Smith in his recent article in the Br J Sports Med
highlights the
importance of aggressively cooling heat stroke victims to improve
prognosis.[1] The paper extensively reviews the major cooling methods, and
the author advocates the immersion in an ice-cold bath as the method of
choice. Whereas this conclusion might be true for young patients who may
tolerate aggressive treatment with ice water (1–5°C...
Smith in his recent article in the Br J Sports Med
highlights the
importance of aggressively cooling heat stroke victims to improve
prognosis.[1] The paper extensively reviews the major cooling methods, and
the author advocates the immersion in an ice-cold bath as the method of
choice. Whereas this conclusion might be true for young patients who may
tolerate aggressive treatment with ice water (1–5°C), the more vulnerable
patients and those with prior cardiovascular illnesses should not be
exposed to unnecessary risks. Therefore, the more conservative technique
that has been proven effective, the pouring of large volumes of tepid
water (12–16°C) and fanning, should be used instead (especially under
field conditions, where ice is not available).[2]
It should also be emphasized that the use of antipyretics
in the
treatment of heat stroke is contraindicated.[3] In heat stroke the
accumulated body heat is not a result of a change in the thermoregulatory
set-point, as is the case in fever. Thus, antipyretics are not effective
in lowering body temperature. Furthermore, certain antipyretics can cause
additional damage; i.e. temperature-induced hepatic dysfunction may worsen
from the use of paracetamol (acetaminophen), administration of
nonsteroidal anti-inflammatory drugs may reduce potassium excretion, and
aspirin (acetylsalicylic acid) may aggravate bleeding diathesis.
References
1. Smith JE. Cooling methods used in the treatment of
exertional heat
illness. Br J Sports Med 2005; 39:503-7.
2. Hadad E, Rav-Acha m, Heled Y, Epstein Y, Moran DS. Heat
stroke: a
review of cooling methods. Sports Med 2004; 34:501-11.
3. Heled Y, Rav-Acha m, Shani Y, Epstein Y, Moran DS. The "golden
hour"
for heatstroke theatment. Mil Med 2004; 169:184-6.
There is a long history of doping in sport. Since the ancient Greco-
Roman times, ergogenic aids in form of natural products, bland chemicals
and animal extracts, have been commonplace in the attempt to push human
performances to the limit. In recent times, remarkable advances in science
and biotechnology have favoured the introduction of synthetic molecules,
recombinant hormones and genetic manipulatio...
There is a long history of doping in sport. Since the ancient Greco-
Roman times, ergogenic aids in form of natural products, bland chemicals
and animal extracts, have been commonplace in the attempt to push human
performances to the limit. In recent times, remarkable advances in science
and biotechnology have favoured the introduction of synthetic molecules,
recombinant hormones and genetic manipulation of athletes.[1]
Doping in sports should be energetically opposed, employing effective
strategies, but definitive tools are yet to be identified. The recent
article of Somerville and colleagues, provides an interesting view and
induces further reflections on this topic.[2] The conclusion is rather
frustrating, as the need to modify the educational process of elite
sportspeople to the doping laws clearly emerged. However, such a
consideration can be extended to the whole problem of the availability of
unfair products to athletes.
Over the past decades, athletes received or purchased doping products from
colleagues, team managers, unfair physicians and black market.[1]
However, the situation is possibly evolving towards more uncontrollable
scenarios. The World Wide Web is the most striking example. So far, there
are plenty of resources and virtual stores on the Web, offering several
doping products, from anabolic steroids to recombinant hormones.[3]
Accordingly, anyone can easily order through the Internet whatever
substance is required to enhance a specific athletic performance. From a
medical view, this is unacceptable. Firstly, as most of these
manufacturers are not forced to strict or certified production procedures,
the claimed products may be unsure and harmful. Sadly, they may even be
unhelpful to the athlete, as there is little warranty that they contain
the supposed ergogenic agent.[3]
Then, there is no effective legal control and virtual stores can not be identified and pursued. Finally, the hazard of this form of cheating is low, as banned products can be shipped
anonymously to the buyer. The scientific community must be aware that
antidoping testing is an effective repressive tool, but it will lead to
much wasted efforts unless appropriate preventive strategies against this
obscure scenario of providing doping to athletes will be established.
References
1. Lippi G, Guidi GC. Gene manipulation and improvement of athletic
performances: new strategies in blood doping. Br J Sports Med 2004;38:641.
2. Somerville SJ, Lewis M, Kuipers H. Accidental breaches of the
doping regulations in sport: is there a need to improve the education of
sportspeople? Br J Sports Med 2005;39:512-6.
3. Dumestre-Toulet V, Kintz P. 19-norsteroids: doping, Internet,
toxicology and analysis. Eur J Emerg Med 2001;8:80.
We appreciate Russell's comments and additional analyses. While there
may be minor points where we still disagree, it is clear from Russell's
comments that he supports our general hypothesis that there is indeed a
safety concern in the sport of slow-pitch softball. We continue to stand
by our field-testing research as well as published human response time
studies that support our claims that the sp...
We appreciate Russell's comments and additional analyses. While there
may be minor points where we still disagree, it is clear from Russell's
comments that he supports our general hypothesis that there is indeed a
safety concern in the sport of slow-pitch softball. We continue to stand
by our field-testing research as well as published human response time
studies that support our claims that the sport of softball is unsafe and
will continue to conduct research studies using human subjects as the
ideal metric for predicting safety in the sport of softball and baseball.
Your diagnosis of rhabdomyolysis appears warranted on the basis of the "dark urine" and "muscle aches combined with massive elevation of creatine kinase. However, I cannot accept the report that there was no myoglobinuria present in these individuals. The urine is dark due to the myoglobin and in view of the CK increase in the thousands, myoglobin must have been present. Many laboratories use outdated and...
Your diagnosis of rhabdomyolysis appears warranted on the basis of the "dark urine" and "muscle aches combined with massive elevation of creatine kinase. However, I cannot accept the report that there was no myoglobinuria present in these individuals. The urine is dark due to the myoglobin and in view of the CK increase in the thousands, myoglobin must have been present. Many laboratories use outdated and insensitive methods and myoglobin deteriorates fairly rapidly in acidic urine. Immunoassay methods are preferred. Additional relevant references are listed.
