I read with interest your PFD -SENTINEL paper and thank you for putting together this consensus process.
As practising sport medicine physicians, we have an interest in lower urinary tract symptoms (LUTs), including incontinence, within our athletic population, both males and females. LUTs, as part of pelvic floor dysfunction, are reportedly common in the general population (2) and vary with the age of the population surveyed – with one recent survey estimating a prevalence of over 70% in those over the age of 70 years olds (3). LUTs is a group of various symptoms related to urination and can include leaking urine, sudden and frequent urges to pass urine, having a weak urine stream or a feeling that you have not completely emptied your bladder. LUTS, and particularly Urinary Incontinence (UI), are considered to be a female health problem that is inevitable and the result of life and health events such as pregnancy, childbirth, and menopause (Casey, E. & Temme, K. 2017). The issue of LUTs is less well understood in male athletes although it has been reported to be present in approximately 15% of athletes surveyed in one study (1). The acceptance of these symptoms, particularly within female athletes, often leads to under reporting or poor engagement with health care practitioners to assess and manage the condition (Anderson & Anderson 2011, Almousa & Bandin Van Loon, 2019, Rodríguez-López, E.S., et al. 2020). The impact of LUT...
I read with interest your PFD -SENTINEL paper and thank you for putting together this consensus process.
As practising sport medicine physicians, we have an interest in lower urinary tract symptoms (LUTs), including incontinence, within our athletic population, both males and females. LUTs, as part of pelvic floor dysfunction, are reportedly common in the general population (2) and vary with the age of the population surveyed – with one recent survey estimating a prevalence of over 70% in those over the age of 70 years olds (3). LUTs is a group of various symptoms related to urination and can include leaking urine, sudden and frequent urges to pass urine, having a weak urine stream or a feeling that you have not completely emptied your bladder. LUTS, and particularly Urinary Incontinence (UI), are considered to be a female health problem that is inevitable and the result of life and health events such as pregnancy, childbirth, and menopause (Casey, E. & Temme, K. 2017). The issue of LUTs is less well understood in male athletes although it has been reported to be present in approximately 15% of athletes surveyed in one study (1). The acceptance of these symptoms, particularly within female athletes, often leads to under reporting or poor engagement with health care practitioners to assess and manage the condition (Anderson & Anderson 2011, Almousa & Bandin Van Loon, 2019, Rodríguez-López, E.S., et al. 2020). The impact of LUTs on quality of life, physical and mental health has been acknowledged in recent years (Almousa & Bandin Van Loon, 2019, Rodríguez-López, E.S., et al. 2020, Whitney et al, 2021) and has brought about a drive to understand the risks and drivers behind its onset as well as optimal diagnosis and management interventions (Bo, K. 2004, Casey, E. & Temme, K. 2017, Bo et al., 2017). National Institute of Clinical Excellence (NICE) Guidance has recommended that the assessment and diagnosis of UI occurs through use of good history taking, clinical examination and the inclusion of validated patient reported outcome measures (PROMS) (NICE, 2019). The International Consultation on Incontinence Questionnaires (ICIQ) was developed to provide a PROM with high quality standardised assessment of urinary, bowel and vaginal symptoms (Uren, A., et al . 2020) which have been utilised in clinical practice for the last 22 years. The ICIQ FLUTS is a modular questionnaire that was developed and validated in a controlled matched study with a female population attending for urodynamic assessment due to UI (Jackson, S., et al. 2006, Uren, A., et al. 2020). It enables assessment of lower urinary tract symptoms and their impact on quality of life. It consists of 12 items taking around 4-5minutes to complete and has had validity, reliability and responsiveness established (Brooks, S.et al. 2004, Jackson, S., et al. 2006, Uren, A., et al. 2020). The ICIQ-FLUTs has been adapted for use in the athletic population (AFLUTs) and my question is therefore whether you considered using the ICIQ-FLUTs questionnaire in your study and/or including it within your pelvic floor dysfunction questionnaire?
Thanks for your time and happy to discuss further.
Kind regards,
Neil
References
(1) Rodríguez-López ES, Calvo-Moreno SO, Basas-García Á, Gutierrez-Ortega F, Guodemar-Pérez J, Acevedo-Gómez MB. Prevalence of urinary incontinence among elite athletes of both sexes. J Sci Med Sport. 2021 Apr;24(4):338-344. doi: 10.1016/j.jsams.2020.09.017. Epub 2020 Oct 1. PMID: 33041208.
(2) https://my.clevelandclinic.org/health/symptoms/24248-lower-urinary-tract...(LUTS)%20include%20vari
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ous%20symptoms%20involving%20urination,can%27t%20empty%20your%20bladder. Accessed on 17/05/2023 at 14.45
(3) Przydacz M, Gasowski J, Grodzicki T, Chlosta P. Lower Urinary Tract Symptoms and Overactive Bladder in a Large Cohort of Older Poles-A Representative Tele-Survey. J Clin Med. 2023 Apr 13;12(8):2859. doi: 10.3390/jcm12082859. PMID: 37109196; PMCID: PMC10142045.
(4) https://cks.nice.org.uk/topics/luts-in-men/diagnosis/assessment/ accessed on 18/05/23 at 11.30
(5) Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett AT. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992 Nov;148(5):1549-57; discussion 1564. doi: 10.1016/s0022-5347(17)36966-5. PMID: 1279218.
