Sport Health Volume 41 Issue 1

Sport

health

FEATURING

• Vigorous physical activity: a promising option for a busy school day

• Thermal stress and strain during the Tour Down Under

• Genesis of the Australian Sports Medicine Federation

Contents

REGULARS

2

From the Chair

SMA Board Chair, Kay Copeland reflects on 60 years of SMA and welcomes the new Board members.

3

From the CEO

Jamie Crain welcomes a return to print for Sport Health and discusses the articles featured in this edition.

FEATURES

4

Genesis of the Australian Sports Medicine Federation

A look back at the formation and early years of ASMF in commemoration of SMA’s 60th Anniversary.

10

Improving older adolescents’ health and well-being using high-intensity activity breaks

Prof David Lubans examines the outcomes of the Burn2Learn program which was trialed in NSW schools.

16

Young People with Old Knees

Dr Brooke Patterson and Dr Andrea Bruder present their views on how to prevent adolescents and young adults retiring prematurely from sport due to traumatic knee injuries.

21

Thermal stress and strain during the Tour Down Under Prof Julian Périard discusses the integration of sport-specific factors to inform environmental heat stress policies in the context of cycling.

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. 10 Brens Drive, Parkville VIC 3052 sma.org.au

ISSN No. 2205-1244 PP No. 226480/00028

Marketing and Member

Engagement Manager

Sarah Hope

Copy Editors

Archie Veera and Anelia du Plessis

Design/Typesetting

Perry Watson Design

Cover photograph

Cameron Spencer, Photodisc

Content photographs

Author supplied; www.gettyimages.com.au

36

People who Shaped SMA: Professor Belinda Beck

39

Sports Medicine Around the World: Romania

27

Vigorous physical activity: a promising option for a busy school day

Stephanie Duncombe, Dr Michalis Stylianou, and Prof Alan Barker assess the relevant literature to explore the effectiveness of HIIE for children and adolescents.

INTERVIEWS

31

Physician Focus: Dr Rachel Harris

42

Sports Trainer Highlight: Harry Saban

FROM THE CHAIR

Celebrating the 60th anniversary of Sports Medicine Australia and its initiation.

DR KAY COPELAND, CHAIR OF THE BOARD OF DIRECTORS (SMA), REFLECTS ON HER INVOLVEMENT WITH THE ORGANISATION OVER THE YEARS, AND HIGHLIGHTS THE 2023 ASICS SMA CONFERENCE.

Welcome to the first edition of Sport Health for 2023.

We are delighted to be celebrating SMA’s 60th anniversary this year. As part of our celebrations, we will be commemorating the anniversary by publishing articles relating to the history and evolution of SMA in this and upcoming editions of Sport Health as well as across our social media channels. Please keep an eye out and get in touch if you have any particular memories you’d like to share.

My own involvement with SMA began in 1985 when I was a member of the newly formed ASMF Victorian Branch Sports Trainers Committee. It has been a long journey that I have shared with many SMA members over those nearly 40 years. My reflections of SMA are an organisation that has grown and adapted to a continually changing landscape in the sports medicine and sports science fields and the expansion into physical activity and injury prevention areas. However, throughout those years there has

been a feeling of unity and comradery within SMA to foster and grow the expanding areas and to ensure all are welcome as part of the SMA family.

I would also like to acknowledge and welcome our new Board members – Professor Belinda Beck and Dr

Laura Lallenec. We look forward to their expert advice and contributions towards the governance and future of this organisation. The Board will continue to work alongside the SMA management team to implement the three-year strategic plan as we support a growing membership and affirm our authority as the peak multidisciplinary body for sports medicine, science and physical activity in Australia.

Finally, preparations for the 2023 ASICS SMA Conference are well underway. This year’s Conference is being held at the Novotel Sunshine Coast Resort from October 11 – 14. The Conference Committee has created an exceptional multidisciplinary scientific program, featuring world-class keynote speakers. Registrations are now open, so join us and learn, discuss, debate, network and celebrate sports medicine and SMA’s 60th year. I look forward to seeing you there.

Dr Kay Copeland

I would like to acknowledge and welcome our new Board members

– Professor Belinda Beck and Dr Laura Lallenec. We look forward to their expert advice and contributions towards the governance and future of this organisation.

FROM THE CEO

We are excited to have Sport Health return to print form for members.

Welcome to the first Sport Health for 2023.

Due to the success of our Best of Sport Health in 2022, this edition marks a full-time return to print for Sport Health. I hope you enjoy flipping through the pages of our magazine, and reading about the many and varied topics of interest that impact and influence our community of sports medicine professionals.

Reducing screen-time for kids and getting them into sport is important for balanced learning, solid health outcomes, and establishing important habits. In our first article, Prof David Lubans discusses the outcomes of the Burn2Learn program for older adolescents, which has been trialed in NSW schools. Additionally, analysis by Stephanie Duncombe, Dr Michalis Stylianou, and Prof Alan Barker further explores the effectiveness of vigorous physical activity in improving health benefits for children and adolescents.

With football season upon us, knees and knee injuries are always topical. Dr Brooke Patterson and Dr Andrea Bruder present their views on how to

prevent adolescents and young adults retiring prematurely from sport due to traumatic knee injuries. Prevention strategies include further education on knee osteoarthritis and other risks, collaboration on health goals, and targeted prevention programs.

While Summer has officially drawn to an end, we need to be mindful of temperature levels as the warm weather patterns extend into Autumn. Heat stress remains a real risk, even in the southern states. In cycling, Prof Julien Periard discusses the effect of thermal stress and strain on athletes during

the Tour Down Under and provides suggestions on how to improve environmental heat stress policies.

Finally, concussion identification and management remains front of mind for all involved in contact sport. At SMA, we take the issue of concussion and repetitive head trauma in sport very seriously, and we continue to work with our broader stakeholder groups to support ongoing learning in this area and promote sensible policies and guidelines. Recently, a team of SMA representatives provided evidence to the Senate Reference Committee Hearing on Concussion and Repeated Trauma in Contact Sports. The Senate Hearing is an ongoing process, and as the peak body in sports medicine, SMA intends to remain actively involved. The report is expected to be delivered in June.

Once again, we hope you enjoy this edition of Sport Health, and please let us know your feedback and ideas for future editions. We look forward to keeping you updated on the world of sports medicine throughout the year.

Jamie Crain jamie.crain@sma.org.au

While Summer has officially drawn to an end, we need to be mindful of temperature levels as the warm weather patterns extend into Autumn.

SMA CEO JAMIE CRAIN SUMMARISES THIS EDITION’S FEATURE ARTICLES AND OUTLINES SMA’S INVOLVEMENT IN THE SENATE HEARING ON CONCUSSION AND REPEATED TRAUMA IN CONTACT SPORTS.

Genesis of the Australian Sports Medicine Federation (ASMF)

THIS YEAR MARKS SMA’S 60TH ANNIVERSARY, AND THERE’S MUCH TO CELEBRATE. SMA WAS BORNE FROM RICH, PASSIONATE AND WELL-CONSIDERED BEGINNINGS THAT CONTINUE TO UNDERPIN THE STRENGTH OF THE ASSOCIATION TODAY.

Comprised of excerpts from the 25th Anniversary book ‘A Healthy Body’ by Wray Vamplew and the 50th Anniversary commemorative edition of Sport Health written by Emma Russell, this article takes you on a journey from SMA’s inception in 1963, when the Australian Sports Medicine Foundation was born, through the first 15 years.

It’s a story that highlights perennial considerations about our identity, purpose and who we represent, immeasurable contributions from so many of SMA’s forebears, and periods of political and parochial friction.

Initial Formation

Clinical sports medicine had long been practiced on an ad hoc basis across Australia, driven by the enthusiasm of sports mad practitioners prepared to work in an honorary capacity for clubs or who saw sporting injuries amongst their regular patients. However, there was no formal organisation for sports medicine until the 1950s when Melbourne’s hosting of the 1956 Olympic Games loomed.

The organisers of the Games elected to tap two major sources. First, they looked to the armed services with air force personnel providing the basic manning of the medical centres at the village and at the Olympic venues. The Games executive also recruited medical men from local sporting bodies [to provide further support].

The Australian Sports Medicine Association (ASMA) sprang out of these arrangements. Bringing many medical men, who were interested in sport together in Melbourne, gave rise to the opportunity to establish an Australian sports medicine organisation. A meeting was held on 14 March 1955 at which the ASMA was formally named.

Following the establishment of the national organisation, several states formed affiliated

bodies to promote sports medicine at a more local level and to cater for the interests of ASMA members in their resident area. As can occur with national organisations, interstate friction produced problems.

When NSW broke away from the ASMA in 1961 to form the Australian Federation of Sports Medicine (AFSM), it was out of frustration at the perceived dominance and lack of consultation coming from the Victorian group in particular, and their inability to instigate a rotating national committee.

For a few years, there was considerable disquiet amongst the VIC, SA, WA and NSW branches, and while the blame was often put on their Victorian colleagues for creating many of the problems, it was in fact the Victorian leaders who paved the way for reconciliation.

With the Commonwealth Games in Perth in 1962, it was suggested the event could be used to facilitate a Council meeting and an amalgamation of the ASMA and the NSW-based AFSM. The merger was unanimous, as was the name change to the Australian Sports Medicine Federation which honoured the derivation from both organisations without preferencing either of them.

There was no formal organisation for sports medicine until the 1950s when Melbourne’s hosting of the 1956 Olympic Games loomed.

Genesis of the Australian Sports Medicine Federation (ASMF)

The newly united ASMF had, as its aims:

“The medical supervision and care of those promoting and conducting physical activities in a sporting and recreational form to safeguard and improve their physical and mental health; the arrangement and support of the scientific study of the effects of physical activities on the human organism; to provide information to sporting bodies throughout Australia by way of the state branches; to cooperate between kindred nation and international bodies such as FIMS; to liaise with the Australian Olympic and Commonwealth Games Federations and advice on medical matters; to act as coordinating body for all state bodies; and to promote policy and undertake responsibilities and tasks in relation to the aims of the Federation”.

Membership

A crucial issue to be managed was composition of the membership. Initially, after considerable discussion, it was decided that full membership, at a cost of ten shillings per annum, should be open only to registered medical practitioners. Special membership by invitation, with equal voting rights and at equal cost, could be available to suitably qualified non-medical graduates approved by state branches. Such membership was to be limited to a 10% maximum of aggregated special and full membership, both at a branch and Federation level, a figure suggested to the 1963 Melbourne meeting by the Australian Medical Association (AMA) delegate, Dr Ross Smith.

