Sport

HEAVOLUME 34 ISSUE 2 2016 LTH WOMEN’S HEALTH ISSUE

Exercise in pregnancy and the postpartum • Interview with Olympian Jessica Trengove period • Managing fractures in sport Active mums and active children • Sport and exercise medicine in France Exercise, breasts and bra fit • Activity levels of Exercise and the menstrual cycle: regionally based Australian pregnant the research women SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEYsma.org.au SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEYNSW SYDNEY STATE SYDNEY SYMPOSIUM SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SATURDAY 19 NOVEMBER 2016 ANZ STADIUM

#SMANSW16

Presenters Include:

* Dr Ebonie Rio * Dr Paul Bloomfield * Dr Donald Kuah

* Mr Kurt Robertson

* Mr Jake Rowe

AND MORE......

The Sports Medicine NSW State Symposium brings together the most relevant current research and practical workshops for sports medicine professionals and sports trainers alike!

Stay up to date with everything related to the symposium via sma.org.au or on Facebook (@sportsmedicineaustralia) & Twitter (@SMA_Events) SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY CONTENTS SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY CONTENTS Volume 34 Issue 2, 2016 SYDNEYsma.org.au SYDNEY SYDNEY SYDNEY SYDNEY SYDNEYREGULARS 02 From the Chairman: Sport and SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEYthe gender divide SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY Gender balance should be across all NSW STATE SYMPOSIUM facets of sport and sports medicine. SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEYDr Andrew Jowett 03 From the CEO: Women in sport SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY SYDNEY More needs to be done to represent women in sport and physical activity. 10 36 Anthony Merrilees NEWS 07 Editorial: Women and sport: 36 Do active mums have How far we have come active children? 18 SMA Member news SYDNEY The journey women have had in sport The relationship between physical over the last century. 20 2016 Sports Medicine Australia activity in mothers and their preschool SATURDAY 19 NOVEMBER 2016 aged children. Dr Anita Green Conference news Kathryn Hesketh ANZ STADIUM 22 The Journal of Science and 44 Council of Discipline news Medicine in Sport: Are regionally based 32 Exercise, breasts and bra fit Australian pregnant women active? FEATURES How women can ensure their bra A republished JSAMS editorial (Volume is supportive and correctly fitted 19, Issue 8, August 2016). 10 Exercise in pregnancy and the when active. postpartum period: NEW position Gordon S. Waddington Dr Deirdre McGhee #SMANSW16 statement 40 Sports Trainer Guide: Fractures The evidence-based process and new 28 Exercise and the menstrual How to manage fractures effectively. guidelines for exercise in pregnancy and cycle...where is the research? the postpartum period. The menstrual cycle and its effect Melanie Hayman and Professor Wendy on exercise performance. INTERVIEWS Brown Georgie Bruinvels Presenters Include: 5 minutes with… Dr Anita Green, Sport and exercise medicine 04 24 People who have shaped Senior Lecturer, The University of in France 42 SMA: Jeni Saunders Queensland, SMA Conference * Dr Ebonie Rio The strengths and weaknesses of Committee Member, Chief Medical the sport and exercise medicine system * Dr Paul Bloomfield Officer 2018. * Dr Donald Kuah in France. * Mr Kurt Robertson 26 Interview with… Jessica D Riviere

* Mr Jake Rowe Trengove, runner, 2014 Commonwealth Games bronze medallist,

AND MORE...... and physiotherapist.

Opinions expressed throughout the Managing Editor/Advertising Manager magazine are the contributors’ own and do Amanda Boshier not necessarily reflect the views or policy of The Sports Medicine Australia NSW State Symposium brings together the most relevant current Design/Typesetting Sports Medicine Australia (SMA). Members Perry Watson Design and readers are advised that SMA cannot research and practical workshops for sports medicine professionals and sports trainers alike! Cover photograph be held responsible for the accuracy of Publisher www.thinkstockphotos.com.au statements made in advertisements nor Sports Medicine Australia Content photographs Stay up to date with everything related to the symposium via sma.org.au or on the quality of goods or services advertised. PO Box 78 Mitchell ACT 2911 Author supplied; www.thinkstockphotos.com.au Facebook (@sportsmedicineaustralia) & Twitter (@SMA_Events) All materials copyright. On acceptance of an sma.org.au article for publication, copyright passes to ISSN No. 1032-5662 the publisher. PP No. 226480/00028

VOLUME 34 • ISSUE 2 2016 1 FROM THE CHAIRMAN FROM THE CHAIRMAN SPORT AND THE GENDER DIVIDE

SMA CHAIRMAN, DR ANDREW JOWETT ADVOCATES FOR GENDER BALANCE ACROSS ALL FACETS OF SPORT AND SPORTS MEDICINE.

s this issue of Sport Health Despite large numbers of women in shines a light on women’s health the medical workforce, 2015 was notable and women in sport, it provides in highlighting the problems of gender an opportunity to acknowledge inequality in medicine with reports Athe work of women in sports medicine, of bullying and sexual harassment, to support growing representation and particularly in surgical training. Whilst to recognise some of the challenges newsworthy on a local level amongst faced by women in the field. our surgical colleagues, sports medicine Andrew Jowett wasn’t immune with the very public [email protected] Women have been widely represented harassment, condemnation and eventual in Australian sports medicine for many dismissal of Dr Eva Carneiro, Chelsea FC years. Indeed, at Rio in the Australian Head Doctor by Jose Mourinho, then team headquarters multidisciplinary Chelsea Manager, for doing her job medical unit, 11 of the 28 staff are female. and attending to an injured player as instructed by the referee (August 2015). In examining the gender divide amongst In Australia, the review by the Royal Fellows of the Australasian College of Australasian College of Surgeons and Sport and Exercise Physicians however, the development of policies and program the current representation of 29 females implementation to address bullying and amongst 139 (21 per cent) is short of the harassment should stand as an example female representation amongst medical to all leaders in the medical workforce. graduates of 41 per cent. There are signs We should all be examining our behavior, of change towards parity, with female not denying the existence of the problem, registrars representing 37 per cent of incorporating tools such as that Despite large numbers all trainees, and the intake in 2016 developed by the Australian Medical reaching near 50:50. We clearly need Association Victoria and others into our of women in the to be mindful of promoting opportunity professional development programs. and retention of women especially in medical workforce, the medical fields of professional sport. Professional and televised sport is still 2015 was notable in heavily biased towards male participants. Women lead a number of academic The locker-room is still a very male highlighting the problems institutions around Australia particularly bastion. Women in sports medicine not in sports medicine research. They are only have to deal with gender bias in of gender inequality in highly regarded both nationally and their specialty training, they have to medicine with reports of internationally, often heading majority deal with it in professional and sporting female academic and professional environments. Many of the pioneer bullying and sexual workforces. Leadership in other areas females in male professional sport harassment, particularly of sports medicine however is not I know report positive experiences consistently gender-balanced including and acceptance, but must have faced in surgical training. some of our member associations and difficulties along the way. even the SMA Board itself. The current Board is committed to addressing I hope this issue of Sport Health provides this disparity across all its activities. a platform for the celebration of the The upcoming AGM and election contribution and representation of provides a perfect opportunity through women in sports medicine, inspiring both elected and nominated positions and supporting greater representation to redress the balance. amongst our leadership.

2 VOLUME 34 • ISSUE 2 2016 FROM THE CEO

FROM THE WOMEN CEO IN SPORT

SMA CEO, ANTHONY MERRILEES SUGGESTS MORE NEEDS TO BE DONE TO REPRESENT WOMEN IN SPORT AND PHYSICAL ACTIVITY.

he 2016 Rio Olympic Games From the perspective of sports medicine, underline what an exciting time the increasing level of professionalism it is in women’s sport all over the in women’s sports is also serving to drive world. The Games are an increased intensity of competition via Timportant focal point for women’s sport, access to improved strength and largely because they provide a relatively conditioning training for women athletes. level playing field in terms of the coverage The by-product of this will be the need provided of female athletes during the for an increased emphasis on injury course of the Games. prevention and injury management for Anthony Merrilees women athletes. [email protected] This of course is not the norm in Australia where coverage of male sports and With sports medicine continuing to grow sporting news will occupy anywhere globally (the industry is expected to grow between 85 to 90 per cent of all sports to $53.6 billion by 2020), the lack of media coverage. This is despite the fact trained professionals may constitute a that participation by women in sport and barrier to growth in our industry. From an physical activity is increasing. organisational point of view, we therefore need to do more to increase the pool of While there have been several high profile women involved in providing medical growth sports for women such as support activities in sport and physical football, , rugby (and even AFL activity to ensure we have as level a establishing its own women’s league), playing field as possible. it is interesting to note that participation by women is dramatically higher in the area of non-organised sport and physical Check out Sports Medicine We need to do more activity such as walking, jogging or going Australia’s Women in Sport injury to the gym. This would seem to suggest prevention and management fact to increase the pool that many traditional barriers to sheet series spanning nutrition, participation in organised sport by women bone health, pregnancy, exercise for of women involved still exist, such as socio-economic and young women, exercise for women in providing medical cultural factors, and thus more needs over 50 and breast support here. to be done to encourage increased support activities in participation in organised sport. sport and physical activity to ensure we have as level a playing field as possible.

VOLUME 34 • ISSUE 2 2016 3 5 MINUTES WITH INTERVIEW 5 MINUTES WITH... DR ANITA GREEN

5 MINUTES WITH… DR ANITA GREEN, SPORTS DOCTOR AND SENIOR LECTURER, THE UNIVERSITY OF QUEENSLAND, SMA CONFERENCE COMMITTEE MEMBER, CHIEF MEDICAL OFFICER COMMONWEALTH GAMES 2018.

What is your profession? How many years have you been working in this area? I am a Sports Doctor and have worked in medicine for over 30 years, with a 20-year interest in sports medicine.

What is a typical day like for you? Every day is different. My roles consist of clinical work consulting in primary care, working in a tertiary hospital at the Heart Lung Institute, sports coverage (some weekends), board work with the local Brisbane North Primary Health Network looking at the broader health system and policy to generate change for better patient care and outcomes, and with Cancer Council Queensland on advocacy and support for research. I like to keep busy and do a variety of things; it makes life interesting when you get to use different parts of your brain and different skillsets.

What has been the highlight of your career to date? To be appointed Chief Medical Officer for the 2018 Commonwealth Games. It is an enormous privilege to be offered the role and will be a great challenge. It not only allows you to bring together your general medicine and sports medicine skills but also your connections, networks and health systems skills. I was in disbelief when I was selected for this role however attribute it to my voluntary work in sports medicine, i.e. SMA and other Board work, the roles outside of my GP stuff. It’s always important to take on different roles outside of your comfort zone as 5 you never know where they might lead. minutes

When, why and how did you become involved with Sports Medicine Australia? I have always had an interest in sport and wanted to become ‘better’ at sports medicine. Early in my career, I worked in an emergency department and realised I and my colleagues were not well prepared for some of the commonest presentations to our department. We received almost no training in sports or musculoskeletal medicine in our undergraduate course, nor in those first few years as a doctor. I wanted to seek out further guidance so I completed the SMA six- month course for doctors in Brisbane in the early 90s. From there, I got to know a few people, joined the SMA QLD Board, and took on the responsibilities of teaching the SMA Sports Trainer courses and organising the coverage for the SMA QLD Branch.

