382 e-Letters

  • Follow up questions to the systematic review

    May I have two questions please?

    1. How the population in the RCTs defined lateral elbow tendinopathy? By resisted strength test, ultrasound scan or MRI? Did the inclusion specific enough to rule out other elbow joint pain such as ligament tear?

    2. If the RCTs did not rule out ligament tear or joint instability pain, does it affect the results?

  • Suggestion to improve the methodology of this study

    Dear Dr Breda and colleagues,

    Thanks for your insightful publication. I would like to add to Georg Supp and Stephanie Moers comments on this article.

    I agree with the previous comments that the current experimental design is more a comparison between the effectiveness of low pain loading exercise and painful loading exercise in patients with patellar tendinopathy according to the current methodology.

    As a fairer comparison, it should be rather progressive tendon-loading exercise versus statics/ regressive loading exercise. Otherwise, it can also be progressive isometric & isotonic tendon-loading exercise versus progressive eccentric loading exercise as well. No clear standardization on the loading of the exercise makes it less convincing to achieve the authors’ conclusion.


    Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
    The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
    It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
    Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
    Regarding the expansion of the non-...

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  • Glovin' up

    Whilst better quality research into concussion in combat sports is welcomed; an equally important and related area of research is gaining insight into the often ‘concussion permissive’ training environments of the many combat sport schools across the country. In my earlier years of competitive MMA training ‘gym wars’ were a common occurrence. Training partners, often encouraged by the coaches, would spar (practice fight) at close to 100% power including strikes to the head. It was not uncommon to see someone get knocked out unconscious, checked on, dragged off to the side of matted training area, then once awakened, asked to continue with the sparring session! I believe over the years this type of training culture has become less prevalent with a growing emphasis on light-contact modified technical sparring or a greater reliance on more dynamic and modality specific pad-work drills. There is still a need though to understand the factors behind schools that promote this unsustainable culture of frequent hard sparring and identify and describe the behaviours behind it. Hopefully then efforts can be made to engage and influence the combat sport athletes to think twice before ‘glovin up’.

  • Explicit motor learning interventions are still relevant for ACL injury rehabilitation: do not put all your eggs in the implicit basket!: Letter to the Editor

    Anne Benjaminse,1,2 Alli Gokeler3, 4, 5
    1 University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, Netherlands

    2 School of Sport Studies, Hanze University Groningen, Groningen, the Netherlands 

    3 Exercise Science and Neuroscience, Department Exercise & Health, Faculty of Science, Paderborn University, Paderborn, Germany

    4 Amsterdam Collaboration for Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands.

    5 OCON Center of Orthopaedic Surgery and Sports Medicine, Hengelo, The Netherlands

    Dear Editor,
    We read the recent manuscript by Kal et al.1 ‘Explicit motor learning interventions are still relevant for ACL injury rehabilitation: do not put all your eggs in the implicit basket‘ with great interest. The authors did a commendable job summarizing the current literature and we highly respect them for being critical, to foster academic discussions to move science forward. We do however have some concerns regarding the methodology and interpretations made by the authors.
    Confusing definition: description vs. execution
 First, the authors write: "Elite athletes have shown to successfully use explicit interventions to de-automate, and subsequently improve, problematic movements.“.2 The paper by Toner et al. is largely based on assumptions, case studies and philosop...

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  • The effects of beta 2 agonists on aerobic performance in healthy adults – implications for PED rules

