I enjoyed reviewing for this journal very much and can only hope that more journals will use a similar electronic system.
Having waited over 16
weeks to hear from a different journal, I think that the electronic system provides an
excellent service to the authors.
The helmets worn in ice hockey - what is their specification and
composition?
They look like canoeing-type and very thin plastic, if so, it
is no wonder head injuries continue. The players need padded helmets more
like motorcycle crash helmets to withstand the knocks with a layer of
polystyrene or other shock absorbing material.
Does BJSM even use its review process? Being a runner and running
trainer and scientist, I am embarrased about this article.[1] The news
*running is unhealthy* quickly went the round. Here in Germany it already
was in TV text, in several online newspapers (with headlines like 'Run
into Osteoporosis'), and has reached internet discussion boards. It will
supposedly appear in printed matter starting tomorro...
Does BJSM even use its review process? Being a runner and running
trainer and scientist, I am embarrased about this article.[1] The news
*running is unhealthy* quickly went the round. Here in Germany it already
was in TV text, in several online newspapers (with headlines like 'Run
into Osteoporosis'), and has reached internet discussion boards. It will
supposedly appear in printed matter starting tomorrow.
The authors measured bone mineral density in female endurance
runners. What, if there was no correlation between running and bone
mineral density? No paper! There was no non-running group for comparison.
What, if there was no correlation between running distance and bone
mineral density? No paper!
Fortunately, there was a correlation.
The results of the regression analyses suggest that the bone mineral
density of the lumbar spine and femoral neck are controlled by different
parameters. They also suggest that aging alone increases the bone mineral
density in the lumbar spine at ages from 18 to 28, whereas it decreases in
the femoral neck from age 18. Does anybody believe this?
The suggested effects of running on bone mineral density are in the
range of the standard deviations of the measurements. If they even
existed, they would be overprinted by the much stronger effects of other
parameters (according to the regression equations), i.e. age.
The regression equation regarding the bone mineral density of the
femoral neck leads to manifold surprising results. For example, that the
entire suggested effect of running would be compensated by a half Mg fizzy
tablet per day.
This paper is a perfect example of pseudo-science. The Press turns
its 'suggestions' into 'truths'. Thousands of female runners are made
feeling insecure. It's embarrassing.
Reference
(1) M Burrows, A M Nevill, S Bird, and D Simpson. Physiological factors associated with low bone mineral density in female endurance runners. Br J Sports Med 2003;37:67-71.
The Italian requirement that all professional and amateur athletes
obtain medical certification of their ability to participate in their
chosen sport dates from 1950.[1] In 1971 and 1982 this mandate was
reinforced by specific legislation of the Italian Ministry of Health,
covering both competitive and non-competitive participants.[2]
Consequently, large numbers of symptom-free and ostensibly health...
The Italian requirement that all professional and amateur athletes
obtain medical certification of their ability to participate in their
chosen sport dates from 1950.[1] In 1971 and 1982 this mandate was
reinforced by specific legislation of the Italian Ministry of Health,
covering both competitive and non-competitive participants.[2]
Consequently, large numbers of symptom-free and ostensibly healthy young
Italians have undergone ECG and echocardiographic screening, with the
intent of avoiding sudden, exercise-induced cardiovascular death.[3,4]
Such procedural norms are in striking contrast with those of other
countries such as Canada, where it is maintained that the constraints of
Bayes theorem limit the value of laboratory cardiovascular testing in
symptomless young athletes.[5,6] Indeed, it is argued that by
generating an undesirable number of false positive responses, such a
policy creates much unnecessary anxiety, and leads to unnecessary warnings
against exercise, effectively worsening the individual's prognosis.
In their most recent article, Pigozzi and associates [1] speak of the
efficacy of the Italian screening programme, although they admit to an
alarming 40% of false positive results from ECG testing. Corrado and
associates [7] found that 9% of Italian athletes had "abnormal" ECGs, and
were required to undergo the additional expense of echocardiographic
screening; on the basis of the latter investigation, it appears that 2%
were barred from athletic participation.
