Karim Miran-Khan

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Research Interests

Exercise is Medicine
Health promotion via Exercise
Type 2 DM prevention

Relevant Thesis-Based Degree Programs


Graduate Student Supervision

Doctoral Student Supervision

Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.

Longitudinal workload monitoring to keep athletes healthy and performing: conceptual, methodological, and applied considerations in sports injury aetiology (2019)

Sports injury aetiology is a process in which internal and external risk factors contribute to an inciting event. The last decade has seen a rapid growth in research that identified how training and competition workloads relate to sports injury risk. My literature review highlighted that existing aetiology models do not describe how workloads contribute to injury. Furthermore, injury risk fluctuates on a time-scale in parallel to these workloads (e.g. daily), which creates several methodological and statistical challenges that have largely been ignored. If researchers are to understand how athletes’ workloads relate to injury risk, their conceptual aetiological models must be updated to incorporate training and competition workloads, and they should use appropriate statistical analyses. After my literature review, I divide this dissertation into three parts. In Part 1 I discuss how workloads relate to injury. I present a novel workload—injury aetiology model, which expands on previous aetiological frameworks and details 3 ways that workloads contribute to injury: 1) exposing athletes to external risk factors and potential inciting events, 2) reducing injury risk through beneficial physiological changes, and 3) increasing injury risk through transient negative changes in athletes’ internal risk profiles. I then present mediation and moderation as potential causal approaches to understand how athlete risk factors interact with workload changes to alter injury risk. In Part 2 I tackle the methodological challenges of analysing workload—injury data. I reviewed prospective cohort studies that reported intensive longitudinal data to analyse workload—injury data in team sports. I identified that few studies utilised statistical approaches that align with theoretical aetiology models or addressed the methodological challenges associated with longitudinal data. My analysis leads me to recommend mixed modeling as one advance, and I exemplify how it can be used by studying how player unavailability affects player outputs. In Part 3 I integrate the conceptual and methodological considerations into two applied settings. First, I describe how a methodological/mathematical concern (mathematical coupling) may influence applied practice (multifaceted player load management) and research (explicitly reporting calculations). Finally, I use mixed modeling to examine pre-season workload and in-season injury risk, controlling for athletes’ weekly workloads.

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Patellofemoral osteoarthritis: characterizing knee alignment and morphology (2017)

Patellofemoral osteoarthritis (OA) is an under-recognized medical condition that may progress to generalized knee OA. It is highly prevalent and is associated with knee pain and disability. Patellofemoral alignment, tibiofemoral alignment or trochlear morphology may influence the prevalence, onset or worsening of patellofemoral OA. Therefore, my main objective in this dissertation was to use magnetic resonance (MR) imaging to quantify the relationships between knee alignment or morphology and prevalent patellofemoral OA. This dissertation is comprised of four studies. First, I systematically reviewed the associations among knee alignment or morphology with patellofemoral OA presence, severity, onset or worsening. Lateral patellar tilt, lateral displacement, patellar height, frontal plane knee alignment, and a shallow sulcus were all associated with OA prevalence and severity. Second, I examined the relationship between key alignment and morphology measures and early patellofemoral OA, one year following anterior cruciate ligament reconstruction. Lateral displacement and a shallow sulcus were associated with early patellofemoral OA.Third, I evaluated alignment and morphology in the Framingham community cohort, a population-based cohort. I established reference values in knees without patellofemoral OA or pain. I then evaluated dose-response patterns of the full sample. The odds of prevalent patellofemoral OA rose monotonically with greater lateral patellar displacement and a shallower sulcus. Odds rose for patellar tilt in both directions, i.e. increased medial or lateral tilt.Fourth, using an upright, open-bore MR scanner, I developed reproducible methods to evaluate three dimensional knee alignment in standing. I then examined differences in alignment from supine to standing positions, and differences in alignment in supine and standing in individuals with patellofemoral OA and matched controls. Key measures of malalignment were greater in standing then supine. In knees with patellofemoral OA, the patella was more laterally tilted, laterally displaced, and proximally displaced compared to controls, and the tibia was more externally rotated. Taken together, these studies suggest that knee alignment and trochlear morphology may influence the risk of patellofemoral OA.

