The research article in the BJSM(1)this month entitled 'Oral
administration of the probiotic Lactobacillus fermentum VRI-003 and
mucosal immunity in endurance athletes' was of high quality in terms of
the study design, apart from the small number of subjects. However, I must
take issue with the way in which the results were used to reach the
conclusion that: "Probiotic supplementation may offer increased protection
agains...
The research article in the BJSM(1)this month entitled 'Oral
administration of the probiotic Lactobacillus fermentum VRI-003 and
mucosal immunity in endurance athletes' was of high quality in terms of
the study design, apart from the small number of subjects. However, I must
take issue with the way in which the results were used to reach the
conclusion that: "Probiotic supplementation may offer increased protection
against viral infection in athletes".
Three subjects reported illness (upper or lower respiratory tract
infections) whilst taking the probiotic whereas seven subjects were unwell
taking placebo. This was not statistically significant (P value 0.27).
However, what was statistically significant was the number of days of
symptoms, thirty in those on the probiotic and seventy-two in those on the
placebo (P value<0.001). But of course these will be large numbers
because the average time per person with symptoms was ten days.
In determining whether the probiotic has any benefit in preventing
illness, the important point is the number of subjects protected by it,
NOT the number of days of illness.
This article may have demonstrated a moderate increase in one of the
cytokines (IFN gamma) in those subjects taking the probiotic. However, the
results from this study do not enable one to conclude that the probiotic
Lactobacillus fermentum VRI-003 has a prophylactic beneficial effect
against respiratory illness in a group of highly-trained distance runners.
(1) Cox AJ, Pyne DB, Saunders PU, Fricker PA. Oral administration of
the probiotic Lactobacillus fermentum VRI-003 and mucosal immunity in
endurance athletes. British J Sports Med 2010;44:222-226
I read with great interest your paper regarding inactivity
physiology. This is a line of research that I have recently come across,
and am still unsure exactly what constitutes sedentary behaviour. I am
aware that many studies incorrectly refer to 'sedentary behaviour' or
'inactivity' as an absence of sufficient moderate or vigorous activity-
categorised by default as opposed to a direct classification of time spent
in se...
I read with great interest your paper regarding inactivity
physiology. This is a line of research that I have recently come across,
and am still unsure exactly what constitutes sedentary behaviour. I am
aware that many studies incorrectly refer to 'sedentary behaviour' or
'inactivity' as an absence of sufficient moderate or vigorous activity-
categorised by default as opposed to a direct classification of time spent
in sedentary behaviour.
A definition has been given by Pate and colleagues(1):
"Operationally, sedentary behaviour includes activities that involve
energy expenditure at the level of 1.0 - 1.5 (METs. Light physical
activity, which often is grouped with sedentary behavior but is in fact a
distinct activity construct, involves energy expenditure at the level of
1.6 - 2.9 METs. It includes activities such as slow walking, sitting and
writing, cooking food, and washing dishes".
I feel it would be useful for researchers to provide a clear
definition of what constitutes sedentary behaviour including both a
quantitative (i.e. energy cost) and qualitative (i.e. type of activity)
frame of reference.
1.Pate R, O'Neill, JR, & Lobelo, F. The Evolving definition of
"Sedentary". Exercise and Sport Science Reviews, 2008.
Ash Routen
PhD Student
Institute of Sport & Exercise Science
University of Worcester
Worcester, UK
We read with interest the commentary piece by McCrory et al. in the
recent online edition of BJSM 1.
It raises an important issue - that sports physicians who work with
professional teams may be under pressure to favour fashion over science.
One of the treatment regimes from a commentary piece of
ours 2 was cited by the authors 1 as their primary example of a 'flawed
approach'. A full read of our or...
We read with interest the commentary piece by McCrory et al. in the
recent online edition of BJSM 1.
It raises an important issue - that sports physicians who work with
professional teams may be under pressure to favour fashion over science.
One of the treatment regimes from a commentary piece of
ours 2 was cited by the authors 1 as their primary example of a 'flawed
approach'. A full read of our original article 2 can assure those who are
interested in this topic that we are advocates of evidence based medicine
(EBM) and consider it fundamental to specialist Sport and Exercise
Medicine
practice, as it is nowadays to all areas of medicine.
