We read with great interest the article published in BJSM by
Dickinson et al (February 2006) (1) on challenge methods for screening
elite winter athletes for exercise induced asthma (EIA). We are in
agreement with the commentary by Professor Rundell that this is a solid
and clear paper reaffirming the efficacy of eucapnic voluntary
hyperventilation (EVH) in diagnosing EIA. However, we believe that...
We read with great interest the article published in BJSM by
Dickinson et al (February 2006) (1) on challenge methods for screening
elite winter athletes for exercise induced asthma (EIA). We are in
agreement with the commentary by Professor Rundell that this is a solid
and clear paper reaffirming the efficacy of eucapnic voluntary
hyperventilation (EVH) in diagnosing EIA. However, we believe that the
negative findings observed by the authors in regards to the laboratory
based exercise challenge may in fact be due to a number of procedural
limitations of the method selected. Anderson and Holzer (2) assert that
EIA is primarily determined via the level of ventilation achieved and
sustained during exercise, which reflects the intensity of exercise and
the water content of the inspired air; thus explaining recommendations for
the 2006 Turin Winter Olympic Games (3) “that the exercise test should be
performed breathing dry air for 8 minutes with the intensity of exercise
close to maximal for the last 4 minutes.” Indeed, in our laboratory, when
we conduct exercise challenge tests on elite athletes with physician-
diagnosed EIA we typically exercise them to volitional exhaustion (4).
Therefore the use of 90% of maximum heart rate for elite endurance
athletes by Dickerson et al (1) does not seem to be an adequate intensity
to allow them to ventilate at sufficiently high rates in order to elicit
airway drying and hence evoke symptoms of EIA. Perhaps reporting the
ventilation rates for each challenge would allow a better comparison of
the different testing procedures.
In addition, Evans et al. (5) recently demonstrated that dryness of
the test conditions rather than a cold temperature is essential to the EIB
response. It is generally accepted that inhaling cold-dry air at high
ventilation rates initiates EIA (4, 5). Rundell and coworkers (6) have
shown that out of 23 subjects who tested positive for EIA in cold-dry air,
18 (78%) subjects tested negative in ambient conditions (21oC and 50%
relative humidity). This suggests that the exercise protocol performed in
ambient conditions in the Dickinson et al. (1) study may have been less
sensitive to identifying changes in airway hyperresponsiveness following
exercise due to inadequate environmental stress.
Sincerely,
Martin R. Lindley, Ph.D.
Timothy D. Mickleborough, PhD. FACSM.
Indiana University.
References
1. Dickinson JW, Whyte GP, McConnell AK, Harries MG. Screening elite
winter athletes for exercise induced asthma: a comparison of three
challenge methods. Br J Sports Med 2006; 40: 179-183.
2. Anderson SD, Holzer K. Exercise-induced asthma: is it the right
diagnosis in elite athletes? J Allergy Clin Immunol 2000; 106: 419-428.
3. International Olympic Committee. Beta2 adrenoceptor agonists and
the Olympic Games in Turin. 2005.
http://multimedia.olympic.org/pdf/en_report_981.pdf (accessed 12 February
2006).
4. Mickleborough TD, Murray RL, Ionescu AA, Lindley MR. Fish oil
supplementation reduces severity of exercise-induced bronchoconstriction
in elite athletes. Am J Respir Crit Care Med 2003;168: 1181-1189.
5. Evans TM, Rundell KW, Beck KC, Levine AM, Baumann JM. Cold air
inhalation does not affect the severity of EIB after exercise or eucapnic
voluntary hyperventilation. Med Sci Sports Exerc 2005; 37:544-549.
6. Rundell KW, Wilber RL, Szmedra L, Jenkinson DM, Mayers LB, Im J.
Exercise-induced asthma screening of elite athletes: field versus
laboratory exercise challenge. Med Sci Sports Exerc 2000; 32: 309-316.
We are pleased that our Leader has engendered interest, thank Prof
Lippi and his colleagues for their letter, and are grateful to the Journal
for the opportunity to reply. We fully agree with their ideas: using
normative data from non-athletic population may well result in over-
investigation and unnecessary worries for athletes. This is why we believe
that serum concentrations of the enzymes in quest...
