Sport Health Volume 41 Issue 2

Sport

health

FEATURING

• Can Pre-Exercise Hyperhydration Improve Exercise Performance in Hot Conditions?

• What to look forward to at the 2023 ASICS SMA Conference

• Fallen warriors: Lessons from rugby-related spinal cord injury in Australia

Contents

REGULARS

02

From the Chair

SMA Board Chair, Kay Copeland welcomes the new JSAMS Plus Editor-in-Chief and reflects on the 60th Anniversary celebrations so far.

03

From the CEO Jamie Crain highlights the new website and member portal, and summarises this edition’s feature articles.

FEATURES

04

SMA and the Disciplines

In commemoration of SMA’s 60th Anniversary, we look back at the growth of the various discipline groups within sports medicine.

08

Can pre-exercise hyperhydration improve exercise performance in hot conditions?

William T. Jardine and Dr Amelia J. Carr assess the appropriateness of pre-exercise hyperhydration as an effective heat mitigation strategy for athletes.

14

Kids with concussion more likely to have poor school performance

Dr Reider Lystad presents his views on the effects of concussion on young people’s school performance and suggests return-to-school protocols.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

Publisher Sports Medicine Australia Melbourne Sports Centre.

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Copy Editors

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Marketing and Member

Engagement Manager

Sarah Hope

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Perry Watson Design

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Content photographs

Author supplied; www.gettyimages.com.au

18

2023 ASICS SMA Conference: What to look forward to

We are excited to have international and nationally renowned experts across all sports medicine streams present on their area of expertise.

22

Fallen Warriors: Lessons from rugby-related spinal cord injury in Australia

Nicole Merrick discusses the immediate outcomes and long-term consequences after spinal cord injury in rugby union players.

INTERVIEWS

34

5 Mins With: Dr Paolo Menaspa

28

Adapting to the summer heat

Harry Brown shares his assessment of seasonal heat acclimatisation studies and indicates potential influencing factors.

38

Physician Focus: Dr Laura Lallenec

42

Sports Medicine Around the World: Bulgaria

44

32 WA Symposium Summary

Dr Myles Murphy and Cobie Starcevich recap the symposia presentations on the topic of gender bias in pain, performance, and sports medicine.

Sports Trainer Highlight: Michael Quill

FROM THE CHAIR

A lively calendar of events for our 60th year.

DR KAY COPELAND, CHAIR OF THE BOARD OF DIRECTORS (SMA), WELCOMES THE NEW JSAMS PLUS EDITOR-IN-CHIEF AND REFLECTS ON THE 60TH ANNIVERSARY CELEBRATIONS SO FAR.

Welcome to the second edition of Sport Health for 2023.

Our 60th year has already revealed itself to be a lively one for SMA and its members. With many online and in-person events on the calendar for the rest of the year, I encourage all members to attend an upcoming event and get curious about the latest happenings in the world of sports medicine.

In April, I travelled to Western Australia to attend the Symposium on Gender Bias in Pain, Rehabilitation and Performance. It was impressive to hear from the various speakers on the challenges regarding gender equity still present in the research and clinical space. Afterwards, I was delighted to attend the networking lunch alongside CEO Jamie Crain to commemorate SMA’s 60th Anniversary. This was a wonderful opportunity to connect and reconnect with many of SMA’s passionate members and celebrate the success of the organisation over the past 60 years.

Continuing with our 60th Anniversary celebrations, this edition’s commemorative article looks back

on the formation and role of the various discipline groups associated with SMA. We also pay homage in the Honour Board to the esteemed Refshauge Lecturers who have provided the opening address at our annual conference over the years.

I am delighted that Dr Jessica Orchard has been appointed as the new JSAMS Plus Editor-In-Chief, our open-access online journal. Dr Orchard is highly qualified to lead the publication as a Senior Research Fellow and NHMRC Emerging Leadership Fellow at the School of Public Health, Faculty of Medicine, at the University of Sydney,

and with over 16,800 citations across her 65 peer-reviewed papers. I look forward to seeing the future direction and growth of JSAMS Plus under Dr Orchard’s supervision.

I wish to thank all those who have submitted a nomination for their relevant State Council. The role of the State Councils is vital for the development of a variety of interesting and appropriate professional development opportunities for SMA members and ensuring the sports medicine community is represented at a regional level. I am confident that all successful nominees will have a profound impact upon their respective state or territory.

With the 2023 ASICS SMA Conference on the horizon, I would like to encourage anyone who is considering applying to become an ASMF Fellow, to begin composing their application. New Fellowships will be announced at the ASMF Fellows Dinner during the conference. I look forward to welcoming the new Fellows on board who have significantly contributed to our great field of sports medicine.

If you have not already, remember to complete your registration for the 2023 ASICS SMA Conference. I am excited to see all our members at this at this amazing event and to join in the 60th Anniversary celebrations.

Dr Kay Copeland

With the 2023 ASICS SMA Conference on the horizon, I would like to encourage anyone who is considering applying to become an ASMF Fellow, to begin composing their application.

FROM THE CEO

A new and improved experience for SMA Members.

Welcome to the latest edition of Sport Health.

The first half of this year has proven to be very busy already, and I have been delighted to attend a number of our events in person. In April, I was proud to present Sarah Polhill with the 2023 ‘Karen Schneider SMA Safer Sport Award’ at the 50th Northern Territory Sports Awards for her outstanding contributions to a safer sporting environment within rugby union. Later that month, I was also able to attend the WA Symposium and networking lunch alongside Kay Copeland, our Chair of the Board of Directors.

Recently, you may have noticed that SMA’s website has undergone a major transformation. Our new site has been rebuilt from the ground up and features a simplified design with a more accessible event registration system that will make it easier to access all the information you need. It also includes a new member portal and introduces the SMA Honour Boards where we celebrate the notable achievements of many of our past and present members.

Managing the long-term outcomes of injuries is at the core of what we do in sports medicine.

Managing the long-term outcomes of injuries is at the core of what we do in sports medicine. In the world of rugby union, Nicole Merrick assesses the wellbeing and care of players affected by spinal cord injuries to help improve safety strategies and longterm support. In addition, Dr Reider Lystad outlines return-to-school protocols for children affected by concussion, an injury that continues to raise important questions for our members and community.

This edition of Sport Health explores the impact of heat in sport through a number of perspectives. In our first article, William Jardine and Dr Amelia J. Carr evaluate the effectiveness of hyperhydration on exercise performance in hot conditions. Additionally, Harry Brown reviews the present research on seasonal heat adaptations and proposes contributing factors that should be taken into consideration.

Finally, a reminder to register before 31st July to get your ‘early bird’ rate for the 2023 ASICS SMA Conference that will be held at the Novotel Sunshine Coast Resort from 11 - 14 October. In this edition, we provide a sneak peek about what to expect at this year’s conference. I would also like to thank everyone who has submitted their work for the abstract, workshop and symposia categories. This year’s conference will feature a rich and diverse program due in large part to the incredible number of quality submissions we have received, and we are confident that this year’s program will have a lasting effect on sports medicine knowledge well into the future. We hope to see you there.

Jamie Crain jamie.crain@sma.org.au

SMA CEO JAMIE CRAIN HIGHLIGHTS THE NEW SMA WEBSITE AND MEMBER PORTAL, AND SUMMARISES THIS EDITION’S FEATURE ARTICLES.

SMA and the Discipline Groups

THIS YEAR MARKS SMA’S 60TH ANNIVERSARY, AND THERE’S MUCH TO CELEBRATE. THIS ARTICLE IS THE NEXT IN OUR COMMEMORATIVE SERIES, AND TAKES US BEYOND SMA’S BEGINNINGS IN THE 1960S AND THE INITIAL JOURNEY OF SELF-REALISATION BASED ON GEOGRAPHY AND MEMBERSHIP MAKE UP, INTO THE 80S AND THE NEXT CHALLENGE OF ENGAGING THE BURGEONING NUMBER OF DISCIPLE GROUPS.

With the battle for nonmedical members fought and won, and their numbers increasing at a greater rate than doctors during the 1980s, Sports Medicine Australia found itself with a new internal challenge on its hands. It had weathered the contest of the states, but the wider growth of sports medicine throughout Australia meant an ever-changing landscape of disciplines. The emerging interest was the growth of the disciplines as a separate entity within sports medicine.

Sports Medicine Australia had always been an umbrella body interested in any issue or activity of a medical or scientific nature that relates to health and wellbeing, particularly in a sports and physical activity context. The issue was that membership of SMA was important to members of all discipline groups but did not provide accreditation, professional development, and

all the collegiate benefits that come with associating with peers who have the same professional qualifications and experiences.

As the membership body of SMA grew in diversity, an organic development

of discipline groups within SMA occurred. Likeminded and leading SMA members within each discipline, banded together to form small sub-groups to cater for the needs of their discipline under the SMA banner. At one stage, SMA initiated a Council of Disciplines to foster this development and ensure the voice of each of the disciplines within SMA was truly taken into consideration. The consequence of this meant that SMA became a true multidisciplinary organisation, promoting and providing growth in all discipline areas of sports medicine and sports science.

Over the years, as the disciplines within SMA grew, these groups gravitated toward their own professional bodies to establish sports medicine key groups within those bodies and moving out from the SMA banner. In some cases, this created brand new organisations, such as the Australian College of Sports and Exercise Physicians and Exercise and Sports Science Australia.

The SMA Conference

The growth of the discipline groups was showcased each year at SMA’s marquee event, the SMA Annual Conference. As the discipline groups grew, it became imperative that new streams were created at the national Conference for each discipline group’s area. This led to a large Conference with discipline and integrated streams servicing across the entire sports medicine community.

Over time, as the disciplines moved back towards their own professional bodies, the Conference evolved to have integrated streams that showed the multidisciplinary nature of sports medicine and the sports sciences. It was decided to be conducted as a large Conference every second year to best facilitate working within a growing landscape of conferences throughout Australia. This led to the successful model of a SMA Conference every two years, and a boutique Conference held in partnership with major sponsor, ASICS, in the alternate year.

Academics and practitioners all agreed that conferences are an excellent forum to harness inter-disciplinary thinking. By providing a place for a variety of people to come together, the result is a collaborative engagement and exchange of ideas across the disciplines of sports medicine.

