We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM l...
We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM landscape for equity, diversity and empowered representationt. All of these factors ensured we had a focus on gender equity at all times in the development of the conference program.
So, is there more work to do? Absolutely! Just as Thorborg and colleagues identify, diversity is not just about gender, but covers many areas. Our College and our conference could be more diverse and this remains our aim in coming years.
References
1. Thorborg K, Krohn L, Bandholm T, et al. ‘More Walk and Less Talk’: Changing gender bias in sports medicine. British Journal of Sports Medicine 2020:bjsports-2020-102966. doi: 10.1136/bjsports-2020-102966
2. Bekker S, Ahmed OH, Bakare U, et al. We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine. British Journal of Sports Medicine 2018;52(20):1287-89. doi: 10.1136/bjsports-2018-099084
We read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
A recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every...
We read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
A recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every foot is aligned and neutral to improve function and avoid or minimize pain. However, when analyzing the study by Rasemberg et al.1 and contrasting with the results of two systematic reviews2,5, we concluded that the position does not seem useful for the treatment of plantar fasciitis.
In our opinion, the manuscript also lacks detail regarding feet typology and the type of correction applied to each orthosis–and these are our second point.
Even though the number of volunteers is representative and proper randomization was applied, the authors did not report the foot type classification, which somewhat confuses the clinical interpretation. Assuming that normal, planus, and cavus feet have different characteristics, it is likely that the participants reacted differently to the proposed treatments. Also, the insole was not described in detail, and it is challenging to understand the correction type used for each volunteer, which may interfere with data analysis and clinical decisions.
All volunteers referred to the podiatrist received the orthosis, but did they need this correction? It is like prescribing glasses for people without vision problems. It is not clear whether podiatrists could exclude volunteers who did not need correction, which may have also influenced the results. Thus, the following question remains: Did the intervention worsen those volunteers who did not need corrections, and results were pulled down?
Burns et al.6 compared the effects of customized and sham insoles in patients with bilateral cavus foot and foot pain. In this study, the insole customization did not aim to modify the hindfoot position. The longitudinal arch was supported, and an extrinsic heel post was introduced to limit the excessive lateral heel support. A superior effect of customized insoles on pain and physical function was found, indicating that specific interventions for specific foot types were efficient.
Another study7 investigated the effects of customized insoles adapted in flip-flop sandals with corrections in individuals with plantar fasciitis for 12 weeks. The authors proposed different supports for the midfoot based on foot typology, thus maintaining the plantar arches function. A significant improvement in morning pain and pain at the end of the day was observed in the intervention group compared with controls.
Therefore, we question the validity of the standard customization maintaining the neutral position regardless of the foot type and the dysfunctions.
The third point regards the way the assessment of the study participants was conducted. Although we agree that the evaluation using pads with different thicknesses to determine the neutral position of the ankle is feasible and used by clinicians worldwide, it may not represent the real patient’s need since significant differences are present between static and dynamic evaluations using this method8. Thus, it is probable that the used measures were insufficient or inadequate for the pad prescriptions, even if supported by a 3D system.
Regarding the sham insoles, we believe that the minimum effects generated by the insole thickness, softness, and different characteristics are important factors for both the comfort perception and pressure reduction sensation, and may have produced similar effects to the customized insole.
In this sense, we invite you to reflect on the next steps in investigating the effects of insoles on plantar fasciitis, ending the cycle of custom-made insoles in a neutral position and beginning the new era of insoles prescribed for function and not for disease.
References
1- Rasenberg N, Bierma-Zeinstra SMA, Fuit L, et al. Br J Sports Med Epub ahead of print:doi:10.1136/ bjsports-2019-101409
2- Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL, Landorf KB. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med. 2018;52(5):322-328. doi:10.1136/bjsports-2016-097355
3- Bruening DA, Pohl MB, Takahashi KZ, Barrios JA. Midtarsal locking, the windlass mechanism, and running strike pattern: A kinematic and kinetic assessment. J Biomech. 2018;73:185-191. doi:10.1016/j.jbiomech.2018.04.010
4- Behling AV, Nigg BM. Relationships between the foot posture Index and static as well as dynamic rear foot and arch variables. J Biomech. 2020;98:109448. doi:10.1016/j.jbiomech.2019.109448
5- Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801. Published 2008 Jul 16. doi:10.1002/14651858.CD006801.pub2
6- Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. J AmPodiatrMed Assoc. 2006;96(3):205-211. doi:10.7547/0960205
7- Costa ARA, de Almeida Silva HJ, Mendes AAMT, Scattone Silva R, de Almeida Lins CA, de Souza MC. Effects of insoles adapted in flip-flop sandals in people with plantar fasciopathy: a randomized, double-blind clinical, controlled study. ClinRehabil. 2020;34(3):334-344. doi:10.1177/0269215519893104
8- Behling AV, Manz S, von Tscharner V, Nigg BM. Pronation or foot movement - What is important. J Sci Med Sport. 2020 Apr;23(4):366-371. doi: 10.1016/j.jsams.2019.11.002. Epub 2019 Nov 8. PMID: 31776068
Contributors: All authors contributed equally to the letter.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared
Patient consent for publication: Not required.
