British Journal of Sports Medicine

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The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport

Identification, evaluation and management of disordered eating (DE) is complex. DE exists along the spectrum from optimised nutrition through to clinical eating disorders (EDs). Individual athletes can move back and forth along the spectrum of eating behaviour at any point in time over their career and within different stages of a training cycle. Athletes are more likely to present with DE than a clinical ED. Overall, there is a higher prevalence of DE and EDs in athletes compared with non-athletes. Additionally, athletes participating in aesthetic, gravitational and weight-class sports are at higher risk of DE and EDs than those in sports without these characteristics. The evaluation and management of DE requires a cohesive team of professional practitioners consisting of, at minimum, a doctor, a sports dietitian and a psychologist, termed within this statement as the core multidisciplinary team. The Australian Institute of Sport and the National Eating Disorders Collaboration have collaborated to provide this position statement, containing guidelines for athletes, coaches, support staff, clinicians and sporting organisations. The guidelines support the prevention and early identification of DE, and promote timely intervention to optimise nutrition for performance in a safe, supported, purposeful and individualised manner. This position statement is a call to action to all involved in sport to be aware of poor self-image and poor body image among athletes. The practical recommendations should guide the clinical management of DE in high performance sport.

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Financial incentives for physical activity in adults: systematic review and meta-analysis

Objective
The use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults.

Data sources
Medline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH.

Eligibility criteria
Randomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA.

Design
A simple count of studies with positive and null effects (‘vote counting’) was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods.

Results
23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9).

Conclusion
Demonstrating rising interest in financial incentives, 23 RCTs were identified. Modest incentives ($1.40 US/day) increased PA for interventions of short and long durations and after incentives were removed, though post-intervention ‘vote counting’ and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive ‘dose’ may promote sustained PA.

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How are we measuring physical activity and sedentary behaviour in the four home nations of the UK? A narrative review of current surveillance measures and future directions

Background/objectives
To explore and describe the comparability between the surveys of the UK home nations (England, Northern Ireland, Scotland, Wales) that monitor compliance with the Chief Medical Officers’ physical activity (PA) recommendations. We also suggest ways to improve the UK national PA and sedentary behaviour (SB) surveillance systems.

Methods
We identified national surveys that monitor PA and SB through searching UK-wide and devolved administration websites, the Global Observatory for Physical Activity Country Cards and the Active Healthy Kids Report Cards. Subsequently, we extracted information from survey documentation on the survey commissioners and contractors, method of administration, current questionnaire details relevant to the PA recommendations, questionnaire changes over the previous decade and the most recent prevalence figures.

Results
For adults and older adults, five surveys assess the moderate-to-vigorous PA (MVPA) recommendation, three assess muscle strengthening and three assess SB. For older adults only, three assess balance and co-ordination. For children, seven assess MVPA, none assess muscle strengthening and five assess SB. Only one survey reports on the under 5 PA recommendation. There is no part of the recommendations for which comparable estimates can be calculated across all four home nations. The greatest variation is among the SB questions and reporting. No survey has regularly used device-based measures.

Conclusion
UK surveillance of the PA recommendations is complex, undertaken separately in the home nations, using multiple surveys that cover adults and children separately. We recommend that the costs and benefits of harmonising the existing questionnaires are considered, along with the potential introduction of device-based measures.

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Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Background
Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise.

Methods
In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers.

Results
We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) –10.7 (–14.1 to –7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) –10.2 (–13.2 to –7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers—these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics.

Conclusions
This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups.

Protocol publication
https://doi.org/10.1186/2046-4053-1-64

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Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

Objective
Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP).

Design
Network meta-analysis (NMA).

Data sources
MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL.

Eligibility criteria
Exercise training randomised controlled/clinical trials in adults with NSCLBP.

Results
Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): –1.86 (–2.54 to –1.19)), resistance (SUCRA=80%; –1.14 (–1.71 to –0.56)) and stabilisation/motor control (SUCRA=80%; –1.13 (–1.53 to –0.74)) for physical function and resistance (SUCRA=80%; –1.26 (–2.10 to –0.41)) and aerobic (SUCRA=80%; –1.18 (–2.20 to –0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (–0.71 to 0.89)) and physical function (SUCRA=20%; –0.31 (–0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; –0.31 (–1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria.

Summary/conclusion
There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

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http://bjsm.bmj.com/cgi/content/short/54/21/1279?rss=1

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons

Aim
To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads).

