425 e-Letters

  • Primary and community care assessment of concussions

    Dear Authors,

    Great work on putting together the child SCOAT6 and this is a really helpful piece for the office sport medicine doctors. However, what about the community healthcare teams, eg General Practitioners, GPs, what tool should they be using? Particularly bearing in mind the time constraints of community health contacts, eg GP consults in the UK are most often limited to 10 minutes. What can we expect non-specialist sport medicine doctors to do to help make the concussion diagnosis and therefore initiate appropriate management promptly? Should we be making a childSCATgp?

    More patients will be attending primary and community care facilities with concussion as the general knowledge around the diagnosis increases and with new policies and procedures identifying community resources to make the concussion diagnosis and management . Indeed, within the UK, there has recently been grassroots concussion protocols released and they advise that all concussions should be diagnosed by a healthcare practitioner. This will cause a number of patients, both children and adults. to present to community practitioners seeking a diagnosis and we therefore need a community tool to diagnose and manage concussions for the non-specialist healthcare practitioners. Time for a consensus meeting to discuss community, non-specialist concussion diagnosis and management?

  • Response to “Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education”

    Dear Editor,
    We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.

    The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.

    The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.

    It is worth noting t...

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  • Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education

    Dear Editor,

    We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].

    Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the...

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  • Blind-sided by fraud
    Eric N Grosch

    Dear Editor

    Pseudo-scientific detection of illusory entities did not end in 1907. Attributing physical mass to the “soul,” a man-made theological construct, exemplifies a fallacy Gould attributed to Mill:

    The tendency has always been strong to believe that whatever received a name must be an entity or being, having an independent existence of its own. And if no real entity answering to the name could be...

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  • The hidden placebo
    Christopher J Beedie

    Dear Editor,

    I read your editorial 'The power of placebo' with some relief. It would seem that all too often, 'advances' in practice and even research are relegating the placebo effect to the status of quackery. Certainly, I am not a great fan of many therapies or technologies that claim scientifically dubious healing or performance-enhancing qualities (I am to be honest even less of a fan of those who sell them...

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  • Comment On: “Injury incidence rates in women’s football: a systematic review and meta-analysis of prospective injury surveillance studies”

    We wish to commend Horan et al. (Horan et al., 2022) on their systematic review and meta-analysis which established overall, match and training IIRs in senior women’s football. It is encouraging to see continued work in this specific area of women’s football epidemiological research.

    We would like to draw the authors attention to the following error contained within their work. We respectfully request that it is amended accordingly so that the readership are aware of all available work in this area.

    Horan et al. (Horan et al., 2022) refer to the systematic review and meta-analysis of López Valenciano et al (López-Valenciano et al., 2021) which they report was recently ‘criticised’ in a published commentary by Mayhew et al (2021). The authors use the following citation:

    30. Mayhew, L. et al. (2021) ‘Incidence of injury in adult elite women’s football: a systematic review and meta-analysis’, BMJ Open Sport & Exercise Medicine, 7(3), p. e001094. doi:10.1136/bmjsem-2021-001094

    The readership should be aware that the citation Horan et al. (Horan et al., 2022) use in their work is not a published commentary but a systematic review and meta-analysis on the incidence of injury in elite women’s football. Our publication was PROSPERO registered and published ahead of Horan et al. (Horan et al., 2022) in BJSM’s sister journal (BMJ Open Sport & Exercise Medicine).

    The corrected citation should be:

    Mayhew, L., Johnson, M.I. and...

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  • Does exercise really boost immune response to Covid-19 Vaccine ?

    There is absolutely no doubt that physical activity is a beautiful phenomenon. In the above study, the study is fair to the extent that those subjects who regularly exercised had lesser hospitalisations. Here both reason and effect exist, but can a direct causal relationship be established between the two?
    Can it be inferred beyond doubt that "the vaccine prevented complications of Covid-19 because exercise strengthened the immune response? The possibility of such a remarkable effect in the short term is pretty unlikely. And all the more, such findings can't be generalised to a larger population.

    Authors seem to be ignoring a hidden confounder affecting the validity of the study, and this confounder is 'frailty'. Simply those doing less exercise were unable to do so because they were frail. And obviously, frailty can be present independent of comorbidities like DM, heart failure or obesity, which were evenly matched between the high and low-exercise groups.