Provenance and peer review: Not commissioned; externally peer reviewed.
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
• Analysis of hospita...
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
• Analysis of hospital data record relating to lower limb injuries to argue the case for an emerging epidemic of osteoarthritis and other conditions of direct relevant to physiotherapist and other sports medicine professionals.(8)
• Comparing the frequency of hospital admissions to emergency department presentations to general practitioner visits for sports injury treatment in a well-defined geographic area.(9)
• Understanding injuries in specific population sub-groups like children(10, 11) and those living in rural settings.(12, 13)
• Monitoring particular types of injury presentations such as concussion(14) and heat-illness,(15, 16) and to prioritise injury prevention efforts in particular sports.(17)
• Evaluating the effectiveness of an implemented low limb injury prevention program.(18)
Many of our studies have used routinely collected hospital data, which use the International Classification of Disease 10th Revision (ICD-10) (19) external causes to identify sports injury cases. This work has been influential in leading international recognition of the value of such ICD-coded data from hospital sources, though they are not without their challenges and limitations.(20, 21) Our studies, together with the larger body of published sports injury data derived hospital records from international groups (not referenced here), shows that the high value such data has for sports medicine is already established and is actually relatively common.
What Machado and colleagues(1) demonstrate is that interrogation and use of hospital data sources should not be restricted to cases with an external injury code. They show that other conditions relevant to sports medicine, like low back pain, can also be explored with hospital data. There is no doubt that more work of this nature would ensure that the sports medicine field is better informed about the conditions most related to their clinical practice.
References
1. Machado G, O'Keeffe M, Richards B, et al. Why a dearth of sports and exercise medicine/physiotherapy research using hospital electronic medical records? A success story and template for researchers. British Journal of Sports Medicine 2020;Published Online First: 21 May 2020. doi: 10.1136/bjsports-2019-101622
2. Finch C, Valuri G, Ozanne-Smith J. Sports and active recreation injuries in Australia: evidence from emergency department presentations. British Journal of Sports Medicine 1998;32(3):220-25.
3. Flood L, Harrison JE. Hospitalised sports injury, Australia 2002-03. Injury Research and Statistics Series Number 27. Flinders University, Adelaide: Australian Institute of Health and Welfare, 2006. (Accessed 31 July 2020):6-23. Available from http://www.aihw.gov.au/publication-detail/?id=6442467828. Accessed 11 Aug 2017.
4. Australian Institute of Health and Welfare (AIHW). Hospitalised sports inury in Australia, 2016-17. Published online as https://www.aihw.gov.au/reports/injury/hospitalised-sports-injury-austra..., 26 Feb 2020: AIHW, 2020. (Accessed 31 July 2020).
5. Finch CF. Getting sports injury prevention on to public health agendas - addressing the shortfalls in current information sources. British Journal of Sports Medicine 2012;46:70-74. doi: 10.1136/70 bjsports-2011-090329
6. Finch C, Wong Shee A, Clapperton A. Time to add a new priority target for child injury prevention? The case for an excess burden associated with sport and exercise injury: population-based study. BMJ Open 2014;4:e005043. [doi:10.1136/bmjopen-2014-43].
7. Victorian Government. Sports Injury Prevention Taskforce final report. Sport and Recreation Victoria. https://sport.vic.gov.au/resources/documents/sports-injury-prevention-ta... 2017. (Accessed 31 July 2020).
8. Finch C, Kemp J, Clapperton A. The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004-2010: A future epidemic of osteoarthritis? . Osteo & Cart 2015;23(7):1138-43. [First published online 04/03/2015 as doi:10.1016/j.joca.2015.02.165].
9. Cassell EP, Finch CF, Stathakis VZ. Epidemiology of medically treated sport and active recreation injuries in the Latrobe Valley, Victoria, Australia. British Journal of Sports Medicine 2003;37:405-09.
10. Fernando T, Berecki-Gisolf J, Finch C. Sports injuries in Victoria, 2012–13 to 2014–15: evidence from emergency department records. Medical Journal of Australia 2018;208(6):255-60. [Published online: 2 April 2018 doi: 10.5694/mja17.00872].
