Recent eLetters

I was very interested to read the article on suicide, sport and medicine and agree that more attention should be paid to the psychological wellfare of athletes. I am a doctor, albeit not a psychiatrist, and have also been part of the British triathlon team since 2005. On several occasions I have been acutely aware of depression in an athlete which has gone apparently undetected. In one particular case a female athlete was deliberately self -harming in response to her perceived poor performance in training. She had inflicted substantial lacerations to her forearms which were obviously visible when swimming. I felt a duty of care to report this to her coaches and challenged them on whether or not they had noticed the wounds. The response from the first coach was they had not noticed and from the other coach was that they had noticed but felt inadequately qualified to address the issue. This is just one example of where education is needed to identify warning signs and hopefully prevent catastrophic consequences. It is not only the sports physician but the whole support team who need to be aware of what signs and symptoms of mental health issues to be aware of.

Conflict of Interest:

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I am a 67 year-old middle and long-distance running coach (level V). Nearly 6 decades ago I began running, and cut my athletics teeth on the old CAC model proposed by A.V.Hill.

Today, after over 2 decades of being a student of exercise physiology, I am fascinated by this new concept proposed by Prof. Noakes.

Many years ago I read that exercise-induced fatigue was a psycho- physiological phenomina that was controlled by the CNS, and that no exertion of will could over-ride the urge to either slow down or stop. The name of the author escapes me now, but in retrospect, it appears that he/she was correct, though I question whether they fully understand the significance of the that statement at the time.

This is a fantastic article, one that has given me new insight into fatigue, and how I can alter the training that I still follow and advocate for the athletes I train.

Kind regards,

@

George D. Aber

Conflict of Interest:

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I am very grateful with the interest and comments by VIKRAM MOHAN and SRIJIT DAS. I consider that the approach suggested with chronic obstructive pulmonary disease subjects may be helpful to clarify to which extension the capacity in identifying correctly the workload could have been due to the afferent feedback from cardiopulmonary system. I also agree that the rate pressure product would be an interesting variable to be measured in the set-up (clinical or experimental), although more direct measures of the SNC would be needed to understand the mechanisms behind the subjective perceived exertion and exercise tolerance relationship.

Conflict of Interest:

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Ratzlaff (1) outlines broad categories in assessing societal activity-levels: occupational and household. While the latter was traditionally the greater source of activity, particularly for men, the nature of work has become steadily more sedentary. However, the same may be less true for household tasks. One conclusion it that women today, as the gender likely to undertake most household tasks, may well be more active than their male counterparts. The gender imbalance may only be partly diminished by the fact that males are more likely - at least at younger ages - to obtain a third category of activity in the voluntary participation in energetic sports.

My concern here is with another category of exercise that entails both occupational and sports elements: the commute to the work-place. Choices of commuting-mode are dependent on distance to be travelled. Short home-to-work distances may render walking predominant. Distances beyond a few kilometres may render powered transport - cars, buses and trains - compulsory, so the scope for exercise may seem limited. The steady increase in the UK of park-and-ride facilities attempts to reduce traffic in major centres such as cities: commuters drive to a strategically located car-park away from the city-centre and continue by public transport. This would not of course alter the conclusion that long-distance commuting does not entail significant activity-levels.

However, multi-modal commuting can include substantial elements of walking, cycling or running; this particularly applies to journeys entailing public transport, where pick-up points for public transport (bus -stops and railway stations) may be at some distance from home. As many would attest, the disadvantages of walking, cycling and running concern poor weather conditions and build-up of sweat, perhaps requiring change of clothing at the work-place. Probably of most importance for all commuters is the issue of conflicts and potential collision with motor traffic.

Despite these problems, the incorporation of exercise into commuting is receiving some official support in the UK. For example, at least one public-transport provider now promotes exercise as a valuable "add-on" to travel by public transport (2) - far removed from the days when exercise-free travel was regarded as a major feature supporting the preference for the private car (3). Furthermore, there are also now governmental schemes to provide grants for the purchase of bikes to access the work-place (4).

To pursue the issues, if the problems with petroleum price and availability continue towards the levels that characterised the 1970s, the private motorcar may come to have a more restricted presence on the road. At that stage, walking, cycling and running could become generally prominent in commuting - in a way that has applied particularly to cycling in the Netherlands for many years. However, for this scenario to continue in the UK beyond the present age of economic downturn requires a societal change in attitude that eschews a thoughtless dependence on the car. That most certainly did not happen after the petroleum crises of the 1970s had passed (5). Perhaps the lessons will be learned this time.

REFERENCES

1. Ratzlaff CR, Good news, bad news: sports matter but occupational and household activity really matter - sport and recreation unlikely to be a panacea for public health. Br J Sports Med 2012 (10.1136/bjsports-2011- 090800).

2. www.translink.co.uk (accessed 25/4/12).

3. www.bike2workscheme (accessed 25/4/12).

4. Wolmar C. Fire and steam: a new history of the railways in Britain. London: Atlantic.

5. Transport statistics Great Britain. 2001. London: Department for Transport.

Conflict of Interest:

None declared

Osteoarthritis is the most common form of joint disease, sparing no age, race, or geographic area. Symptomatic disease also increases with age. This arthropathy is characterized by degeneration of cartilage and by hypertrophy of bone at the articular margins. Inflammation is usually minimal. Hereditary and mechanical factors may be variably involved in the pathogenesis.

Degenerative joint disease is traditionally divided into two types: (1) primary, which most commonly affects some or all of the following: the terminal interphalangeal joints and less commonly the proximal interphalangeal joints, the metacarpophalangeal and carpometacarpal joints of the thumb, the hip, the knee, metatarsophalangeal joint of the big toe, and the cervical and lumbar spine; and secondary, which may occur in any joint as a sequela to articular injury resulting from either intra- articular or extra-articular causes. The injury may be acute, as in a fracture: chronic, that due to occupational overuse of a joint, metabolic disease or neurologic disorders. Obesity is a risk factor for knee osteoarthritis and probably for the hip as well. Recreational running does not increase the incidence of osteoarthritis, but participation in competitive contact sports does. Jobs requiring frequent bending and carrying increase the risk of knee osteoarthritis.  Pathologically, the articular cartilage is first roughened and finally worn away, and spur formation and lipping occur at the edge of the joint surface. The synovial membrane becomes thickened and does not form adhesions. Inflammation is prominent only in occasional patients. The onset of the disease is insidious. Initially there is articular stiffness, seldom lasting more than 15 minutes; this develops later into pain on motion of the affected joint and is made worse by activity or weight bearing and relieved by rest. There is no ankylosis, but limitation of motion of the affected joint or joints is common. Joint effusion and other articular signs of inflammation are mild. As preventive measure, weight reduction has been shown in women to reduce the risk of developing symptomatic knee osteoarthritis. Several epidemiologic studies suggest that estrogen replacement therapy reduces the risk of knee and hip osteoarthritis. For patients with mild to moderate osteoarthritis of weight-bearing joints, a supervised walking program may result in clinical improvement of functional status without aggravating the joint pain. For many patients, acetaminophen in doses of 2.6-4 g/d is as effective as and less toxic than other NSAIDS. Patients who fail to improve with acetaminophen and non-pharmacologic therapies described above can be treated with salycilates or other NSAIDs.

Conflict of Interest:

None declared