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EDITORIAL
What is the future of medicine? Research and developments in medicine over the past twenty years have lead to the UK population living healthier and longer lives. But this all comes at a cost. With predictions of shortages of healthcare professionals in the UK and ever increasing healthcare costs, there is likely to be a heavy strain on resources in the future. The government have identified various health challenges which heavily contribute to this growing strain, and have therefore implemented taskforces and programmes with the aim of alleviating the problems. Lessons learnt from Smoke Free England and the Forecast Report showed that commitment from a variety of stakeholders is required to achieve a successful outcome in these key areas1. One of the main health challenges putting a strain on NHS resources at all levels is obesity. Over the past thirty years, obesity has steadily increased, and it will therefore not be resolved overnight. We all know that preventing obesity is more complex than just simply eating less and doing more. In a letter from the Chief Medical Officer at the launch of Change4Life, it was acknowledged that if nothing is done about the obesity problem in the UK, 90% of today’s children would be classified as overweight or obese by 20502. Launched this year, the Change4Life initiative has brought together a variety of cross-functional stakeholders, with the aim of improving children’s diets and levels of activities, which ultimately would reduce the burden of obesity and its associated conditions on the future NHS. As healthcare students and newly qualified professionals we have an important role in the health of our nation, and we need to take a role in this resource-strained environment, whilst continuing to maintain standards and deliver results. New specialities in medicine, such as Sports and Exercise Medicine (SEM), will be key to tackling these issues, and as healthcare professions we have a responsibility to be aware of what this speciality involves. In our lead article Lebur Rohman, Haroon Rauf and Wisam Alwan assess the awareness, interest, need and exposure of medical students to the new speciality of SEM. The Foresight Report predicted that obesity currently costs the NHS £4.2 billion a year, and physical inactivity accounts for a further £1.89 billion a year1. So the questions raised is, should SEM have an increased presence in our undergraduate training, so we can be armed with the knowledge to contribute to the health issues raised? In the ‘exercise’ aspect of SEM, healthcare students understand the importance of physical activity in recovery and maintaining health. In a review of the effects of exercise on stroke patients, Rauri Hadlington examines the data supporting post-stroke management as outlined in clinical guidelines. With the 2012 Olympics steadily approaching, the UK has an increasing drive to get people involved in sports. Every year there are 29 million sports injuries in the UK. Sports such as rugby union and horse riding are well known as ‘high-risk’ activities. For example the BBC reported that at any given time in rugby union’s Guinness Premiership approximately 25% of players are injured. Another sport associated with a high level of injuries is Cage Fighting. In this issue Stuart Potter explores the BMA’s call to have Cage Fighting banned. The question is if cage fighting is banned; will this lead to changes in regulations for other sports? In our final article Hannah Newham explores through a case-study, the ‘MRI now, talk later’ approach to medical practice that is steadily moving across the pond from the United States to the UK. In future medical practice will we be more concerned about potential litigation, rather than prompt and accurate diagnosis and treatment and patient care? The medicine section of the LSJM is dedicated in helping you develop ideas for publication. We welcome your input into the section and value your feedback and suggestions. If you would like to get involved with writing for us please get in touch with the medicine team at medicine@thelsjm.co.uk. Laura Vincent Section Editor Medicine References Illustration: Ella Beese
1. 2.
Butland B, Jebb S, Kopelman P, McPherson P, Thomas S, Mardell J, et al. 2007. Tackling Obesities: Future Choices. Foresight. London: Government Office for Science. Department of Health. 2008. Chief Medical Officer’s Letter. [Online]. Available from: http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_092026.pdf [Accessed 28th October 2009].
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NEWS Diabetes UK warn of ‘ticking time bomb’ Diabetes UK has warned that seven million people across the UK are thought to have prediabetes, putting them at a 15-fold greater risk of developing the disease. Prediabetes (impaired glucose regulation) is characterised by a higher than normal blood glucose level, slightly below levels observed in Type II diabetic patients. Research has shown that prediabetes can cause long-term cardiovascular damage. Unlike Type II diabetes, prediabetes is normally reversible, and progression can be reduced by 60% through lifestyle modifications, e.g. diet, exercise and weight reduction. Type II diabetes is one of the UK’s healthcare challenges, due to its association with other diseases. The burden on the NHS is approximately £1 million an hour. Prime Minister Gordon Brown was recently asked to explain what the government was going doing to promote healthy lifestyles, better identify prediabetes and curb the incidence of Type II diabetes in the UK. He explained the drive to tackle obesity through campaigns like Change4Life, and also the Risk Assessment Programme for all 40-70 year olds, which was an initiative proposed by Diabetes UK. Diabetes UK has launched its ‘Get Serious’ campaign, in order to raise awareness of the danger of diabetes. The campaign is calling on healthcare professionals to highlight the implications of prediabetes to their patients and give them lifestyle advice. Douglas Smallwood, Diabetes UK chief executive stated “Identifying and educating people with prediabetes is vital, as it’s not too late for many to make healthy lifestyle changes, reverse the condition completely and reduce their risk of developing Type II diabetes”. The charity published figures last week, which showed that more than 145,000 new cases of mainly Type 2 diabetes were diagnosed in the UK during the past year. “It’s time for all of us to get serious about our health if we want to have any chance of defusing the ticking time bomb of Type II diabetes”. Move for Change - European campaign to tackle ignorance of Parkinson’s Recent Italian research into Parkinson’s disease patients has highlighted failings in the early diagnosis, access to specialist care and knowledge of the disease amongst the medical profession1. These findings may not be confined to Italy, and further research is underway to establish the extent of the problem across Europe. The European Parkinson’s Disease Association (EPDA), is concerned with the health and welfare of people living with Parkinson’s’ disease, their families and carers. They have now launched a new action campaign, Move for Change, which will target national parliaments, neurological specialists and the general public across Europe. Professor Fabrizio Stocchi, Director of the Parkinson’s Disease and Movement Disorders Research Centre, commented “The medical profession could do more for people with Parkinson’s. Current gaps in understanding about management and treatment are leading to failures in both diagnosis and care. Even when there is a correct diagnosis in place the tendency is often to delay treatment
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for as long as possible. This practice is not only negatively impacting patients’ lives but also wasting taxpayers’ money. Early Parkinson’s intervention may slow disease progression, improve the quality of patients’ lives and is also associated with significant direct and indirect cost savings”. The Netherlands are leading the way with action for Parkinson’s disease, and they have seen a significant improvement in care. They have set up ParkinsonNet, a regional programme that has allowed patients to receive earlier diagnosis, improved multidisciplinary care and faster access to treatments that slow symptom progression. Both the human and economic costs have been reduced, with the government reporting an estimated €42 million reduction in the cost of care due to the programme. Move for Change will include further research into Parkinson’s management and treatment across Europe, a European Parkinson’s Action Day and carefully coordinated activities aimed at raising awareness across the continent. Mary Baker, the EPDA patron, said “We want to unite Europe in the fight against Parkinson’s. Ignorance is costing everyone, not just those affected by the disease. The EPDA hopes Move for Change will instigate change at the highest levels to ensure that people with Parkinson’s receive proper diagnosis and the right treatment, at the right time”. 1. 2.
