Boston Sports Medicine and Performance Group, LLC Blog

Evidence based medicine: a movement in crisis?

Posted by Boston Sports Medicine and Performance Group on Fri, Aug 29, 2014 @ 08:08 AM




by Trisha Greenhalgh et al

BMJ. 2014; 348: g3725


"Real evidence based medicine has the care of individual patients as its top priority, asking, “what is the best course of action for this patient, in these circumstances, at this point in their illness or condition?”39 It consciously and reflexively refuses to let process (doing tests, prescribing medicines) dominate outcomes"


It is more than 20 years since the evidence based medicine working group announced a “new paradigm” for teaching and practising clinical medicine.1 Tradition, anecdote, and theoretical reasoning from basic sciences would be replaced by evidence from high quality randomised controlled trials and observational studies, in combination with clinical expertise and the needs and wishes of patients.

Evidence based medicine quickly became an energetic intellectual community committed to making clinical practice more scientific and empirically grounded and thereby achieving safer, more consistent, and more cost effective care.2 Achievements included establishing the Cochrane Collaboration to collate and summarise evidence from clinical trials;3 setting methodological and publication standards for primary and secondary research;4 building national and international infrastructures for developing and updating clinical practice guidelines;5 developing resources and courses for teaching critical appraisal;6 and building the knowledge base for implementation and knowledge translation.7

From the outset, critics were concerned that the emphasis on experimental evidence could devalue basic sciences and the tacit knowledge that accumulates with clinical experience; they also questioned whether findings from average results in clinical studies could inform decisions about real patients, who seldom fit the textbook description of disease and differ from those included in research trials.8 But others argued that evidence based medicine, if practised knowledgably and compassionately, could accommodate basic scientific principles, the subtleties of clinical judgment, and the patient’s clinical and personal idiosyncrasies.1

Two decades of enthusiasm and funding have produced numerous successes for evidence based medicine. An early example was the British Thoracic Society’s 1990 asthma guidelines, developed through consensus but based on a combination of randomised trials and observational studies.9 Subsequently, the use of personal care plans and step wise prescription of inhaled steroids for asthma increased,10 and morbidity and mortality fell.11 More recently, uptake of the UK National Institute for Health and Care Excellence guidelines for prevention of venous thromboembolism after surgery has produced significant reductions in thromboembolic complications.12

Despite these and many other successes, wide variation in implementing evidence based practice remains a problem. For example, the incidence of arthroscopic washout of the knee joint, whose benefits are unproved except when there is a known loose body, varies from 3 to 48 per 100 000 in England.13 More fundamentally, many who support evidence based medicine in principle have argued that the movement is now facing a serious crisis (box 1).14 15 Below we set out the problems and suggest some solutions.


To read the full text click HERE 


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The Next Big Thing In Sports Data - Predicting Injury

Posted by Boston Sports Medicine and Performance Group on Tue, Aug 26, 2014 @ 08:08 AM



In sports, injuries don’t just cost wins. They cost money. By one estimate, teams across Major League Baseball spent $665 million last year on the salaries of banged-up guys and their replacements. NBA teams lost $358 million last season; $44 million alone by the injury-ridden Los Angeles Lakers. And in the NFL, where the average salary is about $2 million, starters missed a record 1,600 games in 2013.

Until recently, this was largely seen as the cost of doing business, subject as much to the will of the sports-injury gods as advancements in training. Now, the fast-growing industry of performance analytics says it can minimize those massive losses. The trick: using data to anticipate how an athlete will get hurt before it actually happens.

“We really think [injuries] are the largest market inefficiency in pro sports,” says Adam Hewitt, assistant GM of Peak Performance Project (P3) in Santa Barbara, CA, one of the country’s leading centers of sports science and performance analytics.

What was once the domain of a relatively small group is now hitting the mainstream, increasingly embraced by teams across American pro sports and even the leagues themselves--including the San Antonio Spurs, Oklahoma City Thunder, Seattle SoundersPittsburgh PiratesNew England Patriots, and Philadelphia Eagles, and more. There are a variety of companies and technologies in play, all utilizing the principle of turning everything measurable (from movement to body chemistry) into data, analyzed for distressing patterns.

