416 e-Letters

  • Comment on: ‘Isometric exercise versus high-intensity interval training for the management of blood pressure: a systematic review and meta-analysis’ by Edwards et al.

    In their systematic review and meta-analysis, Edwards et al. (1) aimed to ‘directly compare’ the efficacy of isometric exercise and high-intensity interval training (HIIT) for the management of resting blood pressure. They included 38 randomised controlled trials (18 for isometric, 20 for HIIT) in their pairwise meta-analysis and concluded that isometric exercise appears to be superior to HIIT for improving both systolic blood pressure (mean difference between exercise types = 5.29 mmHg, 95% confidence interval 3.97 to 6.61) and diastolic blood pressure (mean difference between exercise types = 3.25 mmHg, 95% confidence interval 2.53 to 3.96). We were interested in these marked differences because they contrast previous findings (2) and, if correct, may necessitate important changes to guidelines. However, in further examining the article, we identified some issues that we believe require attention as they may invalidate the results and are relevant to readers of this journal.

    None of the included trials in this review appear to contain both isometric and HIIT interventions; therefore, the authors are unable to ‘directly compare’ the interventions. Instead, by analysing the differences between isometric and HIIT subgroups in the meta-analysis, Edwards et al. (1) are making an inference based on the indirect effect, which assumes that the differences between exercise types can be inferred via a common comparator (in this case, the control group) (3). This is, in effe...

    Show More
  • Response to Robert M Leithiser

    This is a classic example of misinterpretation of the available data. Of course, national death rates may be higher than the overall rate for 67 countries. Furthermore, the range of media coverage at the national level is massive, so a comparison with an international registry is not valid.

  • Article being taken out of context as misinformation

    This article is being used to assert that the # of deaths of professional soccer players (now at 27 competing at a national level) is normal by taking the overall total of 465 deaths to all players (of which 42% weren't even reported in the media) as the normal # of professional soccer players who die. In reality this study indicates just 5% of the deaths were of elite athletes comparable to those tracking deaths of professional soccer players. That works out to an average of only about 5 per year from the study and other data show an average of 8.9 total soccer player deaths per year at a national level reported by the media.

  • Isotonic Exercises

    Peru, Lima, December 05, 2021

    Editor of the magazine "British Journal Sports Medicine"

    I address this to you, in relation to the article "Efficacy of progressive tendon load
    exercise therapy in patients with patellar tendinopathy: a randomized clinical trial."
    Their study shows the comparison between the effectiveness of progressive load
    exercises (PLE) with eccentric exercise therapy (EE) in patients with patellar
    tendinopathy (PT). However, it is also known that slow and heavy isotonic exercises lead
    to both short and long-term improvement of pain and other symptoms, because it
    improves the pathology, increases the remodeling of the fibers and normalizes the
    morphology of the fibers. tendon fibrils (1).

    So, you could have added in your research, as this technique has proven to be effective
    and if included it would make a more interesting comparison. Therefore, adding more
    reasons why you should consider incorporating isotonic exercises is that in the study by
    Dr. Qassim et al. validated that a four week heavy slow isotonic training program during
    the season resulted in a gradual improvement in pain in athletes with PT (1), since among
    its multiple benefits of this training is that it can restore muscle mass and the strength of
    the lower limb, and can perform with minimal pain; Unlike the analysis of Purdam Cr. and
    Visnes H. that indicated that the...

    Show More
  • Follow up questions to the systematic review

    May I have two questions please?

    1. How the population in the RCTs defined lateral elbow tendinopathy? By resisted strength test, ultrasound scan or MRI? Did the inclusion specific enough to rule out other elbow joint pain such as ligament tear?

    2. If the RCTs did not rule out ligament tear or joint instability pain, does it affect the results?

  • Suggestion to improve the methodology of this study

    Dear Dr Breda and colleagues,

    Thanks for your insightful publication. I would like to add to Georg Supp and Stephanie Moers comments on this article.

