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...
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 evidence as either “strong or weak based on the (1) balance between benefits and harms, (2) overall quality of the evidence, (3) importance of outcomes (ie, values and preferences of pregnant women), (4) use of resources (ie, cost), (5) impact on health equity, (6) feasibility and (7) acceptability. A strong recommendation is one where “Most or all pregnant women will be best served by the recommended course of action” and a weak recommendation is one where “Not all pregnant women will be best served by the recommended course of action; there is a need to consider other factors such as the individual’s circumstances, preferences, values, resources available or setting. Consultation with an obstetric care provider may assist in decision-making.”
We disagree with how PFMT has been classified in relation to these criteria and would like to question and comment on the following:
1.Balance between benefits and harms: the effect size of antenatal PFMT for prevention of UI is moderate and there are no harms of PFMT, so this would be in favor of a strong recommendation. In addition, many of the studies in the Davenport et al (2018) review did not compare PFMT with no exercise/untreated controls, rather the control groups typically also had some advice or instruction in PFMT as part of ‘routine’ care. Such trials are likely to under- rather than overestimate the effect of PFMT, suggesting the true effect size may be larger than that calculated by Davenport et al (2018).
2.Overall quality of the evidence: There are three issues to consider here:
a. Research design. There are sufficient numbers of RCTs evaluating effect of PFMT on UI during pregnancy to do meta-analyses without including cohort studies with lower internal validity. The Davenport review (2018) referred to cohort studies and showed that general exercise (not PFMT) may increase the odds of developing UI. Aerobic exercise usually includes high impact activities (jumping and running). Numerous studies (Bø 2004, Nygaard & Shaw 2016) have shown that high impact activities are associated with UI, therefore this combination is likely to be provocative of UI and mask a stand-alone effect of PFMT on reduction of UI. Studies on aerobic exercise can therefore not be expected to have a positive effect on UI and should not be recommended to be combined with studies on PFMT. In all reports in this area general exercise /physical activity needs to be separated from specific PFMT, in order not to confuse the readers.
b. Risk of bias. All the trials are inevitably at risk of bias through an inability to blind participants and providers, yet this would be the same for all forms of physical activity (yoga) and should not affect the rating of PFMT more than other exercise. The included trials are also the usual ‘mixed bag’ of less and more robust trials. While most studies are small to moderate in size it seems likely that the true underlying effect is within the existing confidence limits of the effect estimate (Herbison et al 2011). Both in the Cochrane (Woodley et al 2017) and the Davenport et al (2018) reviews the upper limits of the confidence intervals suggest clinically important reduction in UI.
c. Statistical heterogeneity. For PFMT, a plausible explanation for statistical heterogeneity is the different training doses and supervision (Hay-Smith et al 2011). We agree that more work is needed to find a ‘cut off’ for effectiveness in PFMT delivery and dose, but in the meantime there are certainly robust trials with well described interventions demonstrating clinically significant effect that are suitable models for application in practice.
3. Importance of outcome: UI is a prevalent (>30%) and bothersome condition reducing QoL and especially participation in physical activity (Nygaard et al 2005, Hamid et al 2015), and therefore important to prevent. In the Canadian guideline it is stated that prior to convening the panel, "10 pregnant women were recruited by convenience sampling and invited to provide input on the perceived benefits and harms of physical activity, and to identify pregnancy outcomes that were most important to them." Studies consistently finds women perceive UI as stigmatizing and at the same time ‘normal’ for parous women, and UI is a topic they are reluctant to talk about (Hamid et al 2015). Postpartum the dominant view of women is that of ‘if only I’d known then what I know now’, and ‘I wish someone had told me about UI, and taught me how to do PFMT properly’ (Mason et al 2001, Mason et a 2001, Neels et al 2016). If the 10 pregnant women in the expert group were continent, not aware that they might develop incontinence after birth and were more concerned about other common maternity conditions or the health of the babies, UI may not have reached their attention. We are surprised that specialized women's health physiotherapists who are the experts in this field both in high quality research and clinical practice, were not included in the panel nor as experts.
4. Use of resources: PFMT is already part of ante-and postnatal health care in most developed countries. PFMT has proved to be effective as part of group training for women and can therefore be administered at low cost to the health system.
