How exercise medicine has evolved from sports medicine

A growing medical specialty with the potential to improve the health of all Australians

Brevity of expression is in vogue. It is said that the majority of theses should be research articles, that many articles should be research letters and that most blogs should be tweets. As a sign of the times, many organisations are shortening their names: in the sporting genre, for example, the Australian Sports Medicine Federation has recently become Sports Medicine Australia, and the Australian Cricket Board has become Cricket Australia. Why, then, did the Australasian College of Sports Physicians recently decide to swim against the tide and become the Australasian College of Sport and Exercise Physicians? Many neutral observers would find sport and exercise together in a thesaurus, so the need to differentiate them would seem redundant and wordy.

The change recognises that there is a difference between sport and exercise; that difference, in a word, being competition (with respect to sport) or lack thereof (with respect to exercise). In sport, a player or team is trying to win and, hence, will generally try to compete harder than the opponents to secure the win. While exercise overlaps with sport, exercise without sport is physical exertion without competition. As a result, the goals and practice of sports medicine and exercise medicine also differ from each other in many respects. While sports medicine is focused primarily on maximising the performance of athletes, exercise medicine may have greater relevance to all Australians as both a preventive health measure and a treatment for many chronic conditions; the dose of exercise chosen aims to maximise physiological and psychological health benefits, without unduly increasing the risks of participation, including injury.

The development of sports medicine in Australia

The existence of elite athletes — whose raison d’être is to win — no doubt drove the evolution of sports medicine as a specialty in Australia and internationally. The cultural prominence of elite sport in Australia and our unique sporting profile can help explain why Australia has been a world leader in the evolution of the specialty of sports medicine,1 just as we “punch above our weight” in the Olympic environment. The mentality of sports medicine has been one of “keeping the athlete fit and on the playing field”. There has always been a rudimentary evidence base for practice in sports medicine, but even in the early days, it was probably recognised that a degree of placebo effect was a healthy part of the specialty. In convincing athletes to transition from a historical state of being suspicious of doctors — who may be naturally inclined to rule a player out of competition due to carrying an injury — to seeing doctors as allies, has involved an openness in embracing legal medical therapies.2 The psychology of winning in elite sport involves the athlete convincing themselves of being fit to perform, and the doctor has a crucial role to play in reassuring them of this. Sports medicine is certainly prone to fashion, with athletes “looking for an edge” and eager to try any medical advance that the competitors may not have tried yet.2

The lack of evidence base for much of musculoskeletal medicine

The musculoskeletal specialties of rheumatology and orthopaedic surgery are closely related to sports medicine. They face similar challenges, particularly in relation to the poor outcome results compared with placebo obtained in recent high level studies for many of the traditional mainstay treatments for common degenerative conditions, including osteoarthritis and tendinopathy. Such treatments include cortisone injections, painkilling (non-steroidal anti-inflammatory drug [NSAID] and opiate) tablets, and arthroscopic surgery. Cortisone injections show some results on medium term follow-up that may actually be worse than placebo.3,4 Although NSAIDs and opiate tablets may not worsen the conditions being treated compared with placebo, there are serious concerns about the long term safety of both treatments.5,6 Arthroscopic surgery, which was justifiably seen as revolutionary in the late 1970s, in that the traditional post-surgery recovery period could be shortened from months to weeks, is also not comfortably surviving the scrutiny of randomised controlled trials.7,8

The emergence of exercise medicine and exercise dosing

So how does exercise medicine differ from the other musculoskeletal specialties in the management of the common musculoskeletal afflictions of age? As it turns out, exercise programs themselves are proving to be superior to many drugs in treating not only osteoarthritis,9,10 back pain11 and tendinopathy12 but also, amazingly, cancer.13 Sufficient physical activity keeps the musculoskeletal system healthy and can help to prevent and treat cancer, cardiovascular disease, diabetes and other non-communicable diseases.14