For more information go to: http://www.epda.eu.com/ projects/moveForChange/2009/default.asp Research conducted by GfK Eurisko. (September-October 2008
Increasing Figures for Obesity Admissions in England The number of people being treated for obesity has risen dramatically, partly due to bariatric surgery now being more widely available on the NHS, according to a BBC news report. The latest report from the NHS Information Centre for England shows an annual rise of 60% in conditions linked to obesity and a 360% increase since 20041. It reported there were 8085 obesity related admissions in England; over half of these were for surgery, the rest were for treatment for type II diabetes, respiratory disease, organ failure or cardiovascular disease. In 1993, 13% of men and 16% of women were classed as obese; in 2009 these figures are expected to rise to 25% of the population for both genders. Tim Straughan, head of the NHS Information Centre said “The large increase in admissions for obesity reflects the growing impact that obesity has on the health of our nation as well as the demands it is placing on limited NHS resources”. He went on to say “It also reflects the fact that overweight people are resorting to treatments such as bariatric surgery to tackle their health problems”. Bariatric surgery was approved by NICE in 2007 as a treatment for patients with a BMI above 40 (or 35 if there were other underlying health problems), who had not succeed with anti-obesity drugs such as orlistat. Tam Fry, from the National Obesity Forum said “We no longer try to use diet and exercise as a way of treating this problem. The increasing demand for bariatric surgery is going to put a lot of pressure on the NHS”.
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NEWS Change4Life, the government campaign to promote healthy living, is aimed at addressing these issues. The public health minister, Gillian Merron, said “We are taking action to address it and to prevent people becoming obese in the first place, backed up by major investment.” Obesity remains one of the major health challenges, only time will tell if the investment will reduce the waistline of admission figures. 1.
NHS. (2009). Hospital Episode Statistics HES (admitted patient care) England 2008/09. [Online]. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/ hospital-care/hospital-activity-hospital-episode-statistics-hes/hospital-episode-statistics-hes-admitted-patientcare-england-2008-09 [Accessed 31st October 2009].
Team work, communication and patient medications The NHS may be at risk of failing to prevent harm to patients from medicines unless it improves sharing of vital information when people move between services. A Care Quality Commission (CQC) survey published in October has identified that information shared between GPs and hospitals when a patient moves between services is often “patchy, incomplete and not shared quickly enough”1. The survey of 280 GP practices found that 24% are not systematically providing hospitals with previous drug reactions, as well as co-morbidities (14%) and allergies (11%). The picture from hospitals is similar; 81% of the GP practices questions stated that hospital discharge summaries contained incomplete or inaccurate information about prescribed medication,
“all or most of the time”. The CQC urged hospitals and GP practices to ensure they are sharing “timely, complete” information on changes to patient medication, to prevent the risk of medication related patient safety incidents. Cynthia Bowers, CQC Chief Executive, said “We know that incidents related to medication can cause people significant problems and sometimes unnecessary harm and distress. Not all adverse drug reactions are preventable, but the potential risks are clear”. “People have a right to expect clinicians to know details about each stage of their care, and in this day and age they are right to do so. It’s not possible for a clinician to make good decisions about care unless they have key information about a patient. She went on to say that the NHS needs a “change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.” From April 2010, effective medicines management will become a requirement of registration, which will be a legal requirement. The CQC has urged all GP practices and trusts to use the survey findings to identify areas that need improving. 1.
Care Quality Commission. (2009). Managing patients’ medications after discharge. [Online]. Available from: http://www.cqc.org.uk/guidanceforprofessionals/ healthcare/nhsstaff/specialreviews/2008/09/ managingmedicines.cfm [Accessed 29th October 2009].
BACKGROUND
What is Sports and Exercise Medicine?
Lebur Rohman, Haroon Rauf and Wisam Alwan Sport and Exercise Medicine (SEM) was formally acknowledged as a medical specialty in 2005. There had been significant political pressure to the creation of the new specialty due to the rising levels of physical inactivity and obesity and the subsequent burden this has on the National Health Service (NHS) via related injuries1. The bid for the 2012 Olympic Games in London was influential in driving the formal recognition of SEM. Sports and Exercise Medicine is the area of medicine that deals with the effect of sport and exercise on the body. It has roles in both sports injury management and also the promotion of physical activity, disease prevention and disease management in other specialities such as:
• • • •
Rheumatology and Rehabilitation Medicine Cardiology and Respiratory Medicine Metabolic Medicine and Endocrinology Care of the Elderly
• • • • • •
Paediatrics and Child Health Primary Care Occupational Medicine Public Health A&E Orthopaedics2
Topic editor: Laura Vincent For references see thelsjm.co.uk.
Sports and Exercise Medicine is to work in association with “Game Plan”, a governmental strategy to increase physical activity, combating physical inactivity, and enhancing international performance in sport, particularly in popular sports to the public domain, to increase the “feel good factor” affiliated with winning1. The specialty will be required to help manage the expected rise in physical and sport related injuries associated with increased activity. Currently physical inactivity costs the government £1.89billion each year, whilst the NHS spends £590m treating less than 10% of the annual 29 million sports and exercise related injuries3,4. SEM can provide specialist care, ease NHS waiting lists and provide a costeffective service.
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RESEARCH
Medical Students’ Awareness, Interest and Exposure to Sports and Exercise Medicine Lebur Rohman, Haroon Rauf and Wisam Alwan
Graduates 2009 Medicine, St George’s University of London leburrohman@doctors.org.uk doi:10.4201/lsjm.med.008 Table 1: Response rate for each questionnaire and overall result Questionnaire SEM Paediatrics
Number of Questionnaires distributed 194 136
Total
330
Number of Response Rate questionnaires returned (%) 151 121
77.8 89.0%
272
82.4
Table 2: Identification of the definitions of SEM and Paediatrics (Correct definitions in green) Number of responses, % (n) Pre-clinical
Clinical
Which of the definitions below best describes SEM? A)
The area of Medicine that deals with the effect of sport and exercise on the body including the role of physical activity in health promotion, disease prevention and in disease management.
72.4 (42)
83.7 (77)
B)
Sports and Exercise Medicine is concerned with the management of injury, illness and disease associated with elite athletes.
22.4 (13)
14.1 (13)
C)
Sport and Exercise medicine is concerned primarily with research into the effect of sport on the human body.
5.2 (3)
2.2 (2)
Which of the definitions below best describes Paediatrics?
A) B)
The management of diseases that affect children from birth.
