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
I thank the authors for their work in addressing the challenge of evaluation of that enigma of "acute and subacute mechanical non-specific low back pain". However given that this is not a specific diagnosis of a pathology it makes it difficult to truly compare like with like. However as practitioners we assess and manage the back pain patient based upon the symptoms and clinical findings. No practitioner I know uses one modality and expects that to be the most effective therapy, except perhaps the primary care physician prescribing analgesics because of service limitations. Clearly pain is one issue, but objectively we find increased muscle tone/ acute spasm, loss of normal movement patterns and particularly across a number of affected spinal segments and possibly neural referral patterns. Consequently to unpick the combination of pain, spasm and limitation of movement that is self-perpetuating, we use a combination of modalities to achieve specific goals. For example, one might use Western acupuncture to release muscle spasm in paraspinal muscles that may facilitate manual mobilisation that would not have been possible in the presence of the spasm. The mobilisation of the spinal segments facilitates more normal movement patterns which reduces pain on movement. Furthermore as the clinical condition progresses we continually adapt which modality we use at each session in accordance with the patient's response and reduce prescribed medications when the con...
I thank the authors for their work in addressing the challenge of evaluation of that enigma of "acute and subacute mechanical non-specific low back pain". However given that this is not a specific diagnosis of a pathology it makes it difficult to truly compare like with like. However as practitioners we assess and manage the back pain patient based upon the symptoms and clinical findings. No practitioner I know uses one modality and expects that to be the most effective therapy, except perhaps the primary care physician prescribing analgesics because of service limitations. Clearly pain is one issue, but objectively we find increased muscle tone/ acute spasm, loss of normal movement patterns and particularly across a number of affected spinal segments and possibly neural referral patterns. Consequently to unpick the combination of pain, spasm and limitation of movement that is self-perpetuating, we use a combination of modalities to achieve specific goals. For example, one might use Western acupuncture to release muscle spasm in paraspinal muscles that may facilitate manual mobilisation that would not have been possible in the presence of the spasm. The mobilisation of the spinal segments facilitates more normal movement patterns which reduces pain on movement. Furthermore as the clinical condition progresses we continually adapt which modality we use at each session in accordance with the patient's response and reduce prescribed medications when the condition permits. So rather than trying to have a fixed formula of e.g. prescribe NSAIDs for 2 weeks or saying acupuncture does not work because it is trialled in isolation - why can't we compare how experienced teams of practitioners manage back pain and assess their treatment package and outcomes versus the single modality approach, whilst also asking about patient satisfaction?
Sallis and colleagues showed that patients who were not consistently meeting physical activity guidelines prior to COVID-19 contamination had a substantially greater risk of hospitalisation, admission in intensive care units, and death than patients who were consistently meeting physical activity guidelines (>150min/week engaging in moderate or strenuous exercise over 2-months).1 Identifying risk factors associated with negative COVID-19 outcomes is timely. COVID-19 has resulted in almost 3,000,000 deaths worldwide by the middle of April 2021 2, and vaccination seems insufficient without health and political behaviour changes. 3
However, we have some concerns about Sallis and colleague’s conclusions. The authors recommended “efforts to promote physical activity” relied on strong assumptions that meeting physical activity guidelines would cause less COVID-19 negative outcomes such as hospitalisation, admission in intensive care units, and deaths. Although exercise has many benefits to individuals, we cannot allow that the urgency of solving problems lead to hasty and imprecise conclusions of causality, as well as unnecessary efforts for implementation.
Consider a “0-10 causality strength scale”, proposed by Pearl (2018) 4, where 0 is weak evidence of causality and 10 is strong evidence of causality. Depending on the assumptions and procedures used in the studies to test the association between variables, we become more or less confident...
Sallis and colleagues showed that patients who were not consistently meeting physical activity guidelines prior to COVID-19 contamination had a substantially greater risk of hospitalisation, admission in intensive care units, and death than patients who were consistently meeting physical activity guidelines (>150min/week engaging in moderate or strenuous exercise over 2-months).1 Identifying risk factors associated with negative COVID-19 outcomes is timely. COVID-19 has resulted in almost 3,000,000 deaths worldwide by the middle of April 2021 2, and vaccination seems insufficient without health and political behaviour changes. 3
However, we have some concerns about Sallis and colleague’s conclusions. The authors recommended “efforts to promote physical activity” relied on strong assumptions that meeting physical activity guidelines would cause less COVID-19 negative outcomes such as hospitalisation, admission in intensive care units, and deaths. Although exercise has many benefits to individuals, we cannot allow that the urgency of solving problems lead to hasty and imprecise conclusions of causality, as well as unnecessary efforts for implementation.
