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-...
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-maleficence principle, it has been shown that occupational physical activity can be harmful to one’s health, extending the physical activity paradox beyond the harmful effects of intensity. 4 This finding contradicts the idea that physical activity in its various dimensions is beneficial.
Another point that deserves wide attention concerns inequalities and how they impact various aspects of individuals’ relationships with physical exercise. Various studies have indicated that the vulnerability of certain social groups—such as black people, people of low socioeconomic status, and women—interferes with the performance of leisure-time physical activities or even other behaviours considered as healthy 5–6. We view this as an affront to the principle of justice. Moreover, some researchers have disregarded such inequalities and reinforced blaming the individual for his or her ‘failure’ to engage in behaviour considered appropriate, even arguing that it leads to enormous economic costs to society. 7 This position clearly aligns with neoliberal precepts since it places the responsibility for taking care of oneself on the individual, thus removing it from the State. Why, in general, are women less involved with leisure-time physical activities than men? Why is the same true for black people? Why is physical inactivity lower among black women? How do violence, mobility, and urban planning impact physical activity? Are more impoverished people equally likely to have access to leisure-time physical activity? The possibility of exercising does not seem equal for everyone.
Although we recognise that the focus of Pugh et al. 3 was correct medically, we consider that inequities interfere decisively in the possibility that any isolated measure effectively produces some benefit and/or avoids some harm. The principles of beneficence and non-maleficence may not be guaranteed if effective measures to combat inequities are not adopted. Regarding the context of peripheral countries, it is essential to consider adequate bioethical theories, rather than principlism. 8
In particular, socially excluded people—because of their unequal position in society—may sometimes be unable to make autonomous decisions. The capacity to make decisions is in itself incomplete, relative, non-global, and determined by a series of changing contextual aspects.
We also consider it necessary to question the supposed universality of bioethical principles since they are often presented within a colonialist perspective. This posture is reflected in individuals’ concepts of autonomy, which we believe should be decolonised. Decolonisation stimulates the debate about the knowledge and experiences of the community to reveal their richness. This process is in line with a vision of social justice: achieving health equity considering individual and collective empowerment. Therefore, taking advantage of the knowledge and perspectives of social groups to contribute to the development of specific interventions seems essential for yielding effective results.
Finally, we highlight the insistence on considering the relationship between physical exercise and health as a problem that is only biomedical. The resulting discourses reinforce the idea of the medicalisation of exercise. Thus, the practitioner becomes a patient and the pleasure for the practice is always neglected.
References
1. Beauchamp TL, Childress JF. Principles of biomedical ethics. 8 ed. New York: Oxford University Press, 2019.
2. Booth FW, Roberts CK, Laye MJ. Lack of Exercise Is a Major Cause of Chronic Diseases. Compr Physiol 2012; 2:1143-1211.
3. Pugh J, Pugh C, Savulescu, J. Exercise prescription and the doctor’s duty of non-maleficence. Br J Sports Med 2017; 51:1555-1556.
4. Holtermann A, Schnohr P, Nordestgaard BG, Jacob Louis Marott JL. The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults. Eur Heart J 2021; 42:1499-1511.
5. Brodersen NH, Steptoe A, Boniface DR, Wardle J. Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. Br J Sports Med 2007; 41:140-144.
6. Abichahine H, Veenstra G. Inter-categorical intersectionality and leisure-based physical activity in Canada. Health Promot Int 2017; 32:691-701.
7. Allender S, Foster C, Scarborough P, Rayner M. The burden of physical activity-related ill health in the UK. J Epidemiol Community Health 2007; 61:344-348.
8. Garrafa V, Porto D. Intervention bioethics: a proposal for peripheral countries in a context of power and Injustice. Bioethics 2003; 17: 399-416.
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’.
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...