When, why and how did you become involved with SMA Conferences? In 2002, while President of Sports Medicine Australia, I took on the role of Conference Chair (when the incumbent could not continue in the role). From my years on the SMA Board I knew it was vital to ensure we run a high quality scientific

4 VOLUME 34 • ISSUE 2 2016 5 MINUTES WITH INTERVIEW

conference for our members. prevention and treatment of the elite environmental safety standards I enlisted the help of Professor Wendy dance performance students at the are met for athletes in the village, Brown, a highly credentialed and well Queensland University of Technology triathletes in the water and known academic to assist me as and the Queensland Dance School of spectators to the games. Co-Chair. Her skills and academic Excellence, who were mostly female. experience complemented mine. I was also invited to contribute to the Under the anti-doping program, Over the years I have worked with Exercise in Pregnancy Symposium working with ASADA, WADA and Wendy as Co-Chair and then invited with the Australian Sports other National anti-doping agencies, Professor Jill Cook to join us to take Commission which was triggered by we aim to deter and detect doping, over as Chair and then Kay Copeland. the Australian Netball Board banning to allow clean athletes to compete In fact, I have just realised that an athlete who was pregnant. on a level playing field. Sadly, this women have been steering the SMA issue is currently overshadowing Conference for the last 14 years. Describe your role with the sport at the Rio Games. Commonwealth Games in 2018. What are you most looking What’s the best piece of advice The role of Chief Medical Officer forward to at this year’s anyone has ever given you? requires me to be in charge of conference? the medical program and the anti- “You should see your medical degree I am looking forward to connecting doping program. as a passport to working and travelling with colleagues who live around the where you want to go and taking as country, people you may only see Under the medical program many opportunities as you can”. once a year, but it is like being back I need to ensure: I feel you only regret the things you with family. I am also excited about • Provision of medical services for haven’t done rather than the things holding the conference at the MCG elite athletes and team officials. you have done. as it is such an iconic venue. As always • Provision of health services for it is the multidisciplinary nature of our employees, general volunteers Outside of work, what else conference that excites me. I am and spectators. are you passionate about? particularly looking forward to • In partnership with Queensland meeting and hearing our Refshauge Health, that health services in the I love the arts – ballet, opera Lecturer Professor Peter O’Sullivan region can manage the increased and theatre; and travel. speaking about his research into the amount of visitors to the Gold mechanisms of pain and treatment Coast, and Queensland in general. Name four people, living or not, approaches to disabling chronic • The polyclinic and all of the medical you would invite for a dinner back pain. facilities at each of the competition party and why? and training venues run smoothly. Charles Darwin – I have visited his Tell us a little bit about your • Highly skilled sports medicine professionals are recruited to home – ‘Down House’ in Kent – and involvement with women in work the entire Games period. you feel he has just stepped out for sport practice. • Health services, like hospital and one of his daily walks. All those Being one of the few female sports ambulance, link seamlessly to specimens from ‘The Beagle’ are still doctors in Brisbane, I guess you tend provide appropriate levels of care. there. I want to ask how the most to see more female athletes. I was • In partnership with Public Health, extraordinary natural history theory also heavily involved with injury that food and water quality and evolved in his mind. 5 William Shakespeare – of course – minutes to hear some of that exceptional FAVOURITES prose emerge from his lips. Gustav Mahler – to ask how you Travel destination: I have two. Turkey – exotic – beautiful landscapes and imagine such sublime music. And, exceptional Roman, Byzantine and Ottoman historic sites. And, the food is to ask him to play something after fantastic. Iceland – a land of fire and ice. It’s a bit like visiting Middle Earth. dinner.

Sport to play/watch: Swimming and surfing to participate. Swimming, athletics, Dr Who – well he’s been everywhere soccer, rugby league, AFL to watch. in time and space – so you could ask him about any period in history. Cuisine: Thai.

Movie: Women on the verge of a nervous breakdown (Pedro Almodovar).

Song: Going to be a real opera nerd here – The Quartet from Rigoletto (Verdi) – why would you settle for a band when you can have four superb soloists and a full orchestra?

Book: The Book Thief by Markus Zusak and To Kill a Mockingbird by Harper Lee.

Gadget: Dr Who Sonic Screwdriver Universal Remote Control.

VOLUME 34 • ISSUE 2 2016 5 NEW GEL-NIMBUS 18 with CONVERGENCE GEL

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28508 v1F.indd 1 18/03/2016 1:38 pm EDITORIAL

WOMEN

& SPORT…SPORTS DOCTOR, DR ANITA GREEN HIGHLIGHTS THE HOW FAR WE ARDUOUS JOURNEY WOMEN HAVE HAD IN SPORT OVER THE HAVE COME LAST CENTURY.

VOLUME 34 • ISSUE 2 2016 7 EDITORIAL

WOMEN & SPORT… HOW FAR WE

HAVE COME From Sydney 2000 onwards, women edition of our Journal of Science and have made up 45 per cent of the Medicine in Sport. Additional publications Australian Olympic Team. Finally, in Rio and seminars provided advice to 2016, women represent 50 per cent of Parliament, our National Sporting Ten days ago I had the privilege of our team. And, the Australian Women’s Organisations and the HREOC. watching the Trans-Tasman netball final team have just won the inaugural Rugby between the and Sevens gold medal. Two of SMA’s esteemed members, the Swifts. A capacity Professors Wendy Brown and Karim crowd of over 10,000 fans was treated Just as there have been barriers to Khan, have been involved in the IOC to another edge-of-your-seat contest, women’s participation in sport at all Expert Group reviewing the literature won in double extra time by the Firebirds. levels, there have been significant barriers on exercise and physical activity in I was struck by the passionate support to inclusion of women in clinical and pregnancy. These findings Exercise tempered by respect for the quality of physiological studies. Lack of knowledge and Pregnancy in Recreational and Elite the opposing teams’ play. Equally, both about the effects of hormones and cycles Athletes: 2016 Evidence from the IOC captains’ speeches revealed why they have created scientific and economic Expert Group Meeting were published are such icons and role models for girls barriers to recruiting women for research. recently in the British Journal of and young women; intelligent, humble, Results from clinical and performance Sports Medicine. grateful to all those families, coaches studies in men have been assumed to and supporters integral to their journey be able to be extrapolated to women. In this edition of Sport Health we publish to the pinnacle of their sport, and Concern about potential risks to women SMA’s new position statement: Exercise genuinely respectful of the quality of of childbearing age has resulted in a in pregnancy and the post-partum period. their opposition and the closeness of the gender imbalance in scientific study. This document emphasises the vital contest. Excitement too, for the new Overly protective policies regarding message of the importance of sufficient Australian Netball League with greater research may exclude the very groups physical activity throughout a woman’s broadcast exposure and revenue for of people most at risk of injury or illness, life, including the many benefits specific women’s sport. who would be the beneficiaries of that to pregnancy. We know that the birth research. of a child is one of several key times in At the Olympics in 1896, there a woman’s life when she may cease were no female competitors. Pierre de Pregnancy and exercise is one of those exercising and never restart, so Coubertin, the ‘Father’ of the Olympics areas where lack of research and fear of continuing exercise in the postpartum of the ‘modern’ era had a more ‘ancient’ litigation has conspired to limit the advice period is equally important. This view of women’s participation in sport. we can provide to women. In 2001, an document provides evidence based He considered the inclusion of women elite Australian netball player who was in advice for sports clinicians and all of to be “impractical, uninteresting, the early stages of pregnancy was banned our members who prescribe exercise. unaesthetic and incorrect”. Women were from competing by . allowed to compete in 1900. There were She took the Board to the Australian I hope you enjoy this issue of Sport two official women’s sports: lawn tennis Human Rights and Equal Opportunity Health, taking a look at how far women and golf. Women also competed and won Commission (HREOC). Sports Medicine in sport have come over the years, medals in sailing, croquet and equestrian. Australia was invited to participate and and celebrating and highlighting the There were 22 women competitors out provide expert scientific advice to the importance of women in sport. of a total of 997 athletes. In Stockholm in Australian Sports Commission. SMA was 1912 swimming was open to women for able to draw on our highly credentialed, the first time – Australia’s ‘Fanny’ Durack multidisciplinary members to review the ABOUT THE AUTHOR and ‘Mina’ Wylie took gold and silver current literature in clinical sports in the only race on offer, the 100m medicine, physiology, exercise science, Dr Anita Green is a Senior freestyle. A century later, at sports and injury epidemiology, and Lecturer at The University of 2012, with the addition of boxing, women physical activity. This valuable synthesis Queensland and a SMA were finally eligible to compete in all of the evidence was then captured in Conference Committee Member. Olympic sports. a 2002 Special Pregnancy and Sport

8 VOLUME 34 • ISSUE 2 2016

FEATURE NEW POSITION STATEMENT

EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD: NEW POSITION STATEMENT

SPORTS MEDICINE AUSTRALIA HAVE JUST RELEASED THEIR EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD POSITION STATEMENT. LEAD RESEARCHERS, MELANIE HAYMAN FROM CQUNIVERSITY AND PROFESSOR WENDY BROWN FROM THE UNIVERSITY OF QUEENSLAND, DISCUSS THE EVIDENCE-BASED PROCESS AND SHARE THE NEW GUIDELINES.

10 VOLUME 34 • ISSUE 2 2016 FEATURE NEW POSITION STATEMENT

EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD: NEW POSITION STATEMENT

istorically, pregnancy was and also postpartum,3, 7, 10, 12 and assists Since the release of this statement believed to be a time for rest. in the prevention and management of several other peak industry bodies have Women were encouraged to urinary incontinence.13-14 recently released guidelines for physical ‘take it easy’ and refrain from activity and/or exercise during pregnancy, Hparticipating in exercise for fear it may Despite these benefits, few women are targeting general practitioners, exercise cause harm to the mother and/or her sufficiently active during their pregnancy and fitness professionals, and pregnant unborn child.1 However, an increasing to obtain the associated health women. However, these guidelines body of epidemiological and empirical benefits.15-16 In fact, recent research present inconsistent recommendations evidence has recently challenged this suggests that fewer than 30 per cent to one another, and lack evidence-based view.2 It is now widely acknowledged that of Australian pregnant women are research to guide and support their appropriate exercise undertaken during sufficiently active in accordance with recommendations.19 Therefore, a working pregnancy promotes many benefits exercise during pregnancy guidelines.15-17 group of academics (n=3) and health including a reduced risk of pregnancy- Research also suggests that women professionals (n=2) was established in related conditions such as pre-eclampsia significantly reduce the frequency, 2014 to review the current exercise and pregnancy-induced hypertension, intensity and duration of exercise as their during pregnancy and postpartum and reduced incidence of delivery pregnancy progresses, or cease exercise literature. The findings were used to complications such as caesarean altogether once they become guide the development of a new delivery.3-7 In addition, regular physical pregnant.15-16 evidence-based SMA Position Statement activity during pregnancy also helps to on Exercise in pregnancy and the post- reduce back and pelvic pain,8-10 fatigue, In an attempt to help educate pregnant partum period.20 stress, anxiety and depression.3, 8, 11 women and healthcare providers, Sports Moreover, regular physical activity during Medicine Australia (SMA) released the pregnancy leads to greater control over first Australian position statement gestational weight gain during pregnancy ‘Exercise during Pregnancy’ in 2002.18