C)
The medical care of patients up to the age of puberty
The branch of medicine that deals with the medical care of infants, children, and adolescents
8.3 (3)
9.5 (8)
86.1 (31)
79.8 (67)
5.6(2)
10.7 (9)
Table 3a: Responses for the role and scope of work of SEM specialist
Pre-Clinical
SEM involves jobs in primary care (True)
SEM involves management of chronic injuries/ disease (True)
SEM involves roles within child healthcare (True)
26
TRUE
31
40
FALSE
27
18
32
% Correct
53.4
69.0
44.8
Clinical
TRUE
49
70
42
FALSE
42
23
50
% Correct
53.8
75.3
45.7
Table 3b: Responses for the role and scope of work of SEM specialist
Pre-Clinical
172
SEM involves promotion of prescription of exercise in disease prevention and management (True)
SEM involves promotion of the health benefits of sport and exercise (True)
SEM involves treatment that is currently only available under private healthcare (False)
TRUE
50
54
24
FALSE
7
4
34
% Correct
87.7
93.1
58.6
Clinical
TRUE
79
81
39
FALSE
14
11
53
% Correct
84.9
88.0
57.6
BACKGROUND The prolific use of the term ‘Sports Physicians’ has led to confusion regarding what Sports and Exercise Medicine (SEM) entails1. The definition of this emerging field of medicine also varies between health professionals and in different countries. The shroud of confusion surrounding SEM is bound to affect the perception and interest of newly qualified doctors, and future development of this new speciality2. Reviews on undergraduate training in SEM is limited, and with current views from medical students unknown, this raises the question; Are current medical students adequately exposed to SEM during undergraduate training to facilitate an appreciation of the speciality? This study aims to determine the awareness, interest and understanding of SEM in medical students, as well as examining the exposure of the speciality during undergraduate training. METHOD Sampling frame The sampling frame consisted of pre-clinical and clinical medical students from St George’s University of London. Data was collected through questionnaires, and a similarly worded questionnaire relating to paediatrics was used as a control. The questionnaires were distributed randomly during lectures. Questionnaire design For this study the authors adapted questionnaires used instudies with GPs and A&E specialists, and these were subsequently revised by an orthopaedic surgeon with an interest in sports medicine3,4. This was then piloted in 10 students, who were asked to feedback on various aspects of the questionnaire. Responders were asked to select from a list of options e.g. yes, no, unsure, or true, false, or use a 5-point Likert scale e.g. strongly disagree to strongly agree. Statistical analysis Data was collated on the SPSS programme for statistical review. A Pearsons Chi-squared (x2) test was used to assess the statistical significance differences between responses to SEM and paediatrics. A Fisher’s exact test was used when the percentage of cells with an expected count less than 5 was greater than 20%. For questions were a Likert scale response was used, the data was collapsed with scores of 1 and 2 regarded as disagree, while scores of 3, 4 and 5 were regarded as agree. This was based on a pilot on 10 students, where 8 students classified 3 as ‘agree’. Table 1 illustrates the response rates for this study.
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RESEARCH RESULTS SUMMARY Q1. Awareness of Sport and Exercise Medicine Only 29% of pre-clinical (n=17) and 40% clinical students (n=37) were aware of SEM speciality, whereas over 95% of pre-clinical and clinical students were aware of paediatrics as a speciality.
In addition, there was considerable agreement amongst students that receiving further formal teaching in SEM and paediatrics would benefit their future clinical practice (87.2%, n=129; 90.7%, n= 98 respectively, p=0.428). Although not statistically significant this suggests that further teaching in both specialties may be beneficial for future clinical practice.
Q2. Definition of SEM See table 2.
DISCUSSION This study has identified that medical students have limited awareness of SEM, despite demonstrating an interest in the speciality. The respondents were aware of the importance of SEM in the health of the nation, and 74% of responders felt that they did not receive adequate exposure of the speciality in their training. Many students were interested in the speciality, with over one third considering it as a future career path. Many responders had a limited understanding of SEM, believing it involved working with elite athletes with high numeration. If students were aware of the public health aspect of SEM, would the numbers interested in the specialty decrease? Current public health initiatives are focusing on increasing physical activity in the UK to address the obesity epidemic5,6. Currently 5% of Accident & Emergency workload is due to sports injuries, and with more people taking up sports and exercise, there will be an additional burden on the NHS with related injuries7-10. In a study of GPs, over one third of responders felt their undergraduate SEM training was inadequate3. Therefore knowledge of managing sports injuries is essential for healthcare professionals, especially in foundation doctors working within A&E departments11.
Q3. What is the role of a SEM specialist? Over 50% of all students correctly identified the role and scope of a SEM specialist (table 3). The differences in the correct number of answers for SEM compared to paediatrics, is shown in table 4. There were no significant differences between pre-clinical and clinical students in the answers to the SEM questions. There was significant difference in the percentage of students identifying the correct answers for the two specialities, and therefore it was concluded that responders are less aware of the SEM specialists’ role. Q4. Training pathway Only 26.0% of students were aware of the SEM training pathway, in contrast 52.1% were aware of the paediatrics training pathway (p<0.0001). Q5. Interest in/need for Sport & Exercise Medicine Only 34.7% of students express an interest in SEM compared to 80.2% of students expressing an interest in paediatrics. There was no evidence that responders involved in sports or physical activity (89.3%) had a greater interest in SEM, or awareness of the training pathway. 63.3% of responders held the opinion that SEM should be a recognised specialty and 83.9% agreed that the burden of sports and exercise related injuries were enough to justify SEM as a recognised independent speciality. Q6. Exposure/experience in Sport & Exercise Medicine Only 38 responders (25.5%) felt that they had received adequate exposure to SEM in medical school, compared to 45.2% of responders who believed that there was adequate exposure to paediatrics (p=0.001). 67.3% of responders would like to see SEM added to the core curriculum. More students were confident they knew when to refer a patient to a paediatrician (76.9%), compared to a SEM specialist (57.1%) (p= 0.001). In addition medical students were more likely to have gained experience in paediatrics than SEM (p=0.0001).
A study of UK medical schools in 2000, showed that only 13 out of 28 institutions offered some type of SEM teaching, and a further 5 institutions had plans in place to offer this by 200512. This demonstrates a need for a national SEM curriculum in undergraduate training. CONCLUSION The results from this study were obtained from one medical school and therefore future multicentre studies are required to obtain a true representation for UK medical students. Furthermore, every UK institution’s provision of optional special study components in SEM, should be formally quantified and evaluated to establish the availability of self-directed study, outside of the core curriculum. Increasing exposure to SEM in undergraduate training would increase future medics’ ability to identify and manage sports injuries, provide training in the public health aspect of exercise for disease prevention, and finally provide clear understand and guidance for those students wishing to pursue specialist training in SEM. SEM will have a crucial role and impact on public health, and will treat all types of patients, from elite athletes through to school children. For the speciality to develop further, it is essential that early exposure is established in undergraduate medical training, thus starting at the ‘grassroots’ of the medical profession. Therefore the authors of this study conclude that the inclusion of formal training in SEM at the undergraduate level “deserves special consideration”4.
Table 4 : The figures denotes the percentage of each group identifying the correct answer, followed by the number of respondents
Specialty
Paediatrics/SEM is associated with jobs in primary care (p= 1)
Paediatrics/SEM involves management of chronic diseases (p=0.4534)
Paediatrics/SEM is associated with treatment that is currently available only under private healthcare (p=1)
Pre-Clinical
Clinical
Pre-Clinical
Clinical
Pre-Clinical
Clinical
SEM
53.4 (n=31)
53.8 (n=49)
69.0 (n=40)
75.3 (n=70)
58.6 (n=34)
57.6 (n=53)
Paediatrics
83.3 (n=30)
79.5 (n=66)
94.4 (n=34)
97.6 (n=81)
94.3 (n=33)
90.4 (n=75)
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For references see thelsjm.co.uk.