Teams are generally tight-lipped on how they utilize data collection tools for fear of giving away competitive advantage, but a few are more open. The Toronto Raptors is one of them. During practices last season, players on the Toronto Raptors wore a cell phone-sized unit called an OptimEye, created by the Melbourne, Australia-based company Catapult. OptimEye’s gyroscope and accelerometer provides reams of data about how players actually move--accelerations, decelerations, elevations, jumping ranges, and so on--and at what intensity.

“We have an opportunity to take these players and be totally proactive,” says the team’s director of sports science, Alex McKechnie. The data, he says, allows Toronto to tailor programs specifically to each player’s unique physiology, correcting injury-inducing problems like imbalances between each side of the body. A player, for example, could be favoring one leg over the other when jumping, due perhaps to an old injury that never properly healed or muscular weakness never addressed. OptimEye can measure the difference, undetectable to the naked eye, helping trainers diffuse a time bomb before it blows.

The data changed how Toronto practiced as well, by revealing misconceptions of how certain activities impact the body. Ubiquitous shooting drills, for example, turned out to be troublesome.

Continue reading article by clicking HERE 


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Fueling NBA Athletes: Is It Time for Evidence-Based Nutrition?

Posted by Boston Sports Medicine and Performance Group on Mon, Aug 11, 2014 @ 07:08 AM



By Gil Blander, PhD

Each day I open up my email inbox to see several articles on sports nutrition, and many of them read like an infomercial or science fiction story. Millions of dollars are invested in athletes’ bodies, and then lost, often due to injuries and poor performance. The cause is actually the same that teams have faced for years: managing an athlete’s diet. The reason I started my LinkedIn group was to move away from marketing hype and toward sound scientific recommendations based on data. Like the fashion industry, diets face rapid changes and many people jump on a bandwagon without knowing the direction it is going. The medical industry, and specifically sports medicine, is seeing a greater attention to evidence-based practices by applying research and data to improve the outcomes of rehabilitation and prevention. Instead of a collective approach with sports nutrition, we are seeing just the opposite with various gurus trying to market their own agendas to differentiate services or expertise. We need an immediate reality check and an applied sciences approach with collaboration between academic experts and those working in the field, not a marketing machine, to drive health and performance.

In perusing the sports headlines, it becomes quite clear that athletes are now electing to take ownership of their own nutrition by hiring personal nutritionists, many of whom are not licensed or certified, and even more of whom are not following practices that are based on what we know in the scientific literature. The result is an epidemic of risky practices that predispose an athlete to injury and poor performance, which can take weeks and sometimes months to rebound from. My favorite example of this is one star player who was put on a very low carbohydrate diet to improve body composition. He removed specific foods that his advisor suggested may be causing inflammation, but several key nutrients were missing. His hemoglobin thus fell to a level that compromised him aerobically. When a typical nutritionist thinks about fueling, he or she is prescribing macronutrient amounts (eg, carbohydrate, protein, and fat). In reality, biomarkers should guide applied solutions. It will be interesting to follow Lebron James after his reported commitment to eliminating carbohydrates from his diet. Will we see the same pattern of injuries and compromised performance that other teams experienced following this approach? Time will tell.

Another fascinating example of dietary extremism was one InsideTracker client who was told to follow a high fat/high protein diet exclusively. This athlete trained intensely, multiple times a day, but failed to recover appropriately. He had diminished energy on the court and chronic soreness like never before. Exactly two days after testing, what the athlete saw on his InsideTracker dashboard was alarming. Not only was he deficient in basic vitamins and minerals, but his hormone profile resembled that of someone close to retirement, rather than that of an elite athlete. Convinced that his current approach was likely to blame for the recent decline in performance, he adopted a conventional diet that was based on his biomarker status and universally accepted nutritional recommendations. Six weeks later, after following guidance from the InsideTracker algorithm, the baseball player was back to his old self – and his recovery rate was better than during his early years in the league.

Continue reading this article by clicking HERE.



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An Interview with Jose Fernandez - BSMPG Speaker 2012

Posted by Boston Sports Medicine and Performance Group on Fri, Aug 1, 2014 @ 07:08 AM

Interview originally published on FREELAPUSA.COM



Athlete Profiling with Fiber Type and Blood Analysis

Freelap USA — Can you get into some detail about the process from acquisition to analysis with data? For example, a team may do speed testing a few times a year but do blood draws and muscle fiber estimation randomly. Will you break down how organizing testing periods and managing data during a season is more than just picking convenient windows?

