Recent eLetters

Displaying 1-10 letters out of 290 published

  1. New and old: enjoyment of free air

    The German physician Christopher William Hufeland (1762 - 1836) wrote in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the movements is the grand foundation on which health, uniformity of restoration, and the duration of the body, depend; and these certainly cannot take place if we merely sit and think. The propensity to bodily movement is, in man, as great as the propensity to eating and drinking. Let us only look at a child. Sitting still is to it the greatest punishment. And the faculty of sitting the whole day, and not feeling the least desire for moving, is certainly an unnatural and diseased state. We are taught by experience, that those men attained to the greatest age, who accustomed themselves to strong and incessant exercise in the open air. I consider it, therefore, as an indispensable law of longevity, that one should exercise, at least, an hour every day, in the open air."

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  2. The Devil Is In The Detail

    I would like to comment on the conclusions of the recent published meta-analysis by Thorlund et al in the BMJ and the subsequent sensationalist editorial. The conclusions are at odds with my own personal experience and that of my peer group.

    Although the methodology of the study is valid I would take issue with the conclusions reached.

    The meta-analysis on benefit started with nearly 1800 studies and was reduced to 10 (although in the text of the article, only 9 references are cited after this statement). The meta-analysis on harm was on a separate series starting with 2330 studies reduced to 9.

    The devil is in the detail and I will address each study individually. I review papers for journals and would certainly not have allowed some of the conclusions reached in the papers, past the peer review stage.

    To start with, the 9 (or 10!) studies on benefit (or not) are a mixed bunch dealing with degenerative change (3), degenerative meniscal tears (6 - 2 of which are the same study at different time intervals) or a combination of the two (1). Two papers would never pass an ethics committee in the UK and would not be considered for publication in the UK. One of the papers on meniscal injury is related to depression and anxiety and in an obscure journal. I have excluded this from my analysis as I don't generally perform surgery to improve a patients psyche and commenting on this is outside my sphere of competence.

    Benefits (or lack of!)

    Partial Meniscectomy

    Yim et al - well conducted study but in common with other papers, diagnosis had a large reliance on MRI findings and only 2/3 of eligible patients entered the study. Patients who had any form of bony surgery were excluded. This study was performed in South Korea in a population that is very different, culturally and biomechanically from patients in the West and its findings are only directly applicable to similar populations.

    Gauffin et al - This paper states that patients having surgery had significantly less pain than the non-surgery group at 12 months.

    Sihvonen et al - this paper includes a sham surgery arm, which would be regarded as unethical in the UK. Of 205 eligible patients 49 were excluded. Interventions were carried out in 5 centres meaning only 30 in each centre. The authors state only meniscal surgery was performed - "no other surgical procedure was carried out". Tucked away in the supplementary appendix is the "findings at arthroscopy" - only 20% of the intervention group had no or mild degenerative change and 33% of the sham surgery group. 54% of the intervention group had degenerative change and 40% of the sham surgery group and an equal number in each group were osteoarthritic. This study only addresses intervention for one part of the knee when the pathology is likely to be multifactorial and in particular where there was no clear identification of symptoms directly attributable to a meniscal tear.

    Herrlins et al's 2 papers are also interesting, being a 2 and 5 year follow up in the same cohort of patients. It is perhaps the most disturbing, in that the authors of the meta-analysis neatly discard the results and conclusions of the 5 year study "as the other outcomes are only out to 2 years". Perhaps this is because the conclusions of the 5 year outcomes are very different from those of the 2 year outcomes. Specifically - in the 2007 paper (2 year follow up) the abstract states - "arthroscopic partial medial meniscectomy alone, followed by exercise therapy was not superior to supervised exercise alone". In the 2013 (5 year follow up) paper the authors make the same statement but add "however, one third of patients from the exercise group, still had disabling symptoms but improved to the same level after surgery".

    Meniscal tear and Osteoarthritis.

    There is only one, widely quoted, paper in this group by Katz et al. Once again there is a large reliance on MRI diagnosis for degenerative change and meniscal tearing. Enrollment was based on one symptom, of at least 4 weeks duration, that might suggest a meniscal tear and a positive MRI. There were 7 centres involved in the study with numbers per centre ranging from119 to 17 patients. Of 1330 patients eligible for the study only 351 were enrolled. Of the 150 patients in the physical therapy group 51 had crossed to the surgery group in the first 6 months and a further 8 did so between 6-12 months. After surgery these patients improved to the level of the initially operated on patients. At 6 months 67% of surgical patients improved by 8 points on the WOMAC scale compared with 43% patients in the physical therapy group (bear in mind a third of these had crossed over to the operated group). In the UK it is very unusual to see a patient with symptoms of only 4 weeks duration and one must ask the reason why 2/3 of the patients declined to enter the study (not defined by the authors). The most likely reason in my experience is many patients will already have had physiotherapy before referral and not surprisingly, wouldn't want to be randomized to a group receiving treatment that had already failed them.