Additionally, associate membership, costing five shillings, was open to persons not qualifying for either full or special membership on medical, educational, or quota

grounds. They were not entitled to vote, to be delegates to the Council, or act as office-bearers at either state or federal level.

Jim Pannell, President in 1965 believed that sports medicine’s future lay with convincing the medical profession that sport and exercise was required for health and disease prevention, and a close affiliation with the leading medical body in Australia would provide them with the influence they needed. But there were also other senior members who felt just as strongly that sports medicine could only flourish if it was true to its disciplinary mix, which had to

mean accepting disciplines in equal numbers, and allowing that same mix to vote and hold positions of authority alongside the doctors.

The debates amongst themselves, and the negotiations with the AMA went on for several years with very little ground given by both sides of the argument. Eventually, an offer by the AMA to accept a non-medical membership of 20% was turned down at a 1969 Council meeting. The next year, it was agreed that any registered medical practitioner and graduates from an accredited tertiary institution in a discipline relevant to sports medicine, could be a member of the ASMF.

Dr Ken Fitch. As one of the SMA ‘originals’, he is an ASMF Fellow, was SMA Secretary from 1965-73, SMA WA President from 1966-67, SMA President from 1977-79 and was made a Life Member of SMA in 1979.

Engineered Knit Upper and Tongue

Designed to create a balance of comfort, breathability and support, eliminating the need for traditional overlays and stitching to reduce irritation.

PureGEL Technology

Positioned internally under the heel, is lighter and softer than previous GEL™, continuing to provide added cushioning.

FF BLAST™ PLUS ECO

One-piece midsole with increased stack height for an incredibly cushioned underfoot feel.

Full Ground Contact Outsole

Full ground contact outsole and a wider basenett offer the runner a stable platform and smoother transition during their stride.

PARTNER FEATURE

Evolution of the ASICS

GEL-NIMBUS ™ Series

ASICS HAS A RICH HISTORY IN DEVELOPING HIGHPERFORMANCE FOOTWEAR PRODUCTS, AND IN 2023, THERE IS A REVOLUTIONARY UPDATE IN THE GEL-NIMBUS™ SERIES.

The GEL-NIMBUS™25 is the most cushioned GELNIMBUS™ to date, taking dynamic running comfort to new levels. It is modern, relevant and developed with new and improved technologies, following the new ASICS Design Philosophy.

The ASICS Design Philosophy is the guidelines for developing and designing performance running and core performance sports products. This philosophy captures more extensive consumer feedback and insights in development,

with a greater sustainability lens over all future developments.

The GEL-NIMBUS™ 25 is suitable for every day, easy runs for all runners, novice or experienced, who are looking for a highly cushioned, neutral shoe.

The new midsole design features a single layer of FF BLAST™ PLUS ECO cushioning, replacing the FLYTEFOAM™ and FF BLAST™ PLUS technologies used in the previous model, delivering dynamic comfort and a more responsive cushioning experience underfoot. The new

foam contains at least 20% biobased content vs. GEL-NIMBUS™ 24. By raising the stack height by 6mm in the forefoot and 4mm in the rearfoot, the GEL-NIMBUS™ 25 now features an 8mm heel drop.

PureGEL™ technology is strategically integrated in the midsole under the heel, providing enhanced impact absorption and a softer feel. It is 65% softer than previous GEL™ technology.

The GEL-NIMBUS™ 25 features an updated knit tongue and collar construction together with a new soft knit upper for enhanced ventilation, improved flexibility and increased comfort around the ankle.

Full ground contact outsole geometry with a wider basenett offers the runner a smoother, more stable transition from contact through to toe off.

GEL-NIMBUS™ 25 is made with more recycled materials than previous versions, which helps reduce CO2 emissions.

With the ambitious goal of ‘creating the most comfortable running shoe’, extensive design and development work was required, as well as internal and external testing and consumer validation. As part of this push, ASICS Global commissioned The Biomechanics Lab in Adelaide, South Australia to oversee an independent research study to assess the comfort

of the GEL-NIMBUS™ 25 relative to similar models in the marketplace.

Led by Dr Chris Bishop PhD, 100 recreational runners were recruited from running clubs in Adelaide and ran for three minutes in each of the five pairs of shoes in a randomised order. Each of the shoes were blinded so runners couldn’t be biased based on brand, colour or visual appearance. This allowed the runners to assess each shoe on its merits.

Explaining the design of the study, Dr Bishop said, “Comfort is one of the most important factors when purchasing running shoes. But it

is tricky to assess objectively as comfort is not a biomechanical metric. It’s a subjective perception. Where traditional measures of comfort are subjective and prone to bias based on initial perception of the shoe, we used a tool previously developed in our lab (the RUN-CAT) which we have shown makes the runner think specifically about the shoe when they run. This ultimately reducing initial perception bias and is an overall better assessment of the shoe’s design and function.’

The results were conclusive. The GEL-NIMBUS™ 25 was rated as the most comfortable running shoe by runners. “This was a broad, systematic effect that was not influenced by age, gender, foot strike classification or running experience” explained Dr Bishop.

With the ambitious goal of ‘creating the most comfortable running shoe’, extensive design and development work was required, as well as internal and external testing and consumer validation.

Improving Older Adolescents’ Health and Well-Being Using High-Intensity Activity Breaks

Senior school students are stressed

The final years of school are highly stressful, and one in four Australian older adolescents (15-19 yrs) meet the criteria for ‘psychological distress’. Changing social roles, uncertainty about the future, and the pressure to perform in end of school examinations (e.g., Higher School Certificate) are major factors contributing to the spike in mental health problems that emerge during this critical developmental life stage. Physical activity is a universally accepted intervention for the promotion of mental health and the prevention of mental ill-health. However, less than 10% of Australian older adolescents are sufficiently active. It is of additional concern that this generation of adolescents have

lower levels of cardiorespiratory fitness than their parents’ generation.

Schools are universally recognised as key settings for physical activity promotion among children (5-9 yrs) and younger adolescents (10-14 yrs). Schools have the facilities, equipment, curriculum, and personnel to facilitate physical activity. They also provide access to most of the population. However, Australian education departments do not currently mandate PA for senior students (i.e., older adolescents aged 15-19 yrs). This is partly due to the misconception that replacing physical activity opportunities (i.e., physical education and school sport) with additional study will improve academic performance. This

view is ill-informed as there is a growing body of evidence suggesting students with higher levels of physical activity and cardiorespiratory fitness perform better on standardised academic tests and measures of cognitive function.

Our time-efficient solution

We designed the Burn 2 Learn (B2L) program to address these challenges. Our aim was to demonstrate that senior school students could receive the health benefits of physical activity in a time-efficient manner. We provided teachers with training, resources, and support to facilitate the delivery of high-intensity activity breaks (hereafter, referred to as B2L sessions) during lesson time. The high-intensity interval training (HIIT)

PROFESSOR DAVID LUBANS

sessions involved a combination of aerobic (e.g., shuttle runs, jumping jacks, boxing, dancing) and musclestrengthening (e.g., push-ups, squat jumps, and walking lunges) exercises. Students were able to select from a variety of predesigned HIIT task cards which were released across the three phases of the program to promote variety and sustain participant interest (see Figure 1 for an example). In Phase 1, students were introduced to Gym HIIT (combination of basic aerobic and strength exercises) and Sport HIIT (e.g., completing shuttle runs while dribbling a basketball or carrying a rugby ball) and Class HIIT (exercises that could be performed in a standard classroom), and Quick HIIT (using Tabata protocol). In Phase 2, students were introduced

to Hip-Hop HIIT (high-intensity hiphop dance movements), Combat HIIT (involving boxing and mixed martial arts movements), Brain HIIT (activities that encourage thinking while exercising), Rumble HIIT (high-intensity rough and tumble exercises combined with aerobic activity), and Custom HIIT (participants designed their own HIIT workouts). In the final phase, students were encouraged to perform HIIT outside of the school setting using the Beach and Park HIIT options.

In addition to the B2L sessions, the intervention also included: (i) an information seminar focused on the health benefit of HIIT for students’ physical, psychosocial, and cognitive health, (ii) purpose-built smartphone

Figure 1: Example Burn 2 Learn Task Cards

Our aim with the B2L program was to demonstrate that senior school students could receive the health benefits of physical activity in a time-efficient manner.

Improving Older Adolescents’ Health and Well-Being Using High-Intensity Activity Breaks

application (see Figure 2) and heart rate monitors to support B2L session delivery, and (iii) e-newsletters for parents explaining the benefits of the programs. We used a range of implementation strategies to ensure that the program was delivered as intended. For example, teachers were instructed to facilitate the B2L sessions using the Supportive, Active, Autonomous, Fair and Enjoyable (SAAFE) physical activity delivery principles (Figure 3).

Students’ need for autonomy was satisfied by providing opportunities for choice within sessions (e.g., type of activity, music playing, and training partner) and explaining the rationale for the program in an information seminar. The introductory seminar reinforced the importance of exercise for cognitive health and academic performance, which maybe important outcomes for students in the lead up to their end of school examinations.

Competence was satisfied using positive feedback from teachers, with an explicit focus on effort over performance (via heart rate feedback), and through the provision of resources designed to support the development of exercise skills. Finally, teachers were encouraged to use practices that support group cohesion during the B2L sessions (e.g., working in pairs, high fives after completing intervals).

Program evaluation

We evaluated the B2L program using a two-arm cluster randomised controlled trial (RCT) conducted in two cohorts (February 2018 to February 2019 and February 2019 to February 2020) in New South Wales, Australia. Participants (N = 670, 44.6% women, 16.0 ± 0.43 years) were senior school students from 20 secondary schools: 10 schools (337 participants) were randomised to the Burn 2 Learn (B2L) intervention and 10 schools (333 participants) to the control. Our primary outcome was cardiorespiratory fitness (20 metre multi-stage fitness test) and the secondary outcomes were muscular fitness, physical activity (accelerometers), hair cortisol concentrations, mental health (questionnaires) and cognitive function (computer-based test). We assessed outcomes at baseline, 6-months (primary endpoint of the study) and 12-months.