    So, the correct conclusions will likely differ if this confounder is considered. one may not forget that 'Correlation, even if present in a statistically significant portion, may not amount to causation.

    The study might prompt some frail people or even morbidly obese people to engage in heavy exercise soon after the vaccination despite muscle aches and fever (common side effects of the Covid-19 vaccines). And these might have disastrous consequences. So the wo...

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  • Explicit motor learning interventions are still relevant for ACL injury rehabilitation: do not put all your eggs in the implicit basket!: Letter to the Editor

    Anne Benjaminse,1,2 Alli Gokeler3, 4, 5
    1 University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, Netherlands

    2 School of Sport Studies, Hanze University Groningen, Groningen, the Netherlands 

    3 Exercise Science and Neuroscience, Department Exercise & Health, Faculty of Science, Paderborn University, Paderborn, Germany

    4 Amsterdam Collaboration for Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands.

    5 OCON Center of Orthopaedic Surgery and Sports Medicine, Hengelo, The Netherlands

    Dear Editor,
    We read the recent manuscript by Kal et al.1 ‘Explicit motor learning interventions are still relevant for ACL injury rehabilitation: do not put all your eggs in the implicit basket‘ with great interest. The authors did a commendable job summarizing the current literature and we highly respect them for being critical, to foster academic discussions to move science forward. We do however have some concerns regarding the methodology and interpretations made by the authors.
    Confusing definition: description vs. execution
 First, the authors write: "Elite athletes have shown to successfully use explicit interventions to de-automate, and subsequently improve, problematic movements.“.2 The paper by Toner et al. is largely based on assumptions, case studies and philosop...

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  • Cardiopulmonary capacity and muscle strength in transgender women on long-term gender-affirming hormone therapy: A cross-sectional study.

    I appreciate the thoughtful considerations raised. Scientific discussion is always the best way for the opportunity to review points, exchange thoughts and evolve in knowledge. Here are some additional considerations below:

    - About strength and VO2peak controlled by FFM and/or weight:
    We showed these data in the article (strength/FFM; VO2peak/FFM; VO2peak/weight) in the results and table 2. There are no statistical differences comparing all populations (TW,CM and CW).

    - TW with 637 ng/dL testosterone on the day of the tests:
    In the long-term follow-up of a cohort of individuals with daily medication use, temporary failures in the regular use of medications are not uncommon. One of the participants had a high level of testosterone at the time of the study. However, we emphasize that we were careful to assess testosterone levels in the year before the study so that we could confirm the correlation of the values obtained at the time of the study with those in the last year. In addition, the values of haemoglobin denoted testosterone supression in the past 4 months. Although one of the TW was not blocked on test day (total testosterone =637 ng/dL), her value was 79 ng/dL six months before the study. This point did not interfere with her VO2 results (supplementary figure 2).

    - Weight and height:
    Studies in sports medicine generally eliminate the height as an interfering factor in the analyses.
    Height is a consequent characteristic o...

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  • High quality and relevant research needed to inform policy and help in decisions about the participation of transgender women in elite sport.

    Dear Editor:

    Alvares et al. [1] conducted a study to compare performance-related measures such as cardiopulmonary exercise capacity and muscle strength in non-athlete transgender women (TW) undergoing long-term gender-affirming hormone therapy to non-athlete cisgender men (CM) and non-athlete cisgender women (CW). The authors report higher absolute VO2peak (L/min) and muscle strength (kg) in TW compared to CW and lower than CM. The authors conclude that their “…findings could inform policy and help in decisions about the participation of transgender women in sporting activities”.

    However, the authors interpreted their findings on the basis of the absolute data they present and not the relative data that was controlled for body mass and fat-free mass (FFM), as would be appropriate for comparisons of such performance metrics (e.g., aerobic capacity and muscle strength). By focusing on the absolute data, the authors over-emphasise differences between comparison groups (e.g., TW and CW) that are clearly driven by differences in anthropometry. For example, when the data reported in Table 2 [1] are corrected for body mass and fat-free mass (FFM), differences in aerobic capacity and strength between TW and CW disappear. Yet, in the section “WHAT THIS STUDY ADDS” [1], which is the primary focus of many readers, the authors omit the results that control for body mass and FFM, instead leaving the reader with the misleading message that “[t]he mean strength and VO2peak...

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