5. Impact of health equity: Not informing or providing PFMT to pregnant women creates inequity as failure to prevent UI in pregnancy means that women are potentially set up for many years of UI symptoms with all the consequent effects on self-esteem, withdrawal from physical activity, not playing with their children, the cost of buying products and laundry and the cost of physiotherapy and surgery.
6. Feasibility: PFMT has successfully been incorporated in comprehensive exercise classes since 1986 (Bø et al 1990, Mørkved et al 2003, Stafne et al 2012).
7. Acceptability: PFMT research is firmly on the side of acceptability. Studies show that women want to do PFMT as first line treatment, but they must be informed about why and how they should do it (Mason et al 2001, Mason et al 2001). The long-term effect of PFMT is, as for all exercise interventions, dependent on maintenance of training. There are challenges with long term adherence/attrition from all forms of exercise/physical activity programs, and this is NOT a specific nor more pronounced problem for PFMT. Again, this is not an argument for assigning PFMT a weak recommendation.
In summary, it appears the guideline panel has, perhaps in deciding on a weak recommendation, over-emphasized concerns about quality of evidence (in which other areas of exercise in medicine are there more RCTs showing clinically relevant effect?), and may not have ‘heard’ how bothered women are about the problem of UI. Most, or all, pregnant women would benefit from PFMT during pregnancy to prevent UI because: PFMT does prevent UI in late pregnancy, postpartum, and potentially for life (as well as preventing pelvic organ prolapse), it does no harm, women would do PFMT if they knew why it was important (but the system fails them by not giving them this information), women who do leak experience significant bother, and the training can be incorporated with other physical activity to maximize gains from time spent in exercise. The Canadian guidelines' weak recommendation appears inconsistent with the evidence and positive impact of existing research.
Strong recommendation for yoga?
We further question the evidence for the "strong recommendation" and "high quality evidence" that adding yoga and gentle stretching is beneficial. For which conditions is yoga beneficial during pregnancy? It would seem that yoga/ gentle stretching classes would indeed have the same cost and feasibility/ equity/ acceptability concerns as group training of the PFM.
Diastasis recti abdominis
Why is diastasis recti abdominis considered a critical outcome? There is no scientific evidence that this causes any harm. The guidelines refer to the systematic review of Davenport et al (2018 b). They conclude that there is no relationship between prenatal exercise and diastasis. However, the guideline states that continuing aerobic exercise (walking) is associated with less odds of development of diastasis. Based on which studies? Neither Sperstad et al (2016) nor Fernandes de Mota et al (15) found such associations.
The guideline recommends that women with a diastasis postpartum should avoid curl-ups and refer to Mota et al (2015) to support this statement. However, Mota et al (2015) found the contrary; abdominal crunch narrows the inter-rectal distance and indrawing opens the gap. This has now been supported by several studies.
In conclusion, we are concerned that how the Canadian guideline group have defined quality of evidence and weak and strong recommendations, may mislead pregnant women and heath care providers to believe that there is weak scientific evidence for prevention and treatment effects of PFMT for UI. This may discourage pregnant women from starting or continuing PFMT in a very important period to prevent and treat the condition. The guideline group may have - inadvertently – through issuing a weak recommendation for PFMT in pregnancy, put the onus onto individual health care professionals and women to make decisions about teaching or doing the exercises without regard to all the factual information. Women ‘don't know what they don't know’. Are we truly accepting that one third of women will experience stress urinary incontinence by mid-age when this could potentially be prevented through ante-natal PFMT? We urge the panel to re-consider their recommendation and are happy to supply any further evidence as required to guide the evidence grading.
Kari Bø, Professor, PhD. The Norwegian School of Sport Sciences, Dept of Sports Medicine, Oslo, Norway.
Chantale Dumoulin, Professor, PhD. University of Montreal, School of Rehabilitation, Montreal, Canada
Cristine HJ Ferreira, Associate Professor, PhD, University of Sao Paulo, Ribeirao Preto Medical School, Ribeirao Preto, Brazil
Helena Frawley, Associate Professor, PhD, Monash University, Dept of Physiotherapy, Melbourne, Australia
Jean Hay-Smith, Associate Professor, PhD, University of Otago, Wellington, New Zealand
Siv Mørkved, Professor, PhD, Norwegian University of Science and Technology, Dept of Public Health and Nursing, Trondheim, Norway
Ingrid Nygaard, Professor, MD, MS, University of Utah, School of Medicine, Salt Lake City, USA
Margaret Sherburn, PhD, Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
References
Bø K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Med 2004; 34: 451-464.