1987 ASMF Annual Scientific Conference, panel chaired by Peter Barnes (second from right).

SMA and the Discipline Groups

One former SMA President considered SMA to be an organisation that nurtured the sports medicine and science disciplines, and allowed them to start off amongst the team and gradually they developed their own PD and accreditations, then branching off and cutting the umbilical cords before coming back in a more mature form.

Another former SMA President believed there was a wide-spread recognition that uni-disciplinary groups couldn’t best represent their members to a broader audience. Consequently, there was a movement back towards SMA as being the representative body, because the disciplines had to see that SMA weren’t trying to take them over or control them but wanted them to be part of the bigger arena.

There are few SMA members who would dismiss the importance of, or the disturbance created by, the different discipline groups over the years. Most would agree that the disciplines have all contributed a great deal to SMA and vice versa.

There always will be differing views on how much SMA can do or should be doing for the disciplines that identify with sports medicine. As Wray Vamplew noted in the 25th Anniversary history, “There is no single profession to be defined for Sports Medicine. Sports Medicine draws from the various professions but does not

absorb them. A mutual understanding and respect among these professions, therefore, is necessary for the promotion of the ideals of Sports Medicine. Sports Medicine has a responsibility to share, respect, and synthesise the inter-professional implications of its contributors.”

The eight discipline groups that are currently associated with SMA are: Sports and Exercise Podiatry Australia, Australasian College of Sport and Exercise Physicians, Sports and Exercise Physiotherapy Australia, College of Sport and Exercise Psychologists, Exercise and Sports Science Australia, Sports Chiropractic Australia, Sports Dieticians Australia, and Sports Doctors Australia.

Author’s Note:

This article is comprised of excerpts from the 25th Anniversary book ‘A Healthy Body’ by Wray Vamplew, the 50th Anniversary commemorative edition of Sport Health written by Emma Russell, and with assistance from SMA Board Chair, Dr Kay Copeland.

At one stage, SMA initiated a Council of Disciplines to foster this development and ensure the voice of each of the disciplines within SMA was truly taken into consideration.

Delegates attending the 2001 annual conference in Perth.

for JSAMS Plus

Sports Medicine Australia is pleased to announce that Dr Jessica Orchard has been appointed as Editor-in-Chief for JSAMS Plus, the online, open access companion journal to JSAMS. Jessica is a Senior Research Fellow and NHMRC Emerging Leader Fellow at the University of Sydney, NSW.

While JSAMS and JSAMS Plus are closely linked, the aim of JSAMS Plus is to ensure it has its own profile and identity. We plan to offer:

— a large range of article types (in addition to traditional ones) such as protocol papers, results from well-conducted pilot studies, short communications, case series/case reports, “game changers”(brief articles on new and interesting ideas) and “rapid fire”: exchange of ideas,

— rapid reviews via an active and engaged editorial team resulting in online publication once authors corrections have been incorporated,

EDITOR-IN-CHIEF

Dr Jessica Orchard

PhD MPH BEc/LLB(Hons I) FESC Senior Research Fellow, School of Public Health, NHMRC Emerging Leader Fellow Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia

— focus on emerging areas of research and clinical practice, such as sports cardiology and exercise oncology,

— include an active social media presence (including individual promotion of articles, authors and topic areas via social media).

For more information, visit our website and submit your paper.

Note that selected papers will be eligible for a fee waiver for a limited time and be accessible to a broad audience as soon as possible.

Pre-Exercise Hyperhydration

Improve Exercise Performance in Hot Conditions?

Why did we do this?

It is well established that exercise performance is impaired in hot conditions. A recent meta-analysis of 1258 races found that for every degree of wet-bulb globe temperature above 15°C, endurance running and race-walking performance decreased by 0.4%. Furthermore, a statistical analysis of running events in the World Athletics Championships from 1999-2011 reported that performance in hot conditions (≥25°C) was impaired for both males and females in long distance events (5000 m, 10 000 m and the marathon) compared to the same events in cool conditions (<25°C) . Many upcoming and important sporting competitions are being hosted in hot and/or humid environments (e.g., 2024 Olympic Games, Paris), so it is imperative that

athletes utilise appropriate strategies to help attenuate the effect of the heat on health and performance. This is important because, during exercise, skeletal muscle contraction generates heat. In order to prevent excessive heat storage, there are four heat exchange pathways that humans use: convection, conduction, radiation and evaporation. The amount of heat loss that occurs is influenced by the type of sporting activity and the environmental conditions surrounding the athlete. In hot conditions, evaporation is the critical pathway that will influence heat balance in humans.

Increases in environmental temperature, exercise duration and exercise intensity, in conjunction with inadequate fluid replacement, can lead to hypohydration (defined as a

body mass loss of ≥2%). Hypohydration can impair exercise performance in both temperate and hot conditions. A reduction in total body water and total blood volume (resulting from sweat loss) reduces venous return which in turn, lowers end diastolic volume. This leads to a reduction in cardiac output and a subsequent increase in heart rate. As a result, for every 1% of body mass lost, there is a concurrent increase in heart rate (during constant work rate exercise) of ~4 bpm. As total body water and blood volume decreases, peripheral vasoconstriction also occurs in an attempt to maintain mean arterial pressure. A reduction in skin blood flow (caused by vasoconstriction) can negatively impact the body’s ability to dissipate heat via convection and evaporation. This will result in an increase in heat storage and as

WILLIAM T. JARDINE (2021 SMA Research Foundation Grant Winner) and DR AMELIA J. CARR

such, for each 1% of body mass lost, core temperature is suggested to increase by 0.15 – 0.25°C. A rise in core temperature could lead to heatrelated illness, such as heat exhaustion or exertional heat stroke. As such, athletes are required to implement appropriate heat-mitigation strategies to avoid severe health outcomes and prevent impaired race outcomes.

Pre-exercise hyperhydration (defined as an increase in total body water above that of normal levels) is a strategy that can delay or reduce the adverse effects of exercise-induced hypohydration. Ingesting large amounts of fluid alone is an ineffective strategy as it inhibits the release of antidiuretic hormone which leads to an increase in urine production. Nutritional aids, such as glycerol and sodium,

have been investigated for their ability to assist in fluid retention when consumed with large bolus of fluid. Glycerol can be found naturally or as an additive in food and is a sweet tasting and viscous liquid. Once ingested, it is absorbed by the gastrointestinal tract and creates an osmotic gradient, allowing fluids to flow from an area of low to high concentration in an attempt to promote equilibrium.

Glycerol is now a legal substance for athletes to ingest, however between 2010-2017, glycerol was on the World Anti-Doping Agency’s prohibited substance list due to its classification as a plasma expander, which might be used to mask other doping practices. In 2018, glycerol was removed from the WADA banned list after further research found that any effects on the parameters that effect plasma volume (haematocrit and haemoglobin) were minimal, and as such, is now a legal substance for athletes to use. Sodium is another osmotic agent that gained attractiveness as a nutritional aid for hyperhydration protocols. Sodium is the main contributor to plasma osmolality and is a critical in determining the flow of fluids in both the intra- and extracellular compartments. When ingested (in the form of sodium citrate or sodium chloride, for example), sodium stimulates anti-diuretic hormone secretion, thereby promoting water reabsorption in the kidneys and overall, reducing urine production.

Pre-exercise hyperhydration may therefore act as a valuable strategy for endurance events. However, the current evidence surrounding the effect of hyperhydration on exercise performance is unclear, given that the most recent review in this area was published in 2007 and does not include recent articles published in this area.

Pre-exercise hyperhydration (defined as an increase in total body water above that of normal levels) is a strategy that can delay or reduce the adverse effects of exercise-induced hypohydration.

Photo: PeopleImages/ gettyImages

Pre-Exercise Hyperhydration

Improve Exercise Performance in Hot Conditions?

Therefore, the aim of this mini review was to analyse the existing evidence of pre-exercise hyperhydration with regards to exercise performance.

How did we do this?

We searched online databases (SPORTSDiscus, Embase and Medline Complete) for peer-reviewed studies in humans. Studies were included if they were classified as at least Tier 1: Recreationally Active, according to a sport science research participant framework that was published in 2022. This framework was created to enhance the translation of scientific findings to real-world contexts, and to athletes’ performance. Studies that assessed either exercise performance using time-trials (TT) or studies that assessed exercise capacity through time-to-exhaustion (TTE) were included. In this review, we defined a TT as covering a set distance as quickly as possible, measuring total work (in kilojoules) completed in a set amount of time or the total distance covered in

a set amount of time. For this minireview, only studies that involved running or cycling were included due to the popularity of these modalities in the published literature, however, the full systematic review paper includes all exercise modalities. Studies were excluded if hyperhydration was not directly induced (e.g., ingesting small amounts of fluid), or if the hydration protocol comprised of an initial dehydration period and then rehydration prior to exercise, because these design features reduced the clarity of our evaluation of the effects of hyperhydration. Conference abstracts, review papers and unpublished theses and non-English language papers were excluded.

What does the research say?

A total of 18 studies met the criteria for this mini review. Here, we have divided results into TT and TTE, because of the large variation in percentage changes seen with TTE, which creates challenges when comparing these two types of tests.

Time to Exhaustion

1. Running

One study investigated the effect of sodium ingestion (7.72 g·L-1 of sodium citrate + 4.5 g·L-1 of NaCl ingested with 10 mL·kg-1 BM of fluid) on treadmill TTE at 70% VO2max in 32°C and 50% relative humidity. Sodium ingested increased pre-exercise plasma volume by 4.5%, improved TTE by 26% (21 min) and reduced end-exercise core temperature by 0.57°C (Figure 1).

2. Cycling

Seven studies investigated the effect of hyperhydration on cycling TTE in environmental conditions of 24-32°C and 26-70% relative humidity. One study reported an improvement in TTE after sodium ingestion (7.72 g·L-1 of sodium citrate + 4.5 g·L-1 of NaCl ingested with 10 mL·kg-1 BM of fluid) in trained females by 25%. This study also reported an increase in pre-exercise plasma volume by 6.3% and a reduction in heart rate by 9 bpm and a slower rate of rise for core temperature by 0.4°C·hr-1

Hyperhydration does not appear to improve time-trial performance, however this may be due to methodological considerations within the included studies.

