Dear Phillip Page,
Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence t...
Dear Phillip Page,
Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence that RICE alone, or cryotherapy, or compression therapy alone have any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE alone in the treatment of acute LAS (Level 2).”. However, all recommendations are provided per treatment or prevention modality and do not include combination therapy unless otherwise specified and therefore it could be discussed that the content, despite adding clarification, in essence would not change. If readers do wish to learn more on the specifics of each treatment or preventive modality we would like to invite them to read the rest of the guideline and the paragraphs that elaborate on their desired topic.
You outline we did not include any meta-analyses on RICE interventions in supplement 3. This is correct as we were limited due to the heterogeneity in outcome measures, therapy methods and application methods, which did not allow data pooling. Even though multiple studies outlined a decrease in swelling and pain, this was measured using different methods, again not allowing pooling of data. We therefore reported the results in a qualitative manner by means of the number of studies and patients and the level of evidence.
Concerning harmful effects, again this is a just question. Due to the current extent of the evidence we chose to present to the readers, the guideline turned out quite voluminous. We chose to present the most important findings. Where we could or when included evidence outlined harmful effects, we highlighted the potential presence or absence of harmful or side effects: “Use of an ankle brace results in better outcome compared to other types of functional treatment such as sports tape (non-elastic) or kinesiotape (elastic), without showing any side effects[7].”. Unfortunately, the combination of limited information on harmful effects in the included studies and the length and great number of included treatment modalities in our guideline, required us to prioritize and limit our overview.
Another observation you made concerned treatment with NSAIDs, for which we describe prescription should be done so cautiously as they may negatively affect the natural healing process. Although ideally this statement would be based on a recently published RCT including a large cohort, we based it on a systematic review performed in 2003, which we still consider valid. We did not identify any new studies that described this subtopic and this component of NSAID usage was deemed so important that we agreed it should be included in this guideline. It was our task to provide an overview of the evidence on ankle sprain diagnostics, treatment and prevention, health care professionals can further decide which information they require and how they wish to implement this in clinical practice. We specifically mentioned there may be a risk at delay of the natural healing process.
Also, concerning NSAIDs you mention the presentation of our results are conflicting. We understand that you outline the effect of oral NSAID usage on swelling stating 2/3 favored placebo. However, as of all three comparisons of oral NSAID usage the confidence interval still includes 0, we cannot say that either NSAID or placebo is favored. Grouping oral with topical NSAIDs does not change this effect as the confidence interval still includes 0. In defining a recommendation we included these non-significant results with the studies of which we could not pool our data due to heterogeneity of used outcome measures. We understand that, recommending that NSAIDs may be used to reduce pain and swelling, despite an evident effect in our meta-analyses, is confusing. This recommendation was made based on the evident positive effect regarding pain reduction and the fact that some studies were able to show a positive effect, especially of topical NSAIDs on swelling. We agree that some form of clarification going into more detail may have been required to avoid confusion.
In conclusion, even though we have managed to write an extensive overview to describe the current best evidence practice to help professionals in clinical health care in their decision making for patients who have sustained a lateral ankle sprain, we are aware of the fact that we did not present all the evidence out there in literature. In our statements and recommendations we have made our best effort to be as concise as possible. We thank you for your great feedback and will use it in our future research, as we continue to strive to improve!
On behalf of the guideline committee,
Yours sincerely,
Gwendolyn Vuurberg and Prof. Gino M.M.J. Kerkhoffs
1. Cote, D.J., et al., Comparison of 3 Treatment Procedures for Minimizing Ankle Sprain Swelling. Physical Therapy, 1988. 68(7): p. 1072-1076.
2. Airaksinen, O., P.J. Kolari, and H. Miettinen, Elastic bandages and intermittent pneumatic compression for treatment of acute ankle sprains. Arch Phys Med Rehabil, 1990. 71(6): p. 380-3.
3. Rucinkski, T.J., et al., The effects of intermittent compression on edema in postacute ankle sprains. J Orthop Sports Phys Ther, 1991. 14(2): p. 65-9.
4. Tsang, K.K., J. Hertel, and C.R. Denegar, Volume Decreases After Elevation and Intermittent Compression of Postacute Ankle Sprains Are Negated by Gravity-Dependent Positioning. J Athl Train, 2003. 38(4): p. 320-324.