    Chang et al's paper is a small series, with 18 in one group and 14 in the lavage group ie both had an intervention. About half of each group had significant improvement at 12 months, but the authors reach the conclusion that "arthroscopic surgery may be beneficial in certain subgroups". This study is smaller than a study by Hubbard and one has to ask why Hubbards paper (see below), with a larger number of patients, wasn't included despite being almost identical in design.

    Kirkley et al, again compares conservative management with conservative management + meniscal surgery. Once again 26% of those eligible did not complete the trial. The authors excluded any patient with grade 1 radiographic changes and 50% of the patients had grade 3 or 4 osteoarthritis. Generally in the UK there would be little indication for surgical intervention in more advanced OA unless there are associated mechanical symptoms.

    Moseley et al's paper would again not be accepted by an English orthopaedic journal as it includes a sham surgery arm. It has already had a fairly robust rebuttal in an editorial in "Arthroscopy". Of the 324 patients eligible for the trial 144 declined to be enrolled. 25% of the patients had "severe osteoarthritis" - a group that would generally not be considered for surgery in the UK. To quote Bob Jackson "This study was seriously flawed, first by the selection of patients with no clear indication as to how severe the arthritic state was in each case. Second, patients in the Veterans Affairs system do not represent the typical population, which consists of younger people and women (97% of study patients were men). Moreover, VA patients have a vested interest in getting continued benefits for a disability. Third, the statistics used in the paper have been strongly criticized by independent statisticians, as the authors changed their direction on 3 occasions, first using an established device to show superiority of one group over another (which it did not), then using another proven device to demonstrate "equivalence" (which it did not), and then finally using an unvalidated measurement device of their own making, which did prove equivalence of the 3 groups."

    Adverse Events

    The authors of the meta-analysis boldly state - "Arthroscopy is associated with harms" without any qualification of this statement.

    Professor Andy Carr has also recently stated in the BMJ that the death rate from arthroscopic surgery is approximately 1/1000 and deep vein thrombosis as 4 per 1000. Perhaps most worrying is this statement has been published without being referenced and despite emailing him I have not had a reply as to where these figures come from. This is, quite frankly, irresponsible of the BMJ. In my immediate group we have performed approximately 50,000 arthroscopies without a death.

    The authors of the meta-analysis have been disingenuous in that they have taken a separate series of studies on complications and then applied them to the separate series of surgical results they have analysed. This cannot be logical or scientifically valid.

    There are some large studies but these generally include all arthroscopic surgery, including complex ligament surgery, arthroscopic washout for septic arthritis etc, and not just meniscectomy and debridement.

    Maletis et al, analyzing some 21,800 cases , report only one surgically attributable death.

    Hetsroni et al quote a 2.8 /10,000 rate of pulmonary embolism but this is strongly associated with increasing age, complexity of surgery and operating time ie is not directly related to simple arthroscopic surgery.

    Jameson's study included all arthroscopic surgery including ligament reconstruction, with problems once again associated with more complex surgery. Perhaps the most relevant point in this series is that a lower rate of problems was associated with high volume units. The authors state "Complications following arthroscopy of the knee are rare. It is a safe procedure."

    Hame et al's paper states "post operative complications are rare", and this is in a series of patients who were all over 65 - a noted risk factor.

    The authors of the meta-analysis also include 2 papers from the analysed "benefit" series in their analysis of adverse events.

    Although they include the paper by Sihvonen et al the only adverse event was a deep infection, which occurred 4 months after surgery following a dental procedure and surely can't be directly attributed to the operation.

    Perhaps the most interesting paper in their series is the widely quoted paper by Katz et al , which compared surgery against physical therapy followed up for 12 months. They reported 2 deaths - however one occurred in the physical therapy group! Adverse events of mild to moderate severity occurred in 15 patients post surgery and 13 in the physical therapy group. Ie physical therapy seems just as dangerous to the patient.


    I do not believe the stated conclusions of the meta-analysis can be justified by the evidence provided, and the paper does not seem to have been robustly reviewed or edited in appropriate detail. I hope I have demonstrated this in the above commentary.