Four studies reported an improvement in TTE by 14-25% after glycerol ingestion (1.2 g·kg-1 BM of glycerol ingested with 26 mL·kg-1 BM of fluid). Two of the aforementioned studies implemented a steady-state period of cycling before assessing TTE and reported a reduction in core temperature by 0.3°C and reduction in heart rate by 7 bpm. Two studies investigating glycerol ingestion (1.2 g·kg-1 BM of glycerol ingested with 26 mL·kg-1 BM of fluid) or creatine loading on increasing total body water (20 g·day-1 with 2000 mL of fluid for seven days) found no improvement in performance during an incremental TTE or cycling TTE at 63% VO2max (Figure 1).

Time-Trial Performance

1. Running

Four studies investigated running TT performance (5-18 km), or total distance covered over a set period of time. Studies were conducted in environmental conditions of 28-35°C and 30-50% relative humidity (RH) with

glycerol (1.2 g·kg-1 BM glycerol with 26 mL·kg-1 BM) or sodium ingestion (7.5 g·L-1 NaCl ingested with 26 mL·kg-1 BM fluid). Heart rate was significantly lower in one laboratory-based study by 5 bpm and was accompanied by a reduction in core temperature by 0.3°C. Only one study investigated the effect of hyperhydration in a fieldbased study and assessed 10 km TT performance in 28°C participants ingested fluid containing 2.4 g·L-1 of NaCl consumed ad libitum 60 min prior to exercise and found no improvement in exercise performance (Figure 2)

2. Cycling

Six studies investigated cycling TT performance for distance (16.1-48 km), time to complete a set amount of work (200 kJ) or total distance covered in a set amount of time (60 min-90 min). Studies used environmental conditions ranging from 30-36°C and 20-70% RH with glycerol (1.2 g·kg-1 BM of glycerol consumed with 21 mL·kg-1 BM of fluid), glycerol and/or creatine (1.0-2.0 g·kg-1 BM of glycerol, and

10-20 g creatine for seven days) and sodium ingestion (60 mg·kg-1 BM of NaCl with 2 mL·kg-1 BM of water and then unlimited access to fluid for 120 min). Only one study assessed cycling TT performance (48 km) in the field in 28°C with glycerol ingestion (1.0 g·kg-1 BM of glycerol ingested with 29.1 mL·kg-1 BM of fluid) and reported no differences in physiological outcomes or exercise performance (Figure 2).

What can we interpret from the research?

The main finding of this mini review was that pre-exercise hyperhydration may improve time to exhaustion in both running and cycling. The improvement appears to be associated with improvements in core temperature and heart rate, when exercising at a constant work rate. A secondary finding was that hyperhydration does not appear to improve time-trial performance,

considerations

however this may be due to methodological

within the included studies.

Figure 1. Studies that investigated time-to-exhaustion in running and cycling. n = number of participants, RH = relative humidity, CIT = sodium citrate, PV = plasma volume, Tcore = core temperature, HR = heart rate, bpm = beats per minute.

Figure 2. Studies that investigated time-trial performance in running and cycling. n = number of participants, RH = relative humidity, G = glycerol, Na+ = sodium, KJ = kilojoule, CR = creatine, NaCl = sodium chloride.

Photo: Prostock-Studio/ gettyImages

Pre-Exercise Hyperhydration Improve Exercise Performance in Hot Conditions?

Time to Exhaustion

Hyperhydration appears to improve exercise capacity at a constant work rate, with six of eight studies reporting a significant increase in TTE (14-26%) between treatment and control. The improvement in exercise capacity may have been due to an improvement in cardiovascular stability (i.e., decrease in heart rate at the same work rate), along with reduction in core temperature potentially due to an acute increase in pre-exercise plasma volume. Only two of the six studies that found an improvement in exercise capacity measured plasma volume, and those that did reported a significant increase of ~4.5-6.3% after a high sodium dose compared to a low sodium dose. During exercise, sweat is hypotonic relative to plasma, such that more water is lost than solutes. As exercise duration increases, without adequate fluid intake, plasma volume continues to decrease with each percentage of body mass lost. If pre-exercise hyperhydration can increase plasma volume, then it may delay these negative effects and attenuate the detrimental effects of hypohydration, providing a performance advantage. An increase in blood volume via hyperhydration could improve venous return during exercise by maintaining mean arterial pressure, which would prevent large decreases in stroke volume during endurance exercise. Indeed, almost all studies that reported an increased TTE found a significant reduction in mean heart rate after hyperhydration of 3-9 bpm.

Of the six studies that improved TTE, two found a significant reduction in end-exercise core temperature and one found a significant decrease in the rate of rise of core temperature

after hyperhydration compared to control. There were two studies that did not report an attenuated increase in core temperature, which may be explained by the lower environmental conditions (24-27°C). An increase in blood volume, stemming from hyperhydration, may attenuate the rise in core temperature compared to hypohydration, particularly during

exercise in hot conditions, where sweat rate is elevated. In hypohydrated participants, cardiac output and mean arterial pressure are reduced during exercise at a given work rate, as is skin blood flow and sweat rate. A reduced in heat loss via sweating results in an increase in heat storage during exercise in the heat.

Practically, these findings specific to TTE suggest that pre-exercise hyperhydration prior to long-duration training at a constant work rate or pace may be beneficial by lowering core temperature and heart rate during exercise. For a given work rate, hyperhydration may then allow athletes to complete higher training volumes and durations in hot conditions without an increased risk of exercise heat illness or injury. However, we recognise and acknowledge that since athletes typically train for a specific distance or time, the translation of these findings from TTE-based studies remain limited.

Time-Trial Performance

Although the findings of this mini review suggest that hyperhydration does not improve time-trial performance, methodological differences between studies could provide some explanation for this result. For example, a relatively short duration of running was used in two studies (~60 min and ~48 min respectively) which elicited body mass losses of 1.6-2.4%, meaning that the time actually spent ≥2% body mass loss may not have been sufficient to exacerbate physiological strain and impact on performance. Furthermore, the protocol used in the only field-based running study involved ad libitum fluid intake and unmeasured intakes of both the control and sodiumhyperhydration treatments, which makes it difficult to compare the performance results between these treatments. One study implemented a constant work rate period consisting of a 10-km run and 40-km cycle before a 5-km run TT and found no difference in performance However, there was a small sample size (n = 6) for this study. The longest running TT of 18

An increase in blood volume, stemming from hyperhydration, may attenuate the rise in core temperature compared to hypohydration, particularly during exercise in hot conditions, where sweat rate is elevated.

Photo: dusanpetkovic/ gettyImages

km occurred after sodium ingestion; however, participants were stopped at 9 km for 15 min of data collection before finishing the final 9 km, which makes this finding difficult to translate to reallife race conditions. Furthermore, this TT was completed on a treadmill. These considerations (e.g., stopping during the time-trial) indicate that it was not a true TT and this study did not represent typical outdoor race conditions.

In cycling studies, there was an endexercise body mass loss of 1.8-2.3% after glycerol ingestion compared to 2.0% BM loss after placebo. Therefore, in these studies, the time spent at ≥2% body mass loss (i.e., hypohydration) may not have been sufficient. The only field-based cycling study reported no differences in 48-km mountain bike TT performance in 28°C after glycerol ingestion. Furthermore, during this field study, participants were stopped after each 16-km loop for 8 min for measures of core temperature, hydration status and blood analysis, limiting the potential to translate these findings to reallife training or competition.

When considering the findings of the existing studies, pre-exercise hyperhydration may not be beneficial for racing conditions (taking into consideration the results of the TT studies), however, there are several considerations within these studies (e.g., small sample size, limited translation to real-world conditions) that prevent a clear understanding of how hyperhydration may affect TT performance.

What did we conclude and what practical recommendations can we make?

This mini review evaluated the existing literature on the effectiveness of hyperhydration on exercise performance and exercise capacity. The existing evidence suggests that hyperhydration can improve exercise capacity in both runners and cyclists, due to an increase in plasma volume that may aid in reducing heart rate and core temperature when exercising

at a given work rate. This finding may be relevant for athletes that are completing long-duration training in hot conditions at a constant work rate. Future research should investigate the effects of hyperhydration on exercise performance in settings that are representative of real-world competitive events (e.g., field studies that replicate racing conditions) in thermally challenging conditions

using different modalities (e.g., racewalking) whilst implementing a strong level of control (e.g., dietary standardisation). Further TT-based investigations might provide more valid and reliable information about the effects of hyperhydration under real-world racing conditions.

For article references, please email info@sma.org.au

Author Bios

William T. Jardine is a current PhD Candidate at Deakin University. His PhD research focuses on investigating the effect of pre-exercise hyperhydration on endurance running performance in hot conditions. More broadly, he is interested in human physiology, health and performance in challenging environmental conditions, with previous research experience in heat acclimation and other nutritional interventions. Alongside his PhD, he teaches at Deakin University in the areas of human anatomy and exercise physiology. He is always open for collaboration and welcomes any questions from the readers.

Dr Amelia Carr is a Senior Lecturer with the Centre for Sport Research and School of Exercise and Nutrition Sciences at Deakin University in Melbourne. Amelia’s research focuses on adaptations to thermally stressful environmental conditions and nutritional interventions, and the effects on athletes’ performance. Amelia completed her undergraduate degree at the University of Western Australia, and her PhD through the University of Western Australia, at the Australian Institute of Sport in Canberra. Amelia worked with the Australian Defence Force as a Performance Scientist before commencing her current role at Deakin University, and she has received industry-based funding from the Australian Institute of Sport, Gatorade Sport Science Institute, Australasian Fire and Emergency Service Authorities Council and Swedish Winter Sports Research Centre. Amelia’s current projects include research programs which focus on nutritional interventions and heat acclimation training for athletes who are training and competing in hot weather conditions, and a project supported by an Australian Institute of Sport research grant, which investigates elite athletes’ adoption and use of preparation strategies for competing in major international competitions held in hot-weather conditions.

Kids with

concussion

more likely to have poor school performance

ABOUT 1 IN 8 CHILDREN EXPERIENCE A CONCUSSION BEFORE THE AGE OF 18 YEARS. YOUNG PEOPLE WHO PARTICIPATE IN COMPETITIVE SPORT ARE AT EVEN GREATER RISK, WITH ABOUT 1 IN 4 SUSTAINING AT LEAST ONE CONCUSSION IN THEIR LIFETIME.