1: Wu AH, Laios I, Green S, et al. Immunoassays for serum and urine myoglobin: myoglobin clearance assessed as a risk factor for acute renal failure.
Clin Chem. 1994 May;40(5):796-802.
2: Loun B, Astles R, Copeland KR, Sedor FA. Adaptation of a quantitative immunoassay for urine myoglobin. Predictor in detecting renal dysfunction. Am J Clin Pathol. 1996 Apr;105(4):479-86.
3: Chen-Levy Z, Wener MH, Toivola B, et al. Factors affecting urinary myoglobin stability in vitro.
Am J Clin Pathol. 2005 Mar;123(3):432-8.
I was interested to read your recent article in the British Journal of Sports Medicine on a sequential AIIS avulsions in an adolescent long jumper. I have recently had a young patient who was a soccer player, with two sequential avulsions on the right side of the AIIS within a shorter
time frame. I would just like to point out, however, that on the xray, especially in Figure 1, it appears as if the injur...
I was interested to read your recent article in the British Journal of Sports Medicine on a sequential AIIS avulsions in an adolescent long jumper. I have recently had a young patient who was a soccer player, with two sequential avulsions on the right side of the AIIS within a shorter
time frame. I would just like to point out, however, that on the xray, especially in Figure 1, it appears as if the injury in your athlete is more to the anterior superior iliac spine (ASIS), where the sartorius muscle attaches.
In fact, it is identified as this in the caption for Figure 1, but not for the other Figures. I have also seen avulsion injuries to the superior part of the iliac crest where the gluteus medius muscle attaches.
Sincerely,
Connie Lebrun
Director Primary Care Sport Medicine
Fowler Kennedy Sport Medicine Clinic
I read with great interest the systemic review from Dr. Bisset and co-workers "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia" (BJSM 2005; 39:411-
422).
I find it annoying how the authors disregarded the results of the most recent trials regarding treatment of chronic tennis elbow with extracorporeal shock waves. Their conclusion th...
I read with great interest the systemic review from Dr. Bisset and co-workers "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia" (BJSM 2005; 39:411-
422).
I find it annoying how the authors disregarded the results of the most recent trials regarding treatment of chronic tennis elbow with extracorporeal shock waves. Their conclusion that extracorporeal shock wave therapy (ESWT) is not beneficial in the treatment of lateral elbow tendinopathy is as biased as it is wrong!
The methodology of performing a meta-analysis regarding ESWT and tennis elbow is questionable.
A biased outcome will be produced if reviewers combine the results of a group of studies in a meta-analysis — for example, studies of patients with different types of treatment, different types of comparison groups,or different clinical characteristics of patients studied. There is
consensus, for example, among the editorial board of the Cochrane Back Review Group that, if relevant valid data are lacking (data are too sparse or of too low quality) or if data are statistically and clinically too heterogeneous, a meta-analysis should be avoided and reviewers should
perform a qualitative review.
Rating of trials in such a qualitative review, however, is somewhat arbitrarily and there is no consensus how to do it best – reliable and reproducible,
Recently, we had performed computerized searches using Medline (from 1996 to March 2005), and Center for Devices and Radiological Health (US Food and Drug Administration) databases. Only English language publications were considered.
Nine clinical trials were identified.[2-10] The methodological quality of the was examined according to Chalmers et al.[1]
Only 4 studies [2,4,7,9] had a high quality design (the trial from Speed was not found to be of sufficient quality, neither in our study nor in the study from Stasinopoulos [11]). When focusing on those four high-quality trials are clear picture unfolded.
A large trial by Haake et al. had failed to show any efficiency of ESWT.[4] This was a multicenter, randomized, placebo-controlled study reported to be single blind on the basis that the participants were blinded to intervention, but the provider of the intervention was not blinded. However, blinded outcome assessors were used. All patients were treated under local anaesthesia. Overall, therapeutic success rate 12 weeks after intervention (primary end point) was 26% in the ESWT and 25% in the placebo group. The authors concluded that this treatment did not have any
added therapeutic benefit beyond placebo.
This conclusion was seriously debated among the various centers participating in the trial because there were three major differences to a previously published randomized controlled trial [8] showing a beneficial
effect of ESWT: the use of local anesthesia; the use of various shock wave devices with various application parameters, meaning that each patient received a different dose; and the use of anti-inflammatory drugs immediately during and after the three days following an ESWT.
Two studies [7,9] addressed these problems and improved the study design accordingly: they were randomized, placebo-controlled trials with blinded patients and observers. No local anesthesia was applied, and a
single shock wave device and standardized application parameters were used. These changes of the study design compared with the Haake trial [4] resulted in a significantly higher improvement in pain.
In the Rompe study [9] at 3 months 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group. Their results were investigated by a current randomized, placebo controlled trial by Pettrone and McCall.[7] Using exactly the treatment regimen described by Rompe et al. [9]they found a statistically significant difference in pain reduction at 12 weeks. 61% of active treated patients showed at least 50% improvement in pain, compared to 29% in the placebo group. This was found to persist for one year. Together,
Pettrone and McCall [7] stressed ESWT to be a safe and effective treatment for chronic lateral epicondylitis. They pointed out that their results mirrored those of Rompe et al. [9] thus providing additional weight of evidence to the applied treatment regimen.
Chung and Wiley [2] also adopted the treatment regimen proposed by Rompe et al.[9] However, they changed selection of patients from chronic, recalcitrant to acute, previously untreated cases. At eight weeks, success rates in the sham and active therapy groups were 31% and 39%, respectively. No significant difference was detected between groups.
So, taking into account these three trials with a virtually identical treatment regimen, two points become obvious: unsatisfactory results can be expected when a local anesthetic is used during repetitive low-energy ESWT, and when acute instead of chronic cases are selected for treatment.
Therefore, I contradicted the conclusion by Stasinopoulos and Johnson [11] that more sufficiently conducted randomized controlled trials are needed.
