• An innovative circus-based intervention to promote physical activity participation for preschoolers born prematurely
A Decade Later – Essendon Supplements Scandal: The Redeemer of Sports Science & Medicine in Australia
• SMA Members at Paris 2024: Diverse experiences, shared perspectives
02
From the Chair
Dr Kay Copeland celebrates this year’s milestones, while introducing two new Board Members.
From the CEO
Jamie Crain reflects on the success of this year’s joint Conference with ACSEP, highlights key achievements from FY24, and looks to 2025.
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.
Setting the stage for healthier, more active lives:
An innovative circus-based intervention to promote physical activity participation for preschoolers born prematurely. Dr Free Coulston discusses her scoping review, highlighting promising outcomes in physical and social-emotional domains.
SMA Members at Paris 2024: Diverse experiences, shared perspectives
We spoke with Marguerite King and Nick Wilson about their experience at the Summer Olympic and Paralympic Games in Paris this year.
Publisher Sports Medicine Australia State Netball and Hockey Centre - Parkville 10 Brens Drive, Parkville VIC 3052 sma.org.au ISSN No. 2205-1244 PP No. 226480/00028
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Our major partner, ASICS, share the development of their Netburner™ range of netball shoes.
19
A Decade Later –Essendon Supplements
Scandal: The Redeemer of Sports Science & Medicine in Australia
Dr Stephen McMahon walks us through the “The blackest day in Australian Sport” and how it’s been dealt with since.
25
2024 SMA & ACSEP
Conference Unpacked: Four Reflections
Read what some of our #SMAACSEP2024 delegates shared about their experience at this year’s Conference.
30
Exercise training for metabolic dysfunctionassociated steatotic liver disease: exploring the ‘final frontier’
Dr Shelley Keating summarises the importance of exercise training for metabolic dysfunctionassociated steatotic liver disease (MASLD).
5 Mins With: Matthew Hotchkis
38
People Who Shaped SMA: Emeritus Professor Julie Steele
42
Sports Medicine Around the World: Sweden
44
Sports Trainer Spotlight: Caitlin Risstrom
THE CHAIR
DR KAY COPELAND, CHAIR OF THE SMA BOARD, CELEBRATES THIS YEAR’S MILESTONES, AND INTRODUCES TWO NEW BOARD MEMBERS.
Introducing our final edition of Sport Health in 2024.
As we wrap up another remarkable year, I encourage all members to read our Annual Report, now available on the SMA website. It highlights the wide range of activities undertaken in the last 12 months and the unwavering support SMA’s staff, Board, and volunteers provide to our members, the industry, and active communities across Australia.
A significant achievement this year was the development of our 20242027 Strategic Plan, which will guide our efforts over the next three years to strengthen and expand our impact.
The recent 2024 SMA & ACSEP Conference at the MCG brought together over 800 delegates, immersing them in an outstanding sports and exercise medicine program. The feedback was overwhelmingly positive, with attendees praising the breadth of learning opportunities, insightful plenaries, engaging workshops, and unparalleled networking.
I look forward to working with the Board and SMA’s dedicated staff as we bring our 2024-2027 Strategic Plan to life next year.
I extend heartfelt congratulations to all the SMA Award winners recognised at the Conference. The outstanding quality of research presented set an incredibly high standard, making the judges’ task of selecting winners both rewarding and challenging.
At the ASMF Fellows Dinner, we celebrated the induction of seven new Fellows: Professor Eugene Aidman, Dr Susan Keays, Dr Donald Kuah, Simone Muscat, Luke Nelson, Kurt Robinson, and Professor Tony Schneiders. I thank each of them for their contributions to SMA and warmly welcome them into the ASMF Fellows.
At our AGM, we announced the election of two new Board members, Dr Luke Kelly and Dr Ebonie Rio, alongside the re-election of Professor Belinda Beck. I look forward to working with the Board and SMA’s dedicated staff as we bring our Strategic Plan to life in 2025.
I’m excited about our initial planning for the 2025 ASICS SMA Conference, set in the vibrant and culturally rich city of Hobart. By now, you should have the new dates: 29 October - 1 November 2025. Be sure to mark these dates in your diary and continue your education and networking journey with SMA.
On behalf of the SMA Board I wish all our members a wonderful holiday season. I hope all SMA members have enjoyed the benefits of being part of this passionate, multidisciplinary community, and I look forward to working with you all in 2025.
Dr Kay Copeland
FROM THE CEO
SMA CEO JAMIE CRAIN REFLECTS ON THE SUCCESS OF THIS YEAR’S JOINT CONFERENCE WITH ACSEP, HIGHLIGHTS KEY ACHIEVEMENTS FROM FY24, AND LOOKS TO 2025.
Welcome to Volume 42, Issue 4 of Sport Health.
We recently concluded our annual Conference, co-convened with the Australasian College of Sport and Exercise Physicians. It was an incredibly successful event with over 850 delegates representing all sports medicine and sports science disciplines, coming together at the MCG.
Next year, we’re heading to Hobart for the 2025 ASICS SMA Conference, so be sure to mark 29 October to 1 November in your diaries. Further details about the event including our call for abstracts and keynote speaker announcements will be released over the coming months.
This quarter saw the release of our FY24 Annual Report, and we are proud to announce that, for the fourth consecutive year, we delivered a surplus for our members. We hosted 43 professional development events nationwide in various formats, attracting over 3,500 registrations. Additionally, our Safer Sport Program continues to excel, maintaining a high level of accreditation with more than 8,000 qualified sports trainers across the country.
Your SMA member logo is available for download via your portal. Use it to promote your membership and proudly acknowledge your place in Australia’s largest multidisciplinary sports medicine community
download via your portal. Use it to promote your membership and proudly acknowledge your place in Australia’s largest multidisciplinary sports medicine community.
In our final edition of Sport Health for the year, we speak with Marguerite King and Nick Wilson about their experience at the Summer Olympic and Paralympic Games in Paris.
As we look to 2025, we remain committed to the successful implementation of the first year of our new Strategic Plan. Our focus will be on continuously improving performance across all areas of the organisation, ensuring we continue to support our members across their careers.
We extend a warm welcome to all new members who joined us in 2024. Remember, your 2025 SMA member logo is available for
Dr Stephen McMahon looks at how the Essendon Supplements Scandal that came to a head over a decade ago, has transformed the sports science and medicine industry. While Dr Free Coulston discusses her scoping review on how circus activities can be a potentially powerful tool for improving health and well-being in preschoolers born prematurely. Lastly, Dr Shelley Keating highlights the significance of exercise training in managing chronic fatty liver disease.
We sincerely appreciate the ongoing support of our members, and we look forward to helping them deliver great outcomes for our community in 2025.
Jamie Crain
An innovative circus-based intervention to promote physical activity participation for preschoolers born prematurely
DR FREE COULSTON, The University of Melbourne & Murdoch Children’s Research Institute (2023 ASICS SMA Conference – Early Career Researcher ASICS Best Paper in Physical Activity and Health Promotion)
Physical activity is crucial for children’s health and development, particularly at key developmental stages such as the preschool years (3-5 years of age). However, preschool-aged children born before 30 weeks’ gestation often participate in less physical activity, and less community-based activities, compared to their term-born peers. As children born prematurely have higher risk of developmental challenges, they can benefit hugely from the physical, social and cognitive benefits that physical activity provides. And
so, it is essential to understand, and address, this participation gap.
In recent years, circus activities have been transitioning from an entertaining spectacle to a potentially powerful tool for improving health and well-being in children and young people. We conducted a comprehensive scoping review to shed light on this emerging field, revealing promising outcomes across physical and social-emotional domains.
The outcomes reported in the literature reviewed, span both physical and social-emotional domains for young people aged 0-24 years:
1. Physical benefits included improved motor competence, increased participation in physical activity, enhanced postural control, and improved upper limb performance.
2. Social-emotional outcomes encompassed increased resilience and perseverance, enhanced confidence and self-esteem,
In recent years, circus activities have been transitioning from an entertaining spectacle to a potentially powerful tool for improving health and well-being in children and young people.
improved social skills and connection, and a greater sense of inclusion and belonging.
Notably, circus activities demonstrated these benefits across diverse populations, from general populations to those with specific conditions such as cerebral palsy, autism spectrum disorder, and various other intellectual or physical disabilities.
The findings of our review suggests that the efficacy of circus activities as a health intervention may be attributed to several factors:
1. Alignment with contemporary motor learning approaches through repetitive task practice and individual goal setting.
2. Satisfaction of psychological needs for autonomy, competence, and relatedness, fostering intrinsic motivation.
3. Compatibility with the biopsychosocial model of health, particularly the ICF-CY framework and the ‘F-words’ of child development.
4. Delivery in community-based settings, adding to their appeal and accessibility.
Lastly, the wide variety of disciplines available in circus such as aerials, object manipulation, equilibristics, acrobatics, and clowning, offer a unique blend of physical challenge and creative expression. This diversity allows for a wide range of incremental challenges, enabling participants to progress at their own pace, target individual goals, and experience early and frequent achievements.
