Prescribed Exercise for Managing Concussions — the CJSM Blog Journal Club

Our Editor-in-Chief Chris Hughes (R) and Jr. Assoc. Editor Jason Zaremski (L) taking a brief spell from their busy lives.

Our fifth edition of the year went live at the beginning of September, and it’s a special one:  we have devoted the entire issue to the theme of pediatric athletes.

Our guest editor Alison Brooks M.D., M.P.H. has assembled an impressive line up of authors, including John Leddy M.D. of SUNY Buffalo who is the lead on an interesting new study demonstrating the benefits of prescribed aerobic exercise in the recovery of adolescent males from sport-related concussion.

Our Jr. Assoc. Editor Jason Zaremski M.D. has submitted another insightful journal club piece looking at the details of Dr. Leddy’s study.

As fall approaches in the Northern Hemisphere, and spring in the Southern, sports-related concussions will continue to show up in a variety of sports our young athletes play.  This work from Dr. Leddy et al. (including both this new study and his CJSM 2018 study) will be transformative in the way we manage our athletes.

Enjoy the original research paper itself (here) and the journal club article (below).

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Jason Zaremski M.D., Junior Associate Editor CJSM

Title:

Leddy JJ, et al. A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med 2019 29(5):353-360.

Introduction:  

As the temperature begins to change and we enter the fall season, millions of student-athletes have returned to school and sport. With such large participation numbers in sport inevitably comes a rise in injury. One of these injuries is sports related concussions (SRC). In recent years, our overall knowledge of how to diagnose, manage, and treat SRC has improved thanks to the ever-growing research in this area. However, one aspect that is continuing to evolve is the timing and intensity of physical activity after sustaining a SRC. While rest (cognitive and physical) has been a mainstay of treatment in the past, there is a growing body of research that indicates physical activity may accelerate recovery versus physical rest only. Thus, it is our pleasure to provide this month’s CJSM Journal Club by reviewing Leddy and colleagues’ new work on the effects of early aerobic exercise as a potential treatment for SRC in adolescent males.

Purpose/Hypothesis(es):

The primary purposes of this research is to compare early subthreshold aerobic exercise (STAE) versus prescribed rest and days to recovery from concussion for adolescent males. The authors hypothesized that STAE would reduce the days to recovery after treatment prescription. Read more of this post

Five Questions with Dr. Nick Peirce: The Role of Physical Activity and Sport in Mental Health

Dr. Nick Peirce, lead on the FSEM team producing recent exercise and mental health position statement.

Reduce depression and cognitive decline by up to 30% with regular exercise?  Can this be so?

For those of us ‘in the know’ in this field of sport and exercise medicine, that statement may seem understood.  But medical research translating to broadly held knowledge which then may lead to meaningful change:  well, we ALL know how rare that situation can be.  The management of recent concussion events in the FIFA World Cup reminds us of the difficulty of knowledge translation: there were instances where it seemed as if we were ‘partying like it’s 1999’ so to speak.

Reviews of the current state of evidence-based knowledge about medically important findings continue to be of vital importance in ‘getting the word out’.  In that spirit, we couldn’t be happier to see the recent position statement released by one of our partner societies, the Faculty of Sport and Exercise Medicine (UK) : The Role of Physical Activity and Sport in Mental Health.

The lead on the team of authors which produced this FSEM UK Position Statement is Dr. Nick Peirce, Chief Medical Officer of the England and Wales Cricket Board.  We wanted to pick his brain to get a bit more of the background work which resulted in this statement.  The summer Cricket season has kept Dr. Peirce occupied above and beyond his usual level of busyness.  During a gap between competitions, CJSM caught up with him — the results of our interview can be found here.

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1. CJSM: We want to discuss the new FSEM statement on the role of physical activity and sport in mental health, but first can you tell us a bit about yourself: your background as a sports medicine clinician and your involvement with FSEM?

NP: I have been involved in Sports and Exercise medicine for over 20 years having worked across a large number of Olympic and Professional sports, including Leading Sports Medicine for English Institute of Sport (EIS) at the busiest site in the country at Loughborough University, the Davis Cup team and the football team Nottingham Forest. I am a Hospital Consultant in Sport and Exercise Medicine in the NHS and have been Chief Medical Officer for the England Cricket for the more than 10 years. I have been involved in many of the Sports Societies and for 3 years have sat on the Faculty (FSEM), although professional sport commitments make this challenging.

2. CJSM: How did you become involved with this particular FSEM project on mental health – was there a large team involved in the production of this project? Was FSEM the only organization involved in the drafting of this document? Read more of this post

Five Questions with CASEM President Tatiana Jevremovic, M.D.

Tatiana Jevremovic, M.D. — current president of the Canadian Academy of Sport and Exercise Medicine (CASEM)

The Canadian Academey of Sport and Exercise Medicine (CASEM) hosts its annual symposium in Halifax, Nova Scotia, in just a couple of days:  from June 6 to 9 sports medicine clinicians from around Canada and the globe will be attending what looks to be another excellent conference which CASEM is hosting.

This past year Tatiana Jevremovic, M.D. has been serving as the CASEM president.  We thought it would be a good time to catch up with her before the clock runs out on her presidency at the end of this month.

In the midst of all her many, many commitments, she graciously found the time to do this interview.  We were delighted with the results, and we know you will be as well.

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1. CJSM: Where else to begin but by asking you about your year as President of the CASEM. You complete your term at the end of June, after the annual meeting which takes place in Halifax this year. What were your major challenges as president this year?  What were your high points?

TJ: There have been a few high points during my presidency year. We hired a communication advisor that has started elevating CASEM’s profile on social media through infographics and soon-to-be-completed new podcasts. We have met and introduced CASEM to the Public Health Agency of Canada as well as other organizations such as ParticipACTION, and are exploring future collaborations on projects of mutual interest such as concussion and health enhancing physical activity.. We continue to strengthen our professional relationships with friends and stakeholders such at Sport Information Resource Centre (SIRC), Canadian Medical Association (CMA), Royal College of Physicians and Surgeons of Canada (RCPSC), College of Family Physicians of Canada (CFPC), Canadian Concussion Collaborative affiliated organizations (CCC), and others.

It has been an extremely exciting year, and my biggest challenge has been accepting that this role is only for 1 year. I will miss it terribly, but am comforted in knowing that my successor, Dr. Paul Watson, will do a great job. I will also continue to promote the Academy and all of its success in my new role as past president.

2. CJSM: You currently work as an Associate Professor in the Dept. of Family Medicine at Western Ontario and at the Fowler Kennedy Sport Medicine Clinic in London, ON. Can you tell us a little about your background in sports medicine and what you do with your professional time when you are not attending to CASEM Presidential duties? Read more of this post

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

Canadian Women 8+ jane thorton

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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