WARM UP

What have overprescription of NSAIDs, overtraining and modelling physical activity for kids got to do with Barack Obama in Berlin?

Karim Khan

September already! Can you believe it? Are you exhausted from the Olympics? Has it motivated your patients to be active? Interestingly, when Australians were interviewed before and just after the Sydney Games, there was an increase in people thinking about doing physical activity. Unfortunately, a year later physical activity levels had remained unchanged.¹ Not to worry, the Olympics contribute to world peace. So we eagerly anticipate more peace during upcoming Olympics in Vancouver (2010), London (2012) and, we hope, Tromsø (2018).

But on to BJSM business and Barack. In this issue we learn that 10% of FIFA World Cup players took NSAIDs prior to every match (see p 725)! Would paracetamol/acetaminophen have been better choices? Or a placebo? As sports clinicians working with the "healthy elite athlete" is this OK? Futhermore, supplement use was rampant—the champion ingester took 7.4 different supplements before every game! Clearly this player couldn’t play in the Football Association for the Visually Impaired (http://www.favi.co.uk) because his stomach rattle would have him confused for the ball. This is a landmark paper not only for athlete health but also for the terrific collaboration among team physicians—Hippocrates would approve. Fortunately the supplement creatine does not produce liver or kidney damage (see p 731). Good thing. But the question remains—does it provide athletes any benefit? Pluim argued that there is no evidence for its use in tennis.² Another expensive placebo?³ Share your thoughts on the BJSM Blog http://blogs.bmj.com/bjsm/.

The second cover page controversy relates to overtraining/overreaching. IOC Medical Commission Chairman, Dr Arne Ljungqvist, highlighted the challenge of diagnosing this condition and its importance to athletes during the Track and Field symposium at the 2nd World Congress on Sports Injury Prevention in June.^{4 5} In this month’s BJSM, researchers from Canada, France and Belgium scrutinised heart rate measures to see whether they provided an evidence-based guide for coaches and athletes (see p 709). Take a look at this lovely meta-analysis. Half an hour in BJSM can save you 6 months in the library. And it might save you wasting 4 years of (over)training. Go on, click through now!

Sports medicine icon, Professor Roy Shephard, joins in the "overinvestigating" debate (see p 707), specifically arguing against Wilson’s recommendation of mandatory ECG screening of athletes to reduce sudden cardiac death.⁶ As with our "peer-review" fair review section,⁷ BJSM is a "safe place" and lauds academic debate. Respectful, evidence-based "conflict" is healthy and can only advance the field for patients. Corporate guru Lencioni rates "fear of conflict" as the second of the five fatal dysfunctions of a team.⁸ Sports clinicians will be interested in all five because they relate to team dynamics but the point here is that BJSM not only tolerates, but actually encourages, differences of opinion and debate. No threat of Gitmoⁱ without charges here (oops, I am getting ahead of myself). Yes, disagreement is OK—even so far as some young upstart contending that there may be inflammatory cells in tendinopathy (see p 753)!

On the subject of tendinopathy, Alfredson and colleagues from Umeå in Northern Sweden have been at the forefront of tendon treatment innovation for a decade; their Achilles heel-drop paper is 25th (and climbing) in the all-time highest cited papers in the American Journal of Sports Medicine⁹ (note to Ed-AJSM, add one more citation to Alfredson). But crucial to our readership is that even Alfredson struggles when treating insertional Achilles tendinopathy. Cardiff’s Professor Benjamin has taught us that enthesopathies ("enthesis organ") are very different diseases from mid-portion tendon pathology – with much poorer prognosis.¹⁰ Thus, this new programme from Sweden that avoids dorsiflexion is a welcome addition ready for prime time (see p 746)! Share your experience with this new programme and your own successful strategies on the Blog http://blogs.bmj.com/bjsm/. And remember that the Tendinopathies Special Theme Issue of BJSM will run in March 2009. Submissions are closed but what the heck, the way "the e-journal is the journal" these days, you could submit today, have your paper fully accepted within 50 days, and be "Online First" ahead of that issue anyway. Yes, that’s right—the average time from submission to acceptance for the 544 papers reviewed in 2008 in BJSM is 46.2 days—less than 7 weeks on average and you are readable and citable "Online First"!

The "Best of BMJ" section has proven a big hit (literally, we know what you are clicking on!). This month we learn that if you want your kids to be active you probably need to model that for them during their first 5 years. Damn! Just in the years when you are not getting any sleep—you have to go and teach your kids something active like sword-swallowing.¹¹ Great to borrow from a journal with an impact factor of around 10 with well over 100 000 subscribers! If you have time for just one general medical journal check it out at http://www.bmj.com—it really vivifies its mission of helping clinicians and health policy makers improve patient care.