Bø K,Hagen RH, Kvarstein B, Jørgensen J, Larsen S. Pelvic floor muscle exercise for the
treatment of female stress urinary incontinence: III.Effects of two different degrees of pelvic floor muscle exercises. Neurourol Urodyn; 1990: 9,5:489-502.
Davenport MH, Nagpal TS, Mottola MF et al. Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy; a systematic review and meta-analysis. Br J Sports Med 2018; 52: 1397-1404.
Davenport MH (B), Ruchat SM, Sobierajski F et al. Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis. Br J Sports Med. 2018 Oct 18. pii: bjsports-2018-099821. doi: 10.1136/bjsports-2018-099821. [Epub ahead of print]
Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20:200-2005
Hamid TA, Pakgohar M, Ibrahim R, Dstjerdi MV. "Stain in life": The meaning of urinary incontinence in the context of Muslim postmenopausal women through hermeneutic phenomenology. Archieves Geront Geriatr 2015; 60: 514-521.
Hay-Smith EJC, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD009508. DOI: 10.1002/ 14651858. CD009508.
Herbison P, Hay- Smith J, Gillespie WJ. Meta-analyses of small numbers of trials often agree with longer-term results. J Clin Epidem 2011; 64: 245-153.
Mason L, Glenn S, Walton I Hughes C. Do women practice pelvic floor exercises during
pregnancy or following delivery? Physiotherapy 2001, 87; 662-670.
Mason L, Glenn S, Walton I, Huges C. The instruction in pelvic floor exercises provided to women during pregnancy or following delivery. Midwifery 2001; 17: 55-64.
Mota PI, Pascoal AG, Carita AI, Bø K. The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period. J Orthop Sports Phys Ther. 2015;45:781-8.
Mørkved S, Bø K, Schei B, Salvesen KA. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial. Obstet Gynecol. 2003;101: 313-9.
Neels H, Wiebren A,Tjalma A, Wyndaele, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in menopausal women and in peripartum women. J. Phys. Ther Sci. 2016; 28: 3020–3029.
Nygaard IE, Shaw JM. Physical activity and the pelvic floor. Am J Obstet Gynecol. 2016; 214: 164-171.
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a barrier to exercise in women? Obstet Gynecol. 2005;106: 307-14.
Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016;50: 1092-1096.
Stafne SN, Salvesen KÅ, Romundstad PR, Torjusen IH, Mørkved S. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG. 2012 Sep;119(10):1270-80. doi: 10.1111/j.1471-0528.2012.03426.x. Epub 2012 Jul 17.
Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD007471. DOI: 10.1002/14651858.CD007471.pub3.
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.
The last paragraph cites Rolfing when it should be Structural Integration. There are many schools of Structural Integration of which Rolfing Structural Integration is one, Describe the modality as massage if you must, though I would prefer, "a form of manual therapy" or "a form of manual therapy that is often categorized as massage." I am surprised that this error passed through the editors and peer review.
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...
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 (‘‘people’’), and (3) logos (‘‘study of’’) - and roughly translates to ‘‘the study of that which is against people.’’ Today’s modern definition of epidemiology is the “study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems” (3, p.61). This modern definition captures the extent of thought that epidemiologists must consider alongside their multidisciplinary research team. My role involves the careful deliberation of study design with as many decisions made a priori; it considers the control of confounding via methodological control as much as statistical control; it pushes for both internal and external validity, while minimizing the risk of committing a Type I or Type II error; and most importantly, it weighs what is good science and what is doable science, all the while staying committed to working with the assumption of the null hypothesis being true.