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Sex, Gender and Health Promotion: Assessing the Potential for Health Promotion Interventions to Address Health and Gender Inequities (2016)

As a field, health promotion has largely ignored how sex and gender contribute to one’s capacity to increase control over and improve one’s health—the very essence of health promotion. This dissertation urges health promoters to adopt an intersectional view of sex and gender as determinants of health and to develop interventions with explicit attention to improving gender equity. Doing so positions health promotion to improve social as well as health outcomes.To develop this argument, I use intersectional theory to inform: an historical account of the development of health promotion and documentary review of key health promotion charters; an overview of reviews of interventions to increase physical activity, reduce smoking, and limit alcohol consumption among women; and a qualitative study of older women’s involvement in physical activity.Using criteria for gender-sensitive interventions articulated by the World Health Organization, the overview of reviews suggests that, to date, programs to address women’s physical activity and substance use are more likely to be gender-specific—aimed at women—than to be gender-sensitive. Building on this limited range of health promotion programs, I outline a conceptual framework to illustrate that health promotion could reduce gender-related health inequities by transforming gender-related norms, roles, and relations. I illustrate the need for and possibilities of such a framework with examples of social marketing messages directed at women and girls.I then present the findings of a qualitative study of older women’s engagement in physical activity with a gender lens. Though aware of the importance of physical activity for health, the women were motivated to be active to maintain their indepedence and function, rather than by health concerns, which can be understood as reflecting gendered expressions of resistance to the stigma associated with aging and disability—and their challenges to femininity. Informed by the framework on gender-transformative health promotion, programs could increase older women’s involvement in physical activity by aligning with older women’s priorities—stressing how being flexible, strong, and fit can contribute to women’s ability to live independently and pursue personal priorities—and simultaneously working to fight ageism, sexism, and barriers to participation.

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A healthcare operations research analysis of elderly fallers' emergency department services utilization (2012)

Introduction: Falls in the elderly are a significant cause of morbidity. Prescriptionmedication use has been identified as an independent risk factor for falls. Among all Emergency Department (ED) presentations by elderly persons, 14-40% are due tofalls, placing considerable strain on ED resources. Aims: In my thesis I aimed to 1) Provide updated estimates of the association between the use of specific medications and falling, 2) Determine whether the careprovided to elderly fallers while patients in the ED follows published recommendations and was provided in a timely fashion, 3) Estimate the cost per fallresulting in an ED presentation, 4) Design a discrete event simulation (DES) modelsimulating care and then simulating other approaches to care including hypotheticalchanges. Methods: 1) A Bayesian meta-analysis of studies assessing the association between specific classes of medication use and risk of a fall. 2) A cohort study ofelderly fallers presenting to the ED. 3) DES of the ED care received by elderly fallers. Results: Use of anti-hypertensives, diuretics, sedatives and hypnotics, neuroleptics and anti-psychotics, antidepressants, benzodiazepines, and non-steroidal antiinflammatorydrugs are associated with an increased risk of falling.1) In a sample of 101 ED fall presentations, 38% of elderly fallers leave the ED without a geriatric assessment and 14% are assessed by a physiotherapist.Less than 8% of fallers received care which met the wait time benchmarks. The estimated cost per fall causing an ED presentation is $11,408 with the cost per fall-related hospitalization estimated to be $29,363.2) Providing care in a timely fashion could significantly reduce the time an elderly faller spends in the ED and the opportunity costs associated with waiting to be seen by physician or admission to hospital. Summary: Many commonly used medications are associated with falls. The careprovided by the elderly faller in the ED does not currently meet therecommendations of published guidelines, nor is it provided in a timely fashion. The economic burden of falls is significant. By not providing ED care that meetsrecommended wait time benchmarks significant opportunity costs are incurred by the ED.

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An exploration of new therapeutic options for nocturnal leg cramps (2012)