11. Schneuer F, Bell J, Adams S, et al. The burden of hospitalized sports-related injuries in children: an Australian population-based study, 2005-2013. Injury Epidemiology 2018;5:45. [Published online 17/12/2018 as https://doi.org/10.1186/s40621-018-0175-6].
12. Wong Shee A, Clapperton A, Finch C. Increasing trend in the frequency of sports injuries treated at an Australian regional hospital. Australian Journal of Rural Health 2017;25(2):125-27. [Published first online 17/04/2016 as doi:10.1111/ajr.12274].
13. Finch CF, Boufous S. Sports/leisure injury hospitalisation rates in New South Wales – evidence for an excess burden in remote areas. Journal of Science and Medicine in Sport 2009;12:628-32.
14. Finch CF, Clapperton AJ, McCrory P. Increasing incidence of hospitalisation for sport-related concussion in Victoria, Australia. Medical Journal of Australia 2013;198(8):427-30.
15. McMahon S, Gamage PJ, Fortington LV. Sports related heat injury in Victoria, Australia; an analysis of 11 years of hospital admission and emergency department data. Journal of Science and Medicine in Sport 2020 (in press) doi.org/10.1016/j.jsams.2019.08.275
16. Finch CF, Boufous S. The descriptive epidemiology of sports/leisure-related heat illness hospitalisations in New South Wales, Australia. Journal of Science and Medicine in Sport 2008;11(1):48-51. doi: papers3://publication/doi/10.1016/j.jsams.2007.08.008
17. Ekegren C, Gabbe B, Finch C. Medical-attention injuries in community Australian Football: A review of 30 years of surveillance data from treatment sources. Clinical Journal of Sport Medicine 2015;25(2):162-72.
18. Finch C, Akram M, Gray S, et al. Controlled ecological evaluation of an implemented exercise-training program to prevent lower limb injuries in sport – population-level trends in hospital-treated injuries. British Journal of Sports Medicine 2019;53:487-92. [First published BJSM Online First 14/09/2018 as doi: 10.1136/bjsports-2018-099488].
19. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision Geneva: World Health Organization; 2007 [Available from: http://apps.who.int/classifications/apps/icd/icd10online/ accessed 01/09/2011.
20. Finch CF, Boufous S. Activity and place – Is it necessary both to identify sports and leisure injury cases in ICD-coded data? International Journal of Injury Control and Safety Promotion 2008;15(2):119-21. doi: 10.1080/17457300801994936
21. Finch CF, Boufous S. Do inadequacies in ICD-10-AM activity coded data lead to underestimates of the population frequency of sports/leisure injuries? Injury Prevention 2008;14(3):202-04. doi: 10.1136/ip.2007.017251
Roe et al have written a useful article on the continuing misuse of relative risk, and the importance of understanding relative risk and absolute risk difference in injury risk outcomes in randomised controlled trials. In describing the Number Needed to Treat (NNT) they miss out an important word- the NNT is the number needed to treat to prevent one _extra_ adverse event, not to prevent a single adverse event. To see thus suppose the NNT was m. In their notation the risk in the intervention group is IG and the Control group is CG. The number of events expected in the intervention group if we treated m of them is mIG. To prevent one event we have mIG=1 and so we have to treat m=1/IG subjects to prevent one event. However we would expect mCG events in the control group. To prevent one _extra_ event in the intervention group we would require mCG-mIG =1 (assuming CG>IG) . Thus m=1/(CG-IG) which is the definition of the NNT. They could also, perhaps, have mentioned the problems in using the NNT, such as differing baselines leading to it being uninterpretable as described, for example by Stang, A., Poole, C., & Bender, R. (2010). Common problems related to the use of number needed to treat. Journal of Clinical Epidemiology, 63(8), 820–825
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are need...
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are needed to verify the interventional effects.
Second, Øverås et al. reviewed prospective studies to evaluate the associations between objectively measured physical behaviour and the risk or prognosis of neck pain (NP) and/or LBP (3). Eight studies out of 10 handled blue-collar workers, and increased sitting time at work reduced the risk of NP and LBP. Among blue-collar workers, increased physical activity during work and/or leisure increased the risk of NP and LBP. In addition, physical activity was not significantly associated with prognosis of LBP. These findings are not consistent with data by Shiri et al. (1), and type of job might be an important factor on the association.
Finally, Oliveira et al. reviewed prospective studies to investigate the prognostic role of physical activity in the course of LBP (4). Although low quality evidence presented that physical activity might not be a prognostic factor for pain and disability in patients with LBP, additional studies are indispensable to verify the association. I speculate that many factors would affect the relationship and might be complicated.