VOLUME 34 • ISSUE 2 2016 11 FEATURE NEW POSITION STATEMENT EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD

PURPOSE OF THIS Note: A number of high quality reviews FOCUS OF THIS STATEMENT STATEMENT of evidence were excluded from this review as they examined physical activity/ This statement focuses on safe physical The primary purpose of this document exercise and diet, not physical activity/ activity/exercise for healthy women who is to provide an evidence-based, best exercise as an independent variable.33-35 are free of the medical and obstetric practice summary to assist Sports contraindications outlined in Section 6. Medicine Australia (SMA) members DEFINITIONS [including: health professionals (e.g. 1. Summary general practitioners, sports doctors, The term ‘physical activity’ is used in sports physicians, physiotherapists, this document to describe participation • It is important that all pregnant women chiropractors, exercise physiologists, in activities such as walking, cycling, (inactive, active, sportswomen and occupational therapists, podiatrists, swimming and jogging which are typically athletes) consult with their health care sports scientists, psychologists, nurses, undertaken for leisure or transport. The providers (which could etc.); fitness professionals (e.g. fitness term ‘exercise’ is used to describe more include a GP, instructors, personal trainers, aqua structured forms of activity, including obstetrician, instructors etc.)], others who are sports and recreational activities, where midwife involved in sport (e.g. coaches, officials, the focus is usually on performance or administrators, journalists), and players competition. In cases where there is no and athletes themselves, to understand distinction in terms of the evidence the benefits and risks of participation in review, the term ‘physical activity/ physical activity/exercise in pregnancy exercise’ is used. and the postpartum period. PERSPECTIVE This position statement is based on: • A review of the evidence from twelve Reflecting a perception that systematic reviews and meta-analyses exercise might be harmful to the published since 2010.1-12 mother and/or her unborn child, • A review of the findings of nine pregnancy was once considered additional more recent narrative a time for rest, when women reviews of the evidence on exercise were advised to take it easy and pregnancy outcomes and and refrain from participating recommendations, published in physical activity/exercise. since 2010.13-21 Despite the difficulties of • A review of the information included conducting carefully in 11 statements on exercise and controlled randomised trials, pregnancy from 9 countries, as this view is now challenged by summarised in two peer-reviewed a growing body of systematic summary papers.22-23 review level evidence. • Information included in six ‘guidelines’ or ‘fact sheets’ on exercise during pregnancy.24-29 • Information from the scientific reports on the Australian and US physical activity guidelines, and a WHO factsheet on obesity and overweight.30-32

12 VOLUME 34 • ISSUE 2 2016 FEATURE NEW POSITION STATEMENT EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD

or physiotherapist) about physical recommended. SMA suggests that A typical ‘prescription’ for a moderate activity/exercise during and after exercise professionals and health care to vigorous intensity physical activity/ pregnancy. providers should be familiar with these exercise program23, 29 that can be • Evidence from twelve systematic (Section 7). continued during healthy pregnancies reviews suggests that, for healthy • International guidelines also concur (free of medical and/or obstetric women, physical activity/exercise with the view that walking, jogging, complications) is shown below: during pregnancy is safe and is cycling and swimming (at moderate associated with numerous benefits intensity), muscle strengthening Aerobic activities: to the mother and unborn child/foetus exercises (including pelvic floor (Section 6). exercises), water based exercise, Frequency: Daily. • International guidelines on exercise and pregnancy-specific exercise classes during pregnancy concur that there are safe for pregnant women. These Intensity: Intensity (12-14 on Borg rate are contraindications, signs and guidelines also list activities/situations of perceived exertion scale (RPE) – symptoms, which indicate which should be avoided (Section 8). perceived as somewhat hard, can talk that physical activity/ • Evidence from systematic reviews also but not sing). exercise is not supports the view that returning to physical activity/exercise in the post- Time: Accumulate 150-300 minutes partum period has benefits in terms (30-60 minutes on most, if not all, days of the mothers’ physical and mental each week. Longer duration (closer to health and wellbeing (Section 10). 300 minutes, instead of 150 minutes/ week) is associated with more benefits 2. Exercise during pregnancy for i.e. reduced risk of excess weight gain previously inactive women and gestational diabetes.

Pregnant women who were inactive Type: Brisk walking/running/jogging, prior to pregnancy should be cycling (stationary bike), swimming, encouraged to be active during aerobics etc. pregnancy11, 14, 17-18, 29, commencing with low intensity activities such As a general rule of thumb, count each as walking or swimming, and minute of vigorous intensity exercise progressing to the lower end as two minutes of moderate intensity of the range recommended in exercise (i.e. 75 minutes of vigorous the Australian, Canadian and intensity exercise equates with 150 US national guidelines (i.e. 150 minutes of moderate-intensity minutes per week or 30 minutes exercise).30-31 per day of moderate intensity activity on most days).26, 29-32 Muscle strengthening exercise: Activity can initially be accumulated in short (say 15 Frequency: 2 sessions per week. minute) bouts, building towards bouts of longer duration.11, 26, 29-31 Intensity: Sub-maximal intensity using Pregnant women who were inactive own body weight, light weights and/or prior to conception are advised to resistance bands (exhale on effort). consult a health care provider before commencing physical activity/exercise. Type: Work all large muscle groups (refer to PARmed-X for Pregnancy25 3. Exercise during pregnancy for for specific exercises). previously active women Programming: 1 set of 12-15 repetitions For healthy pregnant women who of up to 8-10 exercises.17, 20, 28, 30-31 participated in physical activity/exercise prior to pregnancy, and are experiencing 4. Exercise during pregnancy for the an uncomplicated pregnancy, physical elite pregnant athlete activity/exercise can be continued throughout pregnancy, or until such time Exercise during pregnancy does not that it becomes uncomfortable to do so.11, increase the risk of adverse pregnancy 14, 17-18, 21, 29 or birth outcomes, not even for elite

VOLUME 34 • ISSUE 2 2016 13 FEATURE NEW POSITION STATEMENT

EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD

athletes.16-18 However, pregnant women Time: Vary the duration of the ‘squeeze’ who were very active or elite athletes/ from 4 to 30 second holds; with a sportswomen should have their physical mixture of slow and controlled, and activity/exercise regime overseen and fast and controlled contractions. managed by an expert health care provider to ensure the safety and Type: Try sitting with weight wellbeing of the mother and her unborn forward (hands on knees), child.17, 26, 29 This is particularly important and also sitting upright, as in cases where the foetus is small for this will help to recruit all gestational age. The PARmed-X for muscles, anterior (front) Pregnancy25 can be used to assist and posterior (back), health care providers in the exercise involved in the squeeze prescription process. movement. These exercises can be done in a 5. Exercise modifications during sitting, kneeling, standing, pregnancy lying down or standing with legs astride position. Most exercises/activities during pregnancy present minimal risk to the 6. Benefits of physical mother or the child. However, some activity/exercise during modifications to exercise techniques pregnancy and/or programs may be required to accommodate the anatomical and There is strong evidence, from physiological changes which occur as fifteen systematic reviews/meta- pregnancy progresses.29 In addition to analyses, nine review papers, and a their regular aerobic activity and muscle narrative review of national exercise strengthening exercises, all pregnant during pregnancy guidelines, to suggest women are advised to do pelvic floor that the benefitsof physical activity/ exercises.10, 12, 26 exercise for pregnant women include: • Improved muscular strength and reviews suggest that the effects of Pelvic floor exercises: endurance.11, 17, 29 physical activity alone are currently • Improved cardiovascular function unclear.34 Women are advised therefore Pelvic floor exercises help to strengthen and physical fitness.1, 17, 21, 29 to follow both physical activity AND and improve the tone of the pelvic floor • Decreased risk of pregnancy related healthy eating guidelines to reduce muscles, which provide perineal support complications such as pregnancy- the risk of gestational diabetes. for the pelvic structures, the urethra, induced hypertension and pre- vagina and rectum. There is strong eclampsia.5, 9, 18, 29 7. Contraindications to physical evidence to suggest that women who • Reduced back and pelvic pain.11, 16-17 activity/exercise during pregnancy23-24, do intensive, supervised pelvic floor • Reduced fatigue, stress, anxiety 26-27, 29 exercises during pregnancy may reduce and depression.4, 11, 21, 29 the risk of urinary incontinence (leakage) • Decrease in excessive gestational Although no systematic level evidence postpartum.10, 12, 26 These exercises involve weight gain and post-partum weight exists, national physical activity guidelines repetitive contraction of the pelvic floor retention.13, 16, 18, 21, 29 from around the world agree that in the muscles to build strength and muscle • Fewer delivery complications in women following situations the risks of physical tone. The movement is a voluntary inward who are active during pregnancy.15, 21, 29 activity/exercise are likely to outweigh and upward contraction of the pelvic • Prevention and management of urinary the benefits. Pregnant women who floor. Specific advice should be sought incontinence.10, 12 experience any of the following are from a physiotherapist, nurse continence advised not to exercise, and to seek adviser, or midwife with qualifications and Note: Evidence on the role of physical medical advice: expertise in pelvic floor muscle training. activity/exercise in the prevention of • Ruptured membranes. A typical ‘prescription’ for a pelvic floor gestational diabetes is mixed. It is clear • Signs of preterm labour. exercise program 10, 12, 25 is shown below: that women who gain more than the • Hypertensive disorders of pregnancy. recommended amount of weight during • Incompetent cervix. Frequency: At least 8-12 contractions pregnancy are at increased risk of • Growth restricted foetus. 3 times per day, three to four times developing gestational diabetes. • High order multiple gestation per week. Although many randomised controlled (>triplets). studies have shown that lifestyle • Placenta praevia after 28th week. Intensity: Women should be encouraged intervention (involving both physical to ‘contract maximally’ with an inward activity and diet) can reduce the risk For women who have a history of any and upward squeezing movement. of gestational diabetes,2, 6-8, 11 systematic of the following, we recommend

