We read with interest the systematic review by Tran and colleagues
recently published online(1). The findings build on our own observations
in a systematic review of running and knee osteoarthritis (OA)(2).
Although the focus of our review was narrower than that of Tran et al,
which investigated evidence relating to OA of all joints across a variety
of sports, we would like to comment on some of the si...
We read with interest the systematic review by Tran and colleagues
recently published online(1). The findings build on our own observations
in a systematic review of running and knee osteoarthritis (OA)(2).
Although the focus of our review was narrower than that of Tran et al,
which investigated evidence relating to OA of all joints across a variety
of sports, we would like to comment on some of the similarities and
differences to our own observations.
The findings of both reviews revealed the inconsistent design and
often poor quality of studies in this area of research. Even focussing on
one sport, as we did with running, we found that studies had used
heterogeneous populations and methods, as well as differing criteria to
define OA. Similarly, Tran et al identified this heterogeneity and rated
the quality of the evidence as very low, echoing our own conclusions. This
makes it especially difficult to interpret the evidence, not to mention
the challenges that arise through using a broad range of exposure
variables (different sports) and outcomes (different criteria for OA
diagnosis in multiple joints). In contrast to Tran et al, we chose not to
combine prospective studies in a meta-analysis: as well as having fewer
eligible studies in our review (we included only knee OA), we felt the
heterogeneity of the included studies did not allow meaningful combination
of the results in a pooled estimate.
Despite this divergence in methods, our narrative analysis of the
evidence revealed similar results to that of Tran et al. We disagree,
however, in the interpretation of these results. Tran et al conclude that
the low-quality evidence supports a relationship between sport and OA in
elite participants, but no association between running and OA. In
contrast, we would interpret the results of both reviews as a lack of
evidence of an association between running and OA, rather than evidence of
no association. The poor quality of many of the studies, combined with a
dearth of studies which control for important confounders (e.g. previous
injury), does not fill us with confidence that the available literature is
a reflection of the true relationship (if any) between running and OA.
We should also like to mention some further interesting evidence from
case-control studies that we included in our review. Our literature
search found three case-control studies with knee replacement as an
outcome(3-5), whereas Tran et al include only one of these(4) in their
review. Interestingly, when combined in a meta-analysis, the pooled
estimate of these studies suggested runners had almost 50% reduced odds of
undergoing surgery due to knee OA. Although we hazard some possible
explanations for this in our paper, we are mindful that any interpretation
must be cautious, given the small number of retrospective and unadjusted
studies. Furthermore, there was no cohort evidence to support this
finding. Nevertheless, we feel this highlights the importance of taking
into account the heterogeneity in study design and outcome definition. The
apparent lack of association observed in prospective studies, none of
which used surgery as a criterion for OA, may be masking a more
complicated picture.
We would like to thank the authors for their thorough review,
contributing a broader picture of the evidence relating to sports and OA.
Based on the conclusions of both reviews we would recommend the following.
Firstly, we would like to endorse the authors' plea for further evidence
from well-designed, prospective investigations, which appropriately
consider the potential for confounding arising from sport type, intensity,
and injury. Only then will we be able to evaluate whether there is in fact
no association between sports (including running) and OA, as opposed to no
evidence of an association. Secondly, there is a need for effective
translation of knowledge from research (for example, in injury prevention)
into clinical practice in order to support safe participation in sports at
all levels and potentially reduce risk of disease onset. Finally, and
perhaps most importantly, we recommend that, in the absence of strong
evidence to the contrary, clinicians continue to promote sporting
participation to the public, given the other well-established and varied
benefits to health.
References
1. Tran G, Smith TO, Grice A, Kingsbury SR, McCrory P, Conaghan PG.
(2016) Does sports participation (including level of performance and
previous injury) increase risk of osteoarthritis? A systematic review and
meta-analysis. BJSM. Retrieved from doi:10.1136/bjsports-2016-096142.
Accessed Dec 9 2016.
