Sports and exercise medicine: Beyond injury management

Abstract

There is a limited awareness about the role of Sports and Exercise Medicine (SEM) among medical as well as nonmedical fraternity beyond just management of sports injuries. SEM professionals play a significant role in healthy general population and illness by designing and implementing specific primordial, primary and secondary preventive activities against the lifestyle disorders through exercise. In amateur and professional sports, they provide scientifically sound advice to enhance performance and prevent injuries through pre- and rehabilitative techniques. In the Armed Forces personnel, SEM has a special role beyond these to assess fitness for battle physical efficiency and also enhance the performance in various physical activities of military nature. Scientifically sound professionals in this field can help build a strong army and a healthier nation.

Introduction

Sports and exercise Medicine (SEM) is a relatively new branch of medicine in India. There is limited awareness about the role of this speciality among medical as well as non-medical fraternity beyond just management of sports injuries.¹ This review aims to address this gap in awareness and elaborate the role of SEM in aspects of health beyond injury management which defines the scope of SEM speciality focusing on prevention, diagnosis, treatment, prehabilitation and rehabilitation of injuries, and illnesses occurring during or after physical activity, decision-making in return to play/Activities of Daily (ADL) living, performance enhancement, achieving fitness and wellness through balanced training and diet, medical care of sporting teams and events, medical care in situations of altered physiology, and in dealing with ethical issues like drug abuse in sports (Fig. 1).²

Fig. 1.

Broad outline depicting role of Sports and Exercise Medicine speciality.²

Roles and responsibilities of sports and exercise medicine (SEM) specialist

Role of SEM in health and disease

• a.Health and Wellness

Lifestyle diseases are steadily rising in magnitude and their prevention is the preferred approach instead of event-specific treatment which is both expensive as well as adversely impacts the quality of life. SEM has a multidisciplinary culture that focuses on integrated and holistic care to take action in preventive and rehabilitative areas of achieving health and wellness by behavioural modification, population-based outcome assessment, nutrition, exercise training and monitoring.³

SEM practitioners play a vital role in promoting healthy lifestyles and behaviour modification. They educate individuals about the benefits of regular physical activity, provide guidance on exercise selection and intensity, and help individuals set realistic goals to improve their overall well-being.⁴

Regular physical activity is crucial for managing various lifestyle conditions, such as Obesity, Diabetes Mellitus (DM) Type II, Hypertension, Cardiovascular Diseases, and Degenerative Musculoskeletal Disorders. SEM practitioners collaborate with other healthcare providers to develop exercise prescriptions for individuals with specific health conditions that are safe and effective, thereby reducing complications, managing symptoms, and improving overall functional capacity.

Physical activity has a significant impact on mental health and well-being as well.⁴ SEM professionals recognize the benefits of exercise in reducing stress, elevating mood, and enriching overall mental well-being. They incorporate exercise as part of a comprehensive treatment plan for individuals with mental health conditions, including anxiety, depression, and stress-related disorders.

SEM plays a crucial role in all three levels of prevention—primordial, primary, and secondary—in addressing lifestyle diseases. This plays a vital role in promoting healthy living, reducing the burden of lifestyle diseases, and improving the overall health and well-being of individuals and communities.

Primordial prevention

Primordial prevention aims to prevent the development of risk factors for disease. SEM professionals promote healthy lifestyles by promoting regular physical activity, as a means to prevent the onset of lifestyle diseases. They educate individuals and communities about the importance of engaging in regular exercise, maintaining a balanced diet, managing stress, and avoiding unhealthy behaviours such as tobacco use and excessive alcohol consumption.

Primary prevention

Primary prevention focuses on preventing the occurrence of diseases among individuals who are at risk. Regular exercise not only reduces the risk of developing lifestyle diseases but also helps manage lifestyle disease conditions such as hypertension, diabetes, and obesity.

