5 Questions with Dr. Jane Thornton — what is the physical activity prescription?

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Jane Thornton MD, PhD (2nd from left) — Canadian Olympian and Lead Author of CASEM Position Statement

We are having a sit down with Jane Thornton, MD PhD today as part of our recurring  blog offering, ‘5 Questions with CJSM.’  Among many other things, Dr. Thornton is the lead author of the new Canadian Academy of Sport and Exercise Medicine (CASEM) Position Statement on the ‘Physical Activity Prescription.’  This article, published in our July 2016 issue, has already drawn an immense amount of interest — it is currently free, so do not hesitate to check it out and print out/download the PDF to fully appreciate its contents.

Dr. Thornton is an extraordinarily accomplished individual who is finishing up her family medicine/sport medicine training at the University of Western Ontario.  Besides a medical degree, she has earned a Masters and PhD, doing her studies CJSM Associate Editor Connie Lebrun while at the Fowler Kennedy Sports Medicine Clinic.

With the Rio Olympics set to begin in a few days, it is perfect timing to conduct this interview with Dr. Thornton.  While doing all of that academic work noted previously, she was also training for the Canadian national rowing team. She rowed in the 2008 Olympics in Beijing with the Canadian women’s eight.  She knows a thing or two about physical activity, no doubt. In addition to her authorship of the CJSM manuscript, Dr. Thornton has co-created along with Dr. Mike Evans a website about how to #MakeYourDayHarder, advancing the notion that our every day activities offer abundant opportunity to get in meaningful levels of physical activity.

At CJSM, we have had an abiding interest in research on various aspects of physical activity (e.g. check out our recent post on #PEPA16 and Ann Gates, another mentor of Dr. Thornton’s), and so it is with great pleasure that we share with you our ‘chat’ with Jane Thornton.

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1) CJSM: How effective is an ‘exercise prescription’?  What is the evidence for this intervention?

JT: It may sound like common sense that physical activity is good for us, but it has taken us a long time to understand just how important it really is as a component of treatment. When we understand that it can lead to improved clinical outcomes in over 30 different chronic diseases, and can be as effective as medication in many instances (hypertension, stroke, and mild-to-moderate depression, to name a few), then we can’t ignore the fact that it should be something we talk about with our patients.

To best illustrate its effectiveness, though, let’s compare exercise prescription with smoking cessation counseling.  When we examine the number needed to treat (NNT), studies tell us that we need to counsel 50-120 patients to see one patient successfully quit smoking. When it comes to getting one patient to meet the globally agreed upon physical activity guidelines (150 minutes per week of moderate-to-vigorous physical activity), however, that number drops to 12 – meaning we have an incredible opportunity to help patients make a life-changing adjustment in their lives. No one, including me, would argue that smoking cessation counseling is not incredibly important. But given the recent findings that being inactive is almost as bad for you as smoking, we really should be expanding the conversation at each clinical encounter to include exercise.

2) CJSM: What are the barriers to its use?  Why aren’t more physicians actively engaged in giving their patients an exercise prescription?

JT: The most oft-cited barriers are time constraints, lack of education and training, complex comorbidities… and the most honest among us will also bring up the point that we just don’t think patients are motivated enough or willing to change. Interestingly, if we demonstrate a belief in patients, they will usually rise to the challenge. It may also come as no surprise that doctors who are active themselves are also more likely to counsel their patients to be active. A big obstacle in many countries is, of course, remuneration. It’s hard for some to justify time spent counseling on exercise if there is no billing code they can tack on. That one is a tougher nut to crack. Policy makers should take comfort in the fact that the practice of exercise prescription is also cost-effective.

3) CJSM: You are active on Twitter – if you could compose a 140 character Tweet for the CASEM position statement, what would it be?  Read more of this post

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Doctor, Doctor — Give Me the News!

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CJSM at CASEM 2014 with Pierre Fremont [L], former CASEM President & one of the authors in the new CASEM Position Statement

CJSM has always had a close relationship with the Canadian Academy of Sport and Exercise Medicine (CASEM).  CASEM is, after all, our mother — we were ‘born’ 25+ years ago as the “Canadian Journal of Sport Medicine.”   In the journal, on the podcasts and on these blog pages, CASEM shows up frequently.

Something else that shows up frequently in CJSM media:  research on the benefits of physical activity.  And so it’s not surprising to see in our current issue that CASEM is taking a hard look at the issue of “Exercise is Medicine” and is publishing with CJSM (and other journals) a position statement on the “Physical Activity Prescription:  A Critical Opportunity to Address a Modifiable Risk Factor for the Prevention and Management of Chronic Disease.”

The list of authors involved is a list of sports medicine heavyweights, including several MD/PhDs who have a presence on social media:  if you are not currently following folks like lead author Jane Thornton MD, PhD and former CASEM President Pierre Frémont MD, PhD and BJSM Editor-in-chief Karim Khan MD, PhD….you should.

These ‘doctor doctors,’ as I like to call my colleagues who have fought the good fight to earn an MD and a PhD, have produced a powerful statement that will have significant influence on how physicians can play a role in addressing the worldwide crisis of sedentary behavior.  The global problem of inactivity especially in children has been an ongoing concern of mine, and it has puzzled me that when I have spoken on this issue I frequently find that physicians feel as if they are on the sideline of this battle.  We collectively throw up our hands and say the problem is too big, or it’s not a clinical medicine problem it’s a public health issue.