2. Timmins KA, Leech RD, Batt ME, Edwards KL. (2016) Running and knee
osteoarthritis: a systematic review and meta-analysis. Am J Sports Med.
Retrieved from doi:10.1177/0363546516657531. Accessed Dec 9 2016.
3. Kohatsu N, Schurman D. (1990) Risk factors for the development of
osteoarthritis of the knee. Clin Orthop Relat Res, 261:242-6.
4. Sandmark H, Vingard E. (1999) Sports and risk for sever
osteoarthritis of the knee. Scan J Med Sci Sports, 9:279-84.
5. Manninen P, Riihimaki H, Heliovaara M, Suomalainen O. (2001)
Physical exercise and risk of severe knee osteoarthritis requiring
arthroplasty. Rheumatology, 40(4):432-7.
For over 40 years oral health screening is part of all pre-
participation medical examinatios at the Portuguese Sports Medicine
Centers in The National Institute of Sports. Preparticipation medicals are
compulsory for all athletes who wish to play competitive sports and none
gets full clearance without a full treatment of any oral/dental pathology.
We are aware that oral health is fundamental to maintain sports
performance...
For over 40 years oral health screening is part of all pre-
participation medical examinatios at the Portuguese Sports Medicine
Centers in The National Institute of Sports. Preparticipation medicals are
compulsory for all athletes who wish to play competitive sports and none
gets full clearance without a full treatment of any oral/dental pathology.
We are aware that oral health is fundamental to maintain sports
performance and general health and this theme is part of the syllabus of
our post-graduate Sports Medine courses.
This editorial is misleading. Claiming that the Eatwell Guide is not
evidence based is factually wrong. The Guide is based on comprehensive
expert reviews of the evidence undertaken by the independent Scientific
Advisory Committee on Nutrition (SACN) which advises government, and its
predecessor, the Committee on Medical Aspects of Food Policy.
The latest revisions to the Eatwell Guide were i...
This editorial is misleading. Claiming that the Eatwell Guide is not
evidence based is factually wrong. The Guide is based on comprehensive
expert reviews of the evidence undertaken by the independent Scientific
Advisory Committee on Nutrition (SACN) which advises government, and its
predecessor, the Committee on Medical Aspects of Food Policy.
The latest revisions to the Eatwell Guide were informed by SACN's
2015 evidence review on carbohydrates and health which included 600 recent
research papers. The report halved the maximum sugar levels we should be
consuming. It also recommended that we should eat more fibre from fruits,
vegetables and pulses. Moreover, the Eatwell Guide's proposals are in line
with the international evidence-base and recommendations of organisations
such as the World Health Organization.
Harcome blames the Eatwell Guide and its predecessors for the
dramatic increases in obesity and diabetes which have occurred since the
1970s, based on highly tenuous correlations. She naively assumes that we
as a population are meeting the current guidelines, when in fact survey
data of nutrition intakes show the opposite to be true. For example, 87%
of UK adults are eating too much sugar, 74% are failing to consume 5
portions of fruit and vegetables a day, 68% are eating too much salt and
66% are eating too much saturated fat.1
The reason why levels of some diet-related diseases are on the rise
is not because the guidelines are wrong. It is because our food
environment is not supportive of healthy eating.
This article is unhelpful because it will generate public and
professional confusion, and undermine confidence in the government's
evidence-based Eatwell Guide to healthy eating.
References
1. NatCen Social Research, MRC Human Nutrition Research & University
College London Medical School, 2015a. National Diet and Nutrition Survey
Years 1-4, 2008/09-2011/12. [data collection]. 7th Edition. UK
Conflict of Interest:
No financial or industry funding links to declare.
Dr Mwatsama is a Registered Nutritionist (Public Health), and was a member of the Expert Reference Group which oversaw the review of Public Health England's Eatwell guidelines for healthy eating.
I commend Raftery et al in their recent editorial on concussion
assessment in sport, in particular rugby's response on this matter (1).