    Dear Sir/Madam
    Riiser’s et al paper outlines the long-held belief that beta 2 agonists do not improve aerobic function in a healthy population. Beta 2 agonist however have other performance enhancing affects. Clenbuterol, the beta 2 agonist is a case in point. This drug has been used by athletes for decades to burn fat, through metabolic up regulation. This beta 2 agonist drug is also suggested to improved muscle growth through its effects on protein synthesis. It is hypostasised that Clenbuterol induces phosphorylation of mTOR which resulting in enhanced muscle protein synthesis.
    Drugs are banned in sport based on the presence of 2 of 3 criteria: 1) Performance enhancing. 2) Dangerous to health 3) Against the ethos of sport.
    While Beta 2 agonist may not improve aerobic function, they can be performance enhancing. They also carry significant side effects in unsupervised hands. The ethos of sport is perhaps a moot point.
    Anti-Doping began in earnest in 1967 following the death of a number of athletes. Participant’s health and safety has been the cardinal element in all programs for the past 54 years. The TUE element ensures that every athlete, whatever the medical condition can participate without discrimination, once the disease has been confirmed. If a Beta 2 agent is medically required then an appropriate agent will be approved by the local governing TUE body, and safe participation can follow. Anti- Doping in a complex area and non – binary. A f...

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  • Response for Best Practice Care for musculoskeletal pain

    As a relative newcomer to the PTA profession, I enjoy reading articles that can enhance my skill set. The review provides a comprehensive guide for management of musculoskeletal pain in common pain sites for use by practitioners, patients to measure their quality of care, and management health professionals. The strengths of the review is the large amount of data accessed globally from 11 countries and over 6000 individual records and 44 Clinical Practice Guidelines included in the study with a goal of patient centered care, pain management, and reducing health care expenses. The 11 Clinical Practice Guideline recommendations form a set of principles that reminds practitioners to provide patients with educational facts and advice that can be overlooked in a rush to send the patient to radiology imaging, surgery and/or prescribe opioids.
    These 11 effective CPG's will enhance my own patient interactions and provide patients with more education to assess their own quality of care.

  • Comprehensive Care of Race-Day Emergencies

    We commend Yuri Hosokawa et al. on their recent publication in the BJSM (Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020.) Their hard work moves the race medicine community forwards in the critically important mission of recognizing and treating critical illness in the elite runner.

    In our experience it is evident that clear, concise protocols, and easy-to-read algorithms are of paramount importance for race-medicine, particularly when experienced race physicians are providing care side-by-side with clinical volunteers. A group of experts convened at the Consortium for Health and Military Performance (CHAMP) in 2019 to review race protocols for the Marine Corps Marathon and the International Institute for Race Medicine (IIRM). While reviewing and revising race protocols, we set out to create straightforward algorithms that would aid in the assessment and treatment of a wide range of acute medical conditions. The algorithms developed from this meeting were published in Current Sports Medicine Reports (Oct. 2020, Vol 19) and are available on the CHAMP website (https://champ.usuhs.edu/for-the-provider) under "Guidelines: Management of Mass Participation Events". We are encouraged to see Dr. Hosokawa and colleagues presenting a similar algorithmic approach in their pape...

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  • No workplace is the same.

    We need to (1) develop and evaluate multi-level interventions suchas the North East Better Health at Work Award and (2) consider sector specific differences.


  • Comment on “Effectiveness of treatments for acute and subacute mechanical non- specific low back pain: a systematic review with network meta- analysis”

    Dear Editor:
    We read the paper by Gianola et al1 with interest. The authors performed a network meta-analysis to assess the effectiveness of interventions for acute and subacute non- specific low back pain (NS-LBP) based on pain and disability outcomes. They concluded that with uncertainty of evidence, NS-LBP should be managed with non- pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance. After carefully reading, we wish to put forth the following suggestions.
    Repeatedly including the same study population will affect the total sample size and the number of participants in each group; thus, duplicated studies using the same study population should not be included in a meta-analysis. However, in Table 3, we found that many studies were conducted by the same authors (Takamoto; Williams), with same category of intervention (Manual therapy; Paracetamol) and incidence of adverse events. Hence, we suspect that these are duplicate studies. This will affect the credibility of the result. Although these studies have low weights in the summary estimates, it's a matter of principle. The author should formulate strict inclusion and exclusion criteria, exclude repeated literature using the same study as a whole, and select the literature with the best quality or the largest sample size for analysis.