Thank you for your e-letter of 5th April 2021 regarding our publication ‘Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine 2020;0:e000764. doi:10.1136/ bmjsem-2020-000764’. We welcome your comments and interest in this research as it further highlights the importance of evidence based safe and ethical practice. Our own interest and rationale for this review stems from extensive working with young adults and adolescents involved in elite sport with low back pain.
We take on board your comments, although where good evidence to support one modality over another is lacking, the merits of different approaches concerning risk v benefit must be central to clinical decision making. In this instance, evidence based practice in the UK overwhelmingly supports the use of MRI as the first line investigation; recognising SPECT/CT involves ionising radiation, and that a safe alternative exists with MRI. When undertaken and interpreted correctly, MRI permits the sensitive detection of posterior element bone stress injury in the vast majority of cases and should therefore be used as the first line investigation. SPECT/CT should therefore be reserved for those small minority of cases where (following MRI) diagnostic doubt remains, where there are underlying complexities (such as previous same-level stress injuries)...
Thank you for your e-letter of 5th April 2021 regarding our publication ‘Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine 2020;0:e000764. doi:10.1136/ bmjsem-2020-000764’. We welcome your comments and interest in this research as it further highlights the importance of evidence based safe and ethical practice. Our own interest and rationale for this review stems from extensive working with young adults and adolescents involved in elite sport with low back pain.
We take on board your comments, although where good evidence to support one modality over another is lacking, the merits of different approaches concerning risk v benefit must be central to clinical decision making. In this instance, evidence based practice in the UK overwhelmingly supports the use of MRI as the first line investigation; recognising SPECT/CT involves ionising radiation, and that a safe alternative exists with MRI. When undertaken and interpreted correctly, MRI permits the sensitive detection of posterior element bone stress injury in the vast majority of cases and should therefore be used as the first line investigation. SPECT/CT should therefore be reserved for those small minority of cases where (following MRI) diagnostic doubt remains, where there are underlying complexities (such as previous same-level stress injuries) or when the stakes are unusually high and uncertainty persists (such as in some professional athletes). Moreover, young elite athletes may need repeated imaging for lumbar stress injuries, further supporting the use of MRI over SPECT/CT and repeated exposure to ionising radiation.
We readily acknowledge that radiation doses from SPECT/CT have decreased in recent years, however this does not compare with ‘zero’ exposure for MRI. To continue to endorse SPECT/CT as a routine first line investigation condemns a cohort of predominantly young individuals to unnecessary exposure to ionising radiation, something that basic principles of radiation protection advocate against.
Thank you again for your interest and points raised to allow us to respond.
Dear colleagues, I have read with a great interest this systematic review “Esh R, Grødahl LHJ, Kerslake R, et al. Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis”[1] and would like to make some comments. Further research, as authors concluded, are always desired and I wish there are appropriate studies in the next future to decide if MRI could be a modality of choice for diagnosing PEBSI and not SPECT/CT as it is by now. But the referred articles from this review do not support this assertion for the following reasons.
First, there are just 2 articles from 4 included in this review compared MRI and SPECT/CT and just in 1 of them (Juvenil spondilolysis: a comparative analysis of CT, SPECT and MRI) the results of both techniques were concordant, although the main causes of discrepancy were between MRI and SPECT/CT for diagnoses of stress reaction in absence of overt fracture and distinguishing incomplete fracture from intact pars of complete defects (22 patients and 40 pars defect) [2].
Second, in the 2nd article the authors mention that sensitivity and specificity of MRI was 80 and 100% respectively skipping the SPECT/CT results and author’s conclusion that in the original article was following: “These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. MRI is inferior to bone scintigraphy (with SPECT)/c...
Dear colleagues, I have read with a great interest this systematic review “Esh R, Grødahl LHJ, Kerslake R, et al. Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis”[1] and would like to make some comments. Further research, as authors concluded, are always desired and I wish there are appropriate studies in the next future to decide if MRI could be a modality of choice for diagnosing PEBSI and not SPECT/CT as it is by now. But the referred articles from this review do not support this assertion for the following reasons.
First, there are just 2 articles from 4 included in this review compared MRI and SPECT/CT and just in 1 of them (Juvenil spondilolysis: a comparative analysis of CT, SPECT and MRI) the results of both techniques were concordant, although the main causes of discrepancy were between MRI and SPECT/CT for diagnoses of stress reaction in absence of overt fracture and distinguishing incomplete fracture from intact pars of complete defects (22 patients and 40 pars defect) [2].
Second, in the 2nd article the authors mention that sensitivity and specificity of MRI was 80 and 100% respectively skipping the SPECT/CT results and author’s conclusion that in the original article was following: “These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. MRI is inferior to bone scintigraphy (with SPECT)/computed tomography. Bone scintigraphy (with SPECT) should remain the first-line investigation of active athletes with low back pain followed by limited computed tomography if bone scintigraphy is positive” [3], 39 subjects and 50 pars interarticularis were included. The authors of the review make the opposite conclusion, that there were no false negative results of MRI, but false positive results of SPECT/CT due to SPECT´s high sensitivity of ongoing bone turnover activity and lacked classification system for SPECT.
Regarding to metabolic bone turnover activity I would like kindly remind a metabolism of 99mTc-diphosphonates, which is used for scintigraphy. The incorporation of diphosphonates is carried out in the hydroxyapatite crystals, in such a way that the degree of uptake will be proportional to the presence of those crystals, which, will be proportional to the osteoblastic activity and, therefore, to the metabolic turnover bone activity. The metabolism cannot be deceived, if it is increased focally or diffusely, there are more crystals that will bind with more diphosphonates in the exact localization [4].
Third, the authors mention that there is no established grading system defining SPECT abnormality in lumbar spine. System which normally used in Nuclear Medicine for defining an uptake in scintigraphy with/without SPECT is a semi-quantitative scale or a color scale of ROI (region of interest) lesion. Also nowadays quantitative SPECT has been commercially available for several years [5].