Figure 3: SAAFE delivery principles

We also conducted two sub-studies that were embedded within the larger cluster RCT. The first sub-study was designed to test the acute effects of B2L on students’ on-task behaviour and subjective vitality. On-task behaviour was assessed at baseline and post-test, using a momentary time sampling procedure, and expressed as a percentage of lesson time. At post-test, students self-reported their subjective vitality at the start and end of the lesson using a validated questionnaire. In the second substudy, we examined the impact of B2L on hippocampal metabolism in subset of low fit adolescents (N = 56, 61% female, 16.1 ± 0.4years) using magnetic resonance spectroscopy.

Results from our cluster RCT

We observed a difference between groups in cardiorespiratory fitness (4.1 laps, 95% CI 1.8 to 6.4) in favour of the intervention group. Intervention effects did not differ by baseline socioeconomic status, sex, weight status, mental health, or cardiorespiratory fitness. Improvements in cardiorespiratory were not sustained at 12-months. Differences in upper body muscular endurance were significant at 6-months and 12-months, in favour of the intervention group. Differences were found between groups for steps and light physical activity during school hours at 6 months, in favour of the intervention group. We found a

difference between groups in favour of the intervention group for hair cortisol concentrations at 6-months. No differences were found between groups for any of the mental health outcomes or cognitive function at 6-months or 12-months in the full study sample. However, we observed reductions in perceived stress and internalising problems among those at risk of poor mental health at baseline.

Results from our sub-studies

In the first sub-study, we found significant group-by-time effects for students’ on-task behaviour in favour of B2L (19.3% of lesson time, 95% CI, 0.8 to 37.8). Students also reported higher levels of subjective vitality after participating in B2L, compared with the control group. In our second sub-study, we found evidence of increased metabolism in the left hippocampus following exposure to B2L. Increases in hippocampal metabolism were associated with improvements in fitness and working memory, indicating a potential neurobiological mechanism for the effect of physical activity on cognition.

We conducted an extensive process evaluation to determine if the intervention was delivered as intended. Teachers delivered 2.0 ± 0.8 and 1.7 ± 0.6 sessions/week in Phases 1 and 2 respectively (mean total 25.9 ± 5.2), but only 0.6 ± 0.7 sessions/week in Phase 3. Observation data showed that sessions were delivered with a high degree of fidelity, but heart rate (HR) data indicated that only half of the students reached the prescribed threshold of ≥85% predicted HR max during sessions. Over 80% of teachers reported that they would deliver the B2L program to future student cohorts. Almost 70% of students indicated they intended to participate in HIIT in the future. Students and teachers were highly satisfied with the intervention.

Burn 2 Learn adapted

Following the success of the B2L program, we were approached by a group of special education teachers to develop a similar program for older adolescents with disability. We subsequently conducted a feasibility study in one local high school with 16 students. We found that the Burn 2 Learn adapted (B2La) program was rated as “Good” or “Excellent” by 80% of students and 100% of teachers. Based

Students’ need for autonomy was satisfied by providing opportunities for choice within sessions (e.g., type of activity, music playing, and training partner) and explaining the rationale for the program in an information seminar.

FEATURE

Improving Older Adolescents’ Health and Well-Being Using High-Intensity Activity Breaks

on researcher session observations, the program was delivered effectively by teachers. However, HR data indicated session intensity was lower than intended. The program was considered “adaptable” by teachers, with several observed modifications to HIIT sessions to cater for the needs of adolescents with disability. We observed improvements in a range of fitness outcomes over the 2-month study period. We are currently conducting a cluster randomised trial of the B2La program in 26 schools and approximately 300 students.

Conclusions

Burn 2 Learn appears to be the first school-based physical activity break intervention for senior school students. Our study has demonstrated the health benefits of re-allocating curriculum time to physical activity during the senior school years. The B2L intervention improved cardiorespiratory fitness and muscular fitness in a sample of older adolescents in NSW government secondary schools. In addition, the intervention had a positive effect on hair cortisol concentrations, perceived stress, and internalising problems among students at risk of poor mental health. Our team has started the process of disseminating the program via online training modules co-created with the NSW Department of Education. We are currently seeking funding to evaluate a national dissemination of the B2L program.

Acknowledgements

We would like to thank the participating school, students, and teachers fort their support and cooperation throughout this work. We would also like to acknowledge our partners, including the NSW

Department of Education School Sport Unit and Special Olympics Australia. This project would not have been possible without contributions from the research team that includes Tara Finn, Angus Leahy, Jordan Smith, Narelle Eather, Charles Hillman, Chris Lonsdale, Mike Noetel, Philip Morgan, Ron Plotnikoff, Sarah Valkenborghs, Myrto Mavilidi, James Boyer, Sarah Kennedy, Sarah Costigan, and Michael

Nilsson. The study was funded by the National Health and Medical Research Council (APP1120518) and the New South Wales Department of Education School Sport Unit. Professor David Lubans is supported by a National Health and Medical Research Council Research Fellowship (APP1154507).

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

Author Bio

Professor David Lubans is the Deputy Director of the University of Newcastle’s Centre for Active Living and Learning. He is a former Australian Research Council (ARC) Future Fellow and current National Health and Medical Research Council (NHMRC) Senior Research Fellow.  Professor Lubans has published extensively (>300 peer reviewed articles) and secured funding (>$45M as a chief investigator) from competitive sources including the NHMRC, ARC, Medical Research Future Fund, Sciences and Humanities Research Council Canada, Health Research Council New Zealand, and Hong Kong General Research Fund. He has been recognised as a ‘Clarivate Highly Cited Researcher’ (top 1% most cited for subject field and year of publication) for the past 4 years (2019, 2020, 2011, and 2022). He is internationally recognised as an expert in the design, implementation, and scale-up of school-based physical activity interventions.

Young Adults with

Old Knees Playing

the long game after traumatic knee injury

DR BROOKE PATTERSON AND DR ANDREA BRUDER

TRAUMATIC KNEE INJURIES IN ACTIVE YOUNG ADULTS AND ADOLESCENTS ARE INCREASING IN AUSTRALIA, WITH THE MOST RAPID GROWTH IN WOMEN AND GIRLS (3% PER YEAR). THE JOINT TRAUMA FOR THESE INDIVIDUALS RESULTS IN UP TO 6-FOLD INCREASED RISK OF KNEE OSTEOARTHRITIS COMPARED TO THEIR UNINJURED PEERS. THIS IS NOT JUST ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES – COLLATERAL LIGAMENTS, PATELLAR DISLOCATIONS, MENISCUS AND ARTICULAR CARTILAGE TEARS ALL HAVE AN INCREASED RISK OF OSTEOARTHRITIS. THESE YOUNG ADULTS WITH OLD KNEES CONTRIBUTE TO AUSTRALIA’S SOARING RATE OF KNEE REPLACEMENTS. WE ALL HAVE A ROLE TO STOP THESE YOUNG KNEES FROM SUFFERING AN EARLY RETIREMENT AND PRIORITISE PREVENTION OVER MEDICATION AND SURGERY.

Talking to patients about their post-traumatic osteoarthritis risk

Due to the typical young age of traumatic knee injury, people develop osteoarthritis earlier in life, when they still have work, study, family, social, and sporting responsibilities and aspirations. Approximately 50% of individuals after an ACL injury will develop post-traumatic osteoarthritis 10 to 15 years after injury, regardless of management approach (surgery or rehabilitation alone). But the disease process starts early, our research shows approximately two-thirds of young adults will have early signs of osteoarthritis on MRI and X-ray in the first five years after ACL reconstruction. We cannot shy away from these statistics – prevention strategies and conversations must start early. Discussing the long-term game to maximise joint health after traumatic injury may help to motivate patients to adhere and persist with their rehabilitation, even if they are not aspiring to return to sport. In Australia, many ACL injured patients do not persist with rehabilitation beyond six months, return to sport with ongoing deficits, or do not return to sport or physical activity and gain weight.

Approximately 50% of individuals after an ACL injury will develop posttraumatic osteoarthritis 10 to 15 years after injury, regardless of management approach (surgery or rehabilitation alone)

The conversation can state the facts about post-traumatic osteoarthritis risk, but be balanced with the notion that not everyone will get osteoarthritis, and not everyone with osteoarthritis will get symptoms. Care needs to be taken to not illicit patient fear about a potential outcome (i.e., osteoarthritis) if they are at risk of fear avoidance and inactivity. We know osteoarthritis is common, and we have some clues as to who might be at greater risk. This provides us with a unique opportunity for prevention, to stop, delay or reduce the severity of post-traumatic osteoarthritis.

Old Knees Young Adults with

Our role in preventing post-traumatic osteoarthritis

To guide post-traumatic osteoarthritis prevention strategies, we need to know who, what and when to target…enter OPTIKNEE. The OPTIKNEE international consensus brought together 41 clinician scientists, scientists, patient, and clinician partners from 10 countries to synthesise the evidence and address knowledge gaps related to post-traumatic osteoarthritis. We know a lot about risk factors and interventions for older people with osteoarthritis, but very little about which strategies are effective for younger people with or at risk of post-traumatic osteoarthritis after knee injury. OPTIKNEE has produced 7 systematic reviews merging data from 230 studies to inform worldfirst consensus definitions, clinical and research recommendations to guide rehabilitation practice to optimise health-related outcomes after knee injury. The key findings about who, what, and when to target are outlined below.

Who to target

ٚ All people with single and multi-structure knee injuries have an elevated risk for posttraumatic osteoarthritis and should be made aware of it.

ٚ Those with higher risk (i.e., cartilage damage, medial meniscectomy at time of ACL reconstruction) or symptoms (e.g., pain) and/or functional restrictions (e.g., less physically active) persisting beyond usual recovery times, or with subsequent knee injury should be taught how to manage this risk.

ٚ Older individuals and female sex also trended towards an increased risk of structural posttraumatic osteoarthritis

What and when to target

ٚ Collaborate with the patient to meet their informational needs for knee health and osteoarthritis (education), guide them to self-manage, and teach them how to avoid or address

risk factors for non-traumatic osteoarthritis (e.g., thigh muscle weakness, weight gain, inactivity) through person-centred goals.

ٚ Address knee extensor and flexor muscle weakness, as this is known to increase the risk of tibiofemoral and patellofemoral worsening in those with or at risk of osteoarthritis.

ٚ Provide advice about weight management. Individuals after sports-related knee injury have a higher body mass index (+1.8kg/m) and fat mass index (+1.8kg/m) than their uninjured peers. A higher body mass index increases the risk of early post-traumatic osteoarthritis worsening on MRI in the first five years after ACL reconstruction.