The findings of this scoping review presented compelling evidence for the potential of circus activities as a unique and engaging health intervention for children and young people. This supported the use of circus as a relevant and appropriate vehicle for a participation intervention for children born preterm, so we proceeded to co-design exactly what this intervention should look like.
The first stage of co-designing our circus intervention, was to understand from key groups what was needed: what are the key priorities and considerations from the perspectives of parents of children born preterm, clinicians, and circus coaches? We undertook a mixed methods study to explore this question.
Setting the stage for healthier, more active lives
An innovative circus-based intervention to promote physical activity participation for preschoolers born prematurely
One of our study’s most significant findings highlights the pivotal role of coaches in promoting an encouraging and inclusive environment. Participants emphasised the need for specific training to expand coaches’ understanding and expertise in working with children born prematurely. As one coach noted, “Why programs work and why they don’t work is in the development of the trainers.”
Key training topics identified included:
1. Increasing understanding of the preterm experience
2. Optimising a therapeutic agenda
3. Enhancing meaningful inclusion in recreational physical activity
The study highlighted the need for careful consideration of class size, ability-based grouping, and sufficient adult support to optimise participation.
The study also revealed a strong preference for physical activity that promotes holistic outcomes. Parents and clinicians stressed the importance of focusing on behavioral and social skills alongside physical development. One parent shared,
“It’s not just an activity, it’s actually helping them build confidence and core stability and all of that.”
Clear communication and considered class planning emerged as crucial strategies for engagement. Early and clear communication about program benefits and organisational values was identified as key in “building that trust factor for the parents to let their children engage,” as one parent describes.
Stakeholders also discussed preferences for integrated versus separate tailored classes, with most favouring inclusive integrated classes. However, the study highlighted the need for careful consideration of class size, abilitybased grouping, and sufficient adult support to optimise participation.
The study uncovered a significant tension between the need for lowcost, convenient PA programs and the potential increased costs associated with specialised training and smaller class sizes. As one coach pointed out, “Is this program subsidised somehow or is it more expensive, which doesn’t seem great for accessibility.”
While stakeholders valued clinicians’ expertise in program design and safety considerations, there was a clear preference for maintaining a de-medicalised environment in recreational physical activities. As one
As children born prematurely have higher risk of developmental challenges, they can benefit hugely from the physical, social and cognitive benefits that physical activity provides.
that could significantly improve participation for preschool-aged children born preterm. We then took these strategies forward into a series of co-design workshops, again with parents of children born preterm, clinicians, and circus coaches.
parent suggested, “I think [clinicians’] input in being able to highlight different activities that can target different areas or problem areas, et cetera, would be really good in the design. But, in terms of delivery, I would leave that to the instructors.”
This study provided a wealth of stakeholder-informed strategies
The resulting intervention emerged from the collective wisdom of the codesign team: parents (n = 4), paediatric clinicians (n = 2), circus coaches with expertise in the preschool-age (n = 2), and two clinician researchers. The team members participated in diverse ways throughout the codesign, but primarily through eight 90-minute online workshops. This collaborative approach ensures that the intervention addresses the real needs of families while maintaining clinical excellence. As one coach noted, “The team that was put together was very supportive and comfortable and interested and engaged. Everyone was very open to sharing experiences and knowledge, and very respectful of knowledge as well.”
An innovative circus-based intervention to promote physical activity participation for preschoolers born prematurely
The resulting co-designed intervention was titled by the co-design team as “CirqAll: Preschool Circus for Premmies” and features three carefully crafted components (Figure 1).
First, circus coaches undergo specialised training to understand the unique needs of children born preterm. This comprehensive professional development involves 14 hours of online self-directed learning and four online workshops, ensuring coaches are well-equipped to support these young participants.
The second component introduces children born prematurely and their families to the class environment through two dedicated 60-minute classes. These sessions provide a safe space for children to explore circus activities while allowing coaches and parents to develop personalised strategies for each child’s success.
Finally, children transition into weekly classes alongside their termborn peers, fostering inclusion and developmental growth through ongoing participation.
Initial testing of the coach training component has shown encouraging outcomes, with improvements in coaches’ knowledge, skills, and confidence being maintained three months after completion. With some refinements to enhance retention, the program appears ready for broader implementation and testing.
CirqAll: preschool circus for premmies represents a significant step forward in supporting physical activity
participation for preschool-aged children born preterm. By combining the engaging nature of circus activities with structured support of children, families and activity providers, this initiative demonstrates how innovative thinking and careful, collaborative program design can create meaningful opportunities for physical activity and holistic development for young children who might otherwise face participation challenges.
For article references, please email info@sma.org.au
Dr Free Coulston
Free started her career as an international circus performer, transitioning to become a physiotherapist a decade later. Another 10 years on has found Free combining these passions in a PhD, looking at how circus activities may influence participation and developmental outcomes for children born preterm. As a post-doc researcher Free continues to work alongside people with lived experience in research, including expanding her work in co-design and collaborative research practices. She also holds a lecturing position at the University of Melbourne where she teaches the next generation of physiotherapists and strives to make the student experience more inclusive.
JSAMS – article of the year 2023
“It’s always the bare minimum” –A qualitative study of players’ experiences of tackle coaching in women’s rugby union
Kathryn Dane, Geraldine Foley, Sharief Hendricks, Fiona Wilson
2023 Journal Impact Factor*
3.0
*Journal Citation Reports (Clarivate Analytics, 2024)
JSAMS Plus – most cited article in 2024
Markerless motion capture: What clinicianscientists need to know right now
Naoaki Ito, Haraldur B. Sigurðsson, Kayla D. Seymore, Elanna K. Arhos, Thomas S. Buchanan, Lynn Snyder-Mackler, Karin Grävare Silbernagel
Video Interviews exploring Editor’s Choice Articles with Key Authors
ASICS IS ONE OF THE MOST RENOWNED BRANDS IN THE NETBALL SHOE INDUSTRY, WITH A STRONG REPUTATION FOR BUILDING SHOES THAT ARE SPECIFICALLY DESIGNED FOR THE SPORT’S DYNAMIC MOVEMENTS. AS NETBALL CONTINUES TO GROW AND EVOLVE, SO TOO DOES THE INNOVATION AND DEVELOPMENT OF NETBALL SPECIFIC FOOTWEAR.
Over the years, ASICS has continued to innovate and improve the Netburner™ range, incorporating advanced materials and technologies to enhance performance, comfort and stability for netball players of all levels. The Netburner™ models have consistently adapted to the changing demands of netball, ensuring players have the best possible footwear for their game.
The development of all ASICS product is underpinned by the ASICS Design Philosophy which combines
biomechanical research with extensive consumer feedback and insights. The athlete has always played a crucial role in the design and development of our netball shoes, with ASICS elite athletes, sub-elite and community players testing our products throughout this development process to ensure our shoes meet athletes’ needs.
Athlete input and insights together with testing performed by local research partners here in Australia, continues to provide an understanding of the demands of the game and the necessary footwear design features required to provide optimal support and functionality.
With the ASICS range, the objective has always been to build shoes based on playing styles and player wear issues. The challenge is to balance comfort, stability, grip and durability in the netball shoe. Running shoes are not designed or developed to provide these requirements for netball.
Each Netburner™ model has different characteristics and benefits allowing players to choose a shoe that best suits their game in terms of performance and wear.
In 2025, the Netburner™ 21 is introduced. This model sees advancements in technology designed to provide holistic stability
The development of all ASICS products is underpinned by the ASICS Design Philosophy which combines biomechanical research with extensive consumer feedback and insights.
whilst remaining one of our most durable netball shoe options.
The upper utilises a mesh material that is reinforced with synthetic fibres and a TPU overlay for a stable hold on the foot. This will ensure the foot remains securely on the shoe platform, preventing excessive movement during change of direction. The vamp of the shoe allows for a comfortable fit for the wider foot.
FLYTEFOAM™ midsole material provides lightweight cushioning that is of a firmer density and lower midsole stack height than a running shoe, ensuring a more stable platform for the netballer. The asymmetrical TPU Trusstic has evolved, extending through the midfoot and to the lateral forefoot, enhancing side stability and maintain torsional rigidity of the shoe. This will facilitate higher degree responsiveness allowing for quicker, smoother direction change when needed.
The Netburner™ models have consistently adapted to the changing demands of netball, ensuring players have the best possible footwear for their game.
The Netburner™ 21 is highly durable utilising a one-piece solid rubber outsole that is thicker than other netball shoes. The outsole wraps the edges of the midsole to prevent delamination associated with toe drag, stabilising the midsole further and allowing for proprioceptive feedback when landing on the edge of the shoe.
ASICS is committed to the advancement of netball shoe design and will continue to engage with athletes and our local research partners to ensure we continue to deliver superior netball-specific footwear.
SPORTS MEDICINE AUSTRALIA WAS EXCITED TO HAVE SEVERAL OF OUR MEMBERS JOIN THE MEDICAL TEAM SUPPORTING TEAM AUSTRALIA AT THE PARIS 2024 SUMMER OLYMPIC AND PARALYMPIC GAMES.