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 philosophers' views.2 The authors presume that with adopting explicit learning, patients are not allowed to know the goal of the exercises.3 For clarity, the correct definition of attentional focus needs to be used: Attentional focus relates closely to what you tell your patient prior to the execution of the exercise. An internal focus would be induced to focus the attention on body parts and movements. Conversely, for an external focus, the attention is directed to the outcome or the goal of the movement. Hence, adopting an external focus is related to the planning of the movement, but has nothing to do with the processing of intrinsic feedback or bodily awareness.4 It does not mean that patients are not aware of their body movements, i.e. the ‘explicit interventions’ the authors refer to. It is important to note that bodily awareness is not necessarily inherent to an internal focus of attention.5 Leaning is not possible without bodily awareness.6 An external focus of attention simply means the patient is focusing on the intended movement effect – while preparing for the execution.6 This does not mean that one must never use body related instructions that elicit an internal focus of attention. Of course you can use it. It will just not result in most optimal motor learning.7,8 In summary, it is important to differentiate between telling the goal of the exercise (i.e. description - general instruction) and the specific instruction provided just before the execution of the task. For example, in case of rehabilitation after ACLR: “the goal of this exercise is to improve knee bending while landing, as this promotes a softer landing, which is better for your knee.” Then, as the patient is preparing to execute the exercise, it is critical to shift their attentional focus that corresponds closest to the task goal: e.g. “focus on landing with as little noise as possible”.
Familiarity Second, the million-dollar question, do effects of implicit learning depend on the person’s preference? Here, again, the entire picture needs to be presented. Kal et al. conclude “Implicit or explicit learning appears most effective when it is aligned with an individual’s preference“, even though the original authors state: “Due to the well-documented external focus advantage we are hesitant to argue that direction of attentional focus does not have any influence on skilled motor performance.”.9 The preferred focus, often as a result of past experience with coaching instructions,10 is not always the most beneficial solution.11-15 In addition, retention, a key aspect of motor learning, has not been reported.9 It is thus not possible, and it may give a skewed representation, to conclude learning is most effective when aligned with an individual’s preference, as the definition of learning is ‘a relative permanent change in a person’s capability to perform a skill’.16 To interpret results, the authors need to adhere to the correct definition of motor learning. Directly observable performance improvement is different from sustained improvements over time (retention).16 Often times explicit learning is indicated as being effective, potentially because it shows quick benefits.17 The authors also write: “People with musculoskeletal conditions strongly prefer to consciously control movements.” But again, we need to ask the question if this preference is of benefit to them? Kal et al. should also have stated the conclusion of the paper they refer to: knee pain was more commonly reported by people with a propensity for conscious involvement in their movements.18 Thus, even it is the case that patients prefer to consciously control movements, it is not per se most effective.19 Loss of function, pain, fear of reinjury and other psychological factors, cause a shift in attentional focus towards the injured area such as the knee.19-22 The process behind this needs to be explored in further detail before we can say whether it is beneficial to consciously control movements. After musculoskeletal injuries neuroplastic changes of the central nervous system occur,23 which induces a focus on the injured joint. An ACL injury triggers neurocognitive disruption,23 demonstrating potentially maladaptive neuroplasticity within the brain whereby (pre)motor cortex areas are more active during simple movement tasks compared to uninjured individuals.24 Concluding, it would be unwise to leave patients to their own focus preference or assume they will find the focus that is optimal for them. Verbal and visual feedback The authors pose that explicit verbal feedback on movement has been identified as a key active ingredient in primary ACL injury risk reduction.25 However, again correct interpretation of scientific studies is crucial here. All these training programs are conducted in a relatively controlled setting (e.g. with supervision from researcher) with no retention and transfer effects measured.25 Also, no studies thus far have comparison included with implicit verbal feedback conditions. The authors also state that it is unclear whether improved biomechanics can be attributed to implicit learning per se as this can not proven through self-report.26 Indeed, self-report, although done often,27-29 is not the best way to provide objective evidence.30 But, it is widely known that model learning, as we did in this study,26 or observing and imitating movements facilitates an athletes’ exploration and search for their own most optimal functional task solutions,34-36is part of an implicit learning strategy.34 fMRI studies conclude that functional connectivities, movement outcome and efficiency are maximised when an external focus of attention is promoted.31-33 When providing sound designed research with only the attentional focus instruction being different across groups, including a control group, one can conclude that difference across groups is based on that factor. Vice versa, how can we know athletes in previous research have indeed adopted an internal focus of attention? In sum, we feel the the authors should have presented the entire picture to the readers based on sound synthesis the literature and proper use of definitions.
REFERENCES
1. Kal E, Ellmers T, Diekfuss J, et al. Explicit motor learning interventions are still relevant for ACL injury rehabilitation: do not put all your eggs in the implicit basket! Br J Sports Med 2021.