Plainly, there is a unique opportunity to compare the health
consequences of the Italian approach with that of other countries who
believe that detailed laboratory examination is unwarranted. Are there
fewer episodes of sudden exercise-induced death per 100,000 hours of
competitive and non-competitive athletic activity in Italy than elsewhere?
And which approach gives the smaller number of unnecessary cardiac
neuroses?
To my knowledge, no one has yet made such an analysis, and in its
absence I would suggest it is premature to conclude that the Italian
"state law is noteworthy for the positive results that it has produced."
References
(1) Pigozzi F, Spataro A, Fagnani F, et al. Preparticipation
screening for the detection of cardiovascular abnormalities that may cause
sudden death in competitive athletes. Br J Sports Med 2003;37:4-5.
(2) Decree of the Italian Ministry of Health, February 19, 1982.
Norme per la tutela dell'attività agonistica. Gazetta Ufficiale 1982: Mar
5: 63.
(3) Maron BJ, Shirani, J, Poliac LC, et al. Sudden death in young
competitive athletes. JAMA 1996; 276: 199-204.
(4) Maron BJ. Considerations for preparticipation cardiovascular
screening in young competitive athletes. In: Shephard RJ, Åstrand PO, (Eds)
Endurance in Sport, 2nd ed. Oxford, Blackwell, 2000; Pp. 667-681.
(5) Shephard RJ. The athlete's heart: Is big beautiful? Br J Sports
Med 1996;30:5-10.
(6) Shephard RJ. Medical surveillance of endurance sport. In:
Shephard RJ, Åstrand PO, (Eds) Endurance in Sport, 2nd ed. Oxford,
Blackwell, 2000; Pp.653-666.
(7) Corrado D, Basso C, Schiavon M, et al. Screening for hypertrophic
cardiomyopathy in young athletes. N Engl J Med 1998; 339:364-369.
We cannot help but note the correlation between the results of this study
of female athletes,
and the study conducted on male long distance runners in Denmark [1].
We propose that sunshine might be the common factor driving the observed bone loss in these
two,
apparent...
We cannot help but note the correlation between the results of this study
of female athletes,
and the study conducted on male long distance runners in Denmark [1].
We propose that sunshine might be the common factor driving the observed bone loss in these
two,
apparently disparate, sets of
athletes.
The secosteroid hormone 1,25-dihydroxyvitamin-D (1,25-D) is a
potent stimulator of osteoclast activity [2], and
excessive levels of 1,25-D have a direct effect on
BMD [3].
1,25-D is manufactured by skin keratinocytes upon exposure to
sunlight [4].
Sunscreens have no measurable effect on the
amount of 1,25-D produced by solar exposure [5].
Endurance runners are clearly exposed to unusual amounts of direct sunlight during
both practice and competition, and we believe that excessive concentrations of 1,25-D could
well have been an unconfounded variable in this study.
We would urge
measurement of the level of this hormone during
any future study of BMD in outdoor athletes.
References
(1) Hetland ML, Haarbo J, Christiansen C. Low bone mass and high bone
turnover in male long distance runners. J Clin Endocrinol Metab 1993 Sep;77(3):770-5. Pubmed Abstract
(2) Manolagas SC. Birth and Death of Bone Cells. Basic Regulatory
Mechanisms and Implications for the Pathogenesis and Treatment of
Osteoporosis. Endocr Rev 2000 Apr 01;21(2): 115-137. Publisher Full
Text.
(3) Adams JS, Lee G. Gains in Bone Mineral Density with Resolution of
Vitamin D Intoxication. Ann Intern Med 1997 Aug 1;127(3):203-6. Publisher Full
Text
(4) Marshall TG, Marshall FE. New Treatments Emerge as Sarcoidosis
Yields Up
its Secrets.Clinmed 2003 Jan 27;2003010001 Full Text
(5) Marks R, Foley PA, Jolley D, Knight KR, Harrison J, Thompson SC. The
effect of regular sunscreen use on vitamin D levels in an Australian
population. Results of a randomized controlled trial. Arch Dermatol 1995
Apr; 131(4): 415-21. PubMed Abstract
The presence of false positive ECGs is without doubt a limit to the diagnostic capability of this investigation in the contest of cardiovascular screening of athletes.
These abnormal ECG appearances result mainly from the morphological
adaptations of the heart to training and to the actual sport practised.