    In my own experience, appropriate debridement in early osteoarthritis can produce pain relief and improved function for anything up to 4 to 10 years. This has been shown in the literature in a prospective randomized, single surgeon study on consecutive patients - Hubbard MJS JBJS 1996 (for some reason not included in the meta-analysis) - which reports 50% of patients with continued pain relief at 5 years. Aichcroth et al's paper in 1991 (large number with only a small number lost to follow up) showed 75% of patients had minimal discomfort and improved function at 4 years post surgery and only 14% of patients had had to progress to further surgery. Although this study is not randomized, it was prospective and for a group of patients who had significant symptoms of significant duration who had already failed conservative management.

    As far as meniscal tear goes, from the papers presented, this would seem to be a valid intervention even in series where I would take issue with some of the diagnostic criteria. It has been clearly demonstrated that diagnosis of clinically relevant meniscal tears is more sensitive and specific in the hands of an experienced knee clinician than MRI. - O'Shea K.J., et al Am J Sports Med 1996, and Gelb et al Am J Sports Med 1996.

    To make the diagnosis of meniscal tear based on joint line pain and a positive MRI is clinical laziness at best. Posteromedial tenderness and fullness (often associated with a small parameniscal cyst) which mimics the patients pain, decreased flexion, pain on crouching and pain on sleeping with the knees together, almost always results in immediate pain relief flowing arthroscopic resection of the tear.

    Even despite the poor clinical discrimination, 30% of patients failed conservative management with "continuing disabling symptoms" and were provided with pain relief on surgical intervention. An intervention which, in skilled hands is quick, relatively painless, and has a very, very low morbidity.

    The authors state "these finding do not support the practice of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis" without defining the cause of the pain. This statement is not supported by the evidence provided. A summation of erroneous conclusions does not equate to a new "evidence based" conclusion. To baldly state "arthroscopy is associated with harms" with having looked at the complication rate specifically for simple uncomplicated arthroscopic surgery is unacceptable and should not have been allowed through by the editorial team.

    The worry is that symptomatic patients will be denied appropriate treatment based on the findings of this "scientific study" which are in reality not scientifically valid. As is so often the case, it is the surgeon performing the procedure and not the procedure itself that is critical in getting a good outcome.

    Steve Bollen Consultant Orthopaedic Surgeon.

    Conflict of Interest:

    None declared

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  3. Low dose physical activity and the elderly

    At the age of 86, I am a strong believer in the virtues of moderate physical activity for the elderly, walking some 5 km most mornings, and tending a substantial garden. Moreover, I agree with the proposition that for an elderly population, any physical activity is better than none, and that controlled experiments can be devised to demonstrate some of the short-term benefits of an increase in such activity. However, I was a little surprised that the normally eagle-eyed editors and reviewers of BJSM allowed the current wording of the systematic review and meta- analysis of low-level physical activity and death rates, as published in the October issue. In this article, Hupin et al. [1] repeatedly make the claim that "a dose of MVPA below current recommendations reduced mortality by 22% in older adults." But it seems clear that the papers cited in their well-conducted meta-analysis have demonstrated an association between light physical activity and mortality rather than a causal reduction in mortality. In most of the investigations considered, the better initial health of some participants could account for both their greater habitual activity and also their lower mortality, and the same problem confounds the analysis of dose-response relationships. We cannot determine how much physical activity is the cause, and how much it is a consequence of good health. This is an important issue, and an unfortunate limitation of much epidemiological research. Partial remedies are to follow cohorts with differing levels of physical activity for some years before beginning a study, and to examine the effects of a change in physical activity over the course of observations.


    1. Hupin D, Roche F, Gremeaux V. et al. (2015). Even a moderate-to- vigorous physical activity reduces mortality by 22% in adults aged >60 years; a systematic review and meta-analysis. Br J Sports Med 2015; 49: 1262-1267.

    Conflict of Interest:

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  4. Non-contact anterior cruciate ligament injuries.

    It is common practice to refer lower limb injuries as non-contact, in this paper the categories have been clearly defined. The term pressing needs defining which may help the non soccer community. All lower limb injuries in football ought to be categorised as contact or in-direct contact with respect to the ground or an opponent. The principles of the Laws of Motion from Newtonian mechanics and basic physics might add further an understanding of patterns of movement and relative contact with the ground and the opponent. References: Bunn, JW (1972) Scientific principles of coaching. Englewood Cliffs,New Jersey. Armenti,A (1992) The Physics of Sports. Springer-Verlag, New York.

    Conflict of Interest:

    None declared

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  5. Serum Testosterone In Sedentary, Active And Athletic Males From Kosovo

    Testosterone is one of the anabolic androgen steroids (AAS) that has been abused to improve higher athletic performance by enhancing muscle development and recovery. The purpose of this study was to assess basal level of serum total testosterone in male athletes and to compare it with physically active and sedentary males.