Young people with concussion can experience a wide range of symptoms such as headache, dizziness, sensitivity to light or noise, difficulty remembering, poor concentration and attention, irritability, depression, insomnia, and fatigue. Although these symptoms can resolve within weeks, almost 1 in 3 young people with concussion have symptoms that persist three months or beyond. Whether they are transient or persistent, concussion symptoms can negatively impact on a young person’s functioning and learning at school.

DR REIDAR LYSTAD 2022 ASICS Medal Winner

Our recent study found that young people who were hospitalised with concussion were significantly more likely to not achieve the minimum standard on national assessments for literacy and numeracy (i.e. NAPLAN tests) in school years 3, 5, 7, and 9. Specifically, young people with concussion were 30% more likely to not achieve the minimum standard for numeracy, and about 40% more likely to not achieve the minimum standard for literacy (i.e. reading, writing, spelling, and grammar), compared uninjured matched peers.

Our study also found that young people who were hospitalised with concussion were significantly more likely to not complete high school. That is, young people with concussion were 64% more likely to not complete high school year 11 and 77% more likely to not complete high school year 12, compared to uninjured matched peers.

Our findings supersede previous studies that have attempted to examine the impact of concussion on objective measures of school performance. These previous attempts have been inconclusive because they featured too few young people to be able to detect statistically significant differences in school performance. In our study, we linked educational and health records of more than three thousand young people with concussion and compared them to uninjured children of the same sex, age, and socioeconomic status in New South Wales, Australia, which makes our study the largest of its kind to date.

Why are children with concussion at risk of poor school performance?

There are several compounding reasons for why young people with concussion are more likely to have poorer school performance.

Firstly, young people with concussion often miss one or more days of school, which results in lost opportunities for

learning. Although school absenteeism can vary a lot from individual to individual, research suggests that children, on average, miss about 3-5 days of school after a concussion.

Secondly, concussion disrupts normal brain function, which can result in problems with attention and concentration, memory, and cognitive processing, to name but a few, and these deficits in brain function can become a significant barrier to effective learning. The longer these symptoms persist, the greater the potential impact on learning.

Thirdly, sleep disturbances such as insomnia and drowsiness and fatigue are common in people with concussion, and many studies have demonstrated that sleep problems in young people are associated with impaired academic performance.

How can we prevent poor school performance in children with concussion?

The ideal solution, of course, would be to prevent these brain injuries from occurring in the first place. The main culprits of concussion in children are falls and sports. We do not want young people to stop playing sport and being physically active, but we need to find ways to eliminate or reduce the risk of concussion. This is especially important for sports and activities

Almost 1 in 3 young people with concussion have symptoms that persist three months or beyond.

Photo: yacobchuk/ gettyImages

Kids with

concussion

more likely to have poor school performance

Physical and cognitive rest

(maximum 1-2 days)

with relatively high risk of concussion and high participation numbers such as the football codes. We ought to encourage participation and invest in safer sports that maximises the benefits of physical activity and minimises the risk of brain injury.

There is precedent for modifying how popular youth sports are played to reduce the risk of concussion. For instance, when they prohibited body checking in Canadian youth ice hockey the concussion rates decreased by 64% for under 12s, 40% for under 14s, and 51% in under 18s. That is a tremendous step in the right direction for one of the most popular youth sports in Canada. It is also worth mentioning that there were no

Activities at home (5-15 min at a time)

School activities at home (up to 45 min at a time)

Return to school (gradually from a few hours to full day)

negative consequences for the youth athletes who had less body checking experience in terms of subsequent risk of injury and concussion.

Beyond initiatives to make sports safer, schools need to improve systems for recognising, reporting, and managing

young people with concussion. Although school concussion policies have improved in recent years, there is still a need for better integration of current evidence-based returnto-school protocols for young people with concussion into existing student learning support systems.

There is precedent for modifying how popular youth sports are played to reduce the risk of concussion.

Figure 1. Gradual return to school protocol

Photo: Chinnapong/ gettyImages

Current evidence-based return-toschool protocols stipulate an initial short period of physical and cognitive rest before gradually returning to academic activities, first at home and subsequently at school (Figure 1). The initial period of complete rest should not exceed 48 hours, and complete absence from school for more than one week is generally not recommended. At each stage of returning to school, young people with concussion are also encouraged to engage in aerobic activities that do not worsen their concussion symptoms. It is also important to note that successfully completing the return-to-school protocol should take precedence over returning to sport.

As mentioned above, young people with concussion can experience a wide range of physical, cognitive, emotional, and sleep-related symptoms. It is therefore important that young people with concussion, especially those with persistent symptoms, have access to multidisciplinary specialist concussion services. Unfortunately,

there are very few specialised concussion services available for young people with concussion, and many parents find it difficult to navigate a fragmented healthcare system to access the services that their children could benefit from. Hence, we need to improve active care coordination between acute, primary, allied, and

specialist healthcare settings, as well as schools, to ensure that children with concussion have access to the care they need, so that they can recover as quickly as possible without falling behind at school.

For article references, please email info@sma.org.au

Author Bio

Dr Reidar Lystad PhD, MPH, FRSM, FECSS, FASMF

Dr Lystad is a Research Fellow at the Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, at Macquarie University. Dr Lystad is an epidemiologist with a particular interest in sports injury, traumatic brain injury, spinal injury, paediatric trauma, and combat sports. His research is centred around conducting large population-based cohort studies using data linkage of administrative data collections to investigate health and social outcomes following injury and to guide improvements in health service delivery and health policy. Dr Lystad is a current member of Sports Medicine Australia’s Scientific Advisory Committee, and a Fellow of the Australian Sports Medicine Federation (Sports Medicine Australia), the Royal Society of Medicine, and the European College of Sport Science.

At each stage of returning to school, young people with concussion are also encouraged to engage in aerobic activities that do not worsen their concussion symptoms.

Photo: peterschreiber.media/ gettyImages

2023 ASICS SMA Conference

What to look forward to

THE ANNUAL SMA CONFERENCE HAS ALWAYS HAD A CONSISTENT FORMAT, WHICH IS JUST ONE OF THE MANY REASONS WHY IT’S NOW THE LARGEST MULTIDISCIPLINARY SPORTS MEDICINE EVENT IN AUSTRALASIA. HELD FROM 11-14 OCTOBER 2023 AT THE NOVOTEL SUNSHINE COAST RESORT, THIS YEAR’S CONFERENCE IS SHAPING UP AS A MUST-SEE EVENT FOR MEDICAL PRACTITIONERS, ALLIED HEALTH PROFESSIONALS, ACADEMICS, STUDENTS AND OTHERS INTERESTED IN SPORTS MEDICINE.

High-quality research presentations

We received an incredible number of submissions across all streams this year. It’s a big bump up from previous years, and has allowed us to create a jam-packed, diverse and topical scientific program which includes research from Australian and global academics and practitioners.

The research symposia and clinical workshops will be a highlight of the Conference program. The mornings will feature multiple workshops covering the four focal streams of clinical sports medicine, physical activity and health promotion, sports and exercise science and sports injury prevention. The research symposia will feature global leaders and emerging researchers teaming up to present the state of play across a range of different research areas. The program is rich in diversity and has appeal across all disciplines and areas of interest.

In an exciting program innovation, our headline clinical keynotes will also be presenting clinical workshops, in addition to their keynote lectures.

Keynote speakers

This year, we are excited to have international and nationally renowned experts across all sports medicine streams, who offer a diversity in areas of expertise.

Dr Rodney Whiteley is opening the Conference, delivering the prestigious Sir William Refshauge Lecture. He’s a sports and exercise physiotherapist and has experience at elite level sport dating back 30 plus years. Rod’s currently Assistant Director of Research and Education at Aspetar, which is a world leading accredited sports medicine orthopaedic hospital in Doha, Qatar.

During his address, Rod will discuss how sports medicine in Australia and New Zealand differs from what he’s seen in the rest of the world - what we do well, and what we can learn from others. He believes in stepping back and understanding that sports medicine is still contextually infantile as a profession. While this leads to challenges, it’s an exciting time to be a trusted and engaged participant in the profession’s evolution.

In summary, and to honour SMA’s 60th anniversary, Rod will talk about where we have come from, what the future may look like and how this generation of sports medicine professionals will need to be engaged custodians if we plan to stick around for another 60+ years.

Honour Board

Refshauge Lecturers

This annual lecture headlines the SMA National Conference. It honours Sir William Refshauge, Honorary Physician to Queen Elizabeth II, Director-General of the Australian Government Department of Health, and SecretaryGeneral of the World Medical Association.

2022 Dr Susan White AM

2021 Dr David Hughes

2019 Trish Wisbey-Roth

2018 Adjunct Associate Professor Greg Hoy

2017 Professor Louise Burke OAM

2016 Professor Peter O’Sullivan

2015 Dr Peter Brukner OAM

2014 Professor Danny Green

2013 Adjunct Professor Craig Purdam

2012 Professor Karim Khan AO

2011 Adjunct Professor Ken Fitch AO

2010 Professor Peter Fricker OAM

2009 Professor Caroline Finch AO

2008 Professor Wendy Brown

2007 Dr Sandy Gordon

2006 Professor Tim Olds

2005 Professor Jill Cook

2004 Professor Bruce Abernethy

2003 Dr Brian Sando OAM

2002 Associate Professor Paul McCrory

2001 Professor John Bloomfield AO

2000 Professor Julie Steele AM

1999 Dr Brian Corrigan AM

Dr Rodney Whiteley 2023 REFSHAUGE LECTURE

Sir William Refshauge

2023 ASICS SMA Conference SPECIAL FEATURE

OTHER KEYNOTES

Professor Margo Mountjoy

MD, PhD, CCFP, FCFP, FACSM, Dip Sport Med.

Margo aims to promote elite athlete care and physical activity promotion in the general population, which she fulfilled while as the medical and scientific lead at the Health & Performance Centre at the University of Guelph, Canada. Margo is also the lead author of the IOC Consensus Statements on REDs.

Dr Amy Arundale

PT, PhD, DPT, SCS

Amy is heavily embedded in highperformance extreme adventure sports as physiotherapist at the Red Bull Athlete Performance Centre in Austria. Her experience in this domain, coupled with a strong research background, is quite unique. Amy also presents on topics related to return to sport and performance, ACL rehabilitation, and on-field rehabilitation.