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PERSPECTIVE
Should cage fighting be banned? Stuart Potter
Year 2 Medicine, St.George’s University of London m0700759@sgul.ac.uk doi:10.4201/lsjm.med.010 Introduction
With its engaging combination of subtle technique and intensely focussed physicality, combat sports have fascinated audiences throughout history. From Pankration in Ancient Greece, to Vale Tudo in Brazil in the 1920s mixed martial arts combatants have used a variety of striking and grappling techniques to subdue their opponents1. The popularity of the modern mixed martial arts (MMA), evocatively dubbed ‘cage-fighting’, has flourished under the banner of the ‘Ultimate Fighting Championship’ (UFC). This is a competition that embraces the concept of combatants, fluent in a myriad of martial art styles, testing the effectiveness of their skills. This novel form of mixed martial arts has evoked vociferous opposition from various groups. The British Medical Association’s opposition to MMA is due mainly to concerns about the combatants’ physical health. Other critics sensationally describe MMA as “savage” and “human cockfighting”2,3. Proponents of MMA passionately object to this characterisation, referring to the sport as “human chess” and cite its safety record in defence4. On both sides of the debate, advocates present compelling arguments in defence of, and opposition to, the statement “Cage-Fighting should be banned as called for by the British Medical Association (BMA)”. Arguments For
Many groups have called to ban cage-fighting; politicians, clergy, physicians and- surprisingly- boxing officials have variously described the sport as “grotesque”, “brutal” and “savage.””3,5,6. To opponents of cage-fighting, the sport appears to revel in the glorification of violence, an attitude ‘civilised’ society cannot condone7. Utilising strikes, chokes and grappling techniques to defeat their opponents, injuries are not uncommon amongst cagefighters; deaths have also been reported8. The BMA regards this risk to a participant’s health as sufficient grounds for a ban of the sport9. The results of the report “The Boxing Debate” supported the BMA’s call for a ban of boxing, and other combat sports; describing the trauma caused to the brain, resulting from Illustration by Nana Hene Koduah, Ghana. Email: nanahehek@hotmail.com
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PERSPECTIVE the impact of strikes to the head10. The BMA redefined their opposition to combat sports in 2008 to include mixed martial arts (cage-fighting), as it felt that- although there was a dearth of research on the subject- the risks associated with boxing were applicable to this increasingly popular sport9. It has been estimated that a punch can generate a force on impact of over half a ton, equivalent to being struck with a 6kg mallet at 20mph11. An impact of this magnitude is liable to cause significant trauma as, due to the lack of protection covering the head, the force of the blow is transmitted to the brain parencyhma10. Protected by three membranous meningeal layers and surrounded by cerebrospinal fluid, the brain is relatively free to move within the skull. Trauma impairs normal brain functioning and can cause an abrupt loss of consciousness and both acute and chronic dysfunction can arise from such injury12. Blunt trauma subjects the skull to acceleration and the inertia is transferred to the brain; consequently, the brain collides with skull and ‘shearing stresses’ tear veins and nerves, resulting in subdural haematomas and in severe cases, death13. That participants in combat sports sustain neurological damage is widely supported14,15,16; the long-term effects of neurological impairment can result in the development of Dementia Pugilistica- chronic encephalopathy, or ‘punchdrunk syndrome’, a disorder characterized by a decline in cognitive function and weakness and tremors in the limbs14. These effects are cumulative; the brain becomes more susceptible to injury after initial trauma, increasing the risk of developing neurodegenerative disorders, such as Alzheimer’s disease, in later life17. The BMA believes the damage inflicted in cage-fighting is comparable to boxing, a sport in which approximately 20% of pro-fighters suffer chronic traumatic brain injury18. A 10 year review of Mixed Martial Arts competition revealed that approximately 28% of matches were stopped due to blunt trauma to the head19; the potentially debilitating, or even fatal repercussions of such trauma is unacceptable to the BMA.
Contrary to the BMA’s claims, a 5-year review of MMA competition found the risk of critical injury appeared to be low26. Additionally, the BMA is not calling for a ban on what it considers ‘proper’ martial art sports, such as karate and taekwondo, despite these sports having demonstrably high injury rates9,27,28,29. Compared to other combat sports, MMA has a low knockout rate due to the variety of match winning methods available and possibly a disinclination to strike a hard head with fragile fists, as the regulation 4-6 ounce gloves offer scant protection. In light of this information and the BMA’s admission of higher injury rates in other sports, fans are concerned the BMA is basing their opposition to MMA on ideological grounds, and not on empirical evidence4,9. In an attempt to repair the sports sullied image, supporters of MMA make reference to research that indicates that martial arts training has a beneficial impact in aiding discipline and reducing aggression31,32; this is demonstrated effectively by numerous police schemes, that aim to improve the behaviour of antisocial youths by employing combat training33,34,35. Conclusion
Participants in all combat sports expose themselves to the risk of injury, with the potential to suffer debilitating health impairment. However, the BMA fails to support their assertion that the health risks engendered by MMA is equivalent to that of boxing, and the distinction between MMA and ‘proper’ martial arts appears arbitrary; as research suggests that cage-fighting does not present a health risk greater than other combat sports. In fact, mixed martial artists may face a reduced risk of critical injury due to the unique format of their sport. Further research is required to ascertain the specific risks associated with mixed martial arts, as based on current evidence, the BMA has failed to justify its call for a ban. References 1.
2.
Arguments Against
Advocates of Mixed Martial Arts passionately defend their chosen sport against claims it is “brutal” and “glorified violence”5, contending it is a highly technical showcase of skills. The hypocrisy of some critics is apparent, when it is revealed they ardently support boxing2,21. Officials in the sport recognise that they are partially responsible for the sports tarnished reputation, due to actively marketing early competitions as bloody, brutal events22.
3. 4.
It takes considerable technical expertise to emerge victorious in a mixed martial arts match due to the variety of skills that must be mastered.23 ; This is far from the spectacle of thugs in a street brawl portrayed by opponents of the sport24. However, the stigma remains and proponents of MMA argue that critics have failed to appreciate that the sport has evolved since its inception, instituting new rules and regulations to ensure safety25.
7.
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5.
6.
8.
9.
10.