However, as with some drugs, exercise has a dose–response curve with respect to musculoskeletal disorders which emphasises efficacy in moderate doses. The most active and least active individuals, over both the short and long term, have higher rates of osteoarthritis15 and tendinopathy.16 While in the sports medicine field, the competitive athlete needs to maintain high levels of loading (training) in order to perform, in an exercise medicine practice, insufficiently active patients will be encouraged to load more, whereas injured overly active patients may be encouraged to load less. A mantra for exercise medicine could therefore be “Move, Monitor, Modify”. Reductions from high levels of load to moderate ones are beneficial for preservation of the musculoskeletal system in the longer term, but are not compatible with maintaining a career as an elite athlete. As most people are not elite athletes, the exercise medicine philosophies are far more relevant and beneficial for the whole population. Moreover, far more people in Western societies are insufficiently physically active than excessively active.14

It is also important to differentiate the traditional musculoskeletal specialties of rheumatology and orthopaedics from sport and exercise medicine in terms of their training program environment. Sport and exercise medicine is an unconventional medical specialty in that the majority of specialty training is undertaken outside the hospital setting. This must come with a warning that sport and exercise medicine physicians may be less familiar with rare and life-threatening diseases of the musculoskeletal system than other specialists, as these conditions are far more prevalent in the hospital setting. However, sport and exercise medicine physicians are more familiar with the everyday presentations of the common conditions of osteoarthritis, back pain and tendinopathy.

The mismatch between evidence-based medicine and Medicare Benefits Schedule funding

Every specialty in the musculoskeletal branch of medicine (if not the whole of medicine) needs to move away from outdated treatments now shown in high quality studies to be ineffective or harmful, and move towards the use of treatments shown to be more effective and less harmful — especially if these treatments are non-invasive and non-procedural.

Given the strong evidence for the benefits of exercise across a variety of conditions and the low risk of harm, prescription of exercise in preference to more harmful treatments, such as surgery, cortisone injections and painkillers, must be encouraged. Successful exercise programs need to be nuanced and tailored to each individual patient, taking into account their personal preferences, injury history, biomechanics and feedback. For many people wanting to undertake an exercise program, a gymnasium instructor or personal trainer may suffice, but as the degree of difficulty in adhering to an exercise program increases (eg, because of pre-existing injuries), the more specialist help is needed, such as a sport and exercise medicine specialist. In the current funding environment, however, there are numerous obstacles to achieving this ideal.

The Medicare Benefits Schedule (MBS) has not yet been subjected to the substantial structural reform needed to provide financial incentives for doctors, other health professionals and patients to use exercise for the treatment of these common musculoskeletal ailments. Discredited treatments, such as knee arthroscopy for knee osteoarthritis, are still generously funded under Australia’s MBS, despite having been banned in countries such as Germany.17 However, the MBS rebates for the more effective option of exercise program modifications prescribed by a sport and exercise medicine specialist are substantially lower (in absolute terms) than they were 10 years ago.18 The inability of patients of exercise medicine physicians to be able to access Chronic Disease Management plan MBS item numbers would no doubt contribute to more patients erroneously being referred for knee arthroscopy (still fully funded) rather than exercise advice for knee osteoarthritis. Furthermore, for the same reasons, not enough patients with cancer, diabetes or heart disease — conditions that are national health priorities and for which exercise has been shown to be of great benefit — are being referred to exercise medicine specialists. In addition, very few training positions are currently funded in sport and exercise medicine (despite Australia being a world leader in developing this training program), while other specialties and general practice still do not emphasise exercise prescription in their training programs.

Sports medicine itself is evolving to include subspecialties such as team care, overseas touring medicine, antidoping and sporting body administration. However, because of its broad applicability across the medical spectrum, exercise medicine must eventually receive due recognition under the MBS, and perhaps, it should evolve to dwarf its parent specialty of sports medicine. In doing so, it has potential to become a leading specialty in both the spheres of conventional, treatment-based medicine (for conditions including cancer, diabetes, mental health and cardiovascular disease) and, more importantly, in preventive health care.