Whether you are reading a social media post, a blog, a newspaper article, or a journal paper it should always be read with a critical mind and never taken at face value.

In the world of medical and scientific journal articles it is all too easy to be drawn to an attractive title like “PRP superior to coritsone for lateral elbow pain: meta-anaylsis” to only read through the abstract taking the conclusion as gospel, because after all the title says it’s a meta-analysis which means the paper has to be solid right?

It is true that the strength of an article lies in its design with meta-analysis and systemic reviews at the top of the tree, followed by blinded randomised controlled trials, right down to case reports and editorials. Nevertheless, study design alone is not enough to be able to truly trust an article’s findings.

One must consider the methodology used and how easily it be can be reproduced, in addition to the strength and weaknesses of the selection (inclusion/exclusion) criteria including the outcome measures used. For example, if we are examining tendinopathy and the diagnosis is confirmed by physical examination alone without ultrasound, how many patients in the study will have confirmed tendinopathy? Even if those patients have been selected carefully, they are still at risk of dropping out of the study, which can have disastrous effects on the outcome of a study. As statistical power, or the number of participants required to be able to detect an effect is a vitally important.

Articles are also open to the risk of bias, confounders, errors, and chance which can all influence the outcomes of a study. It maybe the study has selected participants who are known non or strong responders to an intervention being tested, called selection bias. A strong study design aims to mitigate the risks of these occurring however, understanding their impact on a study is imperative when critically reviewing what you are reading. Additionally, articles often use statistical measurements such as, measures of associations and measures of heterogeneity including odds ratio, hazard ratio, relative risk, P value, I2 understanding these is crucial to be able to interpret the results.

Lastly, when consideration has been given to all of these aspects thought must then be given to the results and how they compare to other reputable research available in that area. Are the results consistent with other research, if not why? What research has been used to support their findings and is that research reputable and high quality? Do the results add weight to the existing research to further support an outcome? Do they give rise to a rethink about the existing research? Do they create a new higher standard or intervention? Or did the study use a weak design or were the results influenced by bias, confounders, errors, chance, or a high dropout rate, or poor selection criteria leading one to question the quality of the study’s findings?

Understanding what you are reading in this day in age where “authorities” are in endless supply is extremely important. Regardless of what you are reading, always sit back and ask yourself questions about what you are reading, who is writing it, why are they writing it, how robust is the article, what quality of evidence is it supported by, and are there any parties who will benefit from the results. 

For more interested blog articles check out the Shannon Clinic blog page.

Currently most countries around the world have enacted self-isolation and quarantine rules to help flatten the curb and reduce the spread of COVID-19. An unfortunate by-product of these restrictions has been the closure of gyms and fitness studios, coupled together with a large number of people now working from home. This has made exercising more challenging and reduced people’s motivation to exercise resulting in more sedentary behaviour and reduced physical activity.

At present the physical activity guidelines recommend at least 150mins per week of moderate to vigorous activity. This means exercising at least to a level where you are unable to complete a full sentence without taking a breath. Why is physical activity important? There is a growing body of evidence that shows how beneficial exercise is for a raft of conditions, it helps to reduce your risk of developing chronic preventable diseases like diabetes, obesity and cardiovascular disease, as well as reducing your risks of certain types of cancers including breast, colon, liver, kidney. Additionally, it is beneficial for improving balance, bone health, quality of life, cognition, sleep, mood, mental health and immunity among others. 

To combat this decline in physical activity and to motivate people to keep exercising throughout the COVID-19 pandemic, the Shannon Clinic together with the help from some great friends who are professional athletes, we have started the #getmoving initiative. On the Shannon Clinic Instagram page we are dropping a series of videos every few days this week from pro athletes who are here to encourage you to keep exercising and to show you how easy it is to exercise without access to a gym or equipment.

We hope that you enjoy the videos as they are released, and they motivate you to keep exercising, we also ask you to share the videos and if you have any requests or questions please comment below the posts. Ultimately, we would like spread the word as far and wide as possible and would like more pro athletes to post similar videos of encouragement. I thank my wonderful friends including WTA players Demi Schuurs and Nicole Melichar, Brazilian Jiu Jitsu champion Ben Hall, ATP players Bruno Soares and Alex Peya for helping out, so get out there and get moving!

With the current COVID-19 pandemic creating global disruption, uncertainty and with many countries enforcing society lockdowns, it is making physical activity and exercise more onerous. However, one of the few exceptions to the lockdown rules is exercise, so lets examine the evidence on exercise and immune function.