Methods
All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers’ injury rates. Time lost from illness was also recorded.

Results
All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1–6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD).

Conclusions
Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

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http://bjsm.bmj.com/cgi/content/short/54/21/1288?rss=1

A Swedish primary healthcare prevention programme focusing on promotion of physical activity and a healthy lifestyle reduced cardiovascular events and mortality: 22-year follow-up of 5761 study participants and a reference group

Objective
To evaluate long-term risk of first cardiovascular (CV) events, CV deaths and all-cause deaths in community-dwelling participants of a cardiovascular disease (CVD) prevention programme delivered in a primary care setting.

Methods
Individuals who visited a primary healthcare service in Sollentuna (Sweden) and agreed to participate in the programme between 1988 and 1993 were followed. They had at least one CV risk factor but no prior myocardial infarction and received support to increase physical activity using the programme Physical Activity on Prescription and to adopt health-promoting behaviours including cooking classes, weight reduction, smoking cessation and stress management. Participants (n=5761) were compared with a randomly selected, propensity score-matched reference group from the general population in Stockholm County (n=34 556). All individuals were followed in Swedish registers until December 2011.

Results
In the intervention group and the reference group there were 698 (12.1%) and 4647 (13.4%) first CV events, 308 (5.3%) and 2261 (6.5%) CV deaths, and 919 (16.5%) and 6405 (18.5%) all-cause deaths, respectively, during a mean follow-up of 22 years. The HR (95% CI) in the intervention group compared with the reference group was 0.88 (0.81 to 0.95) for first CV events, 0.79 (0.70 to 0.89) for CV deaths and 0.83 (0.78 to 0.89) for all-cause deaths.

Conclusions
Participation in a CVD prevention programme in primary healthcare focusing on promotion of physical activity and healthy lifestyle was associated with lower risk of CV events (12%), CV deaths (21%) and all-cause deaths (17%) after two decades. Promoting physical activity and healthy living in the primary healthcare setting may prevent CVD.

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Physical activity and other health-related outcomes after knee injury in youth and young adults (PhD Academy Award)

What did I do? The overarching aim of my PhD dissertation was to understand attitudes and beliefs about physical activity (PA), examine key health outcomes and objectively examine PA in youth and young adults (hereafter referred to as youth). I examined PA (actigraphy) and other physical and psychological health outcomes in the time period after recovery from acute knee injury and before a diagnosis of post-traumatic osteoarthritis (PTOA) in individuals who had sustained a previous intra-articular knee injury. Why did I do it? Traumatic knee injuries are among the most common sport-related injuries sustained by youth and are associated with significant societal and personal burden, including increased risk of future PTOA.1 Much research has focused on return to sport (RTS) after knee injury.2 3 However, despite the key role of PA in prevention of disease, disability and death, there is...

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RED-S: not just a female phenomenon

Long-term love of cycling I ran as a schoolboy at both cross-country and middle distance athletics. After a knee injury at university, a school friend introduced me to the pleasures of cycling as a leisure pursuit. In my mid-30s, I joined my local cycle club and I continued to ride for leisure. My peak weight in my early 40s was around 73 kg. At the age of 48, I regained my interest in cycling and started doing club time trials again. My performances were considerably slower after a 12-year break, and after another, year I decided to look for the help of a cycle trainer. Transformation in middle age Working with a trainer completely transformed my training and approach to cycling. My weight was now around 65 kg; however, after a year of gradually increased training load, my weight dipped as low as 62.5 kg. I did not make...

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Kia ora koutou katoa: Australasian College of Sport and Exercise Physicians (ACSEP) warm up

Kia ora koutou katoa. Welcome to the Australasian College of Sport and Exercise Physicians (ACSEP) edition of the BJSM In June/July 2020 the COVID-19 free land of Aotearoa New Zealand launched the first full return of professional basketball to the world. The national women’s team, the Tall Ferns, played in front of a live audience in Auckland shortly before a small cluster of COVID-19 re-emerged and Auckland went again into lockdown. At the time of writing, New Zealand’s ‘team of 5 million’ were socially isolating and getting used to wearing masks in public. While several parts of Australia are COVID-19 free, millions in Melbourne remain in lockdown. While some sports have managed to play in bubbles, others have had system failures and widespread viral infection involving whole teams. As clinicians, COVID-19 has meant providing ‘usual’medical care, to support athletes health, well-being and employment in isolation bubbles and then then in...

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