We attempted to summarise the level of evidence, which we
characterised as 'low', to support
injection therapy in general and the Traumeel/Actovegin regime in
particular. We believe that the
Mueller-Wohlfahrt experience at least qualifies as an unpublished but
large size case series over
three decades by a doctor with a sub-specialty practice in muscle strains.
This should be
distinguished from 'snake oil' treatments, which purport to treat 'every'
condition and draw up images of unregistered practitioners. If elite
athletes report impressive results from a
Traumeel/Actovegin regime, which they have in continental Europe for many
years, then there are
at least three possible explanations: (1) that Actovegin and/or Traumeel
have a beneficial
therapeutic effect on injured muscle (2) that injection therapy in
general, potentially with many
substances, has a beneficial therapeutic effect on injured muscle (the
rationale of glucose
'prolotherapy' (3) that injection therapy (or even perhaps travelling
abroad) has a beneficial placebo
effect. A further confounder with Dr Mueller-Wohlfahrt's personal
management regime is that he
tends to advise against the use of anti-inflammatory medications
(cortisone and NSAIDs). As these
are commonly taken by elite athletes for soft tissue injuries, a
management regime which removes
them may be beneficial if anti-inflammatories are in fact harmful for
healing muscle.
As we did, McCrory et al. referenced the Wright-Carpenter et al.
paper 3 which was a trial comparing
Traumeel/Actovegin and autologous serum injections. It is worth noting
that in this small nonrandomised
study, the autologous serum group had superior results and that neither
group
exhibited any adverse effects. Our conclusion statement that injection
therapy is "an important part
of the landscape of management options for muscle strains", which McCrory
et al. have taken issue
with, is implicit in the very design of the Wright-Carpenter et al. trial.
We also made it clear that we did not advocate any doctor breaching
his or her relevant national
laws for drug regulation and nor would we recommend any treatment to an
elite athlete which was
in breach of WADA regulations. For a country in which Traumeel and
Actovegin are not registered
for injection use, perhaps glucose (prolotherapy) would be the closest
legal substitute in an athlete
subject to WADA regulations.
We hope that our original commentary paper brought further attention
to a management option
that is in common usage by elite athletes, stimulating further debate and
calling for further study. If
there were any advocates at the recent British conferences, referenced by
McCrory et al. 1, who
asserted that Traumeel/Actovegin were either 'proven' or 'essential'
treatments for muscle strains in
elite athletes, then we would similarly advise caution by re-iterating
that the scientific level of
evidence is currently 'low'. We hope our article helped team physicians
with the dilemma of "what
to do when the scientific evidence is unclear". It is a completely valid
viewpoint to recommend no
treatment over a treatment option that has a low level of scientific
evidence. We think it is also
currently a valid viewpoint that some practitioners may reach that the
potential benefits of injection
therapies for muscle strains in elite athletes outweigh the potential
risks. Before coming to their own
conclusions, we would trust the readers of the BJSM to read our commentary
in full 2 rather than to
assume from the McCrory et al. article1 that we had advocated it as proven
best-practice.
We would also caution against any fear that sports medicine is about
to collapse as a specialty
because some team physicians choose to use treatments which have not been
validated in high
quality trials. Orthopaedic surgery has survived very well as a specialty
without requiring all
operations to be subjected to RCTs. Whilst general physicians have a far
larger knowledge base of
published trials, it is worth bearing in mind that a huge number of these
have been funded by the
companies profiting from the medications being tested.
One of the unique aspects of specialist team physician practice is that
elite athletes are different to
the general population, with one of the differences being that they would
always want the so-called
'active' agent and hence would not be interested in being part of an RCT.
This doesn't mean we
should avoid all research on elite athletes or ignore high quality
research on members of the general
population, but it does represent a challenging environment in which to
practice. In fact, if the
definition of a medical specialty includes a criterion that the area must
be distinct from other
medical specialties, then the unique elite athlete environment makes a
very good argument as to
why sports medicine must be considered a stand-alone medical specialty.