Forth, the authors mention possible false positive results of SPECT/TC, saying that scintigraphy uptake occurs frequently in athletes (34-45.2%) in non-painful sites, making a conclusion that such false positive cases are commonly regarded as adaptive changes and are perceived normal, giving as a link an article “Assessment o a clinical significance of asymptomatic lower extremity uptake abnormality in Young Athletes” [6]. Skipping the fact that in this study was used planar scintigraphy of lower extremities and not SPECT/CT of spine, there is a huge difference between false positive and asymptomatic abnormality, which can be translate into some irrelevant for treatment or following but present detection, and this is really frequent in athletes, that’s why it is not recommended to make scintigraphy in the absence of pain [6]. As you can check the images of this article, there are uptakes which are not considered as false positives, the authors are discussing its origin and relevance, but not calling in question the fact of the uptakes.
And the last, the risk of cancer development using nuclear medicine techniques is very low, even if the authors mention that “The effective dose from a single course of X-ray and SPECT-CT scans is 10X more, than what UK dwellings get in a year from natural background radiation exposure”. I can suppose that the authors took an effective dose of ionizing radiation 1mSv per year for UK dwelling and compared with approximately 10mSv received from SPECT/CT. There are epidemiological studies on populations exposed to radiation, such as atomic bomb survivors or radiotherapy patients, showed a significant increase of cancer risk at doses above 100 mSv [7] and despite intensive study, evidence to prove an increased cancer risk associated with radiation doses below ~100 mSv is lacking; however, concerns about ionizing radiation in medical imaging remain and can affect patient care [8]. Also nowadays it is used a lower dose CT protocols when performing SPECT-CT, permitting a reduction in the mean effective dose to 1.8 mSv from 4.0 mSv without a loss of CT image quality [9]. As an effective dose of an adult bone scintigraphy is between 2.9-4mSv [10], so the final effective dose of SPECT/CT is much lower than considered as risky for human health.
As a conclusion, with the analysed studies of this systematic review we can make a conclusion, that SPECT/CT has better sensitivity (100%), than MRI (80%) in 1 study [3], which means a loss of the fifth part of pathology, not detected by MRI and concordant results in the other article [2]. The SPECT/CT is still a technique of choice in patients with PEBSI without neurological symptoms. In the absence of risk, it would be preferably to use more sensible technique, although further research is desired to find out the best test for diagnosing PEBSI.
1) Esh R, Grødahl LHJ, Kerslake R, et al. Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine 2020;0:e000764. doi:10.1136/ bmjsem-2020-000764
2) Campbell et al. Juvenil spondilolysis: a comparative analysis of CT, SPECT and MRI. Skeletal Radiology volume 34, pages63–73(2005) https://link.springer.com/article/10.1007/s00256-004-0878-3
3) Masci et al. 2005. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med 2006; 40:940–946. doi: 10.1136/bjsm.2006.030023 https://www.researchgate.net/publication/6812831_Use_of_the_one-legged_h...
4) Yuda, H., Wakao, H. 99mTc-MDP accumulation mechanisms in bone: Basic study on the adsorption onto hydroxyapatite. Oral Radiol. 12, 27–32 (1996) https://link.springer.com/article/10.1007/BF02351579
5) Kangasmaa, T.S., Constable, C. & Sohlberg, A.O. Quantitative bone SPECT/CT reconstruction utilizing anatomical information. EJNMMI Phys 8, 2 (2021). https://doi.org/10.1186/s40658-020-00348-1
6) Laura A. Drubach, Leonard P. Connolly, Pierre A. D’Hemecourt and S. Ted Treves. Assessment of the Clinical Significance of Asymptomatic Lower Extremity Uptake Abnormality in Young Athletes Journal of Nuclear Medicine February 2001, 42 (2) 209-212. https://jnm.snmjournals.org/content/42/2/209
7) https://www.who.int/news-room/fact-sheets/detail/ionizing-radiation-heal...
8) Ferrero A. et al. Understanding, justifying, and optimizing radiation exposure for CT imaging in nephrourology. Nature reviews. Urology, 01 Apr 2019, 16(4):231-244 https://scite.ai/reports/10.1038/s41585-019-0148-8
9) Sandeep Kumar Gupta et al. Radionuclide bone scan SPECT-CT: lowering the dose of CT significantly reduces radiation dose without impacting CT image quality. Am J Nucl Med Mol Imaging 2017;7(2):63-73 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435612/pdf/ajnmmi0007-0063...
10) The EANM practice guidelines for bone scintigraphy. T. Van den Wyngaert, K. Strobel, W. U. Kampen, T. Kuwert, W. van der Bruggen, H. K. Mohan, G. Gnanasegaran, R. Delgado-Bolton, W. A. Weber, M. Beheshti, W. Langsteger, F. Giammarile, F. M. Mottaghy, F. Paycha, On behalf of the EANM Bone & Joint Committee and the Oncology Committee. Eur J Nucl Med Mol Imaging. 2016; 43: 1723–1738. Published online 2016 Jun 4. doi: 10.1007/s00259-016-3415-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932135/pdf/259_2016_Articl...
Nice study, and great to see you including dog ownership in your COI statements! A plea from a veterinary surgeon interested in dog walking though: please collect and report data about the dogs. A dog isn't a standardised intervention like a Fitbit. Their exercise capacity and exercise desire will vary with breed, age, comorbidities, body condition score, behaviour yet no data about the dogs is included in this publication. In addition, research suggests that owning an ill or behaviourally problematic dog can be very stressful. These canine attributes may have introduced a level of unaccounted for heterogeneity into your intervention arm which may have confounded your results. I'd be happy to point any researchers in this field towards the relevant canine literature, or assist with dog aspects of a study design.
Dear authors, I have read your paper with interest, and I have a couple of remarks that I think needs to be discussed to hopefully stimulate to more studies in this important field.
It is a weakness that there are very few randomised trials on surgical treatment of tendinopathy. To then draw conclusions from few studies is difficult and not always possible.
