Brazilian. Her family eventually settled in Rio and so, with fond memories of playing with my grandfather on the beaches of Copacabana and Ipanema as a boy I eagerly put in my volunteer ap-
This gave me the opportunity to learn about a new sport played by the world’s best in an iconic venue and in a country which regards it as second only to football in terms of popularity. Having previously taken part in some practical research messing about on the beach during holidays and some theoretical research watching Top Gun I didn’t think there was much more to learn in preparation and so was ready for a diverse range of injuries, acutely aﬀecting ankles, finger and shoulders and more chronically aﬀecting knees and lower backs. I was surprised then to learn in my pre-trip reading of the prevalence of digital ischaemia in both volleyball codes. This is a subject in which interest has recently increased and is, apparently, the result plication when the process of repeated trauma to the hands and fingers and so is opened. It is worth emphasising that more common in athletes this process was incredibly who block the ball at the net straightforward and involved as opposed to those who dig forwarding a CV, answering in the back-court. The feaquestions in an online inter- tures of this problem can inview to test one’s “Olympic clude raynauds type sympSpirit” and team ethic and toms at the end of practice then some more specific and, though initially mild, can questions about medical ex- eventually result in chronic perience and so on. Although symptoms and irreversible the outcome of this process damage in later life. was delayed to the point of I had been warned that the an eye watering increase in medical organisation for this the cost of flights you can event may be a little chaotic imagine my delight to be and so was prepared when I given the best job in the arrived at my venue on the world, Field-of-Play doctor first day and negotiated my for the Beach Volleyball com- way around the medical rooms. The set up was such petition.
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that there was a front of house medical room for spectators and then two back of house medical rooms for athletes and all of the other oﬃcials and volunteers. There was one main arena court and then 4 practice courts which also needed to be provided with medical cover. In order to provide this cover the volunteer medical team consisted of a handful of doctors with mixed amounts of experience working with athletes or working out of hospital, a larger number of physios from varied backgrounds and then the majority, nurses, medical and nursing students. This mix of practitioners at times felt a little unbalanced but was a product of the local health system in a developing nation in which doctor’s pay does not allow for luxuries like time oﬀ to volunteer. This situation was somewhat compounded by the mixture of equipment available. On my first day checking through the kit available I noted we had 80 bedpans but only a handful of appropriately sized airways. Likewise, in terms of medication, only a handful of oral antiinflammatories were available but three injectable antireflux preparations were on hand, including one which was banned by WADA. Discussing this with the medical team proved interesting and again highlighted the challenges of working in the developing world. It was suggested that the odd mix of equipment was due to corruption in the procurement of supplies, unfortunately. Further challenges were found in the environment itself with the need to care for a mixture of athletes incredibly
well adapted to the hot conditions and foreign tourists in uncovered seating areas less well adapted to the hot conditions much less when combined with the local
Dr Patrick O Halloran is a Sport and Exercise Medicine Registrar in Birmingham. He currently works with the Wolverhampton Wanderers FC Academy, and has previously held a role with Gloucester Rugby. At Rio 2016, Patrick had the enviable job of being a Field-OfPlay Doctor for the Beach Volleyball Competition. Here, Patrick takes a humorous look at what he learnt while performing, what he accurately describes as, the best job in the world.