5. Hing, W., et al., Comparison of multimodal physiotherapy and "R.I.C.E."self-treatment for early management of ankle sprains. New Zealand Journal of Physiotherapy, 2011. 39(1): p. 13-19.
6. Bleakley, C.M., et al., Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. British Medical Journal, 2010. 340.
7. Kemler, E., et al., A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med, 2011. 41(3): p. 185-97.
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of thes...
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of these basic biological and social facts indicate the potential for gendered differences in roles (e.g. serving on a panel) to be a result of situations arising from free choice. These are very important points to consider when discussing discrepancies between genders, yet were not mentioned in the editorial.
The argument above is of course not for absolute biological determinism, nor that sexism does not exist. Recognizing the fact that there are differences between women and men does not mean equity between genders cannot exist. However, valid evidence should take precedence over ideological narratives. Any statements on this topic should be made with caution as to avoid promoting unnecessary interventions.
The authors of the editorial are free to critically examine the evidence presented opposing their conclusions. However, the editorial demonstrated a low standard of evidence. For this conversation to move forward a higher standard of evidence should be sought and adhered to.
In conclusion, the authors of the editorial failed to meet the necessary burden of proof to claim that implicit bias is a primary cause for the complex phenomenon of gender discrepancies in SEM or society. As such, the likelihood is high that the interventions cited within the editorial are unwarranted and unhelpful.
REFERENCES
1. Bekker, S. et al. We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine. British Journal of Sports Medicine bjsports–2018–099084–4 (2018). doi:10.1136/bjsports-2018-099084
2. Forscher, P. S. et al. A meta-analysis of change in implicit bias. PsyArXiv 1–68 (2017). doi:10.17605/OSF.IO/DV8TU
3. Goldhill, O. The world is relying on a flawed psychological test to fight racism. Quartz (2017). Available at: https://qz.com/1144504/the-world-is-relying-on-a-flawed-psychological-te.... (Accessed: 9 April 2018)
4. Su, R., Rounds, J. & Armstrong, P. I. Men and things, women and people: A meta-analysis of sex differences in interests. Psychological Bulletin 135, 859–884 (2009).
5. Stoet, G. & Geary, D. C. The gender-equality paradox in science, technology, engineering, and mathematics education. Psychol Sci 095679761774171–20 (2018). doi:10.1177/0956797617741719
We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in t...
We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in the context of gender inequity in SEM does not mitigate the role of other factors. We do not suggest that implicit bias is the sole driver of gender inequity, but that it is one that warrants attention.
Boynton et al. note, in the references that they cite arguing against implicit bias, that there may be phenomena such as individual choice that may result in such disparities. This may be true. In addition, we would add that at least one other phenomenon we did not mention is explicit bias. Each of the authors on this editorial can note multiple examples where these explicit biases have played out. The issue of ‘manels’ as a manifestation of gender disparities in SEM is merely the tip of the iceberg. Some of the authors of our editorial have written about other gender issues in different media [4]. Society at large, and the SEM community in particular, is still too disturbingly sexist to escape the conclusion that frank, explicit bias is a major driver of the disparities that concern us [5].
In regards to the issue of implicit bias, the body of literature supporting this concept is deep and underpins several of the resources we mention in our editorial. The LTE authors too easily dismiss this work as ‘ideological.’ We counter that, like any scientific theory, implicit bias is a ‘work in progress,’ and that noting a few references arguing against that theory does not tear down the entire body of evidence.
Gender disparities and contributory biases exist at many levels of our field. This is a problem, which could be seen as big or small depending on the observer. It is, nevertheless, a problem. We assert that it must be addressed.
We do agree, at least in part, with our dissenting colleagues, when challenging those of us interested in these issues to seek a ‘higher degree of evidence.’ While there is no lack of evidence for gender disparity in the SEM community, we applaud deeper investigations into these issues and a higher quality of evidence. Furthermore, we advocate for more research into the phenomena that may underpin these disparities.
For those parties interested in gender issues in sport and SEM, we would encourage them to consider looking more deeply into the problems we describe in our editorial and this response. We would like at the very least to see more documentation of gender (mis)representation among keynote speakers at SEM conferences; within academic divisions and departments; within teams (e.g. head team physicians among elite teams), etc. Moreover, analyses of the decision-making processes that lead to these disparities must also be included in future investigations.