We spoke with Marguerite King and Nick Wilson about their experiences at the global event.
What was your role at the Olympics this year?
In early 2022, I was appointed as the lead national physio for the senior women’s water polo program. My role was leading the musculoskeletal injury management and prevention. Over the Paris Olympic cycle, we focused on implementing significant preventative measures that came to fruition during the Olympics. These preventative measures included really simple behaviors such as great communication and collaboration with the coaches.
During this time, we managed to have a significant cultural shift in how athletes accessed treatment. Previous research found that water polo athletes didn’t seek treatment until 10 days after their injury onset. We tried to really shift this culture to narrow that gap down to around 48 hours.
In a physio sense, we had a great network of physios around Australia (some of which are SMA members) who really drove athletes to trust them in injury management. When the national team got together, it was a seamless transition. I believe that this greatly contributed to the excellent athlete availability we had at the Olympics. I want to highlight Bernadette Petzel from NSWIS, who did an amazing job with the other half of the national team. Thanks to the great work of the physio network, we had all players available at full capacity for the Olympics.
What was your preparation like?
We were away for seven weeks, of which the last two weeks were the Olympics. We had a tournament in Greece and a tournament in the Netherlands. The tournament in Greece was pivotal, because the girls
had done an important physical preparation block earlier on in the year. For the athletes and coaches, I believe that they could start to see all that work coming to fruition. It was also important to have 100% of the team available to participate in the lead up tournaments as we were playing teams who would be in our pool at the Olympics. The team did an incredible job of showcasing and living by their team values and all the work that they had been doing.
Did you anticipate certain injuries, or was there anyone that was predisposed to injuries?
From working in water polo for the last seven years, it has quite a high injury rate. If you look at the percentage of injured athletes at an Olympic Games, and you break it down per sport, water polo has the fifth highest percentage of injured athletes. Last Olympic cycle, in the Australian women’s team, almost half of the injuries were overuse injuries, which is why we did so much work to try and work on injury prevention measures prior to the 2024 games.
Out of all those injuries, shoulder injuries made up about 22% and were the most injured body part
last cycle. This motivated me to start my PhD in 2020 so that I could work on a way of using wearable technology and machine learning techniques to quantify shooting, passing, blocking and swimming in water polo. Unlike football or rugby, there’s no GPS or high intensity movement tracking in water polo so we wanted to come up with a method that was suitable for this sport.
We used waterproof accelerometers and gyroscopes which led us to several studies that are in my PhD, of which two are published. Our proof-of-concept paper was recently published in Medicine and Science in Sport & Exercise as a Special Communication: Methodological Advances (https://journals.lww.com/ acsm-msse/fulltext/2024/05000/a_ dual_inertial_measurement_ unit_system_for.27.aspx).
One of the most satisfying things is seeing athletes, who you’ve worked with for a long time, triumph over major adversities such as injuries and illnesses, as well as major program structural changes over this cycle.
It also led us to have good insights into different movements that were mechanisms for different injuries.
An example of this is blocking and its relationship to medial elbow ligament injuries. Beforehand, we didn’t really understand the magnitude of the blocking impact until we measured it with the sensor. This information led to changes in the physical preparation program. In collaboration with Jordan Desbrow (National and QAS Strength and Conditioning Coach), we instituted
Diverse experiences, shared perspectives
changes to the arm impact dryland physical preparation guided by the new insights from the sensor data.
Another important factor which helped the team was having our fantastic team psychologist, Edel Langan, on the pool deck. She worked with the athletes and staff extensively in this period. From a staff perspective, we spent a significant amount of time working with her on how we were going to perform at our best over the whole seven-week tour. A lot of other staff members are former athletes, so one of the things we all valued was having the time and space to exercise. That was crucial for our mental and physical well-being and being able to sustain our best over such a long period.
What was a big highlight for you at the Olympics, or something you enjoyed?
One of the most satisfying things is seeing athletes, who you’ve worked with for a long time, triumph over major adversities such as injuries and illnesses, as well as major program structural changes over this cycle. The semifinal win over the US was so emotional and poignant for so many reasons. I think when you are a small part of that and know what
athletes and coaches have overcome to execute a world class performance in that moment, that’s the most satisfying thing as a physio you could possibly ever have in my opinion.
Everyone in the team, both athletes and staff, really committed to the team values and a “Never Say Die” attitude, no matter what your role was. That’s why being a part of the Stingers in Paris was definitely one of the best experiences I’ve had as a physio.
What was your role at the Paralympics?
I was a Headquarters Physio at the Paralympics, part of the performance services team. My role primarily consisted of clinical physiotherapy work as part of the wider sports medicine team. Larger sports have funding to bring along their own doctors, physio’s and soft tissue therapists, but the smaller sports with less funding unable to provide this. The HQ team is there to service these athletes and ensure they are ready to compete on race day. We are all assigned specific
sports - I was assigned triathlon, wheelchair tennis, and judo.
We also help out other physical therapies staff members and see other athletes when needed. Along with this, our role was to ensure the wider Paralympic staff were looked after so they could also perform their roles throughout the games period. The majority of the physical therapies team stayed at the team’s Mob hotel and commuted into the village each day.
Our typical day would start at 6.30am running exercise classes and groups for the staff to keep them fit and firing,
Diverse experiences, shared perspectives
then we’d take turns treating any staff members who needed treatment. Then we’d commute to the village to see the athletes and would typically return to the hotel around 6.30pm at night.
As a physio you certainly needed to be flexible and adaptable. One minute you would be treating an athlete, the next helping fit a SmartDrive to a wheelchair, then running out to do a laundry run! There was never a dull moment.
Was there any sort of preparation that you had to do prior to going?
The Paralympic headquarters team had two in-person meetings. That
helped so much with getting to know each other before we arrived in Paris. We also had regular online team meetings to go through all the logistics such as security, transport and to keep updated on the team’s preparation. These were really helpful as when we got to Paris the team clicked straight away, and we got down to work with such a great collaborative atmosphere.
Individually, we got handovers from the physios that were looking after the athletes we would be seeing before they arrived in Paris. I had a couple of athletes that were coming in with injuries that we knew about so it was good to be prepared for this once they got into the village. The
majority of athletes at that stage are pretty fit, firing and ready to go.
What was a highlight that you experienced while you were there?
Oh, there’s a few but just being a part of the team itself was the most special. The Paralympic headquarters team was amazing. There was such a caring and fun atmosphere, and we all looked after one another like family. There was lots of hard work but also lots of laughs and banter which made the experience so much fun. Being in the village and everyone coming together to watch someone compete for a gold medal, and welcoming the gold medalists back into the village was pretty surreal.
Being able to march at the opening ceremony was a highlight. The crowds were enormous and atmosphere was electric as we were only 2 teams in front of the French team. The French public loved the Aussie athletes!
Helping the triathlon team on race day was another highlight. It was pretty special riding the ups and downs with the rest of the team during the day and fortunately for me everyone remained upright, and the Seine was kind to us on the day.
We were also fortunate enough to be able to get out of the village to see some sports when an opportunity arose. I was super lucky to be able to see James Turner break a World record in the T36 400m, which was a massive highlight. Also watching Lauren Parker win Australia’s first dual sport gold for a Paralympian was also really special.
What was your time in Paris like both for work and personally?
It is a pretty special place, so I was very lucky. I got a couple of days or half days, to have a bit of a look around. Paris itself was incredible, and they really put on a show for the event.
Surprisingly it was actually pretty quiet because it was also the school holidays, so I was able to see a lot over there.
Also being able to collaborate with the wider performance services team was an incredible professional development opportunity. There were so many chances to chat to colleagues and develop new skills that will be invaluable in the future.
When you’re back home, where can we find you?
Being in the village, everyone coming together to watch someone compete for a gold medal, and welcoming the gold medallists back into the village was pretty surreal.
I work in a private practice called BODYSYSTEM in Hobart. I’m also a consultant physiotherapist at the Tasmanian Institute of Sport, specifically involved in working with para-sports in the south of the state but also seeing a wide range of athletes from a wide variety of sports. One of the advantages of working in Tasmania is that we get plenty of exposure to different sports and athletes you wouldn’t get in bigger states.
DR STEPHEN MCMAHON, Emergency Registrar and Master of Sports Medicine Student (University of Melbourne); SMA VIC State Council Member
Introduction
“The blackest day in Australian Sport” declaration at the February 2013 Canberra Parliament House pressconference, resoundingly caught the nation’s collective attention. There were federal justice and sports ministers, heads of the Australian Crime Commission, Australian Football League (AFL) and National Rugby League (NRL), all sullen faced and standing shoulder to shoulder in our national crisis. There were nefarious revelations of intertwined sports
doping, match-fixing, organised crime involvement and blatant cheating by athletes, coaches, and support staff.