14 VOLUME 34 • ISSUE 2 2016 FEATURE NEW POSITION STATEMENT

Recent research suggests that fewer than 30 per cent of Australian pregnant women are sufficiently active in accordance with exercise during pregnancy guidelines. Research also suggests that women significantly reduce the frequency, intensity and duration of exercise as their pregnancy progresses, or cease exercise altogether once they become pregnant. professional collaboration between medical (e.g. obstetrician or midwife) • Dizziness or presyncope. • Abdominal trauma or pressure and training (e.g. coaches/trainers) • Dyspnoea, before exertion. (e.g. weight lifting). professionals to ensure that women • Excessive fatigue. • Contact or collision (e.g. soccer, exercise with caution or at a low level, • Excessive shortness of breath. ice hockey, martial arts etc). provided they are asymptomatic at rest. • Muscle weakness. • Hard projectile objects or striking • Previous spontaneous abortion. • Pelvic pain. implements (e.g. hockey, cricket, • Previous preterm birth. • Preterm labour. softball etc). • Mild/moderate cardiovascular • Severe headaches. • Falling (e.g. judo, skiing, skating, horse or respiratory disorder. • Uterine contractions riding etc). • Anaemia (Hb <100 g/L). (premature and/or painful). • Extreme balance, coordination and • Malnutrition or eating disorder. • Vaginal bleeding. agility (e.g. gymnastics, water skiing • Twin pregnancy after 28th week. etc). • Extreme overweight/obesity 8. Activities that are/are not • Significant changes in pressure (BMI >30).32 recommended17, 23-24, 26-27, 29 (e.g. scuba diving, sky diving etc). • Intrauterine growth restriction in • Heavy (greater than submaximal) lifting. current pregnancy. Although no systematic level evidence • High intensity training at altitudes • Other significant medical conditions exists, national guidelines concur that the greater than 2000m. (e.g. poorly controlled type 1 diabetes, following activities are considered to be • Exercise in the supine position, or even hypertension, hyperthyroidism etc). generally safe for pregnant women with motionless supine posture (e.g. in some an uncomplicated pregnancy: yoga positions) may cause hypotension Women who experience any of the • Walking, jogging, cycling and swimming in some women; for safety, avoid supine following symptoms should seek advice (at moderate-intensity). exercise positions after 28 weeks’ from their ante-natal care provider before • Muscle strengthening exercises, gestation; some exercises can be continuing with their physical activity/ including pelvic floor exercises. adapted to lying on the side. exercise program. • Water-based exercise. • Abdominal pain. • Pregnancy specific exercise classes. Specific activities listed above are • Amniotic fluid leakage. examples only; participation in specific • Calf pain or swelling. Activities which are characterised by activities should be discussed with the • Chest pain/tightness/palpitations. the following are considered unsafe for health care provider and should be • Decreased foetal movement. pregnant women and should be avoided: reviewed as pregnancy progresses.

VOLUME 34 • ISSUE 2 2016 15 FEATURE NEW POSITION STATEMENT

EXERCISE IN PREGNANCY AND THE POSTPARTUM PERIOD

9. Additional recommendations recommends that women seek guidance appear to be unsettled after feeding 23-24, 26-27 from their health care provider before immediately after maternal exercise, they begin or recommence their physical mothers could feed their baby before As for all exercise programmes, there activity/exercise regime, but in general exercise, postpone feeding to one hour is consensus (but not always scientific all healthy women should aim (through after physical activity/exercise, or express evidence) that each session should gradual progression) to accumulate milk before exercising, so that it may be incorporate applicable warm up and 150-300 minutes of moderate-vigorous used after the activity.24, 26 The caloric cool down activities, clothing should be intensity aerobic exercise per week. cost of breast feeding is estimated to non-restrictive and made of ‘breathable’ Return to high impact activities or those be about 600 kcal/day. fabric, shoes should be appropriate for that cause high gravitational load on the the activity and a supportive bra should pelvic floor should occur gradually, and in be worn. Avoiding large increases in body consideration of recovery to any damage temperature during exercise is important. to the pelvic floor and abdominal muscles, The following should be considered which will vary according to the mode when planning exercise during pregnancy: of delivery. • Avoid hot and/or humid exercise Sports Medicine Australia would environments and take care to remain There is systematic review level evidence like to acknowledge the following well hydrated. to show that benefits of physical activity/ for their valuable contributions to • Stretching should be controlled and exercise to the mother after pregnancy this position statement. not ‘over-extended’ as joints and include: ligaments are already loose due to • Improvements in emotional well- Melanie Hayman BHMSc, MEd the release of the hormone relaxin being.3-4, 13, 19 PhD Candidate, APA Scholarship in preparation for birth. • Reduced anxiety and depression.3-4, 19 Recipient, School of Medical and • Avoid wide squats, lunges or any • Improved physical conditioning.13, 29 Applied Sciences, 2014/2015 CQ unilateral leg exercises that place • Reduced postpartum weight gain Medicare Local Healthy CQ Grant excessive shearing forces on the and faster return to pre-pregnancy Recipient, CQUniversity Australia pubic symphysis. weight.13, 21, 35 Professor Wendy Brown BSc, 10. Resuming physical activity/ Postpartum physical activity/exercise GradDip (Phys Ed), MSc, PhD, exercise after pregnancy11, 22, 24, 26, 29 and effects on breastfeeding Professor, School of Human Movement and Nutrition Sciences, The postpartum period is defined as the Moderate to vigorous intensity physical Faculty of Health and Behavioural time immediately after birth. There is no activity/exercise and sports will not Sciences, University of Queensland clearly defined end to the post-partum negatively affect breast milk volume, as period, but it is usually considered to be long as there is appropriate food and fluid Dr Katia Ferrar BAppSc (Physio), 6 to 26 weeks following the birth. Many intake.24, 26, 29 This type of exercise or BHlthSc (Hons), PhD, Lecturer, of the physical and physiological changes physical activity has also been shown not Alliance for Research in Exercise, that occur during pregnancy will persist to affect the composition of breast milk Nutrition and Activity, School for four to six weeks after delivery. SMA or infant growth. However, if babies of Health Sciences, University of South Australia

Rosemary Marchese BAppSc (Physio), Certificate IV in Training and Assessment, Physiotherapist, Fitness and Health Vocational Educational Consultant, Right Way Fitness Industry Advisor for Service Skills Australia

Jon Tan BSc (Chiro), BChiro, ICCSP, Cert III/IV Fitness, Chiropractor, Personal Trainer, National Chairman – Sports Chiropractic Australia

16 VOLUME 34 • ISSUE 2 2016

SMA MEMBER NEWS

MEMBER SMA NEWS

2016 SMA CONFERENCE

October 12-15 – MCG,

With just over a month to go, stay up-to-date on the latest information on speakers, social events, sessions and trade via the @smaconf16 Instagram account (hashtag #SMAConf16 #illbethere), @SMA_Events Twitter account, and the conference app (search ‘2016 SMA Conference’ via the App Store). Or visit the conference website.

JSAMS IMPACT FACTOR NEWS The Journal of Science and Medicine in Sport’s (JSAMS) Impact Factor rose to 3.756 in 2015, up from 3.194 in 2014. JSAMS remains the seventh most impactful journal in the sports sciences category. Read the latest issue of JSAMS at jsams.org

18 VOLUME 34 • ISSUE 2 2016 SMA MEMBER NEWS

ACT RESEARCH AWARDS NIGHT SAVE THE DATE November 16, 2016

Join us at this networking evening highlighting some of Canberra’s most prestigious speakers who will share their knowledge and current work. The Research Award Winners will also present their latest research. POSITION STATEMENTS Have you checked out Sports Medicine Australia’s latest position statements? • Concussion • Exercise in Pregnancy and the Postpartum period

SMA SOCIAL MEDIA

In streamlining Sports Medicine Australia’s social media, all state Facebook and Twitter accounts have been replaced by @SMA_Courses on Twitter and the Sports Medicine Australia Courses page on Facebook. These accounts will feature sport safety course information nationwide.

VISIT US ON SOCIAL MEDIA  @SMACEO @sma_news @SMA_Events @_JSAMS @SMAChairman  Search Sports Medicine Australia  Search Sports Medicine Australia

VOLUME 34 • ISSUE 2 2016 19 MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEsma.org.au MELBOURNE MELBOURNE MELBOURNEMELBOURNEsma.org.au MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE2016 MELBOURNE SPORTS MELBOURNE MEDICINE MELBOURNEMELBOURNE2016 MELBOURNE SPORTS MELBOURNE MEDICINE MELBOURNE MELBOURNEAUSTRALIA MELBOURNE MELBOURNE CONFERENCE MELBOURNEMELBOURNEAUSTRALIA MELBOURNE MELBOURNE CONFERENCE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE CRICKET GROUND MELBOURNE Speakers Include: 12-15 OCTOBER 2016 * Dr Paul Balsom (Leicester City FC) #2016SMAConf * Dr Tim Hewett (Preventive Biomechanics: A paradigm shift in musculoskeletal injury prevention)

* Dr Clare Ardern (2016 Consensus Statement on Return to Play)

* Prof Peter O’Sullivan (Time to change how we understand and manage back pain in sport) And many more...

MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEsma.org.au MELBOURNE MELBOURNE MELBOURNEMELBOURNEsma.org.au MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE2016 MELBOURNE SPORTS MELBOURNE MEDICINE MELBOURNEMELBOURNE2016 MELBOURNE SPORTS MELBOURNE MEDICINE MELBOURNE MELBOURNEAUSTRALIA MELBOURNE MELBOURNE CONFERENCE MELBOURNEMELBOURNEAUSTRALIA MELBOURNE MELBOURNE CONFERENCE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNEMELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE CRICKET GROUND MELBOURNE Speakers Include: 12-15 OCTOBER 2016 * Dr Paul Balsom (Leicester City FC) #2016SMAConf * Dr Tim Hewett (Preventive Biomechanics: A paradigm shift in musculoskeletal injury prevention)

* Dr Clare Ardern (2016 Consensus Statement on Return to Play)

* Prof Peter O’Sullivan (Time to change how we understand and manage back pain in sport) And many more...

THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT ARE REGIONALLY BASED AUSTRALIAN PREGNANT WOMEN ACTIVE?

THE FOLLOWING IS A REPUBLISHED EDITORIAL WHICH FEATURES IN THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT (VOLUME 19, ISSUE 8, AUGUST 2016) WRITTEN BY EDITOR-IN-CHIEF, GORDON S. WADDINGTON, PHD.

elcome to the August 2016 focus on increasing activity across this issue. In the physical activity period. Fraser’s research team describe section, Hayman, Short and the physical activity and sedentary Reaburn’s report on behaviour patterns of inpatient adults Wphysical activity levels of regionally based with mental illness and suggest work pregnant women suggests that activity needs to be done on reducing sitting levels fall well short of guidelines and time in this group. reflects a need to re-visit public health initiatives in this group. A study of 1,000 In a systematic review and meta-analysis, workers in Xi’an China by Sun and in the sports and exercise science section, co-workers suggest that significant work Slysz, Stultz and Burr suggest that blood is needed to increase the physical activity flow restriction when combined with levels of civil servants. Wickel and Belton exercise is an effective mechanism for describe the impact of the transition from enhancing both muscle strength and childhood to adolescence on the amount size over relatively short duration of of after school physical activity time, intervention. Almeida and colleagues suggesting the need for programs to randomised controlled trial on the impact

22 VOLUME 34 • ISSUE 2 2016 THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT ARE REGIONALLY BASED AUSTRALIAN PREGNANT

Hayman, Short and Reaburn’s report on WOMEN ACTIVE? physical activity levels of regionally based pregnant women suggests that activity levels fall well short of guidelines and reflects a need to re-visit public health initiatives in this group.

