Dr. Cleather and colleagues’ state, “connecting [statistical] abstractions to the real world requires theoretical and practical assumptions that often depend on discipline-specific knowledge.” We agree: that is why our author line includes both sport and exercise scientists, as well as statisticians who have worked with sports and exercise data. Every single author has co-authored empirical work reporting sport and exercise science or medicine. Our interest in practical questions is exactly why we have carefully evaluated and drawn attention to important errors with methods such as those mentioned in the paper.
Nowhere in our paper did we state nor imply that statisticians should be privileged in any way, nor need they be a part of every study. Our point is simply to collaborate with those who have the expertise to improve the quality of a study. Although our suggestions are far from a panacea for improving sports science and medicine, we believe they are a step in the right direction. Indeed, the improvement of designs and analysis is in no way mutually exclusive of addressing practical considerations and considering philosophically different approaches to analysis. We thank Cleather et al. for providing us with the opportunity to clarify.
We welcome the call of Sainani et al.[1] for greater involvement of statisticians with researchers in sports science. However, effective collaboration requires understanding of context and in sports science research is often exploratory, concerned with small samples or predicated on the need to make practical decisions of relatively low risk. We argue for a collaborative approach that recognises the special needs of sports scientists and end-users of their research.
Where should statistical methods be published?
Sainani et al.[1] suggest that statistical methods should be vetted in statistics or general-interest journals before appearing in discipline-specific journals, implying that statistical methods can be evaluated independently of their context. While the mathematical core of statistics may be invariant among most disciplines, connecting these abstractions to the real world requires theoretical and practical assumptions that often depend on discipline-specific knowledge. Beyond that, there are wide philosophical divides among statisticians of frequentist and Bayesian persuasion. Similarly, we have pragmatic considerations like the degree of uncertainty we can accept when making decisions.
Statistical methods are sometimes developed to answer practical questions to which statisticians are blind. The chemist William Gosset studied the statistics of small sample sizes because he had an interest in barley cultivation arising from...
We welcome the call of Sainani et al.[1] for greater involvement of statisticians with researchers in sports science. However, effective collaboration requires understanding of context and in sports science research is often exploratory, concerned with small samples or predicated on the need to make practical decisions of relatively low risk. We argue for a collaborative approach that recognises the special needs of sports scientists and end-users of their research.
Where should statistical methods be published?
Sainani et al.[1] suggest that statistical methods should be vetted in statistics or general-interest journals before appearing in discipline-specific journals, implying that statistical methods can be evaluated independently of their context. While the mathematical core of statistics may be invariant among most disciplines, connecting these abstractions to the real world requires theoretical and practical assumptions that often depend on discipline-specific knowledge. Beyond that, there are wide philosophical divides among statisticians of frequentist and Bayesian persuasion. Similarly, we have pragmatic considerations like the degree of uncertainty we can accept when making decisions.
Statistical methods are sometimes developed to answer practical questions to which statisticians are blind. The chemist William Gosset studied the statistics of small sample sizes because he had an interest in barley cultivation arising from his employment as a brewer at Guinness[2]. This work didn’t interest contemporary statisticians, who almost always worked with large samples. Similarly, Ronald Fisher developed analysis of variance in the Journal of Agricultural Science and the method was presented side-by-side with the results of its application[3–5]. Few of the new algorithmic approaches that dominate data science were published in statistical journals but rather were developed by computer scientists tackling real-world problems like speech recognition[6].
Magnitude-based inference (MBI) is presented by Sainani et al.[1] as an example of why new methods should not be published in discipline-specific journals. Yet the procedure was developed to address discipline-specific challenges. Criticisms that statisticians have levied against MBI make no reference to the context in which it is being applied[7,8]. Equally, statisticians' modelling of the method has been incomplete and uses assumptions that are not always valid[9]. If publication of the method in sports science journals had engendered a supportive collaboration, then a long-standing and unhelpful dispute would have been avoided. Instead, statisticians have tended to take an uncompromising stance on MBI that fails to engage thoughtfully with arguments in support of the method[10,11].
Should statistical debate be privileged?
Sainani et al.[1] present several studies as cases supporting their contention that research quality can suffer when statisticians are not involved. They define a statistician as someone from a "methodologically-oriented" academic department, but most of the supposedly unsound studies include authors who by any reasonable definition are experienced applied statisticians. In any case, who qualifies as a statistician should be moot, as science is an open society. One of Robert Merton’s norms of scientific behaviour[12] is universalism – ideas should be judged on their merits alone without reference to their originator. Despite this, some of Sainani et al.’s arguments are calls to authority rather than genuine engagement in scholarly debate. Thus, an alternative approach to principal component analysis, disseminated only as a preprint[13], is described as flawed because it “does not interpret the data conventionally, interprets the resulting scores as loadings, and has been criticised by an expert in the field”. Preprints are used to solicit feedback prior to journal submission – they are an open invitation to collaborate. Rather than accept this invitation, Sainani et al. publicly castigate the work using two appeals to tradition and a reference to a Twitter conversation.