ٚ While the main players appear to be inactivity, weight gain and muscle weakness, their interplay with other factors such as biomechanics (e.g., do they load their limbs equally?), psychological (e.g., fear, confidence, self-efficacy), and social (e.g., family support to exercise) should be considered.

ٚ Start these efforts as close to the time of their knee injury as possible and continue across the lifespan.

ٚ As exercise is a behaviour it is important to complement them with techniques that are known to promote behaviour change and self-management including informational support or education and patient centered goal setting.

Playing the long game

When a patient is ready for discharge you may also want to consider touchpoints and/or boosters via scheduled appointments (telehealth may be appropriate) to maintain motivation, accountability, and

continue improving physical and psychological elements. Even beyond the rehabilitation and return to sport phase, patients will have personal performance goals. We all like to progress and see improvement regardless of our level of participation. They may have flare ups and/or new symptoms emerge they don’t feel are necessary to seek care, but can gradually worsen. Your discharge education should focus on selfmanagement and when to seek help. They should leave with an ongoing exercise program, advice on how to manage symptoms, and the importance of physical activity and weight management due to their heightened risk of post-traumatic osteoarthritis.

If their knee symptoms start to affect daily function and physical activity, they should seek advice. Leaving it too late may lead to symptomatic, strength and physical activity decline.

A study just published in BJSM found that the longer you delay the start of exercise-therapy for patients with newly diagnosed osteoarthritis, the more likely they are to become users of addictive opioids. Patients are often told to take some medication, rest, avoid exercise, wait for symptom

resolution, and then build back up. But we know that knee joint structures such as cartilage like load, and that complete rest and fear avoidance is unhelpful. Individuals with an ACL reconstruction are known to underload their knee compared to their uninjured side and healthy controls in the short and long-term (>1 year post injury), which is likely to be heightened by symptoms and reduced confidence. Those who underload their knee are also more likely to have early post-traumatic osteoarthritis. Many people believe that knee pain and osteoarthritis is a disease of “overload”, “wear and tear” and “running and squats are bad for their knees”. There is no evidence to suggest high impact activities (running, jumping/cutting sports) increase the risk of osteoarthritis. Of the few studies investigating the effect of return to sport after ACL injury, it appears returning to sport may be protective of future post-traumatic osteoarthritis risk. Further, recreational runners have less osteoarthritis (3.5%) compared to sedentary people (10.2%) in the general population. When explained to patients, the concept of underloading and these facts can be very empowering.

Longer-term interventions – the evidence

Disappointingly, there is minimal evidence to support the effectiveness of longer-term interventions (e.g., beyond 12 months after ACL injury) on joint health, symptoms, and quality of life. However, there are pilot trials to suggest that exercise and education interventions, with a focus on patientcentred goal setting may be effective at improving knee function and quality of life. An exercise and education intervention was created for individuals at risk of worse future outcomes (persistent symptoms and functional deficits) 12 months post-surgery. The intervention was eight physiotherapy sessions, an ACL- and person-specific lower-limb and core strengthening program, and education on how to maintain a healthy lifestyle. The control was eight physiotherapy sessions to maintain clinical equipoise, and a core strength and stretching program. The intervention resulted in physical and patient-reported improvements likely to be significant in a larger trial.

A website for clinicians and patients with the exercise and education materials was created (task.trekeducation.org). La Trobe University are currently recruiting

If their knee symptoms start to affect daily function and physical activity, they should seek advice. Leaving it too late may lead to symptomatic, strength and physical activity decline.

Old Knees Young Adults with

Author Bios

Brooke Patterson, PhD

La Trobe University Sport and Exercise Medicine Research Centre

B.Patterson@latrobe.edu.au

Twitter: @Knee_Howells

Andrea Bruder, PhD

School of Allied Health, Human Services and Sport, La Trobe University

A.Bruder@latrobe.edu.au

Twitter: @AndreaBruder

Dr Patterson and Dr Bruder are physiotherapists and research fellows at the La Trobe University Sport and Exercise Medicine Research Centre.

participants 9 to 36 months after ACL reconstruction for the larger trial to evaluate the effect of an exercise and education program.

Summary

History of previous traumatic knee injury is a known risk factor for post-traumatic osteoarthritis. Not everyone after traumatic knee injury will develop symptomatic osteoarthritis, but without a cure, prevention is key. While we wait for research to fill our knowledge gaps in effective strategies for reducing osteoarthritis risk, we can focus on addressing risk factors that could reduce the likelihood of ‘young knees’ retiring early. Clinicians are well-positioned as frontline healthcare professionals to

ٚ Educate about future knee osteoarthritis risk, importance of physical activity and weight management

ٚ Collaborate with patients to negotiate short- and medium term knee health goals using behaviour change strategies

ٚ Address fear of re-injury

ٚ Promote ongoing knee injury prevention programs

ٚ Schedule mid-to-long term follow ups

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

Brooke Patterson has worked in public, private, and sports settings, and completed her PhD in 2021, investigating the risk of arthritis after ACL injury, and how physiotherapist-led interventions can help improve outcomes beyond the typical rehabilitation period. Brooke has sustained an ACL injury herself, played in the first three seasons of the women’s national Australian Football League, and is now a coach. She is currently coordinating an injury prevention clinical trial in women’s community Australian football.

Andrea Bruder joined La Trobe University as a Lecturer in Physiotherapy in 2008. She has undertaken various academic roles, including clinical coordinator and teaching several subjects across different year levels. Andrea completed a PhD in 2018 investigating the role of exercise in upper limb fracture rehabilitation. Her research now focuses on primary and secondary prevention of knee osteoarthritis. She is currently a PostDoctoral Research Fellow on an NHMRC funded clinical trial investigating the effect of a supervised exercise and education program on symptoms, function and quality of life in young adults after an anterior cruciate ligament injury.

Since the trial, I lost 8kg, skied for 5 weeks, got my Karate black belt, and am back to the gym daily. You got my physical life back on track – La Trobe University trial participant.

Thermal stress and strain during the Tour Down Under

PROFESSOR JULIEN D. PÉRIARD

Heat stress and event modification

The Tour Down Under (TDU) cycling road race is held annually in Adelaide and regional South Australia, and forms part of the Union Cycliste Internationale (UCI) World Tour. The six-stage race is usually contested in warm to hot conditions with an average daily maximum temperature of ~29ºC across the greater Adelaide region in January. In 2014, Adelaide recorded its hottest summer on record with temperatures exceeding 40ºC for 13 days. In 2017, the opening stage of the TDU was shortened by 26 km due to extreme heat, a scene repeated for stage three in 2018 and stage two in 2019. Although these decisions were aimed at protecting the athletes from exertional heat illness (e.g., heat exhaustion and heat stroke), their basis was not derived from data regarding the increase in core temperature experienced by professional cyclists competing in the heat, or an evidencebased extreme heat policy. Indeed, while the UCI established an extreme weather protocol in 2016 that cites “extreme temperatures” as a condition that allows stakeholders (i.e., race organisers, medical

Thermal stress and strain during the Tour Down Under

officials, and cyclist representatives) to modify an event, the temperatures or environmental conditions that are considered extreme are not defined.

Most sporting organisations (e.g., World Athletics, FIFA) use thresholds derived from the wet-bulb-globe temperature (WBGT) index to determine whether an event should be modified (e.g., shortened, cancelled, or postponed). However, WBGT, along with other thermal stress indices (i.e., Heat Index, Humidex, and universal thermal climate index: UTCI), only integrate environmental characteristics (i.e., dry-bulb temperature: Tdb, wetbulb temperature: Twb, black-globe temperature: Tbg, air velocity, and relative humidity: RH) and do not account for work rate, and thus metabolic heat production. As such, these indices cannot adequately represent human heat strain, which is a combination of climate, clothing, and physical activity. In contrast, the heat stress index (HSI) integrates these factors to evaluate the capacity to attain heat balance, and as such,

predict heat strain and heat illness risk. We were therefore interested in evaluating the environmental characteristics, different thermal indices, as well as the HSI, to determine the extent to which these correlate with work rate (i.e., power output) and the development of thermal (i.e., core temperature) and cardiovascular (i.e., heart rate) strain during multistage racing. The associations between race specific factors (i.e., total ascent, average speed, stage distance and finishing time) and the development of thermal and cardiovascular strain were also determined. Our intention was to provide the framework and stimulate further research regarding the formulation of more specific environmental heat stress policies to protect the health and well-being of cyclists.

Participants and experimental design

A cohort study design was used to characterise work rate, core temperature and heart rate in 22 male cyclists (age: 26 ± 5 y, body mass:

72 ± 7 kg, height: 182 ± 7 cm) from four different teams during the 2019 TDU. Two of the teams were ranked in the top 5, one in the top 10 and one in the top 15 of the UCI team ranking. Participants had 9 ± 4 y of experience as professionals and based on their cycling speciality, one was a oneday race (i.e., classics) specialist, five were time trial specialists, nine were sprinters, and seven were climbers.

The associations between race specific factors (i.e., total ascent, average speed, stage distance and finishing time) and the development of thermal and cardiovascular strain were also determined.

total ascent, mean speed, wining time and finishing time of 22 participants during the 2019 Tour Down Under.

different from Stage

respectively (P≤0.05). *Significantly different to all other Stages (P<0.05).

temperature (Tdb), wet-bulb temperature (Twb), black-globe temperature (Tbg), relative humidity (RH), wet-bulb-globe temperature (WBGT), Heat Index, Humidex, universal thermal climate index (UTCI) and heat stress index (HSI) during the 2019 Tour Down Under.

2.

Eight participants were also considered general classification cyclists.

The distances, total ascent, winning times and participant finishing times are presented in Table 1, and the environmental characteristics, thermal indices and the HSI are presented in Table 2. Environmental characteristics were recorded at the start, mid-point, and finish areas of the race, in conjunction with the cyclists passing through those areas. Thermal stress indices were calculated using environmental data, with partitional calorimetry used to calculate the HSI, including power output extracted from individual cycling computers after each stage. Heart rate was also extracted from the cycling computer and core temperature was measured with a temperature capsule swallowed the evening before each stage.

Table 1. Distance,

Table

Dry-bulb

In 2017, the opening stage of the TDU was shortened by 26 km due to extreme heat, a scene repeated for stage three in 2018 and stage two in 2019.