We are pleased that our Leader has engendered interest, thank Prof
Lippi and his colleagues for their letter, and are grateful to the Journal
for the opportunity to reply. We fully agree with their ideas: using
normative data from non-athletic population may well result in over-
investigation and unnecessary worries for athletes. This is why we believe
that serum concentrations of the enzymes in question should be only part
of the picture, and accurate clinical history and examination should still
rule: a purely mechanistic approach would not serve our patients well.
Also, data should be generated for oher sports: for example, athletes
involved in contact sports and high level martial arts seem to have higher
levels of CK than endurance athletes[1], as have athletes on anabolic
steroids, as pointed out in our Leader. In the absence of a clinical picture of frank pathololgy, we would not
subject these athletes to tests. Furthermore, to further diminish
unnecessary invasive investigations, if CK and LDH levels are elevated, we
suggest a rest from athletic activities for two weeks before testing again
CK and LDH levels[2]. If still elevated, then further, more invasive,
investigations may be necessary
Paola Brancaccio, Francesco Mario Limongelli, Nicola Maffulli
Seconda Università di Napoli
Department of Experimental Medicine
Centre of Excellence of Cardiovascular Disease
Napoli, Italy (PB, FML)
Department of Trauma and Orthopaedic Surgery
Keele University School of
Medicine
Thornburrow Drive
Hartshill, Stoke on Trent
ST4 7QB Staffs
ENGLAND (NM)
I read with interest the article written by Dr. G.J. Buse entitled,
No holds barred sport fighting: a 10 year review of mixed martial arts
competition published in the 6 February 2006 edition of your journal. As
a researcher focused on injury prevention, I have recently been part of a
research group reviewing data from both mixed martial arts competitions
and professional boxing and enjoyed reading...
I read with interest the article written by Dr. G.J. Buse entitled,
No holds barred sport fighting: a 10 year review of mixed martial arts
competition published in the 6 February 2006 edition of your journal. As
a researcher focused on injury prevention, I have recently been part of a
research group reviewing data from both mixed martial arts competitions
and professional boxing and enjoyed reading the information presented by
Dr. Buse.
In an article published in October 2005 in the Southern Medical
Journal, our research group attempted to define the overall injury rate of
athletes participating in professional boxing.[1] We reviewed data from
the fight cards published by the Nevada State Athletic Commission and
noted any injury comments recorded by the ringside physicians. Our
research demonstrated an overall injury rate of 17.[1] injuries per 100
boxer-matches with 11.3% of those matches ending in knockout.
In an attempt to compare boxing injuries to mixed martial arts (MMA)
injuries, we did a review of the fight cards for MMA matches using the
same protocol as for the professional boxing matches. Our data—to be
published soon by The Journal of Sports Science and Medicine—indicate that
the overall injury rate for MMA matches is similar to professional boxing
and the knockout rate is almost half that of professional boxing.[2]
In reviewing Dr. Buse’s data, I would have liked to have seen a
comparison of injury rates before and after the sanctioning of the sport
in September 2001. Though MMA began in the United States in 1993, these
first fights only superficially resemble MMA matches today and were really
very different competitions. Sanctioning brought about many rule changes
that mandated weight classes, time limits for rounds and matches, and
eliminated many of the most dangerous techniques including stomps, head
butts, and groin attacks. Combining MMA matches prior to sanctioning with
the sanctioned matches of today is confusing and is not helpful in
attempting to determine the true injury risk for participants in these
competitions.
