76 e-Letters

published between 2018 and 2021

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

    I thank the authors for their work in addressing the challenge of evaluation of that enigma of "acute and subacute mechanical non-specific low back pain". However given that this is not a specific diagnosis of a pathology it makes it difficult to truly compare like with like. However as practitioners we assess and manage the back pain patient based upon the symptoms and clinical findings. No practitioner I know uses one modality and expects that to be the most effective therapy, except perhaps the primary care physician prescribing analgesics because of service limitations. Clearly pain is one issue, but objectively we find increased muscle tone/ acute spasm, loss of normal movement patterns and particularly across a number of affected spinal segments and possibly neural referral patterns. Consequently to unpick the combination of pain, spasm and limitation of movement that is self-perpetuating, we use a combination of modalities to achieve specific goals. For example, one might use Western acupuncture to release muscle spasm in paraspinal muscles that may facilitate manual mobilisation that would not have been possible in the presence of the spasm. The mobilisation of the spinal segments facilitates more normal movement patterns which reduces pain on movement. Furthermore as the clinical condition progresses we continually adapt which modality we use at each session in accordance with the patient's response and reduce prescribed medications when the con...

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

    Dear Editor,

    Sallis and colleagues showed that patients who were not consistently meeting physical activity guidelines prior to COVID-19 contamination had a substantially greater risk of hospitalisation, admission in intensive care units, and death than patients who were consistently meeting physical activity guidelines (>150min/week engaging in moderate or strenuous exercise over 2-months).1 Identifying risk factors associated with negative COVID-19 outcomes is timely. COVID-19 has resulted in almost 3,000,000 deaths worldwide by the middle of April 2021 2, and vaccination seems insufficient without health and political behaviour changes. 3

    However, we have some concerns about Sallis and colleague’s conclusions. The authors recommended “efforts to promote physical activity” relied on strong assumptions that meeting physical activity guidelines would cause less COVID-19 negative outcomes such as hospitalisation, admission in intensive care units, and deaths. Although exercise has many benefits to individuals, we cannot allow that the urgency of solving problems lead to hasty and imprecise conclusions of causality, as well as unnecessary efforts for implementation.

    Consider a “0-10 causality strength scale”, proposed by Pearl (2018) 4, where 0 is weak evidence of causality and 10 is strong evidence of causality. Depending on the assumptions and procedures used in the studies to test the association between variables, we become more or less confident...

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  • Discussing the return to sport for professional sport leagues in the context of COVID-19: the Rugby Europe experience

    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...

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  • What matters? Program or pain?

    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...

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  • Mental health assessment and management in elite athletes: Comment to the IOC Sport Mental Health Assessment Tool 1 (SMHAT-1)

    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...

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  • Improving the Future of Physical Activity Self-reports – Commentary on „Physical activity self-reports: past or future?”

    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...

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  • Improvement in performance after exogenous testosterone supplementation does not prove that endogenous testosterone levels are associated with performance.

    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...

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  • Clear in our claims: The mental health promotion conundrum facing rugby union

    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....

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  • Putting the WHO 2020 guidelines on physical activity for older people into practice

    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...

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  • The orthopedic community does not oppose non-operative treatment of degenerative meniscal lesions

    “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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