For readers who are following the debate about how training load may relate to injury, Dr Johann Windt considers the implication of the correlation that is pointed out here. Thanks to all the authors. k2
The study raises two questions that one of the authors might be able to help with:
First, the authors report both within group and between group changes in body fat in the abstract. But it is unclear why the authors chose the within-group changes (28% fat loss) as the study conclusion than the between-group change.
The within group change showed a fat loss of 0.45 kg (28%) in favor of interval training (IT), while the between-group changes showed a large difference of 2.28 kg of fat loss in favor of IT. Considering the large difference in fat loss, and some studies recommending to avoid within group differences in meta-analysis, it would be helpful if the authors could comment on this.
Second, maintaining lean body mass (LBM) is one of the primary reasons to include exercise as part of a weight loss strategy. So it is not clear why the authors chose not to include lean body mass as one of the outcomes. It would have certainly helped the reader to make a decision regarding the choice of exercise for weight loss.
Finally, congratulations to all the authors for asking a very relevant question!.
We thank Freke et al. (1) for their systematic review about physical impairments in patients with symptomatic femoroacetabular impingement, nonetheless we have some remarks about methods and results of the article, in particular for range of motion (ROM) outcome.
A meta-analysis of ROM was performed without reporting an overall estimate. Taking into account the amount of studies included and their information, a meta-analysis should have been accomplished. Nonetheless, authors concluded that individuals with symptomatic FAI demonstrated no difference in hip ROM in any direction of movement. This conclusion was unexpected taking into account the findings reported in the primary studies included), and in the previous systematic review published in 2015 (2), that showed instead a reduced ROM.
This discrepancy in literature is already discussed by the Warwick agreement (3), where authors stated that “the evidence on hip range of motion (ROM) in FAI syndrome is surprisingly contradictory” due to contrasting published systematic reviews (1) (2).
Therefore, we checked the accuracy of results reported, analyzing the data reported for every movement assessed in primary studies comparing those reported in this systematic review. We noted some issues in the represented forest plots.
Firstly, some included studies (4), (5), (6), (7) were reported twice in the meta-analysis for different times points or reporting double data of the same patients obtained by two...
We thank Freke et al. (1) for their systematic review about physical impairments in patients with symptomatic femoroacetabular impingement, nonetheless we have some remarks about methods and results of the article, in particular for range of motion (ROM) outcome.
A meta-analysis of ROM was performed without reporting an overall estimate. Taking into account the amount of studies included and their information, a meta-analysis should have been accomplished. Nonetheless, authors concluded that individuals with symptomatic FAI demonstrated no difference in hip ROM in any direction of movement. This conclusion was unexpected taking into account the findings reported in the primary studies included), and in the previous systematic review published in 2015 (2), that showed instead a reduced ROM.
This discrepancy in literature is already discussed by the Warwick agreement (3), where authors stated that “the evidence on hip range of motion (ROM) in FAI syndrome is surprisingly contradictory” due to contrasting published systematic reviews (1) (2).
Therefore, we checked the accuracy of results reported, analyzing the data reported for every movement assessed in primary studies comparing those reported in this systematic review. We noted some issues in the represented forest plots.
Firstly, some included studies (4), (5), (6), (7) were reported twice in the meta-analysis for different times points or reporting double data of the same patients obtained by two instruments to measure ROM. The number of observations in the analysis should match the number of individuals (unit) that are randomized or allocated: reporting twice data from the same patients is not appropriate, resulting in an error of unit of analysis inflating the sample size. Secondarily, two studies were included in the meta-analyses selecting an inappropriate control group. In particular, the control group in one study was represented by post-surgery impingement population instead of the healthy control, even if the displaced forest plot indicated the comparisons “pre versus control” (8). Analogously, an inappropriate population was selected in another study (6) for the femoroacetabular group where authors chose arbitrarily data from the subgroup of patients with cam impingement, while they should have chosen data reported from combined cam or pincer impingement, since the aim of the review was to measure physical impairment in patients with any kind of FAI.
We are confident with data published in this review of Freke et al (1): checking data from all primary studies we confirmed that data were correctly reported by authors in tables 1 and 2, however inconsistency between data extraction and analysis is present. It is unclear the estimate and related confidence intervals reported in each forest plot. Reasons could be related to authors obtain missing outcome data from contacting primary authors, nevertheless, this information should be transparently reported in the systematic review. For every direction of movement analyzed, the confidence intervals appear to be too large and, in some cases, the SMD calculated seemed to be wrong, making non-significant some of the significant differences published in the primary studies.
Considering the errors in selective reporting and aggregation of data we claim the conclusion of the review about ROM is not correct. Even if the authors did not show the diamond of the overall results in forest plots, they concluded that there is no statistically significant deficit in ROM in any plane of movement, and visually impressed stakeholders by the forest plots that sustain this conclusion. Anyway, we correctly re-run the analyses and we found that there is a statistically significant ROM deficit in flexion, abduction, external rotation and internal rotation in patients with FAI versus controls.