SEM specialists play a key role in primary prevention by assessing individuals' risk factors, such as family history of lifestyle disorders, sedentary behaviour, obesity, and poor fitness levels. They design and prescribe personalized exercise programs that target these risk factors and promote overall health and well-being.⁵

Secondary prevention

Secondary prevention aims to detect and manage diseases at an early stage to minimize their impact. SEM professionals contribute to secondary prevention by working with individuals who have already been diagnosed with lifestyle diseases. They design exercise programs that are safe and effective for individuals with specific conditions, such as cardiovascular disease or diabetes.⁶ Exercise can help manage and control the progression of these conditions, improve cardiovascular fitness, enhance glucose control, and reduce the need for medications. They also provide ongoing monitoring, rehabilitation, and guidance to individuals recovering from lifestyle-related illnesses or surgeries, helping them regain optimal function and quality of life. SEM specialists have a vital role to play in guiding remission of lifestyle disorders like DM Type II and Obesity in selected subsets of these patients.

• b.
  Scientific Assessment of Health and Fitness

  • i.
    Cardiovascular Fitness: Cardiovascular fitness, assessed through tests like the maximal oxygen consumption (VO2max) test, provides an objective measure of an individual's aerobic capacity. Higher cardiovascular fitness levels are associated with a reduced risk of cardiovascular disease, improved endurance, and enhanced survival.⁷ SEM specialist plays a vital role in providing exercise prescription considering the cardiovascular fitness of an individual in order to improve their aerobic fitness.
  • ii.
    Body Composition: Body composition assessment helps evaluate the proportion of body fat, lean muscle mass, and other components. Techniques such as Dual-Energy X-Ray Absorptiometry (DEXA) can accurately assess the lean and fat mass, while Bioelectrical Impedance Analysis (BIA) and skinfold measurements can provide reliable assessment of changes in body composition resulting from aerobic and resistance exercise. Improvements in body composition, such as reduction in body fat percentage or an increase in lean muscle mass, contribute to overall health and well-being.⁸ Depending on the body type of an individual and its composition, SEM specialist guides them on their dietary intake as well as exercise program to make them fit into the normal standards of Body Composition.
  • iii.
    Muscular strength, Power and Endurance: Muscular strength can be evaluated through tests like the Isokinetic dynamometer and handgrip strength test. Power can be evaluated through lab tests like Wingate test for lower body by cycle ergometer and for upper body by arm crank ergometer and field tests like vertical jump test, Margaria step test or short sprints.⁹ Endurance capacity can be evaluated through Astrand Rhyming Cycle Ergometer test, and field tests like Canadian beep test, Queens' college step test, Harvard step test and Treadmill tests.¹⁰ Assessing changes in muscular strength and endurance over time helps SEM specialist to monitor the effectiveness of resistance and endurance exercise interventions given by them and their impact on physical performance and functional abilities.
  • iv.
    Metabolic Markers: Lipid profiles, blood glucose levels, markers of inflammation, and lactate levels provide objective measures of the impact of exercise on metabolic health. Regular aerobic and resistance exercise can lead to improvements in these markers, reducing the risk of metabolic disorders such as diabetes, dyslipidaemia, and atherosclerotic cardiovascular diseases. SEM specialist plays a vital role in prescribing such exercises as a therapy in a correct manner considering basic principles of training, adequate frequency, intensity, time and type of exercise so that maximum benefits can be attained in lesser time without exposing the individual to any risk of injury.
  • v.
    Bone Health: Regular weight-bearing aerobic exercises and resistance training have positive effects on bone health, increasing bone mineral density (BMD) and reducing the risk of osteoporosis and fractures. Such exercises are advised by SEM specialist to children of growing age, elderly men and women in the perimenopausal age group to improve bone health. These exercises have to be tailored accordingly by SEM professionals to provide maximum benefits and avoiding any injury. Assessment by DEXA scan, which quantifies BMD, can be used to follow-up the benefits of such training and timely modifications under the supervision of SEM specialist can be done as per requirement.
  • vi.
    Functional Assessments: Functional assessments evaluate an individual's ability to perform ADL, balance, mobility, and other functional tasks involving different joints and muscle groups. These assessments include tests such as the 6-min walk test, Timed Up and Go test, or balance tests.¹⁰ Improvement in functional abilities indicates enhanced physical capacity and independence, which are important for overall longevity and quality of life. Carrying out these tests, interpreting the results and prescribing exercise regimen with individualized, tailored exercise frequency, intensity, type and time, volume and progression and their follow-up for any modification if required and avoiding injuries, is where SEM specialist plays an important role.
• c.Special population

SEM specialist plays a pivotal role in preventing as well as managing sports and exercise-related illnesses or injuries in paediatric age group, females, aged athletes and disabled athletes etc., with knowledge of the difference in physiology among these groups and difference in physiological adaptations with exercise in them.

