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?
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
Dear Editor and authors,
As we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-CO...
Dear Editor and authors,
As we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-COV2 tests were performed in our competitions (1090 RT-PCR and 1089 Antigen tests) and only one RT-PCR test was positive (positive rate of 0.1%). Most importantly, however, is that despite the identification of this case, none of the players and staff in close contact with him tested positive in the 4 weeks that followed and, more, none of the games were cancelled or postponed.
This not only highlights the low risk of contagion even in contact sports already reported by Jones et al.3, but also the strength of sanitary protocols, as described by DiFiori et al.. When other high-risk activities (e.g. socializing, meals, or others) are mitigated using these protocols, the possibility of tracing and managing the risk of contagion increases.
Therefore, we consider to be paramount that all governing bodies design and implement customized return to play protocols that are able to accommodate the specificities of each reality and sport, as suggested by DiFiori et al.1. Likewise, it is crucial that all agents understand the need to follow all the hygiene and sanitary recommendations, as it will enable the demonstration of the strength of these protocols and allow the safe return to sport during the context of COVID-19.
References:
1- DiFiori JP, Green G, Meeuwisse W, et al. Br J Sports Med 2021;55:417–421. doi:10.1136/bjsports-2020-103227
2- World Rugby Player welfare. Rugby Europe: Return to Play Protocol. Link: https://playerwelfare.worldrugby.org/?documentid=224 [Accessed 04.04.2021]
3- Jones B, Phillips G, Kemp S, et alSARS-CoV-2 transmission during rugby league matches: do players become infected after participating with SARS-CoV-2 positive players?British Journal of Sports Medicine Published Online First: 11 February 2021. doi: 10.1136/bjsports-2020-103714
Competing interests: none
Acknowledgements: to Besik Chaduneli, José Carlos Saló, Ekaterina Sidorenko and Alin Popescu, CMOs of the Unions involved in the Rugby Europe Championship 2021, as well as to Rugby Nederland.
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Instructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee funct...
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Instructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee function from a 12-week program with painful eccentric training. To our knowledge, this is the only study where VAS ≥ 5 was used as a requirement. In most studies on tendinopathy and eccentric training, a pain VAS ≤ 5 is recommended.2-4
What is the rationale behind choosing a specific program which had already been found to be ineffective, whereas other eccentric regimes had shown at least some efficacy?5,6
3. Inconsistency in patient education
In the supplemental material the authors refer to the colored pain scale for use in the education of the EET group. This scale clearly identifies a pain above 5 as being in the ‘high-risk-zone’. How does this fit with the instruction for patients to exercise with VAS ≥ 5? Patients might well be fearful of reinjuring their tendon when performing this degree of painful exercise.
4. Insufficient adherence to the programs
How low is too low?
Earlier studies on tendinopathy describe adherence rates between 50 and 79 %.4,7-10
Patients in the PTLE group and EET group only reached an adherence of 40% and 49 % respectively after 24 weeks. The adherence to exercises targeting risk factors was only 21% and 22 % respectively. Even if no significant between-group differences were found for exercise adherence, the low adherence in both groups should be mentioned in the limitation section of the study.
With 76 patients included, this RCT is the largest clinical trial in patients with patellar tendinopathy to date. It raised exceptional attention.11 Nevertheless, the concerns mentioned above might justify some caution concerning the clinical impact of the study.
References
1. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper's knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med. 2005;15(4):227-234. doi:10.1097/01.jsm.0000168073.82121.20
2. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. doi:10.1111/j.1600-0838.2009.00949.x
3. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197-206. doi:10.1034/j.1600-0838.2001.110402.x
4. Roos EM, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14(5):286-295. doi:10.1111/j.1600-0838.2004.378.x.
5. Everhart JS, Cole D, Sojka JH, et al. Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy. 2017;33(4):861-872. doi:10.1016/j.arthro.2016.11.007
6. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-98; discussion 199. doi:10.1136/bjsm.2006.029769
7. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without an AirHeel Brace. A randomized controlled trial. B: Effects of compliance. Disabil Rehabil. 2008;30(20-22):1692-1696. doi:10.1080/09638280701785676
8. Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport. 2007;10(1):52-58. doi:10.1016/j.jsams.2006.05.008
9. Vos RJ de, Weir A, Visser RJA, Winter T de, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41(7):e5. doi:10.1136/bjsm.2006.032532
10. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. 2005;39(2):102-105. doi:10.1136/bjsm.2003.010587
11. Altmetric. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial: Overview of attention for article published in British Journal of Sports Medicine, November 2020. https://bmj.altmetric.com/details/94665680
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und...
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und diagnostic process [2]. However, Self-reports (questionnaires) usually are limited in sensitivity and specificity.