Collaboration will fail if any party grants themselves the authority to decide truth, especially when there is still debate within the literature. Sainani et al.[1] suggest that sports scientists have overlooked statisticians’ guidelines on response heterogeneity, but do not cite reviews on this topic by exercise scientists[14–16] and by exercise scientists collaborating with a statistician[17]. Similarly, meta-analytical and replicated crossover studies by sports scientists[18–20] (informed by statisticians[21–23]) are not cited. Sainani’s criticism of Loenneke and Dankel[24] refers to non-peer reviewed simulations by Tenan et al.[25,26] (one of Sainani’s co-authors) without considering a rebuttal of those simulations[27]. Moreover, Tenan[25] proclaims an intent to write to the editor of any journal that publishes work using the method to notify them that it is incorrect. This is akin to what Gieryn[28] called ‘boundary work’ – ideological activity that circumvents normal scientific discourse.
Statistics is not a unique, higher value skill. Rather, researchers have a range of specialised knowledge and skills (e.g., coding, research design, experimental skill). Deficiencies in any of these areas can lead to flawed research. Science is error-correcting through the organised scepticism of the scientific community (another of Merton’s norms), not through imposing barriers to participation.
Conclusions
Sports scientists and statisticians have different criteria for what makes a method appropriate, and statistical or mathematical concerns don’t automatically trump experimental, philosophical or practical considerations. Instead, effective collaborations involve consensus-building in a spirit of mutual respect. To progress the field effectively, we need genuine partnerships not authoritarian edicts.
References
1 Sainani KL, Borg DN, Caldwell AR, et al. Call to increase statistical collaboration in sports science, sport and exercise medicine and sports physiotherapy. Br J Sports Med Published Online First: 19 August 2020. doi:10.1136/bjsports-2020-102607
2 Box JF. Guinness, Gosset, Fisher, and small samples. Stat Sci 1987;2:45–52. doi:10.1214/ss/1177013437
3 Fisher RA. Studies in crop variation. I. An examination of the yield of dressed grain from Broadbalk. J Agric Sci 1921;11:107–35. doi:10.1017/S0021859600003750
4 Box JF. RA Fisher and the design of experiments, 1922–1926. Am Stat 1980;34:1–7. doi:10.2307/2682986
5 Fisher RA, Mackenzie WA. Studies in crop variation. II. The manurial response of different potato varieties. J Agric Sci 1923;13:311–20. doi:10.1017/S0021859600003592
6 Jelinek F. Statistical Methods for Speech Recognition. MIT Press 1997.
7 Welsh AH, Knight EJ. “Magnitude-based inference”: a statistical review. Med Sci Sports Exerc 2015;47:874. doi:10.1249/MSS.0000000000000451
8 Sainani KL. The problem with" magnitude-based inference". Med Sci Sports Exerc 2018;50:2166–2176. doi:10.1249/mss.0000000000001645
9 Aisbett J, Drinkwater EJ, Quarrie KL, et al. Advancing statistical decision-making in sports science. StatRxiv 2020;2010:13375. doi:arXiv:2010.13375
10 Hopkins WG, Batterham AM. Error rates, decisive outcomes and publication bias with several inferential methods. Sports Med 2016;46:1563–1573. doi:10.1007/s40279-016-0517-x
11 Batterham AM, Hopkins WG. The Problems with “The Problem with ‘Magnitude-Based Inference.’” Med Sci Sports Exerc 2019;51:599. doi:10.1249/MSS.0000000000001823
12 Merton RK. The Sociology of Science: Theoretical and Empirical Investigations. University of Chicago Press 1973.
13 Cleather D. On the use and abuse of principal component analysis in biomechanics. SportRxiv 2019. doi:10.31236/osf.io/f48qk
14 Hopkins WG. Individual responses made easy. J Appl Physiol Bethesda Md 1985 2015;118:1444–6. doi:10.1152/japplphysiol.00098.2015
15 Atkinson G, Williamson P, Batterham AM. Issues in the determination of ‘responders’ and ‘non-responders’ in physiological research. Exp Physiol 2019;104:1215–25. doi:10.1113/EP087712
16 Atkinson G, Batterham AM. True and false interindividual differences in the physiological response to an intervention. Exp Physiol 2015;100:577–88. doi:10.1113/EP085070
17 Hecksteden A, Kraushaar J, Scharhag-Rosenberger F, et al. Individual response to exercise training - a statistical perspective. J Appl Physiol Bethesda Md 1985 2015;118:1450–9. doi:10.1152/japplphysiol.00714.2014
18 Williamson PJ, Atkinson G, Batterham AM. Inter-individual differences in weight change following exercise interventions: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 2018;19:960–75. doi:10.1111/obr.12682
19 Goltz FR, Thackray AE, King JA, et al. Interindividual responses of appetite to acute exercise: A replicated crossover study. Med Sci Sports Exerc 2018;50:758–68. doi:10.1249/MSS.0000000000001504
20 Goltz FR, Thackray AE, Atkinson G, et al. True interindividual variability exists in postprandial appetite responses in healthy men but is not moderated by the FTO genotype. J Nutr 2019;149:1159–69. doi:10.1093/jn/nxz062
21 Senn S. Mastering variation: Variance components and personalised medicine. Stat Med 2016;35:966–77. doi:10.1002/sim.6739
22 Cortés J, González JA, Medina MN, et al. Does evidence support the high expectations placed in precision medicine? A bibliographic review. F1000Research 2019;7:30. doi:10.12688/f1000research.13490.5
23 Mills HL, Higgins JP, Morris RW, et al. Detecting heterogeneity of intervention effects using analysis and meta-analysis of differences in variance between arms of a trial. medRxiv 2020;:2020.03.07.20032516. doi:10.1101/2020.03.07.20032516
24 Dankel SJ, Loenneke JP. A method to stop analyzing random error and start analyzing differential responders to exercise. Sports Med 2020;50:231–238. doi:10.1007/s40279-019-01147-0
25 Tenan AM. ‘Harming the scientific process:’ An attempt to correct the sports science literature, part 3. Retraction Watch. 2020.https://retractionwatch.com/2020/03/11/harming-the-scientific-an-attempt... (accessed 29 Sep 2020).