References
1. Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51(19):1410-1418. doi: 10.1136/bjsports-2016-097352
2. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for nonspecific low back pain: A Cochrane review. Spine (Phila Pa 1976). 2016;41(16):1284-95. doi: 10.1097/BRS.0000000000001645
3. Øverås CK, Villumsen M, Axén I, et al. Association between objectively measured physical behaviour and neck- and/or low back pain: A systematic review. Eur J Pain. 2020 Feb 24. doi: 10.1002/ejp.1551
4. Oliveira CB, Pinheiro MB, Teixeira RJ, et al. Physical activity as a prognostic factor of pain intensity and disability in patients with low back pain: A systematic review. Eur J Pain. 2019;23(7):1251-1263. doi: 10.1002/ejp.1395
Allow me to make use of the opportunity to extend my appreciation to the BJSM for being a publication of high standing, bringing cutting edge information to the sports medical fraternity.
Thank you for the consensus statement of the International Olympic Committee describing the methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] I found it both informative and useful.
I have a comment about the use of the word “Nervous” in the first column of Table 5. It is an adjective whereas the rest of the words in the column are nouns that more accurately describe the tissue type under discussion. It is possibly only a linguistic error, but I am of the opinion that it should be “Nerve” or “Neural tissue”.
Reference
1. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969
We read with interest, and concern, the letter submitted by Schilaty et al arguing bias in our analysis examining the association between concussion and mouthguard use. Schilaty et al argue that a nested case-control study was not optimal and that “Based on a relatively small cohort, a complete case-control study would have been more appropriate than a nested case-control study.” They then go on to argue that “selection criteria of the non-concussion group biased the study as a random sample was not selected from the remaining cohort (n=2,040)” eliminating “from the analysis all non-injured players who wore mouthguards.” Finally, Schilaty et al contend that our study did not “properly compare the incidence of concussion between wearers or non-wearers of mouthguards.” There are multiple concerning statements and assertions made by the authors of the letter, Schilaty et al., that we will address below.
Shilaty et al discuss the desire to compare “incidence of concussion between wearers and non-wearers of mouthguards.” Incidence cannot truly be estimated from a case-control study, given that the number of cases and controls is fixed from the design. Rather, we are after the odds ratio based on the ratio of the odds of exposure in cases relative to controls (the odds ratio of exposure is mathematically the same as the odds ratio of being a case). Modern conceptualizations of the case-control study invoke the idea of pseudo frequencies or quasi-rates related to construc...
We read with interest, and concern, the letter submitted by Schilaty et al arguing bias in our analysis examining the association between concussion and mouthguard use. Schilaty et al argue that a nested case-control study was not optimal and that “Based on a relatively small cohort, a complete case-control study would have been more appropriate than a nested case-control study.” They then go on to argue that “selection criteria of the non-concussion group biased the study as a random sample was not selected from the remaining cohort (n=2,040)” eliminating “from the analysis all non-injured players who wore mouthguards.” Finally, Schilaty et al contend that our study did not “properly compare the incidence of concussion between wearers or non-wearers of mouthguards.” There are multiple concerning statements and assertions made by the authors of the letter, Schilaty et al., that we will address below.
Shilaty et al discuss the desire to compare “incidence of concussion between wearers and non-wearers of mouthguards.” Incidence cannot truly be estimated from a case-control study, given that the number of cases and controls is fixed from the design. Rather, we are after the odds ratio based on the ratio of the odds of exposure in cases relative to controls (the odds ratio of exposure is mathematically the same as the odds ratio of being a case). Modern conceptualizations of the case-control study invoke the idea of pseudo frequencies or quasi-rates related to construction of the odds ratio and what it means.[1,2,3] Regardless, the control group in a case-control study is intended to reflect the exposure (e.g., mouthguard) use in the source population that produced the cases (e.g., concussions).[1] We feel strongly that our control group of non-head injuries reflects well the mouthguard use experience in this source population and that it was sampled independently of exposure status.
