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?
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.
Editor of the magazine "British Journal Sports Medicine"
I address this to you, in relation to the article "Efficacy of progressive tendon load
exercise therapy in patients with patellar tendinopathy: a randomized clinical trial."
Their study shows the comparison between the effectiveness of progressive load
exercises (PLE) with eccentric exercise therapy (EE) in patients with patellar
tendinopathy (PT). However, it is also known that slow and heavy isotonic exercises lead
to both short and long-term improvement of pain and other symptoms, because it
improves the pathology, increases the remodeling of the fibers and normalizes the
morphology of the fibers. tendon fibrils (1).
So, you could have added in your research, as this technique has proven to be effective
and if included it would make a more interesting comparison. Therefore, adding more
reasons why you should consider incorporating isotonic exercises is that in the study by
Dr. Qassim et al. validated that a four week heavy slow isotonic training program during
the season resulted in a gradual improvement in pain in athletes with PT (1), since among
its multiple benefits of this training is that it can restore muscle mass and the strength of
the lower limb, and can perform with minimal pain; Unlike the analysis of Purdam Cr. and
Visnes H. that indicated that the...
Editor of the magazine "British Journal Sports Medicine"
I address this to you, in relation to the article "Efficacy of progressive tendon load
exercise therapy in patients with patellar tendinopathy: a randomized clinical trial."
Their study shows the comparison between the effectiveness of progressive load
exercises (PLE) with eccentric exercise therapy (EE) in patients with patellar
tendinopathy (PT). However, it is also known that slow and heavy isotonic exercises lead
to both short and long-term improvement of pain and other symptoms, because it
improves the pathology, increases the remodeling of the fibers and normalizes the
morphology of the fibers. tendon fibrils (1).
So, you could have added in your research, as this technique has proven to be effective
and if included it would make a more interesting comparison. Therefore, adding more
reasons why you should consider incorporating isotonic exercises is that in the study by
Dr. Qassim et al. validated that a four week heavy slow isotonic training program during
the season resulted in a gradual improvement in pain in athletes with PT (1), since among
its multiple benefits of this training is that it can restore muscle mass and the strength of
the lower limb, and can perform with minimal pain; Unlike the analysis of Purdam Cr. and
Visnes H. that indicated that the EE during the season cannot have any effect or even
worsen the symptoms of patellar tendinopathy (2).
Also, in the article by Aidan Rich et al. their results on slow isotonic exercises reproduced
that of the twenty athletes with PT who participated, the initial mean pain they manifested
was 5/10, and the analgesic response was positively correlated with improvements in
VISA-P at 4 weeks (3) . Similarly, the research by Ebonio Rio et al. stated in their study
that after an acute episode of strength training and isotonic exercise, the numerical pain
rating scale improved by 42% (4).
In conclusion, having the heavy-load progressive isotonic exercises in the research
would have made an important contribution to the conservative treatment of patellar
tendinopathy, particularly for athletes suffering from this condition.
BIBLIOGRAPHIC REFERENCES
1. Dr. Qassim I. Muaidi, Rehabilitation of patellar tendinopathy. Journal of
Musculoskeletal and Neuronal Interactions [online magazine] 2020 May. [cited 2021 Oct
13] 20 (4). Available at: jmni_20_535.pdf
2. Mathijs van Arka, b, Jill L. Cook b, Sean I. Docking b, Johannes Zwerver a, James E.
Gaida b, c, Inge van den Akker-Scheeka, Ebonie Rio. Do isometric and isotonic exercise
programs reduce pain in athletes with patellar tendinopathy in-season? A randomized
clinical trial. Journal of Science and Medicine in Sport [online journal] 2015 NovemberDecember. [cited 2021 Oct 13] 19 (2016) 702–706. Available in:
PIIS1440244015002315.pdf
3. Aidan Rich, Jilliane Leigh Cook, Andrew John Hahne, Ebonie Kendra Rio, Jon Ford.
Randomized, cross-over trial on the effect of isotonic and isometric exercise on pain and
strength in proximal hamstring tendinopathy: trial protocol. BMJ Open Sport Exerc Med
[magazine on the Internet] 2020 November. [cited October 13, 2021] Available at:
e000954.full.pdf
4. Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Alan J
Pearce, Jill Cook. Isometric exercise induces analgesia and reduces inhibition in patellar
tendinopathy. BJ Sports Med. [Magazine on the Internet] 2015 May. [cited November 7,
2021] Available at: 1277.full.pdf
We commend Yuri Hosokawa et al. on their recent publication in the BJSM (Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020.) Their hard work moves the race medicine community forwards in the critically important mission of recognizing and treating critical illness in the elite runner.
In our experience it is evident that clear, concise protocols, and easy-to-read algorithms are of paramount importance for race-medicine, particularly when experienced race physicians are providing care side-by-side with clinical volunteers. A group of experts convened at the Consortium for Health and Military Performance (CHAMP) in 2019 to review race protocols for the Marine Corps Marathon and the International Institute for Race Medicine (IIRM). While reviewing and revising race protocols, we set out to create straightforward algorithms that would aid in the assessment and treatment of a wide range of acute medical conditions. The algorithms developed from this meeting were published in Current Sports Medicine Reports (Oct. 2020, Vol 19) and are available on the CHAMP website (https://champ.usuhs.edu/for-the-provider) under "Guidelines: Management of Mass Participation Events". We are encouraged to see Dr. Hosokawa and colleagues presenting a similar algorithmic approach in their pape...
We commend Yuri Hosokawa et al. on their recent publication in the BJSM (Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020.) Their hard work moves the race medicine community forwards in the critically important mission of recognizing and treating critical illness in the elite runner.
In our experience it is evident that clear, concise protocols, and easy-to-read algorithms are of paramount importance for race-medicine, particularly when experienced race physicians are providing care side-by-side with clinical volunteers. A group of experts convened at the Consortium for Health and Military Performance (CHAMP) in 2019 to review race protocols for the Marine Corps Marathon and the International Institute for Race Medicine (IIRM). While reviewing and revising race protocols, we set out to create straightforward algorithms that would aid in the assessment and treatment of a wide range of acute medical conditions. The algorithms developed from this meeting were published in Current Sports Medicine Reports (Oct. 2020, Vol 19) and are available on the CHAMP website (https://champ.usuhs.edu/for-the-provider) under "Guidelines: Management of Mass Participation Events". We are encouraged to see Dr. Hosokawa and colleagues presenting a similar algorithmic approach in their paper, though our group chose a slightly more conservative approach, recommending aggressive cooling begin at or above a core temperature of 40C/104F in our hyperthermia algorithm. We also describe treatment algorithms for several other emergency situations.
We invite race medical directors and any medical professionals who are interested in race medicine to review the guidelines put forth in both publications for excellent approaches to the athlete suffering a race-day emergency.
Whilst better quality research into concussion in combat sports is welcomed; an equally important and related area of research is gaining insight into the often ‘concussion permissive’ training environments of the many combat sport schools across the country. In my earlier years of competitive MMA training ‘gym wars’ were a common occurrence. Training partners, often encouraged by the coaches, would spar (practice fight) at close to 100% power including strikes to the head. It was not uncommon to see someone get knocked out unconscious, checked on, dragged off to the side of matted training area, then once awakened, asked to continue with the sparring session! I believe over the years this type of training culture has become less prevalent with a growing emphasis on light-contact modified technical sparring or a greater reliance on more dynamic and modality specific pad-work drills. There is still a need though to understand the factors behind schools that promote this unsustainable culture of frequent hard sparring and identify and describe the behaviours behind it. Hopefully then efforts can be made to engage and influence the combat sport athletes to think twice before ‘glovin up’.
1. How the population in the RCTs defined lateral elbow tendinopathy? By resisted strength test, ultrasound scan or MRI? Did the inclusion specific enough to rule out other elbow joint pain such as ligament tear?