For example, endurance athletes show a higher rate of ECG abnormalities
than athletes practising ‘tec...
The presence of false positive ECGs is without doubt a limit to the diagnostic capability of this investigation in the contest of cardiovascular screening of athletes.
These abnormal ECG appearances result mainly from the morphological
adaptations of the heart to training and to the actual sport practised.
For example, endurance athletes show a higher rate of ECG abnormalities
than athletes practising ‘technical sports’ such as sailing, horse riding
or pistol shooting. Cardiac adaptation is correlated with training time
and training intensity. Furthermore, males and young athletes present more
frequently such anomalies, possibly a consequence of their more marked
training-induced cardiac adaptation capability.
In recreational athletes, these morphological adaptations are reduced or
assents, as consequence of the lower the cardiovascular stress and the
effects of training on the heart.
Pelliccia et al recently showed that ECG has a high negative predictive
value (96%), showing that a normal ECG (as indeed it does in non-athletic
individuals) is able to discriminate with a high index of accuracy the
presence of cardiovascular anomaly.[1] On the other hand, an abnormal ECG
points towards a heart problem and further investigations.
This is confirmed by Basso et al, who showed that it is possible to
identify, using electrocardiography, subjects with hypertrophic
cardiomyopathy, a cause of sudden death in athletes.[2] These individuals
were not allowed to take part in competitive sports, and, eight years
after the electrocardiographic diagnosis, did not present with sudden
cardiac death.
Therefore, the identification of subjects at risk and the proscription of
competitive sports activity seem to be the right strategy to prevent
sudden cardiac death. Pre-participation screening for the detection of
cardiovascular abnormalities used in Italy has up to now shown to be an
effective tool to prevent cardiovascular accidents in this context.
References
(1) Pelliccia A, Maron BJ, Culasso F, Di Paolo FM, Spataro A, Biffi A,
Caselli G, Piovano P. Clinical significance of abnormal
electrocardiographic patterns in trained athletes. Circulation 2000; 102
(3): 278-84.
(2) Basso C, Thiene G, Corrado D, Buja G, Melacini P, Nava A. Hypertrophic
cardiomyopathy and sudden death in the young: pathologic evidence of
myocardial ischemia. Hum Pathol 2000;31(8):988-98.
With regard to the Leader by ADG Baxter-Jones and N Maffulli [1] we would
like to extend our appreciation to the authors for their interest in this
never ending “hot debate”.
The authors clearly point out difficulties and
potential pitfalls of exercise testing, exercise prescription and the
interpretation of acute responses and of the chronic adaptation to
exercise training during growth and ma...
With regard to the Leader by ADG Baxter-Jones and N Maffulli [1] we would
like to extend our appreciation to the authors for their interest in this
never ending “hot debate”.
The authors clearly point out difficulties and
potential pitfalls of exercise testing, exercise prescription and the
interpretation of acute responses and of the chronic adaptation to
exercise training during growth and maturation.[1] We totally support the
conclusion that appropriate endurance training in children and adolescents
lowers blood lactate levels (BLC) at given workload and improves peak
oxygen uptake and performance at anaerobic threshold (AT). However, we
strongly feel that the comments on AT especially with respect to so called
“lactate criteria” do not consider the current state of knowledge in this
field of science.
There are a huge number of different concepts of AT that use BLC,
ventilatory measures or the combination of both.[2] In theory the BLC based
concepts of AT are supposed to identify the highest exercise intensity at
which a steady state of BLC can be identified during a prolonged constant
workload. The corresponding steady state BLC is defined as the maximal
lactate steady state (MLSS).[3,4] Depending on the testing condition AT
measurements determine a workload which correlates with the MLSS workload
but which may not be identical to the latter.[3]
Therefore behaviour of the BLC during prolonged constant workload exercise
conditions has been systematically analysed for individuals aged between 9
and 32 years.[5-11] Differences in experimental methods have been
analysed [5] and the procedures were validated against methods previously
established and exclusively used in the adult population.[12] The results
show that at given exercise intensities up to the level of the workload
corresponding to the MLSS the BLC appears to be independent of age across
the whole range of maturation from pre-puberty to adulthood.