Yours sincerely,
John Orchard, Tom Best, Glenn Hunter, Bruce Hamilton
1. McCrory P, Franklyn-Miller A, Etherington J. Sports and exercise
medicine - new specialists or
snake oil salesmen? Br J Sports Med Online First: 29 November 2009
doi:10.1136/bjsm.2009.068999
2. Orchard JW, Best TM, Mueller-Wohlfahrt HW, Hunter G, Hamilton BH,
et al. The early
management of muscle strains in the elite athlete: best practice in a
world with a limited evidence
basis Br J Sports Med 2008;42:158-159
3. Wright-Carpenter T, Klein P, Schauferhoff P, Appell HJ, Mir LM,
Wehling P. Treatment of muscle
injuries by local administration of autologous conditioned serum: a pilot
study on sportsmen with
muscle strains. Int J Sports Med. 2004 Nov;25(8):588-93
Mbalilaki and associates have reported very high daily energy
expenditures for a sample of Masai pastoralists and farmers (56% of whom
were women)(1). The stated average of 10.7 MJ/day (2565 kcal/day) appears
to be a gross value for that part of the day when the subjects were
physically active, although this is not specifically indicated in their
paper. The expenditure is suggested as equivalent to 19 km of walking,
whi...
Mbalilaki and associates have reported very high daily energy
expenditures for a sample of Masai pastoralists and farmers (56% of whom
were women)(1). The stated average of 10.7 MJ/day (2565 kcal/day) appears
to be a gross value for that part of the day when the subjects were
physically active, although this is not specifically indicated in their
paper. The expenditure is suggested as equivalent to 19 km of walking,
which would occupy a total of some 4 hours. The remaining 20 hours would
contribute at least a further 6 MJ of resting energy expenditure, for a
daily total of some 16.7 MJ or 4010 kcal. One earlier Kofranyi-Michaelis
respirometer study of traditional male Inuit did observe daily
expenditures ranging from 10.5 to 18.5 MJ/day for different categories of
hunting in a harsh arctic environment (2). However, the figure of 16.7
MJ/day proposed for the Masai sample is somewhat surprising on several
counts, including the low average body mass of the subjects (56.8 kg), the
relatively low physical working capacity seen in a previous Masai sample
(3) and the conclusions from at least one energy input-output analysis
that food requirements in this environment could be satisfied by working
only two days per week (4).
One potential issue is the method adopted when determining energy
expenditures. Mbalilaki and associates (1) apparently based their estimate
on an interviewer-administered North American questionnaire (5),
translated into Swahili and slightly adjusted for Tanzanian conditions.
The nature of these slight adjustments and their possible impact on test
validity are not discussed, but there are clearly important limitations to
the absolute accuracy of information obtained from most physical activity
questionnaires (including the instrument of Paffenbarger and associates,
5) even in an urban North American environment (6),and many of the items
listed in the published version of the instrument of Paffenbarger et
al.(5) would have little relevance to the Masai sample.
Given the importance of understanding physical activity patterns in
populations that have a low prevalence of cardiovascular risk factors, I
hope that Mbalilaki and associates will soon find opportunity to replicate
their interesting observations, using currently available and relatively
inexpensive objective physical activity monitors.
Roy J. Shephard.
References
1. Mbalilaki JA, Msesa Z, Stromme SB et al. Daily energy expenditure
and cardiovascular risk in Masai, rural and urban Bantu Tanzanians. Br J
Sports Med 2010; 44: 121-126.
2. Godin G, Shephard RJ. Activity patterns in the Canadian Eskimo.
In: Edholm O, Gunderson EK, eds. Polar Human Biology, London, UK:
Heinemann, 1973.
3. Wyndham CH, Strydom NB, Morrison JF et al. Differences between
ethnic groups in physical working capacity. J Appl Physiol 1963; 18: 361-
366.
4. Lee RB. Kung bushmen subsistence: An input-output analysis. In:
Vayda AP. Environment and cultural behavior. New York, NY: Natural History
Press.
5. Paffenbarger RS, Blair SN, Lee IM et al. Measuring physical
activity to assess health effects in free-living populations. Med Sci
Sports Exerc 1993; 25: 60-70.