Being of service to ourselves and our SEM community means meeting people where they stand. This is a more effective endeavor when we can be transparent about where we are starting from. To that end, we would encourage readers to consider these courses of action while we all continue this conversation:
i) consider taking the implicit bias test we reference [3]
ii) speak up when seeing significant gender disparities at conferences and other fora
iii) Men: mentor the female SEM trainees with which you work, and help them achieve higher levels in their field if they are motivated. And listen thoughtfully to what your female colleagues are saying about these issues
iv) Women: yes, ‘lean in,’ as the saying goes; but also continue to identify systemic biases and try to challenge them
Submitted by Sheree Bekker and James MacDonald, on behalf of all authors of the original editorial:
Sheree Bekker, Osman H Ahmed, Ummukulthoum Bakare, Tracy A Blake, Alison M Brooks, Todd E Davenport, Luciana De Michelis Mendonça, Lauren V Fortington, Michael Himawan, Joanne L Kemp, Karen Litzy, Roland F Loh, James MacDonald, Carly D McKay, Andrea B Mosler, Margo Mountjoy, Ann Pederson, Melanie I Stefan, Emma Stokes, Amy J Vassallo, Jackie L Whittaker
In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.
The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
Benefits:
- Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
- Provides ankle stability & protection for users with chronic lateral ankle instability
- Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
- Weighs only 2.4 ounces so users do not feel it
Independent Testing at Boise State University
White Paper Completed January, 2018:
“Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion”
– Tyler Brown, PhD, CSCS, Director COBR
Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices. With the Ankle Roll Guard, p...
The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
Benefits:
- Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
- Provides ankle stability & protection for users with chronic lateral ankle instability
- Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
- Weighs only 2.4 ounces so users do not feel it
Independent Testing at Boise State University
White Paper Completed January, 2018:
“Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion”
– Tyler Brown, PhD, CSCS, Director COBR
Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices. With the Ankle Roll Guard, participants exhibited more natural ankle motions (i.e. plantar flexion) during both the sudden inversion event and vertical jump. This motion allowed the participants to perform better during the vertical jump with the Ankle Roll Guard as compared to the more restrictive brace and tape.
I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a...
I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a proponent of quick and repeated prescription of NSAIDS, I was disappointed to see the statement concluded that NSAIDS may "delay the natural healing process," based on a review commentary published 15 years ago in a non-peer reviewed journal, rather than basing this comment on at least one well-controlled study with evidence that NSAIDS do, in fact, delay the healing process (which I have never seen). Furthermore, when I examined the meta-analysis data on oral NSAIDS on Swelling (3 studies), I noticed that 2 out of 3 favored the placebo, and none of the studies had a significant difference as their confidence intervals all included zero. Only grouping oral with topical NSAIDS provided a favorable effect size. You can't have it both ways when it comes to making statements based on the literature by holding the evidence to different standards to support such statements.
I would like to raise some comments regarding the paper ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ Whittaker et al, 2018, Br J Sports Med. 52(6): 322-328, and the editorial ‘Foot orthoses research: identifying limitations to improve translation to clinical knowledge and practice’, Griffiths & Spooner 52(6) in the same edition.
I would like to applaud the intention of the paper by Whittaker et al, to try and establish a conclusion to the question of foot orthoses efficiency in treating heel pain symptoms. This same praise I also give to the editorial in bring into the discussion the potential issue of the validity of random control trials as a research method to test foot orthoses efficiency. However, some key issues with the paper need exploring beyond the issues raised in the editorial in regarding how orthoses may work.
There are several key issues with the paper by Whittaker et al, which overall is a noble attempt to make sense of the present research on using orthoses for plantar heel pain. The issues are; plantar heel pain is a symptom not a diagnosis (therefore some of these studies may include multiple conditions); the studies are subject to potential bias (addresses by the authors); the studies do not compare like with like studies and seemed to have been shoe horned together to achieve a conclusion; and finally, foot orthoses do not logically conform to randomised control trials. Despite the best efforts of th...
I would like to raise some comments regarding the paper ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ Whittaker et al, 2018, Br J Sports Med. 52(6): 322-328, and the editorial ‘Foot orthoses research: identifying limitations to improve translation to clinical knowledge and practice’, Griffiths & Spooner 52(6) in the same edition.