To Dr. Bisset and co-workers I say that there are well designed trials providing meaningful evidence on the effectiveness of ESWT for the management of tennis elbow. US and German groups [7,9] have independently shown a treatment design leading to successful outcome in close to 70% of
patients with recalcitrant lateral elbow tendinopathy. Their statement "there is evidence that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow" is wrong and should not have been published.
References
1. Chalmers TC et al. A method for assessing the quality of a
randomized control trial. Control Clin Trials 2:31-49, 1981.
2. Chung B, Wiley JP. Effectiveness of extracorporeal shock wave
therapy in the treatment of previously untreated lateral epicondylitis: a
randomized controlled trial. Am J Sports Med 32:1660-1667, 2004.
3. Crowther A et al. A prospective d study to compare extracorporeal
shock wave therapy and injection of steroid for the treatment of tennis
elbow. J Bone Joint Surg 84-B:678-679, 2002.
4. Haake M et al. Extracorporeal shock wave therapy in the treatment
of lateral epicondylitis. J Bone Joint Surg 84-A:1982-1991, 2002.
5. Melegati G et al. Comparison of two ultrasonographic localization
techniques for the treatment of lateral epicondylitis with extracorporeal
shock wave therapy: a randomized study. Clinical Rehabilitation 18:366-
370, 2004.
6. Melikyan EY et al. Extracorporeal shock wave therapy for tennis
elbow. A randomized double blind study. J Bone Joint Surg 85-B:852-855,
2003.
7. Pettrone F, McCall B. Extracorporeal shock wave therapy without
local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg 87-
A; 1297-1304, 2005.
8. Rompe J et al. Analgesic effects of extracorporeal shock wave
therapy on chronic tennis elbow. J Bone Joint Surg 78-B:233-237, 1996.
9. Rompe J et al. Repetitive low energy shock wave treatment for
chronic lateral epicondylitis in tennis players. Am J Sports Med 32:734-
743, 2004.
10. Speed C et al. Extracorporeal shock wave therapy for lateral
epicondylitis: a double blind randomized controlled trial. J Orthop Res
20:895-898, 2002.
11. Stasinopoulos D, Johnson MI. Effectiveness of extracorporeal
shock wave therapy for tennis elbow (lateral epicondylitis).Br J Sports
Med 39:132-136, 2005.
I am writing again, not to engage in a war of words with the authors, but to offer some suggestions which might strengthen the safety concerns reached in the paper by McDowell and Ciocco.[1] Unfortunately, it appears that the authors misunderstood the point of my first letter and assumed that I was criticizing their conclusions regarding the safety in slow-pitch softball. I do not disagree with their conclusion...
I am writing again, not to engage in a war of words with the authors, but to offer some suggestions which might strengthen the safety concerns reached in the paper by McDowell and Ciocco.[1] Unfortunately, it appears that the authors misunderstood the point of my first letter and assumed that I was criticizing their conclusions regarding the safety in slow-pitch softball. I do not disagree with their conclusion that high performance bats present a significant safety risk. My letter attempted to raise three points: (i) that the ASTM 1890 standard which the authors used to define a safe reference APRT from a recommended safe initial BBS" does not accurately predict field performance and therefore should probably not be used to establish a baseline for safety arguments; (ii) that one of the "two major national softball associations in the United States" the authors refer to in their paper has long since abandoned this standard in favor of one which much more accurately predicts field performance of bat, though it does have its own unique problems; and (iii) that I felt the choice of bats used in this study do not represent bats currently used by the majority of those who play recreational softball at the time this paper was finally published.
I will refrain from attempting to refute the authors' professionally offensive claim to be the only researchers capable of "truly independent research" in the area of softball and related performance and safety issues, and I will not respond to their completely unprofessional attacks on my own integrity and research ethics. I would, however, appreciate the opportunity to respond to their challenge to "present published batted-ball speed testing results from a truly independent source." I have to admit I'm not entirely sure I understand what McDowell and Ciocco consider to qualify as a "truly independent source." I am, however, aware of a very thoroughly conducted field study comparing wood and metal baseball bats which resulted in several publications.[2-4] This field study, which used 19 players from high school, college and minor leagues, had hitters swinging at pitched balls with six different metal bats and one wood bat. Multiple high-speed video cameras were used to measure the trajectories of the ball and bat before and after the collision. The study found that metal bats can significantly outperform wood bats and the various published papers provide a wealth of information that could be used to derive APRT values and other data regarding the safety of the game. This study does not directly satisfy the challenge because it deals with baseball bats, not slow-pitch softball bats. However, it is an excellent example of how a proper field study should be carried out, both in terms of the experimental methods which guarantee reliability of the data and statistical repeatability of the results. Such an extensive field study is very expensive to conduct and requires external funding to be brought to fruition. Unfortunately I would guess that such external funding, in this case from the SGMA and NCAA, is what might disqualify this field study from being considered "truly independent research." I am also aware of two field studies concerning men's slow pitch softball, one conducted in Montgomery in 2001 and the other in Charlotte in 2002, which have not yet been published because the researchers are still in the process of analyzing several hundreds of gigabytes of high speed video footage from multiple cameras which were used to record the motion of the bat and ball in 3-D. These two studies were also conducted with a high degree of attention to detail and thoroughness in experimental procedure. I hope these studies will be published in the very near future, as they will provide much needed information on the performance and safety of bats in slow-pitch softball. However, these studies will also probably not count as "truly independent research" since they were funded, at least in part, by the ASA.
