416 e-Letters

  • Response for Best Practice Care for musculoskeletal pain

    As a relative newcomer to the PTA profession, I enjoy reading articles that can enhance my skill set. The review provides a comprehensive guide for management of musculoskeletal pain in common pain sites for use by practitioners, patients to measure their quality of care, and management health professionals. The strengths of the review is the large amount of data accessed globally from 11 countries and over 6000 individual records and 44 Clinical Practice Guidelines included in the study with a goal of patient centered care, pain management, and reducing health care expenses. The 11 Clinical Practice Guideline recommendations form a set of principles that reminds practitioners to provide patients with educational facts and advice that can be overlooked in a rush to send the patient to radiology imaging, surgery and/or prescribe opioids.
    These 11 effective CPG's will enhance my own patient interactions and provide patients with more education to assess their own quality of care.

  • Comprehensive Care of Race-Day Emergencies

    We commend Yuri Hosokawa et al. on their recent publication in the BJSM (Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020.) Their hard work moves the race medicine community forwards in the critically important mission of recognizing and treating critical illness in the elite runner.

    In our experience it is evident that clear, concise protocols, and easy-to-read algorithms are of paramount importance for race-medicine, particularly when experienced race physicians are providing care side-by-side with clinical volunteers. A group of experts convened at the Consortium for Health and Military Performance (CHAMP) in 2019 to review race protocols for the Marine Corps Marathon and the International Institute for Race Medicine (IIRM). While reviewing and revising race protocols, we set out to create straightforward algorithms that would aid in the assessment and treatment of a wide range of acute medical conditions. The algorithms developed from this meeting were published in Current Sports Medicine Reports (Oct. 2020, Vol 19) and are available on the CHAMP website (https://champ.usuhs.edu/for-the-provider) under "Guidelines: Management of Mass Participation Events". We are encouraged to see Dr. Hosokawa and colleagues presenting a similar algorithmic approach in their pape...

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  • No workplace is the same.

    We need to (1) develop and evaluate multi-level interventions suchas the North East Better Health at Work Award and (2) consider sector specific differences.


  • Comment on “Effectiveness of treatments for acute and subacute mechanical non- specific low back pain: a systematic review with network meta- analysis”

    Dear Editor:
    We read the paper by Gianola et al1 with interest. The authors performed a network meta-analysis to assess the effectiveness of interventions for acute and subacute non- specific low back pain (NS-LBP) based on pain and disability outcomes. They concluded that with uncertainty of evidence, NS-LBP should be managed with non- pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance. After carefully reading, we wish to put forth the following suggestions.
    Repeatedly including the same study population will affect the total sample size and the number of participants in each group; thus, duplicated studies using the same study population should not be included in a meta-analysis. However, in Table 3, we found that many studies were conducted by the same authors (Takamoto; Williams), with same category of intervention (Manual therapy; Paracetamol) and incidence of adverse events. Hence, we suspect that these are duplicate studies. This will affect the credibility of the result. Although these studies have low weights in the summary estimates, it's a matter of principle. The author should formulate strict inclusion and exclusion criteria, exclude repeated literature using the same study as a whole, and select the literature with the best quality or the largest sample size for analysis.

  • Letter in response to: “Treating low back pain in athletes: a systematic review with meta-analysis” by Tornton et al.

    Thornton et al.’s “Treating low back pain in athletes: a systematic review with meta-analysis”1 was an interesting read. It was an excellent review that systematically summarized various methods of non-pharmacological conservative management of low back pain in athletes. In particular, this paper analyzed the impact of exercise on low back pain through a meta-analysis of four previous studies.2-5 The meta-analysis was performed using a visual analogue scale and data on disability as outcomes.
    However, we found a few problems with this meta-analysis. First, the authors performed a meta-analysis of the effects of exercise by dividing participants into an exercise group and a control group as shown in Figure 3 of their article. The patients in the exercise group performed specific exercises (periodized resistance training, core stabilization exercise, Swiss ball exercise), while the control group performed another form of exercise (regular recreational activity, conventional lumbar flexion‒extension exercise, exercise on a stable surface) or rested without any exercise. Nevertheless, to investigate the effects of exercise, the authors should have divided patients who performed exercise into an exercise group and a non-exercise group, as a control group, for comparison. However, in the meta-analysis of Tornton et al.’s study, the control group had engaged in exercise in three studies2-4, and had only rested in one study.5 Furthermore, if their intention was to investigat...

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  • Update on Fluid-Based Biomarkers in Sports-Related Concussion Diagnosis


    Recently, an article by Di Pietro and colleagues investigating small non-coding RNAs (sncRNA)s in the saliva of concussed rugby players was published in the British Journal of Sports Medicine (BJSM), a highly rated sports medicine journal [1]. Due to the groundbreaking nature of the study, many media outlets published articles celebrating the authors’ findings. One such article from the Washington Post was titled: “Concussions can be diagnosed through a saliva test, British researchers find.”[2]. As a result, colleagues and clinicians have contacted members of the Sport and Health Interdisciplinary group in Movement & Performance from Acute & Chronic head Trauma (IMPACT), a recently formed international group investigating concussion injury, asking our opinion of the article and what the findings mean for sports-related concussion (SRC) diagnosis. Similar questions emerged in 2018 when the United States of America Food and Drug Administration (FDA) announced approval of a blood test using glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal esterase L1 (UCHL1) to differentiate between computed tomography (CT)-positive and CT-negative results. The headline for this announcement read: “FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults,”[3] which led to confusion among clinicians as to what this meant for concussion assessment and diagnosis. Therefore, the interdisciplinary IMPACT team t...