Thermal and cardiovascular strain

Mean core temperature during the 2019 TDU was 38.3ºC, whereas peak core temperature averaged 39.2ºC (Table 3). This peak core temperature aligns with previous reports during two multi-stage races (38.9°C and 39.3°C) in cool conditions (14°C and 12ºC), and is slightly lower than during the men’s road race at the 2016 World Championships (39.6ºC) in 37ºC conditions. Notwithstanding, individual peak core temperature did exceed 40.0ºC in three stages. The slight differences in mean and peak core temperature between stages during the TDU may be explained by a combination of factors, including climatic conditions, stage profile (i.e., total ascent) and power output, as well as race tactics and individual roles within a team (e.g., domestique or protected team leader).

Although average speed was high (~40 km.h-1) throughout the 2019 TDU, it provides a poor reflection of the physiological demands of a race due to the nature of different courses (e.g., flat versus mountainous). Conversely, heart rate is considered a more accurate representation of physiological strain during cycling, with mean heart rate ranging from 131 to 147 beats.min-1 during the 2019 TDU (Table 3). This was associated with a power output of 180 to 249 W, which is similar to other major tours such as the Tour de France and Vuelta a España. Taken together, these data

reinforce the notion that professional cyclists modulate work rate within and between stages across a range of environmental conditions based on race tactics and course profile.

Thermal indices and heat strain

The thermal indices most strongly correlated with mean power output across the different stages of the 2019 TDU were Tbg, RH, UTCI and WBGT (Figure 1A). The negative and positive relationship between work rate and Tbg and RH respectively, highlights the interaction between these environmental parameters, with a higher radiative heat load associated

with lower humidity. Moreover, the negative association between mean power output and Tbg, along with all other thermal indices, highlights the influence of high ambient temperatures on reducing work rate.

The HSI was the integrative index most strongly associated with both mean core temperature and heart rate (Figures 1B, 1C), which indicates that it provides an indication of the thermal and cardiovascular strain experienced during exercise in the heat. The association between the HSI and core temperature supports the integration of work rate, and thus metabolic heat production, along with clothing, with environmental conditions in determining whether an event held under heat stress should be modified. This is particularly relevant as the WBGT index was not correlated with core temperature and only appears to provide a guide regarding the potential for experiencing adverse outcomes in hot conditions. Of note, Twb, which is related to ambient humidity or the moisture content of air, was a strong predictor of mean core temperature. Twb is always lower or equal (i.e., 100% RH) to ambient temperature (i.e., Tdb) with large differences between temperatures indicative of an increased ability to lose heat via sweating. The correlation between Twb and core temperature therefore supports the notion that changes in core temperature during outdoor exercise are influenced by the

Additional research is also warranted in female athletes to determine if sex differences in sweating capacity require the development of sexspecific heat policies.

Table 3. Mean power output, mean and peak core temperature, and heart rate during the 2019 Tour Down Under.

ability, or inability, to dissipate heat via evaporation across a range of ambient temperatures. Notwithstanding, clearer determinations of thermal and cardiovascular strain can be made by measuring the four parameters of the thermal environment (i.e., temperature, humidity, airflow and solar radiation) and estimating metabolic heat production during exercise with specific clothing or equipment, to estimate evaporative cooling requirements and the likelihood of achieving these, as indicated by the HSI.

Moving forward

By moving beyond the measurement of climatic conditions and integrating sport-specific factors to inform environmental heat stress policies, athletes may be better protected from exertional heat illness during training and competition. At the sporting organisation level, this process may take the form of identifying the individuals most as risk of experiencing heat illness (i.e., those producing the most heat and/or wearing the most clothing/equipment) and establishing sport-specific responses for event modification. In cycling, particular attention should also be placed on total ascent or course profile due to its effect on increasing work rate and reducing heat exchange (i.e., elevated heat production combined with lower airflow when climbing). Additional research is also warranted in female athletes to determine if sex differences in sweating capacity require the development of sex-specific heat policies.

Summary

Work rate during the 2019 TDU was correlated with several thermal indices reflecting the severity of the environment, primarily due to an

elevated ambient temperature. Most cyclists reached or exceeded a core temperature of 39ºC when racing, ~23% reached or exceeded 39.5ºC and some experienced a peak core temperature above 40.0ºC. The highest core temperatures were measured on temperate (~23ºC), warm (~28ºC) and hot (~36ºC) days, which indicates that core temperature during multistage racing is associated with several factors, including environmental conditions, stage profile and metabolic heat production. Heart rate (68 to 77% of peak) across the six stages of the TDU was most strongly correlated with core temperature and work rate. Both thermal and cardiovascular strain were correlated with the HSI, an integrative index that accounts for the factors that influence heat balance, including metabolic heat production (i.e., work rate) and clothing. Future research may seek to adopt the human heat balance approach to model the critical environmental limits at which a safe core temperature can no longer be maintained during cycling, as well as in other sports

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

Author Bio

Correlation with mean heart rate (r)

Figure 1. Repeated measures correlation (r) between mean power output (A), mean core temperature (B) and mean heart rate (C) during the 2019 Tour Down Under, and thermal indices (red circles): Heat Index; HSI: heat stress index; Humidex; RH, relative humidity; Tbg, black-globe temperature; Tdb, dry-bulb temperature; core temperature; Twb, wet-bulb temperature; UTCI, universal thermal climate index; WBGT, wet-bulb-globe temperature; and independent factors (blue circles): average speed, finishing time, mean power output, mean core temperature, stage distance and total ascent. Note: “–” symbol indicates a negative correlation. Data presented as r ± 95% confidence intervals. All P<0.05.

Julien Périard is a Research Professor and Deputy Director of the University of Canberra Research Institute for Sport and Exercise (UCRISE), where he also leads the Environmental Physiology Research Group.

Julien’s integrative research examines the physiological mechanisms that impact on health and performance in adverse environments (heat and altitude), along with strategies to mitigate their influence and harness their adaptive potential. He has worked with both amateur and professional athletes from various disciplines, along with National and International Federations (e.g., FIFA, ITF, UCI, World Athletics and World Triathlon). He has authored over 95 research publications in international journals and edited a textbook on Heat Stress in Sport and Exercise.

Vigorous physical activity

A promising option for a busy school day

AUSTRALIA’S 2022 REPORT CARD ON PHYSICAL ACTIVITY FOR CHILDREN AND YOUNG PEOPLE PROVIDES STRONG EVIDENCE THAT PHYSICAL ACTIVITY LEVELS IN THIS POPULATION ARE LOW, WITH ONLY A QUARTER MEETING THE RECOMMENDED NATIONAL GUIDELINES. THIS IS PROBLEMATIC AS IT INDICATES THAT MOST CHILDREN AND ADOLESCENTS ARE NOT GETTING THE HEALTH BENEFITS THAT ARE ASSOCIATED WITH PHYSICAL ACTIVITY.

Traditionally, moderate-tovigorous physical activity has been recommended for health benefits as per the World Health Organization and Australian guidelines. However, recent studies with improved measurement techniques have started to untangle moderate and vigorous physical activity and have noted that the health effects of physical activity are intensity dependent. There is now evidence that in children and adolescents, vigorous activity is associated with greater improvements to cardiometabolic risk scores, body mass index, and fitness than moderate activity, while requiring

STEPHANIE DUNCOMBE, DR MICHALIS STYLIANOU, AND PROFESSOR ALAN BARKER

Vigorous physical activity

A promising option for a busy school day

less time. These improvements are important for both current and future health. There is also some preliminary evidence showcasing the benefits of vigorous physical activity on attention in children and adolescents. Therefore, research focused on promoting vigorous physical activity has increased within this population.

High-intensity interval exercise (HIIE) is a type of vigorous physical activity characterised by short bouts of strenuous exercise followed by recovery periods. It follows a similar pattern to children’s intermittent style of physical activity acquisition. At present there is no standardised protocol for HIIE in children and adolescents. We reviewed the literature on HIIE in schools and noted that protocols

commonly included a one-to-one ratio of work-to-rest, bouts between 10 to 60 seconds, and an intensity of at least 80% of maximum heart rate or 100% of maximal aerobic speed with some protocols spanning less than 10-minutes total. A large proportion of the current literature focuses on running or cycling-based intervals, most likely as these are the easiest to prescribe and monitor. However, more recent literature has moved to consider game-based HIIE to encourage enjoyment and engagement.

Positive health effects in children and adolescents have been demonstrated after solely a single session of HIIE, such as improved vascular function, blood glucose and insulin, and attention and wellbeing immediately post-session.

Further, repeated HIIE over several weeks has also been associated with positive outcomes such as favourable changes to cardiovascular disease biomarkers, cardiorespiratory fitness, body composition, executive function, and wellbeing. While the positive health effects of HIIE have been established, the literature on the enjoyability of HIIE is divided. Critiques of HIIE maintain that high-intensity physical activity will elicit displeasure due to the body varying away from its homeostasis. They argue that while health benefits may be present, enjoyment and in turn, adherence are necessary for those health benefits to be achieved, which could limit the utility of HIIE. However, most of the current evidence on enjoyment and adherence comes from adult

One attempt at integration of HIIE into schools occurred in Queensland through our Making a HIIT study, where students in Years 7 and 8 designed HIIE workouts within their HPE lessons.

populations and from high-intensity continuous exercise, which does not factor in the effect of the rest intervals provided by HIIE. At present, the few studies that have examined enjoyment in children and adolescents have demonstrated that HIIE did not cause displeasure and produced greater levels of enjoyment compared to moderate continuous exercise. Although currently the literature only includes small samples of participants and is mostly restricted to lab studies. Real-world studies evaluating the long-term impact on outcomes, enjoyment, and engagement in this population are needed.

Schools are the most common setting for HIIE interventions outside of laboratories, as these interventions can reach a large proportion of children and adolescents. Based on our analysis that pooled evidence of 54 papers (42 unique studies), schoolbased HIIE interventions have elicited promising results with improved fitness, body composition, and blood biomarkers in those who completed HIIE compared to a control group. In addition to health benefits, from an educative standpoint, there is evidence demonstrating that off-task time in the classroom is reduced post workout. However, most school-based studies have used laboratory-style HIIE (i.e., a

single interval duration for work and rest using a single type of exercise as opposed to games or partner activities with varying intervals) and have not given much consideration to integration within the school day or practices. One attempt at integration of HIIE into schools occurred in Queensland through our Making a HIIT study, where students in Years 7 and 8 designed HIIE workouts within their HPE lessons to be used in the intervention. This aimed to move away from laboratory-style HIIE workouts and provide freedom and choice to the students in an effort to increase their enjoyment and motivation towards HIIT. Students expressed their satisfaction with the process and with the workouts that they created. Most often, their favourite exercises were those that enabled them to work with their friends and towards a goal (e.g., points). Overall, student evaluations rated the workouts as neutral or enjoyable. In order to maximise enjoyment and engagement of HIIE with children and adolescents both in schools and other contexts, we present several considerations:

ٚ Consider the interests of the participants and choose relatable exercises and exercises that include game-based concepts or partner activities.