hospitality. Add to this the challenge of working on the sand itself and the need to adapt extrication procedures to allow for that, for example in the operation of the split scoop, the metal mechanism of which is not well suited to the seaside! However, set against this backdrop was a local organising team doing an amazing job, in challenging circumstances, with little organisational support and even less sleep. The tireless work ethic of the venue medical managers ensured that day-by-day things improved as the competition unfolded. New supplies arrived each morning and were distributed to key areas. When it became evident that there were not a great many team members with experience out of hospital or in sport specifically, arrangements were made to
come together and plan and practice with a 5-minute pitchside trauma course video made to try and deliver the key messages on the initial assessment and packaging of casualties in this setting. This is a feat which was even more impressive considering that the team was made up of professionals from 10 or so foreign countries with limited to no grasp of Portuguese! As a result, the experience was incredibly rewarding. Thankfully the utilisation of our service was relatively low from the point of view of the
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athletes, however the chance to be immersed in the fantastic spectacle that is international beach volleyball was incredibly rewarding. The venue, the chance to explore an inspirational city, the opportunity to meet my long-lost family and hear some astounding family legends, the chance to see a lot of Olympic sport (with plenty of Team GB Golds!) at an incredibly reasonably price and being able to contribute to making it the best games ever combined to make this a career highlight which I will always cherish. Practically, I think the key take home messages from this experience were: 1. “Pack your own parachute”-When travelling abroad with athletes this must be the mantra. Try to be as self-suﬃcient as possible in terms of equipment and have a plan for sourcing help in preparation for the fact that both supplies and experience may be limited amongst the local medical team. 2. Language Barriers-Shamefully I am only able to order beer in Portuguese and English as a second language is not especially prevalent in Brazil compared
and postgraduate training, courses and conferences was widespread. In the post-Brexit soul-searching I remember being struck by the fact that although travel to Australia is common as an FY3 option we should maybe be more willing to look at some of the amazing learning opportunities on our doorstep. 4. Volunteer-The best piece of advice I have ever had is “don’t be afraid to volunteer your time”. Volunteering for the Commonwealth and Olympic Games have provided great learning experiences, the chance to meet some amazing people and the opportunity to be immersed in a world which few people are lucky enough to experience. It has not been diﬃcult to go through the reto other European councruitment process and the tries. The language barrier logistics are very managewas a real challenge but a able and I would encourcombination of google age anyone interested in translate and an enthusiasthe field to look at opportutic embrace of hand gesnities like the Gold Coast tures and charades alCommonwealth Games in lowed me to get by. 2018 and beyond as a poWarmth, enthusiasm and tential avenue to go down a willingness to laugh at to start this journey. oneself go a long way! 3. Travel broadens the mindI was struck by how well travelled my colleagues were. Several of the Brazilian doctors had travelled through South and North America to study and of the physiotherapists, particularly the Europe based ones, travel through Europe for undergraduate
• £15.00 +VAT • Michael Griffith Education Centre, University Hospital of Wales, Cardiff. • Designed for exercise professionals, doctors, physiotherapists, sport and exercise scientists, students and exercise enthusiasts • The event outlines the developments in Physical Activity for Health and highlights the importance of Physical Activity across a range of areas. • Topics include: Obesity, Sedentary Behaviour, Women Health & Exercise, Getting a nation hooked on sport and more. • Speakers include Professor Greg Whyte OBE (Former Olympian and Professor in Applied Sport & Exercise Science at Liverpool John Moores University), Mr Ian Ritchie (Immediate Past President of The Royal College of Surgeons of Edinburgh) and Professor Steven Blair (Past President of the American College of Sports Medicine) • For tickets follow link: https://www.eventbrite.co.uk/e/wales-exercise-medicine-symposium-2017-tickets28115782061
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AN OVERVIEW OF SPORTS AND EXERCISE MEDICINE (SEM) INTERCALATED DEGREE COURSES JAMES MURPHY 5TH YEAR STUDENT, NEWCASTLE UNIVERSITY. Introduction My personal experience This time last year I was beginning my fourth year of medical school. At this stage the majority of medical students at Newcastle, who wish to intercalate, apply to intercalated degree courses for the following year. At this time I was sure that I wanted to intercalate on a Sports and Exercise Medicine (SEM) course. I had read about the diﬀerent courses oﬀered at Newcastle University, for example, the MRes course which is the most popular, but I was not particularly interested in any of the MRes modules on oﬀer. I had also become more interested and involved in SEM and thought that an intercalated degree would be a great opportunity to pursue my interest further. I had been advised by many people that I should only take a year out to intercalate if was really interested in the subject area. A message of “don’t do an intercalated degree for an easy year or the extra