26 Tenan MS, Vigotsky AD, Caldwell AR. Comment on:“A method to stop analyzing random error and start analyzing differential responders to exercise.” Sports Med 2020;50:431–434. doi:10.1007/s40279-019-01249-9
27 Dankel SJ, Loenneke JP. Authors’ reply to Tenan et al.:“A method to stop analyzing random error and start analyzing differential responders to exercise.” Sports Med 2020;50:435–437. doi:10.1007/s40279-019-01250-2
28 Gieryn TF. Boundary-work and the demarcation of science from non-science: Strains and interests in professional ideologies of scientists. Am Sociol Rev 1983;48:781–795. doi:10.2307/2095325
We read with great interest the article by Asif et al. (1), and applaud their call to action for education and research in sports and exercise medicine in the USA. We want to extend this call to action to the UK medical education system, where a similar need for physical activity (PA) promotion and development of sports and exercise medicine is needed.
Similar to the USA, there is poor adherence to PA guidelines in the UK population with only 66% of adults engaging in ≥150 minutes of moderate PA per week, the minimum amount found to produce health benefits (2). PA is associated with many positive health outcomes such as enhanced psychological well-being, cancer prevention and increased brain and cardiovascular health, showing it is an essential and valid way to better the health of the population (3). Furthermore, physical inactivity is associated with 16.9% of all-cause mortality in the UK, affirming the need to control and reverse the inactivity epidemic (4).
The public view doctors as a respectable source of information, which when coupled with the regular contact they have with the community places them as an invaluable resource for PA promotion in the UK (5). However, in their article, Asif et al. (1) describe how doctors in the USA have not been adequately prepared to provide advice and counselling on PA. It is evident that this inadequacy also applies to doctors in the UK. In 2012, the mean number of hours spent teaching PA science and promotion in UK...
We read with great interest the article by Asif et al. (1), and applaud their call to action for education and research in sports and exercise medicine in the USA. We want to extend this call to action to the UK medical education system, where a similar need for physical activity (PA) promotion and development of sports and exercise medicine is needed.
Similar to the USA, there is poor adherence to PA guidelines in the UK population with only 66% of adults engaging in ≥150 minutes of moderate PA per week, the minimum amount found to produce health benefits (2). PA is associated with many positive health outcomes such as enhanced psychological well-being, cancer prevention and increased brain and cardiovascular health, showing it is an essential and valid way to better the health of the population (3). Furthermore, physical inactivity is associated with 16.9% of all-cause mortality in the UK, affirming the need to control and reverse the inactivity epidemic (4).
The public view doctors as a respectable source of information, which when coupled with the regular contact they have with the community places them as an invaluable resource for PA promotion in the UK (5). However, in their article, Asif et al. (1) describe how doctors in the USA have not been adequately prepared to provide advice and counselling on PA. It is evident that this inadequacy also applies to doctors in the UK. In 2012, the mean number of hours spent teaching PA science and promotion in UK medical schools was just 4.2 across the whole curriculum, compared to 109 hours spent teaching pharmacology (6). Since then, PA teaching within medical school curricula has slightly improved, but there is still a profound lack of knowledge within student populations. Only 14.9% of medical students at the University of Edinburgh could correctly recall the UK adult PA guidelines and a meagre 10% felt they were adequately trained to give PA advice (7). In addition to the lack of effective PA teaching throughout medical school, there were only 9 training places for sports and exercise medicine within the NHS in 2015 - none of which were in Scotland, Northern Ireland or Wales (8). This is a speciality which has the potential to play a monumental role in safe exercise prescriptions and in the prevention of non-communicable diseases, but the scarcity of training in sport and exercise medicine is creating a barrier for the effective practice and PA promotion of our future doctors.
We want to extend and expand upon the call to action put forward by Asif et al. (1) to create change within medical school curricula in the UK:
• Develop and implement physical activity/exercise medicine education curricula in all UK medical schools and increase the number of training places for sports and exercise medicine within the NHS. Comprehensive core exercise medicine and chronic disease modules have been designed for use by medical schools in the UK, but these need to be more widely utilised and embedded within curricula.
• Build upon and improve research to identify clinical models to promote PA in practice. Research is already taking place for the effective prescription of exercise for the improvement of various conditions. However, there is still vast amounts of work to be done to make this evidence more robust and extend it to be applicable to more population groups. Psychology should be used to construct interventions which appeal to patients, and ensure adherence is maintained (9).