I am also aware of a relevant paper by Robert Adair [5] which addresses issues regarding the safety of slow-pitch softball and pitcher reaction times remarkably similar to those raised by McDowell and Ciocco. Adair's paper was published in 1997, long before high performance composite bats, and yet he was able to predict the dangerous impact such bats might have on the game. Adair doesn't use the term "available pitcher reaction time" but he does show similar data for reaction times and comes to the same conclusion that elastic polyurethane softballs hit with high performance softball bats do not allow the pitcher enough time to react to a line drive, and thus present a safety hazard to the game of softball. Adair's paper also raises two additional points regarding safety which are easily verified through a simple computer calculation. I would like to share these points with McDowell and Ciocco because it would make the arguments for safety in their paper much stronger. The calculation plots the trajectory of a softball leaving the bat at a height of 0.8 m above home plate, and with an initial angle of 6.0 degrees above the horizontal so that it follows a line drive path towards the pitcher who is standing 15.24 m away. The effects of air resistance are included during the entire path of the ball using the approach by Giordano [6] which accounts for the fact that air resistance depends on the square of the ball speed, and thus continuously changes during the ball's flight. This results in slightly different APRT values from those reported by McDowell and Ciocco since they used a single constant air drag reduction to obtain an average ball speed for all cases. For the discussion below I use an initial batted ball speed for a composite bat of 167.6 km/h which was extracted from Table 2 of the McDowell and Ciocco paper by removing the constant air drag factor. I compared this calculation with that for a "recommended safe initial BBS of 137.2 km/h." The results of this simple calculation are as follows:
The ball hit by the "safe" bat with BBSi = 137.2 km/h = 38.1 m/s = 85.3 mph arrives at the pitcher in a time of APRT = 0.420s, while the ball hit by the composite bat with BBSi = 167.6 km/h = 46.55 m/s = 104.1 mph arrives at the pitcher in a much shorter time of APRT = 0.350s. My calculated APRT is shorter than that of McDowell and Ciocco due to our different treatments of air resistance. It would appear that correctly accounting for air resistance makes the safety issue even more pronounced. In any case, as expected, the pitcher will have significantly less time to react to the ball hit by the composite bat.
More importantly, perhaps, are the speeds of the balls when they reach the pitcher. The ball hit by the safe bat will be travelling at 35.3 m/s (78.9 mph) when it hits the pitcher, whereas the ball hit by the composite bat will still be travelling with a speed of 43.2 m/s (96.6 mph) when it hits the pitcher. Both hit balls have lost a significant fraction of their initial velocity due to air friction, but the ball from the composite bat is still travelling at a very dangerous speed when it reaches the pitcher. This faster speed means more momentum and more kinetic energy goes into the collision with the pitcher's body. Furthermore, since the COR of the ball decreases as ball speed increases, the higher ball speed also means that the ball will behave less elastically when it hits the pitcher. It should be no surprise that when players are hit by balls from high performance metal and composite bats, the injuries are more severe then they might have been from a ball hit by a "safe" bat.
Thirdly, this simple calculation shows that when the ball from the safe bat arrives at the pitcher's mound it will be 1.55 m (5.08 ft) above the ground. However, the ball hit by the composite bat will be 1.83 m (5.99 ft) above the ground when it reaches the pitcher. This is very important because it means that while the ball from the safe bat might hit the pitcher in the chest or shoulder, the ball from the composite bat (which is already arriving with a much faster speed in a shorter time) will strike the pitcher in the neck or face. A pitcher might be able to get his glove up to chest level in time, but would probably not be able to move it the additional 11 inches up to face level fast enough to intercept the ball hit by the composite bat.
The combination of these three factors: the shorter reaction time, the higher ball speed at impact , and the location of impact on the body provide a much stronger argument regarding safety than does the APRT alone.
In the final paragraph of their paper, McDowell and Ciocco state that the "use of lower compression balls may greatly reduce BBSs and allow the pitcher enough time to react to most batted balls." While I would agree with this statement, the data presented in Table 1 of their paper does not appear to support this conclusion as strongly as they state. If one looks at the data in Table 1, one finds that lowering the compression of the ball from 2371 N/.64cm (529 lb/in) to 1668 N/.64cm (372 lb/in) while keeping the COR constant at 0.47 only reduces the batted ball speed by 1.77 km/h (1.1 mph). This is not a significant reduction in BBS, and the corresponding APRT only increases by 0.005s, which does not seem significant enough to improve the safety of the pitcher. This reduction in BBS is also much less than the reduction in BBS of 4.67 km/h (2.9mph) which was measured during a field study of slow-pitch softball conducted in 2002, and to be published soon. In addition, according to the data in Table 1, one fines that a reduction in the COR from 0.47 to 0.40 while keeping the compression relatively constant (2371 vs. 2460) actually causes the batted ball speed to increase by 1.29 km/h (0.8mph). This completely contradicts what one would expect from a simple physics analysis of the ball-bat collision. Furthermore, is contradicts data from another slow-pitch field study, unfortunately also not yet published, which showed that lowering the COR by the same amount with the same constant compression actually lowered the BBS by 7.89 km/h (4.9 mph). Any one who has played softball with balls of varying compression and COR knows from direct experience that changing the ball properties has a significant effect on the resulting batted ball speed. The data in this paper not only fails to agree with other, unfortunately yet unpublished, field studies, but it also contradicts what players (as well as manufacturers and associations) know actually happens in the field. While McDowell and Ciocco are right in their recommendation that lowering ball compression and COR might make the game safer, the data as presented in this paper does not back up their recommendation, suggesting that perhaps a more accurate method of measuring batted ball speed should be implemented in future studies.
I have one final comment with regards to the authors' comments on the validity of field studies compared to laboratory tests. A serious potential problem with field studies is that the results depend very much on the caliber and ability of the players who participate in the study. This potential variation in skill between players is absent from a carefully controlled laboratory experiment. This issue is especially important if one is trying to draw conclusions concerning the safety of certain bats and one wishes to separate the performance qualities of the bat from the performance skill of the players who swing the bat. Here's an example of what I mean. I play recreational softball in a summer church league. We have a big, tall player on our team who played baseball in college 25 years ago. He uses a 32oz, single-walled aluminum bat (he says the newer high-tech composite bats feel too light), and yet, almost every time he steps up to the plate he routinely punches the ball over the center field wall, more than 300 feet away. If this individual had participated in the McDowell and Ciocco study his mean BBS values for the aluminum single-wall bat would far exceed the 134.0 km/h reported in Table 2, and would probably approach values for Titanium and composite bats. Furthermore, the APRT for a line drive from this player using his single-walled bat would be much shorter than the 0.409s reported for a single-walled bat in Table 3. I'm reminded of the 1980's slowpitch giant Carl Rose, who routinely hit softballs over 400 ft using a singlewall aluminum bat, and embarked on a quest to hit a softball out of every major league baseball field using a single-walled aluminum bat. A limitation of field studies is that they rely too much on the ability of the players who participate in the test, and require a relatively large number of players to ensure statistical reliability of the data. I would agree that as long as one is using "average" players and very carefully define what it means to be a player of "average" ability, then the point McDowell and Ciocco are making is valid. That is, high performance composite bats in the hands of an "average" player present a safety hazard to the game. However, a low performance single-wall aluminum bat in the hands of a high performance player also presents a safety hazard to the game, which the field study described in this paper does not account for.