From this systematic review it is shown that 10 out 12 trials are on tendinopathy in the upper extremities (shoulder and elbow-althogether 998 tendinopathies) and only 2 on tendinopathy in the lower extremities (patellar and Achilles-althogeteher 60 tendinopathies). The authors have unfortunately missed to include 2 randomised studies on surgical treatment of patellar tendinopathy, published by Dr Willberg et al. Althogether, most information is about the shoulder and elbow, and very little about the Achilles and patellar tendons. Anyhow, when conclusions are drawn I get the impression that the authors put all tendinopathies in one group. This might be strongly misleading since there is very little information about the lower extremity tendons (only 2 studies), and conclusions cannot be drawn for Achilles and patellar tendinopathy. Furthermore, such conclusions might lead to that we miss possible differences in load response between upper and lower extremity tendons? The upper extremity non weight-bearing tendons might respond different compared to the lower extremity weight bearing tendons, as it is fo...
Dear authors, I have read your paper with interest, and I have a couple of remarks that I think needs to be discussed to hopefully stimulate to more studies in this important field.
It is a weakness that there are very few randomised trials on surgical treatment of tendinopathy. To then draw conclusions from few studies is difficult and not always possible.
From this systematic review it is shown that 10 out 12 trials are on tendinopathy in the upper extremities (shoulder and elbow-althogether 998 tendinopathies) and only 2 on tendinopathy in the lower extremities (patellar and Achilles-althogeteher 60 tendinopathies). The authors have unfortunately missed to include 2 randomised studies on surgical treatment of patellar tendinopathy, published by Dr Willberg et al. Althogether, most information is about the shoulder and elbow, and very little about the Achilles and patellar tendons. Anyhow, when conclusions are drawn I get the impression that the authors put all tendinopathies in one group. This might be strongly misleading since there is very little information about the lower extremity tendons (only 2 studies), and conclusions cannot be drawn for Achilles and patellar tendinopathy. Furthermore, such conclusions might lead to that we miss possible differences in load response between upper and lower extremity tendons? The upper extremity non weight-bearing tendons might respond different compared to the lower extremity weight bearing tendons, as it is for skeletal bones. Therefore, until we have more knowledge, I suggest that conclusions about tendinopathies are separated to upper and lower extremity.
-The conclusion in the abstract that tendinopathies should be treated with physiotherapy for at least 12 months before the option of surgery is seriously entertained cannot be stated based on the material in this systematic review. Although I myself is a strong promoter of exercise treatment for tendinopathy, at least for the Achilles and patellar tendons there is not enough research backing up such a statement.
-The conclusion that surgery is not superior to sham surgery in patients with tendinopathy is not correct-this can maybe be indicated considering the shoulder and elbow (based on very few studies), but for the lower extremity there are no such studies to refer to.
Althogether, this review clearly shows that much more research is needed in this field.
In their recent viewpoint and article, Stöllberger and Finsterer 1 2 criticize the inadequate regulation of “whole body-electromyostimulation” (WB-EMS), potentially responsible for a variety of adverse effects recently reported. 3-6 Indeed, in contrast to locally applied EMS, the stimulation of all, or at least most, major muscle groups characterizes WB-EMS. Consequently, given that even locally applied EMS might cause severe rhabdomyolysis and hospitalization 7, it is obvious that a technology able to stimulate simultaneously up to 2600 cm2 of muscular area entails a much larger risk of triggering unintended side effects 3-6 at least when inadequately applied. 8
Particularly with regard to the WB-EMS safety guidelines published in 2016 by our national WB-EMS consortium8, Stöllberger and Finsterer2 complain that the enquiring about contraindications and the requirements for a licensed WB-EMS trainer are not adequately specified. Overlapping with the publication of the article of Stöllberger and Finsterer, however it should be noted, that a German standard (DIN 33961-5, 9) was recently released which includes both contraindications for WB-EMS application in commercial, non-medical settings 10 and the requirements for the qualification of EMS trainers. Of importance, the latter was also specified by the 2019 revised German Radiation Protection Statutes (NiSV) a mandatory guideline published by the German “Bundesministerium für Umwelt, Naturschutz und nukleare Sicherhei...
In their recent viewpoint and article, Stöllberger and Finsterer 1 2 criticize the inadequate regulation of “whole body-electromyostimulation” (WB-EMS), potentially responsible for a variety of adverse effects recently reported. 3-6 Indeed, in contrast to locally applied EMS, the stimulation of all, or at least most, major muscle groups characterizes WB-EMS. Consequently, given that even locally applied EMS might cause severe rhabdomyolysis and hospitalization 7, it is obvious that a technology able to stimulate simultaneously up to 2600 cm2 of muscular area entails a much larger risk of triggering unintended side effects 3-6 at least when inadequately applied. 8
Particularly with regard to the WB-EMS safety guidelines published in 2016 by our national WB-EMS consortium8, Stöllberger and Finsterer2 complain that the enquiring about contraindications and the requirements for a licensed WB-EMS trainer are not adequately specified. Overlapping with the publication of the article of Stöllberger and Finsterer, however it should be noted, that a German standard (DIN 33961-5, 9) was recently released which includes both contraindications for WB-EMS application in commercial, non-medical settings 10 and the requirements for the qualification of EMS trainers. Of importance, the latter was also specified by the 2019 revised German Radiation Protection Statutes (NiSV) a mandatory guideline published by the German “Bundesministerium für Umwelt, Naturschutz und nukleare Sicherheit (BMU)” that includes WB-EMS, magnetic resonance imaging (MRI) and other types of “applications of non-ionizing radiation to humans”.11 However, apart from the mandatory instructor training, we are not fully convinced that the formal requirements specified by the NiSV will contribute to higher safety standards or increased effectiveness of WB-EMS.