• Define and expand local, regional and national partnerships that cultivate community resources to promote physical activity/exercise medicine, especially for under-represented minority and medically underserved populations. Social prescribing is a relatively new scheme within the NHS that provides a pathway for healthcare professionals to refer patients to a ‘link worker’. This is a worker that works with local community groups to deliver valuable services to people to improve their health and well-being such as healthy cookery classes, volunteering, exercise groups and art activities - creating a holistic approach to healthcare. The effective partnership between social prescribing and PA promotion in the community is unequivocal, confirming the benefits for its incorporation into medical education curricula.
• Encourage medical students and doctors to be more active. It is known that more active healthcare professionals promote PA more often, with this relationship beginning right from the start of medical school (10).
The benefits of PA for health have been well established but the levels of activity in the UK population still remain low. The implementation of this call to action to improve sports and exercise medicine education within the medical education system in the UK will allow us as healthcare professionals to lead the campaign to enhance and improve the health of millions of people.
References
1. Asif IM, Drezner JA. Sports and exercise medicine education in the USA: Call to action [Internet]. Vol. 54, British Journal of Sports Medicine. BMJ Publishing Group; 2020 [cited 2020 Oct 22]. p. 195–6. Available from: https://www.
2. Scottish Government. The Scottish Health Survey. Scottish Heal Surv. 2018;1.
3. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Scientific Report. US Dep Heal Hum Serv [Internet]. 2018 [cited 2019 Nov 19];1–779. Available from: https://health.gov/paguidelines/second-edition/report/pdf/PAG_Advisory_C...
4. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, et al. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–29.
5. Devine P. Northern Ireland Life and Times Survey 2008 [Internet]. 2008 [cited 2020 Jan 15]. Available from: www.ark.ac.uk/nilt
6. Weiler R, Chew S, Coombs N, Hamer M, Stamatakis E. Physical activity education in the undergraduate curricula of all UK medical schools: are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med [Internet]. 2012 Nov 1 [cited 2020 Oct 22];46(14):1024–6. Available from: http://old.rcplondon.ac.uk/
7. Osborne SA, Adams JM, Fawkner S, Kelly P, Murray AD, Oliver CW. Tomorrow’s doctors want more teaching and training on physical activity for health. Br J Sports Med [Internet]. 2017 Apr 1 [cited 2020 Oct 22];51(8):624–5. Available from: http://blogs.bmj.com/bjsm/2016/03/27/6726/
8. West LR, Griffin S. Sport and exercise medicine in the UK: What juniors should know to get ahead [Internet]. Vol. 51, British Journal of Sports Medicine. BMJ Publishing Group; 2017 [cited 2020 Oct 22]. p. 1567–9. Available from: http://www.fsem.ac.uk/
9. Biddle SJH, Mutrie N, Gorely T. Psychology of Physical Activity: Determinants, Well-being and Interventions. 3rd ed. Abingdon: Taylor & Francis Group; 2015.
10. Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009 Feb;43(2):89–92.
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Additionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negativ...
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Additionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negative predictor.
Next factor concerning to the problem of “true-genetic” subgroup is sex distribution. In Kwon et al. (1) paper females were significant minority i.e. 29.9% while females constituted of at least 40% of studied population (2,3).
The next problem is risk of exercise induced ischemia in HCM. Recent study (4) alerted that 50% patient with HCM experienced myocardial ischemia at resting condition (positive results of high sensitive troponin test). Importantly, half of them had painless angina (silent ischemia). In this particularly dangerous situation, patients may not receive benefit but harm due to exercise training (unsafety fitness with repeated, escalating ischemia). Importantly, ischemia is directly linked with myocardial dysfunction. The functional destruction by both type of ischemia (painful, painless ) was documented recently (5).
In summarize, high sensitive troponin must be evaluated before and monitored after exercise to start safety training program.
References
1. Kwon S, Lee HJ, Han KD, Kim DH, Lee SP, Hwang IC, Yoon Y, Park JB, Lee H, Kwak S, Yang S, Cho GY, Kim YJ, Kim HK, Ommen SR. Association of physical activity with all-cause and cardiovascular mortality in 7666 adults with hypertrophic cardiomyopathy (HCM): more physical activity is better. Br J Sports Med. 2020 Sep 23:bjsports-2020-101987. doi: 10.1136/bjsports-2020-101987. Epub ahead of print. PMID: 32967852.
2. Canepa M, Fumagalli C, Tini G, Vincent-Tompkins J, Day SM, Ashley EA, Mazzarotto F, Ware JS, Michels M, Jacoby D, Ho CY, Olivotto I; SHaRe Investigators. Temporal Trend of Age at Diagnosis in Hypertrophic Cardiomyopathy: An Analysis of the International Sarcomeric Human Cardiomyopathy Registry. Circ Heart Fail. 2020 Sep;13(9):e007230. doi: 10.1161/CIRCHEARTFAILURE.120.007230. Epub 2020 Sep 8. PMID: 32894986; PMCID: PMC7497482.
3. Bos JM, Will ML, Gersh BJ, Kruisselbrink TM, Ommen SR, Ackerman MJ. Characterization of a phenotype-based genetic test prediction score for unrelated patients with hypertrophic cardiomyopathy. Mayo Clin Proc. 2014;89:727-37.