THE PROBLEM: Rest cramps (also known as nocturnal leg cramps) are painful muscle contractions, typically in the legs or feet, that occur during prolonged rest - most often while in bed at night. Although common in older adults, safe and effective treatment options are lacking.OPPORTUNITY AND METHOD #1: Magnesium supplements are readily available and widely marketed to consumers for cramp prophylaxis. However the efficacy of magnesium for this indication is unclear and existing clinical trials are limited by the well recognized poor bioavailability of oral magnesium. To better assess the potential efficacy of magnesium in cramp prophylaxis I conducted a (N=46) double-blind, placebo-controlled RCT on community-dwelling rest cramp sufferers to determine whether a more reliable delivery method (5 consecutive days intravenous infusion of 20 mmol magnesium sulfate) could reduce the frequency of rest cramps. I additionally determined whether the response to treatment varied with the extent to which infused magnesium was retained (as measured by 24-hr urinary magnesium excretion) and performed a Cochrane Systematic Literature Review to find and synthesize all relevant randomised trials.OPPORTUNITY AND METHOD #2: Anecdotal evidence suggested several medications might promote muscle cramping. If true, cramp sufferers using these drugs could potentially gain cramp relief through therapeutic substitution or reduction of these agents. To investigate this potential cramp link I searched BC Ministry of Health databases containing diagnostic and prescribing information on the 4.2 million residents of British Columbia to determine, using sequence symmetry methods, whether quinine starts (i.e. new cramp treatment) increased in the year following introduction of the three most commonly prescribed medications with a link to muscle cramps (diuretics, statins and inhaled long-acting beta2-agonists).CONCLUSION: Although its role in pregnancy-associated rest cramps remains unclear, magnesium supplementation does not meaningfully reduce the frequency of rest cramps in older adults. Alternatively, for some cramp sufferers, reduction or discontinuation of select cramp promoting medications (inhaled long-acting beta2-agonists, potassium-sparing diuretics and thiazides) may be a useful therapeutic maneuver. Over a 13 year period 60.3% of quinine users (cramp sufferers) received at least one of these medications. In contrast, statin and loop-diuretic cramp associations were clinically unimportant.

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Health Economic Studies: A Focus on Health Related Quality of Life, Health Resource Utilization and Falls Prevention in Vulnerable Community Dwelling Seniors (2010)

Introduction: This thesis comprises six studies that address important economic issues related to falls prevention in community living seniors. Aims: 1) To ascertain the economic burden of falls in different countries and examine why these costs differ. 2) To determine which falls prevention strategies provide the best value for money. 3) and 4) To estimate the cost-effectiveness and cost-utility of once and twice weekly resistance training compared with balance and tone classes for one year and two years in terms of falls prevented and quality adjusted life years (QALYs) gained. 5) To: a) quantify the difference in the incremental cost-effectiveness ratio (ICER) when the QALYs are generated from the EuroQol 5D (EQ-5D) and from the Short Form 6D (SF-6D) over the 12-month intervention period of the Brain Power study, b) determine key predictors of changes in health related quality of life and health resource utilization. 6) To determine whether executive functions are independently associated with health related quality of life in older women. Methods: I conducted two systematic reviews, two comprehensive cost-effectiveness and cost-utility analyses, a comparison of two generic preference based utility instruments and an exploratory study of the association between QALYs and cognition. Results: 1) The mean cost of falls ranged from US $3476 per faller to US $26 483 per fall requiring hospitalization. 2) The best value for money in falls prevention comes from interventions targeting high-risk groups. 3) Once weekly and twice weekly resistance training were cost saving compared with balance and tone classes (comparator). 4) The benefits in the year after participating were not sustained for both resistance training groups. 5) ICERs estimated from the SF-6D and EQ-5D may result in different conclusions. 6) Executive function is an independent predictor of QALYs in older women.Summary: Falls prevention strategies can be cost saving and are related to quality of life and executive function in specific groups of community dwelling seniors. Establishing consistency in economic evaluation methods is a priority for comparison of costs, QALYs and value for money between countries and between effective falls prevention strategies.

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Tendon overuse pathology : clinical and laboratory studies (2008)

Background: Painful tendon overuse pathology (tendinosis) is poorly understood. Theobjectives were to identify major cell populations within clinical tendinosis lesions, andto examine factors involved in the regulation of tendon cell death, survival, orproliferation. The overarching hypothesis was that both cell death and cell proliferationplay roles in the development of tendinosis.Methods:1: Chronic patellar tendinosis tissue was compared with normal, pain-free patellar tendonusing Western blot, immunohistochemistry and in situ hybridization. A variety of celltypes were examined in relation to relevant features of soft tissue injury and repairincluding cellular proliferation and versican expression.2: In adult male rats, early tendinosis was induced in the supraspinatus tendon by 4-16weeks of mechanical loading (eccentric exercise). Tendons were analyzedmorphologically using polarized light and transmission electron microscopy, and byimmunolabeling for molecular markers of proliferation and survival.3: The influence of IGF-I on tenocyte survival was tested in response to chronic hypoxiain a cell-culture setting.Results1: Tendinosis was characterized by proliferation of tenocytes, endothelial cells, andsmooth muscle cells within a versican-enriched extracellular matrix. Mast cells were alsomore numerous in patient biopsies, whereas macrophages and lymphocytes were virtuallyabsent. VEGF expression was increased in endothelial cells from tendinosis tendons andwas more marked in patients with shorter symptom duration.2: Mechanical loading of the rat supraspinatus tendon by downhill running caused focaltendon lesions characterized by tenocyte proliferation, collagen disarray andglycosaminoglycan accumulation. Tenocytes in these areas of injury demonstrated aproliferative response which correlated with IGF-I expression and phosphorylation ofERK-l/2and IRS-1.3: Prolonged hypoxia of primary tenocyte cell cultures resulted in tenocyte apoptosis andcaspase activation. Apoptosis could be prevented dose-dependently by IGF-I, whichactivated the PKB survival pathwayConclusionsThe current studies outlined predominant cell populations present in tendinosis lesionsand identified factors which may be involved in regulating their death, survival andactivity. These experiments have opened up new avenues of research into thepathophysiology of tendinosis.