(6)
Sania Almousa & Alda Bandin Van Loon (2019) The prevalence of urinary incontinence in nulliparous female sportswomen: A systematic review, Journal of Sports Sciences, 37:14, 1663-1672, DOI: 10.1080/02640414.2019.1585312
J.C. Andersen, PhD, ATC, PT, SCS; and Beth Andersen, MS, PT, ATC Screening for Urinary Incontinence in Female Athletes Athletic Training & Sports Health Care | Vol. 3 No. 5 2011
Bahr R, Clarsen B, Derman W, Dvorak J, Emery CA, Finch CF, Hägglund M, Junge A, Kemp S, Khan KM, Marshall SW, Meeuwisse W, Mountjoy M, Orchard JW, Pluim B, Quarrie KL, Reider B, Schwellnus M, Soligard T, Stokes KA, Timpka T, Verhagen E, Bindra A, Budgett R, Engebretsen L, Erdener U, Chamari K. 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. 2020 Apr;54(7):372-389. doi: 10.1136/bjsports-2019-101969. Epub 2020 Feb 18. PMID: 32071062; PMCID: PMC7146946.
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Bernard, Stéphanie PT, MSc1,2; Pellichero, Alice MSc, OT1,2; McLean, Linda PT, PhD3; Moffet, Hélène PT, PhD1,2 Responsiveness of Health-Related Quality of Life Patient-Reported Outcome Measures in Women Receiving Conservative Treatment for Urinary Incontinence: A Systematic Review, Journal of Women's Health Physical Therapy: April/June 2021 - Volume 45 - Issue 2 - p 57-67
doi: 10.1097/JWH.0000000000000196
Bø K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Med. 2004;34(7):451-64. doi: 10.2165/00007256-200434070-00004. PMID: 15233598.
Bo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, Bortolini M, Dumoulin C, Gomes M, McClurg D, Meijlink J, Shelly E, Trabuco E, Walker C, Wells A. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Int Urogynecol J. 2017 Feb;28(2):191-213. doi: 10.1007/s00192-016-3123-4. Epub 2016 Dec 5. PMID: 27921161.
Brookes, S., Donovan, J., Wright, M., Jackson, S., Abrams, P. A scored form of the Bristol Lower Urinary Tract Symptoms questionnaire: data from a randomized controlled trial of surgery for women with stress incontinence. Am.J.Obstet.Gynecol. 2004; 191(1): 73-82
Carvalhais A, Natal Jorge R, Bø K. Performing high-level sport is strongly asso- ciated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls. Br J Sports Med 2018; 52(24):1586–1590. http://dx.doi.org/10.1136/bjsports-2017-097587.
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Casey EK, Temme K. Pelvic floor muscle function and urinary incontinence in the female athlete. Phys Sportsmed. 2017 Nov;45(4):399-407. doi: 10.1080/00913847.2017.1372677. Epub 2017 Sep 5. PMID: 28845723.
Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport. 2006 May;9(1-2):3-9; discussion 10. doi: 10.1016/j.jsams.2006.02.009. Epub 2006 Apr 17. PMID: 16616614.
Harris, P., R Taylor, R Thielke, J Payne, N Gonzalez, JG. Conde, Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform. 2009 Apr;42(2):377-81.
Harris, P, R Taylor, BL Minor, V Elliott, M Fernandez, L O’Neal, L McLeod, G Delacqua, F Delacqua, J Kirby, SN Duda, REDCap Consortium, The REDCap consortium: Building an international community of software partners, J Biomed Inform. 2019 May 9 [doi: 10.1016/j.jbi.2019.103208]
Jackson, S., Donovan, J., Brookes, S., Eckford, S., Swithinbank, L., and Abrams, P. (1996). The Bristol female lower urinary tract symptoms questionnaire: development and psychometric testing. British Journal of Urology 77, 805–812.
Ljungqvist A, Jenoure PJ, Engebretsen L, Alonso JM, Bahr R, Clough AF, de Bondt G, Dvorak J, Maloley R, Matheson G, Meeuwisse W, Meijboom EJ, Mountjoy M, Pelliccia A, Schwellnus M, Sprumont D, Schamasch P, Gauthier JB, Dubi C. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009. Clin J Sport Med. 2009 Sep;19(5):347-65. doi: 10.1097/JSM.0b013e3181b7332c. PMID: 19741306.
Orchard JW, Meeuwisse W, Derman W, et al. Sport Medicine Diagnostic Coding System (SMDSC) and the Orchard Sports Injury and Illness Classification System (OSIICS): revised 2020 consensus versions [published online ahead of print, 2020 Feb 29]. Br J Sports Med. 2020;bjsports-2019-101921. doi:10.1136/bjsports-2019-101921
OSIICS version 13.5 was released on 8 July 2021 on this website and includes new codes for Female athlete, psychology and cardiology diagnoses in particular.
Accessed on 25/11/2021 https://www.johnorchard.com/about-osiics.html
Rebullido TR, Stracciolini A. Pelvic Floor Dysfunction in Female Athletes: Is Relative Energy Deficiency in Sport a Risk Factor? Curr Sports Med Rep. 2019 Jul;18(7):255-257. doi: 10.1249/JSR.0000000000000615. PMID: 31283625.
Rodríguez-López ES, Calvo-Moreno SO, Basas-García Á, Gutierrez-Ortega F, Guodemar-Pérez J, Acevedo-Gómez MB. Prevalence of urinary incontinence among elite athletes of both sexes. J Sci Med Sport. 2021 Apr;24(4):338-344. doi: 10.1016/j.jsams.2020.09.017. Epub 2020 Oct 1. PMID: 33041208.
Well done on putting together this paper. Massive undertaking to complete a systematic review of 950 included studies.
I have researched the area of exercise and cardiac rehabilitation for TIA and minor stroke patients. I was therefore keen to know if you included these papers in your review as it wasn’t clear from the supplemental papers I reviewed? For example,
Heron N, Kee F, Mant J, Reilly PM, Cupples M, Tully M, Donnelly M. Stroke Prevention Rehabilitation Intervention Trial of Exercise (SPRITE) - a randomised feasibility study. BMC Cardiovasc Disord. 2017 Dec 12;17(1):290. doi: 10.1186/s12872-017-0717-9. PMID: 29233087; PMCID: PMC5727948.
Heron N, Kee F, Mant J, Cupples ME, Donnelly M. Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme. Br J Gen Pract. 2019 Sep 26;69(687):e706-e714. doi: 10.3399/bjgp19X705509. PMID: 31501165; PMCID: PMC6733604.