I would like to applaud the intention of the paper by Whittaker et al, to try and establish a conclusion to the question of foot orthoses efficiency in treating heel pain symptoms. This same praise I also give to the editorial in bring into the discussion the potential issue of the validity of random control trials as a research method to test foot orthoses efficiency. However, some key issues with the paper need exploring beyond the issues raised in the editorial in regarding how orthoses may work.
There are several key issues with the paper by Whittaker et al, which overall is a noble attempt to make sense of the present research on using orthoses for plantar heel pain. The issues are; plantar heel pain is a symptom not a diagnosis (therefore some of these studies may include multiple conditions); the studies are subject to potential bias (addresses by the authors); the studies do not compare like with like studies and seemed to have been shoe horned together to achieve a conclusion; and finally, foot orthoses do not logically conform to randomised control trials. Despite the best efforts of the researchers to correlate the results to present a conclusion, reading the paper only shows that the paper was challenging statistically to produce. The studies so far published on this subject are so full of issues that any attempt to achieve coherence and a conclusion is potentially meaningless no matter how many attempts at statistical manipulation are thrown at the problem.
Despite this statistical need to achieve a result from poor data, the main problem must be that no attempt was given to provide the symptom of plantar heel pain a diagnosis in some of the studies involved in the review. This immediately invalidates the whole premise that these studies be included. We can hardly expect the same treatment to work for plantar fasciopathy, porta pedis nerve entrapment, Baxter’s neuroma or osteoarthritis of the subtalar joint. Each can cause plantar heel pain, but the mechanism of injury is different. Randomly sticking in insoles will give random results, perhaps the only conclusion we can take from these types of papers.
The editorial by Griffiths and Spooner discusses some of the issues in regards foot orthoses research used in random control trials. The authors of the editorial discuss the way the foot and the orthosis must interplay within the fundamentals of the laws of mechanics. These are principles of mechanics not unique to orthoses, but for anything that creates an interface between the foot and the ground. This is why a sham (placebo) orthosis in a study has potentially the same chance of influencing biomechanics as a so-called ‘real orthosis’. The difference in effects between the sham and the orthosis under test will be dependant on the difference between the shape and materials used in the two insole types.
The manufacture technique to produce the orthosis is probably irrelevant (1.2.3.4). Sadly some studies have failed to establish significant difference between insole types, picking a sham that is very close in design and material to the orthoses under test. Others studies pick custom orthoses of a much more robust design compared to the preform comparison orthosis (5.6). Bias is a serious problem in many studies.
The authors of the editorial claim that foot orthoses “can only exert their effect via placebo effect and/or directly modifying ground reaction forces at the foot-orthosis interface”. Kinematic and realignment effects are dismissed as “unlikely”. This statement is difficult to substantiate when compared to a wealth of published-research where much data on kinematic changes are reported (primarily in the foot) with foot orthoses (4.7.8.9.10.11.12). Similar kinematics changes occur when footwear and lack of footwear are compared (13.14).
Different kinematic effects have also been shown with different prescription additions on orthoses (15.16), which indicates how important individual prescription addition is to get a particular desired effect. However, data in regards to foot orthoses producing kinematic changes in sports related studies are less conclusive (17). This is likely to be in part because the contact time for the foot in running is reduced to around 40% (dependant on running pace) resulting in a significant float phase where neither foot is in ground contact. During float phase the orthosis has no mechanical influence except on increasing the foot segment mass in swing. Orthoses cannot redirect forces if there is no ground reaction force to interact with. Other issues such as preferred movement pathways (18) might over ride the effect of the orthosis or shoes especially in studies conducted on healthy asymptomatic runners.
The issue in sport is different to orthopaedics, in that most commonly in sportspeople, issues of mal-alignment and joint dysfunction are usually small. Sports medicine is largely about treating the ‘fit and well’, pushing their tissues to fatigue. In sport poor lower limb function or mal-alignment of a significant nature enough to significantly influence energetics, is rare. Such dysfunction would prevent a patient from being normally active. In orthopaedics serious postural mal-alignments that cause, or are a cause of dysfunction, are commonly found in patient contacts, and here changes with foot orthoses are likely to be more significant.