4. Dimitrow PP, Czarnecka D, Kawecka-Jaszcz K, Dubiel JS. Sex-based comparison of survival in referred patients with hypertrophic cardiomyopathy. Am J Med. 2004;117:65-6.
5. Gębka A, Rajtar-Salwa R, Dziewierz A, Dimitrow P. Painful and painless myocardial ischemia detected by elevated level of high-sensitive troponin in patients with hypertrophic cardiomyopathy. Adv Interv Cardiol. 2018;14:195-198.
6. Rajtar-Salwa R, Gębka A, Dziewierz A, Dimitrow PP. Hypertrophic Cardiomyopathy: The Time-Synchronized Relationship between Ischemia and Left Ventricular Dysfunction Assessed by Highly Sensitive Troponin I and NT-proBNP. Dis Markers. 2019; 019:6487152. Dis Markers. 2019;2019:6487152.
We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM l...
We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM landscape for equity, diversity and empowered representationt. All of these factors ensured we had a focus on gender equity at all times in the development of the conference program.
So, is there more work to do? Absolutely! Just as Thorborg and colleagues identify, diversity is not just about gender, but covers many areas. Our College and our conference could be more diverse and this remains our aim in coming years.
References
1. Thorborg K, Krohn L, Bandholm T, et al. ‘More Walk and Less Talk’: Changing gender bias in sports medicine. British Journal of Sports Medicine 2020:bjsports-2020-102966. doi: 10.1136/bjsports-2020-102966
2. Bekker S, Ahmed OH, Bakare U, et al. We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine. British Journal of Sports Medicine 2018;52(20):1287-89. doi: 10.1136/bjsports-2018-099084
We read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
A recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every...
We read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
A recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every foot is aligned and neutral to improve function and avoid or minimize pain. However, when analyzing the study by Rasemberg et al.1 and contrasting with the results of two systematic reviews2,5, we concluded that the position does not seem useful for the treatment of plantar fasciitis.
In our opinion, the manuscript also lacks detail regarding feet typology and the type of correction applied to each orthosis–and these are our second point.
Even though the number of volunteers is representative and proper randomization was applied, the authors did not report the foot type classification, which somewhat confuses the clinical interpretation. Assuming that normal, planus, and cavus feet have different characteristics, it is likely that the participants reacted differently to the proposed treatments. Also, the insole was not described in detail, and it is challenging to understand the correction type used for each volunteer, which may interfere with data analysis and clinical decisions.
All volunteers referred to the podiatrist received the orthosis, but did they need this correction? It is like prescribing glasses for people without vision problems. It is not clear whether podiatrists could exclude volunteers who did not need correction, which may have also influenced the results. Thus, the following question remains: Did the intervention worsen those volunteers who did not need corrections, and results were pulled down?
Burns et al.6 compared the effects of customized and sham insoles in patients with bilateral cavus foot and foot pain. In this study, the insole customization did not aim to modify the hindfoot position. The longitudinal arch was supported, and an extrinsic heel post was introduced to limit the excessive lateral heel support. A superior effect of customized insoles on pain and physical function was found, indicating that specific interventions for specific foot types were efficient.
Another study7 investigated the effects of customized insoles adapted in flip-flop sandals with corrections in individuals with plantar fasciitis for 12 weeks. The authors proposed different supports for the midfoot based on foot typology, thus maintaining the plantar arches function. A significant improvement in morning pain and pain at the end of the day was observed in the intervention group compared with controls.
Therefore, we question the validity of the standard customization maintaining the neutral position regardless of the foot type and the dysfunctions.
The third point regards the way the assessment of the study participants was conducted. Although we agree that the evaluation using pads with different thicknesses to determine the neutral position of the ankle is feasible and used by clinicians worldwide, it may not represent the real patient’s need since significant differences are present between static and dynamic evaluations using this method8. Thus, it is probable that the used measures were insufficient or inadequate for the pad prescriptions, even if supported by a 3D system.
Regarding the sham insoles, we believe that the minimum effects generated by the insole thickness, softness, and different characteristics are important factors for both the comfort perception and pressure reduction sensation, and may have produced similar effects to the customized insole.
In this sense, we invite you to reflect on the next steps in investigating the effects of insoles on plantar fasciitis, ending the cycle of custom-made insoles in a neutral position and beginning the new era of insoles prescribed for function and not for disease.
References
1- Rasenberg N, Bierma-Zeinstra SMA, Fuit L, et al. Br J Sports Med Epub ahead of print:doi:10.1136/ bjsports-2019-101409
2- Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL, Landorf KB. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med. 2018;52(5):322-328. doi:10.1136/bjsports-2016-097355
3- Bruening DA, Pohl MB, Takahashi KZ, Barrios JA. Midtarsal locking, the windlass mechanism, and running strike pattern: A kinematic and kinetic assessment. J Biomech. 2018;73:185-191. doi:10.1016/j.jbiomech.2018.04.010
4- Behling AV, Nigg BM. Relationships between the foot posture Index and static as well as dynamic rear foot and arch variables. J Biomech. 2020;98:109448. doi:10.1016/j.jbiomech.2019.109448
5- Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801. Published 2008 Jul 16. doi:10.1002/14651858.CD006801.pub2
6- Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. J AmPodiatrMed Assoc. 2006;96(3):205-211. doi:10.7547/0960205
7- Costa ARA, de Almeida Silva HJ, Mendes AAMT, Scattone Silva R, de Almeida Lins CA, de Souza MC. Effects of insoles adapted in flip-flop sandals in people with plantar fasciopathy: a randomized, double-blind clinical, controlled study. ClinRehabil. 2020;34(3):334-344. doi:10.1177/0269215519893104
8- Behling AV, Manz S, von Tscharner V, Nigg BM. Pronation or foot movement - What is important. J Sci Med Sport. 2020 Apr;23(4):366-371. doi: 10.1016/j.jsams.2019.11.002. Epub 2019 Nov 8. PMID: 31776068
Contributors: All authors contributed equally to the letter.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared
Patient consent for publication: Not required.