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  • Flawed research on treatment of back pain does not reflect clinical practice

    I thank the authors for their work in addressing the challenge of evaluation of that enigma of "acute and subacute mechanical non-specific low back pain". However given that this is not a specific diagnosis of a pathology it makes it difficult to truly compare like with like. However as practitioners we assess and manage the back pain patient based upon the symptoms and clinical findings. No practitioner I know uses one modality and expects that to be the most effective therapy, except perhaps the primary care physician prescribing analgesics because of service limitations. Clearly pain is one issue, but objectively we find increased muscle tone/ acute spasm, loss of normal movement patterns and particularly across a number of affected spinal segments and possibly neural referral patterns. Consequently to unpick the combination of pain, spasm and limitation of movement that is self-perpetuating, we use a combination of modalities to achieve specific goals. For example, one might use Western acupuncture to release muscle spasm in paraspinal muscles that may facilitate manual mobilisation that would not have been possible in the presence of the spasm. The mobilisation of the spinal segments facilitates more normal movement patterns which reduces pain on movement. Furthermore as the clinical condition progresses we continually adapt which modality we use at each session in accordance with the patient's response and reduce prescribed medications when the con...

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  • Put your trainer on hold; the causal relationship between physical inactivity and severe COVID-19 is still not clear.

    Dear Editor,

    Sallis and colleagues showed that patients who were not consistently meeting physical activity guidelines prior to COVID-19 contamination had a substantially greater risk of hospitalisation, admission in intensive care units, and death than patients who were consistently meeting physical activity guidelines (>150min/week engaging in moderate or strenuous exercise over 2-months).1 Identifying risk factors associated with negative COVID-19 outcomes is timely. COVID-19 has resulted in almost 3,000,000 deaths worldwide by the middle of April 2021 2, and vaccination seems insufficient without health and political behaviour changes. 3

    However, we have some concerns about Sallis and colleague’s conclusions. The authors recommended “efforts to promote physical activity” relied on strong assumptions that meeting physical activity guidelines would cause less COVID-19 negative outcomes such as hospitalisation, admission in intensive care units, and deaths. Although exercise has many benefits to individuals, we cannot allow that the urgency of solving problems lead to hasty and imprecise conclusions of causality, as well as unnecessary efforts for implementation.

    Consider a “0-10 causality strength scale”, proposed by Pearl (2018) 4, where 0 is weak evidence of causality and 10 is strong evidence of causality. Depending on the assumptions and procedures used in the studies to test the association between variables, we become more or less confident...

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  • Discussing the return to sport for professional sport leagues in the context of COVID-19: the Rugby Europe experience

    Dear Editor and authors,
    As we have been actively involved in the return to play process in European rugby at international level, it was with great pleasure that we have read the article “Return to sport for North American professional sport leagues in the context of COVID-19” by DiFiori et al.1
    We acknowledge, as the authors do, that an individualized approach must take place for each league and sport, but it is also true that all protocols must be broad and inclusive, going beyond testing and obtaining the active engagement of all agents.
    Rugby Europe is the European governing body of Rugby union and its top senior male and female competitions have just resumed in February 2021 and all over Europe, after a stoppage of 11 months, supported by a robust “Return To Play Protocol”2. This protocol was developed by the Rugby Europe Player Welfare steering group, during the summer and autumn of 2020, and considers different sanitary and testing aspects, most of which are also presented by DiFiori et al.1 in their paper.
    Testing is, of course, an important part of Rugby Europe RTP protocol, but it also includes a large number of sanitary and hygiene measures to be implemented by the match organization and each team. Regarding the SARS-COV2 testing, all players and staff have to be submitted to a RT-PCR test <72 hours before the match of before the travel to the host country, as well as to an antigen test <24h before the match.2 So far, 2179 SARS-CO...

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  • What matters? Program or pain?

    We would like to congratulate the authors on this interesting publication. The supplementary material is of especially high value and we appreciate how it can assist clinicians to evaluate the described program in their daily clinical practice. The studied progressive tendon-loading program reflects, in many aspects, what we find effective with our athletic and non-athletic patient population in our clinic.

    However, from our perspective there are some issues with the study that question the authors’ conclusion of a superiority of Progressive Tendon-Loading Exercise Therapy (PTLE) over Eccentric Exercise Therapy (EET).

    1. Does the study truly compare PTLE with EET?
    In stage 1, patients in the EET group were instructed to perform the exercises with pain VAS ≥ 5/10, whereas the PTLE group performed the exercises ‘within the limits of acceptable pain’. This requirement adds a non-controlled variable. Does the study solely compare the effect of two different progressing loading regimes, or does it compare painful exercises with exercises performed in an acceptable range of pain?
    What matters most here? The program or the pain?

    2. How do the authors justify the ≥ 5 VAS in the EET group?
    Instructing patients to perform exercises that produce at least a pain of VAS 5 is uncommon. To justify this, Breda et al. refer to the study of Visnes (2005).1 This RCT with 29 volleyball players with patellar tendinopathy had shown no effect on knee funct...

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