Walter, D.F. Mixed Martial Arts: Ultimate Sport, or Ultimately Illegal? [Online]. Available from: http://www.grapplearts. com/Mixed-Martial-Arts-3.htm [Accessed 1st April 2009]. Petty, M. Sulaiman slams ‘savage’ sport [Online]. Available from: http://www.skysports.com/story/0,19528,12183_4365313,00. html [Accessed 1st April 2009]. Plotz, D. Fight Clubbed. Slate 1999. Martin, D. Fighters & Promoters Speak Out Against BMA. [Online]. Available from: http://www. mmaweekly.com/absolutenm/templates/dailynews. asp?articleid=4667&zoneid=13 [Accessed 31st March 2009]. Smith, S. True Sport or Glorified Violence? [Online]. Available from: http://news.bbc.co.uk/1/hi/ uk/6906889.stm [Accessed 1st April 2009]. Lessware, J. Cage fighting event is condemned. [Online]. Available from: http://news.bbc.co.uk/1/hi/scotland/glasgow_ and_west/6289042.stm [Accessed 31st March 2009]. BBC News. Call to ban ‘no-holds’ fighting. [Online]. Available from: http://news.bbc.co.uk/1/hi/ health/6978438.stm [Accessed 21st March 2009]. Meltzer, D. MMA fighter Vasquez dies weeks after fight. [Online]. Available from: http://sports.yahoo.com/mma/news?slug=dm-fight erdeath120207&prov=yahoo&type=lgns [Accessed 1st April 2009]. British Medical Association. Boxing. [Online]. Available from: http://www.bma.org.uk/health_promotion_ethics/ sports_exercise/boxing.jsp [Accessed 31st March 2009]. British Medical Association. The Boxing Debate (1993).
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What is Mixed Martial Arts? Mixed Martial Arts (MMA) is a developing combat sport, where competitors use different forms of fighting in a supervised environment. These forms include jiu-jitsu, kickboxing, karate, wrestling and boxing. Competitors score points by striking and grappling their opponent. In 1993 the Ultimate Fighting Championship (UFC) brand offered a series of events, that would be shown on air across the USA. Now top fighters can command up to £500,000 per fight and TV ratings are burgeoning.. Notable cage fighters in the UK include Alex Reid, ex-Hollyoaks actor and Katie Price’s partner and Lee ‘Lighting’ Murray, the accused ringleader of the £53million heist on the Kent Securitas depot. What is Cage Fighting? Cage fighting is an extreme form of MMA, where two contestants enter combat in a cage fenced arena. Some might say it is an exhilarating combination of wrestling and kick-boxing, whilst others would label it as a dangerous and brutal sport that also encourages violence outside of the ring amongst spectators. The Rules of Cage Fighting •
Anything goes, except eye-gouging, biting, hair-pulling, head butting, groin attacks, joint manipulation, fish-hooking and inserting fingers into orifices.
•
No spitting, no abusive language, no attacking during time-out or after the bell has sounded
•
For safety reasons, no striking to the spine or back of the head, no striking downwards using the point of the elbow, and no throat strikes including grabbing the trachea.
•
Timidity, and the corner throwing in the towel during a match is forbidden
The medical society, especially here in the UK where we have relatively free health care, often brands as a health issue practices that result in an increase burden on the service. Is it time that we examined the health consequences of the “sports” we encourage and participate in as a society.
Introduction Although UK doctors joke about the “MRI now, talk later” attitude of US physicians, with malpractice litigation on the rise in the UK, defensive practices are on the rise. Modern Obstetrics in particular lends itself to high-profile legal suits. In an era of extremely low maternal mortality and morbidity, women who have a baby do not expect to be injured in the process and are quick to search for a liable party. In this climate, obstetricians may be tempted to order a large battery of tests to protect themselves from allegations of negligence. Although quick and easy to perform, screening tests often have high sensitivity and low specificity and can yield a high rate of false positives. A false positive result may lead to investigations and treatments that could adversely affect mother and baby. Routine antenatal screening varies significantly across European countries. Current UK protocol does not advocate routine screening for maternal thyroid disease. This case study illustrates how a positive result led to a chain of events that put both mother and baby at risk, and how this risk may have been avoided. For my mini-elective special study module I undertook a 5 week Obstetrics and Gynaecology placement in Rouen, France at the Charles-Nicolle Hospital. Aside from the vast differences in the structure of healthcare services in France when compared to the NHS in the UK, I noticed in France a leaning towards rigorous screening, early intervention and invasive techniques. The Case 23 year-old Mrs J.V, gravida 1 para 0, presented at 14 weeks gestation for routine screening blood tests, including thyroid function testing. She was found to have low TSH (0.01mIU/L), high free T3 (4.32ng/dl) and normal free T4 (1.08ng/dl). She reported no symptoms of hyperthyroidism; no palpitations, nausea, vomiting, weight change or insomnia. On examination, however, she was
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Defensive Medicine in Obstetrics: A Case of Maternal Graves’ Disease Hannah Newham BSc (Hons) Year 5 Medicine, St George’s University of London m0500529@sgul.ac.uk doi:10.4201/lsjm.med.006
found to be slightly tachycardic (HR 95bpm), with brisk reflexes and a fine tremor. Mrs J.V was admitted for further tests, serum testing for anti-TSH antibodies, were raised, and a thyroid ultrasound scan, which showed a regular, homogenous, hypervascular thyroid gland, with no focal lesions. A diagnosis of pregnancy-induced Graves’ disease was made, propylthiouracil treatment was commenced and Mrs J.V was discharged home. A routine antenatal ultrasound at 32 weeks, however, detected enlargement of the foetal thyroid gland. Mrs J.V was admitted and a high resolution foetal thyroid ultrasound was performed. This showed a diffuse foetal goitre, with no constriction of the trachea or oesophagus, and no polyhydramnios. To determine the thyroid status of the foetus foetal blood sampling was performed and showed foetal hypothyroidism: Free triiodothyronine (fT3) = 2.5pmol/L (normal= 1.15-3.5) Free thyroxine (fT4) = 9.2pmol/L (normal= 10.4-16.6) Thyroxine-Stimulating Hormone (TSH) = 31.9mU/L (normal= 2.6-11.8)
The obstetricians withdrew propylthiouracil therapy due to the risk of difficulties during delivery. Surveillance foetal ultrasound showed gradual regression of the foetal goitre. The baby was born by spontaneous vaginal delivery at 39+3 weeks, with no intrapartum or postpartum complications. Discussion - Did the management of this patient place her and her baby at unnecessary risk? Detection and treatment of subclinical hyperthyroidism Maternal hyperthyroidism has an incidence of 1 in 500 pregnancies. Up to 95% of these cases are secondary to Graves’ disease1. In Graves’ disease, autoantibodies (known as thyroid-stimulating immunoglobulins) activate the TSH receptor stimulating excess
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thyroxine production2. Graves’ may present for the first time during the first trimester of pregnancy, but in the majority of cases it occurs in a woman who is already known to have the disorder1,2. In cases where there is a past history, or clinical suspicion of thyroid disease, thyroid function tests should be performed. Hyperthyroidism is confirmed by high levels of fT4 and fT3, with reduced levels of TSH1. The levels of these hormones changes during pregnancy, It is therefore vital that levels are compared to trimesterspecific normal values. Normal TSH levels during pregnancy are: 0.03-2.3mIU/L in the first trimester, 0.03-3.1mIU/L in the second trimester, and 0.13-3.5mIU/L in the third trimester. Normal maternal fT4 levels are 0.7-1.8ng/dL3.