Heron N. Cardiac rehabilitation for the transient ischaemic attack (TIA) and stroke population? Using the Medical Research Council (MRC) guidelines for developing complex health service interventions to develop home-based cardiac rehabilitation for TIA and 'minor' stroke patients. Br J Sports Med. 2019 Jul;53(13):839-840. doi: 10.1136/bjsports-2018-099593. Epub 2018 Sep 4. PMID: 30181325; PMCID: PMC6585273.
These papers show the benefit of physical activity and ex...
Well done on putting together this paper. Massive undertaking to complete a systematic review of 950 included studies.
I have researched the area of exercise and cardiac rehabilitation for TIA and minor stroke patients. I was therefore keen to know if you included these papers in your review as it wasn’t clear from the supplemental papers I reviewed? For example,
Heron N, Kee F, Mant J, Reilly PM, Cupples M, Tully M, Donnelly M. Stroke Prevention Rehabilitation Intervention Trial of Exercise (SPRITE) - a randomised feasibility study. BMC Cardiovasc Disord. 2017 Dec 12;17(1):290. doi: 10.1186/s12872-017-0717-9. PMID: 29233087; PMCID: PMC5727948.
Heron N, Kee F, Mant J, Cupples ME, Donnelly M. Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme. Br J Gen Pract. 2019 Sep 26;69(687):e706-e714. doi: 10.3399/bjgp19X705509. PMID: 31501165; PMCID: PMC6733604.
Heron N. Cardiac rehabilitation for the transient ischaemic attack (TIA) and stroke population? Using the Medical Research Council (MRC) guidelines for developing complex health service interventions to develop home-based cardiac rehabilitation for TIA and 'minor' stroke patients. Br J Sports Med. 2019 Jul;53(13):839-840. doi: 10.1136/bjsports-2018-099593. Epub 2018 Sep 4. PMID: 30181325; PMCID: PMC6585273.
These papers show the benefit of physical activity and exercise for this group of cardiovascular patients (included within a cardiac rehabilitation model) and would add real benefit to your outcomes and findings.
Thank you for your interest in the Sports Concussion Office Assessment Tools, the SCOAT6 and Child SCOAT6. These tools were developed to guide clinicians internationally, using evidence-based components.1 The evidence shows that concussion in children, adolescents and adults affects multiple clinical domains, and the office assessment must address the clinically relevant domains, which will be different in each concussed individual. Using the symptom scales, and interview with the patient, the clinician can identify which clinical domains are endorsed. This guides the clinician towards the appropriate components of the Child SCOAT6 / SCOAT6. Incorporated into the tools are Green “recommended” sections and Orange “optional” sections, to assist the time-challenged clinician in focusing on the most relevant modalities.2,3
Developing the Office tools was a balancing act that primarily considered producing a thorough, multimodal assessment tool but one that was also easy to use and not too lengthy. For instance, we could not ignore research supporting the value of the VOMS but opted for the recently validated modified VOMS which is a validated briefer version.4,5
The scientifically derived clinical reality is that the office assessment of concussed athletes requires a multimodal assessment. Trying to perform a proper multimodal assessment in a 10-minute time period is neither appropriate nor realistic. The concu...
Thank you for your interest in the Sports Concussion Office Assessment Tools, the SCOAT6 and Child SCOAT6. These tools were developed to guide clinicians internationally, using evidence-based components.1 The evidence shows that concussion in children, adolescents and adults affects multiple clinical domains, and the office assessment must address the clinically relevant domains, which will be different in each concussed individual. Using the symptom scales, and interview with the patient, the clinician can identify which clinical domains are endorsed. This guides the clinician towards the appropriate components of the Child SCOAT6 / SCOAT6. Incorporated into the tools are Green “recommended” sections and Orange “optional” sections, to assist the time-challenged clinician in focusing on the most relevant modalities.2,3
Developing the Office tools was a balancing act that primarily considered producing a thorough, multimodal assessment tool but one that was also easy to use and not too lengthy. For instance, we could not ignore research supporting the value of the VOMS but opted for the recently validated modified VOMS which is a validated briefer version.4,5
The scientifically derived clinical reality is that the office assessment of concussed athletes requires a multimodal assessment. Trying to perform a proper multimodal assessment in a 10-minute time period is neither appropriate nor realistic. The concussion diagnostic screen, the SCAT6/Child SCAT6, used within the first 72 hours post-concussion and up to a week, is designed to take 10-15 minutes to implement. The more comprehensive SCOAT6/Child SCOAT6 requires longer appointments with a single clinician, or alternatively, the assessment may be performed by multiple HCPs over several sessions, such as the physiotherapist performing the balance and VOMS assessment. We maintain that a multisystem evaluation remains the most appropriate in the setting of SRC but appreciate real-life clinical scenarios. The tools were developed as the gold standard. It would be more reasonable for health administrations to provide resources to enable practitioners sufficient time to complete the assessment with the tool, rather than compromise the tool to accommodate under-resourced GP practices in some countries. We acknowledge restraints on time, resources and expertise across a range of HCPs and referred to this in the Systematic Review and accompanying editorials introducing the tools.6,7
We are currently endeavouring to develop an electronic version of the SCOAT6 tools which should assist the HCP conducting the assessment and simplify recording of the results.
Finally, as with the SCAT6, the SCOAT6 and Child SCOAT6 contain individually validated elements, but require validation as a combined tool in different clinical and cultural settings and these findings are likely to help evolve the tool in future versions. These changes may include abbreviating any aspects that are found to be redundant.
1. Patricios JS, Schneider GM, van Ierssel J, et al. Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool 6 (SCOAT6) Br J Sports Med 2023;57:651-667.