2. Toner J, Moran A. Exploring the orthogonal relationship between controlled and automated processes in skilled action. Rev Philos Psychol 2020;1–17.
3 Toner J, Moran A. Enhancing performance proficiency at the expert level: considering the role of “somaesthetic awareness. Psychol Sport Exerc 2015, 16, 110e117.
4. Wulf G, Why did Tiger Woods shoot 82? A commentary on Toner and Moran. Psychol Sport Exerc 2016;337-8.
5. Milley KR, Ouellette GP. Putting attention on the spot in coaching: shifting to an external focus of attention with imagery techniques to improve basketball free-throw shooting performance. Front Psychol 2021;16:12.
6. Wulf G. An external focus of attention is a conditio sine qua non for athletes: a response to Carson, Collins, and Toner (2015). J Sports Sci 2016;34:1293-5.
7. Ille A, Selin I, Do MC, Thon B. Attentional focus effects on sprint start performance as a function of skill level. J Sports Sci 2013;31:1705-12.
8. Winkelman NC, Clark KP, Ryan LJ. Experience level influences the effect of attentional focus on sprint performance. Hum Mov Sci 2017;52:84-95.
9. Maurer H, Munzert J. Influence of attentional focus on skilled motor performance: performance decrement under unfamiliar focus conditions. Hum Mov Sci 2013;32:730–40.
10. Porter JM, Wu WFW, Partridge JA. Focus of attention and verbal instructions: Strategies of elite track and field coaches and athletes. Sport Sci Rev 2010;19:199–211.
11. Guss-West C, Wulf G. Attentional focus in classical ballet: a survey of professional dancers. J Dance Med Sci 2016;20:23-9.
12. Stoate I, Wulf G. Does the attentional focus adopted by swimmers affect their performance? Int J Sports Sci Coach 2011;6:99–108.
13. Abdollahipour R, Wulf G, Psotta R, et al. Performance of gymnastics skill benefits from an external focus of attention. J Sports Sci 2015;33:1807–13.
14. LoSarah L, Jagodinsky A, Torry M, et al. Effects of attentional focus cues on lower extremity kinematics during inside of the foot soccer trap among expert soccer players. Int J Sports Sci Coach. 2021;
15. Maloney MA, Gorman AD. Skilled swimmers maintain performance stability under changing attentional focus constraints. Hum Mov Sci 2021;77:102789.
16. Schmidt RAWC. Motor learning and performance. Champaign: Human Kinetics; 2005.
17. Masters R. Knowledge, knerves and know-how: The role of explicit versus implicit knowledge in the breakdown of a complex motor skill under pressure. Br J Psychol 2011;83:343-58.
18. Selfe J, Dey P, Richards J, et al. Do people who consciously attend to their movements have more self-reported knee pain? An exploratory cross-sectional study. Clin Rehabil 2015;29:95-100.
19. Gray R. Differences in attentional focus associated with recovery from sports injury: Does injury induce an internal focus? J Sport Exerc Psychol 2015;37:607-16.
20. Hsu CJ, Meierbachtol A, George SZ, et al. Fear of reinjury in athletes: implications for rehabilitation. Sports Health 2017;9(2):162–167.
21. Ardern CL, Taylor NF, Feller JA, et al. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 2013;41:1549-1558.
22. Podlog L, Dimmock J, Miller J. A review of return to sport concerns following injury rehabilitation: practitioner strategies for enhancing recovery outcomes. Phys Ther Sport 2011;12:36-42.
23. Grooms D, Appelbaum G, Onate J. Neuroplasticity following anterior cruciate ligament injury: a framework for visual-motor training approaches in rehabilitation. J Orthop Sports Phys Ther 2015;45(5):381-93.
24. Needle AR, Lepley AS, Grooms DR. Central nervous system adaptation after ligamentous injury: a summary of theories, evidence, and clinical interpretation. Sports Med 2017;47:1271–88.
25. Sugimoto D, Myer GD, Barber Foss KD, et al. Critical components of neuromuscular training to reduce ACL injury risk in female athletes: meta-regression analysis. Br J Sports Med 2016;50:1259–66.
26. Welling W, Benjaminse A, Gokeler A, et al. Enhanced retention of drop vertical jump landing technique: a randomized controlled trial. Hum Mov Sci 2016;45:84–95.
27. Ruocco AC, Direkoglu E. Delineating the contributions of sustained attention and working memory to individual differences in mindfulness. Person Ind Diff 2013;54,226–30.