Surprisingly, one key aspect of safe and effective WB-EMS application addressed by the DIN 33951-5 is rarely given sufficient attention in the discussion about regulating WB-EMS: the close supervision and interaction during WB-EMS application. Based on the safety guidelines 8, the DIN 33961-5 9 set the supervision ratio for WB-EMS applications to a maximum of two participants per licensed and qualified trainer and training unit. We think that this safety standard contributes significantly to reducing the risk of adverse effects as outlined by Stöllberger et al. 1 2 and boost the effectiveness of WB-EMS on various outcome 12 To comprehend this conclusion, it is crucial to consider the nature of WB-EMS and to separate the technology of "WB-EMS" from other types of EMS. We define WB-EMS as a simultaneous application of electric stimuli via at least six current channels or participation of all major muscle groups with a current impulse effective to trigger muscular adaptations. Apart from the large stimulated area, it should be noted that EMS-technology, be it locally or globally applied, enables a supramaximal workload without voluntary effort. Correspondingly, physiological mechanisms that protect against overloading during conventional training (e.g., muscular fatigue 13) do not come into play during EMS. Additionally, there is no objective parameter for prescribing impulse intensity during WB-EMS; and the sensitivity of the areas stimulated vary considerably. Consequently, the present WB-EMS application strategy focused on extensive feedback about perceived exertion for each area of stimulation consistently requested from the participant and adjusted by the trainer throughout the recommended 20 min session. 8 In order to apply an adequate WB-EMS stimulus without negative impact there is an undisputed consensus among WB-EMS experts that a trainer should supervise no more than two participants simultaneously. 8 14 We justify this narrow ratio of supervision with the need for close attention that includes intense verbal, visual and, when necessary, haptic interaction between licensed trainer and participants. Asking about individual load and readjustment of the current intensity at short intervals is essential for applying an adequate impulse intensity. We conclude that query and adjustment of the individual load must be conducted at least three times per current channel or muscle group during a 20 min training session. Further, a permanent visual control of the participant and eye contact is essential to check participant strain, avoid overload and to react immediately to the first signs of cardiorespiratory or metabolic side effect (e.g., change of face color in the case of stress-induced syncope). Additionally, the distance between trainer and participant has to be close enough to enable visual control, verbal interaction, movement corrections (“spotting”) and rapid assistance in cases of emergency, including cutting off power supply of the device and preventing fall-related injuries. We consider a maximum space of 120 cm between trainer and participants for just sufficient to permit these complex goals. Summing up, taking this key relevance and indispensable role of the physically present, well-trained and attentive WB-EMS trainer for safety and effectiveness into account, it is clear and logical that the optimum WB-EMS application cannot be anything but personal training (1:1 supervision). However, a ratio of two participants per licensed trainer and session, as implemented by most commercial WB-EMS providers, can be still considered as acceptable supervision. But having more than two participants simultaneously supervised by one trainer definitely prevents frequent regulation of workload, spotting, consistent visual control, frequent verbal interaction, and rapid reaction in case of emergency, and would mean low effectiveness and limited safety during WB-EMS application.
In conclusion: although several specifications on WB-EMS safety and effectiveness were published in 2019, we admit that there are still some features and limitations that have to be specified in the nearest future. This refers not only to an obligatory supervision ratio of one trainer and a maximum of two participants, but also to a mandatory commitment by commercial, non-medical WB-EMS institutions to adhere to the safety guideline and to fully respect contraindications 9 10 for WB-EMS. Considering further the rapid international development and dissemination of this novel technology, we fully agree with Stöllberger et al. 2 that initiatives to increase safety of WB-EMS should be implemented at an international level.
References
1. Stollberger C, Finsterer J. Side effects of whole-body electromyostimulation. Wien Med Wochenschr 2019;169(7-8):173-80. doi: 10.1007/s10354-018-0655-x
2. Stollberger C, Finsterer J. Side effects of and contraindications for whole-body electro-myo-stimulation: a viewpoint. BMJ open sport & exercise medicine 2019;5(1):e000619. doi: 10.1136/bmjsem-2019-000619 [published Online First: 2020/01/08]
3. Kastner A, Braun M, Meyer T. Two Cases of Rhabdomyolysis After Training With Electromyostimulation by 2 Young Male Professional Soccer Players. Clin J Sport Med 2014;25(6):71-73. doi: 10.1097/JSM.0000000000000153
4. Teschler M, Weissenfels A, Bebenek M, et al. Very high creatine kinase CK levels after WB_EMS. Are there implications for health. Int J Clin Exp Med 2016;9(11):22841-50.
5. Malnick SD, Band Y, Alin P, et al. It's time to regulate the use of whole body electrical stimulation. BMJ 2016;352:i1693. doi: 10.1136/bmj.i1693
6. Finsterer J, Stollberger C. Severe rhabdomyolysis after MIHA-bodytec(R) electrostimulation with previous mild hyper-CK-emia and noncompaction. Int J Cardiol 2015;180:100-2. doi: 10.1016/j.ijcard.2014.11.148
7. Johannsen AD, Krogh TK. Rhabdomyolysis in an elite dancer after training with electromyostimulation: A case report. Transl Sports Med 2019;2:288-91. doi: 10.1002/tsm2.91
8. Kemmler W, Froehlich M, von Stengel S, et al. Whole-Body Electromyostimulation – The Need for Common Sense! Rationale and Guideline for a Safe and Effective Training. Dtsch Z Sportmed 2016;67(9):218-21. doi: 10.5960/dzsm.2016.246.
9. DIN. DIN 33961-5. Fitness-Studio - Anforderungen an Studioausstattung und -betrieb – Teil 5: Elektromyostimulationstraining. Berlin: Beuth 2019.
10. Kemmler W, Weissenfels A, Willert S, et al. Recommended Contraindications for the Use of Non-Medical WB-Electromyostimulation. Dtsch Z Sportmed 2019;70(11):278-81.
11. BMU, editor. Verordnung zum Schutz vor schädlichen Wirkungen nichtionisierender Strahlung bei der Anwendung am Menschen (NiSV). Bonn: Bundesanzeiger Verlag, 2019.
12. Kemmler W, Weissenfels A, Willert S, et al. Efficacy and safety of low frequency Whole-Body Electromyostimulation (WB-EMS) to improve health-related outcomes in non-athletic adults. A systematic review. Front Physiol 2018;9:573. :doi: 10.3389/fphys.2018.0057.
13. Wan JJ, Qin Z, Wang PY, et al. Muscle fatigue: general understanding and treatment. Exp Mol Med 2017;49(10):e384. doi: 10.1038/emm.2017.194 [published Online First: 2017/10/07]
14. Kemmler W, Kleinöder H, Fröhlich M, et al. Leitlinien WB-EMS-Training: „Safety First“ – Sicherheit beim EMS Training. 2016 [accessed 11.02.2020 2019.