The reason for a standardized laboratory test, such as ASTM F1890 or ASTM 2219 is to provide a way to measure the performance of bats in an accurate and repeatable manner without the variation introduced by the human element. Granted it is absolutely necessary to attempt to correlate the laboratory results with field studies to make sure the laboratory results fall within the range of performances measured by players in the field. As I attempted to explain in my first letter, F1890 completely fails in this regard. In contrast, while F2219 was being developed the laboratory results were correlated with field trials for the highest performing A and B-level players at two different national ASA tournaments. As such, the performance data obtained in the laboratory with F2219 attempts to predict the performance of a bat in the hands of some of the best human players currently playing the game. While F2219 does a much better job of predicting field performance, it is by no means a perfect standard and has its own unique set of flaws. Hopefully through persistent research some of these problems may be eventually resolved. I believe that any laboratory test which more closely predicts actual field performance of bats must be welcomed as a useful tool to ensure the safety and integrity of the game. Of course, if manufacturers chose to take advantage of loopholes (as they are currently doing) and if associations refuse to adopt the more accurate standard (like 5 of the six US softball associations have) and if those associations that do adopt the better test method don't use it correctly (by setting too high a limit or by grandfathering in dangerous bats) then the usefulness of the test method has been greatly diminished and the safety of the game is still in jeopardy.
Safety in the sport of softball is a very important issue. Is it vital that research which addresses this issue of safety be carried out in a professional manner with considerable attention to detail in the experimental process and diligent analysis of the data so that the reported results and conclusions are as accurate and relevant as possible.
These comments are respectfully submitted by
Daniel A. Russell, Ph.D.
Associate Professor of Applied Physics
Kettering University, Flint, MI
References
[1] M. McDowell and M. V. Ciocco, "A controlled study on batted ball speed and available pitcher reaction time in slowpitch softball," Br. J. Sports Med., 39, 223-225 (2005).
[2] J. Crisco, R. Greenwald, L. Penna, and K. Saul, "On measuring the performance of wood baseball bats," Engineering of Sport - Research Development and Innovation, Edited by A. Subic and S. Haake, p.193-200 (Blackwell Science, Oxford, 2000).
[3] R. M. Greenwald, L. H. Penna, and J. J. Crisco, "Differences in Batted Ball Speed with Wood and Aluminum Baseball Bats: A Batting Cage Study," J. Appl. Biomech., 17, 241-252 (2001)
[4] J.J. Crisco, R.M. Greenwald, J.D. Blume, & L.H. Penna, "Batting performance of wood and metal baseball bats," Med. Sci. Sports Exerc., 34(10), 1675-1684 (2002)
[5] R.K. Adair, "The Physics of Baseball: The Standardization of Balls and Bats for Recreational Softball," International Symposium on Safety in Baseball and Softball, ASTM STP 1313, Earl. F. Hoerner and Francis A. Cosgrove, Eds., p. 21-28 (American Society for Testing and Materials, 1997).
[6] N. J. Giordano, Computational Physics, (Prentice Hall, 1997), p.23-32.
In the last years, validity and reliability of tests used is exercise
science has gained a lot of attention. Since the review of Atkinson and
Nevill (1998), many works has published addressing these matters.
Baltaci et al., in the present work, assessed the validity of three
different forms of sit-and-reach (SR) test and compared the results with
flexibility of hip joint for flexion using a go...
In the last years, validity and reliability of tests used is exercise
science has gained a lot of attention. Since the review of Atkinson and
Nevill (1998), many works has published addressing these matters.
Baltaci et al., in the present work, assessed the validity of three
different forms of sit-and-reach (SR) test and compared the results with
flexibility of hip joint for flexion using a goniometer. However, authors
used the Pearson Correlation Coefficient (r) as a validity scale.
Since the work of Altman and Bland (1983), it is well know that r is
not a good way to assess validity or reliability. Really, this notion was
already shown before (Hallman and Teramo, 1981). The reasons, well
described in the work of Altman and Bland (1983), can be resumed in two
points. First, Pearson r is the relation between variation of values
across individuals and variation within individuals. If variations between
individuals are large, correlation will be large, independently of
variation within individuals. In this case, variation between individuals
is large, what can be demonstrated by large standard deviations in Table 1
of the article.
Second, if we want to use this approach to validity, we need to
regress values of one method (in the case of different scales) and
estimate de validity by the Standard Error of Estimate (SEE). The problem
here is that SEE is a value that will change depending of the distance
from the mean.
Authors also stated that SR and BSSR are highly related to hamstrings
flexibility and the CSR test was not related. But, at conclusion, authors
stated that all SR tests had similar criterion related validity. Based on
the r coefficients, all three tests are significantly related and none had
a strong relation. CSR presented a week correlation (0.22 and 0.21,
comparing with GML, as the authors) and SR and BSSR had a moderate
correlation (SR=0.63, BSSRL=0.37, BSSRR=0.50).
Even if Pearson r could be accepted as a good estimate of validity,
the conclusions of the authors appears to be some confusing.
We would like to thank Russell for his letter because we feel the
subject of safety in the sport of men’s slow-pitch softball has been
ignored for too long and it is refreshing to see that others are also
taking notice. An increase in the awareness of this subject through
discussions and scientific publications will help lead to required, well-defined, safety standards in the sport of softball. Unfort...