Schilaty et al argue that non-random selection of controls resulted in bias because it “eliminated from the analysis all non-injured players who wore mouthguards.” We agree that if all non-concussed players were wearing mouthguards, then this would have biased our results. However, Schilaty et al don’t seem to appreciate that some of those non-injured players who would have been selected in a random sample would have been using mouthguards and importantly, some would not. There is nothing inherently biased in sampling non-concussion, but still injured controls who may more accurately capture the mouthguard experience of the source population that produced the cases. It is this split of the proportion in the mouthguard exposed and unexposed groups we are after to tell us what the expectation should be for the cases, under the null hypothesis of no effect of mouthguards. That is, “we want the control group to provide estimates of the relative size of the denominators of the incidence proportions or incidence rates for the compared groups.”[1] Also, it is what allows us to calculate the odds ratio as the measure of effect in a case-control study. Ironically, if the bias Schilaty et al propose did in fact exist (i.e., that all or even a larger percentage of non-selected non-injured controls were using mouthguards), it would have resulted in an even more protective mouthguard effect than what we found-no additional analysis required!
It is very interesting that Schilaty et al are asking us "to estimate mouthguard compliance among youth players and use the estimated trends for all control subjects”. We discussed in the paper that our investigation was conducted within cohorts assembled for other reasons. As such, we had no opportunity to sample controls in a random fashion as Schilaty et al proposed. The very reason we wanted to use the methodologically rigorous approach we chose was to avoid making assumptions about mouthguard use for the entire cohort (given that mouthguard use was the main exposure) and address the potentially important issue of confounding by other factors (e.g., mechanism of injury). The analysis the authors of the letter are arguing for would likely result in an effect more biased toward the null (no effect). This would not be because of a superior sampling approach, but because of misclassification bias of mouthguard use among controls. A serious issue to be sure, and one that Schilaty et al even acknowledge as adding “an additional limitation to the study.”
We are concerned that Schilaty et al are mixing up the issue of random error and systematic error. More subjects in what they describe as a “complete case-control study” would potentially reduce random (i.e., statistical) error, but in isolation, would have no effect on the systematic error of the estimates. That is, a larger sample may provide a more precise estimate (narrower confidence limits), but it does not guarantee less bias.
Regarding the issue of causality, we agree more work is required to understand the primary mechanisms of concussion and how mouthguards may reduce the risk. However, this was not the focus of our study and we were simply outlining potential explanations. We do agree that there continue to be gaps in the evidence base that need to be addressed from a causal mechanism perspective.
In summary, we clearly outlined our methodological and conceptual rationale for the rigorous case-control approach we used in our paper and acknowledged limitations. Our approach was feasible and produced what we argue is strong evidence on the mouthguard-concussion relationship. Schilaty’s approach would involve artificially estimating mouthguard use for thousands of children and sampling from that distribution at, presumably, the time of a concussion. This would add significant limitations to the analysis in terms of capturing mouthguard use and key covariates essential for addressing potential confounding. We respectfully disagree with the approach suggested by Schilaty et al and feel it would be much less methodologically and analytically defensible than what we outlined in our paper.
REFERENCES
1. Rothman, Greenland, Lash. Chapter 8: Case-control studies. Modern Epidemiology. Third Edition. Lippincott Williams & Wilkins, 2008.
2. Miettinen OS. Etiologic research: Needed revisions of concepts and principles. Scand J Work Environ Health 1999; 25 (6, special issue):484-490.
3. Miettinen OS. Epidemiological research: Terms and concepts. Springer, 2011.
Whilst its principal message is clear, I wish to draw attention to three problems arising from the editorial authored by Caneiro et al.:
1. They say, “… pain is described as an altered state of a person’s knee health influenced by biopsychosocial factors, of which many can be modified.”
How is “knee health” different from “whole person health”?
Just how many biopsychosocial factors can be modified?
2. Contemporary evidence is said to support the proposition that “knee health” is “influenced by the interaction of different biopsychosocial factors” that have the property of “modulating inflammatory processes and tissue sensitivity”.
Is there any evidence that such an interaction actually takes place?
And furthermore, what are the postulated mechanisms for such interaction?
3. Their Infographic (“What should you know about knee osteoarthritis?”) contains the statement “rest and avoidance makes pain worse.” Presumably they are referring to avoidance of graded exercise. But even so, how do the authors justify their conclusion that avoidance of exercise or rest "per se" can “make pain worse”?
We read with interest the recent International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] While helping to clarify aspects associated with recording and reporting epidemiological data, based on the definitions included in the statement, we believe that some of the examples in Table 10 require clarification with regards to the recording of injuries and calculation of time loss.
Consider the example for ‘Delayed’ time loss: Sunday injury, thigh contusion, able to train on Monday and Tuesday but unable to train on Wednesday and returns on Sunday (time loss starts on Wednesday even though the injury was on Sunday). Time loss (days) 3. Given the recommended reported time loss of 3-days, and definition provided whereby “time-loss days should be counted from the day after the onset that the athlete is unable to participate”, we assume Wednesday is considered as the day of onset (day 0), with subsequent impact on Thursday, Friday and Saturday resulting in a 3-day time-loss (days). When considering this example, we were then somewhat confused by the example for, ‘Intermittent’ time loss: boy with Osgood-Schlatter disease that gets reported at the start of a training camp on Monday. The player may train fully on Monday, Tuesday and Thursday, but miss training on Wednesday and Friday (time loss co...