28. Scheibner HJ, Bogler C, Gleich T, et al. Internal and external attention and the default mode network. Neuroimage 2017;48:381-89.
29. Porter JM, Nolan RP, Ostrowski EJ, et al. Directing attention externally enhances agility performance: a qualitative and quantitative analysis of the efficacy of using verbal instructions to focus attention. Front Psychol 2010;1:216.
30. Zhou ZW, Lan XQ, Fang YT, et al. The inter-regional connectivity within the default mode network during the attentional processes of internal focus and external focus: An fMRI study of continuous finger force feedback. Front Psychol 2019;10:2198.
31. Mak TCT, Young WR, Wong TWL. Conscious control of gait increases with task difficulty and can be mitigated by external focus instruction. Exp Aging Res 2021;47:288-301.
32. Suzuki LY, Meehan SK. Attention focus modulates afferent input to motor cortex during skilled action. Hum Mov Sci 2020;74:102716.
33. Kuhn YA, Keller M, Ruffieux J, et al. Adopting an external focus of attention alters intracortical inhibition within the primary motor cortex. Acta Physiol (Oxf) 2017;220:289-299.
34. Benjaminse A, Otten E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumatol Arthrosc 2011;19:622-7.
35. Otte FW, Davids K, Millar SK, et al. When and how to provide feedback and instructions to athletes? How sport psychology and pedagogy insights can improve coaching interventions to enhance self-regulation in training. Front Psychol 2020;11:1444.
36. Al-Abood SA, Bennett SJ, Hernandez FM, et al. Effect of verbal instructions and image size on visual search strategies in basketball free throw shooting. J Sports Sci 2002;20:271-8.
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...
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 failure of a specific drug class to have a specific performance enhancement, aerobic performance in this instance, is insufficient evidence to consider allowing all participants to use such an agent
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.
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...
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 paper, though our group chose a slightly more conservative approach, recommending aggressive cooling begin at or above a core temperature of 40C/104F in our hyperthermia algorithm. We also describe treatment algorithms for several other emergency situations.
We invite race medical directors and any medical professionals who are interested in race medicine to review the guidelines put forth in both publications for excellent approaches to the athlete suffering a race-day emergency.
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.
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.
Thornton et al.’s “Treating low back pain in athletes: a systematic review with meta-analysis”1 was an interesting read. It was an excellent review that systematically summarized various methods of non-pharmacological conservative management of low back pain in athletes. In particular, this paper analyzed the impact of exercise on low back pain through a meta-analysis of four previous studies.2-5 The meta-analysis was performed using a visual analogue scale and data on disability as outcomes.
However, we found a few problems with this meta-analysis. First, the authors performed a meta-analysis of the effects of exercise by dividing participants into an exercise group and a control group as shown in Figure 3 of their article. The patients in the exercise group performed specific exercises (periodized resistance training, core stabilization exercise, Swiss ball exercise), while the control group performed another form of exercise (regular recreational activity, conventional lumbar flexion‒extension exercise, exercise on a stable surface) or rested without any exercise. Nevertheless, to investigate the effects of exercise, the authors should have divided patients who performed exercise into an exercise group and a non-exercise group, as a control group, for comparison. However, in the meta-analysis of Tornton et al.’s study, the control group had engaged in exercise in three studies2-4, and had only rested in one study.5 Furthermore, if their intention was to investigat...
Thornton et al.’s “Treating low back pain in athletes: a systematic review with meta-analysis”1 was an interesting read. It was an excellent review that systematically summarized various methods of non-pharmacological conservative management of low back pain in athletes. In particular, this paper analyzed the impact of exercise on low back pain through a meta-analysis of four previous studies.2-5 The meta-analysis was performed using a visual analogue scale and data on disability as outcomes.
However, we found a few problems with this meta-analysis. First, the authors performed a meta-analysis of the effects of exercise by dividing participants into an exercise group and a control group as shown in Figure 3 of their article. The patients in the exercise group performed specific exercises (periodized resistance training, core stabilization exercise, Swiss ball exercise), while the control group performed another form of exercise (regular recreational activity, conventional lumbar flexion‒extension exercise, exercise on a stable surface) or rested without any exercise. Nevertheless, to investigate the effects of exercise, the authors should have divided patients who performed exercise into an exercise group and a non-exercise group, as a control group, for comparison. However, in the meta-analysis of Tornton et al.’s study, the control group had engaged in exercise in three studies2-4, and had only rested in one study.5 Furthermore, if their intention was to investigate the effects of a particular type of exercise, the exercise group had to have some type of similarity in terms of their exercise, which cannot be determined. We cannot pinpoint the type of exercise the authors wanted to investigate or what they wanted to use for comparison.