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Master's Student Supervision

Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.

Consensus methods in patellofemoral pain and patellofemoral osteoarthritis : how rigorous are they? : a scoping review (2023)

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.

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Experiences of individuals with mood disorders in Group Medical Visits focused on physical activity (2020)

Background: Despite numerous proven health benefits of physical activity, there is a physical inactivity pandemic. This is particularly true in individuals with mood disorders. Although research has shown the therapeutic and preventative effects of physical activity in people with mental illnesses, the levels of physical activity in this population remains lower than the general population. Considering the overwhelming evidence, the question is not whether physical activity is beneficial, but how can we better engage persons with mental illness in physical activity. In this study, I explored facilitators and barriers to being physical active in these individuals. The primary aim was to understand the experiences of individuals who took part in a 14-week long Group Medical Visit with a focus on physical activity. The secondary aim was to better understand the key features of such a program.Methods: I interviewed 24 participants clinically diagnosed with mood disorders - Major Depressive Disorder or Bipolar II Disorder. Participants were aged 32-64 years. I evaluated qualitative data from participants with a mood disorder who participated in an exercise program. The interviews were transcribed and managed using NVivo 10™. Thematic analysis was used to analyze the data.Results: The results of this study detail participants’ preferred content and method of delivery of a physical activity program and identify facilitators and barriers to being physically active. The main facilitators are social support, building a routine in daily life, and exposure to nature. The barriers include the mood disorder itself, finances, and fear from stigmatization. The preferred exercise program comprises a variety of light-to-moderate activities, offers the opportunity to connect with other participants with a mood disorder, and being in nature. Conclusion: The individuals in this study felt that key features of a physical activity program for individuals with a mood disorder must utilize a social network approach, take into account preferences of potential participants, and incorporate nature (both green and blue spaces) as a health promotion resource. Green spaces are places such as parks and forests, while blue spaces are attributed to places close to a body of water such as the sea, lake, etc.

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Turning Exercise into Medicine: Exploring the Feasibility of a 3 Step Physician Workshop to Promote the Physical Activity Prescription Behaviours of Family Physicians (2015)

Objective: To investigate the feasibility of an educational workshop with the provision of practical tools to change the proportion of family physicians in our sample who provided their patients with written physical activity prescriptions.Design: A pre-post study.Setting: Abbotsford and Mission, British Columbia.Participants: 25 family physicians registered with the Abbotsford or Mission Divisions of Family Practice. Intervention: A three-hour educational workshop for family physicians combined with practical tools to facilitate physical activity prescription. The educational content of the workshop included 1) assessing patients’ physical activity levels, 2) using motivational interviewing techniques to encourage physical activity, and 3) providing written physical activity prescriptions when appropriate. Tools to facilitate physician behaviour changes included a 1) ‘physical activity vital sign’, a measure of patient self-reported physical activity, and 2) copies of the “Exercise Prescription and Referral Tool” designed by the Exercise is Medicine Canadian Taskforce, a written prescription pad for physicians to provide physical activity prescriptions to their patients. Participating physicians completed a bespoke questionnaire before and four weeks after their attendance at the workshop. Outcome Measures: The feasibility of the intervention was ascertained by assessing changes in the proportion of family physicians who reported providing written physical activity prescriptions at four week follow up, compared to baseline. Exploratory outcomes included changes in physicians’: 1) other physical activity prescription behaviours, 2) the perceived importance of various barriers to physical activity prescription, 3) knowledge and confidence regarding physical activity prescription, 4) knowledge of the Canadian Physical Activity Guidelines and 5) self-reported physical activity levels. McNemar’s test evaluated changes in proportions before and after the workshop, while Wilcoxon signed-rank tests evaluated changes in Likert data. Results: Twenty five family physicians completed the baseline questionnaire and attended the workshop, with 100% follow up response rate. The proportion of family physicians who reported providing written physical activity prescriptions in their clinical practice increased from 10 (40%) at baseline to 17 (68%) four weeks after the intervention.Conclusion: Educational workshops combined with practical tools appear to be a feasible method to encourage the use of written physical activity prescriptions among family physicians in this setting.