Fernandez — We need to evaluate training and measure its impact on the players. New wearables such as the Sensecore and others are working towards integrating external load and its physiological response and I am curious to see how athlete tracking systems develop beyond what they currently provide. I like to keep performance testing very minimal, but it is necessary. Specific power and speed tests done monthly is still useful and can be paired with more functional and movement based metrics.

Daily monitoring has to be passively aggregated along with short collection times for compliance. Wellbeing and subjective data are my starting point. Based on each athlete, coaches can decide whether to collect it remotely or on-site at the training ground. Morning heart rate and heart rate variability are widely used and I prefer mobile options. Facial coding adds more objectivity to the process. Some SDK options such as the Sightcorps platform are mobile and cloud friendly for easier customization. Coaches can explore the demo app if interested. I haven´t figured out what protocols work better with facial expressions but the potential is there, not just purely because of micro-expression analysis and mood correlations but because of the athlete´s honesty increases when interacting virtually.

Soft tissue dynamics and muscle function done weekly is essential since alterations at this level have a direct impact on injuries. Touching on myoanalytics again and without going in too much detail, the combination of thermal diagrams with tensiomyographic data is my preferred option and it’s simple to implement. Superficial temperature shows inflammation 24h post games and helps pinpoint which areas should be followed up with TMG for more structural detail, which can then lead to optimized recovery and therapy between games. Tonometers as the only option are less realistic within team settings due to longer testing times, hence the importance of highlighting areas of risk and use the thermal filter. A second thermal diagram 24h before games allows for comparison.

Trimestral blood panels help to gain insight into all the other areas such as muscle function and soft tissue recovery rates, mood patterns and nutrition. Fiber profiling is done in preseason and follow-up testing strategically placed during the season at similar times as blood analysis enables for comparison. Higher risk players undergo more muscle specific followup weekly to look at monthly patterns.

There are as many athlete monitoring strategies as there are coaches and I am never 100% comfortable with mine. Many more variables such as age, previous injuries, race or genetics, etc., have to be reviewed in order to design more individual approaches. I may change and adapt technologies to each environment, but the above provides roughly an idea of my philosophy. The process needs to be very flexible and adaptable since technology is being developed as we speak and we should be able to make changes and remove or add new metrics seamlessly.

Haloview Muscle Fiber Profiling

Figure 1: Muscle Fiber Estimation profiling by Haloview


Continue reading interview by clicking HERE. 




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Topics: Jose Fernandez

The Cost of Doing Business

Posted by Boston Sports Medicine and Performance Group on Wed, Jul 30, 2014 @ 07:07 AM

"The limiter, therefore, may not be the size of the aerobic bank but the body’s spending habits."

 high performance book


"Imagine you have to water your plants and that if you fill your 5-litre watering can, you will have just enough to do the 5-minute job.  Imagine now, that you fill your can but you discover it has a number of holes in the side and is leaking 200 millilitres a minute.  You will be lefts short.  Is this because the watering can was not big enough or because it leaked? Seal the leaks, and the watering can would be big enough.

The same applies to the repeated shuttles example. If the athlete’s running mechanics were suboptimal, or if turning technique was poor, irrespective or metabolic capacity, the athlete would be spending energy reserves at a much greater rate than a more efficient counterpart.  This is the same as the watering-can example. The limiter, therefore, may not be the size of the aerobic bank but the body’s spending habits."


pg. 31

More Stress...

Posted by Boston Sports Medicine and Performance Group on Mon, Jul 28, 2014 @ 07:07 AM


"We're not optimizing machines but organisms with the invisible hand of biology lurking behind our every behavior."



trading floor


by Robert M. SapolskyArticle originally published at: The Wall Street Journal

The notion that humans are Homo economicus, rational economic decision makers, has taken some serious hits ever since people bought more than 1.5 million Pet Rocks in the 1970s. Research in behavioral economics shows that we are typically more generous in economic games than logic would predict, that we will pay to spitefully punish freeloaders and that we tend to make rapid emotional decisions—and then struggle to rationalize them. A new study adds to this theme by showing how a class of stress hormones can distort decision-making in a setting resembling the stock market.

In a splashy, much-discussed paper published in 2008 in the Proceedings of the National Academy of Science, John Coatesand Joe Herbertof Cambridge University examined the levels of various hormones in male floor traders at the London stock market over the course of eight days of work. They wanted to see if hormone patterns correlated at all with how the market was doing and/or with the trader's own market performance. (Dr. Coates, it is worth adding, had spent his errant youth working as a trader at Goldman Sachs and Deutsche Bank, before being born again as a neuroscientist.)