We read with interest the recent International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] While helping to clarify aspects associated with recording and reporting epidemiological data, based on the definitions included in the statement, we believe that some of the examples in Table 10 require clarification with regards to the recording of injuries and calculation of time loss.
Consider the example for ‘Delayed’ time loss: Sunday injury, thigh contusion, able to train on Monday and Tuesday but unable to train on Wednesday and returns on Sunday (time loss starts on Wednesday even though the injury was on Sunday). Time loss (days) 3. Given the recommended reported time loss of 3-days, and definition provided whereby “time-loss days should be counted from the day after the onset that the athlete is unable to participate”, we assume Wednesday is considered as the day of onset (day 0), with subsequent impact on Thursday, Friday and Saturday resulting in a 3-day time-loss (days). When considering this example, we were then somewhat confused by the example for, ‘Intermittent’ time loss: boy with Osgood-Schlatter disease that gets reported at the start of a training camp on Monday. The player may train fully on Monday, Tuesday and Thursday, but miss training on Wednesday and Friday (time loss counted as Wednesday and Friday only). Time loss (days) 2. Herein, applying the time-loss definition provided in the consensus statement [1] and the logic applied to the delayed time loss example, should the Wednesday not be considered as the onset of time loss and therefore counted as day 0? Based on the two examples and the time-loss (days) provided for each we feel as if time-loss (days) has been calculated differently and as such wish for the authors to clarify. From our position we agree with recording time-loss from the day after the injury when the injury occurs during training on that day, but if an athlete is unable to participate at all due to injury we feel as if this could be considered day 1 of time-loss.
In relation to the above examples it is also unclear as to why these have been considered as single injury reports (cases) given the definitions provided within the consensus statement, “subsequent injuries to the same location and tissue as the index injury are recurrences if the index injury was healed/fully recovered; they are exacerbations if the index injury was not yet healed/fully recovered”, when healed/fully recovered is when an “athlete is fully available for training and competition”.[1] Herein, for the delayed time loss and intermittent time loss examples we would interpret that the injury examples should be considered as multiple injury reports (cases). For delayed time loss, the first case would open following the initial injury on the Sunday and close when the athlete is considered healed/fully recovered, when they return to full training Monday, before a subsequent recurrence on the Wednesday, second case open, which closes on the Sunday (Figure 1a). Similarly for intermittent time loss, it seems that the initial case opens with the initial injury report Monday, closes when the athlete trained fully Monday, second injury case opens on Wednesday as the athlete is unable to train and closes Thursday upon full return to training, before another case opens on the Friday (Figure 1b).
INSERT FIGURE 1A AND 1B ABOUT HERE
Moreover, if the intermittent time loss example should in fact be considered as multiple injury reports (cases), based on time-loss methods suggested within the paper, both Wednesday and Friday would be considered as the onset of time loss and counted as day 0. Therefore, although the athlete missed two days of training, 0 time loss (days) would be calculated (Figure 1b). As a result such an approach for calculating time loss may lead to underreporting. We feel as if this supports our view that an athlete reporting injured at the start of training (and does not participate at all), incurs the first day of time loss and in this example results in two 1-day time-loss events linked to two subsequent injury reports (cases).
It is not our intention to challenge the authors and indeed the updated consensus statements has provided valuable recommendations for injury surveillance. Additionally, we are pleased to see the inclusion of examples within the paper as in our areas of research such examples are a regular occurrence. However, based on the two examples provided, we feel that there are discrepancies with regards to the calculation of time-loss (days) and a lack of clarity surrounding injury recording, specifically with respect to what keeps an injury report (case) open (delayed and intermittent time loss examples). We therefore ask the authors to consider clarification on each point we raise in this letter.
References
Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969
Figure Descriptions
Figure 1: Injury examples from the International Olympic Committee consensus statement, with the inclusion of injury cases and associated time loss (days), based on the healed/fully recovered and time loss (days) definitions provided.
Tables and Figures
Figure available upon reasonable request
The Australian Sports Drug Medical Advisory Committee (ASDMAC) and Drug Free Sport New Zealand (DFSNZ) Therapeutic Use Exemption (TUE) committees welcome the recent discussion paper by our esteemed colleague Dr Ken Fitch entitled "Therapeutic Use Exemptions (TUEs) are essential in sport: but there is room for improvement." As the national bodies responsible for TUE assessment and processing in our respective nations, ASDMAC and DFSNZ agree that the integrity of the TUE process is sound and essential, but could be improved through a peer review process.
