1. The role of the Sports and Exercise Medicine Physician in the NHS: A
questionnaire-based survey. ..................................................................................... 2 2. Measurement of Normal Tibialis Anterior Muscle Architecture by Ultrasound in
Elite Athletes and Controls – a cross-sectional study ................................................ 2 3. Arterial stiffness before and after aerobic exercise in young elite athletes and
controls: a cross-sectional observational study. ......................................................... 4 4. The relative utility of two dimensional and three dimensional ultrasound imaging
for quantifying synovial vascular signal: an observational study of patients with
inflammatory arthritis ................................................................................................. 5 5. High volume image guided injections in recalcitrant mid-tendon Achilles
tendinopathy.............................................................................................................. 6 6. An observational study to identify the presence of Achilles tendinopathy and
ultrasound detected changes in elite footballers and age and gender-matched
controls. .................................................................................................................... 8 7. An in vitro study into the effect of Traumeel? S on myoblast metabolism .......... 9 8. The relationship between hip, spine and shoulder rotation and low back pain in
professional golfers: an observational study. ........................................................... 10 9. The Feasibility & Effectiveness of Supervised Group Exercise Classes for
Breast Cancer Outpatients at St Bartholomew’s Hospital: A Prospective Cohort Study.
10. The effect of eccentric and concentric calf muscle training on Achilles tendon
stiffness: a randomised trial ..................................................................................... 12
1. The role of the Sports and Exercise Medicine Physician in the NHS: A
11111*, Tzortziou-Brown V, Morgan K, Maffulli N, Morrissey D O’Halloran P
1 Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, QMUL, London E14DG
Primary: To investigate the opinions of General Practitioners, Orthopaedic
Surgeons, Rheumatologists, Sport and Exercise Medicine (SEM) Registrars and
Public Health Consultants on several aspects of SEM, including training, caseload, the most appropriate setting and the position of SEM within the NHS.
Secondary: To explore whether any inter-disciplinary agreement could be found
regarding the most appropriate setting for SEM services in the NHS. Method: A cross-sectional, observational, questionnaire-based postal survey was used to investigate the opinions of GPs, Orthopaedic, Rheumatology and Public
Health Consultants and SEM Registrars from three PCTs and associated
Secondary Care Trusts in London and Birmingham. Results: The study achieved a 50% response rate (n=226). 93% (CI 86-100) of
participants felt there was a role for SEM in the NHS. This role was agreed,
across the specialties, to be in both Primary and Secondary Care. 64% (CI 57-
71) of participants felt their practice would benefit from the input of an SEM
physician and 95% (CI 88-100) would consider referring patients to SEM services.
74% (CI 67-81) felt SEM should have a Public Health role and 63% (CI 56-70)
believed these responsibilities should be evenly balanced with the treatment of
sports injuries. 31% (CI 23-39) of participants felt that a lack of education in the
medical profession presented the greatest hindrance to the development of SEM
in the NHS.
Conclusions: Several areas of agreement were demonstrated across the
specialties, many of which matched the views of policy makers. This study
involved participants from a range of cognate disciplines and was the first to
investigate this issue since specialty recognition in 2005.
Keywords: Sport and Exercise Medicine, Sports Medicine, Sports Physician,
2. Measurement of Normal Tibialis Anterior Muscle Architecture by
Ultrasound in Elite Athletes and Controls – a cross-sectional
1 1 2 1, Perry M, Cardinale M, Morrissey D* Wilson M
1 Centre for Sports and Exercise 2 Dr. Marco Cardinale, Medicine, Barts and the London Head of Sports Science and Research
School of Medicine and Dentistry, British Olympic Association QMUL, Olympic Medical Institute, Northwick
London E14DG Park Hospital, Watford Rd, HA13UJ
Background: There are currently no published data describing the normal muscle architecture values for functionally significant muscles such as Tibialis
Anterior in athletic populations. These data would allow investigation of sport-
specific training adaptations, architectural response to injury and recovery.
Objectives: To compile a set of normal values for muscle architecture of the
Tibialis anterior muscle in elite athletes and sedentary controls. Secondly, to
compare the architecture of athletes across different events. Thirdly, to
provide additional evidence for reliability of ultrasound in measuring
Method: The superficial pennate portion of Tibialis Anterior from both legs in
15 elite athletes [mean (sd) height: 1.78m (0.08), weight: 77.4kg (8.7), age:
25.5yrs (3.6), 10 males] and 16 sedentary controls [mean (sd) height: 1.70m
(0.12), weight: 66.9kg (8.72), age: 21.6yrs (1.7), 6 males] was imaged in vivo
using ultrasound. Images were analysed using Image J software to obtain
values for muscle thickness, pennation angle and fascicle length. Results: All analyses were adjusted for gender and leg length. Athletes had
significantly larger pennation angles [adjusted mean (SE) athletes: 12.21?