It is well known that regular bouts of exercise lasting up to 45 minutes of moderate to vigorous exercise is beneficial for immune defence, particularly in older adults and those with chronic diseases. This type of exercise is beneficial for the normal functioning of the immune system and is likely to help lower the risk of respiratory infections/illnesses. However, there is debate within the scientific community whether acute bouts of vigorous intensity exercise leads to a period of immune suppression post exercise.

There has been a long held concept in exercise immunology developed in the 1980s and 1990s called the “open window” hypothesis which proposes a J curve relationship between exercise intensity and infection risk. Which is supported by the belief that athletes who engage in high volume endurance training experience a greater incidence of Upper Respiratory Tract Infections (URTI) compared to those who are less active. Until recently this concept has remained relatively unchallenged.

The “open window” hypothesis suggests that following a prolonged (>1.5hr) and vigorous acute bout of exercise or following chronic intense training (>1.5hr on most days) there is an “open window” which results in an increased risk of opportunistic infections such as URTI’s. The three principles underpinning this concept are:

1). Infection risk increases after prolonged vigorous aerobic exercise

2). Acute bouts of vigorous exercise can lead to temporary reductions in salivary immunoglobulins resulting in higher risk of opportunistic infections

3). A period of post exercise reduction in peripheral blood immune cells resulting in a period of immune suppression.

J Curve – relationship between the risk of infection and level of exercise intensity

Recently though there has been emerging evidence suggesting this concept may be outdated. There is evidence, albeit small that indicates international athletes suffer from less URTI than national athletes. This raises the likelihood that infection susceptibility is more likely multifactorial including genetics, sleep, stress, nutrition, travel, circadian misalignment and increased exposure risks due to close proximity of crowds rather than being directly attributed to acute or chronic bouts of vigorous training. This also indicates that international athletes are potentially better supported, have access to better education helping them to improve their life-style behaviours over national athletes resulting in lower risks of infection.

Secondary to this, evidence supports the opposite of the three principles upholding the “open window” concept. With no changes seen in mucosal immunity which has previously been flagged as an indication of immune suppression. The reduction in blood immune cells (primarily lymphocytes) 1 to 2 hours post exercise reflects a transient and time dependent redistribution of immune cells to peripheral tissues resulting in a heighten state of immune surveillance and regulation leading to enhanced antibacterial and antiviral immunity, not suppression of the immune system.

Further research is needed to confirm or refute the “open window” concept however, it currently appears that the infection risk post vigorous exercise is more likely to be associated with a multitude of other factors rather than purely post exercise immune suppression. So for athletes and non-athletes the message remain the same during COVID-19, regular moderate to vigorous exercise is beneficial to enhance immune function to reduce the risk of bacterial and viral infections including URTI’s. And remember that good hygiene practices (washing hands regularly, not touching your face), physical distancing, getting good quality sleep, reducing stress levels and eating healthy wholefoods are the keys keeping your immune system in peak condition.

Find out more information on COVID-19 here.

COVID-19 Update

In light of the recent federal and state government announcements regarding the closure of non-essential businesses we wanted to notify our patients that as a primary health care service, we are an essential business and will remain open until otherwise informed. 

We receive daily updates from the Department of Health and Human Services and the Australian Chiropractic Association. As such we take infectious disease control very seriously and are doing all that we can to make our clinic as safe as possible including, making hand sanitiser available in our reception area for all patients, regularly wiping down all surfaces including our reception and treatment areas and employing physical distancing in our waiting area. We also ask that all patients undertake physical distancing, good hygiene practices and be aware of the COVID-19 symptoms which include:

  • A fever with or without acute respiratory symptoms
  • Acute respiratory symptoms include a dry cough, shortness of breathe, difficulty breathing.

Those at risk are patients who have travelled internationally in the last 14 days before the onset of symptoms or, who have had close contact in the last 14 days before the onset of symptoms with a confirmed case of COVID-19.

If patients fit this profile they need to be tested for COVID-19 and call the health department on 1300 651 160.

We therefore kindly ask that any patients who fit the case profile above with appointments at the clinic, to call and notify our reception staff to reschedule their appointment and then seek medical attention. We thank you for your understanding in these interesting times.

We have been watching the developments of the COVID-19 pandemic closely and decided that it was important to inform our patients, especially in light of the current media reporting.

There have been 6 coronaviruses to date that have been detected, including the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). To help put the current severity of COVID-19 into perspective with other coronaviruses these are the comparison infection and mortality rates to MERS and SARS.

  • SARS (2002) affected 8096 people with a mortality rate of 10%
  • MERS (2012) affected 2494 people with a mortality rate of 37%.