Professor Julian Périard

PhD, FACSM, FECSS

Julien is a world leader in thermoregulation and was involved with the Tokyo Heat Project. He helps athletes manage their response to training and performing in heat. Julien will present how heat can be a both a barrier to, and also potentially enhance performance and training. He has actively worked with both amateur and professional athletes.

Dr Andrea Mosler

Andrea has extensive experience across Olympic sports and more recently, women’s sport. Her expertise and research focus lies in hip/groin pain and athlete health. She is also a clinical expert in shoulder injuries. Having previously worked at Aspetar, Andrea has investigated risk factors for hip and groin pain in professional football players.

Professor Anne Tiedemann PhD

Anne has interests that span across falls risk assessment and prevention in older people, predictors of exercise adherence in older people, physical activity and yoga for improving independence in older age, and allied health professional education around implementation of fall prevention and increasing physical activity for people aged 50 years and over.

Professor Paulo Ferreira

Paulo is a world leader in lower back pain, whose extensive research in this area has shifted how low back pain is managed through lifestyle management and informed >19 low back pain guidelines worldwide. Paulo’s interests also expand to genetics, eHealth, and lifestyle in chronic pain.

Fallen Warriors

Lessons from rugby-related spinal cord injury in Australia

RUGBY UNION, HENCEFORTH RUGBY, IS A SPORT ASSOCIATED WITH A RISK OF SPINAL CORD INJURY (SCI). WHILE SOME INJURIES ARE ACCEPTED AS SIMPLY A PART OF SPORTS PARTICIPATION, AN INJURY THAT PRESENTS A THREAT TO LIFE OR CAUSES PERMANENT DISABILITY IS GENERALLY CONSIDERED UNACCEPTABLE. WHEN A SCI OCCURS IN RUGBY, THE DEVASTATION AFFECTS THE ENTIRE RUGBY COMMUNITY. DESPITE THE RARE OCCURRENCE OF CATASTROPHIC SPINAL CORD INJURY, THE LEVEL OF IMPAIRMENT AND THE PERMANENCE SUCH AN INJURY BRINGS, MAKE THEM A PRIORITY FOR THE SPORT. EVEN ONE IS TOO MANY.

In 2021, I was awarded a Sports Medicine Australia Research Foundation Grant, to support my PhD research exploring outcomes after rugby-related SCI. The long-term outcomes for people who sustain a SCI require ongoing, complex healthcare over the lifetime. The aim of this research was to understand the immediate experience of injury, explore barriers and facilitators to quality of life (QoL) after rugby-related SCI and identify opportunities to improve support for injured players.

Why is this research important? Injury prevention strategies implemented over the last 10-15 years have been successful in reducing the incidence of rugby-related SCI, though they remain a concern for the rugby community. Rugby related incidents account for around 10% of all cervical spine injuries sustained during sports participation in Australia, with a lifetime cost of approximately $9.5 million. The contact phases of play, tackling and the scrum, contribute to an increased risk of serious spinal injury, with injuries sustained during the scrum found to be most severe.

Less is known about the longerterm outcomes after rugby-related SCI. International studies have investigated outcomes for rugbyrelated SCI cohorts, though significant

NICOLE MERRICK 2021 SMA Research Foundation Grant Winner

Photo: Wavebreakmedia/ gettyImages

Warriors

differences in individual, social and healthcare systems exist, reducing the applicability of many of these findings to the domestic landscape. Previous qualitative research in South African rugby has identified important signs, symptoms and mechanisms of injury which have been used to guide safety strategies. Exploring the immediate experience of rugby-related SCI can be used to inform future prevention strategies. Further, understanding the longer-term outcomes after rugby-related SCI can highlight gaps in care and opportunities to provide better support for this cohort.

The contact phases of play, tackling and the scrum, contribute to an increased risk of serious spinal injury, with injuries sustained during the scrum found to be most severe.

Photo: SciePro/ gettyImages

Fallen Warriors

Lessons from rugby-related spinal cord injury in Australia

How did we go about the research?

Using community engaged methods, this research sought the injured player’s voice. An advisory group comprised of people who had sustained SCI playing rugby was developed. This group assisted with the development of research instruments and recruitment, strengthened the interpretation of results and identified knowledge translation opportunities. There were 12 participants recruited all of whom had sustained a SCI during rugby participation. Participants completed semi-structured interviews which were thematically analysed. Interviews explored the injury experience and longer-term outcomes after SCI.

What did we find?

Qualitative analysis of rugby-related SCI players’ experiences identified a range of feelings immediately after the injury. Participants reported burning, hearing a crack, losing all sensation, feeling like their legs were in the air, buzzing and pins and needles. Understandably, many reported feelings of fear and sadness. Exploration of on-field care identified challenges around early recognition of spinal injury due to a lack of medical personnel availability. Long ambulance wait times were reported and protracted transport to appropriate hospitals, particular for those in regional or remote locations. Participants also noted that when first responders (such as coaches, referees, spectators, team managers or other players) were not first aid attendants or medical personnel, they offered care and reassurance until help arrived. Participants felt safe and supported when those around them remained calm until emergency transport arrived.

Reflecting on the safety culture within clubs during their playing career, participants reported a strong awareness of the risk of SCI and the responsibility to reduce this risk

through safety-driven programs. Most participants were aware of safe scrum engagement techniques, the May Day Call and Procedure and neck strengthening to reduce the risk of SCI. Referees were considered to have an important role in prevention of SCI through controlling game structure. Participants also received intermittent reminders of safety protocols throughout their playing career, delivered via referees.

The rugby community is pretty special in terms of rallying as a community. It’s something about the sport that is pretty amazing to be honest.

Results relating to the longer-term outcomes after rugby-related SCI demonstrate that there is a timebound adjustment period through which people who experience their journey, from the moment of injury to the reconstruction of self-identity. Coming from strong athletic backgrounds had implications for this cohort. Athletic identity can be a barrier or facilitator to adjustment after SCI. Prior studies have explored the influence of athletic

identity on adaptation after SCI, indicating that there can be challenges, particularly in reconciling acquired disability with the “toughness” that is traditionally associated with rugby participation. Our research indicates that this has important implications for males who sustain a SCI playing rugby.

Participants in this research experienced sport as a social pursuit, an opportunity to pursue competitiveness and be active. Most expressed a deep love for the sport and prior to injury described themselves as athletic. Many had desires to pursue a professional rugby career, and some were playing at a high level prior to their injury. While many participants in this study did not have the option to pursue wheelchair sport due to the level of physical impairment caused by their injury, some chose not to. They simply could not reconcile playing sport in a wheelchair. Participants reflected on their athletic identity in relation to adjustment after SCI as a challenge. They described feelings of devastation after being someone so physically strong to then feeling totally vulnerable after SCI.

When reflecting on the role of sport in their lives now, participants in this study expressed a range of responses. Many described being a “fanatic” or “rugby tragic” and still loving the game, with most maintaining some connection to the sport. For those who had the ability and chose to participate, wheelchair sport provided a chance to continue to nurture their athletic identity, express their competitiveness and use the skills they gained from rugby participation. Wheelchair sport also offered other, general benefits to support longterm adjustment. It facilitated social connections with other people with SCI and offered informal peer mentoring opportunities. Participants described the value of wheelchair sport in learning how to move on, how to travel and how to navigate life as a person with SCI, from people they met during wheelchair sport.

Rugby is a sport of ‘community’, but injury and injury risk is divisive for participation. People who sustain a SCI in rugby are supported by the rugby community. Clubs participate in substantial fundraising efforts and offer ongoing support to players and families. One dominant sub-theme from our qualitative analysis was the importance of the rugby community. When a SCI occurred, rugby clubs rallied; they raised huge amounts of money, built and modified homes, provided equipment, chaplaincy, and support to the families. The importance of the rugby community was reinforced as a critical facilitator of social participation and support. Many participants continued to find social connections around the sport after injury, maintaining links with their old clubs and meeting up with friends to watch local and professional games.

Key takeaways & clinical implications

Early recognition of spinal injuries is critical to ensure correct handling

Results relating to the longer-term outcomes after rugby-related SCI demonstrate that there is a timebound adjustment period through which people experience their journey, from the moment of injury to the reconstruction of self-identity.

Photo: Wavebreakmedia/ gettyImages

Fallen Warriors

of injured players and to expediate emergency transport. Further research and collaboration with rugby union representatives to understand how safety can be improved at the community level is warranted. This could include co-designing an educational strategy to support clubs and schools around implementing best practice immediate management.

For rugby athletes who sustain a SCI, athletic identity is an important consideration in the reconstruction of self-identity after injury and can be both a barrier and a facilitator to adjustment. Having an awareness of the challenges of navigating athletic identity and the reconstruction of self after SCI is important in providing wholistic, SCI-informed care. This is an important avenue for future research, to better understand how to provide this support.

For some SCI rugby players, wheelchair sport provides important opportunities to continue to enjoy sport participation. It also enables peer mentoring opportunities which can assist injured players with reintegration into life and the community. Further, research indicates a strong association between participation and QoL which our results suggest might be facilitated by maintaining rugby connections after injury. Governing bodies and support organisations may be well placed to accelerate peer mentorship programs and provide this support in a dedicated and purposeful way.

Conclusions

My PhD research explored outcomes after SCI for Australian rugby players. Results add to a growing body of knowledge regarding rugbyrelated SCI. The information gained from participant interviews offers rich insights around the injury

experience and the longer-term outcomes when a permanent injury occurs due to a sporting incident.

People who sustain a SCI playing rugby experience a sequela of physical and emotional concerns, many of which are consistent with the general SCI population. However, support which acknowledges the loss of athletic identity and facilitates continued connections with the rugby community is important for these injured players. Further, wheelchair sport may offer important opportunities to pursue athleticism, social connections and informal peer mentoring. Future, community engaged research to understand how best to provide this support, and identify opportunities to translate this knowledge into practice, are recommended.

For article references, please email info@sma.org.au

Author Bio

Nicole Merrick is a physiotherapist and research fellow at the University of Melbourne. Nicole’s PhD via Edith Cowan University used community engaged methods to explore and understand spinal cord injuries in Australian community level rugby union. This research investigates outcomes after rugby-related SCI, the long-term consequences and the culture around safety in sport. If you would like to know more, you can contact Nicole at nicole.merrick@unimelb.edu.au or via LinkedIn.