Clinical assessment and diagnosis as well as treatment of mental health symptoms and disorders should ideally be conducted by licensed/registered mental health professionals and require education and clinical training in psychiatry [2]. The coordination of the integrated psychiatric management is a core competence of psychiatrists [2,4]. Following the same argument, children and adolescents should be treated by licensed/registered mental health professionals and psychiatrists for children and adolescents. However, there is still limited access to mental health professionals in sports settings, especially to psychiatrists and specialized psychiatrists (sports psychiatrists) [5]. Psychiatrists and (clinical) psychologists differ in their education and expertise in the management of mental disorders. They complement each other, but the differences in their expertise should be clearly identified.
The authors believe there is a need to complement the SMHAT-1 with these fundamental standards of clinical practice in order to further enhance the management of mental health problems in elite sports.
Furthermore, step 3 describes various actions of the SMHAT-1 [1]: (i) treatment/support provided by a sports medicine/primary care physician; (ii) additional screening questionnaires, including attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD), gambling disorder and/or psychosis, prior to definitive diagnosis and to create an management/intervention plan; (iii) for severe, complex, diagnostically uncertain, even after additional screening and/or nonresponsive, treatment through licensed/registered mental health professionals is recommended.
Sports physicians and other health professionals are important specialists to improve and maintain mental health in competitive sports. Ideally, elite athletes should have access to the best interdisciplinary care [6]. Nevertheless, the role of health professionals without specific expertise in mental health needs to be discussed. Only the inclusion of mental health professionals with expertise in sports psychiatry into athlete’s health teams provides the requirement to further improve interdisciplinary care. Moreover, certain mental disorders, e.g., ADHD and PTSD, require additional training and disease-specific expertise, even for mental health professionals [3].
We also strongly encourage the regular use of SMHAT-1 whenever any significant event for an athlete occurs [1]. At the same time major injury/illness and suspected harassment/abuse often require a clinical consultation and assessment by mental health professionals. Screening questionnaires can be of help in detecting major mental health problems but usually do not address the specific need of athletes in such difficult situations. Hence, in some situations important psychological problems might be missed initially, increasing the danger of later mental disorders. The authors therefore propose an individual interdisciplinary approach in all cases of suspected harassment/abuse of (especially young) athletes.
Mental health in competitive sports
Questionnaires and clinical assessment through trained sports physicians in sports psychiatry could be a valuable part of the sports-medical examination. Additionally, we propose examination by sports psychiatrists as a routine in competitive sports. There is a strong need for mental health professionals, and a qualified medical discipline for mental health in competitive sports [5]. Therefore, a corresponding coordinating office for sports psychiatry and sports psychiatry expertise is required in every association and club [5].
Education and training in sports psychiatry are essential in improving mental health in competitive sports. To impart information on mental disorders for athletes and their entourage is also an important action. A strong collaboration between all professionals is recommended.
Education and training in sports psychiatry. The International Society for Sports Psychiatry (ISSP) released a first curriculum for additional training in sports psychiatry in 2018 [7]. In 2020, the Swiss Society for Sports Psychiatry and Psychotherapy (SSSPP) released a three-part curriculum for qualification in sports psychiatry [8]. Part 1 imparts basic knowledge for psychiatrists as well as sports physicians and psychologists.
Education about mental health symptoms and disorders in competitive sports should complement the specialised qualification in sports psychiatry.
Concluding remarks
Mental health and mental disorders require qualified clinical and medical competence, irrespectively of the nature or severity, a psychiatric expertise and in the case of minors, expertise in child and adolescent psychiatry is required.
The basic concept of SMHAT-1 is excellent and following versions should consider these fundamental standards of clinical practice.
There is a need for psychiatrists and clinical psychologists in competitive sports; it is the hope of the authors that more mental health professionals will engage in these settings.
References
1. Gouttebarge V, Bindra A, Blauwet C, et al . International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health. Br J Sports Med. 2021 Jan;55(1):30-37. doi: 10.1136/bjsports-2020-102411.
4. Bhugra D, Ventriglio A, Kuzman MR, et al . EPA guidance on the role and responsibilities of psychiatrists. Eur Psychiatry. 2015;30(3):417-22. doi: 10.1016/j.eurpsy.2015.02.002.
5. Claussen MC, Gonzalez Hofmann C, Imboden C, et al . Swiss Society for Sports Psychiatry and Psychotherapy SSSPP. SSSPP Position paper: Mental health in competitive sport. Swiss Sports & Exercise Medicine. 2020;68(3):23-6. doi:10.34045/SEMS/2020/20.
6. Reardon CL, Hainline B, Aron CM, et al . Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019;53(11):667-699. doi: 10.1136/bjsports-2019-100715.
7. International Society for Sports Psychiatry (ISSP). Certificate of Additional Training in Sports Psychiatry. Available: https://www.sportspsychiatry.org/page-18106 [Accessed 27 Feb 2021].
8. Claussen MC, Imboden C, Seifritz E, et al . Swiss Society for Sports Psychiatry and Psychotherapy SSSPP. Curriculum Sports Psychiatry And Psychotherapy: Level 1. Sport & Exercise Medicine Switzerland 2020;68(3):48-52. doi.10.34045/SEMS/2020/22.
The authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guid...
The authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guidelines is a challenge in the foreseeable future. Therefore, measuring daily and habitual PA remains a strength of the portable devices for now,3 which should also be employed to inform the adaptations or development of PA questionnaires.
Frequently, however, not enough critical thought is given to which PA (self-report) instrument (or a combination of different measures) to use. There is a recently published decision guide aide as to what important aspects to consider when choosing a PA self-report instrument consisting of: purpose, construct, measurement unit, recall period, population, setting, measurement quality, feasibility/ease of use, and resources.4 Utilizing this decision guide is a step in increasing the appropriateness and thus the quality of PA self-report area. Moreover, we agree and additionally emphasize that “the electronic application of short-term instruments (eg, time use diaries, EMAs, previous day recalls), for example via smartphones, can increase our knowledge about the health-related dynamics of daily behaviours, such as sleep, sedentary behaviour and light-intensity activities, as well as the settings ‘surrounding’ these behaviours.”1(Pg.1) Hence, this multi-dynamic approach should be emphasized and methods should be combined and refined to inform future PA self-report measures.5
We also posit that to improve the field of PA self-report it is necessary to standardize the reporting of PA self-report studies. We recommend that researchers use the Physical Activity Questionnaire Reporting Checklist4 to ensure that all relevant information is provided for cross-study comparisons, inclusion in systematic reviews, and meta-analyses.
References
1 Sattler MC, Ainsworth BE, Andersen LB, et al. Physical activity self-reports: past or future? Br J Sports Med Published Online First: 03 February 2021. doi: 10.1136/bjsports-2020-103595
2 Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behavior. Br J Sports Med 2020;54:1451-1462.
3 Burchartz A, Anedda B, Auerswald T, et al. Assessing physical behavior through accelerometry–State of the science, best practices and future directions. Psychol Sport Exerc. 2020;49. doi: 10.1016/j.psychsport.2020.101703
4 Nigg CR, Fuchs R, Gerber M, et al. Assessing Physical Activity through Questionnaires – A Consensus of Best Practices and Future Directions. Psychol Sport Exerc 2020;50. doi: 10.1016/j.psychsport.2020.101715
5 Reichert, M., Giurgiu, M., Koch, E., et al. Ambulatory Assessment for Physical Activity Research: State of the Science, Best Practices and Future Directions. Psychol Sport Exerc 2020;49. doi: 10.1016/j.psychsport.2020.101742
In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their st...
In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their statement are two of their own articles, one in which they conclude endogenous serum testosterone isn’t related to performance3, and one where eight oligomenorrheic athletes with elevated levels of androgens were found to have better aerobic but not strength performance than the other 43 normoandrogenic participants7. With conflicting results, small sample sizes, and a focus only on endogenous testosterone, these sources should not be used to support the stated conclusion. Additionally, Healy’s study of 689 elite athletes and the authors’ own study of 1332 female and 795 male elite athletes showed that performance was not consistently linked to endogenous levels of testosterone2,4.
Hirschberg, et al found that supplemental testosterone improves aerobic capacity but not anaerobic capacity or strength performance in female athletes1. Yet their introduction and conclusion focus on performance related to endogenous testosterone, going so far as to say their results are “of great importance for the ongoing discussion of whether it is fair to allow athletes with naturally producing high testosterone to compete in the female category without reducing their hormonal concentration to the female range. ” That conclusion is far outside of the scope of their study. There is much to be gained by having reliable and valid studies examining influences on performance across classes, ages, and specialties of athletes, but there is also much harm that can be done when conclusions are misrepresented to advocate for the exclusion of athletes from sport. Policies that have drastic effects on individual athletes’ lives are often based on our sports medicine literature, and we must be sure that our published conclusions match the data we have gathered.