2. If the RCTs did not rule out ligament tear or joint instability pain, does it affect the results?
Thanks for your insightful publication. I would like to add to Georg Supp and Stephanie Moers comments on this article.
I agree with the previous comments that the current experimental design is more a comparison between the effectiveness of low pain loading exercise and painful loading exercise in patients with patellar tendinopathy according to the current methodology.
As a fairer comparison, it should be rather progressive tendon-loading exercise versus statics/ regressive loading exercise. Otherwise, it can also be progressive isometric & isotonic tendon-loading exercise versus progressive eccentric loading exercise as well. No clear standardization on the loading of the exercise makes it less convincing to achieve the authors’ conclusion.
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
Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
Regarding the expansion of the non-...
Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
Regarding the expansion of the non-maleficence principle, it has been shown that occupational physical activity can be harmful to one’s health, extending the physical activity paradox beyond the harmful effects of intensity. 4 This finding contradicts the idea that physical activity in its various dimensions is beneficial.
Another point that deserves wide attention concerns inequalities and how they impact various aspects of individuals’ relationships with physical exercise. Various studies have indicated that the vulnerability of certain social groups—such as black people, people of low socioeconomic status, and women—interferes with the performance of leisure-time physical activities or even other behaviours considered as healthy 5–6. We view this as an affront to the principle of justice. Moreover, some researchers have disregarded such inequalities and reinforced blaming the individual for his or her ‘failure’ to engage in behaviour considered appropriate, even arguing that it leads to enormous economic costs to society. 7 This position clearly aligns with neoliberal precepts since it places the responsibility for taking care of oneself on the individual, thus removing it from the State. Why, in general, are women less involved with leisure-time physical activities than men? Why is the same true for black people? Why is physical inactivity lower among black women? How do violence, mobility, and urban planning impact physical activity? Are more impoverished people equally likely to have access to leisure-time physical activity? The possibility of exercising does not seem equal for everyone.
Although we recognise that the focus of Pugh et al. 3 was correct medically, we consider that inequities interfere decisively in the possibility that any isolated measure effectively produces some benefit and/or avoids some harm. The principles of beneficence and non-maleficence may not be guaranteed if effective measures to combat inequities are not adopted. Regarding the context of peripheral countries, it is essential to consider adequate bioethical theories, rather than principlism. 8
In particular, socially excluded people—because of their unequal position in society—may sometimes be unable to make autonomous decisions. The capacity to make decisions is in itself incomplete, relative, non-global, and determined by a series of changing contextual aspects.
We also consider it necessary to question the supposed universality of bioethical principles since they are often presented within a colonialist perspective. This posture is reflected in individuals’ concepts of autonomy, which we believe should be decolonised. Decolonisation stimulates the debate about the knowledge and experiences of the community to reveal their richness. This process is in line with a vision of social justice: achieving health equity considering individual and collective empowerment. Therefore, taking advantage of the knowledge and perspectives of social groups to contribute to the development of specific interventions seems essential for yielding effective results.
Finally, we highlight the insistence on considering the relationship between physical exercise and health as a problem that is only biomedical. The resulting discourses reinforce the idea of the medicalisation of exercise. Thus, the practitioner becomes a patient and the pleasure for the practice is always neglected.
References
1. Beauchamp TL, Childress JF. Principles of biomedical ethics. 8 ed. New York: Oxford University Press, 2019.
2. Booth FW, Roberts CK, Laye MJ. Lack of Exercise Is a Major Cause of Chronic Diseases. Compr Physiol 2012; 2:1143-1211.
3. Pugh J, Pugh C, Savulescu, J. Exercise prescription and the doctor’s duty of non-maleficence. Br J Sports Med 2017; 51:1555-1556.
4. Holtermann A, Schnohr P, Nordestgaard BG, Jacob Louis Marott JL. The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults. Eur Heart J 2021; 42:1499-1511.
5. Brodersen NH, Steptoe A, Boniface DR, Wardle J. Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. Br J Sports Med 2007; 41:140-144.