Furthermore, I worry that incorrectly identifying myself as a “biostatistician” will continue to undermine the true value of a biostatistician. In an ideal setting, all research teams would be inclusive of both epidemiologists, who would help lead study design, and biostatisticians, who would help lead data analysis development and implementation. These roles would complement one another to ensure both study design and data analysis are well-planned and considered concurrently throughout the entire research process. However, too often, a biostatistician’s role is mischaracterized and seen as someone who simply comes in after data collection occurs and is expected to analyze the data; in the worst cases, it is someone who is expected to “make lemonade out of a lemon”. I am constantly worried my role will be seen as such as well. Neither a biostatistician nor an epidemiologist should be relegated to such a role. I wholeheartedly appreciate Casals and Finch emphasizing that our work “should start at the beginning of the study design process, well before data have been collected” (1, p.1458).
When I was pursuing my master’s degree in epidemiology at The Ohio State University, a professor I much admired jokingly stated that at parties, he seldom introduced himself as an epidemiologist (but rather a biostatistician) in order to not scare and confuse people at social functions. Throughout my doctoral work, I personally found that the use of either term at parties set me up for an evening on the couch with only the host’s dog to keep me company. However, as I’ve maneuvered through this world of sports injury prevention, I find myself more willing to take this chance of social exile and to proudly proclaim myself as a sports injury epidemiologist. I have also found that I have had to vocally emphasize the value of both sports injury epidemiologists and biostatisticians. Our constant nagging about good study design and study limitations, sometimes much to the chagrin of our colleagues, is not meant to annoy. Rather, it is meant to allow our colleagues as well as our readers the ability to carefully consider the validity and generalizability of research. We are a valuable component of any research team. And to jokingly paraphrase Dr. Evil from the Austin Powers film series, “I didn't spend six years in evil [public health] school to be called ‘mister,’ thank you very much.”
Perhaps, my argument is more about semantics than anything else. However, I believe pooling both parties into one term undermines the true value that each of us brings to the table. Still, I appreciate that Casals and Finch have boldly taken the first step to address this issue. I hope my commentary addresses my concerns, but also encourages continued dialogue regarding the necessity for multi-disciplinary teams inclusive of sports medicine professionals, methodologists, and analysts.
References
1. Casals M, Finch CF. Sports Biostatistician: a critical member of all sports science and medicine teams for injury prevention. Br J Sports Med 2018;52:1457-1461.
2. University of North Carolina Injury Prevention Research Center. Leadership and faculty. https://iprc.unc.edu/about-us/our-people/leadership-faculty/. Accessed November 6, 2018.
3. Last JM. Dictionary of Epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.
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...
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 that RICE alone, or cryotherapy, or compression therapy alone have any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE alone in the treatment of acute LAS (Level 2).”. However, all recommendations are provided per treatment or prevention modality and do not include combination therapy unless otherwise specified and therefore it could be discussed that the content, despite adding clarification, in essence would not change. If readers do wish to learn more on the specifics of each treatment or preventive modality we would like to invite them to read the rest of the guideline and the paragraphs that elaborate on their desired topic.
You outline we did not include any meta-analyses on RICE interventions in supplement 3. This is correct as we were limited due to the heterogeneity in outcome measures, therapy methods and application methods, which did not allow data pooling. Even though multiple studies outlined a decrease in swelling and pain, this was measured using different methods, again not allowing pooling of data. We therefore reported the results in a qualitative manner by means of the number of studies and patients and the level of evidence.
Concerning harmful effects, again this is a just question. Due to the current extent of the evidence we chose to present to the readers, the guideline turned out quite voluminous. We chose to present the most important findings. Where we could or when included evidence outlined harmful effects, we highlighted the potential presence or absence of harmful or side effects: “Use of an ankle brace results in better outcome compared to other types of functional treatment such as sports tape (non-elastic) or kinesiotape (elastic), without showing any side effects[7].”. Unfortunately, the combination of limited information on harmful effects in the included studies and the length and great number of included treatment modalities in our guideline, required us to prioritize and limit our overview.
Another observation you made concerned treatment with NSAIDs, for which we describe prescription should be done so cautiously as they may negatively affect the natural healing process. Although ideally this statement would be based on a recently published RCT including a large cohort, we based it on a systematic review performed in 2003, which we still consider valid. We did not identify any new studies that described this subtopic and this component of NSAID usage was deemed so important that we agreed it should be included in this guideline. It was our task to provide an overview of the evidence on ankle sprain diagnostics, treatment and prevention, health care professionals can further decide which information they require and how they wish to implement this in clinical practice. We specifically mentioned there may be a risk at delay of the natural healing process.