Consider a “0-10 causality strength scale”, proposed by Pearl (2018) 4, where 0 is weak evidence of causality and 10 is strong evidence of causality. Depending on the assumptions and procedures used in the studies to test the association between variables, we become more or less confident that an exposure (e.g., physical activity) causes an outcome (e.g., reduction in negative COVID-19 outcomes). Sallis and colleagues conducted a study that tries to understand the relationship of the variables through association, one of the weakest evidence of causation.
Selection bias is a major concern in this study. 5 Firstly, the authors report adjusting for demographics and other risk factors for severe COVID-19 with only a brief mention of the unmeasured confounders. Barbarawi et al. highlighted the importance of unmeasured confounders. Those authors conducted a systematic review that challenged observation evidence to suggest an association between Vitamin D supplementation and cardiovascular disease. 6 The systematic review demonstrates the limitation of using observation data to make causal claims. Even when researchers attempt to emulate the target trial, unmeasured confounding can bias the results. 7
Second, without a causal diagram to understand the assumptions behind the adjustments, it is unclear if, by adjusting for demographics and severe COVID-19 risk factors, the authors have introduced bias into the model, i.e. by adjusting on a collider and opening a back-door path. 8 9 10
We made two recommendations to improve this manuscript. The authors could consider calculating the E-value to assess the sensitivity of results to potential unmeasured confounding. 11 Secondly, we recommend the inclusion of directed acyclic graphs (DAGS). DAGS help depict causal structure to provide a solid theoretical basis on which to base assumptions when considering adjusting for selection bias.12
There is a tendency to accept physical inactivity as a so-called component cause of many illnesses,13 including COVID 19. We understand that this impulse is motivated by a concern for public health. Still, we should not allow author confirmation bias and consistency of these correlational findings to substitute for actual evidence of causality.
Our greatest concern is not that people are advised to increase their physical activity; we are concerned that a misunderstanding of the relation between physical activity and severe COVID-19 leads to an oversimplification of a complex problem that we are just beginning to understand.
We declare no competing interests.
References;
1 Sallis R, Young DR, Tartof SY, et al. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. Br J Sports Med 2021;:1–8. doi:10.1136/bjsports-2021-104080
2 Center CR. COVID19 Dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University.
3 Prado B. COVID-19 in Brazil: “So what?” Lancet 2020;395:1461. doi:10.1016/S0140-6736(20)31095-3
4 Pearl J, McKenzie D. The book of why: Thew new science of cause and effect. Basic Books Inc, Division of HarperCollins 10 E.53rd St. New Year, NY 2018.
5 Hernán MA, Cole SR. Invited commentary: Causal diagrams and measurement bias. Am J Epidemiol 2009;170:959–62. doi:10.1093/aje/kwp293
6 Barbarawi M, Kheiri B, Zayed Y, et al. Vitamin D Supplementation and Cardiovascular Disease Risks in More Than 83000 Individuals in 21 Randomized Clinical Trials: A Meta-analysis. JAMA Cardiol 2019;4:765–75. doi:10.1001/jamacardio.2019.1870
7 Hernán MA, Robins JM. Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available. Am J Epidemiol 2016;183:758–64. doi:10.1093/aje/kwv254
8 VanderWeele TJ, Hernán MA, Robins JM. Causal directed acyclic graphs and the direction of unmeasured confounding bias. Epidemiology 2008;42:157–62. doi:10.1037/a0030561.Striving
9 VanderWeele TJ. Principles of confounder selection. Eur J Epidemiol 2019;34:211–9. doi:10.1007/s10654-019-00494-6
10 Hernán MA. Invited commentary: Selection bias without colliders. Am J Epidemiol 2017;185:1048–50. doi:10.1093/aje/kwx077
11 Vanderweele TJ, Ding P, Mathur M. Technical Considerations in the Use of the E-value. J Causal Infer 2019;:1–11.
12 Hernán MA, Hernández-Díaz S, Robins JM. A structural approach to selection bias. Epidemiology 2004;15:615–25. doi:10.1097/01.ede.0000135174.63482.43
13 Guthold R, Stevens GA, Riley LM, et al. Articles Worldwide trends in insufficient physical activity from 2001 to 2016 : a pooled analysis of 358 population-based surveys with 1 · 9 million participants. Lancet Glob Heal 2016;6:e1077–86. doi:10.1016/S2214-109X(18)30357-7
Dear Editor and authors,
As we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-CO...
