BJSM Podcast

Time to reset: What causes coronary artery disease? Dr Aseem Malhotra.

Britain's leading anti-sugar campaigner and one of the most prolific doctors in the world influencing obesity thinking and highlighting the harms of too much medicine.
In addition to being a Consultant Cardiologist, Dr Malhotra is a member of the board of trustees of UK health think tank, The King’s Fund and a member of the Academy of Medical Royal Colleges Choosing Wisely Steering Group
Here’s the link to his website: http://doctoraseem.com/biography/
Topics covered include:
No association of saturated fats and heart disease in primary or secondary prevention studies.
Focus on sugar -
• CVD mortality has come via reduction in smoking & trans fats with better acute AMI management.
• Statins have a number needed to treat of 1 in 83 for mortality in secondary prevention in men
• Stents save lives during heart attacks but not for 'stable' coronary disease
• PREDIMED and Lyon heart study
• Cholesterol is not the mechanism of action of how diet studies work
• Practical explanation-of frying vegetable oils and dangerous omega 6 (high omega 6 to omega 3 is bad)
• Butter and coconut oils have saturated fatty acids and are stable in cooking.
• Criticism from the Centre for evidence based medicine (Oxford).
Here is the editorial (Free) in BJSM:
http://bjsm.bmj.com/content/early/2017/03/31/bjsports-2016-097285

Exertional Rhabdomyolysis: What you don’t diagnose may kill a patient. Prof Francis O’Connor

What is rhabdomyolysis?
Can it sneak under a clincian’s radar?
What the key clinical features?
When to be alert for rhabdomyolysis
Problems when coaches are too aggressive with a new load
Two cases – clinical scenarios
When sickle cell trait complicates matters
Which athlete with sickle cell trait is at increased risk?
Can clinicians identify the athlete with sickle cell trait who is at risk of death?
To screen or not to screen. Ethics and science.
Who is ready to return to play?
Who is at risk of recurrence? It applies to athletes and war fighters.
Role of genetics – the genetic markers that clinicians can test for in a tertiary care centre
Links to a previous podcast by Fran O’Connor – Exertional leg pain http://ow.ly/j9IU30bs1oe
Links to papers:
Sickle Cell paper in Medicine and Science in Sports and Exercise: https://www.ncbi.nlm.nih.gov/pubmed/?term=harmon+and+Med+Sci+Sports+Exerc
Pathophysiology of exertional death associated with sickle cell trait: can we make a parallel with vaso-occlusion mechanisms in sickle cell disease?
Connes P, Harmon KG, Bergeron MF.
http://bjsm.bmj.com/content/47/4/190.long
Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator.
Harmon KG, Drezner JA, Klossner D, Asif IM.
http://bjsm.bmj.com/content/46/5/325.long
To screen or not to screen for sickle cell trait in American football?
Harmon KG, Drezner JA, Casa DJ.
http://bjsm.bmj.com/content/46/3/158.long
Return to Physical Activity After Exertional Rhabdomyolysis
O'Connor FG; Brennan FH, et al.
http://journals.lww.com/acsm-csmr/Fulltext/2008/11000/Return_to_Physical_Activity_After_Exertional.8.aspx

Mayo Clinic and AMSSM sports medicine specialist, Dr Jon Finnoff, on managing leg pain in sport.