6. Shephard RJ. Limits to the measurement of habitual physical
activity by questionnaires. Br J Sports Med 2003; 37: 197-206.
The article by Tillett and Loosemore describes guidelines for the
prevention and management of travellers' diarrhoea (TD) based on their
experience with the elite athletes and noncompeting members of Team
England during the 2008 Youth Commonwealth Games in India. The authors
recommended that all team members receive oral and written advice
regarding prevention of TD, that all team members are issued alcohol hand
gel and...
The article by Tillett and Loosemore describes guidelines for the
prevention and management of travellers' diarrhoea (TD) based on their
experience with the elite athletes and noncompeting members of Team
England during the 2008 Youth Commonwealth Games in India. The authors
recommended that all team members receive oral and written advice
regarding prevention of TD, that all team members are issued alcohol hand
gel and instruction for its use, and that all noncompeting team members
receive ciprofloxacin for TD prophylaxis. As ciprofloxacin use in elite
athletes is considered controversial because of a possible association
with tendon rupture, the authors recommended that elite athletes consider
the nonabsorbable antibiotic rifaximin as a prophylactic for TD. However,
none of the elite athletes on Team England actually received rifaximin as
a prophylactic therapy for TD. Further, the authors stopped short of
recommending rifaximin for the treatment of TD, simply recommending
treatment with empiric antibiotics per local advice and the results of
stool culture.
We report here that, in 2008, some elite athletes from the United
States received rifaximin either for the prophylaxis or treatment of TD
while in Beijing, China. In this small sample of elite athletes, rifaximin
was safe and well tolerated, and no adverse events were reported.
Rifaximin has been found safe, well tolerated, and effective for both the
prophylaxis and treatment of TD in other populations1-8. Based on our
experience and the excellent safety profile of rifaximin for the treatment
of TD, the use of rifaximin as an antibiotic therapy for the treatment of
TD in elite athletes deserves further consideration.
REFERENCES
1. DuPont HL, Ericsson CD, de la Cabada FJ, et al. Prevention of
travelers' diarrhea with rifaximin- a phase 3 randomized double-blind
placebo-controlled trial in U.S. students in Mexico [abstract]. Am J
Gastroenterol. 2006;101(suppl):S197-S198.
2. DuPont HL, Ericsson CD, Mathewson JJ, et al. Rifaximin: a nonabsorbed
antimicrobial in the therapy of travelers' diarrhea. Digestion.
1998;59(6):708-714.
3. DuPont HL, Haake R, Taylor DN, et al. Rifaximin treatment of pathogen-
negative travelers' diarrhea. J Travel Med. 2007;14:16-19.
4. DuPont HL, Jiang ZD, Ericsson CD, et al. Rifaximin versus ciprofloxacin
for the treatment of traveler's diarrhea: a randomized, double-blind
clinical trial. Clin Infect Dis. 2001;33(11):1807-1815.
5. DuPont HL, Jiang Z-D, Belkind-Gerson J, et al. Treatment of travelers'
diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide,
and loperamide alone. Clin Gastroenterol Hepatol. 2007;5:451-456.
6. DuPont HL, Jiang Z-D, Okhuysen PC, et al. A randomized, double-blind,
placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann
Intern Med. 2005;142(10):805-812.
7. Steffen R, Sack DA, Riopel L, et al. Therapy of travelers' diarrhea
with rifaximin on various continents. Am J Gastroenterol. 2003;98:1073-
1078.
8. Taylor DN, Bourgeois AL, Ericsson CD, et al. A randomized, double-
blind, multicenter study of rifaximin compared with placebo and with
ciprofloxacin in the treatment of travelers' diarrhea. Am J Trop Med Hyg.
2006;74:1060-1066.
Pre-participation screening in competitive athletes in Portugal has
been compulsory for more than 40 years. Yearly ECG was introduced in the
screening at about the same time as in Italy, for all athletes evaluated
at the Sports Medicine Centres in Portugal. The very rare cases of sudden
cardiovascular death that have ocurred in the past 25 years in Portugal
were not screened at the Centres or had further cardiovascular e...