Errors in published systematic reviews are possible (9), but they can limit validity of conclusions of systematic reviews and resulting statements, agreements or clinical guidelines. We understand that peer-reviewers cannot check every calculation or data analysis but the importance of meta-analysis in the hierarchy of evidence need high level of attention and hopefully technical support to the reviewers to avoid relevant mistakes. At the same time, to improve transparency and help the review process, Journals should require authors to submit the raw data and to share the dataset used for the analyses, when they are not reported in the forest plot.
References
1. Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: A systematic review of the evidence. Br J Sports Med. 2016;50(19):1180.
2. Diamond LE, Dobson FL, Bennell KL, Wrigley T V., Hodges PW, Hinman RS. Physical impairments and activity limitations in people with femoroacetabular impingement: A systematic review. Br J Sports Med. 2015;49(4):230–42.
3. Griffin DR, Dickenson EJ, O’Donnell J, Agricola R, Awan T, Beck M, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement. Br J Sports Med. 2016;50(19):1169–76.
4. Nussbaumer S, Leunig M, Glatthorn JF, Stauffacher S, Gerber H, Maffiuletti NA. Validity and test-retest reliability of manual goniometers for measuring passive hip range of motion in femoroacetabular impingement patients. BMC Musculoskelet Disord. 2010;11(194).
5. Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics. Am J Sports Med. 2011;39(1 Suppl):43–9.
6. Harris-hayes M, Mueller MJ, Sahrmann SA, Bloom NJ, Steger-may K, Clohisy MAJC, et al. Persons With Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength. J Orthop Sport Phys Ther. 2014;44(11):890–8.
7. Audenaert EA, Peeters I, Vigneron L, Baelde N, Pattyn C. Hip Morphological Characteristics and Range of Internal Rotation in Femoroacetabular Impingement. Am J Sports Med. 2012;40(6):1329–36.
8. Kubiak-Langer M, Tannast M, Murphy SB, Siebenrock K a, Langlotz F. Range of motion in anterior femoroacetabular impingement. Clin Orthop Relat Res [Internet]. 2007 May [cited 2012 Mar 9];458(458):117–24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17206102
9. Yip R, Islami F, Zhao S, Tao M, Yankelevitz DF, Boffetta P. Errors in systematic reviews : an example of computed tomography screening for lung cancer. Eur J Cancer Prev. 2014;23(i):43–8.
I would like to congratulate the British Journal of Sports Medicine for the publication of the study ‘The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial’ conducted by Harøy et al.[1]. The study investigated the effect of the adductor strengthening programme on the prevalence of groin problems among football players. The findings are incredibly important for the development of sports medicine because of their clinical relevance.
Regarding the methodology of this study, rather than giving criticism, I would like to suggest the authors if they can provide additional information or even a follow-up article on the game performance of the football teams involved in this study. As mentioned in the article, the authors have considered the groin pain causing time loss, decreasing participation or performance of the players [1]. Meanwhile, the previous study literally found that a lower incidence rate was strongly correlated with the number of goals, games won and even team ranking position [2,3]. Therefore, readers are interested whether the performance could be improved too since the results showed a significant reduction in the prevalence of groin pain in the players.
Similar studies have been conducted to investigate the effect of a specific strength training programme on players’ injury prevalence and individuals’ performance [4]. However, no data was included to refl...
I would like to congratulate the British Journal of Sports Medicine for the publication of the study ‘The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial’ conducted by Harøy et al.[1]. The study investigated the effect of the adductor strengthening programme on the prevalence of groin problems among football players. The findings are incredibly important for the development of sports medicine because of their clinical relevance.
Regarding the methodology of this study, rather than giving criticism, I would like to suggest the authors if they can provide additional information or even a follow-up article on the game performance of the football teams involved in this study. As mentioned in the article, the authors have considered the groin pain causing time loss, decreasing participation or performance of the players [1]. Meanwhile, the previous study literally found that a lower incidence rate was strongly correlated with the number of goals, games won and even team ranking position [2,3]. Therefore, readers are interested whether the performance could be improved too since the results showed a significant reduction in the prevalence of groin pain in the players.
Similar studies have been conducted to investigate the effect of a specific strength training programme on players’ injury prevalence and individuals’ performance [4]. However, no data was included to reflect the impact on the teams' performance. Specifically, a unique methodological advantage of Harøy et al. ‘s RCT was based on both individuals and teams ie. 18 teams in the intervention group versus 17 teams in the control group [1]. If there were no significant changes in other factors between the two groups throughout the study period, it is possible to generate more statistics on the teams’ performance for comparison after the intervention.
In summary, these contributions are intended to explore additional data of the study to improve this valuable manuscript even further. Because I believe that this study will have a direct impact on clinical practices, being a reference for deciding the most appropriate injury prevention programme, potentially performance enhancement as well, in sports medicine and the industry.
