398 e-Letters

  • Method used in this paper for assessing neck strength- is it valid in rugby players?

    We are writing to express our concerns regarding this recent study published in BJSM and how the findings may be misleading and the results misinterpreted.

    Farley, T., Barry, E., Sylvester, R., De Medici, A., & Wilson, M. G. (2022). Poor isometric neck extension strength as a risk factor for concussion in male professional Rugby Union players. British Journal of Sports Medicine.

    There are a number of methodological issues with this study which will have contributed to the interpretation of their results and subsequently how these might be used in practice. Most of these issues were not mentioned or addressed in the limitations of the study and should be highlighted as potential confounders:

    Method for assessing neck strength- is it valid for use in rugby players?

    Neck extensors

    Although the authors use a method of assessing neck strength which has documented reliability in an earlier study,(1) this method has not been validated in rugby players (the published reliability was in healthy adults). The reason this method might not be the most appropriate method for assessing neck strength in rugby players is that these athletes have particularly strong necks, much stronger than the average population. The method used in the Farley et al. study requires the player to self-assess their own neck extensors with the player’s shoulders placed in an anatomically weak position where they may not be able to generate enough strength to counter >...

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  • Reply on “Cost-effectiveness of full endoscopic versus open discectomy for sciatica” P. Gadjari et al., Br J Sports Med 2022

    We like to commend the authors with the recent publication of the results of a multicenter randomized controlled trial comparing percutaneous transforaminal discectomy (PTED) versus open microdiscectomy in the treatment of patients with symptomatic lumbar disc herniation[1].
    Based on the data of the non-inferiority trial, we fully agree with the authors conclusion that PTED is non-inferior to open microdiscectomy and can therefore be considered as an effective alternative surgical treatment. The improvement of leg pain and low back in the first 3 months is similar between both groups within the non-inferior margin. Patients treated with PTED seem to report less leg pain (mean difference 7.1) and low back pain (mean difference 6.0) at 12 months. However, these differences were small and did not reach the minimal clinically important difference of 20 mm on a VAS score[2].
    In contrast to the BMJ paper, we do not agree with the suggestion stated in the Br J Sports Med paper, that PTED is less costly and more effective for various reasons. Firstly, costs associated with endoscope equipment and disposables were not included in their cost measurements. The direct costs only included time of the operating room, costs of medications and overnight hospital stay. Secondly, the study protocol reported that all PTED procedures should be performed in daycare and the open microdiscectomy patients were admitted in the hospital for one to two days[3]. For adequate comparison of...

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  • Comment on: ‘Isometric exercise versus high-intensity interval training for the management of blood pressure: a systematic review and meta-analysis’ by Edwards et al.

    In their systematic review and meta-analysis, Edwards et al. (1) aimed to ‘directly compare’ the efficacy of isometric exercise and high-intensity interval training (HIIT) for the management of resting blood pressure. They included 38 randomised controlled trials (18 for isometric, 20 for HIIT) in their pairwise meta-analysis and concluded that isometric exercise appears to be superior to HIIT for improving both systolic blood pressure (mean difference between exercise types = 5.29 mmHg, 95% confidence interval 3.97 to 6.61) and diastolic blood pressure (mean difference between exercise types = 3.25 mmHg, 95% confidence interval 2.53 to 3.96). We were interested in these marked differences because they contrast previous findings (2) and, if correct, may necessitate important changes to guidelines. However, in further examining the article, we identified some issues that we believe require attention as they may invalidate the results and are relevant to readers of this journal.

    None of the included trials in this review appear to contain both isometric and HIIT interventions; therefore, the authors are unable to ‘directly compare’ the interventions. Instead, by analysing the differences between isometric and HIIT subgroups in the meta-analysis, Edwards et al. (1) are making an inference based on the indirect effect, which assumes that the differences between exercise types can be inferred via a common comparator (in this case, the control group) (3). This is, in effe...

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  • Response to Robert M Leithiser

    This is a classic example of misinterpretation of the available data. Of course, national death rates may be higher than the overall rate for 67 countries. Furthermore, the range of media coverage at the national level is massive, so a comparison with an international registry is not valid.

  • Article being taken out of context as misinformation

    This article is being used to assert that the # of deaths of professional soccer players (now at 27 competing at a national level) is normal by taking the overall total of 465 deaths to all players (of which 42% weren't even reported in the media) as the normal # of professional soccer players who die. In reality this study indicates just 5% of the deaths were of elite athletes comparable to those tracking deaths of professional soccer players. That works out to an average of only about 5 per year from the study and other data show an average of 8.9 total soccer player deaths per year at a national level reported by the media.

  • 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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  • 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.


    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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  • 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’.