We agree totally that the acute response and chronic adaptation to
exercise of young athletes is not yet fully understood. However, based on
the current state of knowledge there is no evidence for the statement: “In
general, BLC levels are lower in children and adolescents than in adults
at any given exercise intensity”
and in fact experimental results support
the opposing view point.
References
(1) Baxter-Jones ADG and Maffulli N. Endurance in young athletes: it can be trained. Br J Sports Med 2003; 37: 96-97.
(2) Loat CE, Rhodes EC. Relationship between the lactate and ventilatory
thresholds during prolonged exercise. Sports Medicine 1993;15(2):104-115.
(3) Beneke R. Anaerobic threshold, individual anaerobic threshold, and
maximal lactate steady state in rowing. Med Sci Sports Exerc 1995;27(6):863-867.
(4) Heck H, Mader A, Hess G, et al. Justification of the 4-mmol/l lactate
threshold. Int J Sports Med 1985;6:117-130.
(5) Beneke R, Schwarz V, Leithäuser R et al. Maximal lactate steady state
in children. Ped Exerc Sci 1996;8(4):328-336.
(6) Beneke R, Heck H, Schwarz V, et al. Maximal lactate steady state during
the second decade of age. Med Sci Sports Exerc 1996;28(12):1474-1478.
(7) Beneke R, Leithäuser RM, Schwarz V, et al. Maximales Laktat-Steady-
State bei Kindern und Erwachsenen. Dtsch Z Sportmed 2000;51:100-104.
(8) Heck H. Laktat in der Leistungsdiagnostik. Wissenschaftliche
Schriftenreihe des deutschen Sportbundes. Schorndorf: Verlag Karl Hofmann, 1990.
(9) Mocellin R, Heusgen M, Korsten-Reck U. Maximal steady state blood
lactate levels in 11-year-old-boys. Eur J Pediatr 1990;149: 771-773.
(10) Mocellin R, Heusgen M, Gildein HP. Anaerobic threshold and maximal
steady-state blood lactate in prepubertal boys. Eur J Appl Physiol
1991;62:56-60.
(11) Williams JR, Armstrong N. Relationship of maximal lactate steady state
to performance at fixed blood lactate reference values in children. Ped
Exer Sci 1991;3: 333-341.
(12) Beneke R. Methodological aspects of maximal lactate steady state –
implications for performance testing. Eur J Appl Physiol 2003;89:95-99.
The Ernst and Sran commentary [1]
about 'chiropractic manipulation' is not consistent with the majority of
systematic reviews, nor national guidelines. It is, however, highly
consistent with the previous and prolific writings of the first author
himself on this topic. Surely, the significance of this pattern is an
obvious one, and the suggestion that if anyone else but a chiropractor
performs a ma...
The Ernst and Sran commentary [1]
about 'chiropractic manipulation' is not consistent with the majority of
systematic reviews, nor national guidelines. It is, however, highly
consistent with the previous and prolific writings of the first author
himself on this topic. Surely, the significance of this pattern is an
obvious one, and the suggestion that if anyone else but a chiropractor
performs a manipulation, it is likely to be much safer, speaks for itself?
The same considerations might be applied to journal editorial practice as
well, especially when the affected public may have seriously disabling
problems which could be pivotally changed by the correct treatment.
Reference
(1) Ernst E and Sran MM. Chiropractic spinal manipulation for back pain • Commentary. Br J Sports Med 2003;37:195-196.
We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading.
This is particularly evident in the initial paragraph. The author begins
by generally addressing sports medicine clinicians, including those who
are trained in mobilisation and manipulation, namely osteopaths,
physiotherapists and chiropractors and a...
We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading.
This is particularly evident in the initial paragraph. The author begins
by generally addressing sports medicine clinicians, including those who
are trained in mobilisation and manipulation, namely osteopaths,
physiotherapists and chiropractors and abruptly concludes, for no apparent
reason, that chiropractic manipulation will be the focus of the remainder
of the article. Our question is, "Why single out chiropractic manipulation
when similar forms of manipulation are routinely practised by all of the
other initially identified professions?".[1] This author has a long track
record of reporting the potential adverse reactions specifically related
to manipulation performed by chiropractors. Additionally, the author
chooses a different forum for each "letter". The current leader appears to
be simply rehashing old statements rather than adding new material to the
discussion. Each new forum tends to confuse the issue further, as new
groups of professionals are brought into the debate without all of the
information required to make an informed decision. This type of approach
requires the chiropractic profession to continually respond in a more
defensive fashion. This undermines co-operative research efforts and
thwarts any attempt at productive interprofessional debate.