ٚ Include the children and adolescents in the HIIE design and other components (e.g., music during the workouts) to increase their autonomy and choice.

ٚ Provide an opportunity for the workouts to be led by the children and adolescents depending on their age.

As we move away from laboratorystyle HIIE within the school setting, the prescription and monitoring of HIIE workouts also warrants further consideration. Most often, speed and heart rate during work intervals are used to monitor HIIE. However, gamebased HIIE or HIIE that makes use of partner activities remove speed as a prescription and monitoring option and require changes to how we use heart rate for monitoring as not all students are working and resting at the same time. Further, with class sizes in the high 20s, it is often not feasible for schools to use heart rate. Using a session rating of perceived exertion, where students demarcate how hard they worked on a valid and reliable scale has promise for monitoring HIIE. However, preliminary evidence indicates that the cut points for various intensity levels are most likely lower in HIIE than in continuous exercise with more research needed

Currently, there is not enough evidence to suggest that HIIE is superior or inferior to other types of exercise and therefore, it is recommended as another option for children and adolescents to acquire the health benefits from physical activity.

Vigorous physical activity

A promising option for a busy school day

in this area. In order to monitor HIIT in contemporary settings, we recommend:

ٚ Using an individual students’ average or peak heart rate from the session.

ٚ Comparing the time spent above a heart rate threshold (e.g., > 80% of maximum heart rate) to the amount of time in work for the protocol.

ٚ Using a session rating of perceived exertion.

At present, HIIE interventions within Australian schools have predominately occurred in health and physical education (HPE) lessons. In an attempt to move outside of HPE lessons, the Burn2Learn study in New South Wales targeted senior students where HPE was no longer obligatory. While HPE-based courses still had the largest uptake (17 of 22 classes), the HIIE workouts were also provided in lessons such as mathematics, modern history, and biology. While these studies begin the shift away from laboratorystyle interventions within the school to real-world integration, further research is warranted on the long-term uptake of HIIE, the best method for delivery in this setting, and whether the health benefits provided are mediated by factors such as sex, body mass, motivation levels, and integration within school practice.

In conclusion, HIIE can be beneficial for children and adolescents’ health and wellbeing and is often administered successfully within the school setting. Currently, there is not enough evidence to suggest that HIIE is superior or inferior to other types of exercise and therefore, it is recommended as another option for children and adolescents to acquire the health benefits from physical activity, especially when time is an important consideration. Moving forward, it will be important to study long-term enjoyment and adherence to HIIE and consider how best to integrate it into the lives of children and adolescents.

Author Bios

Stephanie Duncombe is completing her PhD at the School of Human Movement and Nutrition Sciences at the University of Queensland and the Children’s Health and Exercise Research Centre at the University of Exeter. Her PhD focuses of the effect of high-intensity interval training in educational settings. It is funded by the QUEX Institute for Excellence, and a Research Grant provided by Sports Medicine Australia. Stephanie has a background in human physiology and has a Master of Public Health specialising in epidemiology and biostatistics. She worked at the French National Institute of Sport as a data analyst prior to starting her PhD. She is now involved in teaching research methods and exercise physiology courses at the University of Queensland.

Dr Michalis Stylianou is a senior lecturer in Health, Sport and Physical Education with the School of Human Movement and Nutrition Sciences at The University of Queensland. His research interests centre around understanding and enhancing children and young people’s physical activity and creating active and healthy schools. Michalis is a member of the Active Healthy Kids Australia research working group, a collaboration among Australian children’s physical activity and health researchers who advocate for actions to increase the physical activity levels among Australian children using the Physical Activity Report Card for Children and Young People as the core monitoring metric.

Prof. Alan Barker is an Associate Professor of Paediatric Exercise and Health in the Children’s Health and Exercise Research Centre (CHERC) at the University of Exeter. His research focuses on paediatric exercise medicine, and the effect of exercise on cardio-metabolic health outcomes in youth. His primary research interest concerns the potential health- and performance-related benefits that can be gained through performing time-efficient, high-intensity exercise when compared to a work-matched bout of moderate-intensity exercise in children and adolescents.

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

Physician Focus Dr Rachel Harris

Can you tell us a bit about your background?

I am a Sport and Exercise Physician working out of Perth, WA. I’ve been working in this field as a physician for the last four years and prior to that as a Registrar in sports medicine. My journey to this profession started being an athlete myself; I went to the Commonwealth Games and Olympics as a swimmer for the Australian team. So, I have always been heavily involved in sport and exercise and I’m still very enthusiastic about it.

I did hospital medicine for about five years and then decided, after having a bit of a light bulb moment, that I really loved sport and exercise medicine and wanted to go down that path in my career. I did my training for two years here in Perth, and then two years over in Canberra, and then came back to Perth with my family.

I’m involved in private practice a couple of days a week at Perth Orthopaedics and Sports Medicine Centre where I see private patients, a mix of high-level sport, but also everyday people. I’m also the project lead for the Australian Institute of Sport (AIS), Female Performance and Health Initiative (FPHI)

Up until recently, I was the Chief Medical Officer for Paralympics Australia, which covered the Tokyo cycle. I’m doing a project with Swimming Australia, looking at optimising proactive healthcare in the daily training environment. I’ve worked for a number of different teams, including the water polo

team during the Tokyo Olympics. I seem to have had a lot of hats over the last couple of years.

What motivated you to become a Sport and Exercise Medicine Physician?

I didn’t want to do what was expected of me in terms of my post swimming career. My dad was a doctor, and everyone used to say, “You should be a doctor as well.” I always said no, but here I am!

It was the same with Sport and Exercise Medicine. It seemed like the very obvious thing for me to do from the very beginning. But then I went down the hospital Intensive Care pathway in training and got accepted into the training program here in WA. There are rewarding days in intensive care but it’s never going to be an easy day. So, I started to think about what

I really wanted to do and going down the pathway of Sport and Exercise Medicine really seemed to fit.

I think knowing or meeting colleagues in that space was really rewarding. I had some wonderful doctors that were on teams with me back in the day. Dr Brian Sando was an early trailblazer when I was an athlete on the swimming team. I could see the nice mix of being involved in elite sport and affecting change in that space, as well as the ability to improve the lives of everyday people through optimising their health so that they could exercise and perform well.

I think the big piece for so many of us in this field is when you get to the conference and you’re around like-minded people, you really feel like you’ve met your people. That happened to me at the first conference

Physician Focus

Dr Rachel Harris

that I went to. They were part of that branch of medicine that I connected with and people I felt very similar to.

Can you tell us about your role with the AIS Female Performance & Health Initiative?

I’m the project lead for the Female Performance and Health Initiative (FPHI) and I’ve been in that role since October 2019. It initially started as a three-month project, looking at menstrual cycle and hormonal contraception, and specifically, looking at developing education tools in that space and doing research, mainly because we had people coming into the AIS asking for evidencebased information. It’s surprising that in 2019 there wasn’t actually an arm at the AIS that was specifically

devoted to that, even though female athletes make up at least 50% of our high performing population.

Unsurprisingly, the work wasn’t done after three months. There was a huge appetite for it in the high-performance space, but also out wider than that. So. we had the initiative extended and expanded.

Now, we have three main pillars. Firstly, it’s around education and resource development to help improve the literacy of both our female athletes, and the people that sit around them, on basics of health and performance. This includes menstrual cycle, pelvic floor health, bra fit and breast health and a range of other things. We’ve also got newer information on pregnancy

and supporting athletes in that phase of life. We have 14 free online education modules on our website that are a brilliant way to improve health literacy.

Secondly, we have a research and best practice pillar that we are hoping to drive an improvement in because we know that women, not just in sport, but everywhere, are underrepresented in research; both performing the research and also being the actual people being studied. We know that we’ve got so much appetite for the variability that women have across their menstrual cycle but also things like pelvic floor, pregnancy; how do we ensure that we’ve got best practice or evidence-based advice to give that to people when no one’s ever done research in this. We are really

A lot of research at present sits around general health, which absolutely will improve performance, but what can we be doing to improve the strength or endurance performance of our female athletes?

keen to try and collaborate to build on the work that’s been done in this area. We’ve got so many amazing researchers in this space and we really want to try and help amplify the amazing work that they’re doing.

Lastly, we have another arm that’s focused on leadership. We are looking at how to better engage people in this space to make sure that we’re driving excellence, and make sure that we’re not just doing this and working in our silos, but we’re collaborating with people within the system in different specialties; making sure that this filters down to the professional world. In the sporting space, so often, we work in tiny little silos where we’re under resourced and time poor. Whereas if we work together, we are really wanting to achieve the same goal here. A lot of the stuff that we do is not necessarily about getting an edge, it’s about improving the basics of health in the first instance. It’s important we keep trying to continue the enthusiasm that so many people have, and who are starting to drive this change.

Is there a particular area of female athlete health and performance that you believe is misunderstood?

There are so many areas. However, if I could pick one, it would be the misinformation at the present time that we can give everybody in the female population the same advice about what to do at different phases of their menstrual cycle. There is so much individual variation in our menstrual cycle that we cannot take a broad sweeping brush and say everybody should do this at this particular time of the month. We know from the very start of our research that at least 50% of our population in the athletic world are on some form of hormonal contraception, at least one in nine women have endometriosis, around one in six women have PCOS, and at least a couple of our athletes have some form of amenorrhea. If we think about who has a normal cycle in that cohort, it’s actually quite small. And then if you did a survey of your friends and looked at what their normal menstrual cycle was, there’d be so much individual variation. We

need to wind it back and be doing this on a more individualised level. That’s the thing that I find most challenging. We need to help people understand their own individual circumstances, not just be giving non-evidence-based information to the whole of the population.

Where do you see future research for female athlete health and performance going?

There are so many people that are doing amazing things and we need to be doing more high-quality research. We need to take into consideration if we are making broad statements about menstrual cycle and hormonal contraception. If we are talking about injury changes over a cycle, then we really need to be doing best practice study of what their hormones are doing at that time so we’re not just making assumptions about different phases of their cycles. Provided that we can get some good funding for it, we will really be able to change this space, and that momentum is coming.