6. Abichahine H, Veenstra G. Inter-categorical intersectionality and leisure-based physical activity in Canada. Health Promot Int 2017; 32:691-701.
7. Allender S, Foster C, Scarborough P, Rayner M. The burden of physical activity-related ill health in the UK. J Epidemiol Community Health 2007; 61:344-348.
8. Garrafa V, Porto D. Intervention bioethics: a proposal for peripheral countries in a context of power and Injustice. Bioethics 2003; 17: 399-416.
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Additionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negativ...
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Additionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negative predictor.
Next factor concerning to the problem of “true-genetic” subgroup is sex distribution. In Kwon et al. (1) paper females were significant minority i.e. 29.9% while females constituted of at least 40% of studied population (2,3).
The next problem is risk of exercise induced ischemia in HCM. Recent study (4) alerted that 50% patient with HCM experienced myocardial ischemia at resting condition (positive results of high sensitive troponin test). Importantly, half of them had painless angina (silent ischemia). In this particularly dangerous situation, patients may not receive benefit but harm due to exercise training (unsafety fitness with repeated, escalating ischemia). Importantly, ischemia is directly linked with myocardial dysfunction. The functional destruction by both type of ischemia (painful, painless ) was documented recently (5).
In summarize, high sensitive troponin must be evaluated before and monitored after exercise to start safety training program.
References
1. Kwon S, Lee HJ, Han KD, Kim DH, Lee SP, Hwang IC, Yoon Y, Park JB, Lee H, Kwak S, Yang S, Cho GY, Kim YJ, Kim HK, Ommen SR. Association of physical activity with all-cause and cardiovascular mortality in 7666 adults with hypertrophic cardiomyopathy (HCM): more physical activity is better. Br J Sports Med. 2020 Sep 23:bjsports-2020-101987. doi: 10.1136/bjsports-2020-101987. Epub ahead of print. PMID: 32967852.
2. Canepa M, Fumagalli C, Tini G, Vincent-Tompkins J, Day SM, Ashley EA, Mazzarotto F, Ware JS, Michels M, Jacoby D, Ho CY, Olivotto I; SHaRe Investigators. Temporal Trend of Age at Diagnosis in Hypertrophic Cardiomyopathy: An Analysis of the International Sarcomeric Human Cardiomyopathy Registry. Circ Heart Fail. 2020 Sep;13(9):e007230. doi: 10.1161/CIRCHEARTFAILURE.120.007230. Epub 2020 Sep 8. PMID: 32894986; PMCID: PMC7497482.
3. Bos JM, Will ML, Gersh BJ, Kruisselbrink TM, Ommen SR, Ackerman MJ. Characterization of a phenotype-based genetic test prediction score for unrelated patients with hypertrophic cardiomyopathy. Mayo Clin Proc. 2014;89:727-37.
4. Dimitrow PP, Czarnecka D, Kawecka-Jaszcz K, Dubiel JS. Sex-based comparison of survival in referred patients with hypertrophic cardiomyopathy. Am J Med. 2004;117:65-6.
5. Gębka A, Rajtar-Salwa R, Dziewierz A, Dimitrow P. Painful and painless myocardial ischemia detected by elevated level of high-sensitive troponin in patients with hypertrophic cardiomyopathy. Adv Interv Cardiol. 2018;14:195-198.
6. Rajtar-Salwa R, Gębka A, Dziewierz A, Dimitrow PP. Hypertrophic Cardiomyopathy: The Time-Synchronized Relationship between Ischemia and Left Ventricular Dysfunction Assessed by Highly Sensitive Troponin I and NT-proBNP. Dis Markers. 2019; 019:6487152. Dis Markers. 2019;2019:6487152.
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...
Show MoreDear 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.
Peru, Lima, December 05, 2021
Editor of the magazine "British Journal Sports Medicine"
I address this to you, in relation to the article "Efficacy of progressive tendon load
exercise therapy in patients with patellar tendinopathy: a randomized clinical trial."