Chiropractic manipulation is singled out, even though Assendelft et al,[2] concluded the minimum effectiveness of spinal manipulation
irrespective of the provider was not superior to other treatments for back
pain. Such results can also be interpreted as manipulation being at least
equivalent to other available treatments. This would naturally increase
the number of therapeutic options available for the management of a
complex clinical condition. Under these circumstances, clinical
utilisation and decision making should always take into account patient
centred factors such as side effects and patient satisfaction. Professor
Ernst clearly has reservations regarding the United Kingdom's current
national clinical practice guideline and evidence review. This states
that: "Within the first 6 weeks of acute or recurrent low back pain,
manipulation provides better short-term improvement in pain and activity
levels and higher patient satisfaction than the treatments to which it has
been compared" and "the risks of manipulation for low back pain are very
low, provided patients are selected and assessed properly and it is
carried out by a trained therapist or practitioner [3] "; i.e.,
chiropractors, manipulating physiotherapists and osteopaths.
With respect to the forces applied during a manipulation, the paper
quoted by Professor Ernst could appear misleading. The loads reported for
manipulation by Triano and Schultz [4] do not take into account the
surface area of contact and the dissipation of the forces by the local
tissues. This would reduce and dissipate the forces over a wider area.
Professor Ernst also misleads the reader by suggesting that these loads
are inordinately high when in fact, as pointed out by Triano and Schultz [4] "estimates of the loads transmitted were consistent with those observed
in common tasks requiring lifting and twisting movements". Furthermore,
researchers in this area would freely admit that it has been poorly
researched until more recently [5] with chiropractic manipulative forces
being the most extensively studied of all the professions mentioned.
Professor Ernst also appeared to be unaware of the recent publication by
the UK BEAM group.[1] This group, while formulating their methodology
concluded that chiropractic, osteopathic and physiotherapeutic
manipulation had more similarities than differences: this would be
expected to incorporate the potential risks as well as the potential
benefits.
With respect to the statement that "dramatic complications have been
noted with some degree of regularity" Professor Ernst abruptly switches
the argument to cervical manipulation. This statement apparently refers to
the potential yet unproven association made between stroke and cervical
spine manipulation. Although this is out of direct context with the theme
of the leader, namely osteoporosis and back pain, it would suggest there
have been many incidences and that the manipulation was a causative factor
in the production of vertebrobasilar artery accidents. There is
experimental evidence which would argue to the contrary.[6] However, in
the relative absence of direct evidence there exists an alternative, yet
equally plausible hypothesis for this association: namely, that those
people who already have problems with their vertebrobasilar artery
(dissection or plaque) develop symptoms, which would lead them to seek out
a chiropractor for treatment. This is made more evident in a society where
chiropractic is more commonly available, such as Canada and USA. Such
problems in diagnosing a patient in this situation are not unique to
chiropractic. A recent case report in the Lancet [7] presented details of
a patient with acute onset neck pain attending a hospital based emergency
department. This patient was given analgesics and discharged. She returned
(24 hours later) with more advanced symptoms suggestive of an acute
anterior spinal artery syndrome. It is interesting to note that
chiropractic manipulation had been ruled out, as had rapid head movement
and head trauma, however, no mention of ruling out visits to other
practitioners of manipulation was made. Although this is only one isolated
report, it is probable that there are many such incidences that go
unreported in all health care professions.
With respect to the osteoporotic patient, chiropractors are fully
aware of the potential risks involved with the application of manual
forces with respect to relative osseous fragility. As a result,
osteoporosis has been on the British chiropractors list of relative
contraindications for manipulation for years, hence it appears rather
surprising that a Professor of complementary therapies would appear to be
unaware of this fact. We disagree with the statement by Professor. Ernst,
that there is no reliable diagnostic method available to chiropractors.