Undoubtedly one of the major issues facing sport is the lack of clarity
and consistency in identifying concussions on the field; a symptom of the
deficiencies in the last output from the Concussion in Sport Group (the
'Zurich Consensus')(2)
I commend Raftery et al in their recent editorial on concussion
assessment in sport, in particular rugby's response on this matter (1).
Undoubtedly one of the major issues facing sport is the lack of clarity
and consistency in identifying concussions on the field; a symptom of the
deficiencies in the last output from the Concussion in Sport Group (the
'Zurich Consensus')(2)
However, while a commendable effort, on reading the article I am
anxious about contradictions in the detail provided on World Rugby's
protocol, which I believe are an oversight by the authors.
Specifically, while clearly defining much needed indications for
immediate and permanent removal from play ('Criteria Set 1'), the authors
then suggest that these criteria confirm concussion 'unless proven
otherwise'.
The inclusion of the get out clause, 'unless proven otherwise',
without qualification or expansion is, I believe, an error and does not
reflect my understanding of rugby's HIA process. As it is written, Raftery
et al are proposing that a player can sustain a blow to the head, be
knocked unconscious or suffer a seizure or display tonic posturing or
display any of the other Criteria 1 signs, but later might be 'cleared'
of having sustained a brain injury via subjective post-match testing.
The natural conclusion from this being a player can be KO'd on
Saturday after a knee to the head, but apparently 'proven' not concussed
in subsequent, after match and fallible tests and be back in training or
play 2 days later.
To my knowledge there are no tests that can unequivocally and
confidently 'prove' a player is not concussed, as suggested. I would
expect the authors are aware of that, and did not intend the draft to
suggest a protocol that allows players with elements in Criteria Set 1 to
be later cleared of brain injury in this way.
Unfortunately, unless this is clarified, then there is a danger of
promoting the false belief that a robust and infallible test is in current
practice that can 'prove' a player has not sustained a brain injury
despite being knocked unconscious after a blow to the head. The
alternative is the current working definition of 'concussion' needs
revisited.
References
1. Raftery et al. It is time to give concussion an operational definition:
a 3-step process to diagnose (or rule out) concussion within 48 h of
injury: World Rugby guideline. Br J Sports Med 2016;doi:10.1136/bjsports-
2016-095959
2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on
concussion in sport: the 4th International Conference on Concussion in
Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-8.
As a rural and purely clinical sports medicine practitioner, I fully
agree with the premise of this article.
Whilst applauding the wonderful data being produced from around the world,
so little of it has any relevance in my practice. There appears to be much
back slapping happening in the research centres, though so little work on
effectiveness of exercise regimes. I agree that the focus on rigorous
meth...
As a rural and purely clinical sports medicine practitioner, I fully
agree with the premise of this article.
Whilst applauding the wonderful data being produced from around the world,
so little of it has any relevance in my practice. There appears to be much
back slapping happening in the research centres, though so little work on
effectiveness of exercise regimes. I agree that the focus on rigorous
methods excludes much community based research, and this limits the
production of useful research in the real world. I have often been met
with blank looks from researchers when asking them how an exercise
intervention can be implemented in real world, and especially isolated, or
socially disadvantaged settings.
This article is one of the few I have read that endeavors to understand
and explain the dichotomy.
We have read the respective article, and we agreed to all stated
observations and recommendations. This is a very useful article for many
researchers and especially for the scientists working with addiction
sciences.
We would just like to emphasise on the use of quantitative assays for
the cognitive molecules (Lee et al., 2009) beside doping test. Mental
performance is the attribute of three...
We have read the respective article, and we agreed to all stated
observations and recommendations. This is a very useful article for many
researchers and especially for the scientists working with addiction
sciences.
We would just like to emphasise on the use of quantitative assays for
the cognitive molecules (Lee et al., 2009) beside doping test. Mental
performance is the attribute of three different interconnected domains;
namely, Memory, attention and creativity. Many of the neuro-circuits and
different specific molecules, involved in such pathways have been reported
in this modern era of technology. Millions of smart drugs or nootropic
drugs have been reported targeting these specific molecules.