It should also be noted that although there were five deaths in the
boxing ring in the United States during 2005, there has never been an MMA
death in the United States. The death cited by Dr. Buse occurred in an
unregulated event during 1998 in the Ukraine.[3] MMA fighters in the
United States now must pass all the prefight screening tests of
professional boxers and are supervised by referees and ringside
physicians. It is important not to lump MMA competitions with the
infamous “Toughman” competitions—a “sport” that matches amateur
participants against trained fighters using “one size fits all” protective
gear and often supervised by chiropractors and other untrained medical
staff—when comparing MMA to other combat sports. While MMA has never had
a casualty in the United States, at least 12 deaths have resulted from
Toughman competitions.[4]
MMA also has some rules that seem to be an improvement over
professional boxing. The fact that MMA has no “standing eight count”
enabling a concussed participant time to recover and continue fighting is
a tremendous step toward diminishing traumatic brain injury. Furthermore,
by allowing leg and arm attacks opponents have a more diverse target area
and do not focus solely on attacking the head, and if in trouble, a
participant can “tap out” to signify his desire to end the match. In our
study, the “tap out” was the second most common means of ending a bout and
ended approximately 30% of matches.2 Last, most MMA matches are far
shorter than boxing matches. Sanctioned MMA events usually consist of
three 5 minute rounds as compared to the usual ten to twelve rounds of
boxing.
In sum, mixed martial arts competitions are a controversial subject
in today’s sporting world and while no one would argue that these events
are safe, it is important that we in the medical and research communities
stay disciplined in our response to these subjects. I am thankful that
your journal has taken an active role in seeking to determine the inherent
risks of MMA competitions, and I hope that it will continue giving
balanced and constructive suggestions regarding MMA and other such
controversial subjects.
Sincerely,
Gregory H. Bledsoe MD, MPH
Assistant Professor
Department of Emergency Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
References
1. Bledsoe GH, Li G, Levy, F. Injury risk in professional boxing.
Southern Med J 2005; 98:994-998.
2. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G. Incidence of
injury in professional mixed martial arts competitions. The Journal of
Sports Science and Medicine (in press).
3. Porter K. Chipley man dies from injuries suffered in “ultimate
fighting” match [news article online]. Panama City, FL: The News Herald,
1998, http://ap.emeraldcoast.com/nharchive/index.php (accessed 6 Feb
2006).
4. Branch, G. Toughman Competition Faces Its Own Battle. USA Today,
3C, 20 May 2003.
We were very interested by the article of Brancaccio and Collegues
(1), which concluded that biochemical monitoring of athletes, including
measurement of serum creatine kinase (CK) and lactate dehydrogenase (LDH)
activities, might be helpful to reveal the state of the muscle and its
biochemical adaptation to the physical workload. This is a valuable
consideration, and both CK and LDH monitoring in...
We were very interested by the article of Brancaccio and Collegues
(1), which concluded that biochemical monitoring of athletes, including
measurement of serum creatine kinase (CK) and lactate dehydrogenase (LDH)
activities, might be helpful to reveal the state of the muscle and its
biochemical adaptation to the physical workload. This is a valuable
consideration, and both CK and LDH monitoring in elite athletes might turn
out to be reliable markers for athletes’ guidance towards the most suited
individual degree of physical training or recovery and to prevent muscle
damage and decay of the athletic performance. However, a further issue
should be addressed in this perspective. Which are the reference limits
for these markers in elite and professional athletes? This is a crucial
point, to establish whether an athlete is really undergoing unsafe and
disadvantageous training regimens. We have previously demonstrated that
reference intervals calculated from a healthy reference population might
not be widely applicable to subjects undergoing a regular and demanding
physical training (2). This applies also to widely utilized markers of
skeletal muscle and heart injury, such as LDH, total CK and CK isoenzyme
MB, which might be markedly elevated in athletes at resting,
irrespectively of the relative physical workload (3,4). In a further
analysis of these data, we have now estimated the reference ranges for CK
and LDH in 50 male elite endurance athletes, 24 to 48 after exercise and
in 35 matched male sedentary controls. Although values were distributed
over a wide range and seldom overlapping, the upper limits of the relative
reference intervals calculated at the 95th percentile were yet
substantially higher in elite athletes when compared to sedentary
controls, for both CK (395 vs 262 IU/L) and LDH (397 vs 302 IU/L).