2. Child SCOAT6 Br J Sports Med 2023;57:672-688
3. Sport Concussion Office Assessment Tool 6 (SCOAT6). Br J Sports Med 2023;57:651-667.
4. Ferris LM, Kontos AP, Eagle SR, et al. Predictive accuracy of the sport concussion assessment tool 3 and vestibular/ocular-motor screening, individually and in combination: a national collegiate athletic association-department of defence concussion assessment, research and education Consortium analysis. Am J Sports Med 2021;49:1040–8.
5. Ferris LM, Kontos AP, Eagle SR, et al. Optimizing VOMS for identifying acute concussion in collegiate athletes: findings from the NCAA-DoD care consortium. Vision Res 2022;200:108081.
6. Patricios JS, Davis GA, Ahmed OH, et al. Introducing the Sport Concussion Office Assessment Tool 6 (SCOAT6). Br J Sports Med 2023;57:648–650
7. Davis, GA, Patricios, JS, Purcell, L et al. (2023). Introducing the Child Sport Concussion Office Assessment Tool 6 (Child SCOAT6). Br J Sports Med 2023. 57. 668-671. 10.1136/bjsports-2023-106858.
Great work on putting together the SCOAT6 and this is a really helpful piece for the office sport medicine doctors. However, what about the community healthcare teams, eg General Practitioners, GPs, what tool should they be using? Particularly bearing in mind the time constraints of community health contacts, eg GP consults in the UK are most often limited to 10 minutes. What can we expect non-specialist sport medicine doctors to do to help make the concussion diagnosis and therefore initiate appropriate management promptly? Should we be making a SCATgp?
Great work on putting together the child SCOAT6 and this is a really helpful piece for the office sport medicine doctors. However, what about the community healthcare teams, eg General Practitioners, GPs, what tool should they be using? Particularly bearing in mind the time constraints of community health contacts, eg GP consults in the UK are most often limited to 10 minutes. What can we expect non-specialist sport medicine doctors to do to help make the concussion diagnosis and therefore initiate appropriate management promptly? Should we be making a childSCATgp?
More patients will be attending primary and community care facilities with concussion as the general knowledge around the diagnosis increases and with new policies and procedures identifying community resources to make the concussion diagnosis and management . Indeed, within the UK, there has recently been grassroots concussion protocols released and they advise that all concussions should be diagnosed by a healthcare practitioner. This will cause a number of patients, both children and adults. to present to community practitioners seeking a diagnosis and we therefore need a community tool to diagnose and manage concussions for the non-specialist healthcare practitioners. Time for a consensus meeting to discuss community, non-specialist concussion diagnosis and management?
Dear Editor,
We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.
The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.
The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.
Dear Editor,
We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.
The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.
The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.
It is worth noting the statement from the US Preventative Services Task Force:
"Decision makers do not have the luxury of waiting for certain evidence. Even though evidence is insufficient, the clinician must still provide advice, patients must make choices, and policy makers must establish policies".4
So, what was this recommendation based on?
The recommendations are primarily based on the critical outcomes, specifically for the cross-education: knee extensor strength and subjective knee function (supplementary file). The summary for these two outcomes was “There is conflicting evidence for an effect of cross-training on quadriceps strength at the early and intermediate phase. There is no effect at the advanced phase of rehabilitation [D]” and “Cross-training might have a positive effect in the early phase of rehabilitation for the subjective knee function, but no difference in the following phases [D]”.
Regarding the significance of eccentric quadriceps strength, the authors suggest that “robust cross-education effects occur after eccentric training when the effects are tested in the trained contraction type.” In the context of our guideline, out of the 17 different strength reports/results analysed (encompassing various timings, testing modes, testing speeds, etc.) only one study5 reported results on eccentric peak torque strength. The standardized mean difference (SMD) for this study was -0.08, which was not significantly different from the control group (supplementary files).
With this low level ([D]) of conflicting evidence, it is then the job of the guideline to recommend clinical practice. Why would we choose to recommend against this practice?
When our goal is to norrmalise strength, gait, and movement patterns, we find it counterproductive to place excessive emphasis on the healthy leg. This approach makes clinical progression more challenging, as the injured leg is constantly trying to catch up to the improving healthy leg, which sets a moving target.
While training both legs is crucial in postoperative rehabilitation after ACLR, incorporating exaggerated cross-education interventions might increase the time, effort, and training load required to complete the program as planned. Furthermore, these interventions may introduce additional barriers to adhering to the already lengthy rehabilitation process, without a guarantee of significant benefits.
The authors call for “for more high-quality randomised clinical trials investigating the efficacy of cross-education for ACLR rehabilitation before a meaningful evidenced-based recommendation can be made.” We agree regarding the call for more research, but we stand by our recommendation based on the existing data.
References
1. Kotsifaki R, Korakakis V, King E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med 2023;57(9):500-14.
2. Kotsifaki R, Korakakis V, King E, et al. Infographic. Aspetar clinical practice guideline on rehabilitation after ACL reconstruction: an interactive figure. Br J Sports Med 2023;57(9):551-52.
3. Schünemann Holger BJ, Guyatt Gordon, Oxman Andrew. GRADE Handbook 2013. Available from: https://gdt.gradepro.org/app/handbook/handbook.html
4. Petitti DB, Teutsch SM, Barton MB, et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med 2009;150(3):199-205.
5. Zult T, Gokeler A, van Raay J, et al. Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surg Sports Traumatol Arthrosc 2019;27(2):478-90.
We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].
Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the...
We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].
Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the current work, here we focus on two important themes related to cross-education and ACLR that we believe were not considered by Kotsifaki et al. [1] when making their recommendation.
Training specificity: Cross-education follows the principle of training specificity [18]: the largest effects occur in the contralateral homologous muscle [16,19–22]. Kotsifaki et al. [1] stated that cross-education has no effect on hamstrings strength, single-leg hop performance for distance, balance, or proprioception. Yet, all of the included studies, except Minshull et al. [9], prescribed a knee extensors-focused exercise protocol. We argue that recommendations should rely on the evaluation of specific outcome measures addressed directly by the cross-education intervention rather than non-specific outcomes.