of cold water immersion on heart rate clinical practice environments. Cox variability during recovery suggests that and co-workers show that the cognitive ABOUT THE AUTHOR this technique is beneficial if used for function of even apparently healthy 15 minutes at 14°C. Ramirez-Campillo young adults can benefit from exercise Gordon S. Waddington is the and co-workers describe a potential in a systematic review. Editor-in-Chief of The Journal technique for enhancing plyometric of Science and Medicine in Sport. training in female football players with Prinold and Bull lead off the sports injury dietary creatine supplementation. section with a paper describing the Delevatti’s group describe the differences kinematics of shoulder pull up techniques The Journal of Science and Medicine in glucose control in dry land versus and how best to minimise impingement in Sport, published by Sports aquatic training in individuals with risk. Hanninen’s group provide normative Medicine Australia (SMA), is the major type 2 diabetes. reference values for the SCAT3 in ice refereed research publication on hockey players and Kluitenberg and sports science and medicine in In the sports and exercise medicine colleagues describe training related Australia. The Journal provides high section Maddison and colleagues suggest factors related to injury in novice quality, original research papers to that there is significant variability in runners from the NLstart2run study. keep members and subscribers activity profiles and risk of cardiovascular informed of developments in sports disease in 30-70 year olds meaning that The August 2016 issue provides a wealth science and medicine. Produced for interventions need to be tailored to of information for researchers and SMA six times a year by Elsevier activity profiles and responsive to change clinicians and researchers across the Australia, it reflects SMA’s in the profile over time. Tang’s group physical activity, sport sciences, and commitment to encouraging world- provide evidence to support the concept exercise medicine fields. class research within the industry, that ratings of perceived exertion can and its commitment to the continuing guide exercise intensity in everyday education of its members. Journal articles can be found at jsams.org

VOLUME 34 • ISSUE 2 2016 23 FEATURE SPORT AND EXERCISE MEDICINE FRANCE SPORT AND EXERCISE MEDICINE IN FRANCE

THIS ARTICLE, WRITTEN BY D RIVIERE, MD, PHD FORMS PART OF A SERIES PUBLISHED IN SPORT HEALTH TO LOOK AT THE STRENGTHS AND WEAKNESSES OF THE SPORT AND EXERCISE MEDICINE (SEM) SYSTEMS IN VARIOUS COUNTRIES, PROVIDING IDEAS AND INSPIRATION FOR ALL COUNTRIES ON HOW TO IMPROVE INFRASTRUCTURE IN THIS EMERGING SPECIALTY.

VIEW PAST ARTICLES HERE

VIEW PAST SPORT AND EXERCISE MEDICINE AROUND THE WORLD EDITORIAL HERE

n France, approximately 8,000 et Biologie du Sport). This is obtained physicians have a practice solely after acquiring a practising physician dedicated to (a small number) or partly license, i.e. at the end of medical studies focusing on (often a small part) sports and thesis validation. At the end of the first Imedicine. Sports medicine is not a specialty like cardiology or neurology Medical education in France (France year of common studies, for instance. In fact, it is an additional has 37 schools of medicine) spans nine a very selective entrance competence recognised by the French to ten years depending on the specialty, National Medical Chamber (Ordre with six ‘common’ years followed by examination permits only des Médecins). either a three-year internship (specialisation in general medicine) or one person per 7-10 Until 2002, two types of diplomas four-year internship (other specialties). candidates (depending on allowed physicians to obtain certification At the end of the first year of common in sports medicine. The former was studies, a very selective entrance the medical school) to be called C.E.S (Certificat d’Etudes examination permits only one person accepted into the second Spécialisées), i.e. Specialised Studies per 7-10 candidates (depending on Certificate which has since ceased to the medical school) to be accepted year of study, making it a exist and has been replaced with the into the second year of study, making present Sport Medicine and Biology it a very selective field. very selective field. Capacity, SMBC (Capacité de Médecine

24 VOLUME 34 • ISSUE 2 2016 FEATURE SPORT AND EXERCISE MEDICINE FRANCE FRANCE

When undertaking SMBC, the physician two internship stages; one of six College of Sports Medicine and Trauma can perform the learning either months in a sports medicine functional Teachers (for all aspects of sports immediately after their medical thesis, exploration department and another medicine education) and the National or several years after. This education is six months in a sport orthopaedic Professional Council of Sport Medicine performed in approximately 20 countries department. After thesis, the physicians (for all aspects of professional practice). (several schools of medicine gather perform another practical year, called An aim of these associations is the together) and lasts only one year with post-internship, in accredited development of the post graduate approximately 120 hours of theoretical departments of hospitals, clinics or training in sport medicine included in learning on all fields of sports medicine medical centres in high level sport the post graduate training for all French (physiology, orthopaedics, cardiology, institutes (e.g. National Institute of physicians called DPC (Développement physical activity for health, doping). Physical Education, National Institutes Professionnel Continu), i.e. Continuous Forty half days of practical education for Soccer or for Rugby). During these Professional Training. In 2014, the first in accredited hospitals, clinics or medical two years, six periods of three days of official sessions were held during the centres within high level sport institutes theoretical knowledge complementing national meeting of the Sport and are also required. The final diploma is the knowledge acquired during the Exercise Medicine French Association, delivered after a written examination, internship stages is completed. The one on the nutritional aspects of sport with added oral examination depending diploma is delivered at the end of the medicine and the second on medical on the school of medicine. Numerous post-internship, during a national ‘prescription’ of physical activity in physicians seek even greater knowledge examination (usually the day before the chronic pathologies. And very recently, and complement their existing studies annual meeting of the Sport and Exercise the French Parliament voted for a law with specific university diplomas, such Medicine French Association). This on the Prescription of Physical Activity as sport trauma medicine, undersea and examination is based on the appreciation as part of the treatment for long term hypobaric medicine, mountain and of a written report based on original affections. Looking to the future, in emergency medicine, and nutritional research work which is orally presented. 2020-2021, the DESC and SMBC will aspects of sport, to name a few. Taking into account the relatively small be replaced by a Transverse Specialist number of possibilities in post-internship Training (Formation Spécialisée Since 2002, a more specialised path than stages, only one ‘student’ per university Transversale) which is currently being SMBC has become possible. It is called and per year can perform the DESC developed. Specialised Complementary Study (20-24 per year for the whole of France). Diploma, i.e. in French, DESC (Diplôme ABOUT THE AUTHOR d’Etudes Spécialisées Complémentaires). Learning in medicine is never finished. Compared with SMBC, the main interest Professional training in sports medicine D Riviere, MD, PhD is the is the practical training. This education is can be undertaken by joining the Sport Vice President of the Sport not accessible to physicians who have and Exercise Medicine French Association and Exercise Medicine French already completed their studies (they can and attending the national meeting Association and President of the only undertake SMBC) but is available to and/or by joining regional affiliated French College of Sport Medicine those involved in the internship part of associations. More recently, two new and Trauma Teachers. the diploma as this education includes ‘authorities’ were created – The French

VOLUME 34 • ISSUE 2 2016 25 INTERVIEW WITH JESSICA TRENGOVE INTERVIEW WITH... JESSICA TRENGOVE MARATHON RUNNER, 2014 COMMONWEALTH GAMES BRONZE MEDALLIST, AND PHYSIOTHERAPIST.

SPORT HEALTH INTERVIEWED MARATHON RUNNER AND 2014 What are your hopes for the Rio Olympics? COMMONWEALTH GAMES BRONZE MEDALLIST, JESSICA TRENGOVE IN THE LEAD UP TO HER SECOND OLYMPIC GAMES My hopes in the race are to achieve a personal best performance. Ultimately AND DISCUSSED HER PREPARATION FOR RIO, RELATIONSHIP this would be in the form of a time below WITH HER SPORTS MEDICINE SUPPORT TEAM AND 2 hours 27 minutes and 45 seconds but given the unknown conditions for this PHYSIOTHERAPY BACKGROUND. Marathon my coach and I will set a more specific target in the couple of days before the race. I hope to cross the line Firstly, congratulations on being in Rio feeling proud of the way I prepared runs of between 90 minutes to 2.5 hours and raced for Australia and to be selected for the Rio Olympics. – usually on a Wednesday and Sunday. confident that I got the most out of How are you feeling about it all Mondays and Fridays involve a light to myself. As for the Rio Olympics in general, with less than two months to go? steady running or cross training session, I hope to have a fantastic time, to learn a followed by gym. The focus of my gym lot from the experience and to support Thank you. I cannot believe I will be sessions is to condition the stabilising my teammates in as many events leaving for the Australian team pre- muscles specific to running, achieve as possible. Olympic camp in just over five weeks! functional mobility and reinforce optimal Excitement and anticipation about seeing movement patterns for injury prevention. *NOTE: Jess Trengove finished 22nd Rio, moving into the Olympic Village and in the women’s marathon at the Rio of course, race day is building at a fast Tell us about your relationship Olympics in a time of 2:31:44. rate. I look forward to getting another with sports medicine month and a half of solid training and What is your recovery preparation under my belt before the professionals in the lead up Marathon taper begins. to an event and during an like after a marathon? event such as the Olympics? What has been/is your training I like to take it easy for two to four weeks, The team of health professionals who depending on what competitions I have regime in the lead up to Rio, support me pre-, during and post-event coming up. My coach doesn’t set specific i.e. when did you start, how often play an integral role and I am very grateful sessions during this time. Instead, I listen are you training, at what capacity, to have the support of such passionate, to my body and go for light jogs or cross types of training, locations of generous and understanding people. training sessions as I feel appropriate. training? Over the past four years I have worked Usually the delayed onset muscle closely with the South Australian Sports soreness is greatest in my calf muscles My coach, Adam Didyk and I are basing Institute (SASI) and Athletics Australia but the mental break from heavy my preparation on what has worked sports doctors, my physiotherapist, training is just as important as the previously and what areas we can podiatrist, massage therapist and gym physical recovery. progress. I have run six to date coach to ensure that my body responds so am fortunate to have the conditioning positively to the training program set by Let’s rewind to the start. in my legs and experience under my belt my coach, Adam Didyk. Sessions with from those events. Ultimately I am aiming SASI’s exercise physiologist, sports Tell us about becoming to achieve consistency and quality with dietitian and sports psychologist have involved in marathon running. my training. also helped me to get more out of myself as an athlete. These sports medicine We had a fantastic sporting culture A typical training week includes two key professionals know me well as a person in my home-town of Naracoorte. My interval or repetition sessions and a third not just as an athlete. They have all played primary school was surrounded by a pine session of either fartlek or threshold a part in assisting me to develop my forest and cross-country was a big event running. My program often also features knowledge and skills whilst also helping on the calendar every year. After opting a light recovery jog or some form of cross me to achieve a positive head-space to sit on the sidelines because of nerves training on these days. I perform two long for optimal performance. during my first opportunity to race as a