The article Mortality of Japanese Olympic athletes: 1952 – 2017 cohort study currently fails to account for a probable source of non-negligible bias. Whilst the main finding, stating that there is a decreased mortality rate among Japanese Olympians appears to be methodologically reliable, the authors also state that “higher mortality was observed among those who participated in the Olympics twice and three times or more compared with those who participated just once,” which we believe to be a potentially inaccurate finding.
A delayed entry exists at baseline, as those with longer careers tend to be older than those with shorter careers. For instance, someone who has participated in 3 Olympic Games started her/his Olympic career 12 years before those who have participated only once. Thus, there might be an important period effect underlying these findings. Even if the authors have adjusted the analysis by age, this is not equivalent to adjusting for period, as earlier periods in time are related with higher mortality rates, which could explain the findings.
Additionally, another problem often seen in survival studies is ignoring when a death event occurs. This is problematic because deaths will be observed more frequently in subjects with longer follow-up times. In the presence of time-dependent bias, the hazard ratio is artificially underestimated and the length bias leads to an artificial underestimation of the overall hazard [2]. Therefore, faulty interpretat...
The article Mortality of Japanese Olympic athletes: 1952 – 2017 cohort study currently fails to account for a probable source of non-negligible bias. Whilst the main finding, stating that there is a decreased mortality rate among Japanese Olympians appears to be methodologically reliable, the authors also state that “higher mortality was observed among those who participated in the Olympics twice and three times or more compared with those who participated just once,” which we believe to be a potentially inaccurate finding.
A delayed entry exists at baseline, as those with longer careers tend to be older than those with shorter careers. For instance, someone who has participated in 3 Olympic Games started her/his Olympic career 12 years before those who have participated only once. Thus, there might be an important period effect underlying these findings. Even if the authors have adjusted the analysis by age, this is not equivalent to adjusting for period, as earlier periods in time are related with higher mortality rates, which could explain the findings.
Additionally, another problem often seen in survival studies is ignoring when a death event occurs. This is problematic because deaths will be observed more frequently in subjects with longer follow-up times. In the presence of time-dependent bias, the hazard ratio is artificially underestimated and the length bias leads to an artificial underestimation of the overall hazard [2]. Therefore, faulty interpretation may result from the underlying assumptions, which is potentially the case in this study.
The authors argue that the higher mortality rate found among those who participated in multiple Olympics could be related to longer periods of intense training. Yet, this is contradictory to their main finding which demonstrates far lower mortality rates among Olympians in comparison to the general population.
Finally, the higher mortality found among those engaged in multiple Games could also be explained by the missing life status confirmations. There were 1324 Olympians who were assumed to be alive when missing date of death. Previous studies that dealt with the same data source and the submission of life status to national data certification for confirmation found that there was more reliable data for well-known athletes [3]. Thus, date of death is probably more widespread for athletes engaged in multiple games and therefore less well-known athletes, participating in only one Games, may have been mislabeled alive when death information was missing.
The main findings that demonstrate lower mortality rates among Japanese Olympians compared to the general population rely on standard methods and seem to be reliable. The secondary findings that compare mortality among Olympians engaged in multiple games should be revised accounting for the biases described in this letter.
1 Zwiener I, Blettner M, Hommel G. Survival analysis: part 15 of a series on evaluation of scientific publications. Dtsch Ärztebl Int 2011;108:163–9. doi:10.3238/arztebl.2010.0163
2 Wolkewitz M, Allignol A, Harbarth S, et al. Time-dependent study entries and exposures in cohort studies can easily be sources of different and avoidable types of bias. J Clin Epidemiol 2012;65:1171–80. doi:10.1016/j.jclinepi.2012.04.008
3 Antero-Jacquemin J, Pohar-Perme M, Rey G, et al. The heart of the matter: years-saved from cardiovascular and cancer deaths in an elite athlete cohort with over a century of follow-up. Eur J Epidemiol Published Online First: 5 May 2018. doi:10.1007/s10654-018-0401-0
We have read with interest the article by Radenkovic D et al. (1) As final year medical students having experienced both pre-clinical and clinical training, we agree that there is a significant gap in lifestyle medicine training. We appreciate the authors highlighting the gap in formal training and assessment of motivational interviewing. Evidence suggests there is a strong positive correlation in using motivational interviewing and the transtheoretical model of behaviour change as counselling strategies to achieve improved patient outcomes in lifestyle changes. (2)
While this study focused primarily on physical exercise guidelines, it is important to define lifestyle medicine holistically, as it incorporates not only physical exercise but also nutrition, sleep, smoking as well as stress management. It would also be interesting to see how well trained medical students are in these other aspects of lifestyle medicine and how that correlates to lifestyle habits of students across various years of training. This could be done in the form or student welfare surveys throughout the academic year which would allow a more longitudinal holistic analysis of the representation of lifestyle medicine knowledge and student lifestyle habits. This can further inform targeted changes to medical school curriculum and student wellness interventions to ensure students are well equipped to maintain their own well-being and increase their confidence in counselling p...
We have read with interest the article by Radenkovic D et al. (1) As final year medical students having experienced both pre-clinical and clinical training, we agree that there is a significant gap in lifestyle medicine training. We appreciate the authors highlighting the gap in formal training and assessment of motivational interviewing. Evidence suggests there is a strong positive correlation in using motivational interviewing and the transtheoretical model of behaviour change as counselling strategies to achieve improved patient outcomes in lifestyle changes. (2)
While this study focused primarily on physical exercise guidelines, it is important to define lifestyle medicine holistically, as it incorporates not only physical exercise but also nutrition, sleep, smoking as well as stress management. It would also be interesting to see how well trained medical students are in these other aspects of lifestyle medicine and how that correlates to lifestyle habits of students across various years of training. This could be done in the form or student welfare surveys throughout the academic year which would allow a more longitudinal holistic analysis of the representation of lifestyle medicine knowledge and student lifestyle habits. This can further inform targeted changes to medical school curriculum and student wellness interventions to ensure students are well equipped to maintain their own well-being and increase their confidence in counselling patient about lifestyle changes. (3)
As explained in your article seven UK medical schools were contacted with the online Google survey yielded a response rate of 11.6%, this may result in a recruitment bias which would mean that the results of the survey may not represent the wider medical student population who did not participate in the survey. Contacting more medical schools, at various points in the year with a greater window to complete the survey, would increase the probability of more responses. In light of survey design, it may have been interesting to analyse qualitative responses to open questions regarding students’ opinions of how confident they would be in counselling patients regarding lifestyle changes and suggestions on how this could be improved in medical school training.