1. Hirschberg AL, Elings Knutsson J, Helge T, et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br J Sports Med. 2020;54(10):599-604. doi:10.1136/bjsports-2018-100525
2. Bermon S, Garnier PY. Serum androgen levels and their relation to performance in track and field: mass spectrometry results from 2127 observations in male and female elite athletes. Br J Sports Med. 2017;51(17):1309-1314. doi:10.1136/bjsports-2017-097792
3. Eklund E, Berglund B, Labrie F, Carlström K, Ekström L, Hirschberg AL. Serum androgen profile and physical performance in women Olympic athletes. Br J Sports Med. 2017;51(17):1301-1308. doi:10.1136/bjsports-2017-097582
4. Healy ML, Gibney J, Pentecost C, Wheeler MJ, Sonksen PH. Endocrine profiles in 693 elite athletes in the postcompetition setting. Clin Endocrinol (Oxf). 2014;81(2):294-305. doi:10.1111/cen.12445
5. Sönksen PH, Holt RIG, Böhning W, et al. Why do endocrine profiles in elite athletes differ between sports?. Clin Diabetes Endocrinol. 2018;4:3. Published 2018 Feb 7. doi:10.1186/s40842-017-0050-3
6. Handelsman DJ, Hirschberg AL, Bermon S. Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance. Endocr Rev. 2018;39(5):803-829. doi:10.1210/er.2018-00020
7. Rickenlund A, Carlström K, Ekblom B, Brismar TB, von Schoultz B, Hirschberg AL. Hyperandrogenicity is an alternative mechanism underlying oligomenorrhea or amenorrhea in female athletes and may improve physical performance. Fertil Steril. 2003;79(4):947-955. doi:10.1016/s0015-0282(02)04850-1
Considerable attention has focused on the risks of contact sports like rugby union (1), yet the benefits, rewards and opportunities have received less robust analysis. It is for that reason, Griffin et al.’s recent scoping review is a welcome preliminary contribution to our understanding of risk in rugby. There are, however, some concerns that deserve discussion to ensure that cursory readers are not unintentionally misguided by inaccurate claims.
Claims on mental health and wellbeing
In their paper, Griffin and colleagues examine the evidence for three contexts of rugby; Contact, non-contact and wheelchair. For mental health, Griffin et al. have stated:
There is a generally positive relationship between most (emphasis added) forms of rugby union and both (emphasis added) mental health and wellbeing, especially in wheelchair rugby, though further research is required outside of the wheelchair rugby setting.
They also assert, "Despite relatively fewer studies, the relationship between rugby union and both mental health and well-being is generally positive, especially in non-professional settings" (emphasis added).
The data
For the contact rugby context, Griffin et al. cite three studies (3, 4, 5). Each of which evidences elevated levels of common mental health disorders for contact rugby participants in the elite game. No evidence is presented for sevens at any level, the adult amateur community game or youth contact game....
Considerable attention has focused on the risks of contact sports like rugby union (1), yet the benefits, rewards and opportunities have received less robust analysis. It is for that reason, Griffin et al.’s recent scoping review is a welcome preliminary contribution to our understanding of risk in rugby. There are, however, some concerns that deserve discussion to ensure that cursory readers are not unintentionally misguided by inaccurate claims.
Claims on mental health and wellbeing
In their paper, Griffin and colleagues examine the evidence for three contexts of rugby; Contact, non-contact and wheelchair. For mental health, Griffin et al. have stated:
There is a generally positive relationship between most (emphasis added) forms of rugby union and both (emphasis added) mental health and wellbeing, especially in wheelchair rugby, though further research is required outside of the wheelchair rugby setting.
They also assert, "Despite relatively fewer studies, the relationship between rugby union and both mental health and well-being is generally positive, especially in non-professional settings" (emphasis added).
The data
For the contact rugby context, Griffin et al. cite three studies (3, 4, 5). Each of which evidences elevated levels of common mental health disorders for contact rugby participants in the elite game. No evidence is presented for sevens at any level, the adult amateur community game or youth contact game.
For non-contact rugby there is no evidence found or presented. For wheelchair rugby, one study found participation in wheelchair rugby for those with tetraplegia is a positive impact on mental health.
Therefore, there is insufficient evidence to claim that most forms of rugby have a generally positive relationship to mental health. The evidence in this scoping review suggests that based on one study, wheelchair rugby has a positive relationship to mental health. Furthermore, contact rugby, based on limited evidence of the professional context, has a detrimental impact on mental health.
The authors also claim that “any form of rugby union can involve moderate-to vigorous physical activity (MVPA), which … confers a wide range of physical, mental and social well-being benefits”. However, rugby’s high concussion rate needs to be accounted for before accepting any such claim, particularly with the deleterious mental health effects associated with concussion. In a study published in 2020 of 416 New Zealand high school rugby players “69% of players had sustained [at least one] suspected concussion” (7) during their rugby playing at school. So, any MVPA-related mental health benefits derived from rugby would need to be placed in context with the recent finding about brain injuries to school children (and possible mental health consequences), including
The implications
This is particularly important given the widespread dissemination of this article's findings, including to the general public via blogs, infographics and animations; sometimes with the BJSM Approved logo. Indeed, Griffin et al recognise the importance of this work for informed decision making, commenting “A wide range of stakeholders as well as existing and potential participants can use this information to make a more informed decision about participating in and promoting rugby union as a health-enhancing activity” (2).
As examples, some of these pieces include statements such as, "Those who play any form of rugby (outside of the professional setting) could benefit from a range of mental health and wellbeing benefits...". Another claim on an infographic states "Data suggests that participating in rugby union has beneficial effects on numerous proxy measures for mental health and wellbeing, especially in wheelchair and non-professional settings". Given the importance a scoping review like this is for allowing people to make informed and balanced decisions on participation, it is vital that the statements accurately portray not only the benefits (evidenced and perceived) but also the uncertainties and known risks of participation.