But our patients are looking to us for guidance on this issue.  They really do ‘want the news.’ As the authors note in the position statement, “Over 80% of Canadians visit their doctors every year and prefer to get health information directly from their family physician. Unfortunately, most physicians do not regularly assess or prescribe physical activity as part of routine care,  and even when discussed, few provide specific recommendations.

They continue, “Physical activity prescription has the potential to be an important therapeutic agent for all ages in primary, secondary, and tertiary prevention of chronic disease.”  Indeed, Robert Palmer, the singer of “Bad Case of Loving You (Doctor, Doctor)” fame, could not have known how prescient he was when he penned the lyrics, “no pill’s gonna cure my ill…..”  He was talking about love, but he may as well have been talking about the chronic diseases associated with physical inactivity. Prescribing a pill won’t cure this ill: the physical activity prescription, delivered and acted upon, is required.

The beauty of this position statement is that it gives evidence-based tools that primary care physicians as well as sports and exercise medicine physicians can use in their practice to stem the tide of the inactivity epidemic.  I know this statement will be widely read and disseminated; it will be referenced frequently.  I am looking forward even more to seeing its principles put in action by me and my colleagues, around the world–both in our clinics and in the venues where we train future physicians.

Look it over now.  It’s free!  What’s stopping you?

 

May Day

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CJSM: bringing you clinical sports and exercise medicine research, from around the globe

Whether you are celebrating today as International Workers’ Day, running around a May pole, or watching Leicester City try to complete the 5000:1 shot of winning the Premiership, we are sure that today, May 1, can only be a good day:  our third issue of the year has just published.  And this May Day CJSM is full of offerings we’re sure will be of  interest to you.

Two of the articles have a special focus on physical activity as an intervention for medical conditions — one is a meta-analysis from Chinese colleagues finding a protective effect for physical activity against lung cancer, and the other is a prospective, single-blinded, randomized clinical trial looking at rock climbing as an intervention in the treatment of low back pain. This study is from Austria, and had positive findings for dependent measures of disability (the Oswestry Disability Index), a physical examination maneuver, and even the extent of disc protrusion on MRI.  We’re proud to publish these high quality studies from across the globe.

We are also proud to contribute to the growing body of literature on the effectiveness of “Exercise is Medicine.” Read more of this post

LeBron and Exercise-Associated Muscle Cramping

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Does this count as “Old School”? LeBron James, in his first incarnation as a Cleveland Cavalier (photo: Dave Hogg, Wikimedia)

Game 2 of the NBA finals is this weekend, and I’m sure the Miami Heat (despite their nickname) are hoping the air conditioning works.  In truth, I think most of us are hoping that we witness a straight up basketball affair determined more by athletic skill and less by Exercise-Associated Muscle Cramping (EAMC).

If you need a primer to know what I’m talking about, here’s a brief rundown of Game 1 and LeBron’s EAMC. 

‘Most of us’?  I truly have no horse in this race (speaking of that….I most definitely am rooting for California Chrome to bring home the Triple Crown later today), but outside of Texas, it seems that most of the country may be leaning toward the Heat.  At least that’s what ‘Big Data’ would suggest:  check out this great, data-driven map from the New York Times showing the breakdown of team allegiances across the United States.

Truly though, aside perhaps from a pocket deep in the heart of Texas (who may want victory, no matter what!), I think most fans of the NBA would rather see the outcome of the games determined by the players and not by a lack of AC.

As a team physician, like many of you, I have had–along with my Athletic Trainers–to deal with plenty of muscle cramping in my career.  Here in the States, I find it occurs most often in the very beginning of football season:  during August pre-season, or the early September games that may be played in temperatures approaching 90 degrees.  It seems the combination of relative deconditioning, environmental conditions, and plain foolishness (my adolescent athletes frequently forget to stay hydrated, despite constant reminders to do the same)  gives rise to any number of trips on to the field to assist a player downed with quad or abdominal cramps.  At some levels of the game, to circumvent that inability to maintain adequate oral hydration during a game, teams will turn to pre-game intravenous hydration, as has been discussed in literature published in this journal and blog.

Then again, perhaps there are other issues altogether different than these potential risk factors that give risk to EAMC. Despite the high incidence, the etiology of EAMC continues to be debated.

Yes, I am a believer in the powers of pickle juice, but EAMC remains a puzzle to me and others.  And so I turned to the CJSM website  this morning for guidance and found a great 2013 study:  Collagen genes and exercise-associated muscle cramping, from a group of South African authors.  I especially appreciated this article for its contribution to my basic science knowledge:  I learned so much about the biology behind EAMC.  I encourage you all, clinicians and non-clinicians, to check it out.

The authors begin the paper with an excellent overview of various hypotheses of EAMC, ranging from electrolyte depletion to altered neuromuscular control. They then explored the literature that points to the possibility that EAMC may be associated with a genetic predisposition to musculoskeletal soft tissue injury. Specifically, their research hypothesis was that “variants within collagen genes that code for components of the musculoskeletal system would increase susceptibility to EAMC.”  To test this, the authors conducted a ‘retrospective case-control genetic association study’. Read more of this post

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