Provenance and peer review: Not commissioned; externally peer reviewed.
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
• Analysis of hospita...
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
• Analysis of hospital data record relating to lower limb injuries to argue the case for an emerging epidemic of osteoarthritis and other conditions of direct relevant to physiotherapist and other sports medicine professionals.(8)
• Comparing the frequency of hospital admissions to emergency department presentations to general practitioner visits for sports injury treatment in a well-defined geographic area.(9)
• Understanding injuries in specific population sub-groups like children(10, 11) and those living in rural settings.(12, 13)
• Monitoring particular types of injury presentations such as concussion(14) and heat-illness,(15, 16) and to prioritise injury prevention efforts in particular sports.(17)
• Evaluating the effectiveness of an implemented low limb injury prevention program.(18)
Many of our studies have used routinely collected hospital data, which use the International Classification of Disease 10th Revision (ICD-10) (19) external causes to identify sports injury cases. This work has been influential in leading international recognition of the value of such ICD-coded data from hospital sources, though they are not without their challenges and limitations.(20, 21) Our studies, together with the larger body of published sports injury data derived hospital records from international groups (not referenced here), shows that the high value such data has for sports medicine is already established and is actually relatively common.
What Machado and colleagues(1) demonstrate is that interrogation and use of hospital data sources should not be restricted to cases with an external injury code. They show that other conditions relevant to sports medicine, like low back pain, can also be explored with hospital data. There is no doubt that more work of this nature would ensure that the sports medicine field is better informed about the conditions most related to their clinical practice.
References
1. Machado G, O'Keeffe M, Richards B, et al. Why a dearth of sports and exercise medicine/physiotherapy research using hospital electronic medical records? A success story and template for researchers. British Journal of Sports Medicine 2020;Published Online First: 21 May 2020. doi: 10.1136/bjsports-2019-101622
2. Finch C, Valuri G, Ozanne-Smith J. Sports and active recreation injuries in Australia: evidence from emergency department presentations. British Journal of Sports Medicine 1998;32(3):220-25.
3. Flood L, Harrison JE. Hospitalised sports injury, Australia 2002-03. Injury Research and Statistics Series Number 27. Flinders University, Adelaide: Australian Institute of Health and Welfare, 2006. (Accessed 31 July 2020):6-23. Available from http://www.aihw.gov.au/publication-detail/?id=6442467828. Accessed 11 Aug 2017.
4. Australian Institute of Health and Welfare (AIHW). Hospitalised sports inury in Australia, 2016-17. Published online as https://www.aihw.gov.au/reports/injury/hospitalised-sports-injury-austra..., 26 Feb 2020: AIHW, 2020. (Accessed 31 July 2020).
5. Finch CF. Getting sports injury prevention on to public health agendas - addressing the shortfalls in current information sources. British Journal of Sports Medicine 2012;46:70-74. doi: 10.1136/70 bjsports-2011-090329
6. Finch C, Wong Shee A, Clapperton A. Time to add a new priority target for child injury prevention? The case for an excess burden associated with sport and exercise injury: population-based study. BMJ Open 2014;4:e005043. [doi:10.1136/bmjopen-2014-43].
7. Victorian Government. Sports Injury Prevention Taskforce final report. Sport and Recreation Victoria. https://sport.vic.gov.au/resources/documents/sports-injury-prevention-ta... 2017. (Accessed 31 July 2020).
8. Finch C, Kemp J, Clapperton A. The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004-2010: A future epidemic of osteoarthritis? . Osteo & Cart 2015;23(7):1138-43. [First published online 04/03/2015 as doi:10.1016/j.joca.2015.02.165].
9. Cassell EP, Finch CF, Stathakis VZ. Epidemiology of medically treated sport and active recreation injuries in the Latrobe Valley, Victoria, Australia. British Journal of Sports Medicine 2003;37:405-09.
10. Fernando T, Berecki-Gisolf J, Finch C. Sports injuries in Victoria, 2012–13 to 2014–15: evidence from emergency department records. Medical Journal of Australia 2018;208(6):255-60. [Published online: 2 April 2018 doi: 10.5694/mja17.00872].
11. Schneuer F, Bell J, Adams S, et al. The burden of hospitalized sports-related injuries in children: an Australian population-based study, 2005-2013. Injury Epidemiology 2018;5:45. [Published online 17/12/2018 as https://doi.org/10.1186/s40621-018-0175-6].
12. Wong Shee A, Clapperton A, Finch C. Increasing trend in the frequency of sports injuries treated at an Australian regional hospital. Australian Journal of Rural Health 2017;25(2):125-27. [Published first online 17/04/2016 as doi:10.1111/ajr.12274].