Also, concerning NSAIDs you mention the presentation of our results are conflicting. We understand that you outline the effect of oral NSAID usage on swelling stating 2/3 favored placebo. However, as of all three comparisons of oral NSAID usage the confidence interval still includes 0, we cannot say that either NSAID or placebo is favored. Grouping oral with topical NSAIDs does not change this effect as the confidence interval still includes 0. In defining a recommendation we included these non-significant results with the studies of which we could not pool our data due to heterogeneity of used outcome measures. We understand that, recommending that NSAIDs may be used to reduce pain and swelling, despite an evident effect in our meta-analyses, is confusing. This recommendation was made based on the evident positive effect regarding pain reduction and the fact that some studies were able to show a positive effect, especially of topical NSAIDs on swelling. We agree that some form of clarification going into more detail may have been required to avoid confusion.
In conclusion, even though we have managed to write an extensive overview to describe the current best evidence practice to help professionals in clinical health care in their decision making for patients who have sustained a lateral ankle sprain, we are aware of the fact that we did not present all the evidence out there in literature. In our statements and recommendations we have made our best effort to be as concise as possible. We thank you for your great feedback and will use it in our future research, as we continue to strive to improve!
On behalf of the guideline committee,
Yours sincerely,
Gwendolyn Vuurberg and Prof. Gino M.M.J. Kerkhoffs
1. Cote, D.J., et al., Comparison of 3 Treatment Procedures for Minimizing Ankle Sprain Swelling. Physical Therapy, 1988. 68(7): p. 1072-1076.
2. Airaksinen, O., P.J. Kolari, and H. Miettinen, Elastic bandages and intermittent pneumatic compression for treatment of acute ankle sprains. Arch Phys Med Rehabil, 1990. 71(6): p. 380-3.
3. Rucinkski, T.J., et al., The effects of intermittent compression on edema in postacute ankle sprains. J Orthop Sports Phys Ther, 1991. 14(2): p. 65-9.
4. Tsang, K.K., J. Hertel, and C.R. Denegar, Volume Decreases After Elevation and Intermittent Compression of Postacute Ankle Sprains Are Negated by Gravity-Dependent Positioning. J Athl Train, 2003. 38(4): p. 320-324.
5. Hing, W., et al., Comparison of multimodal physiotherapy and "R.I.C.E."self-treatment for early management of ankle sprains. New Zealand Journal of Physiotherapy, 2011. 39(1): p. 13-19.
6. Bleakley, C.M., et al., Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. British Medical Journal, 2010. 340.
7. Kemler, E., et al., A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med, 2011. 41(3): p. 185-97.
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of thes...
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of these basic biological and social facts indicate the potential for gendered differences in roles (e.g. serving on a panel) to be a result of situations arising from free choice. These are very important points to consider when discussing discrepancies between genders, yet were not mentioned in the editorial.
The argument above is of course not for absolute biological determinism, nor that sexism does not exist. Recognizing the fact that there are differences between women and men does not mean equity between genders cannot exist. However, valid evidence should take precedence over ideological narratives. Any statements on this topic should be made with caution as to avoid promoting unnecessary interventions.
The authors of the editorial are free to critically examine the evidence presented opposing their conclusions. However, the editorial demonstrated a low standard of evidence. For this conversation to move forward a higher standard of evidence should be sought and adhered to.
In conclusion, the authors of the editorial failed to meet the necessary burden of proof to claim that implicit bias is a primary cause for the complex phenomenon of gender discrepancies in SEM or society. As such, the likelihood is high that the interventions cited within the editorial are unwarranted and unhelpful.
REFERENCES
1. Bekker, S. et al. We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine. British Journal of Sports Medicine bjsports–2018–099084–4 (2018). doi:10.1136/bjsports-2018-099084
2. Forscher, P. S. et al. A meta-analysis of change in implicit bias. PsyArXiv 1–68 (2017). doi:10.17605/OSF.IO/DV8TU
3. Goldhill, O. The world is relying on a flawed psychological test to fight racism. Quartz (2017). Available at: https://qz.com/1144504/the-world-is-relying-on-a-flawed-psychological-te.... (Accessed: 9 April 2018)
4. Su, R., Rounds, J. & Armstrong, P. I. Men and things, women and people: A meta-analysis of sex differences in interests. Psychological Bulletin 135, 859–884 (2009).