26 VOLUME 34 • ISSUE 2 2016 INTERVIEW WITH JESSICA TRENGOVE

six year-old, I soon discovered a love a member of the ASICS team and am for endurance running! At the age of so happy with their footwear, clothing twenty-one I started to train more and apparel as well as the working seriously for running and decided to relationship that we have developed over stop playing netball to free up my the years. My favourite pair of ASICS weekends for running. After my first half shoes are the DS racer and I have worn marathon in 2010, I was excited about this shoe for my past four Marathons! the prospect of testing myself over the full Marathon distance one day. In March You are also a trained of 2012 my coach and I decided to attempt an Olympic qualifying standard physiotherapist. Why for the London Olympics at the Nagoya physiotherapy? Does your Marathon in my debut over the distance physiotherapy knowledge – we figured we had nothing to lose. help with your marathon running at all? What are some of the I initially dreamed of being a Veterinarian injuries you’ve dealt like my Dad but didn’t feel ready to travel with over your career? to Murdoch University in Western Australia in my first year out of school. I have experienced a proximal hamstring Consequently, I enrolled in Physiotherapy insertion tendinopathy and a second at UniSA to see what it would be like and metatarsal bone injury in each foot. I never looked back. I love learning about the human body and feel that my How have sports medicine physiotherapy knowledge helps me get the most out of my own. I also love professionals aided in your encouraging people to be active and recovery of injuries? helping others to enhance their general wellbeing by having a body Sports medicine professionals have that operates well! helped me with the diagnosis and management of these injuries. Following How do you achieve assessment, imagery was arranged to help determine the best management work/training balance? approach. From there, my physiotherapist, podiatrist and gym I find that my physiotherapy work and trainer worked closely with my sports ambassador roles complement my doctor and running coach to plan my running. They are a helpful distraction rehabilitation. Manual treatment, active outside of training and provide an management strategies, taping, in-shoe additional source of fulfilment and orthoses, specific exercises, cross training inspiration. The balance is best achieved and progressive running training are for me by having a list to work through some of methods that were discussed each day, having an organised diary, among the team. getting enough sleep for my body’s needs and having a supportive group around me Obviously shoes are an important – my family, boyfriend, coach, manager at Stride sports, training squad, employers, part in any marathon runner’s life. sports medicine team and friends. Tell us a little about your involvement with ASICS. What are your goals for I have been an ambassador for ASICS the rest of 2016/2017? since 2013. I have really enjoyed being My goals for this year are to put my best foot forward at the Rio Olympics and produce a result that Australia, my team FAVOURITES and I can be proud of. Beyond Rio I look Athlete: and Cuisine: Thai. forward to becoming an Auntie for the first time and enjoying some travel before David Rudisha. Movie: Notting Hill. getting back into a set running routine. Travel destination: Italy, Song: Toto – Africa. I look forward to 2017 and the Germany and Switzerland – opportunities that lie ahead but at hoping to add Brazil to this list too. Book: Open by Andre Agassi and Running for my life by this stage have not set any specific Sport to watch: Tennis, Lopez Lomong. sporting goals. gymnastics and a good game of AFL. Gadget: Garmin Forerunner 630.

VOLUME 34 • ISSUE 2 2016 27 FEATURE EXERCISE AND THE MENSTRUAL CYCLE EXERCISE AND THE MENSTRUAL CYCLE… WHERE IS THE RESEARCH?

PHD STUDENT, GEORGIE n January 21 2015, the taboo WHY DO WE NOT KNOW is broken, British tennis THE POSSIBLE CAUSES FOR BRUINVELS SUGGESTS superstar Heather Watson PERFORMANCE IMPACTS MORE NEEDS TO BE bows out of the first round FROM THE MENSTRUAL Oof the Australian Open citing that her CYCLE? DONE TO ALLEVIATE menstrual cycle prevented her from THE MENSTRUAL CYCLE playing to her best. Since then numerous Female representation in research global sports stars have spoken out, is greatly lagging behind that of men. EFFECT ON EXERCISE highlighting that their performance has The reasons for this are largely historical PERFORMANCE IN ELITE been affected by their menstrual cycle. – traditionally, and largely because of concerns over damaging unborn babies WOMEN ATHLETES. Our research group recently found nearly research was predominantly conducted in half of the 1,862 people questioned feel men. In the past females and males were that their menstrual cycle affects considered to be the same except for the their exercise performance, with this difference in reproductive hormones increasing to 51.1 per cent in those who which was initially thought to be are of an elite level. But why is this the insignificant. When it was subsequently case, and surely something can be done appreciated that women are much more about it? The crazy thing is that the biologically variable than men it was too answers to this are as yet inconclusive. late, there was too much ground to make So how is it that in the 21st century when up. As scientists we are always guilty of driverless cars are in operation and trips wanting to progress research, not go back to Mars are on the horizon we still don’t and repeat it. As a result, the research know the answers to this. gender gap has grown. From a more medical perspective numerous laws have The participation of girls and women in been passed in an attempt to try and exercise has exponentially increased over address this, and female representation the past 30 years. The Olympics in Rio is gradually starting to increase in the broke previous records with 45 per cent world of sports and exercise medicine. of the total participants being female, However, potentially the most concerning the greatest to date. The Australian fact is that typically when research has team actually has a 52:48 split with involved women it doesn’t explore the more women competing than men. possible impacts that the menstrual cycle may have. Most studies: While this is brilliant and hugely positive, it doesn’t stop the Heather Watson type 1. Are conducted at one specific phase of scenarios. To avoid putting off future the menstrual cycle (days 1 to 5 of the participation or holding women back follicular phase), as here hormone from performing to their best something levels are at their lowest and the needs to be done about it. female hormonal profile is actually

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VOLUME 34 • ISSUE 2 2016 29 FEATURE EXERCISE AND THE MENSTRUAL CYCLE EXERCISE AND THE MENSTRUAL CYCLE… WHERE IS THE RESEARCH?

most similar to that of a man, physiological functioning. Therefore, diminishing or even removing the factoring for the menstrual cycle is likely potential impacts that the ovarian to be costly, and more time consuming, as hormones may have. more tests will be needed. In comparison men can be tested at any point due to the 2. Only test women who are taking significantly smaller biological variability. the oral contraceptive pill so their physiology is much less variable. SO HOW COULD THE MENSTRUAL CYCLE BE 3. Disregard any effects of the menstrual AFFECTING EXERCISE cycle whatsoever so don’t include this PERFORMANCE? as a potential factor/confounder. There are a whole range of different WHY ARE WOMEN MORE hypotheses suggesting how and why BIOLOGICALLY VARIABLE? performance may vary at different THE SCIENCE menstrual cycle phases, the majority of these are likely to be driven by the Typically, from the ages of 13 to 50 years, changes in hormone levels. Some suggest females experience a predictable that muscular strength increases fluctuation in ovarian hormones over proportionally with oestrogen levels, an average of 23 to 38 days, called the so females feel at their strongest around menstrual cycle. It can be split into two ovulation. While ACL injury risk is also main phases, the follicular phase (days 1 said to increase at this time as a result to 14] and the luteal phase (days 15 to 28), of increases in joint laxity. Some suggest with ovulation occurring between. The that fuel utililisation can vary, in addition sex hormones oestrogen (oestradiol) and to endurance capacity, lactate production, progesterone are primarily responsible blood pressure or even immunity. Many for driving the changes that take place. feel that they put on weight or retain These are regulated by a feedback system water at certain times, while others that involves two hormones which are definitively cite that they perform best secreted from the pituitary gland located at one particular time. However, evidence in the brain – follicle stimulating hormone is largely inconclusive and more extensive (FSH) and luteinising hormone (LH). research is required.

Menstrual bleeding occurs at the The oral contraceptive pill is another beginning of the follicular phase marking option often used to gain control of the day 1 of the cycle and typically lasts 3 menstrual cycle, however both the long to 7 days. During this time levels of and short term repercussions of this are oestrogen and progesterone are very unknown. With a number of different low. Oestrogen and progesterone then pills on offer and varying responses begin to increase towards the end of seen it is hard to pass judgement. the follicular phase in preparation for ovulation. After ovulation oestrogen falls Somewhat surprisingly we recently found but progesterone still gradually increases heavy menstrual bleeding to affect more into the luteal phase. Oestrogen then than one third of marathon runners starts to increase again. Towards the end (n=1073), and remarkably, this was as of the luteal phase both hormones fall, common amongst elite athletes. Heavy marking the premenstrual period, and menstrual bleeding is associated with the cycle begins again. an increased risk of iron deficiency, and since those with heavy menstrual As is evident therefore the menstruating bleeding were more likely to cite that female body is constantly changing, so their menstrual cycle impacts upon their women have to be tested many times exercise training and performance it throughout their cycle in line with the could be suggested that a possible cause hormonal variation to gain a full for poor performance could be iron understanding of biological and deficiency be it known or unknown.

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Regardless of heavy menstrual bleeding suffering from premenstrual distress those who exercise have an increased of some sort, and with more than 200 susceptibility to iron deficiency due to symptoms it cannot be ignored. small iron losses occurring as a result of foot-strike haemolysis (destruction While records have been broken at all of blood cells caused by foot impact), phases of the menstrual cycle, this taboo sweating, haematuria and gastro- cannot be ignored much longer. Women intestinal bleeding in some cases – will line up on the start line knowing that Numerous global exacerbating iron deficiency risk someone else is likely to be in their sports stars have amongst this population. situation, however we need to address this head on, and not allow the menstrual spoken out, highlighting However, prior to drawing this conclusion cycle to get in the way of females the impact of iron deficiency on exercise performing at their best. that their performance capacity needs to be ascertained and this has been affected by is what we are currently researching. ABOUT THE AUTHOR their menstrual cycle. WHAT CAN BE DONE NOW? Georgie Bruinvels is a PhD student Women have learnt to ‘just get on with at University College London in it’, and with many male coaches in sport, collaboration with St Mary’s females often do not feel comfortable University and a Research Scientist discussing menstrual issues, but with 75 with Orreco. to 85 per cent of all menstruating females

VOLUME 34 • ISSUE 2 2016 31 FEATURE EXERCISE, BREASTS AND BRA FIT EXERCISE, BREASTS & BRA FIT

APA SPORTS PHYSIOTHERAPIST AND RESEARCHER FROM BREAST RESEARCH AUSTRALIA (UNIVERSITY OF WOLLONGONG), DR DEIRDRE MCGHEE EXPLAINS HOW WOMEN CAN ENSURE THEIR BRA IS SUPPORTIVE AND CORRECTLY FITTED WHEN THEY ARE ACTIVE.

reast support during physical activity is an important but often neglected women’s health issue. In 2011, Sports Medicine Australia Bbecame the first medical organisation in the world to develop evidence-based guidelines for women on breast support and bra fit during exercise. In conjunction with researchers from Breast Research Australia (University of Wollongong) they published Exercise and Breast Support as one of their Women in Sport Fact Sheets. This free resource helped to raise the profile of this sensitive topic and

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Figure 1: Three-dimensional sinusoidal motion. Left photo: Breasts at high point with left forward arm swing; Middle photo: Breasts at low point; Right photo: Breasts at high point with right forward arm swing.

educate clinicians, coaches and female breasted3. Breast size is measured more by a bra is required by women once athletes on how to achieve sufficient accurately in biomechanical studies as they reach their 40s. breast support and correct bra fit to a volume measurement from a three- allow women to exercise in comfort and dimensional scan of the breasts and HOW CAN I TELL IF MY maximise their athletic performance. trunk. Breast volumes can range from SPORTS BRA IS SUPPORTIVE 75ml to 2,500 ml per breast 3, 4. A size ENOUGH? BREAST BOUNCE 10D breast may be 400ml while a 16D may be 1,500ml3. Generally, breasts There are three major considerations During activities such as running, the over 500ml are considered to be large to determine if you have sufficient breasts move in a three-dimensional breasted. The larger the breasts, the breast support: sinusoidal motion, following the greater the breast movement, breast movement of the trunk and arms force, breast slap and not surprisingly, 1. Magnitude of breast movement (Figure 1). This movement is called associated breast discomfort5. Breast movement will vary with the “breast bounce”. The breasts move in an Consequently, women with larger breasts exercise a woman performs. As a anterior/posterior and medial/lateral require a higher level of breast support general rule, the more the trunk direction following arm swing and trunk provided by a bra. moves, the more the breasts will rotation, and in a superior/inferior move5. The breasts will move more direction following the vertical movement THE EFFECT OF AGE during running compared to walking, of the body and trunk1, 2. The downward ON BREAST SUPPORT during horse riding compared to vertical motion of the trunk and, in turn, cycling. Therefore, women need to breasts is halted with heel strike. Any lag The breasts have their own anatomical consider how much trunk movement in time between when the trunk and the support structure, the overlying skin and will occur during their chosen exercise breasts stop their downward motion a three-dimensional fascial network and the force of their arm movement results in “breast slap”, where the breasts within each breast5. Research has found (tennis compared to badminton) to slap against the chest or abdominal wall1. however that the skin of the breast thins determine how much breast support and decreases its elasticity with age. they need. The greater the trunk THE EFFECT OF BREAST A significant decline in breast skin movement and the greater the force SIZE ON BREAST SUPPORT thickness has been found to occur by the of the arm movement, the higher the fourth decade6. This means that the level level of support required. It is not Breast size is usually measured by bra of support provided anatomically is also possible to completely stop breast size, with bra sizes greater than a D cup likely to decline with age and that a higher movement however it should be generally considered to be large level of external breast support provided minimised by a high support bra.