The way forward
In this instance, the authors of the paper should look to moderate their claims to be more reflective of the evidence within their scoping review. They should also, as responsible members of the sports medicine community, make every effort to ensure their work is not misrepresented to the public, which may include retracting and amending the various dissemination tools currently being promoted.
References
1. Pollock, A. M., White, A. J., & Kirkwood, G. (2017). Evidence in support of the call to ban the tackle and harmful contact in school rugby: a response to World Rugby. British journal of sports medicine, 51(15), 1113-1117.
Griffin, S. A., Perera, N. K. P., Murray, A., Hartley, C., Fawkner, S. G., Kemp, S. P., ... & Kelly, P. (2020). The relationships between rugby union, and health and well-being: a scoping review. British Journal of Sports Medicine.
Gouttebarge V, Kerkhoffs G, Lambert M. Prevalence and determinants of symptoms of common mental disorders in retired professional rugby union players. Eur J Sport Sci 2016;16:595–602 PubMed .
Gouttebarge V, Hopley P, Kerkhoffs G, et al. Symptoms of common mental disorders in professional rugby: an international observational descriptive study. Int J Sports Med 2017;38:864–70 PubMed .
Gouttebarge V, Hopley P, Kerkhoffs G, et al. A 12-month prospective cohort study of symptoms of common mental disorders among professional rugby players. Eur J Sport Sci 2018;18:1004–12 PubMed .
Silveira SL, Ledoux T, Cottingham M, et al. Association among practice frequency on depression and stress among competitive US male wheelchair rugby athletes with tetraplegia. Spinal Cord 2017;55:957–62 PubMed .
Salmon, D. M., Mcgowan, J., Sullivan, S. J., Murphy, I., Walters, S., Whatman, C., ... & Romanchuk, J. (2020). What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players. Journal of sports sciences, 1-10.
The World Health Organisation 2020 guidelines on physical activity and sedentary behavior outlines the evidence-based recommendations on physical activity and its health benefits. For older people aged 65 years and older, recommendations include regular physical activity, at least 150 minutes of moderate-intensity aerobic physical activity weekly, muscle-strengthening activities two or more days a week, and multi-component physical activity focusing on functional balance and strength training three or more days a week. These physical activity recommendations are associated with improved physical function as well as reduced risks of falls, fall-related injuries, frailty and osteoporosis. [1]
Specific findings relevant for policy makers are detailed in two systematic reviews supporting these guidelines. A review regarding falls prevention showed that balance and functional exercises of at least three hours per week reduced rate of falls by 42% regardless of age, risk of falls, individual versus group exercise, or whether intervention was delivered by a health professional. [2] Another review regarding osteoporosis showed that higher doses of physical activity, particularly those involving multiple exercise types or resistance exercises improved bone mineral density, particularly in the lumbar spine. [3] These findings imply that different types of physical activities should be performed by older people, at as high a dose as possible, without a need for reliance on hea...
The World Health Organisation 2020 guidelines on physical activity and sedentary behavior outlines the evidence-based recommendations on physical activity and its health benefits. For older people aged 65 years and older, recommendations include regular physical activity, at least 150 minutes of moderate-intensity aerobic physical activity weekly, muscle-strengthening activities two or more days a week, and multi-component physical activity focusing on functional balance and strength training three or more days a week. These physical activity recommendations are associated with improved physical function as well as reduced risks of falls, fall-related injuries, frailty and osteoporosis. [1]
Specific findings relevant for policy makers are detailed in two systematic reviews supporting these guidelines. A review regarding falls prevention showed that balance and functional exercises of at least three hours per week reduced rate of falls by 42% regardless of age, risk of falls, individual versus group exercise, or whether intervention was delivered by a health professional. [2] Another review regarding osteoporosis showed that higher doses of physical activity, particularly those involving multiple exercise types or resistance exercises improved bone mineral density, particularly in the lumbar spine. [3] These findings imply that different types of physical activities should be performed by older people, at as high a dose as possible, without a need for reliance on healthcare professionals for service provision.
So how should these WHO guidelines be applied in practice for older people? Firstly, public awareness campaigns are required to promote the benefits of physical activity and outline what local programmes are available for participation. Planning for these programmes should account for disparities in engaging older people, such as transport and venue accessibility. Opportunities for incidental physical activity requires a supportive environment, such as parks and car-free areas. Exercise groups and family participation may provide social support and encouragement to help maintain these lifestyle changes.
Health care professionals should also be educated regarding these guidelines and how to implement physical activity interventions. This includes knowledge regarding prescribing exercise, available facilities and exercise programmes, and how to tailor recommendations to each older person. All clinical encounters are opportunities to encourage physical activity, particularly for patients at risk of falls, frailty or osteoporosis.