As COVID-19 continues to evolve, the numbers of those infection and the associated mortality rates will fluctuate however, the mortality rate at the time of writing this appears to be lower than that of SARS. Reducing the spread of COVID-19 is currently the key objective and primary concern, meaning patients shouldn’t feel alarmed but they should exercise common sense and good hygiene practices including, washing your hands regularly, not touching your face and maintaining a 1.5m distance to others to aid in controlling the spread of the virus.

The symptoms patients needs to be aware of are:

Those at risk are patients who have travelled internationally in the last 14 days before the onset of symptoms or, who have had close contact in the last 14 days before the onset of symptoms with a confirmed case of COVID-19.

If patients fit this profile they need to be tested for COVID-19 and call the health department on 1300 651 160.

We therefore kindly ask that any patients who fit the case profile above with appointments at the clinic, call and notify our receptionist to reschedule their appointment and then seek medical attention. We thank you for your understanding in these interesting times.

Ketogenic diets or low carbohydrate diets routinely appear in the media with stories ranging from the negative health implications they can have including reduced bone health to the benefits they have on weight loss, diabetes and performance in elite athletes. With such conflicting information out there, let’s turn to the literature to see what the truth is about ketogenic diets and performance.

What Is Keto?

For a diet to be considered ketogenic it needs to contain less than 50g of carbohydrates (CHO) per day, be high in fats 70-80%, with the remaining 15-25% coming from protein. For athletes, especially endurance athletes CHO’s are the preferred fuel source for enhancing performance therefore by restricting CHO intake it forces the body into ketosis. In a ketosis state, ketone bodies (fat molecules) are released from the liver, producing an alternative fuel source to CHO’s.

Why Athletes Choose a Keto Diet

The utlization of fats as fuel becomes one of the primary reasons endurance athletes are attracted to ketogenic diets. This attraction occurs because fats provide a better source of energy than carbohydrates and there is an abundance of fat stores compared to the limited glycogen (CHO) stores in the muscles. Other reasons athletes are attracted to ketogenic diets include, the feeling of enhanced recovery, improvements in body composition and reduced post exercise inflammation.

It is well documented that ketogenic and low CHO diets are beneficial for body composition changes, namely weight reduction through decreases in adipose (fat) tissue. This isn’t surprising considering fat oxidation (fats being burned for fuel) becomes the primary energy source in a ketogenic diet.

Keto Diets and Athletic Performance

In terms of athletic performance the evidence is less clear. Majority of the current studies looking at athletic performance and ketogenic diets routinely involve small sample sizes of elite athletes and over a short time frame (3-10 weeks). As a result, any findings from these studies need to be interpreted and considered with other available literature. With such a specific cohort (study population) transferability of the results to other non-elite athletes becomes difficult.

Exercise Capacity

In terms of endurance performance, there appears to be a reduction in performance during high intensity bouts above 70% of VO2Max when on a short term (3-10 week) ketogenic diet. The postulated causes include; fats require greater oxygen uptake and energy to be broken down compared to CHO, possible impaired glycogen metabolism at higher intensities. However, one study which looked at endurance athletes who were on ketogenic diets for longer than 6 month showed no changes in muscle glycogen stores.

Resistance Training

For resistance training and lean muscle mass it appears that ketogenic diets result in reduced body mass, with conflicting evidence on whether it impacts on lean muscle mass. Regardless, it doesn’t appear to negatively impact strength.

Bone Health

Bone health is an interesting area. An Australian study published early this year revealed that bone resorption (break down of bone) increased and bone formation (new bone formation) decreased in elite athletes (race walkers) while on a short term (3 – 3.5 week) ketogenic diet. This study received a lot of press because the implications are potentially serious; ketogenic diets leading to reduced bone mineral density and bone injuries in elite athletes. However, this study needs to be put into context. It looked at elite race walkers, predominantly males who were on short term ketogenic diets. This is a very specific subgroup of people. As the study rightly points out, further research is needed to understand these findings further before any definitive answer is known about ketogenic diets (short and long term) and bone health in elite athletes and in the general population.

The Wash Up

When it comes to athletic performance ketogenic diets improve fat oxidation and reduce body mass, which is important in endurance sports and weight-class based sports such as boxing, weight lifting, martial arts etc. They don’t negatively affect exercise capacity at submaximal workloads below 70% VO2Max but they do appear to reduce exercise capacity at high intensities. They may also reduce endurance capacity but this appears to be individual, with some athletes being affected and others not. At present, finding the right balance of lower CHO levels which are higher enough not to impact performance at higher intensities is the best approach to maximize athletic performance through a ketogenic diet. One final note, even though CHO intake levels are low, this does not mean an athlete will be running a negative energy balance; energy expenditure should always match energy intake.

[Click Through To Read About Plant-Based Diets]