Supervisor: Miss Catherine Wykes, Consultant in Obstetrics & Gynaecology, East Surrey Hospital
Overt maternal hyperthyroidism increases the risk of premature labour, pre-eclampsia, and perinatal mortality due to foetal tachycardia, foetal growth restriction, premature delivery and stillbirth1,2,3,4. Medical treatment with propylthiouracil (PTU) is recommended in these patients1,2,5. PTU works by inhibiting the thyroperoxidase enzyme thus preventing the conversion of iodide to iodine, which is necessary for T3 and T4 production and has a similar efficacy and side effect profile in pregnancy. However, evidence shows that subclinical maternal hyperthyroidism, defined by suppressed TSH but normal free T4, as in the case of Mrs J.V, is not associated with increased adverse maternal or foetal outcomes. Casey et al conclude that detection of subclinical hyperthyroidism during pregnancy, and subsequent treatment is therefore unwarranted3. Foetal hypothyroidism secondary to anti-thyroid treatment Anti-thyroid medications are able to cross the placenta; hence there is a risk of foetal hypothyroidism and goitre1,2. This risk is minimised by using the lowest dose of PTU or carbimazole, maintaining maternal FT4 and FT3 at high-normal levels and monitoring maternal thyroid function at monthly intervals1,2.
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Foetal hypothyroidism may lead to some degree of irreversible mental retardation in the newborn, and is also associated with miscarriage, late foetal loss and low birth weight1,5. Foetal goitre can cause polyhydramnios due to oesophageal obstruction, respiratory problems at birth due to tracheal obstruction and mechanical difficulties during delivery due to hyperextension of the foetal head6. A study by Mitsuda et al. of 230 mothers with Graves’ disease found only 7 cases of foetal hypothyroidism secondary to anti-thyroid treatment5. The benefits of treatment are generally considered to outweigh the risks2. Foetal thyroid status can be monitored non-invasively by ultrasound monitoring of foetal size, heart rate and goitre4,6. Cohen et al show that serial ultrasound monitoring of foetal thyroid size may detect foetal hypothyroidism as early as 14 weeks of gestation, before goitre develops and hypothyroidism causes impaired foetal development6. They recommend that ultrasound should be used to monitor all mothers with Graves’ disease receiving anti-thyroid treatment. This is supported by Luton et al, who show that foetal ultrasound monitoring of thyroid size has a sensitivity of 92% and specificity of 100% in detecting foetal hypothyroidism7. Investigation and management of foetal goitre In maternal Graves’ disease, foetal goitre may be indicative of foetal thyrotoxicosis secondary to foetal thyroid stimulation by thyroid-stimulating autoantibodies, or hypothyroidism secondary to suppression by maternal anti-thyroid treatment1,2. Foetal thyroid function is difficult to assess in-utero. Amniotic thyroid hormone and TSH levels do not accurately reflect foetal thyroid function, and foetal blood sampling, although very accurate, carries a 1-2% risk of foetal loss4,6. Luton et al show that Doppler ultrasound may be useful in the differentiation of hyperand hypothyroid goitres7. However, is confirmation of foetal thyroid status necessary in cases of foetal goitre? Cohen et al show that reduction of maternal antithyroid treatment leads to regression of foetal goitre in hypothyroid foetuses6. Ochoa-Maya et al also report a resolution of goitre over 10 weeks after discontinuation of PTU8. Both authors advocate non-invasive management and ultrasound monitoring in cases of PTU-induced foetal goitre. In hyperthyroid foetuses, no reduction in foetal thyroid size is seen on cessation of PTU. Cohen et al recommend that foetal blood sampling is reserved for these cases6. Kilpatrick and colleagues similarly conclude that umbilical blood sampling should be considered only when there are signs of foetal hyperthyroidism: intrauterine growth restriction, goitre, cardiomegaly or tachycardia9. Cessation of PTU in the case of Mrs J.V. led to complete resolution of foetal goitre. PTU cessation and ultrasound monitoring may therefore have been more appropriate in the first instance, avoiding the risks associated with foetal blood sampling. Conclusion Modern health care professionals learn that the benefits of every procedure must be balanced against its risks. In accordance with this, the National Institute ���������������������������� of Clinical Excellence (NICE) rebukes the routine medicalisation of pregnancy, emphasising that, “pregnancy is a normal physiological process and that, as such, any interventions offered should have proven benefits and be acceptable to pregnant women.”10.
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Many argue that there is no evidence to support the use of routine screening for thyroid disease, as it does not improve maternal or foetal outcome3. Although this case had a satisfactory outcome, one wonders whether this may have been observed if screening had not been performed and anti-thyroid treatment had not been given. Certainly the foetus was placed at increased risk of developmental delay, intrapartum complications secondary to maternal anti-thyroid treatment and increased risk of miscarriage due to foetal blood sampling. Evidence suggests that a more cautious approach should be taken in the management of maternal Graves’ disease: Mild or subclinical maternal hyperthyroidism should be monitored by repeat thyroid function tests and assessment of maternal and foetal wellbeing. It may not require anti-thyroid treatment2. Those on anti-thyroid medication should undergo regular assessment of foetal heart rate, foetal growth and high-resolution ultrasound monitoring of foetal thyroid size, to detect early signs of foetal hypothyroidism6. If foetal goitre develops, treatment should be withdrawn and resolution of foetal goitre monitored using ultrasound8. Foetal blood sampling should be reserved for cases when foetal goitre does not resolve following cessation of treatment6,9.
References 1. 2.
3.
4.
5.
6.
7.
8.
9.
10.
Baker P.N. (ed) (2006) Obstetrics by Ten Teachers. 18th ed. London: Hodder Arnold. ATA (American Thyroid Association) (2005) Thyroid Disease and Pregnancy. [Online]. Available at: http:// thyroid.org/patients/brouchers/thyroid_dis_ pregnancy_broch.pdf [Accessed 10th April 2009]. DeGroot L. (2006) Subclinical thyroid disease and pregnancy: Evidence-based recommendations for the new guidelines. In: American Thyroid Association 77th Annual Meeting, 13 October 2006, Phoenix Arixona. [Online]. Available at: http://live.blueskybroadcast.com/bsb/client/ CL_DEFAULT.asp?Client=60&PCAT=343&CAT=346 [Accessed 28th October 2009]. Fisher D.A. (1997) ‘Fetal thyroid function: diagnosis and management of fetal thyroid disorders’, Clinical Obstetrics & Gynecology, 40(1), pp.16-31. AACE; American Association of Clinical Endocrinologists (2002) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism & hypothyroidism. [Online]. Available at: http://www.aace.com/pub/pdf/guidelines/ hypo_hyper.pdf [Accessed 28th October 2009]. Cohen O. et al. (2003) ‘Serial in-utero ultrasonographic measurements of the fetal thyroid: a new complimentary tool in the management of maternal hyperthyroidism in pregnancy’, Prenatal Diagnosis 23, pp.740-742. Luton D. et al. (2005) ‘Management of Graves’ disease during pregnancy: the key role of fetal thyroid gland monitoring’, The Journal of Clinical Endocrinology & Metabolism, 90(11), pp.6093-6098. Ochoa-Maya M.R. et al. (1999) ‘Resolution of fetal goiter after discontinuation of propylthiouracil in a pregnant woman with Graves’ hyperthyroidism’, Thyroid, 9, pp.1111-1114. Kilpatrick S. (2003) ‘Umbilical blood sampling in women with thyroid disease in pregnancy: is it necessary?’ American Journal of Obstetrics & Gynecology, 189:1-2. NICE. National Collaborating Centre for Women’s and Children’s Health. (2008) Routine care for the healthy pregnant women. [Online]. Available at: www.nice.org.uk/ nicemedia/pdf/CG62FullGuidelineCorrectedJune2008. pdf [Accessed 28th October 2009].