Ultimately, we applaud the efforts of this article in highlighting the inadequate physical exercise education in medical school curriculum, and we hope to see further work on strategies to bridge this knowledge gap. Going forward, there should be future research into training of other aspects of lifestyle including stress management, nutrition and mental health awareness, in addition to counselling-strategy training in large multicentre cross-sectional studies. This will produce further insight into areas of improvement to ultimately increase confidence and resilience amongst doctors of the future in counselling patients about lifestyle changes.
References:
1. Radenkovic D, Aswani R, Ahmad I, Kreindler J, Robinson R. Lifestyle medicine and physical activity knowledge of final year UK medical students. BMJ Open Sport Exerc Med. 2019;5(1):e000518. Published 2019 Jun 14. doi:10.1136/bmjsem-2019-000518
2. Stonerock GL, Blumenthal JA. Role of Counseling to Promote Adherence in Healthy Lifestyle Medicine: Strategies to Improve Exercise Adherence and Enhance Physical Activity. Prog Cardiovasc Dis. 2017;59(5):455–462. doi:10.1016/j.pcad.2016.09.003
3. Ludwig AB, Burton W, Weingarten J, Milan F, Myers DC, Kligler B. Depression and stress amongst undergraduate medical students. BMC Med Educ. 2015;15:141. Published 2015 Aug 27. doi:10.1186/s12909-015-0425-z
We read the recent publication by Nathan, Davies & Swaine (2018) with great interest due to a mutual interest in the subject of Generalised Joint Hypermobility (GJH) and its influence on injuries within elite sport. The authors of this paper should be commended for undertaking a study with such good participant numbers over a range of sports. We believe that the findings of this study suggesting that GJH may be protective of joint ligament damage may be a very important initial paper leading to valuable further exploration within specific sports and specific joints. However despite this good work we would like to take the opportunity to raise a concern over one of their conclusions and how this may confuse readers of the article.
In the discussion section of this paper Nathan et al. (2018) suggest that the findings of this study may suggest that “regular stretching may increase flexibility, and this could subsequently reduce rates of injury in those that are less flexible.” We believe that this statement may lead to misunderstanding as the terms “flexibility” and “joint hypermobility” are two completely different entities.
GJH is a hereditary physiological entity whereby most synovial joints move beyond their normal limits (Pacey et al., 2010) and may, or may not be symptomatic. This entity is commonly classified by the use of the Beighton Scale, as in the Nathan et al. (2018) paper, whereby adult participants are deemed positive i...
We read the recent publication by Nathan, Davies & Swaine (2018) with great interest due to a mutual interest in the subject of Generalised Joint Hypermobility (GJH) and its influence on injuries within elite sport. The authors of this paper should be commended for undertaking a study with such good participant numbers over a range of sports. We believe that the findings of this study suggesting that GJH may be protective of joint ligament damage may be a very important initial paper leading to valuable further exploration within specific sports and specific joints. However despite this good work we would like to take the opportunity to raise a concern over one of their conclusions and how this may confuse readers of the article.
In the discussion section of this paper Nathan et al. (2018) suggest that the findings of this study may suggest that “regular stretching may increase flexibility, and this could subsequently reduce rates of injury in those that are less flexible.” We believe that this statement may lead to misunderstanding as the terms “flexibility” and “joint hypermobility” are two completely different entities.
GJH is a hereditary physiological entity whereby most synovial joints move beyond their normal limits (Pacey et al., 2010) and may, or may not be symptomatic. This entity is commonly classified by the use of the Beighton Scale, as in the Nathan et al. (2018) paper, whereby adult participants are deemed positive if they score five or more out of nine on the scale (Juul-Kristensen et al., 2017). The term flexibility however would commonly be recognised as the length of the muscle crossing the joint. It is suggested that within the paper the term “flexible joint” is overused, and the correct terminology should be “lax joint” as this would more closely match the fact that the authors are looking to further understand the influence of joint hypermobility.
We would suggest concluding that greater flexibility would decrease injury risk means the authors are misleading readers. It would be hypothesised that the decreased risk of injury within the ankle for example, may come from the ability of the athlete to enter ranges of inversion without stressing the passive ligamentous structures of the ankle which is thought to be in part due to the abnormal ratio of mobile type III collagen in hypermobile participants (Child, 1986). Flexibility of the muscles around the ankle joint is unlikely to provide a protective effect in this position. It is also worth noting that the terminology in the paper suggests that rates of joint sprains are lower in hypermobile participants highlights the fact that the authors were looking at ligamentous injury, and not muscular pathologies. It is unlikely that a stretching protocol would be able to influence the mobility of the passive ligamentous structures to such a degree that they would subsequently be classed as hypermobile, and therefore potentially at decreased risk of injury.
We would again like to highlight that this piece of work by Nathan et al. (2018) is a very important piece in the early stages are trying to better understand the influence of GJH upon injury risk. It is hoped that greater utilisation of the Lower Limb Assessment Score in sports where lower limb pathologies are most common may be able to assist in addressing the impact on practice suggestions from the authors.
References
Child, A.H. (1986). Joint hypermobility syndrome: Inherited disorder of collagen synthesis. The Journal of Rheumatology, 13(2), 239-243.
Juul-Kristensen, B., Schmedling, K., Rombaut, L., Lund, H. & Engelbert, R.H.H. (2017). Measurement properties of clinical assessment methods for classifying generalized joint hypermobility- A systematic review. American Journal of Medical Genetics Part C (Seminars in Medical Genetics), 175C, 116-147.
Nathan, J.A., Davies, K. & Swaine, I. (2018). Hypermobility and sports injury. BMJ Open Sport & Exercise Medicine, 4.
