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Bad medicine: sports medicine

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2025 (Published 30 March 2011) Cite this as: BMJ 2011;342:d2025

Rapid Response:

Response to Dr Spence

Dear Sir or Madam,

I write in response to Des Spence's article 'Bad Medicine: Sports
Medicine' (BMJ 2011;342:d2025).
Before tackling the specifics, I feel a general point is required.
Throughout the article Dr Spence has criticized the mantra of global
corporations making footwear and sports drinks, sports scientists,
athletes and coaches, physiotherapists, podiatrists and sports surgeons -
yet nowhere in the article can I see reference to that which is
eponymously criticized, namely Sports Medicine. It is grossly inaccurate
to label 'Sports Medicine' as 'Bad Medicine' when in fact, not a single
item of the specialities teaching or practice has been referenced within
the article.

In fact 'Sport & Exercise Medicine (SEM)' was established as the
newest medical speciality in the UK in 2005 by Act of Parliament1, has a
Faculty within the Royal College of Physicians of London2, and a
JRCPTB/GMC approved curriculum3 with approximately 50 StR's in training
across the UK's deaneries4, and 35 Consultants on the GMC Specialist
Register5. The point being that the speciality - SEM - has a clearly
separate identity from the entities criticized in the article, the
conceptual linkage is incorrect.

May I now address some of the specifics. As a physician and follower of
research in my chosen field of sport & exercise medicine much of the
article has resonance. It is correct to state that there is little
evidence for motion control footwear6, but the assertion of benefit does
not come from within the field of Sports Medicine, but rather from the
billion dollar sport wear industry. In fact the first pair of modern
running shoes were made in the 70's, not by a doctor, but by a Coach -
Bill Bowerman, who later formed Nike. There was precious little science
involved in those first shoes made in his garden shed with melted rubber
on a waffle maker7. The move towards barefoot running is a least based
partly on evidence however. In 2010 Nature published a study of
exceptional quality comparing the foot strike patterns and impact forces
between habitually barefoot, forefoot striking Africans with habitually
shod, heel-striking North Americans8.

With respect to fluid replacement Dr Spence suggests that we advocate the
teachings of global sports drink companies. In fact the opposite is true.
I would point him to the excellent research and evidence-based guidance
from Tim Noakes, namely to drink thirst, rather than overdrinking9. This
has been my advice to runners for several years.
Next Dr Spence criticised massage and ultrasound. I agree the evidence for
effectiveness is absent, but these are physiotherapy techniques, not
sports medicine, and are largely athlete driven, rather than physician
pushed. Personally I have never prescribed either of these modalities to
my patients, but they are often asked for, and since harmless, given.

Finally biomechanics and orthoses are derided. Does Dr Spence suppose that
injuries occur for no reason? Is it not reasonable to state that abnormal
movement patterns lead to abnormal loading of anatomical structures in
turn leading to failure? In fact, a great many studies have been published
correlating biomechanics with injury risk10.

With regard to surgery, I leave the surgeons to defend themselves.
As a Consultant in Sport & Exercise Medicine, I am very aware of the
limited evidence base from which we practice. Sadly none of the examples
cited by Dr Spence are an accurate reflection of our speciality, and I
find his comments very unfairly derogatory.

There is a sadder story to tell however. At time of writing the NHS and
Universities are failing to develop Sport & Exercise Medicine
services, despite a specific government pledge to develop SEM as a lasting
health legacy of the Olympic Games. Without an NHS SEM service the genuine
benefits of health-enhancing physical activity, as evidenced by the former
CMO11 are unlikely to be realised. Britain is facing an obesity
epidemic12, and exercise rightly should form a regular adjunct in the
management of many chronic diseases. SEM specialists are specifically
trained to prescribe and supervise therapeutic exercise for patients, but
very few NHS trusts have developed these important services. Furthermore
without regular university collaboration the research base for Sports
Medicine is unlikely to expand.

In conclusion, Sport & Exercise Medicine is a young speciality with
much to offer the UK. In time, the evidence base will grow and services
will develop, but we are unlikely to ever have the same level of influence
on public perceptions as global sports companies who spend millions on
marketing campaigns to sell their products - evidence-based or otherwise.

References

1. http://www.legislation.gov.uk/uksi/2005/2120/article/2/made (accessed
31/03/2011)

2. www.fsem.ac.uk (accessed 31/03/2011)

3. http://www.jrcptb.org.uk/specialties/ST3-
SpR/Pages/SportandExerciseMedicine.aspx (accessed 31/03/2011)

4. Personal Correspondence with Faculty of Sport & Exercise Medicine

5. Personal Correspondence with GMC & DH Workforce Review Team

6. Richards CE. Is your prescription of distance running shoes evidence-
based? Br J Sports Med 2009;43:159-62

7. Moore K. Bowerman and the men of Oregon. Holtzbrinck Publishers

8. Lieberman DE, Venkadesan M, Werbel WA et al. Foot Strike patterns and
collision forces in habitually barefoot versus shod runners. Nature 2010
Jan 463(7280):531-5

9. Tam N, Nolte HW, Noakes TD. Changes in total body water content during
running races of 21.1Km and 56km in athletes drinking ad libitum. Clin J
Sport Med 2011 Mar 19 [Epub ahead of print] PMID: 21427566

10. Carvalho AC, Junior LC, Costa LO, Lopes AD. The association between
runners' lower limb alignment with running-related injuries:a systematic
review. Br J Sports Med 2011;45(4):339

11. Chief Medical Officer. At Least 5 a week. Department of Health 2005

12. Tackling Obesities: Future Choices. Foresight report, Government
Office for Science 2007

Dr Leon Creaney

Consultant in Sport & Exercise Medicine

BMedSci MB ChB MRCP MRCGP FFSEM

leoncreaney@hotmail.com

Competing interests: I am a Consultant in Sport & Exercise Medicine

01 April 2011
Leon Creaney
Consultant Physician
BUPA