# 60 e-Letters

published between 2017 and 2020

• Response to 'A few unanswered questions'

Dear Dr. Anoop Balachandran

We would like to thank you for your insightful and interesting comment.

Regarding the first point, we presented the 28.5% to illustrate the relative difference in total absolute fat (kg) change between interventions, so the reader could have information about the relative difference between groups. We would like to highlight that it was only possible to perform this analysis using the within group changes, since the change between group analysis was showed in absolute values.

About the second point, it was not our purpose to analyse lean body mass; however, we agree that this topic is very important for health and athletic performance purposes. This is an unanswered question and we are performing studies to test the effects of interval training on lean body mass to help shedding light in the topic.

Best regards.

• Accounting for Multiple Testing Calls into Question the Significance of these Results

In this article the authors discuss their analysis of 21 female and 22 male athletic events. Testing all 43, they find 3 events significant with p<0.05. When testing 43 events, the expectation is that a well-calibrated statistical test will produce 2 false positives with random data, on average, due to the definition of the p-value. The odds of producing 3 false positives are also rather high; for normally distributed simulated data under the null, I found 3 or more false positives approximately 1/3 of the time such an analysis is performed, see here for a simulation notebook: https://github.com/davidasiegel/False-Positive-Rate-for-Multiple-Tests-i....

This is why adjustments for multiple comparisons needs to be performed. It was neglected in their initial study and neglected again in this study. In the 2017 study they state, "These different athletic events were considered as distinct independent analyses and adjustment for multiple comparisons was not required." This doesn't make sense to me; if the analyses are distinct, then all the more reason to correct for multiple comparisons. If a Bonferroni correction were performed, none of the p-values would test significant at the level of the study (p<0.05/43 = 0.001). Therefore I do not see why there is any reason to reject the null hypothesis for any of these results.

Perfor...

The study raises two questions that one of the authors might be able to help with:

First, the authors report both within group and between group changes in body fat in the abstract. But it is unclear why the authors chose the within-group changes (28% fat loss) as the study conclusion than the between-group change.

The within group change showed a fat loss of 0.45 kg (28%) in favor of interval training (IT), while the between-group changes showed a large difference of 2.28 kg of fat loss in favor of IT. Considering the large difference in fat loss, and some studies recommending to avoid within group differences in meta-analysis, it would be helpful if the authors could comment on this.

Second, maintaining lean body mass (LBM) is one of the primary reasons to include exercise as part of a weight loss strategy. So it is not clear why the authors chose not to include lean body mass as one of the outcomes. It would have certainly helped the reader to make a decision regarding the choice of exercise for weight loss.

Finally, congratulations to all the authors for asking a very relevant question!.

• Response to the Need for Evidence-Based Marketing

The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.

First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-p...

• Evidence based physiotherapy needs evidence based statements from researchers

The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.

The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to sugg...

• Methodological concerns in patients with femoroacetabular impingement: is ROM deficit really absent?

We thank Freke et al. (1) for their systematic review about physical impairments in patients with symptomatic femoroacetabular impingement, nonetheless we have some remarks about methods and results of the article, in particular for range of motion (ROM) outcome.
A meta-analysis of ROM was performed without reporting an overall estimate. Taking into account the amount of studies included and their information, a meta-analysis should have been accomplished. Nonetheless, authors concluded that individuals with symptomatic FAI demonstrated no difference in hip ROM in any direction of movement. This conclusion was unexpected taking into account the findings reported in the primary studies included), and in the previous systematic review published in 2015 (2), that showed instead a reduced ROM.
This discrepancy in literature is already discussed by the Warwick agreement (3), where authors stated that “the evidence on hip range of motion (ROM) in FAI syndrome is surprisingly contradictory” due to contrasting published systematic reviews (1) (2).
Therefore, we checked the accuracy of results reported, analyzing the data reported for every movement assessed in primary studies comparing those reported in this systematic review. We noted some issues in the represented forest plots.
Firstly, some included studies (4), (5), (6), (7) were reported twice in the meta-analysis for different times points or reporting double data of the same patients obtained by two...

• BJSM encourages comments alongside papers - such as this example

Many of you will be familiar with The BMJ and its popular 'Rapid Responses'. Because we are a sister journal to The BMJ (and part of the same publishing company of course) we have the same Platform and we encourage you to use it.

• Letter in response to: The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial.

Dear Editor,

I would like to congratulate the British Journal of Sports Medicine for the publication of the study ‘The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial’ conducted by Harøy et al.[1]. The study investigated the effect of the adductor strengthening programme on the prevalence of groin problems among football players. The findings are incredibly important for the development of sports medicine because of their clinical relevance.

Regarding the methodology of this study, rather than giving criticism, I would like to suggest the authors if they can provide additional information or even a follow-up article on the game performance of the football teams involved in this study. As mentioned in the article, the authors have considered the groin pain causing time loss, decreasing participation or performance of the players [1]. Meanwhile, the previous study literally found that a lower incidence rate was strongly correlated with the number of goals, games won and even team ranking position [2,3]. Therefore, readers are interested whether the performance could be improved too since the results showed a significant reduction in the prevalence of groin pain in the players.

Similar studies have been conducted to investigate the effect of a specific strength training programme on players’ injury prevalence and individuals’ performance [4]. However, no data was included to refl...

• Comment and questions to Mottola et al (2019): 2019 Canadian guideline for physical activity throughout pregnancy

Letter to the Editors
Br J Sports Med