Dear Editor and authors,
As we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-COV2 tests were performed in our competitions (1090 RT-PCR and 1089 Antigen tests) and only one RT-PCR test was positive (positive rate of 0.1%). Most importantly, however, is that despite the identification of this case, none of the players and staff in close contact with him tested positive in the 4 weeks that followed and, more, none of the games were cancelled or postponed.
This not only highlights the low risk of contagion even in contact sports already reported by Jones et al.3, but also the strength of sanitary protocols, as described by DiFiori et al.. When other high-risk activities (e.g. socializing, meals, or others) are mitigated using these protocols, the possibility of tracing and managing the risk of contagion increases.
Therefore, we consider to be paramount that all governing bodies design and implement customized return to play protocols that are able to accommodate the specificities of each reality and sport, as suggested by DiFiori et al.1. Likewise, it is crucial that all agents understand the need to follow all the hygiene and sanitary recommendations, as it will enable the demonstration of the strength of these protocols and allow the safe return to sport during the context of COVID-19.
References:
1- DiFiori JP, Green G, Meeuwisse W, et al. Br J Sports Med 2021;55:417–421. doi:10.1136/bjsports-2020-103227
2- World Rugby Player welfare. Rugby Europe: Return to Play Protocol. Link: https://playerwelfare.worldrugby.org/?documentid=224 [Accessed 04.04.2021]
3- Jones B, Phillips G, Kemp S, et alSARS-CoV-2 transmission during rugby league matches: do players become infected after participating with SARS-CoV-2 positive players?British Journal of Sports Medicine Published Online First: 11 February 2021. doi: 10.1136/bjsports-2020-103714
Competing interests: none
Acknowledgements: to Besik Chaduneli, José Carlos Saló, Ekaterina Sidorenko and Alin Popescu, CMOs of the Unions involved in the Rugby Europe Championship 2021, as well as to Rugby Nederland.
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Instructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee funct...
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Instructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee function from a 12-week program with painful eccentric training. To our knowledge, this is the only study where VAS ≥ 5 was used as a requirement. In most studies on tendinopathy and eccentric training, a pain VAS ≤ 5 is recommended.2-4
What is the rationale behind choosing a specific program which had already been found to be ineffective, whereas other eccentric regimes had shown at least some efficacy?5,6
3. Inconsistency in patient education
In the supplemental material the authors refer to the colored pain scale for use in the education of the EET group. This scale clearly identifies a pain above 5 as being in the ‘high-risk-zone’. How does this fit with the instruction for patients to exercise with VAS ≥ 5? Patients might well be fearful of reinjuring their tendon when performing this degree of painful exercise.
4. Insufficient adherence to the programs
How low is too low?
Earlier studies on tendinopathy describe adherence rates between 50 and 79 %.4,7-10
Patients in the PTLE group and EET group only reached an adherence of 40% and 49 % respectively after 24 weeks. The adherence to exercises targeting risk factors was only 21% and 22 % respectively. Even if no significant between-group differences were found for exercise adherence, the low adherence in both groups should be mentioned in the limitation section of the study.
With 76 patients included, this RCT is the largest clinical trial in patients with patellar tendinopathy to date. It raised exceptional attention.11 Nevertheless, the concerns mentioned above might justify some caution concerning the clinical impact of the study.
References
1. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper's knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med. 2005;15(4):227-234. doi:10.1097/01.jsm.0000168073.82121.20
2. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x
3. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197-206. doi:10.1034/j.1600-0838.2001.110402.x
4. Roos EM, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14(5):286-295. doi:10.1111/j.1600-0838.2004.378.x.
5. Everhart JS, Cole D, Sojka JH, et al. Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy. 2017;33(4):861-872. doi:10.1016/j.arthro.2016.11.007
6. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-98; discussion 199. doi:10.1136/bjsm.2006.029769
7. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without an AirHeel Brace. A randomized controlled trial. B: Effects of compliance. Disabil Rehabil. 2008;30(20-22):1692-1696. doi:10.1080/09638280701785676
8. Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport. 2007;10(1):52-58. doi:10.1016/j.jsams.2006.05.008
9. Vos RJ de, Weir A, Visser RJA, Winter T de, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41(7):e5. doi:10.1136/bjsm.2006.032532
10. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. 2005;39(2):102-105. doi:10.1136/bjsm.2003.010587
11. Altmetric. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial: Overview of attention for article published in British Journal of Sports Medicine, November 2020. https://bmj.altmetric.com/details/94665680
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und...
