A sport and exercise medicine podcast for Canadian medical residents and senior medical students
Physical Activity and Pregnancy
This episode is for all women of childbearing years and all of the healthcare practitioners who provide care to these patients!
The new CSEP Physical Activity throughout Pregnancy Guidelines provide evidence around the benefits and safety of being active throughout pregnancy, for both mother and baby. Physical activity is now seen as a critical part of a healthy pregnancy. Following the guidelines can reduce the risk of pregnancy-related illnesses such as depression by at least 25%, and the risk of developing gestational diabetes, high blood pressure and preeclampsia by 40%. Providers should be educated on the absolute and relative contraindications for exercising during pregnancy to help guide patients safely.
Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active in a variety of ways every day is encouraged. CSEP has created a Get Active Questionnaire for Pregnancy that providers can use to assist with safe exercise prescription.
Pregnant patients should be treated for musculoskeletal pains the same way all other patients are treated. This includes assessing, working up and investigating patients appropriately. Treatments should include active rehabilitation with the mainstay of most MSK pains being treated with exercise. Women should be offered medications, as needed, always trying to use the lowest effective dose possible. First line treatment includes acetaminophen (4g/d max) and second line includes the use of opioids. MSK low back pain is very common! 20-30% will have pain that impacts quality of life and function. Pain education and a multi modal plan should be incorporated just as one would for the general population.
Women often need to be “cleared” to return to exercise, and the 6 week mark is a classic timeline, but this is arbitrary. Waiting for clearance does not mean no movement for 6 weeks. Women should be reassured that early gentle activity is reasonable. This can include activities such as restorative yoga and walking.
Share this episode widely with anyone who treats women of childbearing age. It is our role to encourage women to be active, and as healthcare professionals, we need to work on minimizing barriers to exercise. This includes having conversations and discussions with patients that movement is necessary before, during and after pregnancy!
Lower Extremity Injuries
Lower extremity injuries occur in all sports and high profile athletes draw attention to such injuries. This episode delves into 3 of the most talked about lower extremity injuries in the last years. Using these athletes as a starting point, this episode discusses the differential diagnosis, assessment, work up and rehabilitation plans for lower body sports injuries.
We start with the hip dislocation sustained by now NFL player Tua Tagovailoa. Posterior hip fracture dislocations are relatively rare in sports, but it is always important to think of the common and not to miss diagnoses when evaluating a player. Once the diagnosis is made, treatment should surround improving function and minimizing or preventing future complications.
Moving distally to the knee, NHL player Connor McDavid had one of the most talked about injuries in recent memory, complete with a documentary detailing his rehab and recovery. PCL injuries are also fairly uncommon when compared to ACL, MCL or meniscus injuries, yet, it is important to learn and understand the surgical vs non-surgical treatment options. Rehabilitation is often the mainstay of treatment for knee injuries, so having a good team of dedicated therapists and allied health practitioners to assist in the recovery is imperative. All trainees should spend time working in an allied health clinic to learn the intricacies and nuance of what rehabilitation entails.
Finally, NBA superstar Kevin Durant sustained a calf strain followed by an Achilles tendon rupture suffered in the playoff finals. This case discusses the mechanism of injury and typical symptoms seen with Achilles injuries and other common ankle injures. As part of the rehabilitation plan, all sports medicine providers should be familiar with the Fowler Kennedy Achilles tendon rupture accelerated rehab protocol.
MSK and Sports Medicine Resources for Learners:
PMR Knowledge Now
MSK Medicine: Western University Physiatry Program Physical Exams
Stanford Medicine MSK Physical Exams
Basic MSK Exams
Magee Orthopedic Physical Assessment
The 5 Minutes Sports Medicine Consult
In this episode we review concussion, a large and nuanced topic. There are 200,000 concussions annually in Canada, making concussion knowledge required for coverage of all sports.To gain an understanding of sport related concussions refer to the...
Exercise is Medicine
Physical activity can help prevent and manage chronic diseases such as heart disease, depression and diabetes, but it is not a one size fits all measure. We need to tailor the intervention to the patient, as we would a drug. Check out Exercise is Medicine Canada’s prescription pad – a way to provide a personalized prescription to each of your patients and increase compliance.
