398 e-Letters

  • Sports and exercise medicine education: extending the call to action to the UK

    We read with great interest the article by Asif et al. (1), and applaud their call to action for education and research in sports and exercise medicine in the USA. We want to extend this call to action to the UK medical education system, where a similar need for physical activity (PA) promotion and development of sports and exercise medicine is needed.

    Similar to the USA, there is poor adherence to PA guidelines in the UK population with only 66% of adults engaging in ≥150 minutes of moderate PA per week, the minimum amount found to produce health benefits (2). PA is associated with many positive health outcomes such as enhanced psychological well-being, cancer prevention and increased brain and cardiovascular health, showing it is an essential and valid way to better the health of the population (3). Furthermore, physical inactivity is associated with 16.9% of all-cause mortality in the UK, affirming the need to control and reverse the inactivity epidemic (4).
    The public view doctors as a respectable source of information, which when coupled with the regular contact they have with the community places them as an invaluable resource for PA promotion in the UK (5). However, in their article, Asif et al. (1) describe how doctors in the USA have not been adequately prepared to provide advice and counselling on PA. It is evident that this inadequacy also applies to doctors in the UK. In 2012, the mean number of hours spent teaching PA science and promotion in UK...

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  • Physical activity in hypertrophic cardiomyopathy - be careful in genotype and troponin positive subgroup of patients.

    Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50

    In recently published paper (1) authors showed that moderate-to-vigorous-intensity physical activity in adult population of patients with hypertrophic cardiomyopathy (HCM) (mean age 59.5 years) was associated with progressive reduction of all-cause and cardiovascular mortality. Authors suggested that the impact of physical activity on this population requires further investigation. This suggestion seems to be crucial because evaluated adult patients might be predominantly genotype-negative. In paper by Canepa et al. (2) percent of patients with positive genotype for HCM dynamically decreased over time.
    Additionally, in all three groups according to the tertiles of increasing physical activity the percent of patients with co-diagnosed arterial hypertension was very high (66-67%) (1). This fact may suggest that left ventricle (LV) hypertrophy is not primary type (HCM) but secondary to hypertensive stimulation. Accordingly, univariate and multivariate analyses in Bos et al. paper (3) demonstrated echocardiographic reversed septal curvature, age at diagnosis < 45 years, maximal LVWT ≥ 20 mm, family history of HCM, and family history of SCD to be positive predictors of positive genetic test while hypertension was a negativ...

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  • In response to: ‘More Walk and Less Talk’: Changing gender bias in sports medicine

    We applaud our Danish colleagues(1) on their recent paper on the #sportskongres experience prior to and following the seminal paper by Bekker(2) ‘We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine’. We also congratulate their ongoing efforts to continue and advance the conversation and the opportunities for women in sport and exercise medicine.

    In February 2020, the Australasian College of Sport and Exercise Physicians (ACSEP) hosted our Annual Scientific Meeting in Canberra. Australia. For the first time we had gender equity in our presenters, for both the keynote (1/2) and general presentations (31/62). There were no manels and 47% (8/17) of our sessional chairs were female. This was an increased representation by women in comparison to our 2019 conference where 39% of our presenters were women.

    In a College where women comprise 25% of Fellows and 30% of Registrars, how did we achieve equal gender representation in our program? We looked for it, we planned for it, we invited women and we measured it and celebrated achieving it. The ACSEP currently has a female President and in 2020 the conference convenor was female. The conference committee had gender equity and the College has a Women in SEM committee that are responsible for the promotion of female Registrars and Fellows to leadership positions within the College and be a force for change within the overall culture of the college and the greater SEM l...

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  • Letter in response to: Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study-a randomised controlled trial

    We read with great interest the study by Rasemberg and colleagues1 and appreciate the pragmatic research method illustrating the routine of clinicians in many countries. However, some points drew our attention and motivated this letter.
    A recent systematic review with meta-analysis2 investigated three types of insoles: customized, prefabricated, and sham. The authors included 19 trials (a total of 1,660 participants) and demonstrated that custom insoles did not reduce pain or improve function in the short-term. In the medium-term, the customized insoles were more effective than sham in reducing pain; however, with no improvements in function. In the long-term, the custom insoles did not reduce pain or improve the participants' function.
    At this point, we achieve the first question: what kind of customization did these studies address? When analyzing the studies included in this review, we noticed that customizations were based on Root's subtalar joint neutral theory, in which insoles should keep the subtalar joint aligned in a neutral position, and the internal longitudinal arch supported to optimize its height and control its descent during the mid-stance support phase. This does not seem ideal if we consider the foot mechanics and some particular movements, such as the windlass for impact absorption and propulsion of the foot3,4.
    When customizing an insole to keep both the foot and ankle in a neutral position, the clinician assumes that every...

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    The recent item by Machado et al(1) is a good reminder of the existence of hospital electronic medical records and their value for sports medicine research and practice. However, the authors’ claim that there have been very few studies that have used such data in relation to sports injuries is incorrect. The authors cite only two studies (from 1984 and 1994), despite a large international body of published work addressing hospital-treated sports injury.

    The first national reporting of sports injury patterns in Australia was based on an analysis of emergency department records published in 1998.(2) The Australian Institute of Health and Welfare, a national Australian health authority, has published reports on sports injury hospitalisations for over a decade, the most recent being in 2020.(3, 4) Our sports injury research team has also long demonstrated the value of routine hospital data collections to inform public policy and debate about sports injury prevention.(5) As an example, after demonstrating the excess health burden of hospital treated sports injuries, relative to that of road trauma,(6) the Victorian State Government established a taskforce especially to address injury prevention and targeting of sports medicine provision in community sport.(7)

    Our research team has published several studies addressing the number, nature and burden of sports injury over many years using routinely collected hospital data, including:
    • Analysis of hospita...