Reference
1 Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: A cluster-randomised controlled trial. Br J Sports Med 2018;:145–52. doi:10.1136/bjsports-2017-098937
2 Eirale C, Tol JL, Farooq A, et al. Low injury rate strongly correlates with team success in Qatari professional football. Br J Sports Med 2013;47:807–8. doi:10.1136/bjsports-2012-091040
3 Hägglund M, Waldén M, Magnusson H, et al. Injuries affect team performance negatively in professional football: An 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med Published Online First: 2013. doi:10.1136/bjsports-2013-092215
4 Barengo N, Meneses-Echávez J, Ramírez-Vélez R, et al. The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review. Int J Environ Res Public Health 2014;11:11986–2000. doi:10.3390/ijerph111111986
I had been a sufferer of exercise-associated hyponatraemia for at least a year, when I was living on a farm, as a direct result of drinking bore water. Unlike most bores which are overmineralized and dirty, these ones tapped into deep aquifers, that sourced ultra purified water. Because the water is trapped under deep layers of dolomites and Saprolites, the only way it can travel deeper into the earth is by passing through the micro pores of rocks, which results in micro filtration and ultra purification.
But humans are adaptable to drinking pure water and pure water alone isn't going to make a normal person hyponatraemic, I had at one stage performing a labour intensive job as a tree surgeon. Also, because I have ADHD, I am medicated with adder-all.
My situation was quite rare because I was living on a farm, drinking bore water and had a job pruning trees in residential areas, in the city. There, one would sweat heavily and would be drinking city water, which is one recipe for water that has a good mineral trace element content to it, but going home later that evening meant a diet of pure drinking water or cooking foods in pure water. This messed me up and affected my clear state of mind, often its a state of delirium that you start to feel as one of the typical symptoms.
But then I also go back to the adder-all, which may have some role in making me vulnerable, because its an amphetamine and similar to the way ecstasy makes people become wate...
I had been a sufferer of exercise-associated hyponatraemia for at least a year, when I was living on a farm, as a direct result of drinking bore water. Unlike most bores which are overmineralized and dirty, these ones tapped into deep aquifers, that sourced ultra purified water. Because the water is trapped under deep layers of dolomites and Saprolites, the only way it can travel deeper into the earth is by passing through the micro pores of rocks, which results in micro filtration and ultra purification.
But humans are adaptable to drinking pure water and pure water alone isn't going to make a normal person hyponatraemic, I had at one stage performing a labour intensive job as a tree surgeon. Also, because I have ADHD, I am medicated with adder-all.
My situation was quite rare because I was living on a farm, drinking bore water and had a job pruning trees in residential areas, in the city. There, one would sweat heavily and would be drinking city water, which is one recipe for water that has a good mineral trace element content to it, but going home later that evening meant a diet of pure drinking water or cooking foods in pure water. This messed me up and affected my clear state of mind, often its a state of delirium that you start to feel as one of the typical symptoms.
But then I also go back to the adder-all, which may have some role in making me vulnerable, because its an amphetamine and similar to the way ecstasy makes people become water intoxicated. One good article to that effect is "MDMA Impairs Response to Water Intake in Healthy Volunteers".
Yes, water intoxication is real. It's a possible danger that people should be aware of. That delirious state of mind isn't a pleasant
feeling. For me, drinking only city water is essential, I only need to drink half a litre of bore water, and following a 2 hour time period, a
sickness would occur. I've also come to realize bottled spring water from the shop had similar sickening results.
Medication makes you vulnerable to dilutional hyponatremia, heavy exercise plays a part, so its important to be aware of what liquids you're re hydrating yourself with, because not all water is the same, it has a mineral content that determines its tonicity, it comes in different formulas so to speak.
Many of you will be familiar with The BMJ and its popular 'Rapid Responses'. Because we are a sister journal to The BMJ (and part of the same publishing company of course) we have the same Platform and we encourage you to use it.
Why is this in BJSM? In general, it is best to have papers go through peer review in the most relevant journal to their subject matter to ensure that the production team is well placed to find suitable editors and reviewers.
Letter to the Editors
Br J Sports Med
J Obstet Gynecol Canada
Oslo, Nov 23rd 2018
Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy
We have read the Canadian guideline for physical activity throughout pregnancy with great interest. We note that the guideline team have made their recommendation regarding pelvic floor muscle training (PFMT) based on evidence from a systematic review from the same research group (Davenport et al 2018). The main results of this review are in line with the latest Cochrane review (Woodley et al 2017) on the same topic; while there are some methodological differences and variations in which studies were included or not (two of the largest studies on PFMT was left out from the Davenport review; Mørkved et al 2003 and Stafne et al 2012), the findings in terms of size and precision of effect are similar, although Davenport et al used odds ratio and Woodley et al used risk ratio for their summary statistic. Davenport et al reported that PFMT gave a 50% reduction in prenatal UI and a 35% reduction in postnatal UI, but the guideline team concluded a “weak recommendation” for PFMT because UI was not rated as a "critical outcome" and the evidence was of "low quality". We find this conclusion at odds with the evidence and the interpretation of the evidence based on the guideline team’s own criteria.
The Canadian guideline grades...