For older people with comorbidities, clinicians should optimise treatment of medical conditions and encourage physical activity as tolerated. Healthcare professionals may be apprehensive to recommend physical activity for people with comorbidities. However, physical activity should be viewed as an important adjunct to pharmacological treatment. For complex patients, input from a geriatrician and multidisciplinary team involvement may be required. Clinicians may also consider referrals for specialised programmes, such as cardiac and pulmonary rehabilitation, which have been shown to be safe, beneficial and improves quality of life. [4] For patients not keen to participate in exercise programmes, unsupervised home-based interventions were also effective in physical activity outcomes when accompanied by follow-up prompts, general encouragement, setting specific goals and self-monitoring.
Overall, much work remains to be done after the availability of these physical activity guidelines. Policy and health systems must work together to implement and put these recommendations into practice so that societies can reap its benefits.
References:
1. Bull FC, Saad Al-Ansari S, Biddle S, et al. World Health organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 2020. doi: 10.1136/bjsports-2020-102955
2. Sherrington C, Fairhall N, Kwok W, et al. Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act 2020;17:144. doi: 10.1186/s12966-020-01041-3
3. Pinheiro MB, Oliveira J, Bauman A, et al. Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act 2020;17:150. doi: 10.1186/s12966-020-01040-4
4. Liew JM, Teo SP. Physical activity in older people with cardiac co-morbidities. J Geriatr Cardiol 2018;15:554-555. doi:10.11909/j.issn.1671-5411.2018.08.004
“When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: five reasons that could explain declining rates of common arthroscopic surgeries.” Ardern CL, Paatela T, Mattila V, et al. Br J Sports Med 2020;54:1311-1313.
We have read your editorial with curiosity. Meniscal preservation is a major challenge for modern orthopaedics (1, 2). And when middle-aged patients have knee pain from degenerative meniscus lesions or incipient osteoarthritis, their first treatment should be non-surgical. We are all agreed about that. It was a clear conclusion from ESSKA’s (European Society of Sports Traumatology, Knee Surgery and Arthroscopy) recent consensus project based on strict and transparent methodology (3).
Unfortunately, your editorial overlooked our exhaustive analysis and was, at times, more assertive than empirical. It seemed to assume that orthopaedic surgeons and their societies will oppose non-operative treatments, simply because they are surgeons. This animus is unhelpful: it stigmatises our community; it creates mistrust amongst our patients, and it risks more and disruptive regulations. And we have already been here, with combative publications (4,5) inviting combative replies (6,7). It was to avoid these immature polemics that ESSKA intervened.
We would note that ESSKA’s investigation — and the subsequent Consensus Statement —involved 21 countries (3) and has been disseminated, in their mother tongue...
“When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: five reasons that could explain declining rates of common arthroscopic surgeries.” Ardern CL, Paatela T, Mattila V, et al. Br J Sports Med 2020;54:1311-1313.
We have read your editorial with curiosity. Meniscal preservation is a major challenge for modern orthopaedics (1, 2). And when middle-aged patients have knee pain from degenerative meniscus lesions or incipient osteoarthritis, their first treatment should be non-surgical. We are all agreed about that. It was a clear conclusion from ESSKA’s (European Society of Sports Traumatology, Knee Surgery and Arthroscopy) recent consensus project based on strict and transparent methodology (3).
Unfortunately, your editorial overlooked our exhaustive analysis and was, at times, more assertive than empirical. It seemed to assume that orthopaedic surgeons and their societies will oppose non-operative treatments, simply because they are surgeons. This animus is unhelpful: it stigmatises our community; it creates mistrust amongst our patients, and it risks more and disruptive regulations. And we have already been here, with combative publications (4,5) inviting combative replies (6,7). It was to avoid these immature polemics that ESSKA intervened.
We would note that ESSKA’s investigation — and the subsequent Consensus Statement —involved 21 countries (3) and has been disseminated, in their mother tongues, to orthopaedic surgeons across Europe (English, Italian, French, Spanish, German, and more). It began with recommendations of the French orthopaedic community (8) and was followed by new UK guidelines (9). As a result, there have been changes to British regulations (which proves just how useful a scientific society can be, as a driver of efficient clinical best-practice). By contrast, your editorial was limited to a few countries, and a small number of references.
It is clear that Arthroscopic Partial Meniscectomies (APM) have been declining, and in many countries (10,11), but not as fast as we might have expected. And we can usefully ask why this is — why there is an apparent lag between the scientific data and the everyday-practice (that is, between what actually does happen, and what we think should be happening)?
The answer is that we all work within a Scientific Paradigm. We are scientists, but also practical men/women. We are trained in a paradigm, because it seems to offer the best and most efficient way. And we continue within that paradigm, until the results prove it wrong (or less efficient). So, although we broadly agree with the various pressure groups developed in your editorial, such as surgeons, patients, and regulatory systems — we fundamentally disagree with your proposed solution. Our reasons are as follows:
- The acceptability of RCTs may be questioned. Any RCT has weaknesses and limitations which should be recognised, particularly in the field of functional surgery (12). Selection bias is one of the main arguments. Patients in a study involving sham-surgery cannot possibly claim to represent the general populations of other countries. This raises the question of the external validity of this type of study. This problem goes far beyond our discipline, and affects all medical specialties, urging some authors to a return to so-called “real-life” studies (13). Our ESSKA Meniscus Consensus was a valuable contribution, in this regard, because it allowed for the real diversity of cultures and approaches but managed to find a common path.