Second, in their meta-analysis to investigate the effects of exercise on disability, the authors made a mistake in inputting the data from the study by Seshagirirao et al.5 The mean and standard deviation of the Oswestry Disability Index (ODI) for the exercise group was entered as 18.2 and 0.7, respectively, but the actual numbers in the study by Seshagirirao et al. are 18.8 and 0.8, respectively.
Third, the duration of exercise was heterogeneous. The durations of exercise in the four included studies were 16 weeks2, 8 weeks (2 studies)3, 4, and 4 weeks.5 However, we are curious whether the authors found a study stating that a particular duration of exercise reduced lower back pain or disability. A substantial number of studies used an exercise program of 8 weeks or longer to investigate the effects on lower back pain. Tornton et al. should have at least confirmed the specific homogenous duration of exercise that significantly reduced lower back pain and set a relevant criterion to select studies for inclusion in the meta-analysis.
Finally, in the meta-analysis comparing the effects of exercise on disability between the groups, three studies used ODI data, while one study4 used the Roland‒Morris Disability Questionnaire (RMDQ) score. ODI and RMDQ are different tools; thus, including both in one meta-analysis would create error.
In short, we think that Tornton et al. did not conduct their meta-analysis appropriately. Readers should be aware of the problems we have pinpointed above when interpreting the results of Tornton et al.’s meta-analysis. In addition, Tornton et al. should address the issues we have pointed out.
References
1. Thornton JS, Caneiro JP, Hartvigsen J, et al. Treating low back pain in athletes: a systematic review with meta-analysis. Br J Sports Med 2020:bjsports-2020-102723. doi: 10.1136/bjsports-2020-102723.
2 Jackson JK, Shepherd TR, Kell RT. The influence of periodized resistance training on recreationally active males with chronic nonspecific low back pain. J Strength Cond Res 2011;25:242–51.
3 Kachanathu SJ, Zakaria AR, Sahni A, et al. Chronic low back pain in fast bowlers a comparative study of core spinal stabilization and conventional exercises. J Phys Ther Sci 2012;24:821–5.
4 Antón A, Rodríguez B, Jimenez D. Swiss ball training versus stable surface training for the treatment of low back pain in male judo athletes. Archives of Budo 2015;11:47–52.
5 Seshagirirao M. A randomised controlled study on core stability exercise programme using Swiss ball, THERABAND and floor exercises in cricketers with low back pain. Int J Physiother 2015;2:885–93.
Recently, an article by Di Pietro and colleagues investigating small non-coding RNAs (sncRNA)s in the saliva of concussed rugby players was published in the British Journal of Sports Medicine (BJSM), a highly rated sports medicine journal [1]. Due to the groundbreaking nature of the study, many media outlets published articles celebrating the authors’ findings. One such article from the Washington Post was titled: “Concussions can be diagnosed through a saliva test, British researchers find.”[2]. As a result, colleagues and clinicians have contacted members of the Sport and Health Interdisciplinary group in Movement & Performance from Acute & Chronic head Trauma (IMPACT), a recently formed international group investigating concussion injury, asking our opinion of the article and what the findings mean for sports-related concussion (SRC) diagnosis. Similar questions emerged in 2018 when the United States of America Food and Drug Administration (FDA) announced approval of a blood test using glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal esterase L1 (UCHL1) to differentiate between computed tomography (CT)-positive and CT-negative results. The headline for this announcement read: “FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults,”[3] which led to confusion among clinicians as to what this meant for concussion assessment and diagnosis. Therefore, the interdisciplinary IMPACT team t...