13. Finch CF, Boufous S. Sports/leisure injury hospitalisation rates in New South Wales – evidence for an excess burden in remote areas. Journal of Science and Medicine in Sport 2009;12:628-32.
14. Finch CF, Clapperton AJ, McCrory P. Increasing incidence of hospitalisation for sport-related concussion in Victoria, Australia. Medical Journal of Australia 2013;198(8):427-30.
15. McMahon S, Gamage PJ, Fortington LV. Sports related heat injury in Victoria, Australia; an analysis of 11 years of hospital admission and emergency department data. Journal of Science and Medicine in Sport 2020 (in press) doi.org/10.1016/j.jsams.2019.08.275
16. Finch CF, Boufous S. The descriptive epidemiology of sports/leisure-related heat illness hospitalisations in New South Wales, Australia. Journal of Science and Medicine in Sport 2008;11(1):48-51. doi: papers3://publication/doi/10.1016/j.jsams.2007.08.008
17. Ekegren C, Gabbe B, Finch C. Medical-attention injuries in community Australian Football: A review of 30 years of surveillance data from treatment sources. Clinical Journal of Sport Medicine 2015;25(2):162-72.
18. Finch C, Akram M, Gray S, et al. Controlled ecological evaluation of an implemented exercise-training program to prevent lower limb injuries in sport – population-level trends in hospital-treated injuries. British Journal of Sports Medicine 2019;53:487-92. [First published BJSM Online First 14/09/2018 as doi: 10.1136/bjsports-2018-099488].
19. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision Geneva: World Health Organization; 2007 [Available from: http://apps.who.int/classifications/apps/icd/icd10online/ accessed 01/09/2011.
20. Finch CF, Boufous S. Activity and place – Is it necessary both to identify sports and leisure injury cases in ICD-coded data? International Journal of Injury Control and Safety Promotion 2008;15(2):119-21. doi: 10.1080/17457300801994936
21. Finch CF, Boufous S. Do inadequacies in ICD-10-AM activity coded data lead to underestimates of the population frequency of sports/leisure injuries? Injury Prevention 2008;14(3):202-04. doi: 10.1136/ip.2007.017251
Roe et al have written a useful article on the continuing misuse of relative risk, and the importance of understanding relative risk and absolute risk difference in injury risk outcomes in randomised controlled trials. In describing the Number Needed to Treat (NNT) they miss out an important word- the NNT is the number needed to treat to prevent one _extra_ adverse event, not to prevent a single adverse event. To see thus suppose the NNT was m. In their notation the risk in the intervention group is IG and the Control group is CG. The number of events expected in the intervention group if we treated m of them is mIG. To prevent one event we have mIG=1 and so we have to treat m=1/IG subjects to prevent one event. However we would expect mCG events in the control group. To prevent one _extra_ event in the intervention group we would require mCG-mIG =1 (assuming CG>IG) . Thus m=1/(CG-IG) which is the definition of the NNT. They could also, perhaps, have mentioned the problems in using the NNT, such as differing baselines leading to it being uninterpretable as described, for example by Stang, A., Poole, C., & Bender, R. (2010). Common problems related to the use of number needed to treat. Journal of Clinical Epidemiology, 63(8), 820–825
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are need...
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are needed to verify the interventional effects.
Second, Øverås et al. reviewed prospective studies to evaluate the associations between objectively measured physical behaviour and the risk or prognosis of neck pain (NP) and/or LBP (3). Eight studies out of 10 handled blue-collar workers, and increased sitting time at work reduced the risk of NP and LBP. Among blue-collar workers, increased physical activity during work and/or leisure increased the risk of NP and LBP. In addition, physical activity was not significantly associated with prognosis of LBP. These findings are not consistent with data by Shiri et al. (1), and type of job might be an important factor on the association.
Finally, Oliveira et al. reviewed prospective studies to investigate the prognostic role of physical activity in the course of LBP (4). Although low quality evidence presented that physical activity might not be a prognostic factor for pain and disability in patients with LBP, additional studies are indispensable to verify the association. I speculate that many factors would affect the relationship and might be complicated.
References
1. Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51(19):1410-1418. doi: 10.1136/bjsports-2016-097352
2. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for nonspecific low back pain: A Cochrane review. Spine (Phila Pa 1976). 2016;41(16):1284-95. doi: 10.1097/BRS.0000000000001645
3. Øverås CK, Villumsen M, Axén I, et al. Association between objectively measured physical behaviour and neck- and/or low back pain: A systematic review. Eur J Pain. 2020 Feb 24. doi: 10.1002/ejp.1551
4. Oliveira CB, Pinheiro MB, Teixeira RJ, et al. Physical activity as a prognostic factor of pain intensity and disability in patients with low back pain: A systematic review. Eur J Pain. 2019;23(7):1251-1263. doi: 10.1002/ejp.1395
Allow me to make use of the opportunity to extend my appreciation to the BJSM for being a publication of high standing, bringing cutting edge information to the sports medical fraternity.
Thank you for the consensus statement of the International Olympic Committee describing the methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] I found it both informative and useful.