We would like to thank Russell for his letter because we feel the
subject of safety in the sport of men’s slow-pitch softball has been
ignored for too long and it is refreshing to see that others are also
taking notice. An increase in the awareness of this subject through
discussions and scientific publications will help lead to required, well-defined, safety standards in the sport of softball. Unfortunately, we take
issue with some of Russell’s comments.
The comments by Russell about publishing this paper in an American
journal are without merit. The BJSM is an excellent Journal that is truly
concerned with sports safety. Suggesting or implying that BJSM’s review
process or standards are sub par compared to American Journals is
completely unwarranted.
Russell’s comments on outdated performance standards are misleading.
At the time this paper was prepared the performance standards mentioned in
the paper were in use. The ASTM F2219 standard that he mentioned was
adopted by the ASA association on January 1st, 2004. In addition, it
takes time for a peer review article to be published. We are well aware of
the recent changes in laboratory performance-based testing. In terms of
the sports of softball and baseball, the ASTM is a laboratory performance-
based organization, not a safety-based organization. We are primarily
concerned with safety studies, not laboratory performance standards since
actual field-test studies are the only true test of player safety. We feel
using human reaction time studies and research will lead to a truly safe
sport for the recreational softball player.
The following is attached to each scope section 1.4 with every ASTM
performance standard in the sports of softball and baseball; “This
standard does not purport to address all the safety concerns, if any,
associated with its use. It is the responsibility of the user of this
standard to establish appropriate safety and health practices and to
determine the applicability of regulatory limitations prior to use”.
Based on this fact, Russell’s comments on the use of ASTM standards
are not sufficient to rely on as a safety standard for the sport of
softball or baseball. Again, our primary focus is on the safety aspect of
the sport of slow-pitch softball, not comparisons and evaluations of the
various ASTM laboratory performance standards used by the different
softball associations. There are some important points not mentioned by
Russell that need to be addressed concerning the new ASTM performance
standard, ASTM F2219. Only one of the at least six (6) slow-pitch
associations in the United States are currently using ASTM standard F2219.
In addition, it still remains a laboratory performance-based test which
has its shortcomings compared to real-world field-tests. One very obvious
loophole in the ASTM F2219 test is already being exploited by bat
manufacturers to produce bats that pass the “98 mph (43.8 m/s) limit” but
perform above this limit in real-world conditions.
It should also be mentioned that the ASA, despite claiming to adopt
the ASTM F2219 with a 98 mph (43.8 m/s) limit, still allows bats that
surpass the limit to be used. These “grandfathered” bats include the Miken
Freak, Mizuno Crush, Easton Synergy 2, etc. We realize the associations
may be under a lot of pressure not to ban bats, but it appears that safety
is being compromised in this case. Attend any ASA sponsored tournament and
you will see that most teams are using these “grandfathered” bats because
they out perform other ASA bats. The end result is that the ASTM F2219
with a 98 mph (43.8 m/s) limit is not even being incorporated into the
game today.
There have been a few important safety studies in the sport of
baseball that Russell failed to mention. A safety study by Owings, et
al.,[1] investigated pitcher reaction time as a consideration in design
constraints for baseballs and baseball bats for various age groups. They
found that for the 16-year age group, a minimum reaction time of 0.409
sec. was necessary to reduce the potential for serious or catastrophic
injury. Accounting for ball deceleration, the maximum initial batted-ball
speed to allow 0.409 sec. is 39.1 m/s. While, as Russell points out “The
ASA has set a maximum Batted-Ball Speed limit of 43.8 m/s (157.7 km/h)
using the high-speed impact test F2219”, this equates to an available
pitcher reaction time of only 0.365 sec, which is clearly a significant
safety concern. We are basing our conclusions on published, peer reviewed
literature that at least 0.409 sec. is needed for a player to determine,
decide, and react to a batted-ball[1].
Another study initiated by the NCAA tested a variety of bats on a
specially designed batting machine located at the University of
Massachusetts in Lowell[2]. The recommendation based on this research
effort was to drop the exit speed of a batted-ball to no more than 149.7
km/h (93 mph) in collegiate baseball. In this case this equates to an
available reaction time of 0.420 sec. Again, the 0.365 sec. the ASA
believes is “safe” is much less and illustrates the significant safety
concern.
A recent review article by Nicholls, et al.,[3] investigates the
current literature relating to impact injuries and the role of equipment
performance in the sport of baseball. They surmise that batted-ball
speeds from non-wood bats can reach velocities potentially lethal to
defensive players. Another study by Nicholls, et al.,[4] compared ball
exit velocity between metal and wooden baseball bats. The results of this
study indicate that a “certified” metal bat swung by an experienced hitter
can produce ball exit velocities exceeding that demonstrated by a robotic
hitting machine, which is what is currently used in the sport to determine
bat safety. This illustrates the necessity for field-testing research.
The published literature on pitcher reaction time consistently
supports our claim that the sport is much too dangerous for the
recreational player and we stand by our research findings. Obviously the
only fatal (literally) flaw here is to trust the various softball
associations to set safety standards. An independent organization needs to
set one comprehensive safety standard for the entire sport of Slow-Pitch
Softball.
Russell’s comments on illegal and banned bats are again, misleading.
We used titanium bats as a reference due to the fact that they were
outlawed immediately by their excessive batted-ball speeds. Today’s
composite bats produce batted-balls speeds in excess of titanium bats but
have been in use for the past five years. Our field-test studies indicate
that today’s high-tech composite bats consistently outperform titanium and
aluminium bats yet there are still allowed to be used. The real question
is: Why are bats that consistently outperform the banned Titanium bats
legal for play in some associations today?
As for the comment that this study would have been relevant 5 years
ago, the fact is this study would have been impossible 5 years ago because
neither the Synergy nor the Ultra II were introduced until 2003.
Furthermore, at the time of this study, these bats were legal and still
are legal in some associations. For example the Synergy is still legal in
USSSA and SSUSA play and the Ultra II is still legal in SSUSA play.