For some SCI rugby players, wheelchair sport provides important opportunities to continue to enjoy sport participation.

Lessons from rugby-related spinal cord injury in Australia

summer

Adapting to the heat

ENVIRONMENTAL HEAT STRESS IMPAIRS AEROBIC EXERCISE PERFORMANCE IN RESPONSE TO AN INCREASE IN WHOLE-BODY TEMPERATURE AND THE CONSEQUENT ADJUSTMENTS IN CARDIOVASCULAR, CENTRAL NERVOUS SYSTEM AND SKELETAL MUSCLE FUNCTION.

HARRY BROWN HDR Investigator Award Winner 2022 SMA ACT Research Awards

The rise in whole-body temperature is also associated with a greater risk of exertional heat illness. However, frequent exposures to hot environments, alongside physical activity, can induce adaptations that attenuate the detrimental effects of environmental heat stress. As these adaptations develop, decrements in exercise performance are progressively restored and the risk of exertional heat illness reduced.

Adapting to the heat

Adaptations to heat stress are referred to as heat acclimation when induced in an artificial setting (e.g., climate chamber) and heat acclimatisation when achieved through exposure to a natural environment. Much like acclimation, acclimatisation is used to prepare athletes and military personnel for work in hot environments. Both interventions may be purposely implemented to improve thermoregulatory capacity, cardiovascular stability, and thermal tolerance during heat exposure. However, seasonal heat acclimatisation is largely a background process wherein seasonal changes in ambient conditions can induce heat adaptations. Yet, an increasingly sedentary population and the avoidance of physical activity in warmer parts of the day, the magnitude of adaptation induced via seasonal heat acclimatisation in healthy contemporary populations remains unclear.

There is evidence to support the influence of the natural environment inducing heat adaptations during the summer months (i.e., seasonal heat acclimatisation); however, the reported adaptations differ widely among studies. The differences in seasonal heat acclimatisation suggest that several factors combine to determine the level of heat adaptation attainable during the summer months, in particular the severity of the thermal environment, the accompanying levels of exertion, training status, and exposure time.

In a recent review we systematically evaluated the magnitude of seasonal heat acclimatisation induced in healthy adults, including a lower core temperature and heart rate at rest and during exercise, and an enhanced maximal

sweat rate during exercise. By characterising the magnitude and factors that influence seasonal heat acclimatisation, it was anticipated that athletes, coaches, and policy makers could make more informed decisions regarding performance and safety in the heat.

Core temperature

Two studies reported a 0.16°C reduction in resting core temperature following comparable environmental exposure durations (≥10 h·wk-1) in environments with a mean summer wetbulb globe temperature (WBGT) of 26.2°C and 27.8°C. However, the manner in which time was spent during the environmental exposures was unclear and physical activity (i.e., intensity, duration) was not reported. Therefore, it is difficult to determine how these factors, or their interaction, mediated the reductions in resting core temperature.

The largest reduction in the increase in core temperature during a 90 min treadmill walk was 0.25°C, although it was not statistically significant. This was reported in conjunction with an enhanced sweat rate (0.10 kg·m-2·h-1) and reductions in end-exercise heart rate (10 beats·min-1). The authors did not document physical activity or environmental exposure duration during the study but did report a mean ambient temperature of 30.3°C in the midday shade during summer. This location (i.e., Beer-Sheva, Israel) has previously been shown to induce seasonal heat acclimatisation in untrained males (i.e., greater sweat rate, reduced skin temperature and heart rate during exercise).

Frequent exposures to hot environments, alongside physical activity, can induce adaptations that attenuate the detrimental effects of environmental heat stress.

Photo: Izf/ gettyImages

Adapting to the heat

Heart rate

Within the studies utilising an active or exercise-based heat response test, firm conclusions regarding the influence of seasonal heat acclimatisation on cardiovascular function are difficult to draw, as environmental exposure durations were not provided. Although smaller increases in heart rate during passive or resting heat response tests were noted following summer, none were statistically significant. However, when data from this study were pooled from seven different conditions (i.e., 20 to 32°C and 50 to 70% RH) during a comparison of individuals residing in naturally ventilated or air-conditioned environments, a significantly smaller increase in heart rate during the post-summer passive heat response test was observed. For the most part, these data indicate that heart rate at rest and during exercise in the heat is reduced following summer (Figure 1).

Sweat rate

Whole-body sweat rate is dependent on a number of factors including, heat

acclimatisation status, metabolic heat production, age, sex, environmental conditions, as well as aerobic capacity. Studies utilising a passive heat response test all documented an increased sweating rate after summer, except for a group of mainland Japanese residents and one group of untrained males. In the studies utilising an active heat response test, an earlier onset threshold for sweating was observed following seasonal heat

Figure 1. The difference in the increase in heart rate during active and passive heat response tests following the summer months. The figure shows if heart rate is lower during a heat response test after seasonal heat acclimatisation. Data are presented as mean with 95% confidence intervals. O older, Ok Okinawa residents, Ma mainland residents, NV naturally ventilated, SAC split air conditioners, Y younger.

acclimatisation, as well as enhanced sweating thermosensitivity (i.e., the increase in sweat rate as core temperature increases), and up to a 63% increase in whole-body sweat rate. Although Figure 2 highlights the influence of mean daytime WBGT on the magnitude of increase in sweat rate, the variable nature of the change reiterates the need to consider the other of influencing factors.

relationship between mean daytime wet-bulb globe temperature and the change in sweat rate following summer. Individual dots are reported changes in sweat rate following summer from studies included in the systematic review. The line of best fit is represented with 95% confidence intervals (i.e., surrounding band).

Figure

There is evidence to support the influence of the natural environment inducing heat adaptations during the summer months, however, the reported adaptations differ widely among studies.

2. The

Seasonal heat acclimatisation

Our findings revealed that seasonal heat acclimatisation has been primarily investigated in healthy recreationally active adults. Our findings also reveal that a prerequisite to developing heat adaptations is that the environment is sufficiently stressful to induce an elevated level of thermal strain. However, the necessary environmental conditions required are unclear. We found 29

studies investigating seasonal heat acclimatisation. Using meteorological data, we calculated daytime (08:00 – 18:00) WBGT to provide a common measure for reporting the severity of the environment throughout summer in each study. Across the 29 studies, participants were exposed to a mean daytime WBGT of 24.9 ± 3.1°C, whereas in the studies that documented heat adaptations, mean daytime WBGT was very similar (25.2 ± 2.8°C). The negligible difference in WBGT between the studies that reported heat adaptations and those that did not reinforces the notion that seasonal heat acclimatisation develops in conjunction with several factors, including environmental conditions, exercise intensity, training status, and exposure time.

Summary

The physiological adaptations stemming from seasonal heat acclimatisation can lead to reductions in resting core temperature (0.16°C) and heart rate (range: 5 to 9 beats·min-1),

an attenuated increase in core temperature (range: 0.10 to 0.20°C), reduced sweat sodium concentration (range: -22 to -59%) and an increased sweat rate (range: 0.03 to 0.19 L·h-1) during active and passive heat exposures. These adaptations were associated with a mean summer WBGT of 25.2°C (range: 19.6 to 28.7°C) in our systematic review. However, seasonal heat acclimatisation is influenced not only by the environmental conditions, but also by the quantity, quality, and duration of outdoor exposures. The timing of the outdoor exposures is also important. Ambient temperatures and solar loads are at their greatest in the early afternoons, but for many recreationally active individuals, this coincides with time at work. As such, while many may be training outdoors during summer, insufficient thermal strain may fail to induce heat adaptations.

For article references, please email info@sma.org.au

Author Bio

Harry Brown is a current PhD candidate at the University of Canberra Research Institute for Sport and Exercise (UCRISE). His research is focussed on developing our understanding of seasonal heat acclimatisation and how the summer months can induce adaptations in adults and adolescents. Harry was recently awarded the 2022 HDR Investigator Award at the Sports Medicine Australia ACT Chapter Awards for his systematic review on seasonal heat acclimatisation published in Sports Medicine.

Our findings reveal that a prerequisite to developing heat adaptations is that the environment is sufficiently stressful to induce an elevated level of thermal strain.

Photo: Liudmila Chernetska/ gettyImages

in Pain, Performance and Sports Medicine Symposium

Gender Bias A Summary

THE DIFFERENTIATION OF ‘SEX’ AND ‘GENDER’ HAS FIRMLY DEVELOPED OVER THE PAST DECADES AND, DEFINITELY IN SCIENCE, A CLEAR DISTINCTION IS RECOGNISED. HOWEVER, DESPITE THIS DISTINCTION AND APPRECIATION, BOTH FEMALES AND WOMEN ARE UNDERREPRESENTED IN RESEARCH.

The purpose of this Sports Medicine Australia symposium was to raise awareness of sex and gender bias within the realms of pain neuroscience, performance, rehabilitation, and academia.

Biases within pain neuroscience – Ms Cobie Starcevich (Curtin University)

Ms Starcevich presented on the disproportionate rate that females experience chronic pain, yet 80% of the preclinical research has been performed on males over the past 70 years. Unfortunately, the realworld impact of a male-biased research pool and gender bias within clinicians results in women having twice the risk of experiencing adverse effects to medications and taking longer to receive a diagnosis.

Impact of gendered sport and exercise environments - Dr Mervyn Travers (The University of Notre Dame Australia)

Dr Travers provided a compelling discussion on the impact of gendered sport and exercise environments, the influence this has on participation in sport for girls and women, and

consequently how this impacts the health trajectory of women across a lifetime. He presented data countering some common myths like young girls get too bulky form resistance training and older women cannot get strong.

The Female Performance and Health Initiative - Dr Rachael Harris (Perth Orthopaedic and Sports Medicine Centre)

Dr Harris gave an overview of the

Australian Institute of Sport, Female Performance and Health Initiative, of which she is leading. This project is working to educate athletes and high-performance staff around the intricacies of female athletes. This includes the importance of destigmatising conversations around female athletes’ menstrual cycle, given the role this plays in the health and performance of female athletes.