Importance of eccentric quadriceps strength: In summarising the evidence, Kotsifaki et al. [1] prioritised concentric over isometric strength outcomes (with no mention of eccentric), even though four of the seven studies implemented an eccentric strength training protocol [3–5,8]. Not only is eccentric strength important for ACLR recovery [23], but corticospinal excitability is greater during eccentric contractions compared to forceful concentric contractions [24]. Further, robust cross-education effects occur after eccentric training [21,25–27] when the effects are tested in the trained contraction type [25,28]. Given these facets, the a priori criteria applied by Kotsifaki et al. [1] do not appropriately weigh the evidence with respect to how the interventions were designed.
Our recommendation
Many features of effective cross-education interventions [17] have not been adequately explored with respect to ACLR (e.g., motor skill). There was also considerable variability in how the cross-education training was implemented across studies with differences in exercise intensity, contraction type, muscle group, and training volume [3–9]. This leads us to conclude there is insufficient evidence for a consensus recommendation for the exclusion of cross-education for post-ACLR rehabilitation. We suggest reconsidering the specific “Not Recommended” position regarding cross-education, and instead, contend that “No Recommendation” is more appropriate based on insufficient data. Despite the currently limited literature, cross-education paradigms present a promising and low-risk approach to enhance systems-level rehabilitation. Cross-education has successfully preserved or enhanced the neuromuscular system in many experimental paradigms and during complex rehabilitation. Therefore, we put out a call for action for more high-quality randomised clinical trials investigating the efficacy of cross-education for ACLR rehabilitation before a meaningful evidenced-based recommendation can be made.
References
1 Kotsifaki R, Korakakis V, King E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med 2023;57:500–14. doi:10.1136/BJSPORTS-2022-106158
2 Kotsifaki R, Korakakis V, King E, et al. Infographic. Aspetar clinical practice guideline on rehabilitation after ACL reconstruction: an interactive figure. Br J Sports Med 2023;57:551–2. doi:10.1136/BJSPORTS-2022-106679
3 Papandreou MG, Papaioannou N, Antonogiannakis E, et al. The effect of cross exercise on quadriceps strength in different knee angles after the anterior cruciate ligament reconstruction. Brazilian J Biomotricity 2007;1:123–38.
4 Papandreou M, Billis E, Papathanasiou G, et al. Cross-exercise on quadriceps deficit after ACL reconstruction. J Knee Surg 2013;26:051–8. doi:10.1055/s-0032-1313744
5 Papandreou MG, Billis E V., Antonogiannakis EM, et al. Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. J Orthop Surg Res 2009;4:1–9. doi:10.1186/1749-799X-4-2/FIGURES/2
6 Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: a randomized controlled clinical trial. Eur J Appl Physiol 2018;118:1609–23. doi:10.1007/S00421-018-3892-1/TABLES/6
7 Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surgery, Sport Traumatol Arthrosc 2019;27:478–90. doi:10.1007/S00167-018-5116-Y/TABLES/5
8 Harput G, Ulusoy B, Yildiz TI, et al. Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Knee Surgery, Sport Traumatol Arthrosc 2019;27:68–75. doi:10.1007/S00167-018-5040-1/TABLES/4
9 Minshull C, Gallacher P, Roberts S, et al. Contralateral strength training attenuates muscle performance loss following anterior cruciate ligament (ACL) reconstruction: a randomised-controlled trial. Eur J Appl Physiol 2021;121:3551–9. doi:10.1007/S00421-021-04812-3/TABLES/3
10 Lepley LK, Palmieri-Smith RM. Quadriceps strength, muscle activation failure, and patient-reported function at the time of return to activity in patients following anterior cruciate ligament reconstruction: A cross-sectional study. J Orthop Sports Phys Ther 2015;45:1017–25. doi:10.2519/JOSPT.2015.5753
11 Andrushko JW, Gould LA, Farthing JP. Contralateral effects of unilateral training: sparing of muscle strength and size after immobilization. Appl Physiol Nutr Metab 2018;43:1131–9. doi:10.1139/apnm-2018-0073
12 Hendy AM, Spittle M, Kidgell DJ. Cross education and immobilisation: Mechanisms and implications for injury rehabilitation. J Sci Med Sport 2012;15:94–101. doi:10.1016/j.jsams.2011.07.007
13 Valdes O, Ramirez C, Perez F, et al. Contralateral effects of eccentric resistance training on immobilized arm. Scand J Med Sci Sports 2021;31:76–90. doi:10.1111/sms.13821
14 Cuyul-Vásquez I, Álvarez E, Riquelme A, et al. Effectiveness of unilateral training of the uninjured limb on muscle strength and knee function of patients with anterior cruciate ligament reconstruction: A systematic review and meta-analysis of cross-education. J Sport Rehabil 2022;31:605–16. doi:10.1123/JSR.2021-0204
15 Lepley LK, Grooms DR, Burland JP, et al. Eccentric cross-exercise after anterior cruciate ligament reconstruction: Novel case series to enhance neuroplasticity. Phys Ther Sport 2018;34:55–65. doi:10.1016/J.PTSP.2018.08.010
16 Manca A, Hortobágyi T, Carroll TJ, et al. Contralateral effects of unilateral strength and skill training: Modified delphi consensus to establish key aspects of cross-education. Sport Med 2021;51:11–20. doi:10.1007/s40279-020-01377-7
17 Voskuil C, Andrushko JW, Huddleston B, et al. Exercise prescription and strategies to promote the cross-education of strength: a scoping review. Appl Physiol Nutr Metab Published Online First: 8 May 2023. doi:10.1139/APNM-2023-0041
18 Barnett ML, Ross D, Schmidt RA, et al. Motor skills learning and the specificity of training principle. Res Quarterly Am Assoc Heal Phys Educ Recreat 2013;44:440–7. doi:10.1080/10671188.1973.10615224
19 Andrushko JW, Lanovaz JL, Björkman KM, et al. Unilateral strength training leads to muscle-specific sparing effects during opposite homologous limb immobilization. J Appl Physiol 2018;124:866–76. doi:10.1152/japplphysiol.00971.2017