Obviously, as with most research, there are still many questions to
be answered and we are continuing our field-testing research studies of
slow-pitch softball equipment in order to improve the safety of the game.
Along these lines we have another field-testing research study, soon to be
published, that also indicates that there is a significant safety risk to
slow-pitch softball pitchers. From Owings published results[1], at least
0.409 sec. was deemed necessary to reduce the potential for serious or
catastrophic injury. Below is a subset of the data in this upcoming paper.
The initial batted-ball speeds (BBSi) and the available pitcher reaction
times (APRT) are listed for all softball associations
ASA/USSSA/NSA/ISA/SSUSA and ISF legal non-composite and composite bats.
Non-Composite ASA 2005 Model Bat: BSSi = 45.5 m/s, APRT = 0.351 sec.
Non-Composite USSSA/NSA/ISA/SSUSA/ISF 2005 Model Bat: BBSi = 45.5
m/s, APRT = 0.351 sec.
Composite ASA 2005 Model Bat: BBSi = 45.0 m/s, APRT = 0.355 sec.
Composite USSSA/ISA/NSA/SSUSA 2005 Model Bat: BBSi = 47.4 m/s, APRT =
0.338 sec.
Wooden bat (Reference): BBSi = 38.0 m/s, APRT = 0.421 sec.
The results indicate that there still exists a serious safety issue
that has not been addressed by the softball associations. To that end, we
are continuing our field-testing research efforts and hope that one day
soon a uniform safety standard will be applied to the sport, which we feel
will ultimately reduce serious and catastrophic injures as well as
fatalities that have occurred in the sport over the past few years. The
authors are only concerned with the safety of the game of softball and
having one uniform safety standard for the entire sport of slow-pitch
softball.
In closing, we challenge Russell to present published batted-ball
speed testing results from a truly independent source. He failed to
disclose that he has a conflict of interest when it comes to the
laboratory testing of softball bats by being affiliated directly or
indirectly with at least one softball association, hence his repeated
references to a new ASTM standard that has been adopted by only one
softball association. The authors of this study have no, nor are seeking
an affiliation with any bat or ball manufacturer or softball association
and conduct truly independent field-testing research on softball and
baseball bats and balls free from outside influence. The same cannot be
said of Russell and his colleagues who appear to be actively engaged in
discussions with bat manufactures concerning laboratory testing of
softball bats.
References
1. Owings, T. M., Lancianese, S. L., Lampe, E. M., and Grabiner, M.
D. (2003) Influence of Ball Velocity, Attention, and Age on Response Time
for a Simulated Catch. Medicine & Science in Sports and Exercise. Vol.
35, No. 8, pp. 1397-1405.
3. Nicholls, R.L., Miller, K., Elliott, B.C. (2004) Review: Impact
injuries in baseball: prevalence, aetiology and the role of equipment
performance. Sports Medicine 34(1): 17-25.
4. Nicholls, R.L., Elliott, B.C., Miller, K., Koh, M. (2003) Bat
kinematics in baseball: implications for ball exit velocity and player
safety. Journal of Applied Biomechanics 19: 283-294.
5. McDowell, M, Ciocco, M. and Morreale, B. (2005). "A Composite
Softball Bat Revolution: Why the Pitcher has Little Time to React to a
Batted-Ball". The Sport Journal Vol. 8(1).
6. McDowell, M. (2004). "Assessment of Softball Bat Safety
Performance Using Mid-Compression Polyurethane Softballs". Sports
Biomechanics Vol. 3(2) 185-194.
Dres. Gore and Hahn suggest that the significant mean increase of 6%
in total haemoglobin mass (tHbmass) which we observed after altitude
training in elite junior swimmers might to a major extend be attributed to
few erroneous measurements after altitude training. As already discussed
in the paper, we agree that an increase of about 24% is astonishingly
high. However, as pointed out, we were not the...
Dres. Gore and Hahn suggest that the significant mean increase of 6%
in total haemoglobin mass (tHbmass) which we observed after altitude
training in elite junior swimmers might to a major extend be attributed to
few erroneous measurements after altitude training. As already discussed
in the paper, we agree that an increase of about 24% is astonishingly
high. However, as pointed out, we were not the first to observe a wide
inter-individual variability in the erythropoietic response to altitude
exposure. Large inter-individual differences in the hypoxia-induced
increase in erythropoietin are well known [1-3] and a wide inter-
individual variation has also been described for the increase in red blood
cell volume after altitude training leading to the hypothesis that there
might be “responders” and “non-responders” to altitude training [1].
Furthermore, measurements with Evans Blue dye [1] and with technetium
labelling (cited in 4) yielded comparable significant increases in tHbmass
or total red blood cell volume, respectively, when differences in time and
altitude of exposure are taken into account. It was the aim of our study
to find out if changes in tHbmass after altitude training might be
predicted by the erythropoietin response after short exposure to moderate
normobaric hypoxia. We did not want to provide an answer to the question
whether or not 3 weeks of training at moderate altitude leads to an
increase in the tHbmass of elite junior swimmers. Therefore, we did not
include a control group of elite junior swimmers performing equivalent
training at sea level.
We thank Dres. Gore and Hahn for drawing our attention to the paper
of Parisotto et al. [5] reporting changes in tHbmass after administration
of r-HuEPO. This paper, unfortunately, escaped our attention because
title, abstract and key words did not refer to tHbmass. Two major
differences between this paper and our study might account for the
considerably larger variability in tHbmass in our subjects: First,
Parisotto et al. injected doses of erythropoietin based on body weight
which results in a much smaller inter-individual variability in plasma
levels of erythropoietin than natural exposure to altitude.
Secondly, we
studied elite junior athletes, who might increase total haemoglobin more
than adult elite athletes and might also show greater variability when
subjected to endurance training at altitude as they still experience
growth and maturation. To our knowledge, the erythropoietic response of
adolescent athletes to altitude training has not been studied so far.
We are well aware of the fact that any leak in the CO-rebreathing
system would result in erroneously high values for blood volume.