Many chiropractors have alternative methods available to them for
determining the potential presence of this condition. None more powerful
than a comprehensive case history, which is a fundamental statutory
competency. Furthermore, many chiropractors have alternatives to
radiographs (DEXA, ultrasound) present in their offices or within a
referral service, available for confirmatory objective quantification.
With respect to Professor Ernst's statement concerning information
available to the patient; in Britain it is now necessary (indeed
incorporated in the educational infrastructure) to inform all patient of
the potential risks (benign and potentially serious) as well as expected
therapeutic benefits. This is done under the umbrella term of "evidence
based medicine" which has been the subject of both undergraduate and
postgraduate education in UK chiropractic for at least 10 years. Patients
are advised of all the treatment options, including referral to other
practitioners. Furthermore they are informed about the use of Xrays and
the limitations of plain film Xray to demonstrate the presence or absence
of osteoporosis. They are also informed that osteoporosis is a relative
contraindication to manual interventions and what that means to the
patient in terms of overall case management.
So in conclusion the article by Professor Ernst does not appear to be
well informed or well researched. It appears to target chiropractic
because there is less information available about the other manipulating
disciplines. The chiropractic profession has sought to engage Professor
Ernst in constructive dialogue for at least 5 years. However, he still
appears to have ignored the steps being taken by professions such as
chiropractic whose clinical focus is guided by statutory regulation aimed
at protecting the patient and raising standards of care and education.
References
1. Harvey E, Burton AK, Moffett JK, Breen A; UK BEAM trial team.
Spinal manipulation for low-back pain: a treatment package agreed to by
the UK chiropractic, osteopathy and physiotherapy professional
associations. Man Ther. 2003; 8 (1):46-51.
2. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal
manipulative therapy for low back pain. A meta-analysis of effectiveness
relative to other therapies. Ann Intern Med. 2003; 138 (11):871-81.
3. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical
guidelines for the management of acute low back pain: clinical guidelines
and evidence review. London: Royal College of General Practitioners ,
1996.
4. Triano J, Schultz AB. Loads transmitted during lumbosacral spinal
manipulative therapy. Spine 1997;22:1955–64.
5. Herzog W. Clinical Biomechanics of spinal manipulation. Ed W
Herzog. Pub Churchill Livingston, London, 2002
6. Symons BP, Leonard T, Herzog W. Internal forces sustained by the
vertebral artery during spinal manipulative therapy. J Manipulative
Physiol Ther. 2002; 25(8):504-10.
7. Latronico N, Fassini P, Antonini B, Gasparotti R. A pain in the
neck. Lancet. 2002; 359 (9313):1206.
McCarthy, Byfield [1] and Breen [2] make a number of comments which require a brief reply. I wrote the article on this specific subject because I was invited to do so by the British Journal of Sports Medicine. All three correspondents seem to oppose my "long track record" of writing about adverse effects of spinal manipulation. I do this simply because it is my job. I try to apply the rules of science to al...
McCarthy, Byfield [1] and Breen [2] make a number of comments which require a brief reply. I wrote the article on this specific subject because I was invited to do so by the British Journal of Sports Medicine. All three correspondents seem to oppose my "long track record" of writing about adverse effects of spinal manipulation. I do this simply because it is my job. I try to apply the rules of science to all areas of complementary medicine. To exclude therapeutic safety from this strategy would be unforgivable. I have certainly published more on the adverse effects of herbal medicine than on spinal manipulation. To assume that I have singled out spinal manipulation is therefore pure fantasy.
I disagree with McCarthy and Byfield about their assumption that the safety of cervical manipulation is not directly related to osteoporosis and back pain. Contrary to these authors, I also think that “a comprehensive case history” is not a specific and sensitive diagnostic tool for osteoporosis. However, I do agree with McCarthy and Byfield that many adverse effects of manipulation go unreported. In our own case series under-reporting was precisely 100%.[3] Finally, I am not aware that "the chiropractic profession has sought to engage [me] in constructive dialogue for at least 5 years".