Letter to the Editors
Br J Sports Med
J Obstet Gynecol Canada
Oslo, Nov 23rd 2018
Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy
We have read the Canadian guideline for physical activity throughout pregnancy with great interest. We note that the guideline team have made their recommendation regarding pelvic floor muscle training (PFMT) based on evidence from a systematic review from the same research group (Davenport et al 2018). The main results of this review are in line with the latest Cochrane review (Woodley et al 2017) on the same topic; while there are some methodological differences and variations in which studies were included or not (two of the largest studies on PFMT was left out from the Davenport review; Mørkved et al 2003 and Stafne et al 2012), the findings in terms of size and precision of effect are similar, although Davenport et al used odds ratio and Woodley et al used risk ratio for their summary statistic. Davenport et al reported that PFMT gave a 50% reduction in prenatal UI and a 35% reduction in postnatal UI, but the guideline team concluded a “weak recommendation” for PFMT because UI was not rated as a "critical outcome" and the evidence was of "low quality". We find this conclusion at odds with the evidence and the interpretation of the evidence based on the guideline team’s own criteria.
The Canadian guideline grades evidence as either “strong or weak based on the (1) balance between benefits and harms, (2) overall quality of the evidence, (3) importance of outcomes (ie, values and preferences of pregnant women), (4) use of resources (ie, cost), (5) impact on health equity, (6) feasibility and (7) acceptability. A strong recommendation is one where “Most or all pregnant women will be best served by the recommended course of action” and a weak recommendation is one where “Not all pregnant women will be best served by the recommended course of action; there is a need to consider other factors such as the individual’s circumstances, preferences, values, resources available or setting. Consultation with an obstetric care provider may assist in decision-making.”
We disagree with how PFMT has been classified in relation to these criteria and would like to question and comment on the following:
1.Balance between benefits and harms: the effect size of antenatal PFMT for prevention of UI is moderate and there are no harms of PFMT, so this would be in favor of a strong recommendation. In addition, many of the studies in the Davenport et al (2018) review did not compare PFMT with no exercise/untreated controls, rather the control groups typically also had some advice or instruction in PFMT as part of ‘routine’ care. Such trials are likely to under- rather than overestimate the effect of PFMT, suggesting the true effect size may be larger than that calculated by Davenport et al (2018).
2.Overall quality of the evidence: There are three issues to consider here:
a. Research design. There are sufficient numbers of RCTs evaluating effect of PFMT on UI during pregnancy to do meta-analyses without including cohort studies with lower internal validity. The Davenport review (2018) referred to cohort studies and showed that general exercise (not PFMT) may increase the odds of developing UI. Aerobic exercise usually includes high impact activities (jumping and running). Numerous studies (Bø 2004, Nygaard & Shaw 2016) have shown that high impact activities are associated with UI, therefore this combination is likely to be provocative of UI and mask a stand-alone effect of PFMT on reduction of UI. Studies on aerobic exercise can therefore not be expected to have a positive effect on UI and should not be recommended to be combined with studies on PFMT. In all reports in this area general exercise /physical activity needs to be separated from specific PFMT, in order not to confuse the readers.
b. Risk of bias. All the trials are inevitably at risk of bias through an inability to blind participants and providers, yet this would be the same for all forms of physical activity (yoga) and should not affect the rating of PFMT more than other exercise. The included trials are also the usual ‘mixed bag’ of less and more robust trials. While most studies are small to moderate in size it seems likely that the true underlying effect is within the existing confidence limits of the effect estimate (Herbison et al 2011). Both in the Cochrane (Woodley et al 2017) and the Davenport et al (2018) reviews the upper limits of the confidence intervals suggest clinically important reduction in UI.
c. Statistical heterogeneity. For PFMT, a plausible explanation for statistical heterogeneity is the different training doses and supervision (Hay-Smith et al 2011). We agree that more work is needed to find a ‘cut off’ for effectiveness in PFMT delivery and dose, but in the meantime there are certainly robust trials with well described interventions demonstrating clinically significant effect that are suitable models for application in practice.
3. Importance of outcome: UI is a prevalent (>30%) and bothersome condition reducing QoL and especially participation in physical activity (Nygaard et al 2005, Hamid et al 2015), and therefore important to prevent. In the Canadian guideline it is stated that prior to convening the panel, "10 pregnant women were recruited by convenience sampling and invited to provide input on the perceived benefits and harms of physical activity, and to identify pregnancy outcomes that were most important to them." Studies consistently finds women perceive UI as stigmatizing and at the same time ‘normal’ for parous women, and UI is a topic they are reluctant to talk about (Hamid et al 2015). Postpartum the dominant view of women is that of ‘if only I’d known then what I know now’, and ‘I wish someone had told me about UI, and taught me how to do PFMT properly’ (Mason et al 2001, Mason et a 2001, Neels et al 2016). If the 10 pregnant women in the expert group were continent, not aware that they might develop incontinence after birth and were more concerned about other common maternity conditions or the health of the babies, UI may not have reached their attention. We are surprised that specialized women's health physiotherapists who are the experts in this field both in high quality research and clinical practice, were not included in the panel nor as experts.
4. Use of resources: PFMT is already part of ante-and postnatal health care in most developed countries. PFMT has proved to be effective as part of group training for women and can therefore be administered at low cost to the health system.