One of their key findings concerned cortisol (aka hydrocortisone, part of a class of adrenal steroid hormones known as glucocorticoids). Stress spurs cortisol secretions. If you're stressed like a normal mammal, running from a predator, cortisol helps to save your life. But chronic psychological stress—a human specialty—elevates long-term cortisol levels, which increases the risks of stress-related diseases.

So when did cortisol levels rise in these traders? You might think: when they lost money. But that wasn't it. Instead, market volatility raised cortisol. This made wonderful sense, given that the two key building blocks of psychological stress are lack of control and unpredictable situations.

In addition to its effects throughout the body, cortisol also influences cognition, emotions and behavior. This raised a critical question for the researchers: What do elevated levels of cortisol do to decision-making by traders?

This is what Dr. Coates and his colleagues address in their new study, also published in the Proceedings of the National Academy of Science.

For this work, the researchers administered cortisol to volunteers. They carefully calibrated the amount so that it raised levels not through the roof but into the moderate stress range observed in the 2008 study. Subjects then played a financial risk-taking game.

The result? One exposure to high cortisol did nothing, consistent with prior findings that it's typically chronic exposure to stress levels of the hormone that alters behavior. But eight days of exposure changed the subjects' behavior in the game: The volunteers now preferred low expected returns and lower-variance bets. In other words, they became more averse to risk.

This jibes with prior research. Suppose subjects have learned to respond successfully to a challenge in a certain way. Suddenly, that response stops working. Should they try a new strategy? Maybe, but in such situations, we instead often become perseverative—doing the same thing over and over, faster, more often, while crossing our fingers, while wearing our lucky underwear.

Studies have shown that stress and cortisol make humans and lab animals more perseverative in this way. Moreover, we know the discouraging biological underpinning of such findings: Sustained stress and stress-hormone exposure cause atrophy of the frontal cortex, the brain region that plays a key role in decision-making.

What does it mean that market volatility pushes stress hormone levels into a range that makes people risk-averse? Is this good or bad for the traders?

Don't ask me; I'm no economist. The main point is one that Dr. Coates also emphasizes: We're not optimizing machines but organisms with the invisible hand of biology lurking behind our every behavior.



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Managing Stress in Basketball

Posted by Boston Sports Medicine and Performance Group on Mon, Jul 14, 2014 @ 07:07 AM



trey burke michigan game tying shot lil wayne 570x381



Trey Burke’s heroics may not have been the only thing that led to Kansas’ loss to Michigan in the 2013 Sweet 16.

A scientific study by a group of KU researchers confirms what many might have already assumed: Stress — both on and off the court — affected the Jayhawks during the most crucial point of the season.

After testing for hormone levels in athletes, KU researcher Matt Andre and coinvestigator Dr. Andrew Fry believe they’ve taken a crucial first step in researching the physiology of basketball players.

So what did they find out about KU’s players? And could this change how basketball is played for years to come?


* * * * * *

Initially, KU forward Jamari Traylor was afraid of his cotton ball.

When strength and conditioning coach Andrea Hudy first told Traylor and his teammates they’d be popping a cotton ball in their mouth every Thursday to collect saliva and check their stress levels … well, Traylor’s imagination went a little crazy.

“We were just all thinking, ‘Man, what if we’re tired, but the cotton balls say we’re not tired? Coach is going to go harder on us,’” Traylor said with a laugh. “Crazy stuff like that.”

In actuality, Hudy wasn’t looking for a way to pick on her players — or even immediate results.

After consulting with Fry — a professor in KU’s department of health, sport & exercise sciences — Hudy had volunteered her basketball players to be part of a funded study that would test their hormone levels for each week throughout the season.

The testing was simple: Put a cotton swab in your mouth for two minutes, let the saliva soak in, then drop the swab in a tube for sampling.

KU’s players were tested for 27 out of 30 weeks, starting with the preseason and ending two weeks after their Sweet 16 exit. This season-long study provided comprehensive data on hormone levels in basketball players that had never been published before, even by professional teams.

When the season was over, Andre spent 4-6 hours studying each individual player’s samples, starting an uninterrupted process that included spinning them in a centrifuge.

The final goal was this: Find out the testosterone-to-cortisol ratio of each player for each week — a number that would determine when KU’s players were stressed the most.