Are motor control differences sex-based, or more a reflection of a gendered environment

-

Professor Sophia Nimphius (Edith Cowan University)

Prof Nimphius discussed how the research pool tends to frame injury risk in female athletes in terms of innate risk factors, which are non-modifiable, instead of focusing on the gendered aspects of sporting environments, such as allocation of resources, training environments and opportunities that disadvantage girls and women and elevate injury risk profiles.

Do gender biases exist within the Australian academic environment (the answer is yes) - Associate Professor Tasha Stanton (University of South Australia)

A/Prof Stanton demonstrated that within Australia, a substantial bias exists towards men receiving more grant funding as well as tenured positions. Men and women in academia do have a comparable income in the early stages. However, in later career stages men receive a substantially higher income. This has historically been attributed to women leaving the workplace at that stage, however in a recent analysis of childless women in academia compared to their male counterparts, they still experience a disparity in income which points to systemic issues. Finally, A/Prof Stanton said it was never okay to have an allmale panel (Manel) at a conference.

How is sports medicine and physiotherapy doing as far as equity - Dr Clare Ardern (University of British Columbia)

Dr Ardern discussed where we are as a sports medicine and physiotherapy research community. Unfortunately, women make up the minority of first/ last author positions on research publications and the vast minority of people on journal editorial boards. Dr Ardern also highlighted how important it is to actively promote diversity in

all aspects of academia (including conference organising committees or grant review panels) as this is more likely to result in a follow-through of research that is equitably gendered.

Conclusion – Dr Myles Murphy (Edith Cowan University)

It is impossible for a single person to have considered every perspective or be aware of what is required to support all societal demographics. Therefore, working in teams that are both diverse and inclusive, ensure that the team are in the best possible position to provide services or outcomes that appeal to the breadth of Australian consumers.

Three take home tips to address gender biases

1. Call out manels (all-male panels). Manels are never okay and should be called out and attendance avoided #noexcuses

2. Check your own bias: reflect on your healthcare decisions, is what you’re doing advantaging or disadvantaging the patient?

3. Improve inclusivity of work environments to ensure that people, such as parents, are not disadvantaged.

Author Bios

Dr Myles Murphy is a postdoctoral clinician researcher within the Edith Cowan University Nutrition and Health Innovation Research Institute. Myles is a fellow of the Australian Sports Medicine Federation, an Australian Physiotherapy Association Sport and Exercise Physiotherapist, and Chairperson for the Western Australian branch council of Sports Medicine Australia. Myles’ research involves investigating the drivers of pain and impairment in people with lower-limb musculoskeletal injury and disability as well as novel neuroscience interventions to address these impairments.

Cobie Starcevich is a physiotherapist and PhD candidate at Curtin University where she is undertaking research in the area of ACL injuries, fear of re-injury, and return to sport. She has a Masters of Manipulative Therapy and teaches in the undergraduate physiotherapy program at Curtin University. Cobie’s clinical background includes working with professional acrobats, gymnasts and musicians at Cirque Du Soleil and she is currently in an Advanced Scope Physiotherapy role within the emergency department at Rockingham General Hospital. Cobie is the clinical editor of InTouch magazine, the Australian Musculoskeletal Physiotherapy Associations publication.

5 minutes with Dr Paolo Menaspa

Can you tell us a bit about how you first got involved in sports medicine research?

Around 2005 I graduated and started working in an Italian laboratory called Mapei Sport, which provided sport science and sport medicine support to professional teams, in particular cycling and soccer teams. Mapei Sport was focused on both performance and athletes’ health. I was involved in various roles around research projects on injury prevention which included, for example, studies on the effect of training load and fatigue on several variables. I started simply helping with data collection and then it evolved into a more active role as a researcher.

Menaspa

You were previously the Head of Performance Solutions at AusCycling. What drew you to working in the highperformance sector?

The laboratory I mentioned was my first job and that was in professional sport. I’ve spent most of my grown-up life in high performance sport. That’s just how it happened. Upon reflection, I do think that now is a good time for me to broaden my experiences. Better understanding the whole landscape from participation to high performance will allow me to have a bigger impact across the sport sector.

Describe your role as Chief Science Officer at the AIS?

It’s part of my role to advocate for science in sport. One of my goals is to support Australian athletes, coaches and performance support staff so that they can make evidence-informed decisions. We want them to be able to access the best available evidence to inform their daily practice. We support and promote the whole process from knowledge generation (research) to implementation into the training field or competition. We also keep an eye on the future. An example is that last year, in collaboration with CSIRO, we published the Sporting Megatrends report, which is a look at the next 10 years and what the trends are that will influence the sporting sector.

What is the current research focus for the AIS?

The Australian Sport Commission has led the development of a National Sport Research Agenda, with five priorities including participation in sport, high performance sport, sport system sustainability, the value and benefit of sport, and major event

impacts and legacies. Within the high-performance priority there are four sub-themes: successful athletes (looking at the holistic athlete development), coaching science, performance optimisation (with a focus on the complexity of the competition environment), and practice enhancement (which aims at solving strategic performance issues). Importantly, we want to support research that leads to a better understanding of, and that better supports the needs of, our diverse athlete population, which includes participants that historically have been underrepresented in sport science and sport medicine research.

What research outcomes are you hoping to achieve in the coming years?

My focus is on high quality research. Sport science and sport medicine are not immune to well-known methodological issues (from publication bias to p-hacking), so we want to support research that can be trusted. We are focussing more on

5 minutes with

Dr Paolo Menaspa

quality rather than the quantity. Also, we support research that can solve strategic performance issues which have been identified by athletes and coaches. I have recently come across some discussions on the difference between ‘interesting’ and ‘important’. I feel there is a lot of research answering interesting questions, and I know I’ve done it (a lot of the research I’ve done was to answer a question I thought was interesting). However, now, in my role, especially when it comes to funding and use of resources, I think we should focus on what is important and impactful for the beneficiaries of research, rather than on what is interesting for the researcher.

Building Confidence. Together.

Physician Focus Dr Laura Lallenec

What motivated you to pursue a career in sports medicine?

After I completed my first university degree in science, I worked in the public health service as a health policy officer. During this role, I became more interested in the clinical aspects off the job and decided to apply to study Medicine. After successfully completing my medical degree, I worked in a number of hospitals as a junior doctor where I undertook rotations in orthopedics, emergency medicine and rehab medicine. Working in the hospital system however, I quickly came to realise you’re dealing with unwell people who, whilst motivated to get better during their admission, often get discharged to the community only to return with the same issue. I got a little bit disillusioned with this and decided I wanted to be in an area of medicine where people were proactive about their health. I’ve always loved sport and I’ve come from a family of people who are active. I played a lot of netball in my youth including state league and Nationals. With my sporting background, I liked the idea of trying to find an area of medicine that had that focus and used exercise as medicine rather than medications. After some investigation, I discovered sports medicine as a career path. In sports medicine, patients want to get better so they can be more active and

return to their sport whether that is as an elite athlete or as an everyday recreational athlete. I am passionate about facilitating my patients to remain and become more active.

What do you enjoy most about being a Sport and Exercise Medicine Physician?

It’s a really rewarding and exciting career and it’s varied. One day you might be in a private practice seeing everyday people and budding athletes, and the next day you might be on the side of a sporting field working for a professional team. I also have other roles such as working as a Medical

Advisor for Sport Integrity Australia and as the Chief Medical Officer for Netball Australia. My week involves something different every day. I also love that it’s an area in sports medicine that’s really multidisciplinary and you get to work in a team environment in a lot of our roles.

I’m not just working in private practice in a single room with just myself and the patient but rather working alongside and managing patients with physiotherapists, dietitians, podiatrists, and sports scientists amongst others.

It’s a career where we really get to help people with a simple thing as getting them moving and active and

doing exercise. That’s actually the medicine we use most of the time, more than medications. Additionally, Australia like many other first world nations, is suffering from an obesity epidemic. I think we as Sport and Exercise Physicians can play a really important role in prescribing exercise as medicine and helping to manage chronic conditions like osteoarthritis non-operatively with weight loss and a tailored exercise program including aerobic exercise and strength training.

How did you first become involved with organisations such as the Melbourne Football Club and Netball Australia?

After I decided I wanted to work in sports medicine, I had to apply to get onto the training pathway which requires gaining experience in the sports medicine field before you apply. In my junior doctor years, I worked with Williamstown Football Club VFL team which gave me experience in working in an elite team environment. I got to work alongside really experienced sports physiotherapists, who taught

me a lot about sports medicine. It was a great opportunity for me and resulted in me being offered the role to head up the inaugural AFLW program at Melbourne Football Club in 2016. This was a wonderful team to be involved with, and it was really special to watch these fantastic female athletes become professional players. From there, I continued to work across both the Men’s and Women’s program and in 2020 I was promoted to the head doctor for the men’s team.

Netball is my true sporting love. It’s the first and the main sport that I played in my youth, and I still play today. I’ve always dreamed of an opportunity to work in netball, and I was lucky enough to get the opportunity at the end of last year when the Chief Medical Officer role for Netball Australia came up as Dr Sue White, one of my mentors, retired from the role. The role is both the Chief Medical Officer for Netball Australia, which is less of a clinical role and involves more health governance, and the Diamonds team doctor role, which involves travelling with the team internationally and for camps. Working with the Diamonds has been eye-opening. They are an incredibly professional and humble group of athletes, and I am really excited about travelling to Cape Town with them in July this year for the Netball World Cup.

I think we as Sport and Exercise Physicians can play a really important role in prescribing exercise as medicine and helping to manage chronic conditions.

What led you to becoming a Medical Advisor with Sports Integrity Australia?

Growing up in Canberra, I come from a family of public servants and worked previously in health governance and policy. When the Medical Advisor role at Sports Integrity Australia was advertised, I thought it’s an ideal opportunity to combine my sports medicine experience as well as my experience in policy development. Furthermore, I have always felt strongly about promoting fairness and equality in sport, ensuring a safe place for everyone participating. I felt that this role was a great opportunity to educate athletes and support personnel working in the field about sport integrity matters and making sure it’s a fair playing field for everyone involved. My role at SIA is medical guidance on sport integrity including anti-doping medicine, in particular the use of prohibited substances and methods in sport, safeguarding of children in the sporting environment, as well as assisting the intelligence and investigative officers with medical advice on projects they may be working on.