Pacey, V., Nicholson, L.L., Adams, R.D., Munn, J. & Munns, C.F. (2010). Generalized Joint Hypermobility and Risk of Lower Limb Joint Injury During Sport: A Systematic Review with Meta-Analysis. The American Journal of Sports Medicine, 38(7), 1487-1497.
We read with great interest the systematic review by Joschtel et al.1 on the effects exercise training on physical and psychological health in children with pediatric respiratory diseases such as asthma, bronchiectasis, bronchopulmonary dysplasia and cystic fibrosis (CF). Undoubtedly, the authors should be commended for their effort that they have put into this systematic review on an important research topic. However, we would like to take the opportunity to express some methodological concerns related to the CF studies included in this review.
Joschtel et al.1 included studies on children, adolescents and young adults aged between 4 and 21 years and excluded those with a study population mean age of 21 years. These contradictory criteria have led to a false inclusion of one study 2 that included patients aged 12-40 years (although with a mean (SD) age of 19.5 (6.4) and 19.4 (5.3) for the intervention and control groups, respectively). Other studies 3 4, in which the mean age of the participants is <21 years were not considered for this review. Specifically, 3 out of 4 groups from the Kriemler et al. study 3 would qualify to be included in this review. Joschtel et al.1 did not publish a review protocol and therefore pre-specified inclusion and exclusion criteria cannot be verified.
Joschtel et al.1 have conducted a meta-analysis on peak oxygen uptake (VO2peak), despite substantial heterogeneity of study characteristics (i.e., study...
We read with great interest the systematic review by Joschtel et al.1 on the effects exercise training on physical and psychological health in children with pediatric respiratory diseases such as asthma, bronchiectasis, bronchopulmonary dysplasia and cystic fibrosis (CF). Undoubtedly, the authors should be commended for their effort that they have put into this systematic review on an important research topic. However, we would like to take the opportunity to express some methodological concerns related to the CF studies included in this review.
Joschtel et al.1 included studies on children, adolescents and young adults aged between 4 and 21 years and excluded those with a study population mean age of 21 years. These contradictory criteria have led to a false inclusion of one study 2 that included patients aged 12-40 years (although with a mean (SD) age of 19.5 (6.4) and 19.4 (5.3) for the intervention and control groups, respectively). Other studies 3 4, in which the mean age of the participants is <21 years were not considered for this review. Specifically, 3 out of 4 groups from the Kriemler et al. study 3 would qualify to be included in this review. Joschtel et al.1 did not publish a review protocol and therefore pre-specified inclusion and exclusion criteria cannot be verified.
Joschtel et al.1 have conducted a meta-analysis on peak oxygen uptake (VO2peak), despite substantial heterogeneity of study characteristics (i.e., study durations ranged from <3 weeks up to 3 years; comparison of supervised versus non-supervised studies using different training modalities in different settings etc). Excluding the Hebestreit et al.2 study, which does not meet the age inclusion criterion of 4 to 21 years, the effects on VO2peak became smaller [standardized mean difference (SMD) 0.77 mL.kg-1.min-1 95% CI 0.25 to 1.29 versus 0.70 mL.kg-1.min-1 95% CI 0.12 to 1.29]. Further, it could be argued that the in-hospital trial by Selvadurai et al.5, in which children were treated for an acute infectious pulmonary exacerbation, is not comparable with the other studies in a meta-analysis, where children were treated as outpatients and those in unstable clinical condition were excluded. If this study is also excluded, the effects on VO2peak are no longer existent (SMD 0.77 mL.kg-1.min-1 95% CI 0.25 to 1.29 versus SMD 0.54 mL.kg-1.min-1 95% CI -0.04 to 1.12).
The authors1 also did a meta-analysis on health-related quality of life (HRQoL) in patients with asthma and CF and concluded that their analysis shows “a large significant effect size for HRQoL (SMD 1.36, 95% CI 0.42 to 2.30)” and that “exercise training significantly improves HRQoL in children with asthma and CF”. It is important to note that the meta-analysis for CF was based on two small-sized studies (n=22 and n=20) from the same research group 6 7, of which one study showed a statistically significant result in favor of exercise training. The authors of the original publications assessed HRQoL with the validated Cystic Fibrosis Questionnaire (CFQ-R) - the younger children ( 11 years) were interviewed and children >12 years completed the questionnaire themselves. In both original studies, no statistically significant effects were reported for HRQoL after exercise training.6 7 The authors of the two studies reported pre- and post median (min, max) values for the exercise and control groups, respectively. We could not reproduce the HRQoL data in the forest plot (Figure 4) by Joschtel et al.1 following Cochrane handbook instructions (as the authors report using for their analysis) for the conversion of median (ranges) into mean (standard deviation) values.
Finally, systematic reviews aim to provide patients and healthcare professionals with the best available evidence on a specific topic and are used to guide healthcare decisions. However, conclusions drawn from systematic reviews (and meta-analysis) that are based on questionable methodology and non-reproducible data are unlikely to be helpful for either patients or healthcare professionals.
References
1. Joschtel B, Gomersall SR, Tweedy S, et al. Effects of exercise training on physical and psychosocial health in children with chronic respiratory disease: a systematic review and meta-analysis. BMJ Open Sport Exerc Med 2018;4(1):e000409.
2. Hebestreit H, Kieser S, Junge S, et al. Long-term effects of a partially supervised conditioning programme in cystic fibrosis. Eur Respir J 2010;35:578-83.
3. Kriemler S, Kieser S, Junge S, et al. Effect of supervised training on FEV1 in cystic fibrosis: A randomised controlled trial. J Cyst Fibros 2013;12:714-20.
4. Del Corral T, Cebria IIMA, Lopez-de-Uralde-Villanueva I, et al. Effectiveness of a Home-Based Active Video Game Programme in Young Cystic Fibrosis Patients. Respiration 2018;95:87-97.
5. Selvadurai HC, Blimkie CJ, Meyers N, et al. Randomized controlled study of in-hospital exercise training programs in children with cystic fibrosis. Pediatr Pulmonol 2002;33:194-200.