Cortisol levels have been a recent hot topic in sports study, as at a base level, the hormone is catabolic, meaning it tears down muscle.

Because each person has a different baseline, however, cortisol is best tested when compared to a person’s testosterone level.

“If testosterone plummets and cortisol is up, then you have a problem … mood, performance, everything,” Hudy said. “But with cortisol down and testosterone up, you could rule the world.”

Andre was about to find out that the Jayhawks did have times when they were rulers of the world … just not during the most important stage of the season.

Continue reading this article by clicking HERE 


Inside Tracker

 You Can't Manage What You Don't Measure

Stress is Stress

Posted by Boston Sports Medicine and Performance Group on Wed, Jul 2, 2014 @ 07:07 AM


slide courtesy of Eric Oetter, BSMPG 2014



Chronic Psychological Stress Impairs Recovery of Muscular Function and Somatic Sensations Over a 96-Hour Period

Stults-Kolehmainen, Matthew A.1,2; Bartholomew, John B.1; Sinha, Rajita2

Abstract: Stults-Kolehmainen, MA, Bartholomew, JB, and Sinha, R. Chronic psychological stress impairs recovery of muscular function and somatic sensations over a 96-hour period. J Strength Cond Res 28(7): 2007–2017, 2014—The primary aim of this study was to determine whether chronic mental stress moderates recovery of muscular function and somatic sensations: perceived energy, fatigue, and soreness, in a 4-day period after a bout of strenuous resistance exercise. Undergraduate resistance training students (n = 31; age, 20.26 ± 1.34 years) completed the Perceived Stress Scale and the Undergraduate Stress Questionnaire, a measure of life event stress. At a later visit, they performed an acute heavy-resistance exercise protocol (10 repetition maximum [RM] leg press test plus 6 sets: 80–100% of 10RM). Maximal isometric force (MIF), perceived energy, fatigue, and soreness were assessed in approximately 24-hour intervals after exercise. Recovery data were analyzed with hierarchical linear modeling growth curve analysis. Life event stress significantly moderated linear (p = 0.027) and squared (p = 0.031) recovery of MIF. This relationship held even when the model was adjusted for fitness, workload, and training experience. Perceived energy (p = 0.038), fatigue (p = 0.040), and soreness (p = 0.027) all were moderated by life stress. Mean perceived stress modulated linear and squared recovery of MIF (p < 0.001) and energy (p = 0.004) but not fatigue or soreness. In all analyses, higher stress was associated with worse recovery. Stress, whether assessed as life event stress or perceived stress, moderated the recovery trajectories of muscular function and somatic sensations in a 96-hour period after strenuous resistance exercise. Therefore, under conditions of inordinate stress, individuals may need to be more mindful about observing an appropriate length of recovery.


"Social garbage in,
Musculoskeletal garbage out."

- Charlie Weingroff

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BSMPG 2014 Highlights - Patrick Ward

Posted by Boston Sports Medicine and Performance Group on Mon, Jun 30, 2014 @ 07:06 AM


Click below to see highlights from our 2014 BSMPG Summer Seminar featuring Patrick Ward.

More highlights are set to come in the next few weeks so stay tuned!

A special thanks again to our SPONSORS! 




patrick ward







Topic: From Data Collection to Application: The Evolving Role of the Strength Coach

From 2006 to 2012, Patrick Ward ran his own sports performance training facility in Phoenix, AZ, where he worked with athletes across a variety of sports, including golf, volleyball, football, soccer and other world-class athletes training for international competition. Patrick earned a Master of Exercise Science from California University of Pennsylvania in 2007, holds NSCA and CSCS certifications and is a licensed massage therapist. Currently Patrick works within the Nike Sports Research Lab in Portland, OR, where he works with some of the greatest athletes in the world and helps Nike collect sports performance insights.

Patrick maintains an active blog,, where he frequently writes about his thoughts and ideas in the world of health and human performance.


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Topics: Patrick Ward

What the Leaders are Reading - Neil Rampe

Posted by Boston Sports Medicine and Performance Group on Thu, Jun 19, 2014 @ 07:06 AM


We asked the leaders in Sports Medicine and Performance Training what they are either currently reading or have read and here is what they said!

See complete (and ever growing) list of suggested reading at the BSMPG LIBRARY. 




Neil Rampe  BSMPG


Arizona Diamondbacks




Topics: Neil Rampe, BSMPG Summer Seminar