5. Impact of health equity: Not informing or providing PFMT to pregnant women creates inequity as failure to prevent UI in pregnancy means that women are potentially set up for many years of UI symptoms with all the consequent effects on self-esteem, withdrawal from physical activity, not playing with their children, the cost of buying products and laundry and the cost of physiotherapy and surgery.
6. Feasibility: PFMT has successfully been incorporated in comprehensive exercise classes since 1986 (Bø et al 1990, Mørkved et al 2003, Stafne et al 2012).
7. Acceptability: PFMT research is firmly on the side of acceptability. Studies show that women want to do PFMT as first line treatment, but they must be informed about why and how they should do it (Mason et al 2001, Mason et al 2001). The long-term effect of PFMT is, as for all exercise interventions, dependent on maintenance of training. There are challenges with long term adherence/attrition from all forms of exercise/physical activity programs, and this is NOT a specific nor more pronounced problem for PFMT. Again, this is not an argument for assigning PFMT a weak recommendation.
In summary, it appears the guideline panel has, perhaps in deciding on a weak recommendation, over-emphasized concerns about quality of evidence (in which other areas of exercise in medicine are there more RCTs showing clinically relevant effect?), and may not have ‘heard’ how bothered women are about the problem of UI. Most, or all, pregnant women would benefit from PFMT during pregnancy to prevent UI because: PFMT does prevent UI in late pregnancy, postpartum, and potentially for life (as well as preventing pelvic organ prolapse), it does no harm, women would do PFMT if they knew why it was important (but the system fails them by not giving them this information), women who do leak experience significant bother, and the training can be incorporated with other physical activity to maximize gains from time spent in exercise. The Canadian guidelines' weak recommendation appears inconsistent with the evidence and positive impact of existing research.
Strong recommendation for yoga?
We further question the evidence for the "strong recommendation" and "high quality evidence" that adding yoga and gentle stretching is beneficial. For which conditions is yoga beneficial during pregnancy? It would seem that yoga/ gentle stretching classes would indeed have the same cost and feasibility/ equity/ acceptability concerns as group training of the PFM.
Diastasis recti abdominis
Why is diastasis recti abdominis considered a critical outcome? There is no scientific evidence that this causes any harm. The guidelines refer to the systematic review of Davenport et al (2018 b). They conclude that there is no relationship between prenatal exercise and diastasis. However, the guideline states that continuing aerobic exercise (walking) is associated with less odds of development of diastasis. Based on which studies? Neither Sperstad et al (2016) nor Fernandes de Mota et al (15) found such associations.
The guideline recommends that women with a diastasis postpartum should avoid curl-ups and refer to Mota et al (2015) to support this statement. However, Mota et al (2015) found the contrary; abdominal crunch narrows the inter-rectal distance and indrawing opens the gap. This has now been supported by several studies.
In conclusion, we are concerned that how the Canadian guideline group have defined quality of evidence and weak and strong recommendations, may mislead pregnant women and heath care providers to believe that there is weak scientific evidence for prevention and treatment effects of PFMT for UI. This may discourage pregnant women from starting or continuing PFMT in a very important period to prevent and treat the condition. The guideline group may have - inadvertently – through issuing a weak recommendation for PFMT in pregnancy, put the onus onto individual health care professionals and women to make decisions about teaching or doing the exercises without regard to all the factual information. Women ‘don't know what they don't know’. Are we truly accepting that one third of women will experience stress urinary incontinence by mid-age when this could potentially be prevented through ante-natal PFMT? We urge the panel to re-consider their recommendation and are happy to supply any further evidence as required to guide the evidence grading.
Kari Bø, Professor, PhD. The Norwegian School of Sport Sciences, Dept of Sports Medicine, Oslo, Norway.
Chantale Dumoulin, Professor, PhD. University of Montreal, School of Rehabilitation, Montreal, Canada
Cristine HJ Ferreira, Associate Professor, PhD, University of Sao Paulo, Ribeirao Preto Medical School, Ribeirao Preto, Brazil
Helena Frawley, Associate Professor, PhD, Monash University, Dept of Physiotherapy, Melbourne, Australia
Jean Hay-Smith, Associate Professor, PhD, University of Otago, Wellington, New Zealand
Siv Mørkved, Professor, PhD, Norwegian University of Science and Technology, Dept of Public Health and Nursing, Trondheim, Norway
Ingrid Nygaard, Professor, MD, MS, University of Utah, School of Medicine, Salt Lake City, USA
Margaret Sherburn, PhD, Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
References
Bø K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Med 2004; 34: 451-464.
Bø K,Hagen RH, Kvarstein B, Jørgensen J, Larsen S. Pelvic floor muscle exercise for the
treatment of female stress urinary incontinence: III.Effects of two different degrees of pelvic floor muscle exercises. Neurourol Urodyn; 1990: 9,5:489-502.
Davenport MH, Nagpal TS, Mottola MF et al. Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy; a systematic review and meta-analysis. Br J Sports Med 2018; 52: 1397-1404.