Dr Jonathan Finnoff, DO, is the Medical Director for Mayo Clinic Square, Sports Medicine Center, Minneapolis, Minnesota. He is a specialist in Physical Medicine and Rehabilitation and Sports Medicine. He benefits from his experience as a former professional athlete in his work as the Team Physician for professional basketball teams -- the Minnesota Timberwolves and Lynx.
Dr Finnoff addresses the case of a 24 year old basketball player who has calf pain that stops her from playing but responds relatively quickly when she stops running.
Timeline
• The differential diagnoses include chronic exertional compartment syndrome, vascular problems such as popliteal artery entrapment, as well as neurological causes
• Physical examination is critical and there are some key tests to distinguish those different pathologies
• The role of investigations including imaging
• How does one make the compartment pressure diagnosis?
• Treatment for chronic exertional compartment syndrome including gait retraining
• More aggressive treatment including use of the meniscotome, botox injection and surgery
• Outcomes of treatment including botox and surgery
Link to previous podcasts:
This podcast is complemented by one with Professor Francis O’Connor: https://soundcloud.com/bmjpodcasts/professor-francis-oconnor-from-the-amssm-challenging-leg-paincalf-pain-and-military-injuries?in=bmjpodcasts/sets/bjsm-1
Andy Franklin-Miller’s BJSM podcast on exertional compartment syndrome and gait retraining: https://soundcloud.com/bmjpodcasts/running-injuries-with-andy
Andy Cornelius on how to assess a runner and what to do when you see abnormalities:
https://soundcloud.com/bmjpodcasts/keeping-runnners-running-the-secrets-of-running-assessment-advice-and-exercise-progressions

Professor Francis O’Connor, from the AMSSM: Challenging leg pain/calf pain and military injuries

BJSM’s good friend Fran O’Connor is Director of Emergency Medicine and Sports Medicine at Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland. He is a former President of the American Medical Society for Sports Medicine (AMSSM, @theAMSSM). He also held leadership positions in the American College of Sports Medicine and the American Medical Athletic Association. He is a prolific researcher with more than 60 scientific journal publications, 25 book chapters and numerous national and international presentations.
In the podcast he addresses the following questions:
• What are the main challenges seen by clinicians who work in military settings?
• What is the differential diagnosis to consider in the patient with calf pain, leg pain?
• How does one make the compartment pressure diagnosis?
• What are the challenges of measuring compartment syndrome?
• What is the conservative management for compartment syndrome? (Prof O’Connor touches on gait retraining first and foremost, Pose running technique, botox injection)
• Is there a role for surgery, and if so, which surgery? What are the outcomes?
• What is the role of orthoses?
Link to previous podcasts:
This podcast is complemented by one with Dr Jonathan Finnoff: https://soundcloud.com/bmjpodcasts/mayo-clinic-and-amssm-sports-medicine-specialist-dr-jon-finnoff-on-managing-leg-pain-in-sport?in=bmjpodcasts/sets/bjsm-1
Andy Franklin-Miller’s BJSM podcast on exertional compartment syndrome and gait retraining:
https://soundcloud.com/bmjpodcasts/running-injuries-with-andy
Andy Cornelius on how to assess a runner and what to do when you see abnormalities:
https://soundcloud.com/bmjpodcasts/keeping-runnners-running-the-secrets-of-running-assessment-advice-and-exercise-progressions

Football Medicine Supremo Mike Davison: A decade of dramatic change in sportsmedicine/sportsphysio

How has football medicine changed in the past 10 years? What is its future?
Mike Davison, managing director of Isokinetic Medical Group in London, one of the FIFA medical centers of excellence, gives us an excellent overview of football medicine: past, present and future. In this hard-hitting podcast we also preview the upcoming Isokinetic Conference in Barcelona, where representatives from over 88 countries are attending.
Topics discussed in this podcast include:
-Where has football medicine come from? What is the state of play now?
-The challenges in managing re-injury and long-term rehab
-Is there too much over medicine in sport? How has this come about?
-What can we expect from the Isokinetic Conference?
-Practical tips to break into the field for aspiring clinicians
For articles on this topic, visit http://bjsm.bmj.com/

From the AMSSM: 3 sports medicine legends on running injuries, illness and footwear

