382 e-Letters

  • Inconsistent referencing and underlying conclusion issues

    If it's not too late. The authors may wish to correct their referencing throughout the paper. I noticed that the 3rd paragraph in the Introduction provides references that do not support the statements made. e.g. the Biswas et al paper did NOT assess the impact of PROLONGED sitting. Evidence on bouts of sitting is still very unclear, and none of these interventions have shown is has a meaningful impact.

    It is also unclear how the authors can make their statement about 30 min/day being “likely to be clinically meaningful” – when it probably depends on what the sitting was replaced with (i.e. with standing vs. movement, etc) and the isotemporal substitution paper that is cited to support this assertion is based on a ‘theoretical’ shift of sitting to light activity from a cross sectional study (with risk of reverse causation). This seems to be selling a story that really isn't there.

    A more reasoned conclusion might be that VERY SMALL reductions in TOTAL sitting per day seem possible (a drop in the bucket?) with interventions that require significant resources (notably, not too dissimilar to PA interventions), but whether or not such shifts in sitting per se would make any meaningful difference for health outcomes/biomarkers remains very unclear. Not much good if there is no efficacy for outcomes. The reducing sitting story comes across as more of an hypothesis and 'feel good' story, but the evidence upon which it is based (in terms of effic...

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  • Response to Phillip Page, correspondence 'Evidence for RICE in acute sprains?'

    Dear Phillip Page,
    Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
    First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
    In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence t...

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  • ACSEP Endorses Paper.

    The Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...

  • ACSEP Endorses Paper.

    The Australasian College of Sports and Exercise Physicians endorses this paper. Please read their statement here - https://www.acsep.org.au/page/resources/position-statements/consensus-st...

  • On editorials, access and bias at the BJSM

    In May 2018, the following tweet was posted from the BJSM twitter account:

    '115K views. via brave iconocolast @DrAseemMalhotra. Importantly, no rebuttals. Real food saturated fat does not clog arteries - beware processed food that causes hyperinsulinemia (& hypertension). #Rethink'

    Followed by signposting to a linked editorial(1)

    Several people responded, including Catherine Collins (https://twitter.com/RD_Catherine/status/1001707243828596737), pointing out that a number of rebuttals to the editorial in question had in fact been made, not least a 2017 PubMed Commons/PubPeer commentary (https://pubpeer.com/publications/8741FBE4D9D7A38A7802515B33302E), which form the precursor of our rebuttal here. In response to Catherine, the BJSM Editor in Chief (EIC) Karim Khan contacted the lead author here indicating he had missed his email a year previous regarding our commentary originally offered to the BJSM as a formal rebuttal [see PubPeer post]. The EIC indicated he would be happy to publish our PubPeer rebuttal in the BJSM. The lead author thanked the EIC and, with co-authors Duane Mellor, Nicola Guess, and Ian Lahart, submitted a revised version in July 2018.

    In the interest of fairness and open debate, we made a request to the EIC and BJSM editorial board that our manuscript be made o...

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  • Should a pregnancy test be required before scuba diving?

    In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.

  • Rolfing---not. Structural Integration---yes

    The last paragraph cites Rolfing when it should be Structural Integration. There are many schools of Structural Integration of which Rolfing Structural Integration is one, Describe the modality as massage if you must, though I would prefer, "a form of manual therapy" or "a form of manual therapy that is often categorized as massage." I am surprised that this error passed through the editors and peer review.

  • The Ankle Roll Guard is a Tested & Effective Alternative to Braces & Tape for Lateral Ankle Support

    The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
    - Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
    - Provides ankle stability & protection for users with chronic lateral ankle instability
    - Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
    - Weighs only 2.4 ounces so users do not feel it

    Independent Testing at Boise State University
    White Paper Completed January, 2018:
    “Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion” 
    – Tyler Brown, PhD, CSCS, Director COBR
    ​Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices.  With the Ankle Roll Guard, p...

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  • Evidence for RICE in acute sprains?

    I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a...

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  • No evidence for dehydration

    This is a case of exertional heat stroke in which a young, experienced woman runner exerts herself and develops heat stroke. There is no effort to describe the patient's state of hydration besides indicating that she drank 250 mL prior to running (in what timeframe?) and that she drank 200mL after/during collapse. We are unaware of her weight and thus cannot even roughly calculate what her fluid deficit range may be after 90 minutes of running. We are unaware of her dress, which could lead to heat retention. Per figure 2, it appears that her blood pressure was approximately 110/70 at the time of collapse, which does not support hypovolemia. Values of BUN and creatinine are not presented that would have supported dehydration as a predisposing condition. Certainly in a road race there were other runners that reached her same level of hydration - why did they not suffer heat stroke?
    While this is a classically presented case of exertional heat stroke in a road race, there is insufficient evidence to associate it with dehydration.