Davenport MH (B), Ruchat SM, Sobierajski F et al. Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis. Br J Sports Med. 2018 Oct 18. pii: bjsports-2018-099821. doi: 10.1136/bjsports-2018-099821. [Epub ahead of print]
Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20:200-2005
Hamid TA, Pakgohar M, Ibrahim R, Dstjerdi MV. "Stain in life": The meaning of urinary incontinence in the context of Muslim postmenopausal women through hermeneutic phenomenology. Archieves Geront Geriatr 2015; 60: 514-521.
Hay-Smith EJC, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD009508. DOI: 10.1002/ 14651858. CD009508.
Herbison P, Hay- Smith J, Gillespie WJ. Meta-analyses of small numbers of trials often agree with longer-term results. J Clin Epidem 2011; 64: 245-153.
Mason L, Glenn S, Walton I Hughes C. Do women practice pelvic floor exercises during
pregnancy or following delivery? Physiotherapy 2001, 87; 662-670.
Mason L, Glenn S, Walton I, Huges C. The instruction in pelvic floor exercises provided to women during pregnancy or following delivery. Midwifery 2001; 17: 55-64.
Mota PI, Pascoal AG, Carita AI, Bø K. The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period. J Orthop Sports Phys Ther. 2015;45:781-8.
Mørkved S, Bø K, Schei B, Salvesen KA. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial. Obstet Gynecol. 2003;101: 313-9.
Neels H, Wiebren A,Tjalma A, Wyndaele, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in menopausal women and in peripartum women. J. Phys. Ther Sci. 2016; 28: 3020–3029.
Nygaard IE, Shaw JM. Physical activity and the pelvic floor. Am J Obstet Gynecol. 2016; 214: 164-171.
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a barrier to exercise in women? Obstet Gynecol. 2005;106: 307-14.
Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016;50: 1092-1096.
Stafne SN, Salvesen KÅ, Romundstad PR, Torjusen IH, Mørkved S. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG. 2012 Sep;119(10):1270-80. doi: 10.1111/j.1471-0528.2012.03426.x. Epub 2012 Jul 17.
Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD007471. DOI: 10.1002/14651858.CD007471.pub3.
The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.
The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to sugg...
The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.
The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to suggest that they are harmful to patients. Whilst most agree there is a lack of compelling evidence to support the use of Kinesiotape, there is no research data (rock solid or otherwise) to demonstrate that this practice is measurably harmful.
The public assertion that a treatment is ‘harmful’ is a serious one indeed, and if patients are truly being harmed by any element of care, then an inquiry at the highest level (Physiotherapy governing bodies) would be required to identify and prevent future adverse events. Other professions are very successful at both defining and quantifying harmful events 4 5. They do this with a specific professional interest in future prevention, and providing patients with a measure of the risk of interventions6 or screening7. There is no reason why physiotherapy cannot aspire to this level of scientific scrutiny.
The concept that the use of non-efficacious physiotherapeutic management options may lead to delays to ‘best care’ is well understood, and is frustrating to observe. However, to suggest that this somehow translates into material harm is at best distortion of reality and at worst a wilful manipulation of the available data. This unfortunately manifests into opinion based medicine, or fake news, which is misleading to therapists, patients and the general public alike. The validity of recording patient safety and capturing harm data is affected by many factors, including the variable definitions of patient harm, together with the lack of valid and reliable data on the types of harm and prevalence rates in practice across all areas of healthcare. These acknowledged limitations affect our ability to quantify harm, BUT should not deter us from attempting to do so.
This response to the editor, categorically does not support the use of non-efficacious treatments. However, in the interest of communicating health risk in science publications 8 it does support the concept of conveying clear, consistent messages. This requires accurate definitions and robust data to support statements that appear in the public domain and may impact on patient decision making, safety and care.
We challenge the authors of this editorial to provide the harm data on the specific physiotherapy interventions named, OR withdraw their claim on the basis that it is not supported by their Utopian ideal of ‘rock solid research data’.
References
1. Zadro JR, O'Keeffe M, Maher CG. Evidence-based physiotherapy needs evidence-based marketing. Br J Sports Med 2018 doi: 10.1136/bjsports-2018-099749 [published Online First: 2018/10/29]
2. Xiang J, Wang W, Jiang W, et al. Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials. J Rehabil Med 2018;50(10):852-59. doi: 10.2340/16501977-2385 [published Online First: 2018/09/29]
3. Hauger AV, Reiman MP, Bjordal JM, et al. Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 2018;26(2):399-410. doi: 10.1007/s00167-017-4669-5 [published Online First: 2017/08/19]
4. Rozental A, Kottorp A, Boettcher J, et al. Negative Effects of Psychological Treatments: An Exploratory Factor Analysis of the Negative Effects Questionnaire for Monitoring and Reporting Adverse and Unwanted Events. PLoS One 2016;11(6):e0157503. doi: 10.1371/journal.pone.0157503 [published Online First: 2016/06/23]
5. Duggan C, Parry G, McMurran M, et al. The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials. Trials 2014;15:335. doi: 10.1186/1745-6215-15-335 [published Online First: 2014/08/28]
6. The Health Foundation. Levels of harm: ; 2011 [Available from: https://www.health.org.uk/publications/levels-of-harm accessed 21/11/2018 2011.