    The study sample was composed of 40 males divided in four groups of different physical activity level: two athlete groups (basketball and football), one physically active and one sedentary group. The subjects were assessed for the level of total testosterone by Chemiluminescent Immunoassay, controlling for biological parameters including age, body mass index (BMI), lean body mass (LBM), diurnal variations. LBM of basketball players (70.2 ? 1.9 kg) was higher (p < 0.05) than other groups.

    Basketball players showed a lower testosterone level (10.8 ? 1.0) compared with other groups (p < 0.05). The highest significant difference (p < 0.05) according to basal level of total testosterone was between basketball players and sedentary (16.7 ? 1.5). Decreased basal level of total testosterone of basketball players correlates with high LBM in respect to other physically active groups (p < 0.05). Future suggestion for WADA is to review the upper reference limit of basal level of total testosterone after the vigorous training periods for Basketball players

    Conflict of Interest:

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  6. Time to bust the myth?

    Recent editorials have renewed the debate on the role of physical inactivity in the current obesity epidemic. [1, 2] Malhotra and colleagues cite an opinion piece suggesting "little change of physical activity levels in the past 30 years," while Blair counters that U.S. Dept. of Labor statistics show "mining, agriculture and agricultural jobs declined substantially."

    Both statements have some truth, but they neglect the degree of energy imbalance needed to make a person obese. In moving from an acceptable body mass to obesity (BMI > 30 kg/m2), an adult accumulates about 15 kg of fat, and a child 5 kg. If spread over 10 years, this equates to 10-30 g/week, or a daily energy imbalance of about 50-150 kJ. Current statistics lack the accuracy to detect such an imbalance.

    Many of the obese are children, unaffected by changes in mining. However, walking or cycling 1-2 km to and from school is now widely replaced by transportation in their parents' cars. This could easily reduce daily energy expenditure by 50-150 kJ.


    1. Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med 2015; 49: 907-8. 2. Blair SN. Physical inactivity and obesity is not a myth: Dr. Steven Blair comments on Dr. Aseem Malhotra's editorial. Br J Sports Med 2015; 49: 908-9.

    Roy J. Shephard, PO Box 521, Brackendale, BC V0N 1H0, Canada.

    Phone: 604-898-5527 e-mail:

    Conflict of Interest:

    None declared

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  7. Coke and sports

    It is like saying Coca-Cola is the favorite drink of many athletes. The truth is much more complex. Research in this field that is funded by the beverages industry tends to be biased. There will always be people in any field, including scientific research, who will do almost anything to make a buck. I can understand the necessity of balancing the views on any public health issue, but here the balance is tipped over by an evident conflict of interest.

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  8. Re:Re:12 Reasons why the "Physical Activity Myth" paper should not have been published; Request for retraction or modification based on open external peer-review

    In response to Professor Cooper:

    We thank Prof Cooper for his comments (15th June 2015) on our Letter to the Editor, and in particular his critique of our Point 3. We stated in our original letter that "we invite discussion and criticism of our review, and will gladly amend any sections that can be shown to be incorrect." In that spirit we will modify our Point 3 accordingly to better reflect the evidence, but we would also like to discuss further the issue that Prof Cooper has raised.

    In our letter we pointed to the "Physical Activity Guidelines Advisory Committee Report" in relation to studies showing that physical activity (PA) has an effect on body weight and to challenge the (unreferenced and un-evidenced) claim by Malhotra et al., that "...physical activity does not promote weight loss". The text on page G4-5 to G4-6 of the report clearly describes that from 20 identified RCTs, 4 had appropriate designs and sufficient statistical power to assess weight loss. They showed weight loss of 1-3 kg for 13-26 MET.hours per week, with greater losses at greater doses of PA (1). Presumably Prof Cooper does not dispute this interpretation of the evidence.

    We believe the discussion here should focus on the selection of included studies, critique of exposure and outcome measures, and assessment of risk of bias within each study. Debate should also focus on whether 1-3 kg has population level public health relevance as only very large doses of PA resulted in losses greater than the 5% suggested by the report as having clinical relevance.

    Perhaps of greatest importance is whether the PA regimens used in these studies could ever be implemented at a population level. On this point we suspect not, and we would highlight again we are sceptical that PA alone is an answer to obesity. It was not our intention to give this impression but to show that the claims of Malhotra et al., did not represent the available evidence. We agree that the evidence suggests diet has a substantially greater effect than PA, and in our original letter we went on to cite further evidence stating that diet plus PA appears to have the greatest effect (2).