• d.Physical Activity in Challenging Environment of Altered Physiology

SEM specialist also plays an important role in guiding the individuals on physical activity/exercise in extremes of environments like high altitude, hot/cold environment or at depth, all of which alter the normal physiology of the human body and require modifications in physical activity/exercise keeping in mind those alterations in physiology to provide individuals with maximum benefits of these exercises/physical activity by incorporating balanced training and avoiding any injuries/illnesses.

Role of SEM professionals in sports

SEM plays a critical role in sports for injury prevention and performance enhancement. They contribute to these areas in following ways:

• a.TEAM PHYSICIAN

SEM specialists also plays a major role as team physician and often called as ‘Captain of the Ship’, Ship being the team of medical care professionals and sports sciences professionals working together for the benefit of the sporting team (Fig. 2). Role of Team physician includes wide array of roles and responsibilities including overall medical care, administrative duties, handling ethical issues and medicolegal issues of the sporting team apart from performing pre participation evaluation, emergency management of injuries/illnesses on field and managing travel-related medical issues.^14,15

• b.
  INJURY PREVENTION

  • i.
    Pre-participation Screening: Comprehensive pre-participation screening by SEM specialists helps to identify athletes for any pre-existing conditions, assess an individual's fitness level, and evaluate injury risk factors. This allows for tailored recommendations and interventions, assessing fitness for the event or resetting of targets to minimize the risk of injuries.¹¹
  • ii.
    Training Program Design: SEM professionals verify and give final approval to the training programs designed for athletes by coaches, considering their specific sport, goals, and individual needs. These programs focus on progressive and appropriate training loads, proper technique, injury prevention exercises, and periodization to reduce the likelihood of overuse injuries and overtraining syndrome and optimize performance.¹²
  • iii.
    Biomechanical Analysis: Analysis of the biomechanics of movement patterns by SEM physicians in conjunction with biomechanist to identify faulty mechanics or imbalances that may contribute to injury risk, helps guide SEM specialist to provide corrective exercises, technique modifications, or referral of individuals to specialists such as physical therapists or strength and conditioning coaches for further intervention.¹³
  • iv.
    Education and Injury Prevention Strategies: SEM professionals educate athletes and coaches about injury prevention strategies, including proper warm-up and cool-down routines, appropriate nutrition and hydration, recovery techniques, and the importance of rest and periodization. They also provide guidance on appropriate equipment and protective gear to minimize the risk of injuries during training and competition.
• c.
  Performance Enhancement

  • i.
    Fitness Assessment: SEM professionals assess an athlete's fitness level, including cardiovascular endurance, muscular strength and endurance, flexibility, and agility. This helps in identifying areas for improvement and tailoring training programs to enhance specific aspects of performance.
  • ii.
    Sports Nutrition Guidance: SEM professionals provide evidence-based nutrition guidance in conjunction with sports nutritionist/dietician, including meal planning, timing of nutrient intake, and hydration strategies, to optimize an athlete's performance. Proper nutrition supports energy production, muscle recovery, and overall health, contributing to enhanced performance.
  • iii.
    Performance Monitoring and Testing: SEM professionals utilize various performance monitoring tools, such as tracking training load, assessing performance metrics, and conducting physiological testing, to evaluate an athlete's progress and make data-driven adjustments to training programs considering the basic principles of training. This helps optimize training strategies and identify areas where performance enhancements can be made, maximum benefits can be provided and any risk of injuries/illnesses can be avoided.
  • iv.
    Psychological Support: SEM professionals provide mental and psychological support to athletes, addressing factors such as stress management, motivation, goal setting, and resilience. They collaborate with sports psychologists to enhance an athlete's mental preparedness and focus, which can have a significant impact on performance.