We believe even though the doping test as per its principle is a
general test available but at the same time, there is a need of looking at
the molecular mechanisms which may vary from one individual to other and
yes, if there is no effect on the cognitive molecules, then as per stated
in the title, depending on the use of specific smart drug for targeting
either memory or attention or creativity must have raised the said
molecule and such molecules are needed to be quantified in the executives
inclusive of the coaches in the team for a better understudying of the
specific fraction of mental performance Vs doping test.
Injury data from the RWC 2011, 89.1 per 1000 player-hours2011 and the
earlier tournament of 2007, 83.9 per 1000 player-hours may have had an
effect on all teams.
But success could only be accorded to the winner in the final match.
The All Blacks had a long history of not even making the semi-finals.
However the RWC 2011 success was not due to the negative effect of injury
on the team but rath...
Injury data from the RWC 2011, 89.1 per 1000 player-hours2011 and the
earlier tournament of 2007, 83.9 per 1000 player-hours may have had an
effect on all teams.
But success could only be accorded to the winner in the final match.
The All Blacks had a long history of not even making the semi-finals.
However the RWC 2011 success was not due to the negative effect of injury
on the team but rather on the individual team members,for instance the
goal kicker. Other reasons may be due to the organisational arrangements
by the coach and support of its management and the infrastructure of the
national rugby.
At the RWC 2015 success was clearly a cognitive achievement by all teams
when they compare themselves with earlier RWC tournaments but did injury
have an effect? Or was success due to organisational arrangements?
We thank Dr. Bollen for his interest in our paper on knee arthroscopy
for the middle-aged and older patient with a painful knee (Thorlund et al.
2015a,b).
The consistent high-level evidence (Thorlund et al. 2015a,b; Khan et
al. 2015) questioning the benefit of arthroscopic surgery has so far had a
very limited effect on the practice of arthroscopic surgery in middle-aged
and older patients with a...
We thank Dr. Bollen for his interest in our paper on knee arthroscopy
for the middle-aged and older patient with a painful knee (Thorlund et al.
2015a,b).
The consistent high-level evidence (Thorlund et al. 2015a,b; Khan et
al. 2015) questioning the benefit of arthroscopic surgery has so far had a
very limited effect on the practice of arthroscopic surgery in middle-aged
and older patients with a painful knee and suspected meniscus or cartilage
lesion (Cullen et al. 2009, Bohensky et al. 2012, Dearing and Brenkel
2010, Lazic et al. 2014, Thorlund et al. 2014).
Yet, patients included in the randomized controlled trials analyzed
in the recent systematic reviews (Thorlund et al. 2015a,b; Khan et al.
2015) comprise the dominant patient group routinely treated with
arthroscopic knee surgery. Thus, 3 out of 4 patients arthroscopically
treated for suspected meniscus rupture, cartilage lesion or osteoarthritis
of the knee are reported to be older than 35 (Roos and Lohmander 2009,
Cullen et al. 2009, Bohensky et al. 2012, Dearing and Brenkel 2010,
Thorlund et al. 2014, Mattila et al. 2015). Further, a recent
characterization of patients treated with arthroscopic surgery found that
half had a diagnosis of old meniscus tear or osteoarthritis (Bergkvist et
al. 2015). These studies collectively show that a large proportion of
arthroscopic surgeries performed are done in patients where current high-
level evidence does not support the benefit of arthroscopic surgery over
non-surgical treatment.
Arguments that favor arthroscopy focus on patient subgroups among the
middle-aged and older with a painful knee, such as those with "mechanical
symptoms", where arthroscopic surgery is claimed to be effective. However,
criteria for such subgroups remain to be defined, and the benefit of
arthroscopic surgery over non-surgical intervention to be shown in well
designed studies. Indeed, the devil lives in the details.
Dr. Bollen fails to recognize that even extensive clinical
impressions can be very deceiving (Cobb et al. 1959, Wartolowska et al.
2014), and that multiple psychological mechanisms are activated when faith
in clinical experience is questioned by systematically collected evidence.