Recently, an article by Di Pietro and colleagues investigating small non-coding RNAs (sncRNA)s in the saliva of concussed rugby players was published in the British Journal of Sports Medicine (BJSM), a highly rated sports medicine journal [1]. Due to the groundbreaking nature of the study, many media outlets published articles celebrating the authors’ findings. One such article from the Washington Post was titled: “Concussions can be diagnosed through a saliva test, British researchers find.”[2]. As a result, colleagues and clinicians have contacted members of the Sport and Health Interdisciplinary group in Movement & Performance from Acute & Chronic head Trauma (IMPACT), a recently formed international group investigating concussion injury, asking our opinion of the article and what the findings mean for sports-related concussion (SRC) diagnosis. Similar questions emerged in 2018 when the United States of America Food and Drug Administration (FDA) announced approval of a blood test using glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal esterase L1 (UCHL1) to differentiate between computed tomography (CT)-positive and CT-negative results. The headline for this announcement read: “FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults,”[3] which led to confusion among clinicians as to what this meant for concussion assessment and diagnosis. Therefore, the interdisciplinary IMPACT team thought it appropriate to address this “hot topic” by writing a discussion to provide an update on fluid-based biomarkers in SRC diagnosis.
Current state of research in fluid-based biomarkers
Continuing the discussion of the aforementioned blood-based proteins GFAP and UCHL1, it has been found that these are unlikely candidates for SRC diagnosis [4,5]. Blood-based proteins have been the predominate research area for an SRC fluid-based biomarker since the early 21st century. However, there has been little focus on obtaining blood from athletes immediately post-SRC to determine if a blood-based protein could be useful in sideline/proximity SRC diagnosis. To date, only one study has focused on collecting blood samples immediately post-injury and was unable to distinguish between concussed and non-concussed athletes [6]. More studies are needed investigating proteins in fluid collected immediately after SRC to tackle this information gap.
Research on miRNAs as a method for diagnosing traumatic brain injury has been investigated since 2010 [7]. However, the study of miRNAs has had the same limitations in timing of sample collection, with the majority of studies collecting fluid hours after injury [4,7]. The Di Pietro study is the first of its kind to measure sncRNAs, which include miRNAs, from saliva collected immediately post-SRC (SRC+) and compare it to sncRNAs from non-concussed controls, musculoskeletal injury controls, and players who were suspected of concussion but tested negative (SRC-) [1]. In our opinion the comparison between the SRC+ and SCR- athletes is unique in this study and the most important comparison, as the use of a biomarker for concussion diagnosis is most helpful is these types of situations. The comparison of sncRNAs between the SRC+ and SRC- athletes showed that five biomarkers were significantly different between groups. However, the area under the receiver operating characteristic curve (AUC), which is a statistical test used to determine the diagnostic ability of biomarkers, was found to be low. The biomarker with the greatest diagnostic ability was has-miR-126-3p with an AUC of 0.71; all other biomarkers had an AUC < 0.70. This is disappointing as an AUC of 0.7 – 0.8 is considered a fair test while an AUC of 0.6 – 0.7 is considered a poor test. On a positive note, the ability of sncRNAs to distinguish between SRC+ and SRC- athletes improved with time giving an AUC of 0.89 for the biomarker has-let-7f-5p comparing SRC+ to SRC- players post-match and at 36-48 hrs. post-match. AUC also improved when combining biomarkers.
Studies investigating miRNAs in athletes have found that certain miRNAs are elevated in athletes compared to non-athletes and fluctuate throughout a sport season, indicating variability in miRNAs that can be used for SRC diagnosis [8]. The sncRNAs that distinguished between SRC+ and SRC- subjects did fluctuate with time in the Di Pietro study suggesting variability in these biomarkers [1]. Although we share in the enthusiasm of media outlet reporting, we are cautiously optimistic, as variations in sncRNAs occur among individuals and there is a paucity of research investigating sncRNAs immediately post-SRC. Furthermore, once a fluid-based biomarker(s) is/are identified in diagnosing SRC, confirming the ability of these biomarkers to diagnose SRC will require rigorous testing by various laboratories to show repeatability of results. Following this, large technological advancements must be made to allow the biomarkers to be measured on the sideline/proximity of an athletic event. With the global media coverage focused on SRC, it is important that the scientific community and media are clear about the depth and scope of research findings. As such, although exciting, we are still some way from having a fluid-based concussion test.
References
1 Di Pietro V, O’Halloran P, Watson CN, et al. Unique diagnostic signatures of concussion in the saliva of male athletes: the study of the concussion in rugby union through microRNAs (SCRUM). Br J Sports Med;Epub ahead of print. doi:10.1136/bjsports-2020-103274
2 Kilgore A. Concussions can be diagnosed through a saliva test, British researchers find. The Washington Post. 2021.https://www.washingtonpost.com/sports/2021/03/23/concussion-saliva-test/...