application points” was reiterated to me several times. Having established that I wanted to intercalate in SEM, I had to investigate how many UK universities offered SEM intercalated degree courses and how many of these accepted external applicants, and it was no easy task. This article is intended to give current medical students interested in intercalating in SEM an overview of the diﬀerent options open to them. I provide, to the best of my ability, is a comprehensive list and basic description of the SEM and closely related courses oﬀered in the UK. The information provided comes from the online descriptions of each course pages and from my own contacts with the course directors. I have added my own observations on the courses and these are provided in bold in the section on the description of the courses below, and in the Discussion. Sports and Exercise Medicine courses
Sports and Exercise Medicine MSc, Nottingham University All students on the MSc course complete modules in SEM as well as a research project. Over the year students undertake 140 credits of compulsory modules, this includes the ‘Project and Dissertation’ module, and then another 40 credits of optional modules. The compulsory modules are SEM focused, for example there are modules on anatomy, the assessment of sports injury, and another covering “common sporting injuries"(1) and how to manage them. The ‘Pitchside Care of the Injured Athlete’ compulsory module is a great opportunity for students to learn about, and get some experience in, providing pitchside care; as part of the module students study for and attend a two-day “advanced emergency care on the field of play course”(1) (EMMiITS) and also provide first aid cover at some University sports pitches. The other compulsory modules are: ‘Physical Activity in Health and Disease’, ’Research Methods’, and the research project. The optional modules allow students to pursue individual interests, such as: nutrition, physiology, rehabilitation or further teaching in research methods and statistics. A complete list of all the modules, and details about them, can be found on the webpage below. https://www.nottingham.ac.uk/pgstudy/courses/medicine /medical-sciences/sports-and-exercise-medicine-msc.as px Despite the stated entry requirements, the course directors are open to applications from intercalating students. Students should discuss their applications with the course director (currently Dr Kim Edwards) before submitting them. BSc Sports and Exercise Medicine, Queen Mary, University of London On this course students complete 120 credits, organised in to six modules. The modules are: ‘Research Methods’, ‘Injuries and medical problems in sport’, ‘Literature reviewing’, ‘Research project’, ‘Biomechanics and rehabilitation’
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and ‘Exercise as a Health tool’. The breakdown of the modules can be found on the below website. http://www.smd.qmul.ac.uk/undergraduate/course s/intercalated/sem/index.html The taught research methods and literature reviewing modules prepare students to carry out research and critically appraise papers, helping students to be able to produce high quality systematic reviews. Relating the research skills to sports and exercise medicine papers and studies allows students to see the importance and application of the skills. As part of the degree students undertake a systematic review and a full research project, many students work towards, and succeed in having their work published. BSc (Med Sci) Clinical Medicine, Glasgow University Students wishing to intercalate in sports medicine can apply to undertake the Sport and Exercise Medicine subject and research project within this Clinical Medicine Degree. The degree is split into four diﬀerent areas: the ‘Core Course’ (which aims to provide students with “transferable research skills and a knowledge of current issues in medical research”(3)), the ‘Specialist subject’, ‘Medical Statistics’, and a ‘Research project’. For their specialist subject students can apply to take the SEM course. The SEM course aims to cover “exercise in health promotion, disease prevention and treatment of disease states”.(3) Students are initially taught as a small group before undertaking three modules with students on the MSc Sport and Exercise Science and Medicine degree course. The modules are: ‘Clinical Sports Injuries’, ‘Sports Medicine in Practice’ and ‘Exercise in Clinical Populations’. It is useful to read the learning outcomes for these modules which are broken down clearly on the information sheet attached. A research project is a key part of the course and students are given a varied list of potential projects to choose from. University of Glasgow B.Sc. (Med. Sci.) Clinical Medicine Sport and Exercise Medicine - Course information
http://www.gla.ac.uk/schools/medicine/undergraduate/int ercalateddegrees/clinicalmedicine/ Sports and Exercise Science courses Sports and Exercise Science (intercalated), Loughborough university This one year intercalated degree programme has been run by Loughborough University for a number of years. Students taking the Intercalated degree study alongside the final year Sport and Exercise Science BSc students. Intercalated students take 120 credits worth of modules from a great variety of options (the list can be found on the website below). Alongside their modules students complete a research project and have the opportunity to observe sports medicine practitioners in NHS clinics in Leicester. http://www.lboro.ac.uk/departments/ssehs/undergraduate /courses/ses-intercalated/ In my opinion the list of modules oﬀered is the most varied amongst all the SEM courses in the UK. With no compulsory modules this course provides students control over what modules make up their Sports and Exercise Science degree. BSc in Medical Sciences (Sports Health and Exercise Science), University of Hull. This degree oﬀers students the “opportunity to engage with the theories and methods related to the bio-scientific study of sport and exercise, including sports injury.”