Although the World Anti-Doping Agency (WADA) does screen TUEs entered in Anti-Doping Administration and Managements System (ADAMS), the supplementary screening of TUE Committees themselves, including the members, their TUE processes and procedures, as suggested by Dr Fitch would improve the reliability and standardisation of TUEs. In 2018 and 2019, ASDMAC and DFSNZ with the support of the World Anti-Doping Agency (WADA) TUE expert group designed and conducted a TUE Peer Review Audit. This process included the documentation of the proposed audit process, followed by the respective visits of each Chair to the others TUEC meeting. During the visits the Chairs assessed a number of TUE applications and outcomes to ensure that those granted were done so in accordance with the WADA ISTUE and that the WADA Medical Information to Support TUEC decisions had been appropriately interpreted. These visits also includ...
The Australian Sports Drug Medical Advisory Committee (ASDMAC) and Drug Free Sport New Zealand (DFSNZ) Therapeutic Use Exemption (TUE) committees welcome the recent discussion paper by our esteemed colleague Dr Ken Fitch entitled "Therapeutic Use Exemptions (TUEs) are essential in sport: but there is room for improvement." As the national bodies responsible for TUE assessment and processing in our respective nations, ASDMAC and DFSNZ agree that the integrity of the TUE process is sound and essential, but could be improved through a peer review process.
Although the World Anti-Doping Agency (WADA) does screen TUEs entered in Anti-Doping Administration and Managements System (ADAMS), the supplementary screening of TUE Committees themselves, including the members, their TUE processes and procedures, as suggested by Dr Fitch would improve the reliability and standardisation of TUEs. In 2018 and 2019, ASDMAC and DFSNZ with the support of the World Anti-Doping Agency (WADA) TUE expert group designed and conducted a TUE Peer Review Audit. This process included the documentation of the proposed audit process, followed by the respective visits of each Chair to the others TUEC meeting. During the visits the Chairs assessed a number of TUE applications and outcomes to ensure that those granted were done so in accordance with the WADA ISTUE and that the WADA Medical Information to Support TUEC decisions had been appropriately interpreted. These visits also included meetings with other members of the National Anti-Doping Organisation (NADO) such as the TUE Secretariat and other staff in leadership and education roles. The entire process was presented and discussed at the WADA TUE Expert Group meetings.
Having conducted this peer review, ASDMAC and DFSNZ TUEC would commend this process to all NADO and International Federation (IF) TUECs. There is great potential to use this Peer Review process to ensure the quality and transparency in granting elite athlete TUEs around the world and across nations and sports, as well as supporting smaller, less experienced TUECs to establish robust processes in their work as TUE Committees. The universal adoption of a TUEC peer review process would be beneficial to all organisations involved in anti-doping and to athletes and sports to whom the integrity of the TUE process reflects the integrity of sport and performance itself.
We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM l...
Show MoreWe read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
Show MoreA recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every...
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
Show More• Analysis of hospita...
Roe et al have written a useful article on the continuing misuse of relative risk, and the importance of understanding relative risk and absolute risk difference in injury risk outcomes in randomised controlled trials. In describing the Number Needed to Treat (NNT) they miss out an important word- the NNT is the number needed to treat to prevent one _extra_ adverse event, not to prevent a single adverse event. To see thus suppose the NNT was m. In their notation the risk in the intervention group is IG and the Control group is CG. The number of events expected in the intervention group if we treated m of them is mIG. To prevent one event we have mIG=1 and so we have to treat m=1/IG subjects to prevent one event. However we would expect mCG events in the control group. To prevent one _extra_ event in the intervention group we would require mCG-mIG =1 (assuming CG>IG) . Thus m=1/(CG-IG) which is the definition of the NNT. They could also, perhaps, have mentioned the problems in using the NNT, such as differing baselines leading to it being uninterpretable as described, for example by Stang, A., Poole, C., & Bender, R. (2010). Common problems related to the use of number needed to treat. Journal of Clinical Epidemiology, 63(8), 820–825
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are need...
Show MoreAllow me to make use of the opportunity to extend my appreciation to the BJSM for being a publication of high standing, bringing cutting edge information to the sports medical fraternity.
Thank you for the consensus statement of the International Olympic Committee describing the methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] I found it both informative and useful.
I have a comment about the use of the word “Nervous” in the first column of Table 5. It is an adjective whereas the rest of the words in the column are nouns that more accurately describe the tissue type under discussion. It is possibly only a linguistic error, but I am of the opinion that it should be “Nerve” or “Neural tissue”.