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Breast Research Australia has uncomfortable to wear7. Breast of the lower limb (running versus developed a web-based App called movement and discomfort should jogging), the greater the magnitude Sportsbra (https://bra.edu.au/ be minimal BUT the sports bra of breast movement also8. sportsbra/) that uses high-speed MUST also be comfortable to wear! movies to guide women on WHAT DOES A HIGH SUPPORT ‘acceptable’ and ‘unacceptable’ 3. Number of breast bounces SPORTS BRA LOOK LIKE? amounts of breast movement. The Women are often very shocked by the high-speed movies are of women with number of times their breast bounce Sports bras come in two basic designs; small, medium and large breasts. during an exercise session. The breasts crop top sports bras (which compress the bounce every time the heel strikes the breasts as a unit against the chest wall) 2. Level of discomfort ground. During a 60-minute run, this and encapsulating bras (which encase In conjunction with breast movement, would approximate 10,000 breast each breast separately in a cup – these Sports Medicine Australia and Breast bounces5. The higher the total number bras come both with and without Research Australia also recommend of breast bounces, the higher the level underwire [soft-cup bras]). Research that women use breast discomfort of support required. Therefore, women has found encapsulating sports bras during exercise as a guide of adequate involved in hours of exercise per week are superior to crop top sports bras in breast support. Breast discomfort that involves running and jumping, limiting breast movement9. Therefore, during exercise should be nil to mild need a high level of breast support encapsulating sports bras are with adequate breast support. Both even if their breasts are NOT a large recommended for women with large the bra and the breasts need to be size. Furthermore, biomechanical breasts, however women with bra sizes comfortable. Sports bras that are studies measuring breast movement greater than a DD size cup may require very constrictive can be have found that the faster the cadence two bras (an encapsulating sports bras with a crop top worn over it) to achieve an acceptable level of breast movement and comfort.

The basic features of high support crop tops and encapsulation sports bras are similar:

• Band: made of strong elastic material, wide enough relative to the breast mass (A cup – 1 clip wide; B/C cup – 2 clips wide; D+ – 3 clips wide).

• Cups: cover the breasts completely by supportive material (not lace/lycra).

• Straps: wide and padded for comfort.

Figure 2: Top two photos: High support crop top sports bra. Below two photos: High support encapsulation underwire sports bra.

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The presence of underwire is a personal preference. If women choose to wear an underwire sports bra it is vital that it fits correctly. That is, the underwire must sit on bone (ribs and sternum) – NOT breast tissue. Depending on the shape of a woman’s breast, correct underwire fit may NOT be possible. There are many soft-cup encapsulation sports bras on the market that provide a high level of breast support.

CHANGE ROOM TEST

When trying on a new bra, women are recommended to perform a version of the exercise they plan to participate in within the change room to assess if the bra provides adequate breast support. Breast movement should be an ‘acceptable’ (as per the web App Sportsbra), breast discomfort should be nil to mild and the bra should be Figure 3: Top two photos: Side-view correct and incorrect underwire fit, with the comfortable to wear. Research conducted underwire sitting on ribs in the first photo and on breast tissue in the second photo. by Breast Research Australia has found Below two photos: Front-view correct and incorrect underwire fit, with the underwire that 85 per cent of women are wearing sitting on the sternum in the first photo and on breast tissue in the second photo. the wrong size bra10, 11. Wearing the wrong size bra is not only uncomfortable; it will also affect the level of support the sports bra provides. That is, a high support sports bra in the wrong size, will not be supportive as per its design. Correct bra Proof08 25.11.11 fit is as important as a supportive sports The SMA Exercise and Breast Support bra design! Women in Sport Fact Sheet can be a useful icebreaker of this important WHAT IS CORRECT BRA FIT? women’s health issue for coaches and clinicians, as well as an educational Exercise and • Band: does not ride up with movement resource for any active female. The ability breast support of arms (too big), no flesh bulging over to find a comfortable, supportive bra that A guide to understanding breast support during physical activity and how the superior edge of the band (too fits correctly is fundamental to keeping to determine correct bra fit small). women both active and healthy throughout their lives. • Cup: no wrinkles or gaps (too big), no bulge of breasts over the top or sides of the cup (too small).

• Straps: not sliding off (too big), or digging in (too small). ABOUT THE AUTHOR • Underwire: sitting on ribs and sternum, not on any breast tissue (too small). Dr Deirdre McGhee is an APA Sports Physiotherapist and • Front band: sits flat against sternum. researcher from Breast Research Australia (University of Wollongong).

VOLUME 34 • ISSUE 2 2016 35 FEATURE ACTIVE MUMS ACTIVE CHILDREN

DO ACTIVE MUMS HAVE ACTIVE CHILDREN? RESEARCHER, KATHRYN HESKETH PROVIDES INSIGHT INTO HER STUDY WHICH LOOKED AT THE RELATIONSHIP BETWEEN PHYSICAL ACTIVITY IN MOTHERS AND THEIR PRESCHOOL AGED CHILDREN.

mongst sport, academic and health professionals, it is well RECOMMENDED GUIDELINES known that physical activity is beneficial for physical health ADULTS: 150 minutes of moderate Aand mental wellbeing, in both adults and to vigorous physical activity (ideally children. Higher activity levels are also on five or more days) per week. related to improved metabolic health, social and motor development, and PRESCHOOLERS: 180 minutes of any decreased adiposity in very young activity above sedentary each day. children (2 to 5 years).1 Yet despite these benefits, there is a general decline in But it is not only their own activity levels activity levels throughout childhood that may be affected, as parents also into adulthood. This lack of physical influence their children’s behaviour activity is particularly marked, perhaps across a range of domains. Importantly, unsurprisingly, during the childbearing behaviours established in young children years: new parents are usually less active during the early years have a large than their childless peers, and often fail influence on their future health and to accrue the recommended levels of development. The mechanisms activity each day.2 Worryingly, activity suggested for the relationship between levels in new parents frequently fail to parental-child activity can be direct and/ return to pre-parenthood levels. or indirect, ranging from genetics,

36 VOLUME 34 • ISSUE 2 2016 FEATURE ACTIVE MUMS ACTIVE CHILDREN through modeling or support, to mutual participation. Engaging in activity together seems to be important for activity levels in school-aged children, but there is less evidence that this is the case in younger children. However, studies have often used different methods of data collection, and in particular, the use of self-report measures to assess physical activity. We therefore conducted a study using an objective measure of physical activity – the Actiheart, a light-weight heart-rate accelerometer – to look at the relationship between physical activity in mums and their preschoolers.

We used data from the Southampton Women’s Survey (SWS), a population- based longitudinal cohort study based in Southampton, UK. Women in their 20s and 30s were recruited during pregnancy from General Practices during the late 1990s, and those that went on to have live births have been followed up, along with their children, at various intervals since.3 Children turning four in the late noughties and their mothers were invited to take part in a sub-study to assess their habitual or daily physical activity. Mother- child pairs both wore an Actiheart activity monitor for seven days continuously, and completed a validated questionnaire to provide background socio-demographic data. Physical activity was then matched exactly in the pairs by hour and day (excluding sleep) to provide a like-for- like comparison between mother-child physical activity levels.

INTENSITIES OF PHYSICAL ACTIVITY with examples4,5

Sedentary (1-1.4 METs): Sitting quietly, reading.

Light (1.5-2.9): Standing, slow walking.

Moderate-to-vigorous (MVPA; >3.0): Walking, running, playing with balls, skipping.

VOLUME 34 • ISSUE 2 2016 37 FEATURE ACTIVE MUMS ACTIVE CHILDREN

DO ACTIVE MUMS HAVE Undoutbedly, the role of mums, be it through co-participation, facilitation or ACTIVE as a role model, is very important for CHILDREN? their child(ren)’s physical activity.

By far the largest sample of mother- activity. Though the evidence base is weekends to get out and get active as a child dyads assessed to date, we included less well formed and more studies are family. Anna, who has a 7- and 4-year old, data from 554 mothers and preschoolers. needed, dads likely compliment maternal and is currently also pregnant, said that We found that daily activity levels were influences on physical activity, engaging they often went out as a family “to the positively associated across a range of in active play with children at different swimming pool on Saturday morning or intensities (i.e. sedentary, light and times of the day and week. Indeed, we historical places of interest, where the moderate-to-vigorous activity[MVPA]).6 found that the relationship between children can run around.” So for example, for each additional 10 mother-child activity was stronger at the minutes of MVPA a mum did each hour, weekend for light activity and during the Though we looked at the relationship her 4-year-old was 4 minutes more week for MVPA. Speaking to mothers of between mother-child pairs, we also active. Whilst this doesn’t sound like a lot, 4-year-old children, this seems to hold explored women’s physical activity levels mothers who met the recommended true. Jess, a mother of a 4- and 2-year- in more detail. As is the case with many guidelines (i.e. 30 minutes of MVPA per old stated that her partner ‘took over’ the adults, only 53 per cent of the women we day) had children who did 12 minutes childcare at weekends, allowing her to get assessed managed to get 30 minutes of more MVPA on average each day on with household chores: “[He] will take moderate-to-vigorous physical activity compared to children of mothers who them out at weekends – maybe to the on at least one day per week.6 Moreover, engaged in no physical activity. When park or the swimming pool in summer higher BMI was related to increased combined over the course of the week – to get them out from under my feet. sedentary and decreased light physical and month, this can add up to a large I’m running around after them during activity. And the number and amount of additional physical activity. the week, so it gives me age of children at chance to get things home, and Due to the way data were collected, we done”. Others women’s weren’t able to tell exactly what mothers may use the working and their children were doing when they were active: active kids likely require mums to run around after them, and active mums may encourage their children to get moving. In reality, it’s probably a bit of both, but even if mums aren’t active with their children, they can still help promote physical activity by providing a positive active environment, encouraging active play, and being a positive role model. Our results also suggest that by encouraging the lesser-active of a mother-child pair to move a little bit, it might be possible to boost activity in the other.