(7) Students choose 120 credits, 40 of which are the dissertation module. Students then choose between groups of modules to make up the rest of the credits. Module group 1: (at least two of) ‘Human Locomotive Systems’, ‘Ageing, Obesity and Health’, ‘Fitness and Injury Prevention’. Optional Modules: (at least two of) ‘Environmental Physiology’, ‘Performance Enhancement and Injury Prevention’, ‘Psychology in Sport Rehabilitation’, ‘Sport and Exercise Nutrition’, ‘Exercise Physiology’. (note students are only allowed to choose either Sport and Exercise Nutrition or Exercise Physiology not both) The course handbook also provides a detailed list of all the diﬀerent members of staﬀ areas of interest. Students
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can get in touch with these members of staﬀ about a research project in their area. The general areas are: psychology, exercise physiology, biomechanics and sport rehabilitation. http://www.hyms.ac.uk/undergraduate/intercalated -degrees/intercalation University of Hull, Sports Health and Exercise Science 2016 programme description Sport and Exercise Science (intercalated) BSc (Hons), Cardiﬀ Metropolitan University This is a one year course at the Cardiﬀ School of Sport, Cyncoed Campus. Intercalating students join with students on the final year of the BSc (Hons) Sport and Exercise Science degree. Students study ‘Biomechanics of Sport and Exercise’ and “an independent project in one or more of Biomechanics, Physiology or Psychology”(8) and then choose three optional modules. The optional Modules are: ‘Exercise Physiology for Sport Performance’, ‘Exercise Physiology for Health’, ‘Sport Psychology’, ‘Exercise Psychology’. http://www.cardiﬀmet.ac.uk/schoolofsport/courses /Pages/Sport-and-Exercise-Science-(Intercalated)BSc-(Hons).aspx BSc in Sport and Exercise Science, Brighton and Sussex Medical School Intercalating students join the final year of the BSc Sport and Exercise Science course at the University of Brighton. However, students are also given the chance to attend second year lectures and laboratory sessions if they wish. On the course students develop research method skills and complete a dissertation. Final and second year modules can be found in the “Course in detail”(9) section on the below webpage. https://www.brighton.ac.uk/courses/study/sport-an d-exercise-science-bsc-hons.aspx Students hoping to gain hands on experience are able to complete a placement at a sports medicine practice on campus (numbers permitting). There are some high distinguished professionals lecturing on this course for example Professor Nick Web-
born (medical oﬃcer to olympic and paralympic teams) and Professor Yannis Pitsiladis (one of the leading scientists for the World Anti-Doping Agency). BMedSci Sports Science Medicine, University of Edinburgh This course combines SEM with the sports performance and exercise sciences (biomechanics, physiology, psychology and skill acquisition). Students can gain an “understanding of sports injuries and the health, performance and rehabilitation role that exercise can play in active sports people, specific patient groups and the wider population”.(11) The connection with the university’s SEM centre allows students to shadow members of the multidisciplinary SEM clinics. Students also acquire transferable skills such as literature appraisal, and how to plan and execute a research project. It is important to note that external applications wishing to apply must email the Undergraduate Admissions oﬃce. https://media.ed.ac.uk/media/Intercalated+Honours+in+S ports+Science+Medicine/1_8iujw34v/42261371 http://www.ed.ac.uk/medicine-vet-medicine/undergraduat e/medicine/mbchb/intercalated-honours
B.Sc. Sport Science in Relation to Medicine, University of Leeds Having contacted the University of Leeds about their course I was kindly sent a flyer by Stuart Egginton, Professor of Exercise Science at the University of Leeds. The flyer explains what students can expect from the course, such as a chance to develop “research, analytical and critical evaluation skills,” and “an opportunity to develop a detailed knowledge in the major sport science disciplines biomechanics, exercise physiology, psychology and motor control.”(both 12) There is also a further point which states that the course provides students the “opportunity to develop advanced knowledge and understanding of the links between exercise and health from a scientific perspective.”(12) Comments from previous students, course requirements and desired characteristics of applicants are also included in the flyer. As part of the course students undertake a research project and compulsory modules in ‘Interdisciplinary issues in Sport and Exercise Sciences’, ‘Advanced Exercise Physi-