(0.40), controls: 10.27? (0.39), p=0.002] and thicker muscles than controls
[athletes: 1.12cm (0.03), controls 1.02cm: (0.03), p=0.024]. No significant
differences were found for fascicle lengths between athletes and controls
[athletes: 5.54cm (0.23), controls: 5.73cm (0.22), p=0.577]. Sprinters had
larger pennation angles than fencers [sprinters: 12.92? (0.43), fencers: 10.34?
(0.67), p=0.004] and controls [controls: 10.24? (0.36), p=0.000]. Fencers had
longer fascicle lengths than sprinters [fencers: 6.55cm (0.39), sprinters:
5.15cm (0.25), p=0.008].
Conclusions: This study describes normal muscle architecture for Tibialis
Anterior in elite athletes and sedentary controls. This information needs to be
built on using larger subject numbers in order to provide a base for examining
architecture in muscular injuries.
Key Terms: Muscle architecture, athletes, Tibialis Anterior, ultrasound
3. Arterial stiffness before and after aerobic exercise in young elite
athletes and controls: a cross-sectional observational study.
12211* Nahas S, Conway M, Greenwald S, Twycross-Lewis R, Morrissey D
2 1 Centre for Sports and Exercise Institute of Cellular and Molecular Medicine, Barts and the London Sciences, School of Medicine and Dentistry, Barts and the London School of
QMUL, Medicine and Dentistry, QMUL,
London E1 4DG London, E1 2AT
Background: Pulse wave velocity (PWV) is used to determine arterial
stiffness. Increased arterial stiffness in adults is associated with greater cardiovascular mortality and morbidity. Aerobic training can reduce arterial
stiffness, however, to date, only one1 has studied this relationship in children.
Also, there has been little research comparing the immediate effects of exercise on arterial stiffness, which may reveal mechanisms of how the
cardiovascular system adapts to intense exercise training. Objective: To measure and compare pulse wave velocity PWV of elite young
footballers and sedentary controls before and immediately after aerobic
Methods: PWV was measured with Doppler ultrasound by detecting pulse
waves at proximal and distal arterial sites. Transit times between the sites
were then calculated using data capture software. The PWV was initially measured at rest and immediately after 7 minutes of cycling at 30.0 Km/h.
Results: PWV increased significantly pre and immediately post exercise for
both the athlete and control group (athlete group P = 0.089; control group P =
0.097). No significant difference was seen in PWV 20 to 150 seconds post
exercise in the control group (P = 0.349), however, PWV continued to
increase 150 seconds post exercise in the athlete group (P = 0.035), therefore
demonstrating a prolonged PWV recovery time when compared to controls.
Conclusions: The athletic group had a longer recovery period, indicating a
greater cardiovascular response to the exercise. Widespread lack of
significance between groups may reflect actual correlation or, problems in
ultrasound measurement after exercise and small sample sizes.
Key terms: pulse wave velocity, arterial stiffness, athlete, sedentary,
4. The relative utility of two dimensional and three dimensional ultrasound
imaging for quantifying synovial vascular signal: an observational study of
patients with inflammatory arthritis
2 112*, Dooley W, Morrissey D, Pitzalis C Kelly S
1 Centre for Sports and Exercise 2 Head of Centre for Experimental Medicine
Medicine, Barts and the London and Rheumatology , 2nd Floor, John Vane School of Medicine and Dentistry, Science
William Harvey Research Institute e: firstname.lastname@example.org Barts and the London School of Medicine and
t: 02082238459 Dentistry
London EC1M 6BQ
Background Ultrasound (US) imaging is a promising tool for imaging inflammatory arthritis. Currently the DAS 28 (Disease Activity Score) is used routinely in clinic to monitor disease
activity but has many subjective components. US may improve currently available assessment
1. To explore the relationship of 2D and 3D US imaging with DAS and its components.
2. To investigate the responsiveness of 2D, 3D and DAS28 as tools to monitor change in
disease activity in patients with Rheumatoid Arthritis.
Methods 20 consecutive patients were recruited for a cross-sectional study and their Metacarpal-phalangeal joints (MCP) were imaged with 2D and 3D US and assessed clinically by
the DAS28 at a single clinic visit. 10 patients were recruited for a prospective study and given
15mg of oral prednisolone daily for 14 days and imaged on day 1(pre-dose),2,7 and 14. All the images were analysed quantitatively and semi-quantitatively. Results The inter-class correlation coefficient for 2D and 3D imaging were 0.81 and 0.52
respectively. Pearson’s correlations coefficient of 0.97, 0.95 and 0.89 were achieved for 2D
transverse, 2D longitudinal and 3D imaging comparing reader. Correlation between US and the
DAS scores showed Spearman’s rank coefficients of 0.593 and 0.713 for 2D and 3D
respectively. With the prospective data, all imaging modalities showed significant change from
Day 1 to7 and 14. Standardised response mean calculations showed 2D Transverse and 3D
imaging to be most responsive to change in the treatment group. Conclusions The results from this study suggest that the DAS28 score could be improved by
incorporating the use of PDU. Whilst 3D imaging responds well to change there are still
potential issues with data acquisition and reader variability.
