eLetters

62 e-Letters

published between 2015 and 2018

  • What's this got to do with sports medicine?

    Why is this in BJSM? In general, it is best to have papers go through peer review in the most relevant journal to their subject matter to ensure that the production team is well placed to find suitable editors and reviewers.

  • Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy

    Letter to the Editors
    Br J Sports Med
    J Obstet Gynecol Canada
    Oslo, Nov 23rd 2018
    Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy
    We have read the Canadian guideline for physical activity throughout pregnancy with great interest. We note that the guideline team have made their recommendation regarding pelvic floor muscle training (PFMT) based on evidence from a systematic review from the same research group (Davenport et al 2018). The main results of this review are in line with the latest Cochrane review (Woodley et al 2017) on the same topic; while there are some methodological differences and variations in which studies were included or not (two of the largest studies on PFMT was left out from the Davenport review; Mørkved et al 2003 and Stafne et al 2012), the findings in terms of size and precision of effect are similar, although Davenport et al used odds ratio and Woodley et al used risk ratio for their summary statistic. Davenport et al reported that PFMT gave a 50% reduction in prenatal UI and a 35% reduction in postnatal UI, but the guideline team concluded a “weak recommendation” for PFMT because UI was not rated as a "critical outcome" and the evidence was of "low quality". We find this conclusion at odds with the evidence and the interpretation of the evidence based on the guideline team’s own criteria.
    The Canadian guideline grades...

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  • Evidence based physiotherapy needs evidence based statements from researchers

    The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.

    The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to sugg...

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  • Response to the Need for Evidence-Based Marketing

    The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.

    First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-p...

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  • “No, my first name ain’t ‘Biostatistician’. It’s ‘Epidemiologist’ (Dr. Kerr, if you’re nasty)”

    It is with great pleasure that I read the commentary by Casals and Finch on the role of the Sports Biostatistician in injury prevention (1). Thank you to the authors for considering this important area of focus. With that said, I hope my additional comments, despite being a relatively new Sports Injury Epidemiologist in the field (receiving my PhD in 2014), can continue the discussion and dialogue that the authors have generated since this publication.

    First, as noted above, I prefer to describe myself as a “Sports Injury Epidemiologist” and not the term Casals and Finch use (“Sports Biostatistician”). Casals and Finch are forthright in denoting that their term is not well known and includes “the combination of statistics and epidemiology and public health or medicine and sports science (1, p.1457). Still, I am hesitant to use this term myself as my training was in epidemiology and not in biostatistics (although the expectation is that I have a good working knowledge of the latter as much as the former). I would not feel comfortable using a term that describes a role for which I was not trained. And although I cannot express the opinion of my former advisor and mentor, Dr. Steve Marshall, I would believe that he would agree, particularly as his faculty webpage describes himself as an epidemiologist and not a biostatistician (2).

    The term “epidemiology” originates from 3 Latin roots - (1) epi (Latin for ‘‘on,’’ ‘‘upon,’’ and ‘‘against’’), (2) demos (‘‘pe...

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  • Inconsistent referencing and underlying conclusion issues

    If it's not too late. The authors may wish to correct their referencing throughout the paper. I noticed that the 3rd paragraph in the Introduction provides references that do not support the statements made. e.g. the Biswas et al paper did NOT assess the impact of PROLONGED sitting. Evidence on bouts of sitting is still very unclear, and none of these interventions have shown is has a meaningful impact.

    It is also unclear how the authors can make their statement about 30 min/day being “likely to be clinically meaningful” – when it probably depends on what the sitting was replaced with (i.e. with standing vs. movement, etc) and the isotemporal substitution paper that is cited to support this assertion is based on a ‘theoretical’ shift of sitting to light activity from a cross sectional study (with risk of reverse causation). This seems to be selling a story that really isn't there.

    A more reasoned conclusion might be that VERY SMALL reductions in TOTAL sitting per day seem possible (a drop in the bucket?) with interventions that require significant resources (notably, not too dissimilar to PA interventions), but whether or not such shifts in sitting per se would make any meaningful difference for health outcomes/biomarkers remains very unclear. Not much good if there is no efficacy for outcomes. The reducing sitting story comes across as more of an hypothesis and 'feel good' story, but the evidence upon which it is based (in terms of effic...

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  • Response to Phillip Page, correspondence 'Evidence for RICE in acute sprains?'

    Dear Phillip Page,
    Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
    First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
    In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence t...

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  • ACSEP Endorses Paper.

    The Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...

  • ACSEP Endorses Paper.

    The Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...

  • On editorials, access and bias at the BJSM

    In May 2018, the following tweet was posted from the BJSM twitter account:

    '115K views. via brave iconocolast @DrAseemMalhotra. Importantly, no rebuttals. Real food saturated fat does not clog arteries - beware processed food that causes hyperinsulinemia (& hypertension). #Rethink'

    Followed by signposting to a linked editorial(1)

    Several people responded, including Catherine Collins (https://twitter.com/RD_Catherine/status/1001707243828596737), pointing out that a number of rebuttals to the editorial in question had in fact been made, not least a 2017 PubMed Commons/PubPeer commentary (https://pubpeer.com/publications/8741FBE4D9D7A38A7802515B33302E), which form the precursor of our rebuttal here. In response to Catherine, the BJSM Editor in Chief (EIC) Karim Khan contacted the lead author here indicating he had missed his email a year previous regarding our commentary originally offered to the BJSM as a formal rebuttal [see PubPeer post]. The EIC indicated he would be happy to publish our PubPeer rebuttal in the BJSM. The lead author thanked the EIC and, with co-authors Duane Mellor, Nicola Guess, and Ian Lahart, submitted a revised version in July 2018.

    In the interest of fairness and open debate, we made a request to the EIC and BJSM editorial board that our manuscript be made o...

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