lsjm 30 november 2009 volume 01
REVIEW
The Effect of Exercise on Stroke Survivors Rauri Hadlington BSc (Hons) MCSP Graduate 2009, Physiotherapy, Kings rauri.hadlington@kcl.ac.uk doi:4201/lsjm.med.007
Introduction Yearly, an estimated 150000 people in the UK have a stroke; it’s the third most common cause of death and the leading cause of severe disability1. Patients who have suffered a stroke remain at an increased risk of a further stroke of between 30% and 43% within five years2. It was therefore stated in the National Clinical Guidelines for Stroke that all patients should be given appropriate advice on regular exercise3. This review aims to investigate the effect of exercise on stroke survivors. Exercise and Chronic Stroke Physiological Outcomes of Aerobic Exercise in Hemiparetic Stroke Patients is a seminal paper in the area of stroke survivors’ response to exercise4. Despite its age and small sample size, its findings that hemiparetic stroke patients, at least six months post onset may improve their aerobic capacity and submaximal exercise systolic blood pressure response with training, still ring true today. Macko et al5 stated that stroke survivor’s capacity to perform activities of daily living (ADLs) was based on both the severity of the residual neurological deficit, resultant gait defects, individuals exercise capacity and the relative energy demands of the task. One significant finding in post stroke exercise research is that subject’s exercise capacity improved by more than expected for the percentage improvement in maximal oxygen consumption (VO2max)4,5,6. This suggests improved efficiency of movement as well as cardiovascular function. This equates to an increase in an individual’s exercise capacity due to improved cardiovascular fitness, and a decrease in relative energy demands of tasks due to improved efficiency of movement. However, sample sizes in these studies have been small and exercise programmes were intense-three weekly sessions, between thirty and forty minutes, for ten weeks to six months. Such extensive programmes are perhaps unrealistic for everyday practice. This is exemplified by high drop-out rates of 22% which sparks question as to the ability of community dwelling stroke patients to attend or maintain a long term aerobic training6. Furthermore 25% of subjects screened for a treadmill based exercise programme were unable to participate due to co-morbidity or inability to use equipment5, therefore more suitable training methods are needed. Also fitness testers were not blinded as to patient group and there
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is limited potential for subject blinding across all studies as patients are always going to be aware of whether or not they are exercising6. An important finding is that improvements have been found in subjects a mean three years post stroke, outside the accepted therapeutic window, after conventional physiotherapy rehabilitation6. This challenges our current practice in the arena. Currently outpatient stroke rehabilitation consists of approximately nine physiotherapy sessions and concludes between 28 and 140 days post stroke6. However, it has been shown nearly 40% of stroke survivors’ mobility declines in the first year post inpatient treatment and post discharge treatment has been identified as key in functional improvement at one year follow up7. Investigation into specific subsets of stroke survivors has given similar results. In a small study of African-American stroke patients, Rimmer et al saw that three, one hour aerobic training sessions a week for twelve weeks improved fitness 8. However the small sample size (35) reduced the statistical power of this study. Furthermore participants chose from a range of exercise machines and moved between them throughout the programme. The authors failed to provide information as to what equipment was used or the format of the exercises and thus it is impossible to determine the varying effect of machines on outcomes. Finally, the “lag-control group” design, whereby the control group simply performed the same intervention at a later date to the treatment group, is flawed. The control group were tested once before intervention (pre-test), once at 12 weeks, after the experimental group had performed the programme (post-test 1), and then again at 24 weeks after they had partaken in the programme (post-test 2). This means by the time their final outcome measures were assessed they had performed the test 3 times, once more than the treatment group and no mention is made of a potential learning affect on final outcomes. Finally, it is not clear if control group outcome scores are post-test 1 or post-test 2. Post-test 1 scores could in fact be considered pre-test scores for this group as they were taken prior to intervention. This omission makes it impossible to determine training affect, or lack thereof. Given all of the above the only viable result
For the full list of references see thelsjm.co.uk.
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is the significant group x time interactions in the treatment group, however even these may well be disputed given the lack of such significant improvements being reported at the post-test 2 stage in the control group. There is also no mention of blinding in the paper so the effect of bias and placebo cannot be ruled out.
health benefits of exercise for chronic stroke survivors and that functional ability may be further enhanced through motor relearning. This warrants further research however solid conclusions cannot be drawn on the basis of the current review due to small sample sizes and poor study design amongst trials.
Chu et al split a very small sample of 13 subjects between a waterbased aerobic exercise (n=7) group and a land-based upper limb functional exercise group (n=6)9. They reported a 22% improvement in VO2max in the experimental group, a greater improvement than the 8-14% seen in land based studies4,5,8. This was thought to be as a result of the increased resistance provided by the water. However Chu et al did not see the marked improvement in work load (9%9) previously noted (28%-44%4,5,8). This was put down to the fact that a water based programme did not have the same capacity for task-specific motor learning as land based programmes that used the same tasks to assess and treat. To this end one may conclude that training methods that replicate ADLs and improve cardiovascular fitness may be of most benefit to stroke survivors. This also reinforces the hypothesis that the greater than expected improvement in workload for a given improvement in VO2max might be down to increased efficiency of movement in subjects4,5,6. Chu et al experienced a 92% adherence despite the programme consisting of three one hour long sessions a week for eight weeks which may suggest that water-based training is preferable to patients than land-based. The very small study size diminishes the reliability of the findings. The sample are also all said to have been able to exercise at 70%-80% of their baseline age predicted maximum heart rate, a high level, given the well documented low fitness levels in chronic stage stroke survivors. Unfortunately the only blinding mentioned is that the subjects were not aware cardiovascular fitness was the main outcome measure. The authors failed to provide information as to blinding therapists across the control and intervention groups, or those responsible for testing outcomes is mentioned.
Exercise and Sub Acute Stroke The ideal window in which exercise should be prescribed to stroke survivors is another area that has spawned research. Duncan et al randomised twenty mild to moderate stroke patients, 30-90 days post stroke into an exercise and a control group13. The experimental group performed an eight week, three times a week exercise programme designed to improve strength balance and endurance. The results of the paper found little improvement with the only real significant differences being improved gait speed and lower limb function in experimental subjects. This did not translate to significant functional improvements for ADLs. The poor quality of the study and the lack of significant outcomes mean only limited conclusions can be drawn from this body of work. Firstly the authors stated that 17 of the 20 participants would have been unable to participate had transport not been provided to and from sessions so raising questions over the feasibility of centre based programmes in this area. The study also suggests that it is possible to exercise sooner after stroke than previously thought; many of the subjects were in what is thought to be in a fragile early stage shortly poststroke and yet no adverse events were reported.