Therefore, we performed our measurements with great care to avoid such
leakages. Should nevertheless any leakage have occurred in some
measurements, it can be expected to be distributed randomly between
baseline and post-exposure measurements. Therefore, the reported average
increase in tHbmass of 6% should not have been affected substantially,
while erroneous measurements could at least in part account for a lack of
correlation between the increase in plasma erythropoietin levels and
tHbmass. However, as mentioned in our paper, there are other
investigations that could not find a significant correlation between
tHbmass and erythropoietin response under comparable circumstances.
Furthermore, C.J Gore and A. G. Hahn refer to the study of Burge and
Skinner [6] and state that the small dose of CO used in our study and the
larger rebreathing volume are suboptimal. Burge and Skinner recommend an
increase in COHb of at least 6.5 % to achieve a good degree of sensitivity
and precision for the determination of tHbmass. However, they also admit
that in another study of Thomsen et al. [7] changes in COHb > 5%
reduced the coefficient of variation only marginally and that an increase
of COHb of about 5 % also produces acceptable results in the measurement
of tHbmass. The CO-volume of 0.85 ml • kg-1 in our study induced a mean
increase in COHb of 5.2% which thus cannot be considered as “suboptimal”.
In summary, we conclude that the mean 6 % increase in tHbmass, which
is in agreement with increases reported by other investigators [1,4],
cannot be explained by erroneous measurements.
References
1. Chapman RF, Stray-Gundersen J, Levine BD. Individual variation in
response to altitude training. J Appl Physiol 1998; 85: 1448-1456.
2. Richalet J-P, Souberbielle J-C, Antezana A-M, et al. Control of
erythropoiesis in humans during prolonged exposure to the altitude of 6542
m. Am J Physiol 1994; 266: R756-R764.
3. Ge RL, Witkowski S, Zhang Y, et al. Determinants of
erythropoietin release in response to short-term hypobaric hypoxia. J Appl
Physiol 2002; 92:2361-2367.
4. Rusko HK, Tikkanen HO, Peltonen JE: Altitude and endurance
training. J. Sports Science 2004; 22: 928-945.
5. Parisotto R, Gore CJ, Emslie KR, et al. A novel method utilising
markers of altered erythropoiesis for the detection of recombinant human
erythropoietin abuse in athletes. Haematologica 2000; 85: 564-572.
6. Burge CM, Skinner S. Determination of haemoglobin mass and blood
volume with CO: evaluation and application of a method. J Appl Physiol
1995; 79: 623-631.
7. Thomsen JK, Fogh-Andersen N, Bülow K, Devantier A. Blood and
plasma volumes determined by carbon monoxide gas, 99m Tc-labelled
erythrocytes, 125 I-albumin and the T 1824 technique. Scand J Clin Lab
Invest 1991; 51: 185-190.
Dear Editor,
Smith in his recent article in the Br J Sports Med highlights the importance of aggressively cooling heat stroke victims to improve prognosis.[1] The paper extensively reviews the major cooling methods, and the author advocates the immersion in an ice-cold bath as the method of choice. Whereas this conclusion might be true for young patients who may tolerate aggressive treatment with ice water (1–5°C...
Dear Editor,
There is a long history of doping in sport. Since the ancient Greco- Roman times, ergogenic aids in form of natural products, bland chemicals and animal extracts, have been commonplace in the attempt to push human performances to the limit. In recent times, remarkable advances in science and biotechnology have favoured the introduction of synthetic molecules, recombinant hormones and genetic manipulatio...
Dear Editor,
We appreciate Russell's comments and additional analyses. While there may be minor points where we still disagree, it is clear from Russell's comments that he supports our general hypothesis that there is indeed a safety concern in the sport of slow-pitch softball. We continue to stand by our field-testing research as well as published human response time studies that support our claims that the sp...
Dear Editor,
Your diagnosis of rhabdomyolysis appears warranted on the basis of the "dark urine" and "muscle aches combined with massive elevation of creatine kinase. However, I cannot accept the report that there was no myoglobinuria present in these individuals. The urine is dark due to the myoglobin and in view of the CK increase in the thousands, myoglobin must have been present. Many laboratories use outdated and...
Dear Editor,
I was interested to read your recent article in the British Journal of Sports Medicine on a sequential AIIS avulsions in an adolescent long jumper. I have recently had a young patient who was a soccer player, with two sequential avulsions on the right side of the AIIS within a shorter time frame. I would just like to point out, however, that on the xray, especially in Figure 1, it appears as if the injur...
Dear Editor,
I read with great interest the systemic review from Dr. Bisset and co-workers "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia" (BJSM 2005; 39:411- 422).
I find it annoying how the authors disregarded the results of the most recent trials regarding treatment of chronic tennis elbow with extracorporeal shock waves. Their conclusion th...
I am writing again, not to engage in a war of words with the authors, but to offer some suggestions which might strengthen the safety concerns reached in the paper by McDowell and Ciocco.[1] Unfortunately, it appears that the authors misunderstood the point of my first letter and assumed that I was criticizing their conclusions regarding the safety in slow-pitch softball. I do not disagree with their conclusion...
Dear Editor,
In the last years, validity and reliability of tests used is exercise science has gained a lot of attention. Since the review of Atkinson and Nevill (1998), many works has published addressing these matters.
Baltaci et al., in the present work, assessed the validity of three different forms of sit-and-reach (SR) test and compared the results with flexibility of hip joint for flexion using a go...
Dear Editor,
We would like to thank Russell for his letter because we feel the subject of safety in the sport of men’s slow-pitch softball has been ignored for too long and it is refreshing to see that others are also taking notice. An increase in the awareness of this subject through discussions and scientific publications will help lead to required, well-defined, safety standards in the sport of softball. Unfort...
Dear Editors,
Dres. Gore and Hahn suggest that the significant mean increase of 6% in total haemoglobin mass (tHbmass) which we observed after altitude training in elite junior swimmers might to a major extend be attributed to few erroneous measurements after altitude training. As already discussed in the paper, we agree that an increase of about 24% is astonishingly high. However, as pointed out, we were not the...
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