3 FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. 2018.https://www.fda.gov/news-events/press-announcements/fda-authorizes-marke... (accessed 30 Sep 2020).
4 Davies D, Yakoub KM, Scarpa U, et al. Serum miR-502: A potential biomarker in the diagnosis of concussion in a pilot study of patients with normal structural brain imaging. J Concussion 2019;3:1–13. doi: 10.1177/2059700219886190
5 Asken BM, Bauer RM, DeKosky ST, et al. Concussion BASICS III: Serum biomarker changes following sport-related concussion. Neurology 2018;91:e2133–43. doi: 10.1212/WNL.0000000000006617
6 Rogatzki MJ, Morgan JE, Baker JS, et al. Protein S100B and brain lipid-binding protein concentrations in the serum of recently concussed rugby players. J Neurotrauma 2021;:Epub ahead of print. doi:10.1089/neu.2021.0004
7 Redell JB, Moore AN, Ward III NH, et al. Human traumatic brain injury alters plasma microRNA levels. J Neurotrauma 2010;27:2147–56. doi:10.1089/neu.2010.1481
8 Papa L, Slobounov SM, Breiter HC, et al. Elevations in microRNA biomarkers in serum are associated with measures of concussion, neurocognitive function, and subconcussion trauma over a single national collegiate athletic association division I season in collegiate football players. J Neurotrauma 2019;36:1343–51. doi: 10.1089/neu.2018.6072
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
Show MoreThe 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-...
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’.
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,
Show MoreWe 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...
Dear Sir/Madam
Show MoreRiiser’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...
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.
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...
Show MoreWe need to (1) develop and evaluate multi-level interventions suchas the North East Better Health at Work Award and (2) consider sector specific differences.
http://fuseopenscienceblog.blogspot.com/2020/02/workplace-health-and-cau...
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.
Thornton et al.’s “Treating low back pain in athletes: a systematic review with meta-analysis”1 was an interesting read. It was an excellent review that systematically summarized various methods of non-pharmacological conservative management of low back pain in athletes. In particular, this paper analyzed the impact of exercise on low back pain through a meta-analysis of four previous studies.2-5 The meta-analysis was performed using a visual analogue scale and data on disability as outcomes.
Show MoreHowever, we found a few problems with this meta-analysis. First, the authors performed a meta-analysis of the effects of exercise by dividing participants into an exercise group and a control group as shown in Figure 3 of their article. The patients in the exercise group performed specific exercises (periodized resistance training, core stabilization exercise, Swiss ball exercise), while the control group performed another form of exercise (regular recreational activity, conventional lumbar flexion‒extension exercise, exercise on a stable surface) or rested without any exercise. Nevertheless, to investigate the effects of exercise, the authors should have divided patients who performed exercise into an exercise group and a non-exercise group, as a control group, for comparison. However, in the meta-analysis of Tornton et al.’s study, the control group had engaged in exercise in three studies2-4, and had only rested in one study.5 Furthermore, if their intention was to investigat...
Introduction
Recently, an article by Di Pietro and colleagues investigating small non-coding RNAs (sncRNA)s in the saliva of concussed rugby players was published in the British Journal of Sports Medicine (BJSM), a highly rated sports medicine journal [1]. Due to the groundbreaking nature of the study, many media outlets published articles celebrating the authors’ findings. One such article from the Washington Post was titled: “Concussions can be diagnosed through a saliva test, British researchers find.”[2]. As a result, colleagues and clinicians have contacted members of the Sport and Health Interdisciplinary group in Movement & Performance from Acute & Chronic head Trauma (IMPACT), a recently formed international group investigating concussion injury, asking our opinion of the article and what the findings mean for sports-related concussion (SRC) diagnosis. Similar questions emerged in 2018 when the United States of America Food and Drug Administration (FDA) announced approval of a blood test using glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal esterase L1 (UCHL1) to differentiate between computed tomography (CT)-positive and CT-negative results. The headline for this announcement read: “FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults,”[3] which led to confusion among clinicians as to what this meant for concussion assessment and diagnosis. Therefore, the interdisciplinary IMPACT team t...
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