Griffiths & Spooner’s editorial proposes that the effects of orthoses are most likely to be due to kinetic changes within the tissues. This leads to the suggestion that for research, orthoses must be chosen that equally change the tissue stresses within specific tissues in different individuals, rather than picking the same prescription.
Sadly as we have no way of routinely assessing internal body kinetics within tissues dynamically, this suggested research pathway is not yet readily open to us. If possible, such an approach would also raise complications in that individual variance in morphology and body tissue composition would still make subject selection as well as prescription selection quite challenging. Orthoses requirements to achieve the same outcome could be quite different, unless subjects were match on many physiological and anatomical similarities. This would also make random control trials almost impossible.
There are other ways by which foot orthoses can be implied to change tissue kinetics. Changes in muscle activity in the presence of foot orthoses would imply that tissue kinetics has changed. Such evidence exists if not strongly (19), although evidence exists of rocker shoes altering muscle activity (20.21). As stated before orthoses and shoes work on the same interface.
Foot orthoses may also be able to initiate a neuro-mechanical effect. Something touching the body will create a reaction, possibly just in reaction to avoid the object as occurs when we feel a small stone in our shoe. What ever induces changes in muscle activity is likely to change kinematics, energetics as well as internal and external kinetics.
Again it must be understood that a so-called ‘sham orthosis’ has the potential to alter biomechanics and energetics. This single fact seriously questions whether random control trials using a so-called ‘sham orthosis’ are suitable for testing so called ‘real foot orthosis’ efficiency.
Another consideration is that poor biomechanics is primarily more than just forces being applied to the body in the wrong direction. Joint and muscle dysfunction are intrinsically linked. As a consequence, outside of the research world, foot orthoses are rarely used in isolation. If exercises, mobilisation, manipulation, shoe selection and foot orthoses all produce statistically arguable benefit when studied individually, there might yet be a significant effect when each are combined appropriately together. There is a challenge for research to look at treatment protocols rather than one treatment at a time!
Where the possibility of merely a placebo effect achieved by foot orthoses can firmly be challenged is in papers like Halstead et al (22), which looks at changes in pathology over time with foot orthoses on MRI and is the kind of randomised control trial that is more suitable for foot orthoses. More of these studies on diagnostic image changes produced by foot orthoses are required if we are ever going to learn more specifically which prescription variances are required to reduce stress and therefore strain on specific musculoskeletal tissues and their pathologies. Whether the outcome is good or bad, will still give us a far greater insight into the orthoses ability to change tissue stresses.
The reason good foot orthoses research is limited is more a result of most studies not knowing what effects they wished achieve to resolve particular pathologies. Especially so in studies where symptoms, rather than pathology is chosen. These ‘chosen’ pathologies need to be very specific, for in just the case of Achilles tendinopathy the mechanical causes are multiple, and specific areas within the tendon function differently (23.24.25).
To compare effects of a foot orthosis prescription in a manner similar to a random control trial of a pharmaceutical would need a large scale study performed on subjects of similar mass, strength, tissue age, morphology, and limb segment lengths. Subjects would need to have the same pathology and mechanism of injury with the same level of tissue damage. I would also suggest that treatment orthoses were tested for effects on energetics too to test comparable effects on mechanical efficiency. Any other type of random control study risk being like testing a drug for its effect on abdominal pain, regardless of the cause. Sadly most foot orthoses studies published at present make establishing truth within them extremely difficult and the construction of coherent random control reviews almost impossible.
References:
1. Landorf K, Keenan AM, Herbert R. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006. 166:1305-10. doi: https://doi.org/10.1001/archinte.166.12.1305
2. Davis I, Zifchock R, Deleo A. A comparison of rearfoot motion control and comfort between custom and semicustom foot orthotic devices. J Am Podiatr Med Assoc. 2008. 98(5):394-403. PMID:18820043
3. Redmond A, Landorf K, Keenan AM. Contoured, prefabricated foot orthoses demonstrate comparable mechanical properties to contoured, customised foot orthoses: a plantar pressure study. J Foot Ankle Res 2009. 2:20. doi: https://doi.org/10.1186/1757-1146-2-20
4. Short L, Chockalingam N. Kinematic comparison of functional foot orthoses produced to three different manufacturing protocols: An exploratory study. OA Musculoskeletal Medicine 2015 10;2(2):14.