These mechanisms are inherently human, and are likely applicable also to
orthopaedic surgeons. When high level evidence speaks against clinical
experience and unquestioned routine, cognitive dissonance results.
Defenders of questioned treatments focus on potential scientific flaws in
the published trials to invalidate trial results to decrease their level
of cognitive dissonance, while at the same time they ignore the inherent
bias of clinical experience (Horton 1996, Miller & Kallmes 2010).
Another universal human trait is confirmation bias that makes us ignore,
or not want to be exposed to, information or opinions that challenge what
we already believe, while we readily accept information and beliefs that
confirm what we already believe. This leads to overconfidence in personal
beliefs and reinforces beliefs in the face of contrary evidence. The
effects are stronger for emotionally charged issues and deeply entrenched
views (Prasad et al. 2012, Aspenberg 2014, Lohmander and Roos 2015). A
further contributing factor to lacking implementation of high-level
evidence contrary to unquestioned routine is the organization of the care
pathway which can create perverse incentives to maintain procedure rates
(Hamilton and Howie 2015).
References
Aspenberg P. Mythbusting in orthopedics challenges our desire for meaning.
Acta Orthop 2014;85:547.
Bergkvist D, Dahlberg LE, Neuman P, et al. Knee arthroscopies:
who gets them, what does the radiologist report, and what does the surgeon
find? Acta Orthop 2015;in press.
Bohensky MA, Sundararajan V, Andrianopoulos N, et al. Trends in elective knee
arthroscopies in a population-based cohort, 2000-2009. Med J Aust.
2012;197:399-403.
Cobb LA, Thomas GI, Dillard DH, et al. An evaluation
of internal mammary artery ligation by a double-blind technic. N Engl J
Med 1959;260:1115-18.
Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United
States, 2006. Natl Health Stat Report 2009;11:1-25.
Dearing J, Brenkel IJ. Incidence of knee arthroscopy in patients over
60 years of age in Scotland. Surgeon 2010;8:144-50.
Hamilton DF, Howie CR. Knee arthroscopy: influence of systems for
delivering healthcare on procedure rates. BMJ 2015;351:h4720.
Horton R. Surgical research or comic opera: questions, but few
answers. Lancet 1996;347:984-5.
Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for
degenerative tears of the meniscus: a systematic review and meta-analysis.
CMAJ 2014;186:1057-64.
Lazic S, Boughton O, Hing C, et al. Arthroscopic washout for the
knee: a procedure in decline. Knee 2014;21:631-4.
Lohmander LS, Roos EM. The evidence base for orthopaedics and sports
medicine. Scandalously poor in parts. BMJ 2015;350:g7835.
Mattila VM, Sihvonen R, Paloneva J, et al. Changes in
rates of arthroscopy due to degenerative knee disease and traumatic
meniscal tears in Finland and Sweden. Acta Orthop 2015;in press.
Miller FG, Kallmes DF. The case of vertebroplasty trials. Promoting a
culture of evidence-based procedural medicine. Spine 2010;35:2023-6.
Prasad V, Cifu A, Ioannidis JPA. Reversals of established medical
practices. Evidence to abandon ship. JAMA 2012;307:37-8.
Roos EM, Lohmander LS. Young patients--old knees. Knee problems in
the middle age often osteoarthritis. Lakartidningen 2009;106:1645-8.
Thorlund JB, Hare KB, Lohmander LS. Large increase in arthroscopic
meniscus surgery of middle-aged and older in Denmark from 2000 to 2011.
Acta Orthop 2014;85:287-92.
Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for
the degenerative knee: systematic review and meta-analysis of benefits and
harms. BMJ 2015a;350:h2747.
Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for
degenerative knee: systematic review and meta-analysis of benefits and
harms. Br J Sports Med 2015b;49:1229-35.
Wartolowska K, Judge A, Hopewell S, et al. Use of placebo controls in the evaluation of surgery: systematic
review. BMJ 2014;348:g3253.
