eLetters

428 e-Letters

  • Understanding the Significance of Effect Size in Study Assessing Cardiovascular Health in Rheumatoid Arthritis Patients

    Dear Editor,
    A recent publication titled “High-Intensity Interval Training Improves Cardiovascular and Physical Health in Patients with Rheumatoid Arthritis: A Multicentre Randomised Controlled Trial” by Bilberg et al., published in the British Journal of Sports Medicine.1This research provides valuable insight into the efficacy of high-intensity interval training for patients with rheumatoid arthritis, yet the study also presents certain weaknesses and limitations that should be considered.2
    Such as, study did not present an ANCOVA table detailing essential values such as the F ratio and degrees of freedom, which are critical for interpreting the analysis comprehensively. Although the study has mentioned that they have used Cohens’d (d) for Effect Sizes (ES), after the analysis we found the data we derived is different from the calculated value as mentioned. To address these limitations, values for d, Glass’s delta (Δ), and Hedge’s g (g) have been calculated due to their specific applications. “g” serves as a variation of d, beneficial for standard mean differences. While △ estimates ES using only the control group's standard deviation (SD). Both g and d are interpreted similarly, with Cohen’s guidelines.3 Post-hoc analysis, conducted through G*Power, is used to determine the statistical power of a study, ensuring that findings are robust and reliable.4 For VO2, the ES was 0.50 for both d and g. 0.51 for the △ and the power was 0.63. O2 pulse recorded co...

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  • A Rebuttal to “Flat feet: deformities or healthy anatomical variants?”

    Significant discrepancies and controversies exist in assessing and understanding the “flat feet” syndrome (FFS). Understanding the underlying aetiology of FFS is essential to understanding how FFS may cause symptoms and how to manage, treat, and prevent symptoms and progression of the deformity (1). However, understanding the underlying aetiology of the prevalent FFS remains limited—as a formal diagnosis is not established (2, 3, 4).

    This limited understanding and, significantly, no diagnosis of the underlying cause of the prevalent FFS (including the related valgus-pronatory mechanical phenomenon of the rearfoot) is the most significant gap in the foot and ankle orthopaedics and musculoskeletal (MSK) podiatry clinics and their to-go scientific literature. Additionally, there is limited understanding, research, and controversy about the FFS-related foot orthoses (FOs) intervention, prescription/assessment, and design (5).

    Challenging the editorial's premise and the general concept that “flat feet” are “healthy anatomical variants” mainly assessed on symptoms is essential. The assessment of the FFS, if problematic, based on whether it is symptomatic, represents a limited understanding of the physiological alignment of the arthroskeletal structures and related mechanisms of the foot and ankle. Throughout the editorial, the assumption is that the FFS is not a problem if there are no symptoms or only a problem if (when) there are symptoms. Do malalignment, e...

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  • DOES LOVE AND PEACE PROTOCOL HAVE EFFECTS ON THE MANAGEMENT OF SOFT TISSUE INJURIES?

    Dear Editor,

    We recently reviewed the article " Soft-tissue Injuries Simply Need PEACE and LOVE" in the British Journal of Sports Medicine. (1) This study presented preliminary evidence suggesting that the LOVE and PEACE protocol may offer potential benefits in managing acute soft tissue injuries. We hope this discussion will inspire further research on this significant topic.

    Soft tissue injuries (sprains, strains, contusions, tendinitis, and bursitis) require complicated rehabilitation. The abbreviations used to guide their administration have changed throughout time, going from ICE to RICE (2), then PRICE (3) and POLICE (4). There is not enough evidence to support these treatments, despite their widespread usage. Under the ICE/RICE/PRICE approach, acute care gets priority over sub-acute and chronic phases of tissue rehabilitation.

    The P.E.A.C.E and L.O.V.E. approach addresses the long-term effects and condition management in addition to the immediate therapy of a soft tissue injury. These acronyms offer a promising alternative to traditional acute injury management techniques like RICE. (1) These two new acronyms cover soft tissue injury management, from first care to post-injury management. As a result, it is regarded as a practical principle that encourages optimal healing and lowers the likelihood of damage recurrence. (5)

    According to a 2023 observational study by Eshaan Rotellu and Dr. Nisha Shinde, the importance of patient ed...