However, after 4 years of player and coach bans/suspensions, multiple criminal investigations, formal enquiries, exhaustive legal processes and tactics, exposed failures by regulatory agencies and split public opinion - the reality for Australian sport was far less grandiose. An AFL club had demonstrated how profoundly committed it was to pursue and fund a “sports supplements arms race”
to achieve premiership success at all costs, without hesitation or insight from high performance staff, even as red flags were raised within the Essendon Football Club, by both some players and club doctor Bruce Reid.
Newly appointed senior coach and AFL legend James Hird was ambitious for success and recruited past premiership coach Mark Thompson - who brought with him the high-performance guru Dean Robinson, with formal university qualifications in medical science, exercise & sports science, physiotherapy and strength and conditioning and a history of delivering improved elite
team performance. However, the next Essendon hire was the now infamous Stephen Dank. Despite having only an honours degree in biochemistry and no formal professional qualifications in sports science or a clinical/health profession, he was employed as a pseudo sport scientist to manage their supplements program and was given full control of the playing group. Dank then quite extraordinarily appointed a compounding chemist, to be the official supplier of pharmacy products to Essendon in November 2011.
The covert operation masterminded and executed by Dank, supported
by other high-performance staff and endorsed by club coaches, involved regular clandestine team injection sessions, which were deliberately off site from the club training base to stay hidden from Dr Bruce Reid. Players were en masse encouraged and some pressured to sign informed consent documents and were knowingly misinformed that these injections were completely safe and fully compliant with both Australian Sports AntiDoping Agency (ASADA) and World Anti-Doping Agency (WADA) rules.
However, even after Dr Bruce Reid formally wrote to Head Coach James
Hird and General Manager of Football Paul Hamilton in January 2012, to raise serious concerns about the supplements being given to players without his approval, the supplement injection program continued unabated and in secret, until ceased in May 2012. Essendon then self-reported its concerns about the supplements program to both the AFL and ASADA - now called Sport Integrity Australia (SIA), with ASADA not beginning its investigation until February 2013.
The Essendon Football Club was left in turmoil and its reputation destroyed. Senior Coach James Hird was suspended and never coached again. High Performance Manager Dean Robinson was sacked, and 34 players faced ASADA infraction notices and back dated doping bans with most missing the 2016 season, once all legal appeals were finally exhausted and the WADA decision was upheld by the Court of Arbitration of Sport (CAS). Essendon was fined $2 million and charged with WorkSafe breaches. Stephen Dank was found guilty of 10 breaches of the anti-doping code and received an AFL life-time ban.
Pharmacological Considerations
The motive for the disastrous and ill-conceived supplements program was to simply improve soft tissue recovery times after matches and training sessions and for players to endure the benefits of heavier training loads, without the usual concomitant increased injury risk. To enhance individual performance, lessen injury rates and elevate overall team success. The four drugs subcutaneously injected were:
AOD9604 Hexadecapeptide, Thymosin Beta-4, Colostrum and Tribulus. These pharmacological ergogenic aids with ambiguous efficacy, were administered experimentally, to enhance training adaptations and improve exercise performance.
AOD9604 and Thymosin Beta-4 were either on the WADA prohibited list or not for human use, so by default also on the list with unknown and potentially harmful effects on players.
AOD9604 is a peptide fragment of human growth hormone (hGH), that is secreted by the pituitary gland. It has similarities to the homologous region of the hGH molecule and can therefore mimic binding to the hGH-
The
key recommendation was that Exercise and Sport Science Australia (ESSA) – previously Australian Association for Exercise and Sports Science (AAESS) founded in 1991 – was to be recognised and promoted as the single national professional accrediting body by all sporting employers in Australia.
The Redeemer of Sports Science & Medicine in Australia
receptors and activates various cellular signalling cascades, depending on the tissue. It regulates an assortment of biological functions such as stimulating the secretion of InsulinLike Growth Factor-1 (IGF-1), which induces growth in most body tissues, including skeletal muscle, cartilage, bone, and nerves. hGH is the major driver promoting growth in children, however in adults it plays a key role in metabolism. It reduces fat cell mass by inducing the inhibition of lipoprotein lipase activity in adipose/fat tissue, stimulating lipolysis in adipocytes. AOD9604 impersonates hGH and higher circulating levels correlate to lesser adiposity (obesity) without influencing appetite. Long-term hGH use is associated with increased risk of diabetes, cancer, oedema, and hypertension with AOD9604 seen as a potential safe alternative without these undesired side effects.
Thymosin Beta-4 (TB4) is a sequestering peptide naturally found in the body that is synthesised in most cells. It is highly prevalent in inflammatory cells and platelets. TB4 is believed to have a pertinent role in tissue homeostasis and repair. At tissue injury sites, TB4 is released in high quantities and has shown significant therapeutic potential in animal studies for myocardial injury and protecting and repairing the heart, inducing angiogenesis (increased capillarisation), and accelerated would healing. However, there is potential metastatic action on tumour cells.
Bovine Colostrum (BC) is the initial supercharged yellow liquid expressed by the mammary glands (breasts in humans) before milk
production commences after birth. It is a tremendous source of energy, micro-nutrients, immunoglobulins (resistance to infection), peptides, and growth factors. There is mounting evidence that BC may benefit the treatment of multiple medical conditions in both children and adults. It has been applied as a powdered ergogenic aid/supplement for athletes to advance exercise performance and recovery since the late 1990’s, however there is only lowmoderate evidence to support this.
Tribulus (plant extract) is claimed to simulate luteinizing hormone (LH) which stimulates natural production of testosterone and is promoted as a supplement with testosterone boosting capacity for greater gains in strength and muscle mass during training. However, human research does not support any effects on strength during resistance training or effects on body composition.
The Essendon supplement scandal spontaneously birthed the ‘Dank-Hird’ effect on Australian Sports Science and Medicine.
The misnomer of labelling 2013 the darkest year in Australian sport could be more accurately viewed as the year we lost our innocence regarding sports doping. Most Australians had a subjective and parochial opinion that all our nation’s sporting success and glory was consistently produced by our ‘always clean’ world class athletes. It was only athletes from other nations that used performanceenhancing drugs (PEDs). Part of all competitive sport is to push the limits of both human performance and the sport’s rules without crossing the line. However, Essendon did go beyond the pale and once well over the line, kept going until enough
‘whistle-blowers’ forced them to selfreport and face the consequences.
The Essendon supplement scandal spontaneously birthed the ‘DankHird’ effect on Australian Sports Science and Medicine. The AFL and NRL ‘supplements arms race’ were conducted by pseudoscience mercenaries, quacks, and unregulated professional cowboys. They peddled their ‘snake oil’ to cashed up professional sporting clubs, that were aggressively placing success and profits above athlete welfare and health, without any semblance of ethics, respect for rules, professional
Players were pressured to sign consent forms and misinformed that the injections were safe and fully compliant with ASADA and WADA rules.
conduct, or any accountability. The appalling club culture was so shamelessly unconstrained and unprofessional, even the staff were dosing PEDs for aesthetics.
Due to the outrageous actions of the ‘Dank-Hird’ coterie, a 2013 Senate Enquiry into the Practice of Sports Science in Australia was held. In 2017, all its recommendations were implemented, and it has transformed the Sports Science and Medicine industry and related professions.
The key recommendation was that Exercise and Sport Science Australia
(ESSA) - previously Australian Association for Exercise and Sports Science (AAESS) founded in 1991was to be recognised and promoted as the single national professional accrediting body by all sporting employers in Australia. When an individual is employed in a sport science role in any sport or code, they must hold current ESSA accreditation which prevents ‘rogue’ individuals from sport code-hopping. ESSA administers a national system of sports science and high-performance manager professional accreditation, requiring a of minimum of bachelor and/or master level qualifications
The Redeemer of Sports Science & Medicine in Australia
and demonstrated industry-specific experience and offers specialisation in relevant sports science disciplines. It demands strict adherence to professional standards, a code of conduct and continuous professional development and education. Other recommendations included a statement of ethics applying to all Australian sporting participants (overseen by SIA); universities offering sport science courses must include curriculum on ethics, duty of care to athletes and protecting their health and welfare. Finally, sporting organisations/clubs must provide athletes entering professional/high performance programs with training/ education in ethics, integrity, and rights and responsibilities concerning their long-term health and welfare.
Without the pain and saga of the Essendon supplements scandal 11 years ago, the sport science industry and profession in Australia may still be unregulated, without qualification standards, an agreed code of conduct, nor an athletecentric model where their welfare and health and compliance to SIA/ WADA rules is paramount. It was a salient lesson of the dangers and consequences of the irresponsible and unprofessional application of sports pharmacotherapeutics.
For article references, please email info@sma.org.au
Dr Stephen McMahon is a Ballarat based Emergency Registrar and Master of Sports Medicine student (University of Melbourne) and aspires to specialise as a Sport & Exercise Physician and GP. He is an Exercise & Sports Science and Honours graduate in Exercise Physiology at Federation University. After 17 years as a Biology/ Physical Education Teacher and Tutor/Lecturer at Federation University and ACU, he graduated Medicine in 2019 (University of Notre Dame Sydney).