Key Terms Rheumatoid arthritis, three-dimensional ultrasound, two-dimensional ultrasound, DAS28, steroid
5. High volume image guided injections in recalcitrant mid-tendon
1 2 1 1 11*, Chan O, Crisp T, Padhiar N, Twycross-Lewis R, Morrissey D Acharya N
1 Centre for Sports and Exercise 2 London Independent Hospital Medicine, Barts and the London ! Beaumont Square
School of Medicine and Dentistry, London E1
Objectives: To assess pain and clinical outcome of patients with mid-tendon Achilles tendinopathy (AT) at 2, 6 and 12 weeks after high volume image guided
injections (HVIGI), using the Victorian Institute of Sports Assessment–Achilles tendon (VISA-A) questionnaire, and to investigate changes in maximal Achilles
tendon thickness (TT) at 2 weeks after HVIGI. Secondary objective includes
investigation of the presence of a correlation between maximum TT and VISA-A scores.
Methods: Patients with a clinical diagnosis of recalcitrant mid-tendon AT were referred to a specialist sports medicine centre. Patients received diagnostic US and
Achilles tendon size was recorded. Using an aseptic technique and real-time US guidance, patients were injected with 10mL of 0.5% Bupivacaine hydrochloride
mixed with 25mg of Hydrocortisone Acetate. This was followed by a further 40mL of
0.9% NaCl saline solution under real-time ultrasound guidance. Patients were then
given a strict eccentric rehabilitation program with a view to returning to normal
activity in 2 weeks. VISA-A questionnaire was used to assess clinical improvement.
A follow-up US was arranged at 2 weeks, where tendon size was re-measured.
Results: 27 patients (30 tendons) with a mean age of 46 ? 10 years (range = 25-64), with a mean duration of symptoms of 13 ? 36 months (range = 3-42) were included. Statistically significance from ANOVA analysis was seen for VISA-A scores (pre HVIGI = 38 ? 16; 2 weeks post HVIGI = 68 ? 17; P < 0.001, 6 weeks
post HVIGI = 77 ? 15; P < 0.001, and 12 weeks post HVIGI = 83 ? 14; P < 0.005).
Tendon thickness reduced from 8.50 ? 1.71 mm to 6.91 ? 1.25 mm (P < 0.001) at a
mean 2 week follow-up. No significant correlation was noted between VISA-A scores and tendon thickness.
Conclusion: HVIGI, in combination with eccentric exercise rehabilitation,
significantly reduces pain and improves function in patients with AT of the main
body of the Achilles tendon, in the short term which is maintained through to 12
weeks. HVIGI also reduces the maximal Achilles TT within 2 weeks.
Keywords: Achilles tendinopathy, high volume image guided injections, power
Doppler ultrasound, neovascularisation.
6. An observational study to identify the presence of Achilles
tendinopathy and ultrasound detected changes in elite footballers
and age and gender-matched controls.
1 1 2 31*, Perry M, Ahmad M, O’Driscoll G, Morrissey D Teatino R
1 Centre for Sports and Exercise Medicine, Barts and the
London School of Medicine and Dentistry, QMUL, London E14DG
The primary objective of this study was to determine and compare the prevalence
of AT symptoms and ultrasound defined signs of tendinopathy in elite male
footballers and controls. The study also aimed to observe the prevalence of
asymptomatic ultrasound signs in footballers. Methods:
This was a cross-sectional observational design, investigating both tendons in 25
male elite footballers [mean(sd) age 22.8 years (3.6), height 1.81m (0.07), weight
77.5kg (6.9)] and 25 male age matched controls [mean(sd) age 22.3 years (1.5),
height 1.76m (0.05), weight 74.3kg (10.1)] between April and May 2009.
Participants in the football group were recruited from an English Premier League
club via the club’s medical team, while control subjects were selected if they
trained for less than 3 hours per week on average. All participants completed a
questionnaire regarding their present or past history of Achilles tendinopathy, and
were scanned using grey-scale and power Doppler ultrasound for evidence of
tendon hypoechoicity, neovascularisation and abnormal thickening.
The football group experienced a significantly (p<0.001) greater lifetime history of AT symptoms. Longitudinal Achilles antero-posterior thickness measures, adjusted for height, were all significantly greater (p<0.001) in the footballer
tendons than the control tendons. Abnormal tendon thickening, hypoechoic areas
and neovascularisation were significantly greater in the football group (p<0.002).