20 Green LA, Gabriel DA. The effect of unilateral training on contralateral limb strength in young, older, and patient populations: a meta-analysis of cross education. Phys Ther Rev 2018;23. doi:10.1080/10833196.2018.1499272
21 Manca A, Dragone D, Dvir Z, et al. Cross-education of muscular strength following unilateral resistance training: a meta-analysis. Eur J Appl Physiol 2017;117:2335–54. doi:10.1007/s00421-017-3720-z
22 Munn J, Herbert RD, Gandevia SC. Contralateral effects of unilateral resistance training: A meta-analysis. J Appl Physiol 2004;96:1861–6. doi:10.1152/JAPPLPHYSIOL.00541.2003/ASSET/IMAGES/LARGE/ZDG0050430490002.JPEG
23 Lepley LK, Wojtys EM, Palmieri-Smith RM. Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction. Knee 2015;22:270–7. doi:10.1016/j.knee.2014.11.013
24 Howatson G, Taylor MB, Rider P, et al. Ipsilateral motor cortical responses to TMS during lengthening and shortening of the contralateral wrist flexors. Eur J Neurosci 2011;33:978–90. doi:10.1111/j.1460-9568.2010.07567.x
25 Hortobágyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997;29:107–12. doi:10.1097/00005768-199701000-00015
26 Farthing JP, Chilibeck PD. The effect of eccentric training at different velocities on cross-education. Eur J Appl Physiol 2003;89:570–7. doi:10.1007/s00421-003-0841-3
27 Chen TC, Wu S-H, Chen H-L, et al. Effects of unilateral eccentric versus concentric training of non-immobilized arm during immobilization. Med Sci Sport Exerc Published Online First: 20 February 2023. doi:10.1249/MSS.0000000000003140
28 Lepley LK, Palmieri-Smith RM. Cross-education strength and activation after eccentric exercise. J Athl Train 2014;49:582–9. doi:10.4085/1062-6050-49.3.24
Pseudo-scientific detection of illusory entities did not end in 1907.
Attributing physical mass to the “soul,” a man-made theological construct,
exemplifies a fallacy Gould attributed to Mill:
The tendency has always been strong to believe that whatever received
a name must be an entity or being, having an independent existence of its
own. And if no real entity answering to the name could be...
Pseudo-scientific detection of illusory entities did not end in 1907.
Attributing physical mass to the “soul,” a man-made theological construct,
exemplifies a fallacy Gould attributed to Mill:
The tendency has always been strong to believe that whatever received
a name must be an entity or being, having an independent existence of its
own. And if no real entity answering to the name could be found, men did
not for that reason suppose that none existed, but imagined that it was
something peculiarly abstruse and mysterious.[1]
Gould cited the fallacy in noting that Benet, originator of IQ, intended
none of the social elitism to which it has given rise.[1] IQ exemplifies
a related fallacy:
The test-trait fallacy begins with the assumption that test scores
are trait measures. The second assumption is that trait measures are
basic properties of the person...This sequence...converts a dependent
variable into an independent variable; hence a measurement is reified into
a causal force...the unsound logic of drawing inferences about ability on
the basis of observed performance is integral to the test-trait
fallacy[2].
Medical test-scores masquerade as traits, e.g., “board-certified
internist,” “Fellow of the Royal College of Surgeons” and the like. Under
aegis of the American Board of Medical Specialties (purveyor-in-chief of
board-certification), Sharp et al comprehensively reviewed as much
evidence from as many medical and surgical specialties as they could find,
in an effort to introduce specialty-board certification to the age of
evidence-based medicine and correlate it with superiority of clinical
outcomes. They failed, yet concluded:
Despite the lack of unequivocal evidence documenting the value of
board certification, we do not advocate removing it as a measure of
expertise.[3]
They thus violated a fundamental scientific and ethical tenet by ignoring
evidence they had adduced. Even more Americans subscribe to the bunkum of
board-certification than to alien-abduction.
References
(1). Gould SJ. The Mismeasure of Man. Norton, NY, 1981
(2). Tryon WW. The test-trait fallacy. Am Psychologist. 1979
May;34(5):402-6
(3). Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty
board certification and clinical outcomes: the missing link. Acad Med.
2002 Jun;77(6):534-42. PMID: 12063199
I read your editorial 'The power of placebo' with some relief. It
would seem that all too often, 'advances' in practice and even research
are relegating the placebo effect to the status of quackery. Certainly, I
am not a great fan of many therapies or technologies that claim
scientifically dubious healing or performance-enhancing qualities (I am to
be honest even less of a fan of those who sell them...
I read your editorial 'The power of placebo' with some relief. It
would seem that all too often, 'advances' in practice and even research
are relegating the placebo effect to the status of quackery. Certainly, I
am not a great fan of many therapies or technologies that claim
scientifically dubious healing or performance-enhancing qualities (I am to
be honest even less of a fan of those who sell them). However, by
dismissing the power of such artefacts/interventions to bring about a wide
range of positive effects, we are also dismissing the power of the mind to
bring about these very same effects.
Certainly the placebo effect, based essentially on the twin processes
of conditioning and expectancy (i.e. human beliefs), may be more easily
elicited in the more suggestible individual, and certainly may not be
powerful enough to operate in a wide range of conditions in which various
authors have made some fairly extreme claims. However, evidence, both
empirical and anecdotal, suggests that it is very much alive and well, if
hidden from view much of the time. It will remain hidden until the sports
science community adopts methodologies that allow it to demonstrate its
power. For example, the use of no-placebo control groups alongside placebo
and experimental groups (allowing not only the comparison of placebo and
experimental conditions but placebo and no-placebo conditions) might
reveal placebo effects of a far greater magnitude than one would imagine.