7. Cotter AR, Vuong K, Mustelin L, et al. Do psychological harms result from being labelled with an unexpected diagnosis of abdominal aortic aneurysm or prostate cancer through screening? A systematic review. BMJ Open 2017;7(12):e017565. doi: 10.1136/bmjopen-2017-017565 [published Online First: 2017/12/15]
8. Freeman ALJ, Spiegelhalter DJ. Communicating health risks in science publications: time for everyone to take responsibility. BMC Med 2018;16(1):207. doi: 10.1186/s12916-018-1194-4 [published Online First: 2018/11/14]
The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.
First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-p...
The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.
First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-pocket costs and a referral from another care provider. Referrals to physical therapy remain overall very low (7-16.3%). We would argue that the PT First strategy as a direct to consumer marketing approach is necessary and that this viewpoint likely varies based on the unique and complex interactions of healthcare delivery that are different between each society.
Our second point involves the use of physical therapy services as a substitute for traditional methods that have not shown benefit. Recently, the Centers for Disease Control and Prevention (CDC) released guidelines that recommended nondrug approaches such as physical therapy over long-term or high-dosage use of addictive prescription painkillers.[5] They made this recommendation despite the current lack of high-quality research to support physical therapy; they did so because the current approach was not working. Although Zadro and Colleagues' state that early access to harmful or ineffective physical therapy treatments is unlikely to improve patient outcomes or the opioid crisis, harms associated with PT are lower than those associated with other common first-line choices. In addition to harm, it’s important to also consider other outcomes that are valuable to patients. Porter et al.[6] argue for the capture of outcomes such as prevention of inappropriate downstream care, burden of receiving care, and delay in receiving care, which are not routinely collected in clinical trials. Promising findings from the PT-First studies suggests that downstream use of opioids, injections, and surgeries decreases when PT is accessed early.
Our third point is bound around the concept of high-value care. As Traeger and colleagues have stated, “Most commentators accept that the solution is not simply to stop providing low-value care, but rather that high-value healthcare requires the replacement of inappropriate care with appropriate care”.[7] We argue that replacement of inappropriate care is the backbone of the PT First initiative. Whereas further work is needed to optimize “appropriate care”, inappropriate care options are now well established. Reducing first line high stakes, high-risk options should at a minimum be a priority. Strategies designed to change system level issues are a priority. Insurance companies are paying attention and considering alternate payment and compensation models. Mass media campaigns have been called for to address the overemphasis of imaging, medication, and surgery,[8] and we feel that the PT First approach is a step in the right direction.
In summary, we agree with the editorial that more research is needed to identify appropriate triaging for MSK pain. We argue that it is also needed to support a primary care first strategy, a surgeon first strategy, a chiropractor first strategy and essentially every other provider. We felt that the editorial points fell short in its assessment of the potential immediate benefits of a PT First approach. Yes, we must continue to improve and promote utilization of evidence-based treatments within physiotherapy but let’s optimize on the opportunities that are currently available and that are already known (e.g., reducing opioids, inappropriate imaging, and low-value surgical options). We do not feel that “PT First” marketing is anti-collaborative, “failing to be part of team-based care and wanting to create a hierarchy among providers” as the majority of PT-First studies took place in multi-disciplinary and collaborative care settings. The focus of “PT First” in marketing was intended to promote an alternative to opioids, injections, or advanced imaging as first-care choices. In other words, “choose PT first, before choosing other higher risk treatment strategies.”
References
1 Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012;197:100–5.
2 Gidwani R, Sinnott P, Avoundjian T, et al. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely? Am J Manag Care 2016;22:e68–76.
3 Friedman BW, Chilstrom M, Bijur PE, et al. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine 2010;35:E1406–11.
4 Lin DH, Jones CM, Compton WM, et al. Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers. JAMA Netw Open 2018;1:e180235–e180235.
5 CDC Guideline for Prescribing Opioids for Chronic Pain. 2018.https://www.cdc.gov/drugoverdose/prescribing/guideline.html (accessed 11 Nov 2018).
6 Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N Engl J Med 2016;374:504–6.
7 Traeger AC, Moynihan RN, Maher CG. Wise choices: making physiotherapy care more valuable. J Physiother 2017;63:63–5.
8 O’Keeffe M, Maher CG, Stanton TR, et al. Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care. Br J Sports Med 2018;:bjsports – 2018–099691.
For readers who are following the debate about how training load may relate to injury, Dr Johann Windt considers the implication of the correlation that is pointed out here. Thanks to all the authors. k2
https://bjsm.bmj.com/content/early/2018/05/28/bjsports-2017-098925
The study raises two questions that one of the authors might be able to help with:
First, the authors report both within group and between group changes in body fat in the abstract. But it is unclear why the authors chose the within-group changes (28% fat loss) as the study conclusion than the between-group change.
The within group change showed a fat loss of 0.45 kg (28%) in favor of interval training (IT), while the between-group changes showed a large difference of 2.28 kg of fat loss in favor of IT. Considering the large difference in fat loss, and some studies recommending to avoid within group differences in meta-analysis, it would be helpful if the authors could comment on this.