I believe Breen [2] is wrong in stating that 2the majority of systematic reviews" do not agree with my article. We have recently evaluated all reviews of spinal manipulation for back pain published in the last 10 years.[4] Sixteen reviews met our inclusion criteria; 9 reached a positive and 7 a negative conclusion about the effectiveness of spinal manipulation. An overall positive conclusion was most significantly associated with low methodological quality of the review and first authorship by a chiropractor or osteopath.
In summary, I feel that my article was as evidence-based as it could be given its brevity while the comments of McCarthy, Byfield and Breen seem to bear the hallmarks of an emotional ad hominem attack.
References
(1) McCarthy PW and Byfield DC. Observations concerning chiropractic spinal manipulation for back pain a reply [electronic response to Ernst and Sran Chiropractic spinal manipulation for back pain - Commentary] bjsports.com 2003http://bjsm.bmjjournals.com/cgi/eletters/37/3/195#38
(2) Breen AC. The "war" on chiropractors [electronic response to Ernst and Sran Chiropractic spinal manipulation for back pain - Commentary] bjsports.com 2003http://bjsm.bmjjournals.com/cgi/eletters/37/3/195#38
(3) Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107-10.
(4) Canter PH, Ernst E. Sources of bias in reviews of spinal manipulation for back pain. Submitted 2003.
Dear Editor
I enjoyed reviewing for this journal very much and can only hope that more journals will use a similar electronic system.
Having waited over 16 weeks to hear from a different journal, I think that the electronic system provides an excellent service to the authors.
Dear Editor
The helmets worn in ice hockey - what is their specification and composition? They look like canoeing-type and very thin plastic, if so, it is no wonder head injuries continue. The players need padded helmets more like motorcycle crash helmets to withstand the knocks with a layer of polystyrene or other shock absorbing material.
Dear Editor
Does BJSM even use its review process? Being a runner and running trainer and scientist, I am embarrased about this article.[1] The news *running is unhealthy* quickly went the round. Here in Germany it already was in TV text, in several online newspapers (with headlines like 'Run into Osteoporosis'), and has reached internet discussion boards. It will supposedly appear in printed matter starting tomorro...
Dear Editor
The Italian requirement that all professional and amateur athletes obtain medical certification of their ability to participate in their chosen sport dates from 1950.[1] In 1971 and 1982 this mandate was reinforced by specific legislation of the Italian Ministry of Health, covering both competitive and non-competitive participants.[2] Consequently, large numbers of symptom-free and ostensibly health...
Dear Editor
We cannot help but note the correlation between the results of this study of female athletes, and the study conducted on male long distance runners in Denmark [1]. We propose that sunshine might be the common factor driving the observed bone loss in these two, apparent...
Dear Editor
The presence of false positive ECGs is without doubt a limit to the diagnostic capability of this investigation in the contest of cardiovascular screening of athletes. These abnormal ECG appearances result mainly from the morphological adaptations of the heart to training and to the actual sport practised. For example, endurance athletes show a higher rate of ECG abnormalities than athletes practising ‘tec...
Dear Editor
With regard to the Leader by ADG Baxter-Jones and N Maffulli [1] we would like to extend our appreciation to the authors for their interest in this never ending “hot debate”.
The authors clearly point out difficulties and potential pitfalls of exercise testing, exercise prescription and the interpretation of acute responses and of the chronic adaptation to exercise training during growth and ma...
Dear Editor
The Ernst and Sran commentary [1] about 'chiropractic manipulation' is not consistent with the majority of systematic reviews, nor national guidelines. It is, however, highly consistent with the previous and prolific writings of the first author himself on this topic. Surely, the significance of this pattern is an obvious one, and the suggestion that if anyone else but a chiropractor performs a ma...
Dear Editor
We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading. This is particularly evident in the initial paragraph. The author begins by generally addressing sports medicine clinicians, including those who are trained in mobilisation and manipulation, namely osteopaths, physiotherapists and chiropractors and a...
Dear Editor
McCarthy, Byfield [1] and Breen [2] make a number of comments which require a brief reply. I wrote the article on this specific subject because I was invited to do so by the British Journal of Sports Medicine. All three correspondents seem to oppose my "long track record" of writing about adverse effects of spinal manipulation. I do this simply because it is my job. I try to apply the rules of science to al...
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