Pre-participation screening in competitive athletes in Portugal has
been compulsory for more than 40 years. Yearly ECG was introduced in the
screening at about the same time as in Italy, for all athletes evaluated
at the Sports Medicine Centres in Portugal. The very rare cases of sudden
cardiovascular death that have ocurred in the past 25 years in Portugal
were not screened at the Centres or had further cardiovascular evaluation
pending, and threfore were not qualified for practice. Several athletes
have been disqualified from sports participation for cardiovascular
reasons, most of them were further investigated because of rest ECG
changes findings. We strongly favour the use of 12 lead ECG in the pre-
participation screening process. Presently, we routinely screen about
20.000 athletes per year in the 3 Sports Medicine Centres in Portugal.
May I register a plea on behalf of all your British readers? To us,
the sport of football is synonymous with soccer. To Americans, it refers
to a completely different sport involving major collision. I'm not at all
sure what it means to Antipodeans.
I read the otherwise excellent article by Davis et al on cervical
canal stenosis in a "footballer" in your December 2009 issue with
increasing...
May I register a plea on behalf of all your British readers? To us,
the sport of football is synonymous with soccer. To Americans, it refers
to a completely different sport involving major collision. I'm not at all
sure what it means to Antipodeans.
I read the otherwise excellent article by Davis et al on cervical
canal stenosis in a "footballer" in your December 2009 issue with
increasing irritation. It became clear that the authors were referring to
the sport we British readers call "American football"- the precise term
used correctly by Caine in your January 2010 editorial.
I know it is totally unrealistic to expect North American authors and
journals to adopt clearer terminology, but I contend that the British
Journal of Sports Medicine should be setting the gold standard as part of
its editorial policy and house style.
Yours faithfully
Dr Richard Hardie
Consultant Neurologist
Frenchay Hospital
BRISTOL
BS16 1LE
UK
The research article in the BJSM(1)this month entitled 'Oral administration of the probiotic Lactobacillus fermentum VRI-003 and mucosal immunity in endurance athletes' was of high quality in terms of the study design, apart from the small number of subjects. However, I must take issue with the way in which the results were used to reach the conclusion that: "Probiotic supplementation may offer increased protection agains...
I read with great interest your paper regarding inactivity physiology. This is a line of research that I have recently come across, and am still unsure exactly what constitutes sedentary behaviour. I am aware that many studies incorrectly refer to 'sedentary behaviour' or 'inactivity' as an absence of sufficient moderate or vigorous activity- categorised by default as opposed to a direct classification of time spent in se...
Dear Editor,
We read with interest the commentary piece by McCrory et al. in the recent online edition of BJSM 1. It raises an important issue - that sports physicians who work with professional teams may be under pressure to favour fashion over science. One of the treatment regimes from a commentary piece of ours 2 was cited by the authors 1 as their primary example of a 'flawed approach'. A full read of our or...
Mbalilaki and associates have reported very high daily energy expenditures for a sample of Masai pastoralists and farmers (56% of whom were women)(1). The stated average of 10.7 MJ/day (2565 kcal/day) appears to be a gross value for that part of the day when the subjects were physically active, although this is not specifically indicated in their paper. The expenditure is suggested as equivalent to 19 km of walking, whi...
The article by Tillett and Loosemore describes guidelines for the prevention and management of travellers' diarrhoea (TD) based on their experience with the elite athletes and noncompeting members of Team England during the 2008 Youth Commonwealth Games in India. The authors recommended that all team members receive oral and written advice regarding prevention of TD, that all team members are issued alcohol hand gel and...
Pre-participation screening in competitive athletes in Portugal has been compulsory for more than 40 years. Yearly ECG was introduced in the screening at about the same time as in Italy, for all athletes evaluated at the Sports Medicine Centres in Portugal. The very rare cases of sudden cardiovascular death that have ocurred in the past 25 years in Portugal were not screened at the Centres or had further cardiovascular e...
Dear Sir
May I register a plea on behalf of all your British readers? To us, the sport of football is synonymous with soccer. To Americans, it refers to a completely different sport involving major collision. I'm not at all sure what it means to Antipodeans.
I read the otherwise excellent article by Davis et al on cervical canal stenosis in a "footballer" in your December 2009 issue with increasing...
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