Of course the role of fathers should not be discounted, and smaller studies have shown that fathers also influence their children’s physical

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hours also seemed to influence women’s inactivity/activity.

This seems perfectly feasible. But whilst we found that the more hours a woman worked, the less active she was, it is also important to consider just what women are doing at work that might contribute to their physical inactivity/ activity. For example, as a Pediatric Accident and Emergency Nurse, Anna works two 12 hour shifts per week – but as the shift lead, this involves being Taken on her feet for at least 11 hours, with together, rarely a moment to sit down. When she both our work gets home, understandably she flops. and first-hand In contrast, Jess “sits on [her] bum for accounts from mothers of eight hours a day at work. But there is a preschoolers highlight that many it is – far greater than the sum of their gym near work so I tend to pop out during factors contribute to inactivity/activity individual parts. Physical activity is vitally my lunch hour most days to do a class. in women and their children including important for health and wellbeing, but It means I don’t need to worry about time constraints; varying degrees of it does not have to be synonymous with additional childcare in the evening.” fatigue and partner support; the cost and hours at a gym or in organised classes. availability of childcare; and opportunities Simply by ‘moving a bit more, sitting a Women with children of differing ages to be active. These also represent just bit less’, mums and practitioners alike are also likely to face differing challenges some of the competing demands that can ensure that our children remain both in and outside the home. Anna must be balanced in order for women and active today, and do not become the explained “When Jack was four, Sara their children to meet activity guidelines inactive parents of tomorrow. was one, so I was limited to what I could over the course of a week. do. When Jack was at school I would walk for an hour about once a week with Sara Undoutbedly, the role of mums, be it ABOUT THE AUTHOR in her pram. But she was a physically through co-participation, facilitation or demanding baby and I had very little as a role model, is very important for Dr Kathryn R. Hesketh is a energy so the most I could manage was their child(ren)’s physical activity. Sir Henry Wellcome Postdoctoral keeping up with the housework, with the Yet considering how all members of Fellow at the Centre for Diet and occasional trip to the park with both of a household can contribute is likely Activity Research (CEDAR). them. But when Sara turned three and to provide the greatest number of started preschool, I joined the gym. opportunities to boost physical activity. I could do a couple of classes a week and With siblings and parents influencing also swim when Jack was at swimming each other’s activity, positive gains are lessons. My husband also helped out with likely to occur when practitioners harness the childcare on the odd evening too.” the family’s potential, seeing it for what

VOLUME 34 • ISSUE 2 2016 39 SPORT TRAINERS GUIDE SPORT TRAINERS GUIDE FRACTURES

SPORTS MEDICINE AUSTRALIA PROVIDES SPORTS TRAINERS WITH ADVICE ON HOW TO MANAGE FRACTURES EFFECTIVELY.

A fracture is an injury where bone tissue • Call for an ambulance or medical loses its normal structure, usually as assistance. a result of direct or indirect trauma. • Control bleeding if there is an open Although many fractures are not wound and cover it with a sterile immediately life threatening, fractures dressing to reduce infection. can cause shock and major internal • Check that circulation is present distal and external bleeding. to the fracture. If not, call for urgent medical aid. SIGNS OF A FRACTURE • If the athlete needs to be moved, • Deformity – the affected part immobilise the area of the suspected is changed in shape. fracture first. • Bone protruding from an open wound. • Immobilise the injured limb in the • Localised swelling. position you found it. • Movement in a limb occurring other • Be sure to immobilise the area above than at a joint. and below the fracture. • Loss of normal movement or function. • If the fracture needs to be splinted, • Signs of shock. the splint must be long enough to extend past the joints above and below SYMPTOMS OF A FRACTURE the fracture site as well as wide enough • Pain and tenderness at the site. to support the fracture site. • The sound of a snap or pop at the • Check the athlete for other injuries time of injury. and treat appropriately. • Feeling/sound of bone ends grating. • Apply ice packs or cold compresses, • Tingling or numbness. if possible, for up to 20 minutes if pain • Symptoms of shock. permits. Reapply ice every two hours if necessary. Do not apply ice to open MANAGEMENT OF fractures. FRACTURES • Assess for shock and treat as required. Acute management of fractures depends on the location of the injury and the type Want to learn more on managing of fracture; however, for the purposes fractures? Sports Medicine Australia of providing immediate treatment, the runs a range of sports safety courses. following steps apply to most fractures. Visit sma.org.au for more information. • Follow DRSABCD principles as appropriate. • If the athlete is conscious, reassure them and advise them not to move.

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FRACTURES

VOLUME 34 • ISSUE 2 2016 41 PEOPLE WHO SHAPED SMA

PEOPLE WHO SHAPED SMA JENI SAUNDERS JENI SAUNDERS’ START IN SPORTS MEDICINE BEGUN DURING educating doctors in this specialty. Jeni is still very active in ACSEP Committees and MEDICAL SCHOOL WHEN PLAYING SPORTS FOR UNIVERSITY. continues to advocate for her profession UPON TEAM MEMBERS ASKING HER ADVICE ON INJURY amongst medical colleagues.

TREATMENT SHE QUICKLY REALISED NO ONE SPECIALISED IN Jeni’s career begun when Sports or NON-OPERATIVE CARE. HER INTEREST IN SPORTS MEDICINE Exercise Medicine was not common practice. She ‘made it happen’. She WAS THUS BORN AND SHE BEGAN RESEARCHING VARIOUS opened her clinic door and the injured INJURIES TO PASS ON HER KNOWLEDGE. came (it took a while though!). During this time, she was also the Team Doctor for St George Rugby League Football Club and Jeni undertook her undergraduate on to assist and teach the initial post- travelled with the Australian Women’s medical degree at the University of New graduate course run by the Royal Hockey Team. South Wales and spent three years within Australian College of General the hospital system. She established her Practitioners and is a Founding Member Her work also includes being a volunteer sports medicine clinic shortly after. At this and Fellow of the Australasian College of doctor on the Westpac Rescue Helicopter time there were no formal post-graduate Sports and Exercise Physicians (ACSEP) and was Medial Director for a period of programs for sports medicine. She went – a college dedicated to promoting and time. Later she became a founding

42 VOLUME 34 • ISSUE 2 2016 PEOPLE WHO SHAPED SMA

Pictured from left: Ian Badham, Peter MacCormick, Jeni Saunders, Rick Mailey and John Hoad. Some of CareFlight’s founding members came back to our Westmead base on July 29 to celebrate CareFlight’s first flight 30 years ago. A MOMENT WITH JENI

What have been your career highlights?

Attending my first Olympic Games as a Medical Officer, becoming a Founder of a new Medical College and securing the College Specialist Registration, and being a Founding Director of CareFlight.

What do you believe is your most important contribution to your industry?

I am very proud to be a founder of the Australasian College of Sports and Exercise Physicians. I am also proud that I was the first woman to be allowed into a professional Rugby League dressing room, paving the way for women in our profession. I have never considered my ability to be a good professional was impeded by my gender so I have never let it get in the way.

What is your advice to those starting out in their career?

Follow your passion, listen and work hard!

Do you have any career regrets?

Not really. It has been a highly varied, interesting career so far. I have met many wonderful people and had the opportunity to work with some amazing JENI SAUNDERS colleagues. Director of CareFlight – a medical Secretary and then National Councillor – Jeni currently works as a self-employed evacuation, rescue and retrieval positions she held for many years. Sports and Exercise physician working in helicopter service based in Sydney which More recently she has re-joined the NSW private practice, predominantly in Sydney now has a presence in other states of Committee and has been Vice President. with a travelling component to the Alpine Australia and will celebrate its 30th region of NSW to look after NSW anniversary later this year. Some of the major initiatives Jeni has Institute of Sport winter athletes. been involved in during her time with Since the early years she has travelled SMA include: the initial development of with Track and Field, Women’s Volleyball, the Sports Trainer Course and developing Netball, Swimming and attended the this as a two tier program, establishing as a Team this course as a pre-requisite for trainers Medical Officer. in the Australian Rugby League (then the NSW Rugby League), and being Over her career, Jeni has played a leading appointed to the NSW Ministerial role in Sport Medicine Australia (SMA). Committee on Women in Sport which She joined SMA as a student member provided a great avenue to promote the and shortly after she graduated she was role of sports and exercise medicine and involved in the NSW Council. From there the role in which SMA plays in this. she became a Council Member, Treasurer,

VOLUME 34 • ISSUE 2 2016 43 COUNCIL OF DISCIPLINE NEWS AND EVENTS

COUNCIL OF DISCIPLINE NEWS AND EVENTS

CALENDAR Australasian Academy of Podiatric Sports Medicine (AAPSM) SEPTEMBER 2016

The AAPSM national regional series came to the Gold Coast at Metricon 16 Stadium in July. Sixty delegates attended the full day lower limb seminar. Sports Physiotherapy Australia Presenters included sports physicians, physiotherapists, podiatrists, a Mastering Lower Limb Tendinopathy musculoskeletal physician and a dietitian. Other recent events around the with Dr Peter Malliaras, Eights Mile country have included strapping workshops, running load management, Plains, QLD and footwear research and development.

It is a jam-packed final half to 2016 for AAPSM! AAPSM will launch the 21 sports career pathway, run a pre-conference workshop before the SMA Sports Physiotherapy Australia Conference featuring Professor Jay Hertel on the unstable ankle and host a Lateral Hip Pain – Why It’s Probably regional series in South Australia, Western Australia, Victoria and Tasmania. NOT Hip Bursitis, Camberwell, VIC 24 Australasian College of Sport and Sports Physiotherapy Exercise Physicians (ACSEP) Mackay Sport and Exercise Medicine Australia (SPA) Symposium 2016, Mackay, QLD The Australian Physiotherapy Association now offers more courses in more areas to Sports Physiotherapists after centralising their professional development management. OCTOBER 2016 Check out some of the courses below. 4 SPA is a member of IFSPT. If you are a Titled Sports Physiotherapist you can apply for reciprocal recognition Sports Physiotherapy Australia as a Sports Physiotherapist in other countries. Marathon & Distance Running Training: A Coaches’ Perspective, Kent Town, SA Sports Physiotherapy Australia is now on Facebook. Become involved, engage in clinical discussion, learn about 29 courses nationally and internationally and keep up to date on your profession. Sports Physiotherapy Australia Advanced Knee Rehabilitation, Silverwater, NSW Sports Dietitians Australia (SDA) FEBRUARY 2017 As summer pre-season training begins, don’t forget to engage your local Accredited Sports Dietitian. Their 7-14 versatility can support you and your athletes with meal planning, anthropometry and hydration testing, Australasian College of Sport and supplement recommendation, injury prevention Exercise Physicians (ACSEP) and rehab nutrition, and food suggestions for Keeping You Active Conference intolerance and allergies, to name just a few. Surfers Paradise, Marriott Hotel, To find one in your local area visit www. Gold Coast, QLD sportsdietitians.com.au or follow Twitter @sportsdietaust and Facebook for credible sports nutrition information.

44 VOLUME 34 • ISSUE 2 2016 SH_Asics_Concept_FA.indd 1 4/02/2015 4:53:19 PM Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028