Therefore, increased markers of muscle damage might reflect adaptation to
a demanding aerobic physical activity rather than an underlying muscle
sufferance. In this respect, we believe that identification and
implementation of reliable and specific reference limits for laboratory
parameters in elite athletes are necessary prerequisites to avoid
equivocal interpretation of results and to prevent further unnecessary
examinations.
References
1. Brancaccio P, Limongelli FM, Maffulli N. Monitoring of serum
enzymes in sport. Br J Sports Med 2006;40:96-7.
2. Lippi G, Brocco G, Franchini M, Schena F, Guidi G. Comparison of
serum creatinine, uric acid, albumin and glucose in male professional
endurance athletes compared with healthy controls. Clin Chem Lab Med
2004;42:644-7.
3. Lippi G, Brocco G, Salvagno GL, Montagnana M, Dima F, Guidi GC.
High-workload endurance training may increase serum ischemia-modified
albumin concentrations. Clin Chem Lab Med 2005;43:741-4.
4. Lippi G, Salvagno GL, Montagnana M, Schena F, Ballestrieri F,
Guidi GC. Influence of physical exercise and relationship with biochemical
variables of NT-pro-brain natriuretic peptide and ischemia modified
albumin. Clin Chim Acta 2005 Dec 30; [Epub ahead of print].
The influence of a regular physical exercise on health and fitness is
well-established, as physically active subjects are characterized by a
consistently decreased risk of cardiovascular disease, diabetes, cancer,
osteoporosis, obesity, fractures and mental health problems. Accordingly,
the current guidelines recommend 30 minutes or more of moderate-intensity
activity on most days of the week, and tha...
The influence of a regular physical exercise on health and fitness is
well-established, as physically active subjects are characterized by a
consistently decreased risk of cardiovascular disease, diabetes, cancer,
osteoporosis, obesity, fractures and mental health problems. Accordingly,
the current guidelines recommend 30 minutes or more of moderate-intensity
activity on most days of the week, and that people already achieving this
would benefit further from participation in more vigorous activity.[1]
However, there is still an open debate regarding the intensity and the
type of physical activity required to achieve most favourable health
changes in the general population without overwhelming the relative
benefits or eliciting osteoarthritis and cardiovascular abnormalities not
present at rest.[2] It was recently observed that the volume of lifestyle
activities of moderate intensity in leisure time was inversely associated
with all cause mortality in women but not in men and. Therefore, with
regard to the health enhancing physical activity recommendation as a
threshold, there were favourable findings only in women.[3]
In recent
investigations on male professional athletes, we demonstrated that a
vigorous and regular endurance aerobic training regimen does not influence
markers of hemostatic or endothelial activation,[4] does not induce any
persistent phlogistic reaction,[5] nor it is associated with biochemical
signs of significant and irreversible chronic cardiac involvement, as
reflected by normal concentrations of the NT-pro-brain natriuretic peptide.[6]
Therefore, as a substantial intensification in leisure-time physical
activity within the population does not apparently produces any acute
increase of the risk of adverse cardiovascular events[4-6] and it is
likely to be more effective for eliciting supplemental gains in health,[2] we suggest that higher intensities and amounts of aerobic training
may be safely implemented in free-living sedentary individuals as a
preventive or therapeutic measure to increase the health benefits,
especially in individuals who are most at risk of developing health
problems.
References
1. Willett W. Harvesting the fruits of research: new guidelines on
nutrition and physical activity. Cancer J Clin 2002; 52: 66-67.
2. Lee, IM, Sesso, HD, Oguma, Y, Paffenbarger, RS Jr Relative
intensity of physical activity and risk of coronary heart disease.
Circulation 2003; 107: 1110-1116.
3. Bucksch J. Physical activity of moderate intensity in leisure time
and the risk of all cause mortality. Br J Sports Med 2005;39:632-8.
4. Lippi, G, Salvagno, GL, Montagna, M, Guidi, GC Chronic influence
of vigorous aerobic training on hemostasis. Blood Coagul Fibrinolysis
2005; 16: 533-534.
5. Lippi, G, Salvagno, GL, Guidi, GC Other advantages to aerobic
exercise. CMAJ 2005;173:1066.