Second, maintaining lean body mass (LBM) is one of the primary reasons to include exercise as part of a weight loss strategy. So it is not clear why the authors chose not to include lean body mass as one of the outcomes. It would have certainly helped the reader to make a decision regarding the choice of exercise for weight loss.
Finally, congratulations to all the authors for asking a very relevant question!.
We thank Freke et al. (1) for their systematic review about physical impairments in patients with symptomatic femoroacetabular impingement, nonetheless we have some remarks about methods and results of the article, in particular for range of motion (ROM) outcome.
Show MoreA meta-analysis of ROM was performed without reporting an overall estimate. Taking into account the amount of studies included and their information, a meta-analysis should have been accomplished. Nonetheless, authors concluded that individuals with symptomatic FAI demonstrated no difference in hip ROM in any direction of movement. This conclusion was unexpected taking into account the findings reported in the primary studies included), and in the previous systematic review published in 2015 (2), that showed instead a reduced ROM.
This discrepancy in literature is already discussed by the Warwick agreement (3), where authors stated that “the evidence on hip range of motion (ROM) in FAI syndrome is surprisingly contradictory” due to contrasting published systematic reviews (1) (2).
Therefore, we checked the accuracy of results reported, analyzing the data reported for every movement assessed in primary studies comparing those reported in this systematic review. We noted some issues in the represented forest plots.
Firstly, some included studies (4), (5), (6), (7) were reported twice in the meta-analysis for different times points or reporting double data of the same patients obtained by two...
Dear Editor,
I would like to congratulate the British Journal of Sports Medicine for the publication of the study ‘The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial’ conducted by Harøy et al.[1]. The study investigated the effect of the adductor strengthening programme on the prevalence of groin problems among football players. The findings are incredibly important for the development of sports medicine because of their clinical relevance.
Regarding the methodology of this study, rather than giving criticism, I would like to suggest the authors if they can provide additional information or even a follow-up article on the game performance of the football teams involved in this study. As mentioned in the article, the authors have considered the groin pain causing time loss, decreasing participation or performance of the players [1]. Meanwhile, the previous study literally found that a lower incidence rate was strongly correlated with the number of goals, games won and even team ranking position [2,3]. Therefore, readers are interested whether the performance could be improved too since the results showed a significant reduction in the prevalence of groin pain in the players.
Similar studies have been conducted to investigate the effect of a specific strength training programme on players’ injury prevalence and individuals’ performance [4]. However, no data was included to refl...
Show MoreI had been a sufferer of exercise-associated hyponatraemia for at least a year, when I was living on a farm, as a direct result of drinking bore water. Unlike most bores which are overmineralized and dirty, these ones tapped into deep aquifers, that sourced ultra purified water. Because the water is trapped under deep layers of dolomites and Saprolites, the only way it can travel deeper into the earth is by passing through the micro pores of rocks, which results in micro filtration and ultra purification.
But humans are adaptable to drinking pure water and pure water alone isn't going to make a normal person hyponatraemic, I had at one stage performing a labour intensive job as a tree surgeon. Also, because I have ADHD, I am medicated with adder-all.
My situation was quite rare because I was living on a farm, drinking bore water and had a job pruning trees in residential areas, in the city. There, one would sweat heavily and would be drinking city water, which is one recipe for water that has a good mineral trace element content to it, but going home later that evening meant a diet of pure drinking water or cooking foods in pure water. This messed me up and affected my clear state of mind, often its a state of delirium that you start to feel as one of the typical symptoms.
But then I also go back to the adder-all, which may have some role in making me vulnerable, because its an amphetamine and similar to the way ecstasy makes people become wate...
Show MoreMany of you will be familiar with The BMJ and its popular 'Rapid Responses'. Because we are a sister journal to The BMJ (and part of the same publishing company of course) we have the same Platform and we encourage you to use it.
Why is this in BJSM? In general, it is best to have papers go through peer review in the most relevant journal to their subject matter to ensure that the production team is well placed to find suitable editors and reviewers.
Letter to the Editors
Show MoreBr J Sports Med
J Obstet Gynecol Canada
Oslo, Nov 23rd 2018
Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy
We have read the Canadian guideline for physical activity throughout pregnancy with great interest. We note that the guideline team have made their recommendation regarding pelvic floor muscle training (PFMT) based on evidence from a systematic review from the same research group (Davenport et al 2018). The main results of this review are in line with the latest Cochrane review (Woodley et al 2017) on the same topic; while there are some methodological differences and variations in which studies were included or not (two of the largest studies on PFMT was left out from the Davenport review; Mørkved et al 2003 and Stafne et al 2012), the findings in terms of size and precision of effect are similar, although Davenport et al used odds ratio and Woodley et al used risk ratio for their summary statistic. Davenport et al reported that PFMT gave a 50% reduction in prenatal UI and a 35% reduction in postnatal UI, but the guideline team concluded a “weak recommendation” for PFMT because UI was not rated as a "critical outcome" and the evidence was of "low quality". We find this conclusion at odds with the evidence and the interpretation of the evidence based on the guideline team’s own criteria.
The Canadian guideline grades...
The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.
The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to sugg...
Show MoreThe editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.
First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-p...
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