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und diagnostic process [2]. However, Self-reports (questionnaires) usually are limited in sensitivity and specificity.
Clinical assessment and diagnosis as well as treatment of mental health symptoms and disorders should ideally be conducted by licensed/registered mental health professionals and require education and clinical training in psychiatry [2]. The coordination of the integrated psychiatric management is a core competence of psychiatrists [2,4]. Following the same argument, children and adolescents should be treated by licensed/registered mental health professionals and psychiatrists for children and adolescents. However, there is still limited access to mental health professionals in sports settings, especially to psychiatrists and specialized psychiatrists (sports psychiatrists) [5]. Psychiatrists and (clinical) psychologists differ in their education and expertise in the management of mental disorders. They complement each other, but the differences in their expertise should be clearly identified.
The authors believe there is a need to complement the SMHAT-1 with these fundamental standards of clinical practice in order to further enhance the management of mental health problems in elite sports.
Furthermore, step 3 describes various actions of the SMHAT-1 [1]: (i) treatment/support provided by a sports medicine/primary care physician; (ii) additional screening questionnaires, including attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD), gambling disorder and/or psychosis, prior to definitive diagnosis and to create an management/intervention plan; (iii) for severe, complex, diagnostically uncertain, even after additional screening and/or nonresponsive, treatment through licensed/registered mental health professionals is recommended.
Sports physicians and other health professionals are important specialists to improve and maintain mental health in competitive sports. Ideally, elite athletes should have access to the best interdisciplinary care [6]. Nevertheless, the role of health professionals without specific expertise in mental health needs to be discussed. Only the inclusion of mental health professionals with expertise in sports psychiatry into athlete’s health teams provides the requirement to further improve interdisciplinary care. Moreover, certain mental disorders, e.g., ADHD and PTSD, require additional training and disease-specific expertise, even for mental health professionals [3].
We also strongly encourage the regular use of SMHAT-1 whenever any significant event for an athlete occurs [1]. At the same time major injury/illness and suspected harassment/abuse often require a clinical consultation and assessment by mental health professionals. Screening questionnaires can be of help in detecting major mental health problems but usually do not address the specific need of athletes in such difficult situations. Hence, in some situations important psychological problems might be missed initially, increasing the danger of later mental disorders. The authors therefore propose an individual interdisciplinary approach in all cases of suspected harassment/abuse of (especially young) athletes.
Mental health in competitive sports
Questionnaires and clinical assessment through trained sports physicians in sports psychiatry could be a valuable part of the sports-medical examination. Additionally, we propose examination by sports psychiatrists as a routine in competitive sports. There is a strong need for mental health professionals, and a qualified medical discipline for mental health in competitive sports [5]. Therefore, a corresponding coordinating office for sports psychiatry and sports psychiatry expertise is required in every association and club [5].
Education and training in sports psychiatry are essential in improving mental health in competitive sports. To impart information on mental disorders for athletes and their entourage is also an important action. A strong collaboration between all professionals is recommended.
Education and training in sports psychiatry. The International Society for Sports Psychiatry (ISSP) released a first curriculum for additional training in sports psychiatry in 2018 [7]. In 2020, the Swiss Society for Sports Psychiatry and Psychotherapy (SSSPP) released a three-part curriculum for qualification in sports psychiatry [8]. Part 1 imparts basic knowledge for psychiatrists as well as sports physicians and psychologists.
Education about mental health symptoms and disorders in competitive sports should complement the specialised qualification in sports psychiatry.
Concluding remarks
Mental health and mental disorders require qualified clinical and medical competence, irrespectively of the nature or severity, a psychiatric expertise and in the case of minors, expertise in child and adolescent psychiatry is required.
The basic concept of SMHAT-1 is excellent and following versions should consider these fundamental standards of clinical practice.
There is a need for psychiatrists and clinical psychologists in competitive sports; it is the hope of the authors that more mental health professionals will engage in these settings.
References
1. Gouttebarge V, Bindra A, Blauwet C, et al . International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health. Br J Sports Med. 2021 Jan;55(1):30-37. doi: 10.1136/bjsports-2020-102411.
4. Bhugra D, Ventriglio A, Kuzman MR, et al . EPA guidance on the role and responsibilities of psychiatrists. Eur Psychiatry. 2015;30(3):417-22. doi: 10.1016/j.eurpsy.2015.02.002.