6. Lippi, G, Salvagno, GL, Montagnana, M, Schena, F, Balestrieri, F,
Guidi, GC Influence of physical exercise and relationship with biochemical
variables of NT-pro-brain natriuretic peptide and ischemia modified
albumin. Clin Chim Acta (in press).
This study emphasizes use of personal experience rather than the
scientific evidence in medical treatment of patellofemoral pain sydrome
(PFMS) and Achilles tendinopathy (AT). Being a physiatrist working in
this field, I feel that we need to look at observations of these
practitioners more carefully. The authors suggested the following four
factors not using scientific evidence for the management of P...
This study emphasizes use of personal experience rather than the
scientific evidence in medical treatment of patellofemoral pain sydrome
(PFMS) and Achilles tendinopathy (AT). Being a physiatrist working in
this field, I feel that we need to look at observations of these
practitioners more carefully. The authors suggested the following four
factors not using scientific evidence for the management of PFPS and AT:
1. The literature base in sports medicine is smaller than other clinical
fields.
2. Practitioners were unaware of supporting literature.
3. Management plans can not be adapted by busy clinical personnel to improve
scientific experience in medical treatment.
4. Patients preferred not to
use some of the scientific applications in the management plan. Moreover,
we also frequently seen clinicians attempting to practice evidence based
medicine who become frustrated with the process when they are unable to
find any useful practical information to answer their clinical questions.
In some cases, information may become available, but the evidence might be
inconclusive or contradicting. These observations clearly shows us the
need for a close cooperation between practitioners and clinical medical
personnel for a medical treatment in sports and exercise medicine.
Research programs structured using this cooperation will certainly create
conclusive and practically applicable medical treatments in this area. It
is important for clinicians to keep in mind that clinical decisions are
not made by evidence alone; as such, research evidence should never be
accepted blindly. Research study results must include not only knowledge
and experiences of clinician and practitioner but also scientific evidence
and most importantly appreciation of the patient.
Dear Editor,
We read with great interest the article published in BJSM by Dickinson et al (February 2006) (1) on challenge methods for screening elite winter athletes for exercise induced asthma (EIA). We are in agreement with the commentary by Professor Rundell that this is a solid and clear paper reaffirming the efficacy of eucapnic voluntary hyperventilation (EVH) in diagnosing EIA. However, we believe that...
Dear Editor,
We are pleased that our Leader has engendered interest, thank Prof Lippi and his colleagues for their letter, and are grateful to the Journal for the opportunity to reply. We fully agree with their ideas: using normative data from non-athletic population may well result in over- investigation and unnecessary worries for athletes. This is why we believe that serum concentrations of the enzymes in quest...
Dear Editor,
I read with interest the article written by Dr. G.J. Buse entitled, No holds barred sport fighting: a 10 year review of mixed martial arts competition published in the 6 February 2006 edition of your journal. As a researcher focused on injury prevention, I have recently been part of a research group reviewing data from both mixed martial arts competitions and professional boxing and enjoyed reading...
Dear Editor,
We were very interested by the article of Brancaccio and Collegues (1), which concluded that biochemical monitoring of athletes, including measurement of serum creatine kinase (CK) and lactate dehydrogenase (LDH) activities, might be helpful to reveal the state of the muscle and its biochemical adaptation to the physical workload. This is a valuable consideration, and both CK and LDH monitoring in...
Dear Editor,
The influence of a regular physical exercise on health and fitness is well-established, as physically active subjects are characterized by a consistently decreased risk of cardiovascular disease, diabetes, cancer, osteoporosis, obesity, fractures and mental health problems. Accordingly, the current guidelines recommend 30 minutes or more of moderate-intensity activity on most days of the week, and tha...
Dear Editor,
This study emphasizes use of personal experience rather than the scientific evidence in medical treatment of patellofemoral pain sydrome (PFMS) and Achilles tendinopathy (AT). Being a physiatrist working in this field, I feel that we need to look at observations of these practitioners more carefully. The authors suggested the following four factors not using scientific evidence for the management of P...
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