The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements is the grand foundation on which health, uniformity of
restoration, and the duration of the body, depend; and these certainly
cannot take place if we merely sit and think. The propensity to bodily
movement is, in man, as great as the propensity to eating and drinking.
Let us...
The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements is the grand foundation on which health, uniformity of
restoration, and the duration of the body, depend; and these certainly
cannot take place if we merely sit and think. The propensity to bodily
movement is, in man, as great as the propensity to eating and drinking.
Let us only look at a child. Sitting still is to it the greatest
punishment. And the faculty of sitting the whole day, and not feeling the
least desire for moving, is certainly an unnatural and diseased state. We
are taught by experience, that those men attained to the greatest age, who
accustomed themselves to strong and incessant exercise in the open air. I
consider it, therefore, as an indispensable law of longevity, that one
should exercise, at least, an hour every day, in the open air."
Dear Editor,
As for Fifa standards this is very lovely explained as well. The benefit of activity is in common interest of health professionals and the state.
Conflict of Interest:
Physiotherapy
Dear Editor,
We read with interest the systematic review by Tran and colleagues recently published online(1). The findings build on our own observations in a systematic review of running and knee osteoarthritis (OA)(2). Although the focus of our review was narrower than that of Tran et al, which investigated evidence relating to OA of all joints across a variety of sports, we would like to comment on some of the si...
For over 40 years oral health screening is part of all pre- participation medical examinatios at the Portuguese Sports Medicine Centers in The National Institute of Sports. Preparticipation medicals are compulsory for all athletes who wish to play competitive sports and none gets full clearance without a full treatment of any oral/dental pathology. We are aware that oral health is fundamental to maintain sports performance...
Dear Editor,
This editorial is misleading. Claiming that the Eatwell Guide is not evidence based is factually wrong. The Guide is based on comprehensive expert reviews of the evidence undertaken by the independent Scientific Advisory Committee on Nutrition (SACN) which advises government, and its predecessor, the Committee on Medical Aspects of Food Policy.
The latest revisions to the Eatwell Guide were i...
Dear Editor,
I commend Raftery et al in their recent editorial on concussion assessment in sport, in particular rugby's response on this matter (1). Undoubtedly one of the major issues facing sport is the lack of clarity and consistency in identifying concussions on the field; a symptom of the deficiencies in the last output from the Concussion in Sport Group (the 'Zurich Consensus')(2)
However, while a c...
Dear Editor,
As a rural and purely clinical sports medicine practitioner, I fully agree with the premise of this article. Whilst applauding the wonderful data being produced from around the world, so little of it has any relevance in my practice. There appears to be much back slapping happening in the research centres, though so little work on effectiveness of exercise regimes. I agree that the focus on rigorous meth...
Dear Editor,
We have read the respective article, and we agreed to all stated observations and recommendations. This is a very useful article for many researchers and especially for the scientists working with addiction sciences.
We would just like to emphasise on the use of quantitative assays for the cognitive molecules (Lee et al., 2009) beside doping test. Mental performance is the attribute of three...
Dear Editor,
Injury data from the RWC 2011, 89.1 per 1000 player-hours2011 and the earlier tournament of 2007, 83.9 per 1000 player-hours may have had an effect on all teams.
But success could only be accorded to the winner in the final match. The All Blacks had a long history of not even making the semi-finals. However the RWC 2011 success was not due to the negative effect of injury on the team but rath...
Dear Editor,
We thank Dr. Bollen for his interest in our paper on knee arthroscopy for the middle-aged and older patient with a painful knee (Thorlund et al. 2015a,b).
The consistent high-level evidence (Thorlund et al. 2015a,b; Khan et al. 2015) questioning the benefit of arthroscopic surgery has so far had a very limited effect on the practice of arthroscopic surgery in middle-aged and older patients with a...
The German physician Christopher William Hufeland (1762 - 1836) wrote in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the movements is the grand foundation on which health, uniformity of restoration, and the duration of the body, depend; and these certainly cannot take place if we merely sit and think. The propensity to bodily movement is, in man, as great as the propensity to eating and drinking. Let us...
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