And finally to Barack—apparently an advocate for physical activity. In a Canadian national newspaper (Globe and Mail), journalist John Ibbitson reported a McCain camp advertisement that said, during Obama’s visit to Germany in July, the Illinois senator "made time to go to the gym but cancelled a visit with wounded troops". Now this was supposed to be a criticism of Senator Obama. Wow!! What audacity! My immediate thoughts were twofold. One, which US political party sanctioned the invasion into Iraq that caused the soldiers to be wounded? US Senator Bernie Sanders (Vermont) tells us that more than 1.6 million American troops have been deployed in Iraq and Afghanistan. More than 4000 have been killed. More than 65 000 have been wounded or injured. Nobel laureate and economist Joseph E. Stiglitz calculates that, conservatively, 3 trillion US dollars have been devoted to the invasion of Iraq. Some of sports medicine’s best physicians work to help these troops regain their quality of life—despite soldiers’ amputations, disfigurement and head injuries. No-one denies these clinicians are remarkable healers, and clearly no-one wants to make political mileage at the expense of brave souls. But it was surprising that such an advocate of "the surge" as McCain would bring up the sports/military medicine issue of wounded troops.

My second thought was that I must have missed the memo that said going to the gym is something to hide! Wouldn’t you want the President to have full cognitive function,¹² protection against cardiac disease, diabetes and cancer? Shouldn’t Obama be on top of jet lag in a crucially important week meeting with chancellors and prime ministers? The advertisement should have been asking him for the secret of how he manages to maintain his fitness despite the schedule. What I find remarkable is that, even though the US has been provided an excellent, achievable plan for waging a war against physical inactivity,^{13 14} the potential commander-in-chief is chastised for practising what the American College of Sports Medicine, and others, have preached for a long time—Exercise Is Medicine. As physical activity is the most powerful health modality available across systems, we must ensure that taking a few minutes a day to maximise our health is never something to be ashamed of. Never. Never. Never.

Competing interests: None declared.

ⁱ "Gitmo" is a North American media abbreviation of "Guantanamo Bay"; interested readers are directed to: Jackson T. Torture: the Guantanomo guidebook; is toture a good idea? BMJ 2005;330:543 (5 March), doi:10.1136/bmj.330.7490.543 and Roehr B. US doctors lobby for end to torture of terrorism suspects. BMJ 2006;333:10 (1 July), doi:10.1136/bmj.333.7557.10-d.

1. Murphy NM, Bauman A. Mass sporting and physical activity events—are they "bread and circuses" or public health interventions to increase population levels of physical activity? J Phys Act Health 2007;4:193–202.[Medline]
2. Pluim BM, Ferrauti A, Broekhof F, et al.. The effects of creatine supplementation on selected factors of tennis specific training. Br J Sports Med 2006;40:507–11; discussion 511–2.[Abstract/Free Full Text]
3. Godlee F. Reclaiming the placebo effect. BMJ 2008;336:0. (3 May), doi:10.1136/bmj.39567.551181.47.
4. Ljungqvist A. Sports injury prevention: a key mandate for the IOC. Br J Sports Med 2008;42:391.[Free Full Text]
5. Abstracts. 2nd World Congress on Sports Injury Prevention, 26–28 June 2008, Tromsø, Norway. Br J Sports Med 2008;42:491–548.[Free Full Text]
6. Wilson MG, Basavarajaiah S, Whyte GP, et al.. Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. Br J Sports Med 2008;42:207–11.[Abstract/Free Full Text]
7. Khan KM, Stovitz SD, Pluim B, et al.. Addressing conflicts of interest and clouding of objectivity: BJSM’s "peer review: fair review" section. Br J Sports Med 2008;42:79.[Free Full Text]
8. Lencioni P. The five dysfunctions of a team: a leadership fable. San Francisco: Jossey Bass, 2002:229.
9. Alfredson H, Pietila T, Jonsson P, et al.. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360–6.[Abstract/Free Full Text]
10. Benjamin M, Moriggl B, Brenner E, et al.. The "enthesis organ" concept: why enthesopathies may not present as focal insertional disorders. Arthritis Rheum 2004;50:3306–13.[CrossRef][Medline]
11. Witcombe B, Meyer D. Sword swallowing and its side effects. BMJ 2006;333:1285–7.[Abstract/Free Full Text]
12. Kramer AF, Colcombe SJ, McAuley E, et al.. Enhancing brain and cognitive function of older adults through fitness training. J Mol Neurosci 2003;20:213–21.[CrossRef][Medline]
13. Booth FW, Chakravarthy MV, Gordon SE, et al.. Waging war on physical inactivity: using modern molecular ammunition against an ancient enemy. J Appl Physiol 2002;93:3–30.[Abstract/Free Full Text]
14. Booth FW, Gordon SE, Carlson CJ, et al.. Waging war on modern chronic diseases: primary prevention through exercise biology. J Appl Physiol 2000;88:774–87.[Abstract/Free Full Text]

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