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  • Concerns regarding respiratory data interpretation, 'athlete' definition and group matching in 'Strength, power and aerobic capacity of transgender athletes: a cross-sectional study'

    Dear Editor,

    Hamilton et al (1) conducted a study to assess strength, power and aerobic capacity of transgender athletes. They conclude the results may be useful for sports governing bodies and inform sports policy. However, policy should be informed by accurate scientific information and, unfortunately, this study contains fundamental errors in design, methodology and interpretation. In this letter, we focus on the incorrect interpretation of respiratory testing, the inappropriate definition of ‘athlete’, and group matching.

    The study compares respiratory function of transgender and non-transgender individuals using cardiopulmonary exercise testing, as well as conventional lung function testing (spirometry, lung volumes and gas transfer). The authors report that transgender women (TW - male individuals who identify as women) had greater forced expiratory volume in 1s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) and a reduced FEV1/FVC ratio relative to cisgender women (CW - female individuals without a differing gender identity). From this data, the authors conclude that TW have decreased lung function, increasing their work of breathing relative to CW.

    Firstly, the methodology employed to measure lung function does not appear to conform to accepted, published testing guidelines (ATS/ERS) (2). Lung function is typically measured repeatedly within 150mL, with the highest numeric value for each variable recorded, to ensure...

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  • Have we forgotten about the healthy worker effect when comparing elite athletes to the general population?

    The "healthy worker effect" is an obvious explanation for the authors' findings. In this case, they have compared the extreme winners of the genetic lottery (sub 4-minute mile male runners) with the general population, a mixed bag of healthy and non-healthy people. The outcome of all-cause mortality also presents issues, as the reason of death may or may not be health-related.

    The steep decline in the longevity advantage over time indicates that this advantage may not last as the general population becomes healthier (and possibly more active). It is plausible that there may even be an opposite effect (sub 4-minute mile male runners live shorter lives) in the coming decades.

    While general population statistics are easier to obtain, comparing them with those of elite athletes to make conclusions about lifespan does not answer the question of whether extreme exercise has a detrimental effect on health. A more fair comparison group would be marathoners, short-distance runners, or even runners who have not broken the 4-minute mark.

  • Lots of good sports not a lot of good sports to play them
    Richard Clarke Cobey

    Dear Editor

    I must fully concur with Dr McCrory's assessment of youth sport. Here in the US, we have a great many fathers find enjoyment in coaching their children-however there are far more whom become engulfed in the desire to win at all cost, pushing their children, dramatizing local saturday morning football as if it were the Super Bowl or World Cup. I find it highly objectionable to their behavior and the role...

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  • Concerns with Strength, power and aerobic capacity of transgender athletes: a cross-sectional study

    We appreciate the efforts of the authors of Strength, power and aerobic capacity of transgender athletes: a cross-sectional study (1) to provide data on transgender athletes. However, we have several concerns regarding the study design and analysis which we opine severely compromise the conclusions reached by the authors.
    First, the inclusion criteria were that participants must “participate in a sport at a competitive level or undergo physical training three times per week”, which includes all forms of health promoting physical fitness or sports participation. We are fully aware of the difficulties recruiting suitable research participants, and particularly those from a small demographic group, but we think that much more specific inclusion criteria would have ensured more uniformly trained and comparable research participants.
    The descriptive data did not provide enough information on the frequency, intensity, duration, or exercise mode of the participants to determine what type of athletes had been evaluated. While the authors state that 36% of the participants were endurance athletes, 26% team sports athletes, and 38% power sports athletes, there was no breakdown of sports participation within each comparison group. Therefore, it is not possible to know if this was a comparison of similar groups of athletes.
    The data for the cisgender women and transgender women demonstrate great dissimilarity. Based on the data for body composition, muscle strength,...