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Community-driven injury prevention in youth female soccer (2013)

Introduction: Youth female soccer players are at high risk of lower-extremity (LE) injury. Randomized controlled trials (RCTs) have previously demonstrated the efficacy of team-based neuromuscular training in decreasing injury rates in youth female soccer players. In an RCT, the neuromuscular training program used in this study was efficacious in reducing the risk of all injuries by 38% and acute-onset injuries by 43% in youth soccer players. The aim of this thesis was to determine the effectiveness of such an injury prevention program when community initiated, taught and delivered. Research design: Historical cohort study Participants: In 2008, 23 teams participated in the collection of quality assurance data (n=351). In 2010, 15 teams completed the study (n=187). Players in both cohorts were ages 9 to 17.Intervention: The program included a team-based neuromuscular training warm-up (including dynamic stretching, strength, agility, plyometric and balance components) and an individual home-based wobble board training program. Main outcome measures: Soccer injury resulting in time loss of one week or more. A soccer injury was defined as any injury occurring during soccer activity resulting in medical attention and/or the removal of the player from the current session and/or subsequent time loss of at least one soccer session as a direct result of that injury. Results: In study 1, the Risk Ratios (RR) comparing the intervention season to the control season were: all injury (RR, 0.73; 95% CI, 0.37-1.45), acute-onset injury (RR, 0.69; 95% CI, 0.33-1.44) and LE injury (RR, 0.74; 95% CI, 0.34-1.64). In study 2, there was evidence that player position and right knee flexion-to-extension ratio were significant risk factors for injury in youth female soccer players participating in an injury prevention program.Conclusions: RR point estimates suggest that a community-driven team-based neuromuscular training program may be protective of all injury, acute-onset injury and LE injury in youth female soccer players. The magnitude of this effect is similar to that previously determined in RCT studies examining a similar neuromuscular training program. Future research should focus on the implementation context of delivery of such a program to evaluate adherence and maintenance in a youth soccer population.

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Health outcome measures in an aging population: Validity, reliability and interpretability (2013)

In Canada, older adults currently represent a record high proportion of about 15% of the population. Associated with aging is the increased prevalence of multiple morbidity, resulting in widely varied and complex health statuses among our aged. Identifying effective strategies to promote healthy aging and reduce comorbidity hinges on the ability to accurately measure health outcomes. This requires the use of valid and reliable instruments with associated reference statistics to enhance interpretability of test scores.In Chapter 2, I present a validity study of a patient-reported outcome measure, the Patellofemoral Pain and Osteoarthritis Outcome Scale (PFOOS). The PFOOS is designed to evaluate symptoms relating to patellofemoral (PF) pain and osteoarthritis. I recruited 54 adults aged 18+ with peri- or retro-patellar pain for ≥ 3 months, rated ≥3/10 on a numeric pain scale, aggravated by PF-loading tasks (e.g. squats). People with diffuse knee pain, history of total knee or hip replacement, or severe knee trauma in the past year were excluded. Recruitment was done through adverts to staff & students at an Australian University. Participants completed paper & online versions of the PFOOS, Anterior Knee Pain Scale and SF-36, and repeated the PFOOS in 1-2 weeks. Analysis included internal consistency (Cronbach’s α), test-retest & alternate forms reliability (ICC), and construct validation (hypothesis testing). ICCs were ≥ 0.79, Cronbach’s α ≥ 0.61. The PFOOS performed largely as hypothesized. Overall, the PFOOS demonstrated good validity & reliability in this sample. In Chapter 3, I report results of a cross-sectional study aimed to develop normative data for the de Morton Mobility Index (DEMMI). The DEMMI is a performance-based instrument that measures mobility across a spectrum from bed bound to functional independent mobility. A sample of 183 healthy, community-dwelling adults age 60+ were recruited. Mean DEMMI scores varied by age category, by living arrangement (independent vs. assisted living), and by use of mobility aid (p
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