The American Medical Society for Sports Medicine (AMSSM) has its Annual Meeting come up (May 8-13, 2017) so we celebrate with this podcast. Dr Devin McFadden (Sports Medicine Fellow, Washington D.C) is your host. He chats with Dr Bert Fields (Sports Medicine Physician, North Carolina), Dr Robert Oh (Sports medicine, Fort Benning, Georgia) and Dr Chad Asplund (Athletic Sports Medicine, Georgia Southern University)
Topics discussed include:
• Common mistakes made by amateur running athletes – training errors and hip abduction weakness get a mention
• Is one type of exercise best for reducing the risk of cardiovascular disease? The trade-off between health benefits and injury risk.
• Non-MSK running injuries- which ones do we need to think about?
• Biomechanics of running and types of shoes
• Minimalist and barefoot running- evidence supporting a different running style?
Link to JAMA study that mentioned the ‘weekend warrior’ promoting health: https://www.ncbi.nlm.nih.gov/pubmed/?term=JAMA+internal+medicine+and+weekend+warriors and the BJSM editorial commenting on it (FREE this weekend!) http://bjsm.bmj.com/content/early/2017/02/23/bjsports-2017-097538
Link to BJSM paper suggesting you can’t run to your way to health weight http://bjsm.bmj.com/content/49/15/967.long (FREE)
Link to 2016 BJSM paper where 1 in 13 runners had illness in the lead up to an event http://bjsm.bmj.com/content/50/15/939.long
Link to BJSM RED-S consensus statement: Relative Energy Deficiency (Sport) http://bjsm.bmj.com/content/48/7/491.long (FREE)

Dark underbelly of competitive sport - Harassment and abuse. Dr Margo Mountjoy. Host Dr Karen Litzy

What is abuse and how does it manifest itself in sport? In this hard-hitting podcast, Karen Litzy hosts Dr Margo Mountjoy, IOC medical commission, FINA executive board member, and associate clinical professor at McMaster University. Dr Mountjoy explores the various types of harassment, how it can occur, and what safeguards can be put in place to help athletes report abuse.
Highlights include:
-What does it mean when we talk about abuse and harassment?
-Youth sport and why we need to be especially careful in our younger athlete
- Top tips to recognizing abuse: when is the athlete trying to tell us something?
-Putting in safeguarding mechanisms to protect athletes and report abuse
-The impact of social media in sport especially among “millennials”
-Take home messages for working in practice
Dr Mountjoy is a Senior Associate Editor at BJSM and here’s the link for her previous podcast about energy deficiency among sportspeople (RED-S) http://ow.ly/w6w430aBmKJ
Link to the open access (FREE) IOC consensus statement on non-accidental violence in sport: http://ow.ly/YzMd30aBmA2

Dr Ben Kibler: Clinical assessment of the tennis player with a focus on the shoulder

In part 1 of two podcasts, Dr Ben Kibler, international shoulder authority, shares top tips on examination and diagnosis of the tennis player. (Part 2 will focus on baseball pitchers)
Dr Ben Kibler, orthopaedic surgeon and medical director of Lexington Clinic in Kentucky is a world expert on management of shoulder injuries with a particular focus on the role of the scapula (scapular dyskinesis). He has held regular ‘scapular summit’ meetings of experts in his hometown of Lexington, Kentucky, USA. The most recent summary of that meeting can be read here: http://bjsm.bmj.com/content/47/14/877
In this podcast, we discuss:
• Briefly how Dr Kibler, a surgeon, learned about biomechanics
• Examination of the tennis player’s shoulder including how to perform a biomechanical analysis
• Simple tests to recognize abnormal asymmetry in the tennis player
• Diagnosis of injury in tennis players; search for culprit (the real cause) – don’t just incriminate the victim
• The rise in the double-handed backhand in tennis and how it has increased the incidence of ulnar wrist injuries
• Role of communication within the multidisciplinary team: how much should the physician know about the biomechanics?
• Two tests commonly used to assess shoulder function – the Scapular Assistance Test (SAT) and the Scapular Retraction Test (SRT).
Remember to keep an eye out for Part 2 – management of the overhead throwing athlete. You can meet with Dr Kibler in person at the AMSSM annual conference. May 9-13, 2017, San Diego. It’s a prime spot on the sports medicine calendar. https://www.amssm.org/Content/pdf%20files/BROCHURES/2017_Annual_Meeting.pdf

Professor Graham Smith, Society of Sports Therapists: Return to play and more!