    Prof Cooper is quite right to say that Figure G4.2 shows that diet has a greater effect than exercise (PA). To directly quote the original study from which the figure was adapted "Randomized trials consistently show benefits of exercise for weight loss, but the effects are often modest" (3). Again we invite debate on the included studies, control conditions used, definition of "modest", and whether these findings have public health relevance - but they clearly contradict the Malhotra claim.

    Prof Cooper requests "In the spirit of rigor and honesty I think they should revise their criticism # 3. Even more importantly, they should provide evidence that exercise alone prevents or reduces obesity or they should acknowledge - as the NIH document does - that exercise alone is ineffective."

    We have clarified above how the cited report (1) and the 1999 paper it references (3) show that PA (exercise) reduces body weight. We have also submitted an addendum to our Point 3 accordingly to acknowledge that there is debate over the magnitude and clinical relevance of effect, and to emphasise that diet appears to be more effective than PA for reducing obesity. Further, we welcome continued debate on effect, effect size, clinical relevance, study quality, scalability and generalizability. To suggest that the debate on the usefulness of PA is finished is misleading and should be questioned - as Prof Cooper correctly pointed out the Physical Activity Guidelines Advisory Committee Report is equivocal in its interpretation of the evidence. More importantly we also caution against PA only approaches and recommend multi-component approaches combining diet and PA (4).

    Finally, we note Prof Cooper refers to "curbing the obesity epidemic". We would point out that this inherently refers to the relative merits of PA and diet in weight maintenance, which is different to weight reduction and has not been the focus of this discussion.

    1. Committee PAGA. Physical activity guidelines advisory committee report, 2008. Washington, DC: US Department of Health and Human Services. 2008;2008:A1-H14.

    2. Johns DJ, Hartmann-Boyce J, Jebb SA, Aveyard P. Diet or exercise interventions vs combined behavioral weight management programs: a systematic review and meta-analysis of direct comparisons. J AcadNutr Diet. 2014;114(10):1557-68.

    3. Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Medicine and science in sports and exercise. 1999;31(11 Suppl):S547-52.

    4. Hunt K, Wyke S, Gray CM, Anderson AS, Brady A, Bunn C, et al. A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Lancet (London, England). 2014;383(9924):1211-21.

    Conflict of Interest:

    We receive funding from a number of national and international research councils, and companies that make devices for physical activity and sedentary behaviour research. We do not receive funding from the food industry.

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  9. Re:12 Reasons why the "Physical Activity Myth" paper should not have been published; Request for retraction or modification based on open external peer-review

    Kelly et al make a number of useful comments about the unfortunate editirial by Malhotra et al. However they too obscure the main point. They use a 2008 NIH document as the key reference to refute the editorialists' claim that exercise does not lead to weight loss.

    What the NIH document actually says -

    The magnitude of weight loss due to physical activity is additive to caloric restriction, but physical activity is generally insufficient by itself to bring about clinically significant weight loss.

    The accompanying figure very clearly demonstrates the degree to which exercise alone does not result weight loss, and cannot be promoted as a public health strategy to curb obesity.

    This quesiton is in fact the key issue at stake here, whatever one might think of the other dubious claims ay Malhotra et al.. Data accumulated since 2008 add further support to that conclusion. Only a lower intake of calories is effective as a means of weight reduction.

    As a co-author of a reference used in the ediorial, which argues that exercise alone is ineffective, I obviously have some stake in this debate and would like to see more tranparency on this issue. If there is a disagreement among observers we should at least be willing use the data sources correctly. Kelly et al are wrong to claim that -

    "All study designs provide clear evidence of a dose-response relation between physical activity and weight loss."

    In the spirit of rigor and honesty I think they should revise their criticism # 3. Even more importantly, they should provide evidence that exericse alone prevents or reduces obesity or they should acknowledge - as the NIH document does - that exercise alone is ineffective.

    Conflict of Interest:

    NIH funding on energy balance.

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  10. If you can click through to this Google+ Community I hope it will help...

    It seems very clear that there are two different ways of interpreting the tile of this editorial. BJSM is grateful for the terrific engagement in this important debate - we revel in debate.

    But it's not helpful to have two soliloquys going on so I respectfully suggest there are two basic interpretations of the title.

    Please click through to this Google Community to see the two interpretations and what may have been a better title (my fault on the title bit!)...

    You'll find more in the 'print' version of BJSM (ie. online in issue format) from July 17 - the issue of BJSM that puts a spotlight on South Africa and SASMA (South African Sports Medicine Association).

    Conflict of Interest:


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