Can you describe a career highlight that made you proud of what you do?

It would definitely be the AFL 2021 Grand Final which Melbourne Football Club won in Perth. By then I’d been at the club for five years and worked my way up the ranks from the VFL to AFLW and then to the men’s program. You really invest in the highs and lows of these athletes’ careers. It was so nice to see them have success after all these years of working hard through tough times and for it all to come together, and for them to achieve the ultimate success in their career winning an AFL Grand Final, which is a really hard thing for a team to do. We’d just been

in a final’s hub in Perth due to COVID and had been at Perth living together at the same resort for five weeks. The players and staff lived day in, day out together, ate all our meals together and after five weeks away from family and friends, to end in such a highlight was really a once in a lifetime experience.

Do you have any advice for people starting out their career in sports medicine?

I think back to when I was starting out and what really helped me was getting involved and finding mentors. Reaching out, joining Sports Medicine

Australia, looking at the jobs board and getting opportunities from that, involving myself in sports medicine events and conferences, networking, just immersing myself in the area of sports medicine. Sports Medicine Australia particularly are great because they have lots of education events and a great conference every year. There are sports physicians that are members as well as allied health professionals. It’s a great network to be part of. I would also say take the opportunities that pop up. You’ll get offered opportunities to cover sport and you might think “I’m not sure if I’m experienced enough to do that role” but throw yourself inthere’s always support available to help you. Always make sure you have a more senior sports doctor that you know that you can call for advice. Get a mentor – someone to bump ideas off and discuss ideas on the phone with. Learn from the physios and the other allied health professionals. There are always really experienced people working at these clubs and you can learn a lot from them. Particularly when you’re starting and you haven’t got lots of exposure to sports medicine yet, use those opportunities with physiotherapists to learn how they do examinations and how they take histories from the athletes and manage them. Go to events, go to conferences, and really network with like-minded people. That’s how opportunities happen.

SportsBulgaria Medicine in

Sports medicine in Bulgaria has a long history. In 1925, a physical education section was organized at the Department of Physical Education of the Ministry of Public Education, which was considered the first sports medicine service.

Twenty years later, the Law on Medical Supervision of Physical Education and Sports was adopted in Bulgaria. This law regulates the sports-medical assistance of athletes. In 1952, the first center for sports medicine began to function in Sofia, whose main task was to monitor the health of registered athletes in Bulgaria. The center has organized regular training courses for sports physicians. In the following years, 13 sports medicine centers were established in the larger cities of Bulgaria.

In 1950, undergraduate training in sports medicine was introduced for the students of the Medical University.

Since 1958 sports medicine is included in the training program for students at the Higher Institute of Physical Education (now National Sports Academy). In 1973, a department of Sports Medicine was established there.

Establishment of the Bulgarian Society of Sports Medicine and Kinesitherapy

The first sports medicine scientific unit was founded in the Scientific Research Institute of Physical Culture in 1949. The Bulgarian Scientific Society of Sports Medicine and Kinesitherapy (BSSSMK) was founded in 1953 as a

Photo: Tina Douva/ gettyImages

non-profit organization. The main objectives of the society are to stimulate scientific and research work, increase the qualifications of sports physicians, implementation in practice of the latest achievements in sports medicine science.

The first chairman of BSSSMK was Prof. Dragomir Mateev. Over the years, presidents of the BSSSMK have been Prof. Petar Slanchev, MD, Dr. Slavcho Savov, MD, Prof. Maria Toteva, MD, Dsci, Prof. Ivan Topuzov, MD, Prof. Ivan Maznev, MD, Ph.D., Prof. Diana Dimitrova, MD, Ph.D. Soon after the establishment of the BSSSMK, it was accepted as a member of FIMS.

In 1969, BSSSMK was co-founder of the Balkan Association of Sports Medicine in Bucharest (Romania). A representative of Bulgaria took part in the FIMS Congress, held in Porto, Portugal (1996), during which the European Federation of Sports Medicine was founded.

Since its establishment, the BSSSMK has organized several national congresses, conferences, symposia, scientific meetings, and two Balkan Congresses.

BSSSMK does not publish its own journal, as the specialists have the opportunity to publish in two journals - Мeдицина и спорт (Medicine and Sports) in Bulgarian, and Journal of Applied Sports Sciences, which is published by National Sports Academy in English and Bulgarian.

Medical education in Bulgaria

In Bulgaria, medicine is taught in five medical schools across the country: the Medical University of Sofia; the Faculty of Medicine at Sofia University St. Kliment Ohridski, Medical University of Pleven, Medical The University of Varna, the Medical University of Plovdiv, and the Faculty of Medicine at Trakia University, Stara Zagora.

The complete medical education lasts six years. The training corresponds to a syllabus developed based on the state requirements and is organized in three stages. The first stage is preclinical training (two years) which provides the

students with fundamental biological and medical knowledge, offering the basis for their clinical training. Clinical training starts in the third year, lasts three years, and aims to acquire knowledge and skills in diagnostics and treatment. After the 3rd year, the training is carried out according to a cyclic system, in which the exams are held after the completion of a training cycle of 4-6 weeks in the respective discipline. The third stage is a pre-graduation practice, which is carried out in the form of rotations at the departments of the University hospitals and bases. It aims to acquire knowledge and skills at the patient bedside and outpatient clinics. The final state examination comprises five exams in Internal Medicine, Surgery, Pediatrics, Obstetrics and Gynecology, and Hygiene and Ecology. The successful graduates conferred the Master’s degree and Physician (MD) qualification. Sports medicine presents as an elective course in

Photo: emicristea/ gettyImages

the undergraduate curriculum of the Medical University of Plovdiv and as a part of the core course of Orthopedics and Traumatology in other Medical Universities.

All Bulgarian Medical Universities offer postgraduate medical study programs (specialization training or residency specialization) for medical doctors who have completed their 6-year medical studies. The medical specialty typically last 3-5 years. The Medical University of Sofia is a training base in 52 medical specialties. The postgraduate qualification is acknowledged after a final examination in front of a State Examination Commission.

The acquisition of a specialty in Bulgaria is regulated by an Ordinance of the Ministry of Health, which approves the procedures for conducting the specializations and determines the duration of the training for their acquisition. The specialty in

the healthcare system is acquired on a syllabus executed and after examination in theory and practice successfully passing before the State Examination Commission appointed by the Health Minister’s order.

Bulgarian medical specialization training takes place at Medical University Hospitals or affiliated clinics, and it includes full-time practical training 8 hours per day in a position with duties about the curricula of respective specialties.

Every medical university has a Commission for Postgraduate Education appointed by the Rector and admits to the Specialty State Examination only the candidates who have completed the respective specialization curricula. In turn, medical specialists who have successfully passed the Specialty State Examination receive a certificate of a recognized specialty from the Medical University.

Sports medicine education in Bulgaria

Sports medicine is recognized as a medical specialty with four years of training since 1960.

The curriculum includes the following basic modules, such as Functional anatomy and biomechanics, Exercise physiology and biochemistry, Body composition assessment and interpretation, Sports traumatology, Sports Cardiology, Sports-specific diseases, Emergency Medicine, Physical therapy, Sports Nutrition and recovery, Doping, and anti-doping regulations.

Currently, the sports medicine course is also mandatory, proposed at a pre-graduate level in all universities that teach sports coaches, physical education teachers, and kinesitherapists (physiotherapists). The National Sports Academy also offers many modules in different fields of sports medicine in postgraduate programs, such as Physical activity and health, Sports nutrition, Doping and sports, Body composition assessment in athletes, First aid for non-medical persons, Sportsmedical problems in adolescents who play sports, and others.

At this time, there are about 40 active specialists in sports medicine in the country.

Author Bio

Prof. Diana Dimitrova, MD, PhD is a university professor of sports medicine at the National Sports Academy. She is a Chairman of the Bulgarian Society of Sports Medicine and Kinesitherapy and a National Sports Medicine Consultant to the Ministry of Health of Bulgaria.

Sports Trainer Highlight

Michael Quill

What inspired you to become a sports trainer?

My uncle Allan! He was a sports trainer for a local footy club back in the day and said to me “Why don’t you give it a go?”. I had a background in volunteering for St John’s through my teenage years and was always interested in medical “stuff”. I also played footy but by my mid-twenties had given it up – too many injuries – so I moved to the sports trainer aspect.

When reflecting on your experience as a sports trainer, are there any highlights or challenges that stand out to you?

The definite highlight is all the people you meet. I’ve been fortunate to travel the country with various elite sporting teams as well as with disability inclusion carnivals. I worked with Hawthorn Football Club for 15 years down in Tasmania. I’ve worked with the Tasmania Police every year when they go away for their national carnival for 15 years now and I’ve just been inducted as a life member of

the Tasmania Police - which there are not many civilians that get awarded a life membership. I’ve helped at the national BMX championships. I also had the privilege of assisting with the rowing at the Masters Games. Tassie is a small place, and everyone knows what I do, so I normally get roped into doing some type of medical support when I go to a sporting event.

Is there a particular aspect of sports training that you enjoy most?

I love teaching and mentoring people on sports training. Most people are really hesitant to put their hand up at the local level – they are sometimes just mums and dads trying to help out their kids’ teams. I try and make it as “unscary” as possible and it’s important to build confidence in them too. I do my best to encourage and impart many hints and tricks in learnings for them. One of the most

powerful aspects is being able to add real life situations that have occurred. I think this definitely gives people a more realistic viewpoint of what a sports trainer may do. Sometimes the theory is overwhelming and when I can relate it to an actual story it’s easier for them to learn and relate to.

How has being part of SMA helped your career so far?

I have been very fortunate to progress to delivering various courses for SMA in Tasmania which has been a

highlight of my 45+ years in the game. Sports training is something that unfortunately, unless you are at an elite level with other qualifications, doesn’t really give you a career opportunity as a full-time job. Mostly we all have our jobs to go to, but come the weekends and training nights, you will find sports trainers at your local sporting clubs supporting local sport.

What advice do you have for people wanting to get started as a sports trainer?

Give it a go! You will form friendships for life, contribute to your community and whilst you might think it’s a bit too challenging – educate yourself –come along to one of SMA’s sports trainer courses. My hope is that we get more young people to come through because you are still very involved in the sport, and you are a very important cog in that club and organisation.