As well as cardiovascular fitness benefits Pang et al investigated the effect of a fitness and mobility exercise (FAME) programme on bone mineral density (BMD)10. Again it was an intense, long programme with three one hour long sessions weekly for 19 weeks, with attendance rates were just over 80%. The study was well blinded; patients were simply made told which exercise group they were in; upper limb or lower limb. Personnel who performed outcome measures were blinded as to patient group. The sample size was 32 in the intervention group and 31 in the control group at baseline and no significant differences were found in descriptive data, 30 subjects completing final outcome measures in both groups. A power calculation showed that 21 participants were needed per group to provide a power of 0.80 and P<.05 based on an average VO2max + standard deviation of 17.3 + 3.0 mL/kg per minute and a desired 15% change, to this end the sample size would appear sufficient, but for VO2max analysis only. The results of the study showed that those enrolled in the FAME programme had significantly better outcomes in cardiovascular fitness, mobility and paretic limb muscle strength and the intervention group maintained hip BMD, unlike controls. Results are generalised with caution due to the mediocre sample size and the specific nature of the subjects. Further research is warranted into the effect of exercise on BMD in stroke patients given the high occurrence of falls and resultant hip fractures in this population11,12. Evidence does appear to show that there are many physiological
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More recently Marylin et al and Katz-Leurer et al investigated exercise capacity and response to training respectively in early (within one month) post stroke patients14,15. Peak oxygen consumption (VO2peak) at one month post stroke was 60% that of age matched sedentary individuals indicative of a decrease in aerobic capacity in this population14. Caution must be used when interpreting this as non-standardised testing protocols were used across subjects and the sample size of twenty-nine is too small to make general judgements. However a group of patients an average of just 15.4 days post stroke showed significant improvements in work time and work load following an eight week aerobic leg cycle ergometer training programme15 and similarly to data in chronic stroke4,5,6 these improvements were greater than expected for the improvements in cardiovascular function. Again there were no drop outs and no adverse events reported in the exercise group, strengthening the notion that exercise is not detrimental to this population. Good blinding procedures, a relatively large sample of ninety-two patients and the use of validated outcome measures strengthens findings, but it is important not to extrapolate them beyond the sub-acute stroke population. In a study of 100 sub acute stroke patients 3 subjects in the control group suffered second strokes, however this was not deemed sufficient to stop intervention and as none of these events occurred during exercise sessions, they were not deemed to be as a direct result of exercise16. The study concluded that physiological exercise is effective in improving the sub acute post mild to moderate stroke phase in subjects with low levels of baseline endurance and numerous co-morbidities. Significant improvements were seen in VO2peak, exercise duration, balance, six minute walk distance and gait velocity. The authors did however identify that the study was very resource intensive, experimental subjects received 54 hours of one-on-one therapy which may not be viable in many trusts. Also they could not ascertain the effective â&#x20AC;&#x153;doseâ&#x20AC;? of exercise and
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thus admitted a more efficient group intervention model could be effective and stated further research is needed to improve the efficiency and targeting of the model. Assessors were blinded as to patient intervention group, however patients were aware of their treatment group and thus bias may have been evident in self reporting outcomes despite the fact subjects were unaware of the study hypothesis. These findings are of higher significance given the control group received usual care from the trusts involved. The fact that significant improvements are on top of spontaneous recovery and usual care increases potential impact on service provisions. Long-Term Follow-Up Any gain in quality of life through exercise in the sub acute stroke population had dissipated by 6 months.17,18 One possible explanation is that despite improved aerobic capacity, the intervention group did not tend to exercise more than controls after training had ceased and thus the training effect was lost18. This notion is supported by the interaction effect of aerobic capacity on functional outcome measure scores demonstrated in the results of the study18. Again it is of note that despite a sample size of 92, 125 subjects screened for one study were deemed inappropriate for participation, raising questions as to its general applicability to a real life stroke population18. It was concluded then that advanced aerobic abilities could only have a real affect on functional outcomes in the presence of high motivation.
survivors. Sample sizes are generally low and training programmes are often unrealistic for service providers. However outcomes are positive and could have great benefits for the population. References 1. 2.
3.
4.
5.
6.
7.
The Stroke Association. [Online]. Available at: http://www.stroke. org.uk/information/index.html [Accessed 1st November 2009]. Mant J, Simpson S (2004) Health care needs assessment: the epidemiologically based needs assessment reviews. Second edition. Oxford: Radcliffe Medical Press. The Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke – 2nd Edition. (2004). Available at: http://www.rcplondon.ac.uk/pubs/books/stroke/stroke_ guidelines_2ed.pdf [Accessed 1st November 2009]. Potempa K, Lopez M., Braun LT, Szidon JP, Fogg L, Tincknell T. 1995 Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke. 1995;26:101–105. Macko R, Smith G, Dobrovolny C, Sorkin J, Goldberg A, Silver K. 2001. Treadmill Training Improves Fitness Reserve in Chronic Stroke Patients. Arch Phys Med Rehabil. Vol 82, July 2001 879-884. Macko R, Ivey F, Forrester L, Hanley D, Sorkin J, Katzel L, Silver K, Goldberg A. 2005. Treadmill Exercise Rehabilitation Improves Ambulatory Function and Cardiovascular Fitness in Patients with Chronic Stroke. Stroke. 2005;36;2206-2211. Paolucci S, Grazia Grasso M, Antonucci G, Bragoni M, Troisi E, Morelli D, Coiro P, De Angelis D and Rizzi F. 2001. Mobility status after inpatient stroke rehabilitation: 1-Year follow-up and prognostic factors. Arch Phys Med Rehabil .Vol 82, January 2001
This was further enhanced by two first year follow up studies of the effects of exercise on stroke19,20. In these studies an intensive exercise group was compared to a regular exercise control, however unexpectedly the controls maintained the same level of activity as the intensive group. This was despite not being provided with treatment as part of the study and simply being advised to remain as active as possible. This regular exercise group then sought their own treatment and as a result displayed similar functional ability to the intervention group at three, six and twelve month follow up. In analysis of health related quality of life (HRQoL) those who sought their own treatment fared better than those on a prescribed exercise programme20. It was hypothesised that exercise with high levels of patient motivation has the best outcomes for HRQoL. Calculations showed a power of 80% for both studies, yet the sample size of 75 limits the extrapolation of results to a wider population. Both were double blinded and well randomized and given the unexpected nature of the results, they warrant further research. Conclusion Exercise has been shown to improve cardiovascular fitness in stroke survivors and although long standing functional benefits have not been demonstrated there is a well established link between cardiovascular fitness, functional ability and stroke occurrence. Given that cardiovascular disease is the leading prospective cause of death in people with stroke it is fair to assume that improvements in this area are beneficial22,23,24. Further to this, improved efficiency of movement and subsequent decreased load on the cardiovascular system could further reduce the cardiovascular risk. Future studies should investigate the optimal intensity and method of exercise as well as the financial implications of long, intense exercise programmes. Education programmes as to the benefits of regular exercise could also be researched given the profound benefits of high motivation.19,20,21 Much research exists into the effects of exercise on stroke
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