I have a comment about the use of the word “Nervous” in the first column of Table 5. It is an adjective whereas the rest of the words in the column are nouns that more accurately describe the tissue type under discussion. It is possibly only a linguistic error, but I am of the opinion that it should be “Nerve” or “Neural tissue”.
Reference
1. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969
Dr. Cleather and colleagues’ state, “connecting [statistical] abstractions to the real world requires theoretical and practical assumptions that often depend on discipline-specific knowledge.” We agree: that is why our author line includes both sport and exercise scientists, as well as statisticians who have worked with sports and exercise data. Every single author has co-authored empirical work reporting sport and exercise science or medicine. Our interest in practical questions is exactly why we have carefully evaluated and drawn attention to important errors with methods such as those mentioned in the paper.
Nowhere in our paper did we state nor imply that statisticians should be privileged in any way, nor need they be a part of every study. Our point is simply to collaborate with those who have the expertise to improve the quality of a study. Although our suggestions are far from a panacea for improving sports science and medicine, we believe they are a step in the right direction. Indeed, the improvement of designs and analysis is in no way mutually exclusive of addressing practical considerations and considering philosophically different approaches to analysis. We thank Cleather et al. for providing us with the opportunity to clarify.
Andrew Vickers
On behalf on the authors
Introduction
We welcome the call of Sainani et al.[1] for greater involvement of statisticians with researchers in sports science. However, effective collaboration requires understanding of context and in sports science research is often exploratory, concerned with small samples or predicated on the need to make practical decisions of relatively low risk. We argue for a collaborative approach that recognises the special needs of sports scientists and end-users of their research.
Where should statistical methods be published?
Sainani et al.[1] suggest that statistical methods should be vetted in statistics or general-interest journals before appearing in discipline-specific journals, implying that statistical methods can be evaluated independently of their context. While the mathematical core of statistics may be invariant among most disciplines, connecting these abstractions to the real world requires theoretical and practical assumptions that often depend on discipline-specific knowledge. Beyond that, there are wide philosophical divides among statisticians of frequentist and Bayesian persuasion. Similarly, we have pragmatic considerations like the degree of uncertainty we can accept when making decisions.
Statistical methods are sometimes developed to answer practical questions to which statisticians are blind. The chemist William Gosset studied the statistics of small sample sizes because he had an interest in barley cultivation arising from...
Show MoreWe read with great interest the article by Asif et al. (1), and applaud their call to action for education and research in sports and exercise medicine in the USA. We want to extend this call to action to the UK medical education system, where a similar need for physical activity (PA) promotion and development of sports and exercise medicine is needed.
Similar to the USA, there is poor adherence to PA guidelines in the UK population with only 66% of adults engaging in ≥150 minutes of moderate PA per week, the minimum amount found to produce health benefits (2). PA is associated with many positive health outcomes such as enhanced psychological well-being, cancer prevention and increased brain and cardiovascular health, showing it is an essential and valid way to better the health of the population (3). Furthermore, physical inactivity is associated with 16.9% of all-cause mortality in the UK, affirming the need to control and reverse the inactivity epidemic (4).
Show MoreThe public view doctors as a respectable source of information, which when coupled with the regular contact they have with the community places them as an invaluable resource for PA promotion in the UK (5). However, in their article, Asif et al. (1) describe how doctors in the USA have not been adequately prepared to provide advice and counselling on PA. It is evident that this inadequacy also applies to doctors in the UK. In 2012, the mean number of hours spent teaching PA science and promotion in UK...
Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50
In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
Show MoreAdditionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negativ...
We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.
In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.
In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM l...
Show MoreWe read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
Show MoreA recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every...
The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.
The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)
Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
Show More• Analysis of hospita...
Roe et al have written a useful article on the continuing misuse of relative risk, and the importance of understanding relative risk and absolute risk difference in injury risk outcomes in randomised controlled trials. In describing the Number Needed to Treat (NNT) they miss out an important word- the NNT is the number needed to treat to prevent one _extra_ adverse event, not to prevent a single adverse event. To see thus suppose the NNT was m. In their notation the risk in the intervention group is IG and the Control group is CG. The number of events expected in the intervention group if we treated m of them is mIG. To prevent one event we have mIG=1 and so we have to treat m=1/IG subjects to prevent one event. However we would expect mCG events in the control group. To prevent one _extra_ event in the intervention group we would require mCG-mIG =1 (assuming CG>IG) . Thus m=1/(CG-IG) which is the definition of the NNT. They could also, perhaps, have mentioned the problems in using the NNT, such as differing baselines leading to it being uninterpretable as described, for example by Stang, A., Poole, C., & Bender, R. (2010). Common problems related to the use of number needed to treat. Journal of Clinical Epidemiology, 63(8), 820–825
Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.
First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are need...
Show MoreAllow me to make use of the opportunity to extend my appreciation to the BJSM for being a publication of high standing, bringing cutting edge information to the sports medical fraternity.
Thank you for the consensus statement of the International Olympic Committee describing the methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] I found it both informative and useful.
I have a comment about the use of the word “Nervous” in the first column of Table 5. It is an adjective whereas the rest of the words in the column are nouns that more accurately describe the tissue type under discussion. It is possibly only a linguistic error, but I am of the opinion that it should be “Nerve” or “Neural tissue”.
Reference
1. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969
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