The other area of research is learning about the basics. Professor Louise Burke’s group at ACU have done some audits on nutrition research but most of the studies have been done in men; we don’t even have information on female athletes. So the tide is changing. We need to get

more women encouraged to be doing research; doing the research but also being part of the research.

At present, we’ve had some great responses to call outs for research. There’s so much coming in the future and I think the big thing will be not just doing research in the health space but doing it in the performance space. A lot of research at present really sits around general health, which absolutely will improve performance, but what can we be doing to improve the strength or endurance performance of our female athletes? I think that’s going to be the next big step.

What is the best piece of advice that you have received in your career?

There’ve been so many, but I was really lucky to be involved in the inaugural AIS Women in STEMM leadership group that ran about a year ago. We are very much our own inner critics. I think for many of us in this space we bring ourselves down, but one of the great things that we had in that group was, “What would that team around you say about making that decision rather than your internal critic? What would that cohort of your peers say about it when you are making this decision?” And so, externalising that and understanding what your own cheer squad would say about you was really great advice.

Panelists speaking at the FPHI Women in Sport Congress 2022.

The Australian Institute of Sport Female Performance & Health Initiative

The AIS Female Performance & Health Initiative (FPHI) was developed in 2019 to improve systems of support for Australian female athletes, through collaboration with National Sporting Organisations, National Institute Networks, academic and specialist networks.

The AIS has partnered with specialist medical practitioners, high performance athletes and high performance coaches to design a suite of online learning modules for athletes, parents, coaches, and medical practitioners.

Nutrition

This module aims to:

1. Provide further information on the topic of nutrition in female athletes

2. Consider goals within sports nutrition that are commonly prioritised by athletes

3. Provide helpful tips to address these key areas of athlete nutrition

Breast Health

This module aims to provide information on the following topics:

1. Breast structure and bra support

2. Breast injuries

3. Breast cancer awareness

4. Normalise conversations around breast health to improve athlete awareness, knowledge, and health

Considerations for Medical Practitioners Managing Female Athletes

An athlete’s medical providers are an essential part of their health and performance team. It is important for female athletes to have their own medical practitioner and to be proactive about their health.

This module covers several unique considerations relating to the health and performance of female athletes, including:

1. Female-athlete specific demands of competition and training

2. Menstrual abnormalities such an amenorrhoea, menorrhagia, and dysmenorrhoea

3. Bone health in young exercising females

4. Contraception, particularly from an athletic performance perspective

5. Anti-doping information and resources

6. Referral options for medical and allied health practitioners

To learn more, visit ais.gov.au/fphi/education

Journal of Science and Medicine in Sport and sister journal JSAMS Plus

Official journals of Sports Medicine Australia

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For the Most Cited Highlight: Nowhere to hide: The significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes

https://doi.org/10.1016/j.jsams.2020.05.016

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For the Most Cited Highlight: Markerless motion capture: What clinician-scientists need to know right now - ScienceDirect

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People Who Shaped SMA Prof Belinda Beck

Can you tell us about your educational background, and what made you decide on a career in sports medicine?

When I was in high school, I was interested in health but was far too lazy to do the study necessary to become a doctor. I was a runner and hockey player and constantly had shin pain. It was so confusing to me why nobody could tell me why it happened, much less how to fix it or avoid it. I thought, if my doctors can’t help me, maybe that’s something that I could do. Because I was a kid, to me health and exercise meant being a PE teacher. So I went to university and studied human movement studies at UQ. I was a PE teacher for a couple of years, but it didn’t take me long to realise that being out on a hot oval in the Lockyer Valley was not going to give me the answers I needed. I was also interested in travel so I decided to go overseas and do a Master’s degree in sports medicine.

I ended up at the University of Oregon (UO) in the US. They had a sports medicine Master’s program that was perfect for me (as I discovered it had been for many illustrious Aussies before me – the likes of John Bloomfield, Alan Morton, Tony Parker and others who have been associated with SMA).

I did a thesis on tibial stress injuries, and realised research was the job for me, so I followed it up by doing a PhD at Oregon as well. I started off in animal research looking at mechanotransduction mechanisms; I wanted to know what was transmitting the signal from exercise loading to bone and causing it to adapt. Along the way I discovered I was pretty good at anatomy and so I was able to pay my way through grad school by teaching it to undergrads at UO.

I also discovered that animal research was not for me, so once I graduated with my PhD, I went to Stanford University and did a postdoc and started working with humans. That’s where I learnt how to run clinical trials. Ultimately though, once I finished my postdoc, it was my anatomy teaching expertise that got me headhunted back to Australia to Griffith University.

How did you end up in the education space working with future clinicians?

I always liked teaching. That wasn’t what I disliked about being a PE teacher. High school meant teaching kids who didn’t want to be there.

I liked the idea of teaching students who wanted to be there and could see how cool and relevant anatomy is to their careers. There’s really only one place you can do that and that’s at a university. So, my academic position allowed me to do both things I loved – to teach a subject I’m passionate about, and do research in bone.

An added bonus was that Griffith is on the Gold Coast, and I was born and raised in Brisbane. I was appointed as a Lecturer in the School of Physiotherapy and Exercise Science which had just launched a 5-year Exercise Science/Physio double degree. I loved the idea of a physio program with exercise science embedded. This truly prepared our physio graduates to apply exercise clinically as the powerful therapy it is. Because it was a fledgling program, I was able to develop my own musculoskeletal anatomy course and embed my favourite topic, bone, into everything I taught. So that was where I first started teaching budding physiotherapists and exercise physiologists. After a

while, I began to recruit grad students to my research program. And we all know how important grad students are to research productivity.

Can you talk about your work in musculoskeletal conditions and their management? What is a part of your research that stands out to you, or that you are particularly proud of? When I started putting my research program together, naturally it was driven by my ongoing fascination with bone. To me it’s just the most incredible tissue. I brought some funding back from the US to look at the effect of electric field stimulation on healing of stress fractures. But I could see from my work at Stanford, that really, osteoporosis was where it was at in bone research. Whilst stress fractures affected people like me and athletes or people in the military, they’re not life threatening, and they mostly go away if you just rest.

So, I turned my focus onto osteoporosis, which is this terrible, insidious condition that happens without you realising it until you have your first fracture. It affects people just when they are thinking about what they are going

to do with their retirement and are excited about new adventures. It can really put a downer on that. And I discovered a catch 22. I knew from my animal research that if you wanted to build bone, you have to load it heavy, but conventional thinking at the time was that people with osteoporosis couldn’t do that, because everyone thought they’d break bones.

So basically, the mantra to prevent osteoporotic fracture was that you had to do lots of heavy loading in childhood and as a young healthy adult. But by the time you had osteoporosis, you could only do low intensity exercise to stop the falls that cause fractures. And I’m thinking to myself as I was recommending this, surely, we can do better than that. So, I started looking for evidence that a heavy lifting program could benefit people with osteoporosis. And there was nothing. We all just assumed it would cause fractures, so nobody had actually tested it because we were all too scared.

I’ve always been a bit of a myth buster. I always wanted to make sure that evidence was driving practice, not myths, anecdotes, fear and supposition.

So, we did the LIFTMOR trial. LIFTMOR was a heavy, high intensity resistance and impact training program for postmenopausal women with low to very low bone mass. And lo and behold, after eight months we discovered not only did our women grow bone, but we didn’t hurt them and we saw many other benefits. Their function was better, they were standing up straighter, they were falling less, they were stronger, their quality of life was better, there was just so much that was positive about this heavy lifting program. We did the same study in older men with low bone mass and found almost the exact same thing. When people ask me what work I’m most proud of, it’s those LIFTMOR trials. We stuck our necks out to test something very risky and our findings are now changing people’s lives.

What inspired you to establish The Bone Clinic in 2015?

The Bone Clinic grew out of the findings of those trials. We now knew the program worked in a randomised controlled trial, but I didn’t know if it would work and be safe in the real world. Everybody thought, “You can’t have an exercise program that

you have to supervise because then nobody will do it.” We didn’t know whether that was the case. It needed to be tested! So that’s why I opened The Bone Clinic. Although it is a business and health service, it is first and foremost, a translational research facility. Every person who comes to the clinic is a research participant as well as a client. This allows us to not only continue to deliver our high intensity program (that we call Onero) to sometimes very high-risk clients with expert supervision, but to collect high quality data to test whether the program is practical, effective and feasible in the real world. The Bone Clinic opened in 2015 and we’re going stronger than ever because now we have data showing exactly that.

Turns out, even people who are very frail can do Onero as long as they’re supervised by expert coaches, and we’re getting fantastic outcomes. The Bone Clinic clients get all the bone benefits we saw in the LIFTMOR trials and more. Improved osteoarthritis symptoms, reduced back pain – all sorts of ancillary benefits that add up to an improved quality of life. We have licensed the Onero program so it can

People Who Shaped SMA Prof Belinda Beck

be delivered all around the world, and we are continuing to ask important research questions about medications, comorbidities, dose response, diet and a whole raft of other things that simply would not be possible to study in a clinical trial setting in the current funding climate. Aside from the bone benefits, it’s very gratifying to walk into a clinic and see a client who previously couldn’t stand without a walker standing unaided on one leg with a great big smile on her face.

How has being part of SMA and being involved with the organisation helped you in your career?

Being part of SMA has helped me find my tribe. Not only does it keep you up to date with what other scientists are doing, it puts you in touch with this big network of scientists and clinicians that helps you to collaborate. Collaboration is the only way to go in research. You can’t achieve the same degree of scope and impact alone as you can when you work with others and you don’t want to waste time doing something on a small scale that someone else is already doing. You’re better to join forces. Networking is the key. Go to the SMA conference, talk to people, submit posters, be on committees, have a voice. You meet interesting people who are doing fascinating things, and along the way, you make great friends.

How did you become an ASMF Fellow?

Two of those SMA friends nominated me and encouraged me to apply, and Dr Kay Copeland also urged me to apply. It’s important to have strong and respected women being good role models in the society. So that inspires me, and I hope that my journey will inspire others. I was a QLD State Council member for a number of years. I’ve been on SMA conference program committees, presented at SMA events multiple times, and mentored students who have won SMA awards along the way.

So those are my main contributions in the process of becoming an ASMF Fellow. I just applied, put my CV in and crossed my fingers.

What are your aspirations as a current Board Member of SMA?