Stephen is a former national level distance runner and Level 4 Athletics Coach - past Head of Athletics & Cross Country at Haileybury College, state/national team coach and personal coach to 5 Australian representatives (2010 World Schools Cross Country Champion and 2015 World 50KM Championships). Past National President of Sports & Exercise Medicine Students’ Australia (SEMSA) and current SMA VIC State Councillor. He has multiple publications and conference presentations in exercise physiology, coaching and heat-related sports injuries. Sport experience: Western Bulldogs - VFL Men, GWV Rebels U18 Boys/Girls - AFL Coates Talent League, St Patrick’s College Ballarat Ireland Football Tour, National Road Cycling Championships and Lorne Pier to Pub Swim. As a St John Ambulance VIC major event doctor - Melbourne, Great Ocean Road and Ballarat Marathons, Run Melbourne Half Marathon, and FIFA Women’s World Cup (Field of Play). Visit the SIA website to learn more
THIS YEAR’S CONFERENCE MARKED A SIGNIFICANT MILESTONE, WITH OVER 820 DELEGATES IN ATTENDANCE, MAKING IT OUR LARGEST EVENT TO DATE. HOSTED AT THE ICONIC MELBOURNE CRICKET GROUND (MCG), THE CONFERENCE PROVIDED AN IDEAL BACKDROP FOR NETWORKING, COLLABORATION, AND KNOWLEDGE-SHARING.
Over the course of four days, attendees were treated to a dynamic and diverse program that included cutting-edge symposia, handson workshops, insightful presentations, and lively social events. With experts and thought leaders from across the globe, the sessions covered a wide range of topics, sparking engaging discussions and inspiring new ideas.
From the first keynote address to the closing reception, the energy and enthusiasm throughout the event were palpable. It’s clear that this year’s Conference will be remembered as our most successful yet, setting a high bar for future gatherings.
Hear what a few of our delegates had to say about their experience.
Unpacked
The experience was truly incredible. Everyone was so welcoming, which made the event feel less overwhelming, despite the large number of attendees and the wealth of information.
DR RIA LESTARI
How have SMA Conferences helped your career?
These SMA Conferences are always fantastic, as each year brings new updates across a broad range of topics. This year, I was particularly impressed by the sessions on runner stress fractures and hip injuries. These insights will undoubtedly enhance my understanding of common yet complex injuries, to provide better care and more effective rehabilitation for my patients.
What was your favorite session?
The talks on female health were particularly relevant to my current research, reinforcing key themes while also offering new perspectives and emerging trends that will inform my work. It was exciting to hear from experts and connect theory with practice. Additionally, presenting my two posters was also a highly rewarding experience. It was a great opportunity to showcase my work, engage with fellow researchers and clinicians, and build confidence in sharing my work with a broader audience.
How did you enjoy this year’s Conference?
This is actually my first Conference, as I’ve just completed my Bachelor of Exercise in Sports Science, and I never had the opportunity to attend one until now. The experience was truly incredible. Everyone was so welcoming, which made the event feel less overwhelming, despite the large number of attendees and the wealth of information. Thanks to the support and kindness of others, everything has gone smoothly, and I’ve felt right at home.
Do you have a favorite session? I’m most interested in specialising in Sports Medicine, so hearing Dr Andrew Massey’s keynote was a highlight. I really appreciated how he shared so many practical tips in such an engaging and accessible way. His insights were not only informative but also highly applicable to my own aspirations in the field.
I’ve really loved that it was a joint Conference with the ACSEP. Being able to attend sessions from medical doctors and gain their perspectives has been eye-opening and offered a refreshing change.
How has being a part of SMA helped your career so far?
As a member of the SMA Student Networking Committee, this Conference has been a great opportunity to raise awareness about our efforts. It’s clear that SMA is placing a strong emphasis on supporting students and early-career professionals, providing them with valuable opportunities for growth. From an organisational perspective, SMA has been incredibly supportive. For example, at the SMA Student Networking Night, I had an informal but insightful conversation with Michael Kenihan, President of the SMA ASMF Fellows, about our mission and how we can help promote sports medicine as a career path.
Four Reflections
Did you enjoy the Conference?
I think it was brilliant. I’ve attended several SMA Conferences, but what I’ve really loved about this one is that it was a joint Conference with the ACSEP. Being able to attend sessions from medical doctors and gain their perspectives has been eye-opening and offered a refreshing change. This cross-disciplinary approach has truly made this Conference one of the best I’ve experienced.
What was your favourite session?
I think it’s been a collective experience. Yesterday, I attended a couple of the medical sessions, and the debates were fantastic - everyone had strong opinions, which led to some great discussions. That said, I may be a bit biased, but my favorite session was definitely by my boss, Dr Andrew Massey. While all the keynotes have been exceptional, his session really stood out to me.
How has SMA helped your career?
SMA is great for building connections with other health professionals, and its sport-specific focus makes it particularly relevant to my work, more so than some other organisations. The Conference quality is top-notch, the content is highly valuable, and the publications are excellent. It’s a great resource all around!
What was your highlight from this Conference?
I’d have to say the highlight was definitely the ASMF Fellows’ Dinner last night, where I was inducted. Beyond that, though, it’s been the casual conversations, engaging in meaningful discussions, and picking the brains of the presenters. It’s also been great reconnecting with people I’ve met over the years. Being face-to-face again has been incredibly valuable, especially after missing out on those interactions during the pandemic.
Do you have a favorite session?
My main area of interest is running, so I’ve been actively seeking sessions related to that topic. However, the “Trial Women Study” session was particularly insightful. Overall, I’ve really enjoyed everything - being a part of SMA gives you access to knowledge across multiple disciplines, offering a great diversity of perspectives and information. It’s been a fantastic learning experience.
DR SHELLEY KEATING, School of Human Movement and Nutrition Sciences, The University of Queensland (2023 ASICS SMA Conference – Senior Career Researcher ASICS Best Paper in Sports and Exercise Science)
Metabolic dysfunctionassociated steatotic liver disease (MASLD) is the most common chronic liver disease in Australia and globally. MASLD affects 1 in 3 adults and up to 80% of people living with obesity. Formerly known as nonalcoholic fatty liver disease (NAFLD), MASLD is characterised by excess fat accumulation in the liver and strongly related to the development of type 2 diabetes, cardiovascular disease and lifestyle-related cancers. In the setting of insulin resistance and inflammation, MASLD can progress to metabolic dysfunction-associated steatohepatitis with varying degrees of liver fibrosis. A proportion of people will further develop liver cirrhosis and end stage liver disease. With the high prevalence of MASLD worldwide, metabolic dysfunction-associated steatohepatitis is becoming a leading indication for liver transplantation.
In Australia, there is currently no pharmacological agents available for the treatment of MASLD. This year the FDA approved the first drug (a thyroid hormone receptor-beta agonist) for the treatment of those with moderate-to-advanced liver fibrosis.
Further promising pharmacological agents are in phase III clinical trials. For all people living with MASLD, including those receiving medication, lifestyle modification comprising a heart healthy diet and regular exercise, are the mainstay of MASLD management. Management guidelines recommend 3-5% body weight loss to reduce liver fat and improve cardiometabolic heath; however, at least 7-10% is recommended to achieve histological improvement in
MASLD, i.e. regression of steatohepatitis and liver fibrosis. Without the right support, this level of weight loss can be challenging to achieve and difficult to sustain long-term.
Regular exercise, and in particular aerobic exercise, can reduce liver fat (steatosis), improve cardiometabolic health and increase cardiorespiratory fitness, even in the absence of weight loss.
The benefits of exercise training for MASLD are now well established (Figure 1). Regular exercise, and in particular aerobic exercise, can reduce liver fat (steatosis), improve cardiometabolic health and increase cardiorespiratory fitness, even in the absence of weight loss. In 2023 we published exercise guidelines for the management of MASLD in collaboration with Exercise and Sports Science Australia (ESSA). The publication was designed to be a resource for exercise professionals and clinicians who are working with people with MASLD. A summary of recommendations is provided in Box 1.
Regular exercise enhances insulin sensitivity in peripheral tissues (muscle and adipose tissue). This improves glucose uptake and reduces the release of free fatty acids (FFAs) from adipose tissue, which in turn reduces the amount of FFA delivered to the liver via the portal vein. Improved insulin sensitivity also reduces the
Exercise training for metabolic dysfunction-associated steatotic liver disease exploring the ‘final frontier’
activity of lipogenic transcription factors in the liver (like SREBP-1c and ChREBP), which lowers the rate of de novo lipogenesis (the synthesis of fatty acids from non-lipid sources within the liver). Additionally, exercise stimulates mitochondrial biogenesis and increases the expression of mitochondrial enzymes involved in β -oxidation, which enhances the capacity of muscles and the liver to oxidise FFA. Collectively, these alterations in substrate metabolism leads to a reduction of fat stored in the liver (Figure 2). Other potential mechanisms for benefit include reduced visceral adipose tissue, improved gut microbiome and reduced inflammation, although the exact interplay of these pathways and their relative importance require further investigation.