5. Claussen MC, Gonzalez Hofmann C, Imboden C, et al . Swiss Society for Sports Psychiatry and Psychotherapy SSSPP. SSSPP Position paper: Mental health in competitive sport. Swiss Sports & Exercise Medicine. 2020;68(3):23-6. doi:10.34045/SEMS/2020/20.
6. Reardon CL, Hainline B, Aron CM, et al . Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019;53(11):667-699. doi: 10.1136/bjsports-2019-100715.
7. International Society for Sports Psychiatry (ISSP). Certificate of Additional Training in Sports Psychiatry. Available: https://www.sportspsychiatry.org/page-18106 [Accessed 27 Feb 2021].
8. Claussen MC, Imboden C, Seifritz E, et al . Swiss Society for Sports Psychiatry and Psychotherapy SSSPP. Curriculum Sports Psychiatry And Psychotherapy: Level 1. Sport & Exercise Medicine Switzerland 2020;68(3):48-52. doi.10.34045/SEMS/2020/22.
The authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guid...
The authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guidelines is a challenge in the foreseeable future. Therefore, measuring daily and habitual PA remains a strength of the portable devices for now,3 which should also be employed to inform the adaptations or development of PA questionnaires.
Frequently, however, not enough critical thought is given to which PA (self-report) instrument (or a combination of different measures) to use. There is a recently published decision guide aide as to what important aspects to consider when choosing a PA self-report instrument consisting of: purpose, construct, measurement unit, recall period, population, setting, measurement quality, feasibility/ease of use, and resources.4 Utilizing this decision guide is a step in increasing the appropriateness and thus the quality of PA self-report area. Moreover, we agree and additionally emphasize that “the electronic application of short-term instruments (eg, time use diaries, EMAs, previous day recalls), for example via smartphones, can increase our knowledge about the health-related dynamics of daily behaviours, such as sleep, sedentary behaviour and light-intensity activities, as well as the settings ‘surrounding’ these behaviours.”1(Pg.1) Hence, this multi-dynamic approach should be emphasized and methods should be combined and refined to inform future PA self-report measures.5
We also posit that to improve the field of PA self-report it is necessary to standardize the reporting of PA self-report studies. We recommend that researchers use the Physical Activity Questionnaire Reporting Checklist4 to ensure that all relevant information is provided for cross-study comparisons, inclusion in systematic reviews, and meta-analyses.
References
1 Sattler MC, Ainsworth BE, Andersen LB, et al. Physical activity self-reports: past or future? Br J Sports Med Published Online First: 03 February 2021. doi: 10.1136/bjsports-2020-103595
2 Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behavior. Br J Sports Med 2020;54:1451-1462.
3 Burchartz A, Anedda B, Auerswald T, et al. Assessing physical behavior through accelerometry–State of the science, best practices and future directions. Psychol Sport Exerc. 2020;49. doi: 10.1016/j.psychsport.2020.101703
4 Nigg CR, Fuchs R, Gerber M, et al. Assessing Physical Activity through Questionnaires – A Consensus of Best Practices and Future Directions. Psychol Sport Exerc 2020;50. doi: 10.1016/j.psychsport.2020.101715
5 Reichert, M., Giurgiu, M., Koch, E., et al. Ambulatory Assessment for Physical Activity Research: State of the Science, Best Practices and Future Directions. Psychol Sport Exerc 2020;49. doi: 10.1016/j.psychsport.2020.101742
In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their st...
In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their statement are two of their own articles, one in which they conclude endogenous serum testosterone isn’t related to performance3, and one where eight oligomenorrheic athletes with elevated levels of androgens were found to have better aerobic but not strength performance than the other 43 normoandrogenic participants7. With conflicting results, small sample sizes, and a focus only on endogenous testosterone, these sources should not be used to support the stated conclusion. Additionally, Healy’s study of 689 elite athletes and the authors’ own study of 1332 female and 795 male elite athletes showed that performance was not consistently linked to endogenous levels of testosterone2,4.
Hirschberg, et al found that supplemental testosterone improves aerobic capacity but not anaerobic capacity or strength performance in female athletes1. Yet their introduction and conclusion focus on performance related to endogenous testosterone, going so far as to say their results are “of great importance for the ongoing discussion of whether it is fair to allow athletes with naturally producing high testosterone to compete in the female category without reducing their hormonal concentration to the female range. ” That conclusion is far outside of the scope of their study. There is much to be gained by having reliable and valid studies examining influences on performance across classes, ages, and specialties of athletes, but there is also much harm that can be done when conclusions are misrepresented to advocate for the exclusion of athletes from sport. Policies that have drastic effects on individual athletes’ lives are often based on our sports medicine literature, and we must be sure that our published conclusions match the data we have gathered.