Reference
1. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969
We read with interest, and concern, the letter submitted by Schilaty et al arguing bias in our analysis examining the association between concussion and mouthguard use. Schilaty et al argue that a nested case-control study was not optimal and that “Based on a relatively small cohort, a complete case-control study would have been more appropriate than a nested case-control study.” They then go on to argue that “selection criteria of the non-concussion group biased the study as a random sample was not selected from the remaining cohort (n=2,040)” eliminating “from the analysis all non-injured players who wore mouthguards.” Finally, Schilaty et al contend that our study did not “properly compare the incidence of concussion between wearers or non-wearers of mouthguards.” There are multiple concerning statements and assertions made by the authors of the letter, Schilaty et al., that we will address below.
Shilaty et al discuss the desire to compare “incidence of concussion between wearers and non-wearers of mouthguards.” Incidence cannot truly be estimated from a case-control study, given that the number of cases and controls is fixed from the design. Rather, we are after the odds ratio based on the ratio of the odds of exposure in cases relative to controls (the odds ratio of exposure is mathematically the same as the odds ratio of being a case). Modern conceptualizations of the case-control study invoke the idea of pseudo frequencies or quasi-rates related to construc...
Show MoreWhilst its principal message is clear, I wish to draw attention to three problems arising from the editorial authored by Caneiro et al.:
1. They say, “… pain is described as an altered state of a person’s knee health influenced by biopsychosocial factors, of which many can be modified.”
How is “knee health” different from “whole person health”?
Just how many biopsychosocial factors can be modified?
2. Contemporary evidence is said to support the proposition that “knee health” is “influenced by the interaction of different biopsychosocial factors” that have the property of “modulating inflammatory processes and tissue sensitivity”.
Is there any evidence that such an interaction actually takes place?
And furthermore, what are the postulated mechanisms for such interaction?
3. Their Infographic (“What should you know about knee osteoarthritis?”) contains the statement “rest and avoidance makes pain worse.” Presumably they are referring to avoidance of graded exercise. But even so, how do the authors justify their conclusion that avoidance of exercise or rest "per se" can “make pain worse”?
We read with interest the recent International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] While helping to clarify aspects associated with recording and reporting epidemiological data, based on the definitions included in the statement, we believe that some of the examples in Table 10 require clarification with regards to the recording of injuries and calculation of time loss.
Consider the example for ‘Delayed’ time loss: Sunday injury, thigh contusion, able to train on Monday and Tuesday but unable to train on Wednesday and returns on Sunday (time loss starts on Wednesday even though the injury was on Sunday). Time loss (days) 3. Given the recommended reported time loss of 3-days, and definition provided whereby “time-loss days should be counted from the day after the onset that the athlete is unable to participate”, we assume Wednesday is considered as the day of onset (day 0), with subsequent impact on Thursday, Friday and Saturday resulting in a 3-day time-loss (days). When considering this example, we were then somewhat confused by the example for, ‘Intermittent’ time loss: boy with Osgood-Schlatter disease that gets reported at the start of a training camp on Monday. The player may train fully on Monday, Tuesday and Thursday, but miss training on Wednesday and Friday (time loss co...
Show MoreThe Australian Sports Drug Medical Advisory Committee (ASDMAC) and Drug Free Sport New Zealand (DFSNZ) Therapeutic Use Exemption (TUE) committees welcome the recent discussion paper by our esteemed colleague Dr Ken Fitch entitled "Therapeutic Use Exemptions (TUEs) are essential in sport: but there is room for improvement." As the national bodies responsible for TUE assessment and processing in our respective nations, ASDMAC and DFSNZ agree that the integrity of the TUE process is sound and essential, but could be improved through a peer review process.
Although the World Anti-Doping Agency (WADA) does screen TUEs entered in Anti-Doping Administration and Managements System (ADAMS), the supplementary screening of TUE Committees themselves, including the members, their TUE processes and procedures, as suggested by Dr Fitch would improve the reliability and standardisation of TUEs. In 2018 and 2019, ASDMAC and DFSNZ with the support of the World Anti-Doping Agency (WADA) TUE expert group designed and conducted a TUE Peer Review Audit. This process included the documentation of the proposed audit process, followed by the respective visits of each Chair to the others TUEC meeting. During the visits the Chairs assessed a number of TUE applications and outcomes to ensure that those granted were done so in accordance with the WADA ISTUE and that the WADA Medical Information to Support TUEC decisions had been appropriately interpreted. These visits also includ...
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