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  • Understanding NNTs

    Roe et al have written a useful article on the continuing misuse of relative risk, and the importance of understanding relative risk and absolute risk difference in injury risk outcomes in randomised controlled trials. In describing the Number Needed to Treat (NNT) they miss out an important word- the NNT is the number needed to treat to prevent one _extra_ adverse event, not to prevent a single adverse event. To see thus suppose the NNT was m. In their notation the risk in the intervention group is IG and the Control group is CG. The number of events expected in the intervention group if we treated m of them is mIG. To prevent one event we have mIG=1 and so we have to treat m=1/IG subjects to prevent one event. However we would expect mCG events in the control group. To prevent one _extra_ event in the intervention group we would require mCG-mIG =1 (assuming CG>IG) . Thus m=1/(CG-IG) which is the definition of the NNT. They could also, perhaps, have mentioned the problems in using the NNT, such as differing baselines leading to it being uninterpretable as described, for example by Stang, A., Poole, C., & Bender, R. (2010). Common problems related to the use of number needed to treat. Journal of Clinical Epidemiology, 63(8), 820–825

  • RE: Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies

    Shiri et al. conducted a meta-analysis to examine the effect of leisure time physical activity on non-specific low back pain (LBP) (1). Adjusted risk ratio (RR) (95% confidence interval) of moderately/highly active individuals, moderately active individuals and highly active individuals against individuals without regular physical activity for frequent/chronic LBP was 0.89 (0.82 to 0.97), 0.86 (0.79 to 0.94) and 0.84 (0.75 to 0.93), respectively. For LBP in the past 1-12 months, adjusted RR did not reach the level of significance in any levels of physical activity. The authors concluded that leisure time physical activity might reduce the risk of chronic LBP by 11%-16%. I have some concerns about their study by presenting negative information regarding protection of LBP by physical activity.

    First, Saragiotto et al. conducted a meta-analysis on the effectiveness of motor control exercise (MCE) in patients with nonspecific LBP (2). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles. They concluded that MCE was probably more effective than a minimal intervention for reducing pain, but did not have an important effect on disability, in patients with chronic LBP. In addition, there was no clear difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Although there is no definite information to recommend MCE for non-specific LBP, further studies are need...

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  • International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))

    Allow me to make use of the opportunity to extend my appreciation to the BJSM for being a publication of high standing, bringing cutting edge information to the sports medical fraternity.
    Thank you for the consensus statement of the International Olympic Committee describing the methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))”.[1] I found it both informative and useful.
    I have a comment about the use of the word “Nervous” in the first column of Table 5. It is an adjective whereas the rest of the words in the column are nouns that more accurately describe the tissue type under discussion. It is possibly only a linguistic error, but I am of the opinion that it should be “Nerve” or “Neural tissue”.

    1. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med Published Online First: 18 February 2020. doi: 10.1136/bjsports-2019-101969

  • Response to: “Potentially Biased Results on Mouthguard Use and Reduction of Concussion Risk”

    We read with interest, and concern, the letter submitted by Schilaty et al arguing bias in our analysis examining the association between concussion and mouthguard use. Schilaty et al argue that a nested case-control study was not optimal and that “Based on a relatively small cohort, a complete case-control study would have been more appropriate than a nested case-control study.” They then go on to argue that “selection criteria of the non-concussion group biased the study as a random sample was not selected from the remaining cohort (n=2,040)” eliminating “from the analysis all non-injured players who wore mouthguards.” Finally, Schilaty et al contend that our study did not “properly compare the incidence of concussion between wearers or non-wearers of mouthguards.” There are multiple concerning statements and assertions made by the authors of the letter, Schilaty et al., that we will address below.

    Shilaty et al discuss the desire to compare “incidence of concussion between wearers and non-wearers of mouthguards.” Incidence cannot truly be estimated from a case-control study, given that the number of cases and controls is fixed from the design. Rather, we are after the odds ratio based on the ratio of the odds of exposure in cases relative to controls (the odds ratio of exposure is mathematically the same as the odds ratio of being a case). Modern conceptualizations of the case-control study invoke the idea of pseudo frequencies or quasi-rates related to construc...

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  • Comment on "Three steps to changing the narrative about knee osteoarthritis: a call to action."

    Whilst its principal message is clear, I wish to draw attention to three problems arising from the editorial authored by Caneiro et al.:

    1. They say, “… pain is described as an altered state of a person’s knee health influenced by biopsychosocial factors, of which many can be modified.”

    How is “knee health” different from “whole person health”?

    Just how many biopsychosocial factors can be modified?

    2. Contemporary evidence is said to support the proposition that “knee health” is “influenced by the interaction of different biopsychosocial factors” that have the property of “modulating inflammatory processes and tissue sensitivity”.

    Is there any evidence that such an interaction actually takes place?

    And furthermore, what are the postulated mechanisms for such interaction?

    3. Their Infographic (“What should you know about knee osteoarthritis?”) contains the statement “rest and avoidance makes pain worse.” Presumably they are referring to avoidance of graded exercise. But even so, how do the authors justify their conclusion that avoidance of exercise or rest "per se" can “make pain worse”?