5. Trotter, L, Pierrynowski, M. The short-term effectiveness of full-contact custom-made foot orthoses and prefabricated shoe insets on lower-extremity musculoskeletal pain. J Am Podiatr Med Assoc. 2008. 98(5): 357-363. PMID:18820037
6. Trotter, L.C., Pierrynowski, M.R. (c). Changes in gait economy between full-contact custom-made foot orthoses and prefabricated inserts in patients with musculoskeletal pain. J Am Podiatr Med Assoc. 2008. 98(6): 429-435. PMID:19017850
7. McPoil TG, Cornwall MW. The effect of foot orthoses on transverse tibial rotation during walking. J Am Podiatr Med Assoc. 2000. 90(1): 2-11. doi: https://doi.org/10.7547/87507315-90-1-2
8. Reed L, Bennett P. Changes in foot function with the use of Root and Blake Orthoses. J Am Podiatr Med Assoc. 2001 91(4):184-193. PMID:11319248
9. Branthwaite HR, Payton CJ, Chockalingam N. The effect of simple insoles on three-dimensional foot motion during normal walking. Clin Biomech. 2004. 19(9):972-977. doi: https://doi.org/10.1016/j.clinbiomech.2004.06.009
10. Eslami M, Begon M, Hinse S, et al. Effect of foot orthoses on magnitude and timing of rearfoot and tibial motions, ground reaction force and knee moments during running. J Scien Med Sport. 2009. 12(6): 679-684. doi: https://doi.org/10.1016/j.jsams.2008.05.001
11. Levinger P, Menz H, Marrow A, et al. Relationship between foot function and medial knee joint loading in people with medial compartment knee osteoarthritis. J Foot Ankle Res. 2013. 6:33 http://www.jfootanleres.com/content/6/1/33
12. Rodrigues P, Chang, R, TenBroek T, et al. Medially posted insoles consistently influence foot pronation in runners with and without anterior knee pain. Gait Posture. 37(4):526-531. https://doi.org/10.1016/j.gaitpost.2012.09.027
13. Divert C, Mornieux G, Baur H, et al. Mechanical comparison of barefoot and shod running. Int J Sports Med 2005. 26(7): 593-598. doi https://doi.org/10.1055/s-2004-821327
14. Eslami M, Begon M, Farahpour, et al. Forefoot-rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running. Clin Biomech 2007. 22(1): 74-80. doi: https://doi.org/10.1016/j.clinbiomech.2006.08.002
15. Nakajima K, Kakihana W, Nakagawa T, Mitomi H, et al. Addition of an arch support improves the biomechanical effect of a laterally wedged insole. Gait Posture. 2009. 29(2): 208-213. doi: https://doi.org/10.1016/j.gaitpost.2008.08.007
16. Zhang X, Li B, Hu K, et al. Adding an arch support to a heel lift improves stability and comfort during gait. Gait Posture. 2017 58(1): 94-97. doi: https://doi.org/10.1016/j.gaitpost.2017.07.110
17. Ferber R, Davis IM, Williams DS. Effect of foot orthotics on rearfoot and tibial coupling patterns and variability. J Biomech. 38(3): 477-483.
doi: https://doi.org/10.1016/j.jbiomech.2004.04.019
18. Nigg B, Baltich J, Hoerzer S, et al. Running shoes and running injuries: mythbusting and a proposal for two new paradigms:’preferred movement path’ and ‘comfort filter’. Br J Sports Med. 2015 49(20): 1290-1294. doi: https://doi.org/10.1136/bjsports-2015-095054
19. Murley G, Landorf K, Menz H et al. Effect of foot posture, foot orthoses and footwear on lower limb muscle activity during walking and running: A systematic review. Gait Posture 2009. 29(2): 172-187. doi: https://doi.org/10.1016/j.gaitpost.2008.08.015
20. Stöggl T, Müller E. Magnitude and ariation in muscle activity and kinematics during walking before and after a 10-week adaption period using unstable (MBT) shoes. Footwear Scienc. 2012: 4(2): 131-143.
21. Maffiuletti N. Increased lower limb muscle activity induced by wearing MBT shoes: physiological benefits and potential concerns. Footwear Scienc. 2012: 4(2): 123-129.