1. Hirschberg AL, Elings Knutsson J, Helge T, et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br J Sports Med. 2020;54(10):599-604. doi:10.1136/bjsports-2018-100525
2. Bermon S, Garnier PY. Serum androgen levels and their relation to performance in track and field: mass spectrometry results from 2127 observations in male and female elite athletes. Br J Sports Med. 2017;51(17):1309-1314. doi:10.1136/bjsports-2017-097792
3. Eklund E, Berglund B, Labrie F, Carlström K, Ekström L, Hirschberg AL. Serum androgen profile and physical performance in women Olympic athletes. Br J Sports Med. 2017;51(17):1301-1308. doi:10.1136/bjsports-2017-097582
4. Healy ML, Gibney J, Pentecost C, Wheeler MJ, Sonksen PH. Endocrine profiles in 693 elite athletes in the postcompetition setting. Clin Endocrinol (Oxf). 2014;81(2):294-305. doi:10.1111/cen.12445
5. Sönksen PH, Holt RIG, Böhning W, et al. Why do endocrine profiles in elite athletes differ between sports?. Clin Diabetes Endocrinol. 2018;4:3. Published 2018 Feb 7. doi:10.1186/s40842-017-0050-3
6. Handelsman DJ, Hirschberg AL, Bermon S. Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance. Endocr Rev. 2018;39(5):803-829. doi:10.1210/er.2018-00020
7. Rickenlund A, Carlström K, Ekblom B, Brismar TB, von Schoultz B, Hirschberg AL. Hyperandrogenicity is an alternative mechanism underlying oligomenorrhea or amenorrhea in female athletes and may improve physical performance. Fertil Steril. 2003;79(4):947-955. doi:10.1016/s0015-0282(02)04850-1
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...
Show MoreI thank the authors for their work in addressing the challenge of evaluation of that enigma of "acute and subacute mechanical non-specific low back pain". However given that this is not a specific diagnosis of a pathology it makes it difficult to truly compare like with like. However as practitioners we assess and manage the back pain patient based upon the symptoms and clinical findings. No practitioner I know uses one modality and expects that to be the most effective therapy, except perhaps the primary care physician prescribing analgesics because of service limitations. Clearly pain is one issue, but objectively we find increased muscle tone/ acute spasm, loss of normal movement patterns and particularly across a number of affected spinal segments and possibly neural referral patterns. Consequently to unpick the combination of pain, spasm and limitation of movement that is self-perpetuating, we use a combination of modalities to achieve specific goals. For example, one might use Western acupuncture to release muscle spasm in paraspinal muscles that may facilitate manual mobilisation that would not have been possible in the presence of the spasm. The mobilisation of the spinal segments facilitates more normal movement patterns which reduces pain on movement. Furthermore as the clinical condition progresses we continually adapt which modality we use at each session in accordance with the patient's response and reduce prescribed medications when the con...
Show MoreDear Editor,
Sallis and colleagues showed that patients who were not consistently meeting physical activity guidelines prior to COVID-19 contamination had a substantially greater risk of hospitalisation, admission in intensive care units, and death than patients who were consistently meeting physical activity guidelines (>150min/week engaging in moderate or strenuous exercise over 2-months).1 Identifying risk factors associated with negative COVID-19 outcomes is timely. COVID-19 has resulted in almost 3,000,000 deaths worldwide by the middle of April 2021 2, and vaccination seems insufficient without health and political behaviour changes. 3
However, we have some concerns about Sallis and colleague’s conclusions. The authors recommended “efforts to promote physical activity” relied on strong assumptions that meeting physical activity guidelines would cause less COVID-19 negative outcomes such as hospitalisation, admission in intensive care units, and deaths. Although exercise has many benefits to individuals, we cannot allow that the urgency of solving problems lead to hasty and imprecise conclusions of causality, as well as unnecessary efforts for implementation.
Consider a “0-10 causality strength scale”, proposed by Pearl (2018) 4, where 0 is weak evidence of causality and 10 is strong evidence of causality. Depending on the assumptions and procedures used in the studies to test the association between variables, we become more or less confident...
Show MoreDear Editor and authors,
Show MoreAs we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-CO...
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Show MoreInstructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee funct...
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und...
Show MoreThe authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guid...
Show MoreIn their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
Show MoreIn the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their st...
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