The Society of Sports Therapists was established in the UK in 1990 to address the growing demands from sport and leisure on everyone involved in the management and care of injured participants.
In this 2nd podcast with BJSM, Professor Smith highlights hot topics such as: (i) readiness to return to play and how it differs from return to competition, (ii) training load and contribution of new data in the training-injury field. I summarise the program for the 2017 conference “From Pain to Performance” (May 20th, 2017) that features Peter Brukner, Bill Knowles, and Susan Alexander.
The Society of Sports Therapists is one of 25 member societies that partners with BJSM:
Links:
Home page for the Society of Sport Therapists
http://www.society-of-sports-therapists.org/index.php
Where to study Sports Therapy (BSc Hons)
http://www.society-of-sports-therapists.org/index.php/public/degree_courses_BSc
Where to study Sports Therapy if you already have a relevant degree (MSc)
http://www.society-of-sports-therapists.org/index.php/public/degree_courses_MSc
Previous podcast: 2016
https://soundcloud.com/bmjpodcasts/focus-on-sports-therapists-and-students-considering-sports-therapy-professor-graham-smith

What are the odds? Understanding Risk and Uncertainty

What are the odds? Understanding Risk and Uncertainty.
Today we welcome Dr. Rod Whiteley for the first time ever to the BJSM podcast. Rod has done a bunch of work in shoulder injuries (measuring load and strength long before it got sexy). And the rumour is he’s still got a pretty good curve ball. A clinician for well over 20 years, He is the current assistant director of the Rehab department here at Aspetar Orthopaedic and Sports Medicine Hospital, and he has also contributed heavily in the area of hamstring rehabilitation and groin injuries. Look out for him on twitter @RodWhiteley, where’s he’s happy to be unpopular to point out the obvious.
Rod is a clinical researcher, interested in how practitioners can understand statistics better, and integrate that in their daily practice. In this podcast, Rod and I talk about how we understand risk, in particular percentages and odds. And no, they’re not the same thing.
2:45 The difference between odds, ratios, and percentages.
3:20 An example: ACL and hamstring injuries as an example, looking at the base rate for how often these injuries happen (ACL infrequently, and hamstrings quite frequent), and then adding a likelihood ratio and how does that change the odds.
5:20 Chad Cook and Erik Hegedus really turned our ideas around interpreting risk around. Clinicians need to understand pre- and post-test odds. Find the related articles here (http://bmj.co/2m65v43) and in the links below.
6:30 Mladen Jovanovic (@Physical_Prep) - heuristics and uncertainty, published recently here (http://bmj.co/2nrRUUX) in the Aspetar journal. We have to get more comfortable with the uncertainty of these tests.
7:46 Understand base rates, and using tests that have large likelihood ratios in our clinical assessment. Pre-test odds will influence how you interpret your clinical test, which then changes your post-test odds.
10:14 Can we do the same for prevention, and identifying risk? IOC world conference prevention of injury and illness in sport (http://bmj.co/2m64AR8) in Monaco will focus this year on the value of screening. Screening allows us to identify modifiers and change potential interventions at a group level.
10:31 The importance of population level studies, looking for associations with subsequent injury. Screening is useful for injury prevention. “But if you’re doing a test to tell someone they are or aren’t gonna get injuried, you’re gonna make a monkey of yourself in open court pretty quickly.”
12:27 WHO report on risk of cancer risk associated with eating bacon/processed meat. If we ignore the base rate, we might be fooled by the actual change in risk. And then you still need to interpret that for the individual.
14:00 Absolute vs Relative risk, and what is the actual event happening. We don’t think of delayed onset of muscle soreness (DOMS) and sudden cardiac death the same.
14:15 Two players with the same risk of injury, but totally different interpretation of their result.
15:12 Predicting vs Forecasting - “An experiment that only happens once.” You only get one season and and you either get an injury or you don’t. We have to be more comfortable with that kind of uncertainty.
16:35 Predicting return to play with clinical outcome measures.
18:30 How do we interpret and incorporate percentages and odds into our clinical setting.
Links:
IOC world conference prevention injury and illness in sport (http://bmj.co/2m64AR8)
Available for FREE from BJSM (http://bjsm.bmj.com/)
Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests (http://bmj.co/2mwMP90)
A combination of initial and follow-up physiotherapist examination predicts physician-determined time to return to play after hamstring injury, with no added value of MRI (http://bmj.co/2mx0r3Z)