Fig. 2.

The Sports and Exercise Medicine team (2).

By focusing on injury prevention, fitness optimization, injury management, and performance enhancement, SEM professionals contribute to the overall success and longevity of both amateur and professional athletes. Their expertise and interventions help athletes achieve their potential while minimizing the risk of injuries and promoting long-term fitness.

• d.Prehabilitation and Rehabilitation:

In collaboration with physical therapists, strength and conditioners, psychologist, nutritionist and biomechanist, SEM physician plays an important role in providing prehabilitation/rehabilitation program to athletes with sports injuries in their preoperative and postoperative phase and also in those who do not require to undergo operative procedure and get those athletes to return to sports with their best performance levels and reducing the chances of reinjury.

• e.Doping and Other Ethical Issues

Physicians have ethical and legal duties towards each athlete they see, which is dictated by multiple bodies. They are each held to the professional code of conduct of their respective country. In addition, sports physicians involved in the care of an athlete, are responsible for adhering to the rule set by the governing body of that particular sport. Sports physicians play a role in educating athletes/patients in respect to adverse side effects of prohibited performance-enhancing drugs and guide them with the intake of supplements/drugs with anti-doping perspective and thus plays a major role in Doping prevention.^16,17

• f.Training Monitoring

SEM specialist plays a pivotal role in guiding the coaches and athletes with the athletes’ training regimen with the knowledge of basic principles of training including specificity, progressive overload, reversibility, periodization and individuality.² The SEM practitioner guides the coaches/athletes regarding the training frequency, intensity, time, type, volume and progression in a balanced way with the aim to get the maximum benefits to the athlete (performance enhancement) and avoiding any risk of injury or illness at the same time i.e. preventing overtraining syndrome.

Role of SEM professionals in Armed Forces personnel

Physical performance and fitness assessment techniques for Armed Forces personnel for evaluating their battle readiness and general fitness levels require the identification of endurance, muscular strength and agility. SEM Physician can play a pivotal role in providing scientific basis to these assessment techniques and use modern methods which are more accurate and less cumbersome to perform.

• a.
  Scientific Ways of Fitness Assessment –

  • i.
    Cardiorespiratory endurance testing – Since military operations and duties demand remaining active over extended periods of time, aerobic metabolism becomes dominant source of energy for such tasks. Hence, cardiorespiratory endurance testing is a critical occupational fitness component in armed forces for both genders, keeping the gender differences in cardiorespiratory physiology in consideration.¹⁸

While timed run tests are commonly used in armed forces to assess cardiovascular endurance and overall fitness, there are alternative assessment methods that are more scientific and accurate in providing valuable insights into an individual's physical capabilities, which include:

Maximal Oxygen Consumption (VO2max) Testing: VO2max testing is considered the gold standard for evaluating cardiovascular fitness. It measures the maximum amount of oxygen an individual can utilize during intense exercise. This test provides an objective measure of an individual's cardiovascular endurance capacity and can be more comprehensive than a simple timed run. VO2max testing can be conducted using various methods, including lab and field tests.

Field-Based Endurance Tests: These tests mimic the physical demands encountered in military operations and may involve activities such as loaded marches (route marches), carrying heavy equipment or weights, or performing functional tasks under time constraints. These tests evaluate an individual's ability to sustain physical effort, endure loads, and perform tasks specific to operational requirements.

Interval Training Protocols: Interval training involves alternating between periods of high-intensity exercise and active recovery or lower-intensity exercise. This type of training can be utilized as an assessment tool, where individuals perform specific exercises or tasks at high intensity for a set duration followed by a recovery period. Monitoring heart rate response, perceived exertion, or other physiological markers during the intervals can provide insights into an individual's cardiovascular fitness and work capacity.

SEM physician plays an important role in conducting and assessing the individuals’ maximum aerobic capacity based on these tests and they can recommend and provide these alternatives as an idea to the institution for assessing aerobic fitness of Armed Forces personnel instead of just relying on traditional timed run tests for fitness assessment.