22. Halstead J, Chapman G, Gray J et al. Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016. 35(4): 987-996. doi: https://doi.org/10.1007/s10067-015-2946-6
23. Zifchock, R, Piazza, S. Investigation of the validity of modelling the Achilles tendon as having a single insertion site. Clin Biomech. 2004. 19 (3): 303-307. doi: https://doi.org/10.1016/j.clinbiomech.2003.11.010
24. Lee, S, Piazza, S. Inversion-eversion moment arms of gastrocnemius and tibialis anterior measures in vivo. J Biomech. 2008. 41(16): 3366-3370. doi: https://doi.org/10.1016/j.jbiomech.2008.09.029
25. Franz J, Slane L, Rasske K, et al. Non-uniform in vivo deformations of the human Achilles tendon during walking. Gait Posture. 2015. 41(2):192-197. doi: https://doi.org/10.1016/j.gaitpost.2014.10.001
This is a case of exertional heat stroke in which a young, experienced woman runner exerts herself and develops heat stroke. There is no effort to describe the patient's state of hydration besides indicating that she drank 250 mL prior to running (in what timeframe?) and that she drank 200mL after/during collapse. We are unaware of her weight and thus cannot even roughly calculate what her fluid deficit range may be after 90 minutes of running. We are unaware of her dress, which could lead to heat retention. Per figure 2, it appears that her blood pressure was approximately 110/70 at the time of collapse, which does not support hypovolemia. Values of BUN and creatinine are not presented that would have supported dehydration as a predisposing condition. Certainly in a road race there were other runners that reached her same level of hydration - why did they not suffer heat stroke?
While this is a classically presented case of exertional heat stroke in a road race, there is insufficient evidence to associate it with dehydration.
Dear Phillip Page,
Show MoreThank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence t...
Title:
Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine
A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.
The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.
Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3
Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of thes...
Show MoreWe want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].
We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].
It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.
We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.
We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in t...
Show MoreThe Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...
The Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...
In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.
The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
Benefits:
- Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
- Provides ankle stability & protection for users with chronic lateral ankle instability
- Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
- Weighs only 2.4 ounces so users do not feel it
Independent Testing at Boise State University
Show MoreWhite Paper Completed January, 2018:
“Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion”
– Tyler Brown, PhD, CSCS, Director COBR
Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices. With the Ankle Roll Guard, p...
I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a...
Show MoreI would like to raise some comments regarding the paper ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ Whittaker et al, 2018, Br J Sports Med. 52(6): 322-328, and the editorial ‘Foot orthoses research: identifying limitations to improve translation to clinical knowledge and practice’, Griffiths & Spooner 52(6) in the same edition.
I would like to applaud the intention of the paper by Whittaker et al, to try and establish a conclusion to the question of foot orthoses efficiency in treating heel pain symptoms. This same praise I also give to the editorial in bring into the discussion the potential issue of the validity of random control trials as a research method to test foot orthoses efficiency. However, some key issues with the paper need exploring beyond the issues raised in the editorial in regarding how orthoses may work.
There are several key issues with the paper by Whittaker et al, which overall is a noble attempt to make sense of the present research on using orthoses for plantar heel pain. The issues are; plantar heel pain is a symptom not a diagnosis (therefore some of these studies may include multiple conditions); the studies are subject to potential bias (addresses by the authors); the studies do not compare like with like studies and seemed to have been shoe horned together to achieve a conclusion; and finally, foot orthoses do not logically conform to randomised control trials. Despite the best efforts of th...
Show MoreThis is a case of exertional heat stroke in which a young, experienced woman runner exerts herself and develops heat stroke. There is no effort to describe the patient's state of hydration besides indicating that she drank 250 mL prior to running (in what timeframe?) and that she drank 200mL after/during collapse. We are unaware of her weight and thus cannot even roughly calculate what her fluid deficit range may be after 90 minutes of running. We are unaware of her dress, which could lead to heat retention. Per figure 2, it appears that her blood pressure was approximately 110/70 at the time of collapse, which does not support hypovolemia. Values of BUN and creatinine are not presented that would have supported dehydration as a predisposing condition. Certainly in a road race there were other runners that reached her same level of hydration - why did they not suffer heat stroke?
While this is a classically presented case of exertional heat stroke in a road race, there is insufficient evidence to associate it with dehydration.
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