Because I’m pretty new to the Board, the scope of the role probably isn’t entirely clear to me. I’m looking forward to contributing my opinion and my expertise as issues arise, and hopefully making a difference. I feel like my view from academia (research, teaching and learning), as well as from business, through The Bone Clinic, can bring quite a bit to the table. I’m particularly looking forward to supporting initiatives to increase membership, because there’s strength in numbers. You have a much bigger voice in society with a big membership. You can change policies and field more innovative ideas from more members. Ideally, I’d like to help SMA and the Board to influence policy and practice in a way that benefits the broader community.

Do you have any advice for anyone going into Sports Medicine?

Sports medicine is such a broad topic. It can mean different things to different people, depending on their background, but I do have some general advice. The first is learn your anatomy. Now I know I’m biased. But the truth is, as a sports medicine expert, you can never know too much anatomy, whereas you can sure know too little! The more anatomy you know, the more it will benefit you in every walk of life. The second is, stick to the facts. I’ve raised this issue of myths, and they’re sort of my pet peeve. Keep your eyes peeled for myths in practice. If there is no evidence, always question if what you’re doing makes sense. If it doesn’t, go looking in the literature to see if there’s any evidence around it. And if there’s not and you’ve got the ability to do it, do some research and find the real answer yourself. That’s

how you change practice. There are many myths out there in medical practice, including in sports medicine. I know this from my own experience with tibial stress injuries. Think critically.

My advice in terms of careers is that it’s important to specialise, so that you can develop your expertise. The more you know about something, the more you can help others. But keep an eye on the vast pool of knowledge encompassed by this discipline. There’s an abundance of expertise in sports medicine that is surprisingly applicable in everyday life. From managing your child’s sprained ankle, helping out at the local sports club with how they’re doing their warmup, helping an accident victim, buying a pair of running shoes, and so on. None of those things are specifically my area, but I feel qualified to at least help because I read broadly and try to stay current . But then, of course you have to know when to draw the line and defer to an expert. Don’t become a purveyor of myths!

I’ve always been a bit of a myth buster. I always wanted to make sure that evidence was driving practice, not myths, anecdotes, fear and supposition.

Sports Medicine in Romania

Sport today is more than meets the eye. We need experts in order to achieve high performance as a professional athlete or as an individual who wants to stay healthy. Nowadays, Sports Medicine is a well-defined specialty that brings lots of benefits to the scientific support of great sporting performances. Sports Medicine has a preventive character, and gives the ability to prevent injuries and traumas under the influence of the natural environment.

Athletes should get back on the sports field as quickly and as efficiently as possible after rehabilitation, and Sports Medicine has made some impressive progress in helping them

recover faster. Sports Medicine has a crucial role in the so-called athlete, coach, and medical staff triangle.

Sports medicine has a long history in Romania dating back almost 100 years. A description of the first forms of activity in this specialty can be found in the 1923 paper written by Professor Dr Ion Pavel. It wasn’t long until in 1932, when Iuliu Hateganu, Florin Ulmeanu, Adrian Ionescu, and Miron Georgescu founded in Cluj-Napoca the Physical Education Medicine Society/The Medical Society of Physical Education that shared the same objectives as FIMS.

The Romanian government decided on 6th December 1949 to establish the

Network of Physical Culture Medicine, which later changed its name to Sports Medicine in 1985. This movement aimed to provide medical assistance during training and competitions. The Society of Physical Culture Medicine was founded in 1951, which later became The Sports Medicine Society, affiliated to FIMS in 1990.

In December 1962, The Sports Medicine Centre was created. Being a unit of national interest for medical control and assistance for Olympic and National teams, the unit represents the methodological forum of the sports medicine network. It was in 1991, at the request of the Ministry of Sports and Youth, that the Sports Medicine Center was converted into the National

Institute of Sports Medicine, which operates to this day. In addition to the clinical centers affiliated with public hospitals that are part of the national sports medicine network, there are sports medicine facilities as part of sports clubs (over 300 in Romania) and medical centers at National and Olympic sports bases.

Since its beginnings, the Sports Medicine Network’s achievements have been recognized and rewarded for exceptional results obtained at the Olympic Games, World Cups and many other competitions. Scientific contributions are well-known and appreciated by international forums, in particular for medical-biological selection in sport, recovery, training and competitions at medium altitude and patents of pharmaceutical compounds (ergogenic and recovery aids).

In 1967, The University of Medicine and Pharmacy “Carol Davila”, Bucharest introduced a specialized degree in

Sports Medicine, which continues to thrive to this day. The Romanian Medical Residency Program requires EEA students (such as Romanians) to sit for an entrance examination. Medical students who achieve a passing score on the state exam can choose the Sports Medicine Residency Program. As part of the curriculum, 200 didactic hours (courses, seminars, case presentations) are provided per year of university study for the topic presented, along with 40-50 hours of individual study. The Sports Medicine Residency Program takes 4 years to be completed. Of the time allocated to training, 20-30% are didactic, with the remaining 70-80% being dedicated to practical activities and individual study.

The curriculum includes the following basic modules: effort physiology, biomechanics, anthropometry, sports traumatology, sports cardiology, internal medicine, sports specific diseases, sports nutrition, recovery, sports medication, emergency

situations, pitch side care, doping and anti-doping regulations. At the end of each training module, a stage evaluation is conducted in the training unit by the program coordinator. A logbook tracks the entire training activity, including stage evaluations in credits, participation in research programs, and participation in conferences and continuing educational events. It is worth mentioning the fact that every year we have foreign doctors that start the Sports Medicine Residency Program in Romania. Besides the aforementioned program, the Sports Medicine Discipline within The University of Medicine and Pharmacy “Carol Davila”, holds several lectures during the academic university year on the physiology and physiopathology of physical exercise.

The Romanian Society of Sports Medicine (www.sroms.ro) represents professionals in sports medicine. It promotes quality education in sports medicine and sports science

in Romania and beyond. Our members represent and embody the multidisciplinary spirit that is the key to the specialty. Our integrated community includes doctors, physiotherapists, sports nutritionists, sports physiologists, sports scientists, and sports psychologists. In addition to the annual national congress, The Romanian Society of Sports Medicine is a reliable partner when organizing international events such as the past Balkan Sports Medicine Congresses (1997 and 2008- Bucharest) and the future EFSMA Congress of Sports Medicine in 2025, Bucharest.

Sports Medicine in Romania has travelled in these directions in the past several decades. In a time when movement and sport are everyday realities, we must accept that the only medical specialty that has the ability to understand the biopsychosocial strain on the body of physical exercise and to use exercise as a health factor wisely is Sports Medicine.

Author Bio

Prof Anca Ionescu

Professor, Head of the Sports Medicine

Department at the University of Medicine and Pharmacy “Carol Davila” and Senior Physician Specialist in Sports Medicine at the National Institute of Sports Medicine, Bucharest, Romania

ٚ European trainer for Sports Medicine (UEMS-MJC)

ٚ Honorary President of the Romanian Society of Sports Medicine and past President

ٚ Secretary General of EFSMA, Member Executive Committee FIMS

ٚ President of Medical Commission – Romanian Olympic and Sport Committee

I am focusing my activity on sports physiology and physiopathology, sports nutrition and sports cardiology in order to optimize sports performance and promote health.

Building Confidence. Together.

Harry Saban Sports Trainer Highlight

How did you first get involved in sports training?

I became involved about eight years ago when one of my sons was playing football in the Under 8s. The club was looking for volunteers and I saw they needed accredited Sports Trainers for every game, and there weren’t many of them. I got my Level 1 Sports Trainer accreditation and found that I really enjoyed being involved and part of the team. And then, as the age groups got older, I saw there weren’t many Level 2 sports trainers. So, when I had gotten my hours up in my Level 1, I got my Level 2 accreditation through SMA.

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

I got my Level 2 Sports Trainer accreditation through SMA. I later saw that they were looking for presenters and put in an expression of interest. I thought it would be a great way to help get more people in the club and the wider community involved. The good thing about SMA and being part of the SMA team is the people in the background. As presenters, we turn up with all the information, and we present and we do everything, but there’s a great team of people behind the scenes that make it all work and make it look easy for us. Ongoing support from SMA is fantastic. A big mention to Kaitlyn, Mitch and Ben; they’re great. Especially if we’re doing any courses, they’re backing us and supporting us or if I’m stuck on something or something’s not working.

Can you tell us about a specific highlight or challenge during your time working with the Parramatta Eels Under 16s squad? How did you come to be working in that space?

We were doing a reaccreditation through SMA for the Parramatta Eels. So, all their trainers come in once a year and we do all the reaccreditations. I got talking to them and talking about the season. They advised one of their trainers had commitments this year and would not be

Sports Trainer Highlight

Harry Saban

able to make it, and they were asking what my accreditations were. I was then invited to join the Parramatta Eels in 2023 as a Level 2 Sports Trainer for their Harrold Matthews squad. It was a really great experience and I have learned a lot from the other trainers and staff. There are physios, there’s doctors on hand, there’s other trainers, so the support is really good. The highlight for me is being part of the Parramatta Eels system and part of the team. It’s one of the foundation football teams and it’s a good club to be involved in.

What do you love most about being a sports trainer?

I enjoy being able to know what to do if there is an incident. If something happens, a lot of people freeze up. Because of the role as a sports trainer, you’ve got to be on your feet, you’ve got to be out there, you’ve got to know what to do and control the situation. I enjoy that part of it. It’s rewarding being part of the team and the club and helping people in need. I enjoy watching the juniors go through the ranks and the levels and seeing the athletes they become. It’s great meeting and working with other trainers who are like-minded and learning from them. You’ve got to get there early, you’re usually one of the last to leave and sometimes you can miss seeing your own child play. But the role is really enjoyable, and you can get a lot of satisfaction out of it.

Do you have any advice for people wanting to get involved in sports training or pursue it as a career?

Just do it – get involved. Chat to your local club because they are always looking for volunteers. The sports trainers play a really important role. Without them, the games can’t go ahead. It’s the same as the referees. If there’s no referees, there’s no game. If there’s no sports trainers, there’s no game either. So, the more people that get involved at the local level, the better. You also don’t need any specific background to become a sports trainer. I’m not a doctor, I’m not a physio, I’m a panel beater by trade, but it’s really great to get involved. Who knows where it may take you!

Ongoing support from SMA is fantastic, especially if we’re doing any courses. They’re supporting us and always there if I’m stuck on something or something’s not working.