Rob Bertelink, Cardiac Rehab Supervisor at the Toronto Rehabilitation Institute Rumsey Centre and registered Kinesiologist discusses the evidence behind cardiac rehab, at home exercise hacks, how to prescribe HIIT training safely and how to decide which patients need an exercise treadmill test.
Whether you review the Canadian Physical Activity Guidelines with your patient or the World Health Organization Guidelines on Physical Activity and Sedentary Behaviour, the key message is any amount of physical activity is better than none and more is better!
Remind patients that all physical activity counts, including work, sports, leisure, transport and activities of daily living!
To learn more, click on the resources discussed in this episode:
1. Exercise is Medicine Canada Exercise Prescription Tools https://www.exerciseismedicine.org/canada/support_page.php/eimc-exercise-prescription-and-referral-tool/
2. Physical Activity Prescription: a modifiable risk factor for the prevention and management of chronic disease https://bjsm.bmj.com/content/50/18/1109
3. Practical Approaches to Prescribing Physical Activity https://pubmed.ncbi.nlm.nih.gov/26897182/
4. Fitness as a Clinical Vital Sign: https://pubmed.ncbi.nlm.nih.gov/27881567/
5. Advice on exercise from a Family Physician can help sedentary patient become active https://pubmed.ncbi.nlm.nih.gov/9713663/
6. Health e-Univeristy: Cardiac College & Diabetes College (available in multiple languages) https://www.healtheuniversity.ca/EN/Pages/default.aspx
Diet and Sports Nutrition
Jennifer Sygo is a dietitian, sports nutritionist, author, and speaker specializing in nutrition for prevention and performance.
Jen discusses how to help athletes optimize their diets to maximize their performance. She explains how to personalize dietary advice including how to counsel patients on dietary deficiencies, high risk diets and how to eat for sport performance. She gives a phenomenal overview of relative energy deficiency in sport (RED-S), a highly complex and nuanced topic. Finally, we delve into the various categories of supplements - supplements for deficiencies, supplements for health optimization and performance supplements.
For more information, please refer to the following resources discussed in this episode:
IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 Update https://bjsm.bmj.com/content/52/11/687.long
IOC consensus statement: dietary supplements and the high performance athlete https://bjsm.bmj.com/content/52/7/439.long
Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and the American College of Sports Medicine: Nutrition and Athletic Performance https://jandonline.org/article/S2212-2672(15)01802-X/fulltext
American College of Sports Medicine, Medicine and Science in Sports and Exercise, Position Stand: Exercise and Fluid Replacement http://journals.lww.com/acsm-msse/Fulltext/2007/02000/Exercise_and_Fluid_Replacement.22.aspx
American College of Sports Medicine Full List of Position Stands https://www.acsm.org/acsm-positions-policy/official-positions/ACSM-position-stands
Professor Louise Burke – Head of Sports Nutrition, Australian Institute of Sport, Canberra https://www.acu.edu.au/research/our-research-institutes/mary-mackillop-institute-for-health-research/our-people/louise-burke
Low Back Pain
Low back pain is one of the most common clinical conditions seen in outpatient clinics by family physicians, physiatrists and allied health practitioners
It affects so many people and can be quite debilitating
Dr. Stuart McGill is a world renowned back pain clinician and research, with over 30 years experience
In this episode he helps teach Dr. Alex McDougall, physiatry resident, how to approach patients with low back pain
For more information on Dr. McGill and to learn more about his research and books please visit his website https://www.backfitpro.com
Episode Pearls -
-Back pain is complex and never nonspecific - help identify the cause of your patient’s back pain to create and guide a specific treatment plan.
-Listen to your patient - each patient comes with their own triggers for their back pain and this can be the key to their recovery
-Every patient needs a tailored physical exam to identify their specific pain generators
-Understanding and using the psychology of pain is critical for the rehabilitation of back pain
-Empower your patients to take control of their pain, teach them how to implement spine hygiene techniques when completing everyday activities
-Walking should not be underestimated! It is a very valuable tool for back pain rehab
McGill's Big 3 Exercises:
1. Bird dog
2. Side bridge
3. McGill curl up
Image Courtesy of Vox