Figure 1. Benefits of exercise training in MASLD. Image created with BioRender.
Figure 2. Putative mechanisms for the effects of exercise on reducing hepatic steatosis. Solid lines indicate enhanced mechanisms (e.g. insulin sensitisation). Dashed lines indicate reduced mechanisms (e.g. reduced concentrations of plasma insulin and glucose, reduced de novo lipogenesis). VAT visceral adipose tissue, SAT subcutaneous adipose tissue, FFA free fatty acid, TG triglyceride, SREBP- 1c sterol regulatory element binding protein, ChREBP carbohydrate responsive element binding protein, DNL de novo lipogenesis, FAS fatty acid synthase, ACC acetyl-coenzyme A carboxylase, VLDL very low-density lipoproteincholesterol, AMPK adenosine monophosphateactivated protein kinase, SIRT1 sirtuin 1, IRS-1 insulin receptor substrate 1, PI3K phosphatidylinositol-3-kinase, GLUT4 glucose transporter type 4, G6P glucose 6-phosphate. Created with BioRender. com. Reproduced from Keating et al. Sports Medicine (2023) 53:2347–2371
Aerobic exercise training provides a significant non-pharmacological method of improving liver health in individuals with MASLD.
While clear and consistent evidence exists for the benefit of exercise training on liver fat, the benefit of exercise training on the histological features of MASLD, namely the resolution of steatohepatitis and regression of liver fibrosis, is yet to be determined. Our exercise guidelines emphasised the need to clarify the independent effect of exercise on liver fibrosis irrespective of weight loss. This is important because liver fibrosis is the key prognostic indicator for serious liver-related consequences, such as cirrhosis and hepatocellular carcinoma. Surrogate markers for liver fibrosis, such as a ≥30% reduction in MRI-measured liver fat and/or a ≥17 IU/L decrease in alanine aminotransferase (ALT), have been used as endpoints in MASLD drug trials, but have not been thoroughly explored in the context of exercise interventions.
Figure 3. Change in absolute liver fat (A), proportion achieving ≥30% liver fat reduction (B) and proportion achieving both ≥30% liver fat reduction and >17 IU/L ALT reduction (C) in exercise versus control. Data are within-group estimated marginal mean change from baseline (95%CI) from linear mixed model or within-group proportion (%). Reproduced from Cuthbertson DJ*, Keating SE*, Pugh CJ et al. Liver International. 2024;44:2368–2381.
The study presented at 2023 ASICS SMA conference (11-14 October 2023, Novotel Sunshine Coast Resort, Twin Waters, QLD) sought to address this gap by conducting a post-hoc analysis of pooled data from three previous randomised controlled trials of aerobic exercise interventions in people with MASLD. The objective was to determine whether exercise could induce clinically meaningful changes in surrogate markers of liver histology (specifically using a ≥30% reduction in MRI-measured liver fat as a primary outcome, with ALT changes as a secondary outcome), even in the absence of clinically significant weight loss.
Study Design and Participants:
The post-hoc analysis pooled data from three randomised controlled trials that included 88 adults with MASLD (54 in the exercise group, 34 in the control group), with a mean age of 51 and a mean BMI of 33.3 kg/ m². The exercise interventions lasted 12-20 weeks, with aerobic exercise programs varying across the studies.
Key Findings: Participants in the exercise training group had a significantly greater relative reduction in liver fat (-30.6%) compared with the control group (-1.4%), demonstrating a nearly 5-fold greater likelihood of achieving a clinically meaningful reduction in liver fat [OR 4.86 (1.72, 13.8), p=0.002] (Figure 3).
The beneficial effect of exercise training on liver fat reduction was independent of clinically significant weight loss (<3%). Exercise training also significantly improved cardiorespiratory fitness, as measured by V̇O2peak, ventilatory threshold, and exercise capacity. While exercise did not significantly
Further research is warranted to confirm the effect of exercise training on liver histology, especially in the presence of established fibrosis and in longer-term studies.
affect all serum biomarkers of liver disease severity, there was a notable reduction in serum cytokeratin-18 (CK-18), a marker of liver fibrosis.
Limitations: Findings from this study should be considered in the context of study limitations including the pooling of data from trials with varying exercise protocols, the relatively short study durations when compared with typical pharmaceutical studies, and the small sample size for some of the biomarkers of liver disease severity. Further research is warranted to confirm the effect of exercise training on liver histology, especially in the presence of established fibrosis and in longer-term studies.
Clinical Implications: Aerobic exercise training provides a significant nonpharmacological method of improving liver health in individuals with MASLD. The study underscores the importance of incorporating regular aerobic exercise into comprehensive MASLD management strategies. While weight loss remains a beneficial goal, this research demonstrates positive changes in surrogate measures of liver histology, liver fat and cardiorespiratory fitness independently of weight loss, offering an effective and accessible intervention for people with MASLD.
Dr Shelley Keating
Dr Shelley Keating is a Senior Lecturer and Accredited Exercise Physiologist from the School of Human Movement and Nutrition Sciences at The University of Queensland. With a strong grounding in exercise metabolism and body composition, Dr Keating’s mission is to change the way that exercise is prioritised and accessed to improve the health and wellbeing of people with cardiometabolic disease, with a focus on metabolic dysfunctionassociated steatotic/fatty liver disease (MASLD) and type 2 diabetes. Dr Keating has developed national and international exercise guidelines for MASLD. Her research has been adopted into exercise prescription recommendations in 17 international guidelines for MASLD management across 12 countries
Exercise Recommendations:
Aerobic exercise: 150–240 minutes per week of moderate-vigorous intensity aerobic exercise can reduce hepatic steatosis (liver fat) by ~2-4% (absolute reduction). Even 135 minutes per week has shown effectiveness. There is no clear evidence of an intensity-dependent benefit, if the recommended volume is met. Further increases in volume may yield additional benefits, particularly for weight loss.
Resistance training: Should be considered in addition to (not instead of) aerobic exercise. The impact of resistance training in isolation on hepatic steatosis is less clear, requiring further research. However, resistance training has established benefits on glycaemic control, muscle mass and other cardiometabolic disease risk factors. Resistance training prescription can be guided by evidence and recommendations for related conditions (e.g. type 2 diabetes).
High-intensity interval training (HIIT): Emerging evidence suggests HIIT may be comparable to moderate-intensity continuous training for reducing hepatic steatosis. HIIT may be an enjoyable alternative or adjunct and is safe when people with MASLD are appropriately screened, supervised and monitored by appropriately qualified professionals.
Stepped and person-centred approach: Many people with MASLD will have low initial workcapacity and working to achieve the levels of exercise recommended in guidelines should follow a progressive and stepped approach, cognisant of individual capabilities and preferences.
Clinical Assessment and Management:
Symptoms: MASLD often presents without specific symptoms. Diagnosis usually relies on blood tests (e.g. liver aminotransferases), imaging (e.g. ultrasound), and consideration of clinical characteristics like obesity, type 2 diabetes or other cardiometabolic disease risk factors.
Assessment: Exercise professionals should assess cardiometabolic risk factors, physical capacity, comorbidities, and patient-important outcomes (e.g., fatigue, energy levels).
Referral: Referral to other healthcare professionals (e.g., dietitian, psychologist, physician) may be necessary for comprehensive multidisciplinary management.
Additional Considerations:
MASLD awareness: Many people with MASLD are unaware they have the condition and many referrals for people with MASLD may be primarily for other related conditions (e.g. obesity, type 2 diabetes). Awareness and assessment of MASLD within primary care in Australia is increasing.
Safety: While exercise training is generally safe when appropriately screened and monitored, consider potential interactions with medications and the presence of comorbidities.
Advanced liver disease: People with cirrhosis require special considerations regarding exercise prescription and dietary intervention. Close collaboration with other healthcare professionals is crucial to ensure conditions associated with advanced liver disease (e.g. gastroesophageal varices, hepatic encephalopathy) are managed prior to exercise initiation.
Benefits beyond weight loss: It is important to counsel people living with MASLD of the modest weight loss likely to be achieved by exercise alone (i.e., without concomitant diet) and highlight that many of the benefits of exercise training and changes in diet quality occur irrespective if weight loss.
What’s your current role or research area?
I’m in Canberra now as the lead of five clinics with a team of eight podiatrists. That takes up a lot of my time, but I also like to be involved in sports as well as the clinic. I’m solely treating MSK patients but a mix between athletes and the general population, so it’s a variety of patients and team mentoring daily.
How did you get into podiatry?
When I started working private practice, I gravitated more towards sports podiatry. I’ve been involved heavily with sports throughout my youth and into my adulthood, so I enjoyed that component of podiatry and focused my time on that field. From there I started my private clinics and pursued an ApodA accreditation as a Sports Podiatrist.
Is there anything that you want to move onto in the future?
I’m comfortable with where I am at currently, but I am always looking to improve. I like that I get to split my week between treating, training/ mentoring and upskilling other podiatrists in my team, and family time. I’ve got a great balance right now.