- As we have already said, surgeons work within a paradigm, unless or until that paradigm is proven incompetent (at which point they will adapt and change). And, as surgeons, they are trained to consider surgery first (14). This cannot be otherwise, and therefore every surgical study should be scrutinized for confirmation bias or prejudice (15, 16). Anathemas do not help, but educational programmes do, if they are properly supported. This is where universities and scientific societies are important, because they can reform an inefficient paradigm.
- Patient expectations are also important because they also reflect a paradigm, and one which may be out-of-date. What patients demand from their surgeons differs from country to country. In many countries, patients with months of pain may despair of non-operative treatment, and urge a surgeon for something more active. This is a mistake on their part, of course, but it is one which RCTs ignore. Here again, consensus and “real life” studies are valuable, because they alone can correct such mistakes.
- Then there is the diversity amongst healthcare systems which makes any global approach very difficult. The type of healthcare-professionals, their availability, and their pay, these all vary from country to country. Coercion may not be the best way to limit the number of APMs. We would prefer consultation, on the basis of proper and agreed data.
- Finally, it all takes time. The history of Meniscus Repair (17,18), shows that it takes many years to develop medical and surgical practice. And there is a good reason for this. Paradigms are not fashions, that come and go with the seasons. They are much more important. So we need to get them right.
In conclusion: meniscus preservation is a major issue. For Degenerative Meniscus Lesions, the first-line treatment must be non-operative. But this does not exclude APM for selected cases, in accord with international recommendations. The surgical community is not opposed to reducing APM in this context. It is only through education and consultation, and accepting the cultural differences between countries, that such a common goal can be achieved.
Needless confrontation, does not help.
References
1.Pujol N, Beaufils P. Save the meniscus again! Knee Surg Sports Traumatol Arhrosc. 2019;27(2):341-342.
2.Seil R, Becker R. Time for a paradigm change in meniscal repair: save the meniscus! Knee Surg Sports Traumatol Arthrosc. 2016;24(5):1421-3.
3.Beaufils P, Becker R, Kopf S, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):335-346.
4.Lohmander LS, Thorlund JB, Roos EM. Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients--time to abandon ship. Acta Orthop. 2016 ;87(1):2-4.
5.Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015 16;350:h2747
6.Lubowitz JH, et al. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy. 2014. 30(6):654-5
7.Bollen SR Is arthroscopy of the knee completely useless? Meta-analysis--a reviewer's nightmare. Bone Joint J. 2015 Dec;97-B(12):1591-2.
8.Beaufils P, Hulet C, Dhénain M,et al. Clinical practice guidelines for the management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults. Orthop Traumatol Surg Res. 2009 ;95(6):437-42
9.Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. Br J SportsMed 2018;52:313.
10.Jacquet C, Pujol N, Pauly V, et al. Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017.Orthop Traumatol Surg Res. 2019;105(4):677-682
11.Benjamin R Parker 1, Shepard Hurwitz 2, Jeffrey Spang 3, et al. Surgical Trends in the Treatment of Meniscal Tears: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database. Am J Sp Med. 2016;44(7):1717-23.
12.Reeves M. EPI-546 : Fundamentals of Epidemiology and Biostatistics. Course Notes – Lecture 7 The RCT.https://learn.chm.msu.edu/epi/Coursepack/EPI546_Lecture_7_course_notes.pdf
13.Saturni S, Bellini F, Braido F, et al. Randomized Controlled Trials and real life studies. Approaches and methodologies: a clinical point of view. Pulm Pharmacol Ther. 2014;27(2):129-38.
14.Becker R, Kopf S, Seil R, et al. From meniscal resection to meniscal repair: a journey of the last decade. Knee Surg Sports Traumatol Arthrosc. 2020;28(11):3401-3404.
15.Elston DM. Confirmation bias in medical decision-making. J Am Acad Dermatol. 2020;82(3):572
16.Reider B Editorial : To Cut … or Not? Am J Sports Med 2015;43(10):2365-7.
17.Beaufils P, Becker R, Verdonk R, et al. Focusing on results after meniscus surgery. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):3-7.
18.Seil R, Karlsson J, Beaufils P, et al. The difficult balance between scientific evidence and clinical practice: the 2016 ESSKA meniscus consensus on the surgical management of degenerative meniscus lesions. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):333-334
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,
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 MoreDear Editor and authors,
Show MoreAs we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-CO...
We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.
However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).
1. Does the study truly compare PTLE with EET?
In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
What matters most here? The program or the pain?