In the footballers, 65% of tendons had asymptomatic US signs.
This study suggests that elite footballers experience significantly more symptoms
and ultrasound signs of AT, and have significantly thicker Achilles tendons than
the normal population. This indicates that elite football is a risk factor for Achilles
tendinopathy and that clinicians should be vigilant for this condition in this group
of players. The high percentage of footballers with asymptomatic US signs, and
previous evidence of the high rate of progression from asymptomatic to
symptomatic signs in Danish footballers, suggests that US screening may be
beneficial for elite Premiership footballers.
7. An in vitro study into the effect of Traumeel? S on myoblast
121 12, Screen H, Pollock N,Twycross-Lewis R, Chaudhury T, Dawson V1*Morrissey D
1 Centre for Sports and Exercise Medicine, 2 Barts and the London School of Medicine and Medical Engineering Division, Dentistry, QMUL,London E14DG Department of Engineering,
QMUL, Bancroft Road, Mile *Corresponding author End, London, E1 4NS
Background: Traumeel? S is a homeopathic preparation widely used in the
treatment of a number of conditions, namely muscular strains. Evidence for its
use is limited and, to date, no studies have assessed the effects of
Traumeel? S on myocytes.
Objective: The primary objective of this study was to assess toxicity of
Traumeel? S on myoblasts in vitro. Secondary objectives were to measure
the effect of Traumeel? S on damaged myoblasts. Methods: Metabolism rates of c2c 12 murine myoblasts in solution with
different dilutions of Traumeel? S were measured using an alamarBlueTM
assay across three consecutive days. Cells were seeded in 96 well plates and
exposed to varying volumes of Traumeel? S at 10 μl increments. Negative
(non-toxic) and positive (toxic) controls were included for comparison. All test
wells, including controls, contained 200 µL of media and 100 µL of Traumeel
plus phosphate buffer solution. 150 µL alamarBlueTM was added to each well
and read using a spectrophotometer.
Results: Overall, Traumeel? S does not adversely affect myoblast
metabolism in vitro. There was evidence of a dose-response relationship on days 2 and 3 with overall cell metabolism decreasing over time (day 2: R2 =
0.326, P = 0.003; day 3 R2 = 0.611, P < 0.001). Potential optimal volumes of
Traumeel? S appeared to cluster around the middle volumes of the drug (day
3, 40 μl Traumeel, P < 0.001; day 3, 60 μl Traumeel, P < 0.001).
Conclusions: Traumeel? S does not adversely affect myoblasts in vitro.
However, the benefit of the drug, in differing volumes, remains unclear. It
appears the drug may exhibit a dose-response relationship with higher volumes of Traumeel? S increasing rates of metabolism in treated myoblasts.
Further research is required in order to build on the preliminary evidence
established in this study.
Keywords: Traumeel? S, in vitro, homeopathy, myoblast, viability
8. The relationship between hip, spine and shoulder rotation and low
back pain in professional golfers: an observational study.
11111 Murphy S, Goodman J, West S, Twycross-Lewis R, Woledge R, 1*Morrissey D
1 Centre for Sports and Exercise Medicine, Barts and the London School of
Medicine and Dentistry, QMUL, London E14DG
Background: Low back pain (LBP) is the most common musculoskeletal
complaint in professional golfers, with static measures of hip rotation
demonstrating deficits associated with LBP incidence. To date, no work has investigated hip rotation during the golf swing with respect to LBP. Objectives: The primary objective of this study was to establish whether
professional golfers with LBP have reduced lead hip internal rotation during
the golf swing. Secondary objectives included identifying any related
compensatory movements elsewhere in the spine or shoulder girdles. Method: Thirty-eight professional golfers (33 male ages, 5 female ages) were
recruited for this observational case-control study. Allocation to LBP (n=18) and control (n=20) groups was by questionnaire. Dynamic spine and shoulder
movement was measured using an active motion analysis system at a driving
range. Kinematic analysis was used to determine segmental rotations, while
passive hip range was measured by goniometry.
Results: No significant differences in hip rotation during the golf swing were
found between groups (LBP = 81 ? 19?; control = 76 ? 13?; t = 0.217; P =
0.830). A significant negative correlation between total lead hip and upper
thorax axial rotation was observed in the whole sample (r = 0.4; P = 0.05).
Additionally, in contrast to published literature, passive hip rotation was no
different between groups (t = 0.04; P = 0.97).
Conclusion: No differences in hip, spine or shoulder movement, during the golf swing, were found between professional golfers with and without LBP.
The inverse relationship between axial spinal and hip rotation is consistent
with current technique guidance. Future, prospective studies may be needed to better understand the patho-mechanics of LBP in golfers.
Keywords: Golf, LBP, Hip, Shoulder, Rotation