Recently you had a work trip to the United States, what did you do over there?
I was asked to assess a player at the Washington Commanders NFL franchise. He had a chronic foot injury that was persisting, and I was asked to assess it with our 3D in-shoe pressure analysis system that analyses peak and average force areas of feet. I assessed the data and with that information I advised on appropriate footwear and orthoses needs for that player.
The second part of my trip involved my giving a CPD presentation to the Commanders medical staff on modern foot assessment techniques and foot orthoses in football cletes.
What’ your experience been like with SMA?
I’m an active member of SMA and I have previously presented at the annual Conference. If you’re looking
to get into podiatry, I definitely recommend being a part of SMA, Australian Podiatry Association and Sports and Exercise Podiatry (SEPA) as it’s important to show your support to governing bodies.
What’s been a career highlight?
It’s a lot of small things that all contribute to the joy of my podiatry journey. The US trips have been great, as has presenting at SMA, but overall, it’s the people and the patients throughout the journey that are most special.
An ongoing highlight that gives me satisfaction is seeing a new graduate podiatrist in my team grow and develop into skillful and empathetic podiatrists. Their development and progression are fulfilling and important to the sustainability of the podiatry profession.
What’s your advice to young podiatrists?
Work hard at your craft and find your passion within the profession. Finding your niche within the profession comes with time, experience and some fine tuning, it doesn’t happen overnight. Patience, persistence and knowing that you are making a positive difference to patients’ lives is the key to success.
I’ve been involved heavily with sports throughout my youth and into my adulthood. I enjoyed the sports podiatry component and focused my time on that field.
What motivated you to pursue a career in sports medicine?
Well, it was entirely by chance. It wasn’t planned. I originally wanted to be a Physical Education teacher because when I was younger, women were discouraged from professions other than teaching and nursing. So, I attended Kuring-gai College of Advanced Education because the institution specialised in training teachers. Interestingly, I knocked back a scholarship to the University of Sydney because I was advised by a male school inspector that women shouldn’t attend university and that I was better off going to teacher’s college.
When I commenced my Diploma of Teaching, there was a lack of teachers, so students were attracted to studying education by being offered substantial scholarships (i.e., we were paid to study). However, by the time I graduated in 1980, there was an over-abundance of teachers, meaning there were no jobs. So, I travelled to the University of Western Australia (UWA), which offered a unique one-year course enabling students to convert their teaching diploma into a degree. In the 1980s, UWA was Australia’s leader in human movement science, guided by Professor John Bloomfield, who
People who shaped SMA
was responsible for many initiatives in human movement science and sport in Australia, including the Australian Institute of Sport. Professor Bloomfield was President of the Australian Federation of Sports Medicine (now Sports Medicine Australia) in the 1970s.
After completing my degree, I was encouraged to undertake an Honours program and needed to choose a supervisor and an area of specialisation. With a minimal science background but a passion for netball, I searched for a supervisor who would allow me to undertake a research project focused on netball. As the physiology staff already had too many students, that led me to Professor Bruce Elliott and
the specialty of biomechanics. Bruce Elliott was a fabulous supervisor (and lifelong mentor) and allowed me to examine the biomechanics of netball goal shooting, launching my career in biomechanics. Given my lack of science training at school, I had to massively upskill in physics and mathematics.
After completing my Honours degree in 1982, I applied for a senior lecturer position at the University of Wollongong, a job that, as a new graduate, I didn’t have the experience for. However, with solid references from highly respected UWA staff and a favorable interview, I was offered a one-year junior lecturing position at the University in 1983, which evolved into a 38-year career at the University.
One of my mentors at the University of Wollongong was Tom Penrose, who was extremely passionate about sports medicine. He strongly encouraged me to become involved with SMA, which was then called the Australian Sports Medicine Federation (ASMF).
In the 1980s, there were local branches, and I became actively involved in the South Coast branch
of ASMF. In 1986/1987, I was the branch Secretary and Education Officer, helping to run local educational seminars, all done on a volunteer basis.
My first ASMF conference was in 1984 in Perth, which was brilliant. I vividly remember the vigorous debates about the latest techniques to reconstruct an ACL and the high-quality applied sports science research. It impressed me as a young and naïve academic. One of my fondest memories was in 1993 when I won the ASMF Young Investigator Award, which included a trip to present my research at the 1994 American College of Sports Medicine in Indianapolis, as a special guest.
One of my highlights was being the Censor of the Fellows, together with Stephanie Hanrahan, from 2002 for 20 years. This gave me a fabulous insight into the incredible achievements of SMA members.
The SMA Conferences were a great forum to interact with clinicians who made you question what you were doing in the lab to ensure it was transferable to the real world, and to make your research meaningful.
How did Sports Medicine Australia help your career?
One of the reasons I kept attending SMA Conferences throughout my career was its unique multidisciplinary nature. As my career progressed, I was intensely involved with specialist biomechanics societies such as the International Society of Biomechanics and the International Society of Biomechanics in Sports. However, I loved having a national multidisciplinary networking opportunity, one that was held regularly with amazing people. Apart from the educational benefits, I developed lifelong friendships with other researchers and clinicians. The Conferences were a great forum to interact with clinicians who made you question what you were doing in the lab to ensure it was transferable to the real world and to make your research meaningful. We were privileged to receive several awards, including the 2011 ASICS Medal for Best Overall Paper, which one of my students received. Those awards on your CV and Conference presentations really help your career progression.
Has there been a standout career highlight with SMA?
I was flabbergasted in 2000 when I was invited to present the prestigious Sir William Refshauge Lecture at the Pre-Olympic Congress on Sports Science, Sports Medicine and Physical Education. I remember thinking, ‘Why on earth would they want me
to do this?’ but it was a fabulous experience. I was also incredibly proud to receive a Fellowship from ASMF in 1998. One of my other highlights was being the Censor of the Fellows, together with Stephanie Hanrahan, from 2002 for 20 years. This gave me a fabulous insight into the incredible achievements of SMA members.
Why would you recommend SMA to those starting their career in sports medicine?
SMA consists of an incredibly welcoming cohort of diverse professionals. It is not a threatening environment. For someone new in
their career, SMA provides you with opportunities to present your work in a non-judgmental environment, often in exotic locations. It is a place where young researchers can establish professional networks to enhance their career opportunities, with social interactions at the Conferences leading to lifelong friendships.
I strongly encourage students and established researchers and clinicians to be involved in SMA. And if there is any way of going back to the concept of the 1980s, where there were local opportunities to be involved in SMA, that would be fabulous.
SPORTS MEDICINE HAS A LONG-STANDING TRADITION IN SWEDEN, STARTING IN THE 1940S. IT IS MULTIDISCIPLINARY, TRADITIONALLY INCORPORATING PHYSIOLOGY-BIOMECHANICS, ORTHOPAEDICS AND REHABILITATION AND INTERNAL MEDICINE/SPORTS MEDICINE. IN RECENT YEARS, THE SCOPE HAS BEEN EXTENDED TO INCLUDE EXERCISE FOR HEALTH/EXERCISE ON PRESCRIPTION.
Although many work in the field in various forms, Sports Medicine is not a speciality or sub-speciality for physicians in Sweden, although this has been an aim for many years for the Swedish Society for Sports and Exercise Medicine (SFAIM). SFAIM is part of (and a voting member) of the Swedish Medical Society, thus functioning as a referral body, for sports and exercise related topics from various governmental institutions. SFAIM has a Board, with a Chairman chosen by the members for a 2–3-year period. SFAIM also has 10 associate chapters, mainly regionally distributed across the country (n=8), but also two dedicated to concussion (Swedish Sports Concussion Society) and YFA (Health care personnel for Physical activity). SFAIM organises an annual
scientific meeting (the 2-day Spring meeting), since 1972, and produces its own journal (Svensk Idrottsmedicin “Swedish Sports Medicine”). Step 1, 2 and 3 educational courses in Sports Medicine, are organised regionally, with national attendance, and represent the formal education of Sports Medicine in addition to courses in anti-doping. At present, SFAIM has around 1500 members.
At University level, Sports Medicine related research is performed at all Medical Universities in Sweden, although clinically Sports Medicine is spread among a lot of clinicians with special interest, but coming from various specialities, both from the private and public sectors. Internationally, SFAIM is associated to the European Federation of Sports
Medicine (EFSMA) and Federation International Medicine du Sport (FIMS), as voting members. SFAIM is also (through YFA) part of the European Exercise is Medicine (EIM) initiative.