2. How do the authors justify the ≥ 5 VAS in the EET group?
Show MoreInstructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee funct...
Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent [1]. However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists [1]. At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und...
Show MoreThe authors of the editorial „Physical activity self-reports: past or future?” take a well thought through approach to this important area. We agree that “self-reports will continue to fill important roles now and in the future”, 1(Pg.1) that a combination of PA assessment methodologies is the most informative approach, and that there is no one-size-fits-all approach to PA self-report. We wish to go a step further and not only argue that self-report very much is part of the PA measurement future but to improve the field of PA-self-report.
The trend towards a more thorough confinement of PA behavior became obvious in the recently published WHO guidelines,2 which are no longer based only self-reported, but also from device-based measures of PA. The new guidelines now require new approaches to determine guideline adherence (i.e. the guidelines changed from 60 minutes of moderate-to vigorous (MV)PA every day to an average of 60 minutes of MVPA per day in children and adolescents) as well as updating survey questions and sampling methods for future monitoring.2 However, changing the question wording is unlikely to address the need for PA monitoring among children who, especially at young ages, are unable to answer a potentially complex question about average behavior over the past few days, weeks, or months. The alternative of asking daily PA for an entire week may be more accurate but increases survey response frequency and time. Assessing adherence to the new WHO guid...
Show MoreIn their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
Show MoreIn the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their st...
Considerable attention has focused on the risks of contact sports like rugby union (1), yet the benefits, rewards and opportunities have received less robust analysis. It is for that reason, Griffin et al.’s recent scoping review is a welcome preliminary contribution to our understanding of risk in rugby. There are, however, some concerns that deserve discussion to ensure that cursory readers are not unintentionally misguided by inaccurate claims.
Claims on mental health and wellbeing
In their paper, Griffin and colleagues examine the evidence for three contexts of rugby; Contact, non-contact and wheelchair. For mental health, Griffin et al. have stated:
There is a generally positive relationship between most (emphasis added) forms of rugby union and both (emphasis added) mental health and wellbeing, especially in wheelchair rugby, though further research is required outside of the wheelchair rugby setting.
They also assert, "Despite relatively fewer studies, the relationship between rugby union and both mental health and well-being is generally positive, especially in non-professional settings" (emphasis added).
The data
For the contact rugby context, Griffin et al. cite three studies (3, 4, 5). Each of which evidences elevated levels of common mental health disorders for contact rugby participants in the elite game. No evidence is presented for sevens at any level, the adult amateur community game or youth contact game....
Show MoreThe World Health Organisation 2020 guidelines on physical activity and sedentary behavior outlines the evidence-based recommendations on physical activity and its health benefits. For older people aged 65 years and older, recommendations include regular physical activity, at least 150 minutes of moderate-intensity aerobic physical activity weekly, muscle-strengthening activities two or more days a week, and multi-component physical activity focusing on functional balance and strength training three or more days a week. These physical activity recommendations are associated with improved physical function as well as reduced risks of falls, fall-related injuries, frailty and osteoporosis. [1]
Specific findings relevant for policy makers are detailed in two systematic reviews supporting these guidelines. A review regarding falls prevention showed that balance and functional exercises of at least three hours per week reduced rate of falls by 42% regardless of age, risk of falls, individual versus group exercise, or whether intervention was delivered by a health professional. [2] Another review regarding osteoporosis showed that higher doses of physical activity, particularly those involving multiple exercise types or resistance exercises improved bone mineral density, particularly in the lumbar spine. [3] These findings imply that different types of physical activities should be performed by older people, at as high a dose as possible, without a need for reliance on hea...
Show More“When taking a step back is a veritable leap forward. Reversing decades of arthroscopy for managing joint pain: five reasons that could explain declining rates of common arthroscopic surgeries.” Ardern CL, Paatela T, Mattila V, et al. Br J Sports Med 2020;54:1311-1313.
We have read your editorial with curiosity. Meniscal preservation is a major challenge for modern orthopaedics (1, 2). And when middle-aged patients have knee pain from degenerative meniscus lesions or incipient osteoarthritis, their first treatment should be non-surgical. We are all agreed about that. It was a clear conclusion from ESSKA’s (European Society of Sports Traumatology, Knee Surgery and Arthroscopy) recent consensus project based on strict and transparent methodology (3).
Unfortunately, your editorial overlooked our exhaustive analysis and was, at times, more assertive than empirical. It seemed to assume that orthopaedic surgeons and their societies will oppose non-operative treatments, simply because they are surgeons. This animus is unhelpful: it stigmatises our community; it creates mistrust amongst our patients, and it risks more and disruptive regulations. And we have already been here, with combative publications (4,5) inviting combative replies (6,7). It was to avoid these immature polemics that ESSKA intervened.
We would note that ESSKA’s investigation — and the subsequent Consensus Statement —involved 21 countries (3) and has been disseminated, in their mother tongue...
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