• ii.Body composition assessment – Body composition analysis evaluates the proportion of fat, muscle, bone, and other tissues in the body. It is scientifically more relevant to analyse body composition to check fitness of an individual rather than just using body weight or body weight for height/age as a criterion for fitness assessment. Methods commonly used for body composition assessment include skinfold measurements using callipers, BIA, Air Displacement Plethysmography (ADP) and DEXA scans. These assessments help determine candidates' overall body composition and identify any potential weight-related issues.¹⁸

SEM physician may recommend these types of more accurate assessment methods instead of traditional anthropometric measures which will give detailed insight into body composition and fitness parameters of Armed Forces personnel. Also, depending on the body type of an individual and its composition, SEM specialist guides them on their dietary intake as well as exercise program to make them fit into the normal standards of body composition.

• iii.Muscular strength testing – Evaluations of muscular strength assess individuals' ability to generate force. Muscular strength tests are not routinely used in military settings for fitness assessment. The recommended assessments for muscular strength testing for Armed Forces personnel may include exercises like Vertical Jump Test, Standing Broad Jump Test and Hand Grip Strength Testing by Dynamometer etc.¹⁸
• iv.Muscular endurance testing – Muscular endurance testing of upper and lower body are equally important. The tests done for upper body include a variety of repeated lift tests and maximum repetition tests of which push-ups and chin-ups are most commonly done. Tests for lower body muscular endurance testing include sprints like 100-400 m.¹⁸ These can be recommended by SEM physicians and if incorporated in Armed Forces for fitness assessment of Armed Forces personnel, can provide better fitness parameters which can be improved upon by working on specific deficiencies.
• v.Flexibility assessment – Flexibility assessments include a range of motion and joint flexibility. Adequate flexibility is important for injury prevention and overall physical performance.^19,20 SEM physicians can recommend to carry out these assessment methods in Armed Forces along with other parameters so that the shortcomings are taken care of and will prepare Armed Forces personnel better for their duties and for battlefield.
• vi.Psychological assessment – When selecting and timely monitoring fitness and wellness of candidates for Armed Forces, it is crucial to assess mental wellness as well. SEM Physicians in collaboration with psychologist can carry out psychological assessment of Armed Forces personnel on timely basis which will definitely aid in promoting overall health and wellness of Armed Forces.
• b.Performance enhancement and Injury prevention – SEM physician plays an important role in guiding the instructors with the military training regimen with the knowledge of basic principles of training including specificity, progressive overload, reversibility, periodization and individuality.² The SEM practitioner guides the PT/Drill instructors and the soldiers regarding the training/exercise frequency, intensity, time, type, volume and progression in a balanced way with the aim to get the maximum benefits to the athlete (performance enhancement) and avoiding any risk of injury or illness at the same time i.e. preventing overtraining syndrome.
• c.Prehabilitation and rehabilitation – SEM physician plays an important role in providing prehabilitation/rehabilitation program in collaboration with Physical therapists, strength and conditioners, psychologist, nutritionist and biomechanist, to Armed Forces personnel with training-related injuries in their preoperative and postoperative phase and also in those who do not require to undergo operative procedure and get those soldiers to return to their duties with their best performance levels and reducing the chances of reinjury.

Conclusion

The role of SEM specialists has been thought to be restricted to management of sports-related injuries, especially in the Armed Forces. While it is an important aspect of this specialty, SEM specialists can have a far-reaching impact on the general health and wellness of the community as well. The scope of SEM speciality encompasses a wide array of roles and responsibilities including prevention, diagnosis, treatment, prehabilitation and rehabilitation of injuries and illnesses occurring during or after physical activity, decision-making in return to play/ADL, performance enhancement, achieving fitness and wellness through balanced training and diet, medical care of sporting teams and events, medical care in situations of altered physiology and in dealing with ethical issues like drug abuse in sports. It is imperative that both the SEM specialists, those training to be one, and their clientele be made aware of the wide horizon of roles that they can be effective in as professionals. This will benefit the organization in building up a stronger and fitter workforce and community in scientific enrichment of overall health and wellness.

Patients/ Guardians/ Participants consent

Not applicable.

Ethical clearance

Nil.

Source of support

None.

Disclosure of competing interest

The authors have none to declare.