5. Stoet, G. & Geary, D. C. The gender-equality paradox in science, technology, engineering, and mathematics education. Psychol Sci 095679761774171–20 (2018). doi:10.1177/0956797617741719
We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in t...
We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in the context of gender inequity in SEM does not mitigate the role of other factors. We do not suggest that implicit bias is the sole driver of gender inequity, but that it is one that warrants attention.
Boynton et al. note, in the references that they cite arguing against implicit bias, that there may be phenomena such as individual choice that may result in such disparities. This may be true. In addition, we would add that at least one other phenomenon we did not mention is explicit bias. Each of the authors on this editorial can note multiple examples where these explicit biases have played out. The issue of ‘manels’ as a manifestation of gender disparities in SEM is merely the tip of the iceberg. Some of the authors of our editorial have written about other gender issues in different media [4]. Society at large, and the SEM community in particular, is still too disturbingly sexist to escape the conclusion that frank, explicit bias is a major driver of the disparities that concern us [5].
In regards to the issue of implicit bias, the body of literature supporting this concept is deep and underpins several of the resources we mention in our editorial. The LTE authors too easily dismiss this work as ‘ideological.’ We counter that, like any scientific theory, implicit bias is a ‘work in progress,’ and that noting a few references arguing against that theory does not tear down the entire body of evidence.
Gender disparities and contributory biases exist at many levels of our field. This is a problem, which could be seen as big or small depending on the observer. It is, nevertheless, a problem. We assert that it must be addressed.
We do agree, at least in part, with our dissenting colleagues, when challenging those of us interested in these issues to seek a ‘higher degree of evidence.’ While there is no lack of evidence for gender disparity in the SEM community, we applaud deeper investigations into these issues and a higher quality of evidence. Furthermore, we advocate for more research into the phenomena that may underpin these disparities.
For those parties interested in gender issues in sport and SEM, we would encourage them to consider looking more deeply into the problems we describe in our editorial and this response. We would like at the very least to see more documentation of gender (mis)representation among keynote speakers at SEM conferences; within academic divisions and departments; within teams (e.g. head team physicians among elite teams), etc. Moreover, analyses of the decision-making processes that lead to these disparities must also be included in future investigations.
Being of service to ourselves and our SEM community means meeting people where they stand. This is a more effective endeavor when we can be transparent about where we are starting from. To that end, we would encourage readers to consider these courses of action while we all continue this conversation:
i) consider taking the implicit bias test we reference [3]
ii) speak up when seeing significant gender disparities at conferences and other fora
iii) Men: mentor the female SEM trainees with which you work, and help them achieve higher levels in their field if they are motivated. And listen thoughtfully to what your female colleagues are saying about these issues
iv) Women: yes, ‘lean in,’ as the saying goes; but also continue to identify systemic biases and try to challenge them
Submitted by Sheree Bekker and James MacDonald, on behalf of all authors of the original editorial:
Sheree Bekker, Osman H Ahmed, Ummukulthoum Bakare, Tracy A Blake, Alison M Brooks, Todd E Davenport, Luciana De Michelis Mendonça, Lauren V Fortington, Michael Himawan, Joanne L Kemp, Karen Litzy, Roland F Loh, James MacDonald, Carly D McKay, Andrea B Mosler, Margo Mountjoy, Ann Pederson, Melanie I Stefan, Emma Stokes, Amy J Vassallo, Jackie L Whittaker
In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.
Letter to the Editors
Show MoreBr 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...
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.
The last paragraph cites Rolfing when it should be Structural Integration. There are many schools of Structural Integration of which Rolfing Structural Integration is one, Describe the modality as massage if you must, though I would prefer, "a form of manual therapy" or "a form of manual therapy that is often categorized as massage." I am surprised that this error passed through the editors and peer review.
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...
Show MoreDear Phillip Page,
Show MoreThank 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...
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of thes...
Show MoreWe want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in t...
Show MoreThe 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...
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...
In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.
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