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ology’ and ‘Sports Medicine, Health and Nutrition’. Students also complete 40 credits of optional modules. Professor Egginton and colleagues are currently working to update the course webpage. Information was obtained from B.Sc. Sport Science in Relation to Medicine course flyer. Reading the course flyer I get the impression that this course does have more of a scientific focus than a clinical one and therefore would be more suitable to students with this particular interest. Discussion The discussion is focused on some specific topics. SEM vs Sports and Exercise Science Courses On both SEM and Sports and Exercise Science courses students learn how to appraise and carry out research. However I think a major advantage of the SEM courses over the Sports and Exercise Science courses is that students develop transferable skills in clinical examination and management, that will help them whatever career path they choose in medicine. Students on Sports and Exercise Science courses will gain experience in research and skills in research methods but the taught modules may not be as useful or applicable for a career in SEM. Diﬀerences between the courses I think it is important to note that the Sports Science or Sports and Exercise science degrees often oﬀer a diﬀerent mix of modules. For example many oﬀer modules in Sports or Exercise Psychology where as the three Sports and Exercise Medicine courses do not. Students can check out detailed descriptions of modules on all the courses by reading through the course webpages. Some of the courses oﬀer practical experience either as a module as part of the course (the MSc at Nottingham Uni) or through working with linked clinics (Edinburgh Uni, Brighton and Sussex Uni,
Loughborough Uni, Queen’s Mary London)). If practical experience is important for students then they could maybe consider these courses over the others. Another point to consider is that there may be diﬀerent extra-curricular activities at the universities for students to get involved in. For example I thought about moving down to London for a year so I would be better placed to go to lots of conferences and events. Students may also wish to move to a diﬀerent university for more personal. Should I intercalate or just finish medical school? I think students should really think hard about intercalating. It is a great opportunity to study an area of interest further and to gain some experience and skills in research. Whilst being fun and interesting the year out is going to be hard work and there is obviously the additional cost to consider. Should I intercalate in SEM or another subject? I was fortunate to have people to ask for advice. I spoke at length with students intercalating at the time, two on the Queen’s SEM BSc and one on the Nottingham SEM MSc. It was really helpful to ask lots of questions about their courses and to hear their advice. I knew one of these students from my own medical school and was fortunate to meet the others at SEM conferences. Conferences such as the upcoming British Association of Sports and Exercise Medicine (BASEM) and Undergraduate Sports and Exercise Medicine Society (USEMS) conferences provide excellent opportunities for network with like minded students and to ask SEM professionals for their advice. USEMS have set-up a page on their new website for students who have completed electives or intercalated degrees in SEM to provide their experience and to leave their contact details for those wishing further information. I advise students to make the most of this. Do I have to be interested in research to intercalate? All of the intercalated degrees involve a research project or dissertation. So students must at least be prepared to complete this. I think the intercalated degrees oﬀer a really good opportunity to learn research skills and the process of completing a project. For those not interested in research some of the above courses have no compul-
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sory modules in research methods. Students could look towards these courses and just accept that they may find the research project quite tough and have to work extra hard on this module. Will intercalating now mean I don’t need to do a masters later? The courses listed above are all open to undergraduate applicants. The courses have diﬀerent requirements for the number of years of medical school applicants should have completed, so students should read the course pages carefully. Intercalating in SEM is not the only chance students have to complete a degree in this area. Students who don’t wish or are unable to intercalate can complete university courses at a later stage. It is possible to study a part-time masters while working or to take a year out from work to study full time on a masters or diploma course. Universities such as Bath, Glasgow and Queens all oﬀer MSc courses in SEM but are only open to postgraduates. List of References
10. http://www.ed.ac.uk/medicine-vet-medicine/undergraduate/medici ne/mbchb/intercalated-honours 11. https://media.ed.ac.uk/media/Intercalated+Honours+in+Sports+Sc ience+Medicine/1_8iujw34v/42261371 12. B.Sc. Sport Science in Relation to Medicine course flyer. Other Resources USEMS website http://www.thestudentroom.co.uk/wiki/A_Brief_Guide_to_Intercalat ed_Degrees
Acknowledgements Much of the information in this article is taken from course webpages and handbooks with the permission of the Universities. My thanks go to the course directors and leaders who gave me permission to include the courses in this article. Their help and support was much appreciated. James is currently intercalating on the MSc Sports and Exercise Medicine course at the University of Nottingham.
1. https://www.nottingham.ac.uk/pgstudy/courses/medicine/medical -sciences/sports-and-exercise-medicine-msc.aspx 2. http://www.smd.qmul.ac.uk/undergraduate/courses/intercalated/s em/index.html 3. http://www.gla.ac.uk/schools/medicine/undergraduate/intercalated degrees/clinicalmedicine/ 4. University of Glasgow B.Sc. (Med. Sci.) Clinical Medicine Sport and Exercise Medicine - Course information 5. http://www.lboro.ac.uk/departments/ssehs/undergraduate/courses /ses-intercalated/ 6. http://www.hyms.ac.uk/undergraduate/intercalated-degrees/interc alation 7. University of Hull, Sports Health and Exercise Science 2016 programme description 8. http://www.cardiﬀmet.ac.uk/schoolofsport/courses/Pages/Sport-a nd-Exercise-Science-(Intercalated)-BSc-(Hons).aspx 9. https://www.brighton.ac.uk/courses/study/sport-and-exercise-scie nce-bsc-hons.aspx