81 e-Letters

published between 2018 and 2021

  • Flawed research on treatment of back pain does not reflect clinical practice

    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...

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  • Comment on “Effectiveness of treatments for acute and subacute mechanical non- specific low back pain: a systematic review with network meta- analysis”

    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.

  • Isotonic Exercises

    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
    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...

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  • Comprehensive Care of Race-Day Emergencies

    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...

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  • Glovin' up

    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’.

  • Follow up questions to the systematic review

    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?

  • Suggestion to improve the methodology of this study

    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.

  • Put your trainer on hold; the causal relationship between physical inactivity and severe COVID-19 is still not clear.

    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...

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    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-...

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  • Physical activity in hypertrophic cardiomyopathy - be careful in genotype and troponin positive subgroup of patients.

    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...

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