    I agree with the previous comments that the current experimental design is more a comparison between the effectiveness of low pain loading exercise and painful loading exercise in patients with patellar tendinopathy according to the current methodology.

    As a fairer comparison, it should be rather progressive tendon-loading exercise versus statics/ regressive loading exercise. Otherwise, it can also be progressive isometric & isotonic tendon-loading exercise versus progressive eccentric loading exercise as well. No clear standardization on the loading of the exercise makes it less convincing to achieve the authors’ conclusion.


    Some decades ago, Tom Beauchamp and James Childress proposed four principles for biomedical ethics (i.e., respect for autonomy, non-maleficence, beneficence, and justice). They postulated that such an approach, called principlism, could be applied universally. 1
    The relationship between regular physical activity and the prevention of some diseases has been disseminated widely in scientific literature. 2 Pugh et al. 3 highlighted the importance of broadening the debate on this relationship and not relying solely on the principle of beneficence. It would also be necessary for the authors to acknowledge practically the principle of non-maleficence. Within this perspective, Pugh et al. 3 commented on the risk of damage, possibly even death, from vigorous physical exercise for the practitioners (whom they called patients).
    It is worth noting that the principles of non-maleficence and beneficence have played a central role in the history of biomedical ethics. However, respect for autonomy and justice seem to be often neglected. 1 Even though we may agree on some points with Pugh et al. 3, it is imperative to bring other bioethical principles to the debate.
    Thus, we would like to contribute, although briefly, to the debate on the topic addressed by Pugh et al. 3 and suggest that the focus on non-maleficence should be broadened. In addition, we highlight the indispensable focus on the principle of justice and autonomy.
    Regarding the expansion of the non-...

    Show More
  • Glovin' up

    Whilst better quality research into concussion in combat sports is welcomed; an equally important and related area of research is gaining insight into the often ‘concussion permissive’ training environments of the many combat sport schools across the country. In my earlier years of competitive MMA training ‘gym wars’ were a common occurrence. Training partners, often encouraged by the coaches, would spar (practice fight) at close to 100% power including strikes to the head. It was not uncommon to see someone get knocked out unconscious, checked on, dragged off to the side of matted training area, then once awakened, asked to continue with the sparring session! I believe over the years this type of training culture has become less prevalent with a growing emphasis on light-contact modified technical sparring or a greater reliance on more dynamic and modality specific pad-work drills. There is still a need though to understand the factors behind schools that promote this unsustainable culture of frequent hard sparring and identify and describe the behaviours behind it. Hopefully then efforts can be made to engage and influence the combat sport athletes to think twice before ‘glovin up’.

  • 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...

    Show More
  • The effects of beta 2 agonists on aerobic performance in healthy adults – implications for PED rules

    Dear Sir/Madam
    Riiser’s et al paper outlines the long-held belief that beta 2 agonists do not improve aerobic function in a healthy population. Beta 2 agonist however have other performance enhancing affects. Clenbuterol, the beta 2 agonist is a case in point. This drug has been used by athletes for decades to burn fat, through metabolic up regulation. This beta 2 agonist drug is also suggested to improved muscle growth through its effects on protein synthesis. It is hypostasised that Clenbuterol induces phosphorylation of mTOR which resulting in enhanced muscle protein synthesis.
    Drugs are banned in sport based on the presence of 2 of 3 criteria: 1) Performance enhancing. 2) Dangerous to health 3) Against the ethos of sport.
    While Beta 2 agonist may not improve aerobic function, they can be performance enhancing. They also carry significant side effects in unsupervised hands. The ethos of sport is perhaps a moot point.
    Anti-Doping began in earnest in 1967 following the death of a number of athletes. Participant’s health and safety has been the cardinal element in all programs for the past 54 years. The TUE element ensures that every athlete, whatever the medical condition can participate without discrimination, once the disease has been confirmed. If a Beta 2 agent is medically required then an appropriate agent will be approved by the local governing TUE body, and safe participation can follow. Anti- Doping in a complex area and non – binary. A f...

    Show More