Historically, the establishment of a clinic for “Health checks” of athletes at the Stockholm Stadion (1912 Olympic arena) in 1944 by the National Federation of Sports (RF), is considered as the start of organised Sports Medicine in Sweden. A few years later, in 1952, SFAIM was founded and was soon affiliated to the Swedish Medical Society. Some of the first topics discussed in SFAIM were knee injuries in ice-hockey, cardiac events in master athletes as well as concussions in boxing. Very timely topics also in our times! Interest in Sports Medicine increased considerably in the 1960s in parallel to the boom of leisure-time activity and competitions (running, swimming, skiing and cycling). In fact, a Swedish long-term tradition of performing the 4 various “classic” endurance competitions, all within the time-frame of one year: the Vasaloppet 90 km cross-country ski race; the Lidingöloppet 30 km cross-country running race; Vansbro swimming race and Vätternrundan, 300 km road-cycling race. The completion of this task is considered something of an achievement, being dubbed the “Swedish classic”. Such races increasing in size and attendance, contributed to both research and clinical development in Sports Medicine.
As early as 1899, Prof Henschen, produced the first thesis on what we today would call “athletes’ heart”- the adaptation of the heart in size to endurance activity.
The contribution from Swedish researchers and clinicians in Sports Medicine internationally, has been considerable. Initially, physiology was leading the way. As early as 1899, Prof Henschen, produced the first thesis on what we today would call “athletes’ heart”- the adaptation of the heart in size to endurance activity. Prof Per-Olof Åstrand, from the Swedish School of Sports and Health Sciences, presented
his classic thesis on the “Åstrand cycle ergometer test” in 1955, a test that today is the standard globally. Another important figure is Prof Gunnar Borg, who published his original scale on perceived exertion, the “Borg-scale” in 1962. Other internationally wellknown sports physiologists include Prof Bengt Saltin and Prof Björn Ekblom. In traumatology, multiple clinicians and researchers have excelled, including Prof Ivar Palmer, Prof Ejnar Eriksson as well as in more recent years Prof Jon Karlsson, Prof Jan Ekstrand (UEFA injury studies), Prof Jack Lysholm (Lysholm score) and Prof Yelverton Tegner (Tegner score). The professors Lars Pterson and Per Renström, are authors to the most read Sports Medicine textbook worldwide, recently updated in 2024. In medicine, Prof Arne Ljungqvist, has had tremendous impact on the fight against doping (former Chairman of WADA), while Bengt Eriksson was a pioneer in paediatric (sports) cardiology. This was just a glimpse of the vast scientific contribution from Sweden in this field. Numerous non-physicians (in addition to the physiologists) have also contributed to the research at high international level.
A long-term tradition of performing the 4 various classic endurance competitions, all within the timeframe of one year - the Vasaloppet, Lidingöloppet, Vansbro and Vätternrundan - is dubbed the “Swedish classic”.
Similar to the development in other countries, the increased importance of physical activity for health, is shown in the association changing name to “sports AND EXERCISE medicine” around 2010. At the turn of the century, SFAIM was asked to compile the evidence for the health effects of physical activity for various diseases, according to FITT (frequency, intensity, time, type), with the aim to prescribing activity in health care. The result was the FYSS-book, now considered to be the main scientific reference work, collecting the evidence for effect as well as information about contraindications, mechanisms, sideeffects, risk stratification, etc. The latest version of FYSS, was published in 2021 (FYSS2021), edited by Ing-Mari Dohrn, Eva Jansson, Maria Hagströmer and Mats Börjesson. However, one of
the most important achievements of YFA, is the development of a clinical model, for exercise prescription in health care, FaR (Swedish PAP), which is now part of the national guidelines for lifestyle behavioural change, from the National Board of Health and Welfare (Socialstyrelsen).
The government has recently, in 2023, allocated a large sum of money dedicated to the different Health care regions of Sweden, for improved implementation of PAP at ground level.
For research grants, the Center for Sports Research (CIF) offer scientific grants in all disciplines of Sports Science (wider than Sports Medicine), as well as grants for PhD-students. The prestigious organisation SCIF (local organiser of the Olympics in 1912 in Stockholm) gives a yearly Sports Science research award.
Importantly, we do believe that a major part of the success and growth of Sports Medicine in
Sweden, is the multidisciplinary collaboration. Gaining experience from the work and collaboration between disciplines in medical teams around the teams, SFAIM do include doctors and nurses, but sections have also been established for sports physiologists, physiotherapists, naprapaths and chiropractors.
In summary, Swedish Sports Medicine is well and thriving. We do aim to be a (sub) speciality, following other countries who have achieved this. Education is a constant challenge, as is the recruitment of young professionals, both to research but also to clinical work in sports medicine, for instance as team physicians. Sports Medicine has been integrated into the education of some/many University programs and courses, but the need for all parts of Sports Medicine, not least physical activity for health, is needed for this development to continue. This is not only a hope, but also a necessity for society.
Mats Börjesson MD is Professor of Sports Physiology, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden. Specialist in Cardiology and Internal Medicine. FESC, FACC, FACSM. Director of the Center for lifestyle intervention (CFLI), Sahlgrenska University Hospital.
Chairman of the section of Sports Cardiology, European Society of Cardiology, 2008-10 Chairman of the Swedish Society of Cardiology, 2016-18. Chairman of the Swedish Society of Exercise and Sports Medicine 2013-15. Currently chairman of the Swedish Football Association Medical Committe. Board of Trustees, ACSM (2024-). Team physician at 11 European, World Cups and Olympic Tournaments, mainly for Swedish Women’s soccer team (2009-). FIFA venue medical officer at WC 2022 and Arab Cup 2021. Editor of the Swedish reference book on exercise prescription (FYSS2021) and the ESC Sports Cardiology book (2019). Main research areas are Physical activity for health, Sports Cardiology and Sports Medicine. 276 peer-reviewed publications. Invited speaker at >180 international conferences.
What motivated you to become a sports trainer through SMA?
In my first year of university, our course coordinator recommended that we receive an accreditation so we could start working in the industry. They recommended either sports trainer or strength and conditioning, and as I had a background in Surf Life Saving, I chose to become a sports trainer as it was more relevant to my experience.
In my first season, I was asked to join a rugby union club, and then after that, I started working with the Southport Sharks who I’m still with today. Following the team through, the whole season is rewarding especially because our girls’ teams won both premierships this year.
What was your experience like at the 2024 UniSport Nationals?
I worked mostly on netball for five days. It was really good because we had a team of three to four different trainers so we could collaborate on cases if we needed to. We also got to know a lot of the players who came to us regularly. I found that to be important as we got to know everybody who was there, and all the teams were great at trusting us and listening to our advice.
SMA prepared us really well. They gave us an online induction on what injuries to expect, what kind of things to bring, and they gave us all our specific paperwork. Having worked in the industry for a couple of years, I felt confident in my skills but having the
online inductions helped so I knew exactly what I was going to be doing.
We had some bizarre injury presentations, and it was amazing to see a lot of people who were bringing us back their X-rays after they went to the hospital so they could show us the follow-up process. We were able to follow the players that we helped as it was such a long event and that’s something we don’t always get to do at every event. I think that’s what made it such a special event. That would definitely help with career aspects as it is sometimes hard when you mostly do one-off events because you never know what will happen afterwards. I also got to network, especially with the sports trainers through SMA. I plan
to do it next year as well as it will be on the Gold Coast, my hometown.
Would you recommend becoming a Sports Trainer through SMA to others?
Definitely. For me, it’s been great as it’s given me an opportunity to network and get a lot of experience in the industry. There are a lot of different avenues you can go into, whether you want to be a runner for field sports or be involved in sideline court sports. I also know that there are also people who work with extreme sports, like BMX.
There are a lot of different opportunities and different avenues, depending on what your interests are in. For me, I’ve
SMA prepared us really well for the 2024 UniSport Nationals. They gave us an online induction on what injuries to expect, what to bring along, and gave us all our specific paperwork.
been able to get into AFL because that’s the sport I grew up watching and that’s what I understand the most. It made sense for me to be able to transition into that. However, I still enjoy going to UniSport Nationals and having the chance to work at netball and other sports.
Do you have plans for the future in your Sports Trainer Career?
I’m open to doing whatever I enjoy. I think I like being in a team sport environment because I’m able to work with different people and collaborate – that way I can learn from everybody. Eventually, I want to get into medicine as I have an EP
I like being in a team sport environment because I’m able to work with different people and collaborate – that way I can learn from everybody.
degree so being a sports trainer is a really good avenue to receive all that first-response experience.
It’s a flexible job that you can work in while still studying and learning
industry connections as you can meet all kinds of people. At my footy team, I talk a lot to our sports doctors about different injuries and their management, meaning I’ve built a great professional network and deep knowledge.
I’m planning to still do sports training even throughout medicine as I think it fits in well and gives me something to do on the side. It is also a really fun job to have, and I love working with players, getting to socialise and watching sports.
How has SMA helped with that aspect of studying medicine and getting to know the industry? I’ve jumped onto quite a few of the online PD events and found them really interesting. Especially the ones about exercising in the heat, which was relevant because I did a placement in Darwin and worked with the NTFL and we were almost always under heat guidelines.
SMA is important to anyone studying any kind of Allied Health as it’s great to help you get a foot in the industry and get some experience working and networking. Especially if you’re in a degree as it’s also really flexible. I feel like I’ve met so many people from so many different walks of life, and I wouldn’t have gotten that anywhere else.