In fact, a recent meta analysis indicated that placebo effects may account
for up to 75% of the overall therapeutic effect of anti-depressant drugs
[1]. Certainly, such methodologies are complex and require a
high degree of control over variables, but they provide a far better
picture of what is really going on when, for example, an athlete takes a
tablet to reduce pain or sits on a treatment table.
What is all too often forgotten by practitioners is that the placebo
effect does not operate in isolation; it sits alongside many other
processes (e.g. pharmacological or biomechanical) and, if utilised
effectively, may augment many intervention significantly. On this basis
alone, it warrants far greater exploration in sport.
For those sceptics among us, or those who would like an informed
debate as opposed to the often emotional and opinionated rhetoric on this
subject, I strongly recommend Dylan Evans’ recent book on the subject [2]. Evans proposes a sound physiological basis for the placebo effect, and on
this basis, offers a strong case for a range of conditions being either
placebo responsive or not. A very useful starting point for practitioners
interested in the phenomenon.
Yours
Dr Chris Beedie
Canterbury, UK
No competing interests
References
1. Kirsch, I. Sapirstein, G., 1998, Listening to Prozac but Hearing Placebo.
A Meta-Analysis of Antidepressent Medication. Prevention and Treatment.
1(2): 1 – 15.
2. Evans, D., 2003, Placebo: The Belief Effect. London: Harper Collins.
We wish to commend Horan et al. (Horan et al., 2022) on their systematic review and meta-analysis which established overall, match and training IIRs in senior women’s football. It is encouraging to see continued work in this specific area of women’s football epidemiological research.
We would like to draw the authors attention to the following error contained within their work. We respectfully request that it is amended accordingly so that the readership are aware of all available work in this area.
Horan et al. (Horan et al., 2022) refer to the systematic review and meta-analysis of López Valenciano et al (López-Valenciano et al., 2021) which they report was recently ‘criticised’ in a published commentary by Mayhew et al (2021). The authors use the following citation:
30. Mayhew, L. et al. (2021) ‘Incidence of injury in adult elite women’s football: a systematic review and meta-analysis’, BMJ Open Sport & Exercise Medicine, 7(3), p. e001094. doi:10.1136/bmjsem-2021-001094
The readership should be aware that the citation Horan et al. (Horan et al., 2022) use in their work is not a published commentary but a systematic review and meta-analysis on the incidence of injury in elite women’s football. Our publication was PROSPERO registered and published ahead of Horan et al. (Horan et al., 2022) in BJSM’s sister journal (BMJ Open Sport & Exercise Medicine).
We wish to commend Horan et al. (Horan et al., 2022) on their systematic review and meta-analysis which established overall, match and training IIRs in senior women’s football. It is encouraging to see continued work in this specific area of women’s football epidemiological research.
We would like to draw the authors attention to the following error contained within their work. We respectfully request that it is amended accordingly so that the readership are aware of all available work in this area.
Horan et al. (Horan et al., 2022) refer to the systematic review and meta-analysis of López Valenciano et al (López-Valenciano et al., 2021) which they report was recently ‘criticised’ in a published commentary by Mayhew et al (2021). The authors use the following citation:
30. Mayhew, L. et al. (2021) ‘Incidence of injury in adult elite women’s football: a systematic review and meta-analysis’, BMJ Open Sport & Exercise Medicine, 7(3), p. e001094. doi:10.1136/bmjsem-2021-001094
The readership should be aware that the citation Horan et al. (Horan et al., 2022) use in their work is not a published commentary but a systematic review and meta-analysis on the incidence of injury in elite women’s football. Our publication was PROSPERO registered and published ahead of Horan et al. (Horan et al., 2022) in BJSM’s sister journal (BMJ Open Sport & Exercise Medicine).
The corrected citation should be:
Mayhew, L., Johnson, M.I. and Jones, G. (2021) ‘Comment on: “Injury Profile in Women’s Football: A Systematic Review and Meta‑analysis’’, Sports Medicine, 51(12), pp. 2665–2666. doi:10.1007/s40279-021-01531-9.
Our systematic review and meta-analysis is thus cited in Horan et al (2022) but is not referred to in text as a previous systematic review and meta-analysis within this area of research. The readership should be made aware of all relevant work and we invite the authors to comment on the contents of this letter.
Dear Giagio et Al,
I read with interest your PFD -SENTINEL paper and thank you for putting together this consensus process.
As practising sport medicine physicians, we have an interest in lower urinary tract symptoms (LUTs), including incontinence, within our athletic population, both males and females. LUTs, as part of pelvic floor dysfunction, are reportedly common in the general population (2) and vary with the age of the population surveyed – with one recent survey estimating a prevalence of over 70% in those over the age of 70 years olds (3). LUTs is a group of various symptoms related to urination and can include leaking urine, sudden and frequent urges to pass urine, having a weak urine stream or a feeling that you have not completely emptied your bladder. LUTS, and particularly Urinary Incontinence (UI), are considered to be a female health problem that is inevitable and the result of life and health events such as pregnancy, childbirth, and menopause (Casey, E. & Temme, K. 2017). The issue of LUTs is less well understood in male athletes although it has been reported to be present in approximately 15% of athletes surveyed in one study (1). The acceptance of these symptoms, particularly within female athletes, often leads to under reporting or poor engagement with health care practitioners to assess and manage the condition (Anderson & Anderson 2011, Almousa & Bandin Van Loon, 2019, Rodríguez-López, E.S., et al. 2020). The impact of LUT...
Show MoreDear Authors,
Well done on putting together this paper. Massive undertaking to complete a systematic review of 950 included studies.