Their study shows the comparison between the effectiveness of progressive load
exercises (PLE) with eccentric exercise therapy (EE) in patients with patellar
tendinopathy (PT). However, it is also known that slow and heavy isotonic exercises lead
to both short and long-term improvement of pain and other symptoms, because it
improves the pathology, increases the remodeling of the fibers and normalizes the
morphology of the fibers. tendon fibrils (1).
So, you could have added in your research, as this technique has proven to be effective
Show Moreand if included it would make a more interesting comparison. Therefore, adding more
reasons why you should consider incorporating isotonic exercises is that in the study by
Dr. Qassim et al. validated that a four week heavy slow isotonic training program during
the season resulted in a gradual improvement in pain in athletes with PT (1), since among
its multiple benefits of this training is that it can restore muscle mass and the strength of
the lower limb, and can perform with minimal pain; Unlike the analysis of Purdam Cr. and
Visnes H. that indicated that the...
We commend Yuri Hosokawa et al. on their recent publication in the BJSM (Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020.) Their hard work moves the race medicine community forwards in the critically important mission of recognizing and treating critical illness in the elite runner.
In our experience it is evident that clear, concise protocols, and easy-to-read algorithms are of paramount importance for race-medicine, particularly when experienced race physicians are providing care side-by-side with clinical volunteers. A group of experts convened at the Consortium for Health and Military Performance (CHAMP) in 2019 to review race protocols for the Marine Corps Marathon and the International Institute for Race Medicine (IIRM). While reviewing and revising race protocols, we set out to create straightforward algorithms that would aid in the assessment and treatment of a wide range of acute medical conditions. The algorithms developed from this meeting were published in Current Sports Medicine Reports (Oct. 2020, Vol 19) and are available on the CHAMP website (https://champ.usuhs.edu/for-the-provider) under "Guidelines: Management of Mass Participation Events". We are encouraged to see Dr. Hosokawa and colleagues presenting a similar algorithmic approach in their pape...
Show MoreWhilst better quality research into concussion in combat sports is welcomed; an equally important and related area of research is gaining insight into the often ‘concussion permissive’ training environments of the many combat sport schools across the country. In my earlier years of competitive MMA training ‘gym wars’ were a common occurrence. Training partners, often encouraged by the coaches, would spar (practice fight) at close to 100% power including strikes to the head. It was not uncommon to see someone get knocked out unconscious, checked on, dragged off to the side of matted training area, then once awakened, asked to continue with the sparring session! I believe over the years this type of training culture has become less prevalent with a growing emphasis on light-contact modified technical sparring or a greater reliance on more dynamic and modality specific pad-work drills. There is still a need though to understand the factors behind schools that promote this unsustainable culture of frequent hard sparring and identify and describe the behaviours behind it. Hopefully then efforts can be made to engage and influence the combat sport athletes to think twice before ‘glovin up’.
May I have two questions please?
1. How the population in the RCTs defined lateral elbow tendinopathy? By resisted strength test, ultrasound scan or MRI? Did the inclusion specific enough to rule out other elbow joint pain such as ligament tear?
2. If the RCTs did not rule out ligament tear or joint instability pain, does it affect the results?
Dear Dr Breda and colleagues,
Thanks for your insightful publication. I would like to add to Georg Supp and Stephanie Moers comments on this article.
I agree with the previous comments that the current experimental design is more a comparison between the effectiveness of low pain loading exercise and painful loading exercise in patients with patellar tendinopathy according to the current methodology.
As a fairer comparison, it should be rather progressive tendon-loading exercise versus statics/ regressive loading exercise. Otherwise, it can also be progressive isometric & isotonic tendon-loading exercise versus progressive eccentric loading exercise as well. No clear standardization on the loading of the exercise makes it less convincing to achieve the authors’ conclusion.
Dear 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 MoreSome decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
Show MoreThe relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
Regarding the expansion of the non-...
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Show MoreAdditionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negativ...
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