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  • Response to Brown and O'Connor (1) and Call for More Original Collaborative Research

    We thank Brown and O'Connor (1) for their interest in our research (2) and we welcome their constructive criticism, especially regarding our study design, analysis and interpretation. We consider such exchanges equally important as the dissemination of the original research and hence, we wish to address all concerns. Concerns were raised about the need for more specific inclusion criteria to ensure comparability among research participants. Specifically, Brown and O’Connor (1) raised valid concerns about the lack of detailed information on the frequency, intensity, duration, and mode of exercise among our research participants. While we appreciate and totally agree with these comments, the task of recruiting suitable research participants, mainly from small demographic groups such as transgender athletes, is challenging. Many transgender athletes, especially those with high profile, feel too intimidated to come forward in the current polarised climate. Given this, we had to balance the need for stringent inclusion criteria with the necessity of obtaining a representative sample of transgender athletes to better understand their physiological and performance characteristics. We aimed to strike a balance between providing an informative overview of the participants' sporting backgrounds and protecting the anonymity of the transgender athletes involved in the study. We fully acknowledge that a more granular breakdown would have been beneficial for assessing comparab...

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  • Update on content authored by Dr Paul McCrory

    We have reviewed Dr McCrory’s sole authored content for plagiarism as we described in our prior editorial.[1] The University of Melbourne asked for a review of several other articles.

    This has resulted in the retraction of four ‘warm up’ editorials [2 3,4,5 ] and one book review in BJSM [6] due to plagiarism. A letter in BJSM [7] has been retracted due to duplicate publication. A research article [8] and a review article [9] in BJSM have also been corrected due to inappropriate reuse of content.

    Dr McCrory agrees with our decisions. No further concerns have been raised to us about content authored by Dr McCrory. This concludes our planned investigation. If further allegations are made about Dr McCrory’s work published in BJSM or in other BMJ journals, we will investigate them.

    This investigation has been conducted by the Editor-in-Chief of BJSM in conjunction with the integrity team of BMJ. BJSM is published by BMJ.

    BMJ Content Integrity Team, Dr Helen Macdonald and Ms Helen Hardy

    BJSM Editor-in-Chief, Prof. Jonathan Drezner

    1. Macdonald H, Ragavooloo S, Abbasi K, et al. Update on the investigation into the publication record of former BJSM editor-in-chief Paul McCrory. British Journal of Sports Medicine 2022;56:1327-1328.
    2. McCrory P. “Elementary, my dear Watson”. British Journal of Sports Medicine 2006;40:283-284.
    3. McCrory P. Cheap solutions for big problems? British Journal of Sports Medicine 2007;41:545.
    4....

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  • Letter to the editor: response to patient-reported outcome measures for gluteal tendinopathy – more empirical evidence is needed?

    In responding to the comments raised in the letter to the editor regarding the recommendation of the VISA-G questionnaire for gluteal tendinopathy, we first want to acknowledge qualified agreement with the points raised while also emphasising the practical considerations and guidelines that informed our recommendation.

    1. A key conclusion of our recent publication was that we were not able to form a Core Outcome Set as no outcome measure had sufficient clinimetric properties (1). For a measure to be selected for a Core Outcome Set, it should have at least high-quality evidence of good content validity (2 3). As part of the COS-GT consensus process, we completed a systematic review that collected and evaluated measurement properties of all outcome measures used to evaluate patients with gluteal tendinopathy. (4) No outcome measures met this threshold. Of the ICON disability domain outcome measures that had been validated in people with gluteal tendinopathy (the VISA-G and the two HOS outcome measures), the VISA-G had, albeit low, the best available evidence for content validity (low-quality evidence of sufficient comprehensibility and very low-quality evidence of sufficient comprehensiveness and relevance). (4) After much consideration the final recommendation for interim use was based on consideration of the impact of not providing a recommendation and the COSMIN systematic review guidelines for formulating recommendations. (p45, 4.2 Step 9) (5)

    2. We ackno...

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