I have researched the area of exercise and cardiac rehabilitation for TIA and minor stroke patients. I was therefore keen to know if you included these papers in your review as it wasn’t clear from the supplemental papers I reviewed? For example,
Heron N, Kee F, Mant J, Reilly PM, Cupples M, Tully M, Donnelly M. Stroke Prevention Rehabilitation Intervention Trial of Exercise (SPRITE) - a randomised feasibility study. BMC Cardiovasc Disord. 2017 Dec 12;17(1):290. doi: 10.1186/s12872-017-0717-9. PMID: 29233087; PMCID: PMC5727948.
Heron N, Kee F, Mant J, Cupples ME, Donnelly M. Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme. Br J Gen Pract. 2019 Sep 26;69(687):e706-e714. doi: 10.3399/bjgp19X705509. PMID: 31501165; PMCID: PMC6733604.
Heron N. Cardiac rehabilitation for the transient ischaemic attack (TIA) and stroke population? Using the Medical Research Council (MRC) guidelines for developing complex health service interventions to develop home-based cardiac rehabilitation for TIA and 'minor' stroke patients. Br J Sports Med. 2019 Jul;53(13):839-840. doi: 10.1136/bjsports-2018-099593. Epub 2018 Sep 4. PMID: 30181325; PMCID: PMC6585273.
These papers show the benefit of physical activity and ex...
Show MoreResponse: Who should undertake the SCOAT6?
Thank you for your interest in the Sports Concussion Office Assessment Tools, the SCOAT6 and Child SCOAT6. These tools were developed to guide clinicians internationally, using evidence-based components.1 The evidence shows that concussion in children, adolescents and adults affects multiple clinical domains, and the office assessment must address the clinically relevant domains, which will be different in each concussed individual. Using the symptom scales, and interview with the patient, the clinician can identify which clinical domains are endorsed. This guides the clinician towards the appropriate components of the Child SCOAT6 / SCOAT6. Incorporated into the tools are Green “recommended” sections and Orange “optional” sections, to assist the time-challenged clinician in focusing on the most relevant modalities.2,3
Developing the Office tools was a balancing act that primarily considered producing a thorough, multimodal assessment tool but one that was also easy to use and not too lengthy. For instance, we could not ignore research supporting the value of the VOMS but opted for the recently validated modified VOMS which is a validated briefer version.4,5
The scientifically derived clinical reality is that the office assessment of concussed athletes requires a multimodal assessment. Trying to perform a proper multimodal assessment in a 10-minute time period is neither appropriate nor realistic. The concu...
Show MoreDear Authors,
Great work on putting together the SCOAT6 and this is a really helpful piece for the office sport medicine doctors. However, what about the community healthcare teams, eg General Practitioners, GPs, what tool should they be using? Particularly bearing in mind the time constraints of community health contacts, eg GP consults in the UK are most often limited to 10 minutes. What can we expect non-specialist sport medicine doctors to do to help make the concussion diagnosis and therefore initiate appropriate management promptly? Should we be making a SCATgp?
Dear Authors,
Great work on putting together the child SCOAT6 and this is a really helpful piece for the office sport medicine doctors. However, what about the community healthcare teams, eg General Practitioners, GPs, what tool should they be using? Particularly bearing in mind the time constraints of community health contacts, eg GP consults in the UK are most often limited to 10 minutes. What can we expect non-specialist sport medicine doctors to do to help make the concussion diagnosis and therefore initiate appropriate management promptly? Should we be making a childSCATgp?
More patients will be attending primary and community care facilities with concussion as the general knowledge around the diagnosis increases and with new policies and procedures identifying community resources to make the concussion diagnosis and management . Indeed, within the UK, there has recently been grassroots concussion protocols released and they advise that all concussions should be diagnosed by a healthcare practitioner. This will cause a number of patients, both children and adults. to present to community practitioners seeking a diagnosis and we therefore need a community tool to diagnose and manage concussions for the non-specialist healthcare practitioners. Time for a consensus meeting to discuss community, non-specialist concussion diagnosis and management?
Dear Editor,
We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.
The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.
The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.
It is worth noting t...
Show MoreDear Editor,
We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].
Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the...
Show MoreDear Editor
Pseudo-scientific detection of illusory entities did not end in 1907. Attributing physical mass to the “soul,” a man-made theological construct, exemplifies a fallacy Gould attributed to Mill:
The tendency has always been strong to believe that whatever received a name must be an entity or being, having an independent existence of its own. And if no real entity answering to the name could be...
Dear Editor,
I read your editorial 'The power of placebo' with some relief. It would seem that all too often, 'advances' in practice and even research are relegating the placebo effect to the status of quackery. Certainly, I am not a great fan of many therapies or technologies that claim scientifically dubious healing or performance-enhancing qualities (I am to be honest even less of a fan of those who sell them...
We wish to commend Horan et al. (Horan et al., 2022) on their systematic review and meta-analysis which established overall, match and training IIRs in senior women’s football. It is encouraging to see continued work in this specific area of women’s football epidemiological research.
We would like to draw the authors attention to the following error contained within their work. We respectfully request that it is amended accordingly so that the readership are aware of all available work in this area.
Horan et al. (Horan et al., 2022) refer to the systematic review and meta-analysis of López Valenciano et al (López-Valenciano et al., 2021) which they report was recently ‘criticised’ in a published commentary by Mayhew et al (2021). The authors use the following citation:
30. Mayhew, L. et al. (2021) ‘Incidence of injury in adult elite women’s football: a systematic review and meta-analysis’, BMJ Open Sport & Exercise Medicine, 7(3), p. e001094. doi:10.1136/bmjsem-2021-001094
The readership should be aware that the citation Horan et al. (Horan et al., 2022) use in their work is not a published commentary but a systematic review and meta-analysis on the incidence of injury in elite women’s football. Our publication was PROSPERO registered and published ahead of Horan et al. (Horan et al., 2022) in BJSM’s sister journal (BMJ Open Sport & Exercise Medicine).
The corrected citation should be:
Mayhew, L., Johnson, M.I. and...
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