6. Santana Sosa E, Groeneveld IF, Gonzalez-Saiz L, et al. Intrahospital weight and aerobic training in children with cystic fibrosis: a randomized controlled trial. Med Sci Sports Exerc 2012;44:2-11.
7. Santana-Sosa E, Gonzalez-Saiz L, Groeneveld IF, et al. Benefits of combining inspiratory muscle with 'whole muscle' training in children with cystic fibrosis: a randomised controlled trial. Br J Sports Med 2014;48:1513-7.
Thank you to the authors for emphasizing this topic. Physical inactivity remains the big problem and major pandemic in the world. Besides Sweden, many developing and developed countries have this serious problems. Researchers may suggest that physical inactivity cost lead to bigger healthcare cost and economic burden in the future. Physical inactivity is contributed to about 6-10% of ischaemic heart disease, stroke, diabetes, breast and colon cancer(1). Global physical inactivity cost is estimated $67.5 billions in total which consist direct cost around $53.8 billions and indirect cost around $13.7 billions (2). As for Europe and North America, it remains higher cost than in Asia. In China, the total cost of physical inactivity is estimated total about $6.7 billions (3). As for Korea, cost as much as 83.6 million was contributed to physical inactivity(4). While in North America and Europe, it remains high each $28.9 billions and $15.5 billions in total cost (2).
It is much appreciated that the research filling the gap of data especially in Sweden. Other countries especially developing countries, should have the same idea about calculating the economic cost of physical inactivity. The current data in developing countries are inadequate, both direct and indirect cost which are very important. So that, the government can realize the important and dangerous effects of physical inactivity. Implementation should be underlined more on promotive and preventive action rath...
Thank you to the authors for emphasizing this topic. Physical inactivity remains the big problem and major pandemic in the world. Besides Sweden, many developing and developed countries have this serious problems. Researchers may suggest that physical inactivity cost lead to bigger healthcare cost and economic burden in the future. Physical inactivity is contributed to about 6-10% of ischaemic heart disease, stroke, diabetes, breast and colon cancer(1). Global physical inactivity cost is estimated $67.5 billions in total which consist direct cost around $53.8 billions and indirect cost around $13.7 billions (2). As for Europe and North America, it remains higher cost than in Asia. In China, the total cost of physical inactivity is estimated total about $6.7 billions (3). As for Korea, cost as much as 83.6 million was contributed to physical inactivity(4). While in North America and Europe, it remains high each $28.9 billions and $15.5 billions in total cost (2).
It is much appreciated that the research filling the gap of data especially in Sweden. Other countries especially developing countries, should have the same idea about calculating the economic cost of physical inactivity. The current data in developing countries are inadequate, both direct and indirect cost which are very important. So that, the government can realize the important and dangerous effects of physical inactivity. Implementation should be underlined more on promotive and preventive action rather than curative one. It can be emphasized in cost-effectiveness programme that can intervene the factors of physical inactivity. Another thing, the data are not updated yet. The current global and regional data in 2013 and need to be regularly updated (2).
Reference:
(1) Lee, I. M., Shiroma, E. J., Lobelo, F., Puska, P., Blair, S. N., & Katzmarzyk, P. T. (2012). Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet, 380(9838), 219-229. doi:10.1016/s0140-6736(12)61031-9
(2) Ding, D., Lawson, K. D., Kolbe-Alexander, T. L., Finkelstein, E. A., Katzmarzyk, P. T., van Mechelen, W., & Pratt, M. (2016). The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet, 388(10051), 1311-1324. doi:10.1016/s0140-6736(16)30383-x
(3) Zhang, J., & Chaaban, J. (2013). The economic cost of physical inactivity in China. Prev Med, 56(1), 75-78. doi:10.1016/j.ypmed.2012.11.010
(4) Min, J. Y., & Min, K. B. (2016). Excess Medical Care Costs Associated with Physical Inactivity among Korean Adults: Retrospective Cohort Study. Int J Environ Res Public Health, 13(1). doi:10.3390/ijerph13010136
Dear Dr Obedkova
Thank you for your e-letter of 5th April 2021 regarding our publication ‘Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine 2020;0:e000764. doi:10.1136/ bmjsem-2020-000764’. We welcome your comments and interest in this research as it further highlights the importance of evidence based safe and ethical practice. Our own interest and rationale for this review stems from extensive working with young adults and adolescents involved in elite sport with low back pain.
We take on board your comments, although where good evidence to support one modality over another is lacking, the merits of different approaches concerning risk v benefit must be central to clinical decision making. In this instance, evidence based practice in the UK overwhelmingly supports the use of MRI as the first line investigation; recognising SPECT/CT involves ionising radiation, and that a safe alternative exists with MRI. When undertaken and interpreted correctly, MRI permits the sensitive detection of posterior element bone stress injury in the vast majority of cases and should therefore be used as the first line investigation. SPECT/CT should therefore be reserved for those small minority of cases where (following MRI) diagnostic doubt remains, where there are underlying complexities (such as previous same-level stress injuries)...
Show MoreDear colleagues, I have read with a great interest this systematic review “Esh R, Grødahl LHJ, Kerslake R, et al. Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis”[1] and would like to make some comments. Further research, as authors concluded, are always desired and I wish there are appropriate studies in the next future to decide if MRI could be a modality of choice for diagnosing PEBSI and not SPECT/CT as it is by now. But the referred articles from this review do not support this assertion for the following reasons.
Show MoreFirst, there are just 2 articles from 4 included in this review compared MRI and SPECT/CT and just in 1 of them (Juvenil spondilolysis: a comparative analysis of CT, SPECT and MRI) the results of both techniques were concordant, although the main causes of discrepancy were between MRI and SPECT/CT for diagnoses of stress reaction in absence of overt fracture and distinguishing incomplete fracture from intact pars of complete defects (22 patients and 40 pars defect) [2].
Second, in the 2nd article the authors mention that sensitivity and specificity of MRI was 80 and 100% respectively skipping the SPECT/CT results and author’s conclusion that in the original article was following: “These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. MRI is inferior to bone scintigraphy (with SPECT)/c...
Nice study, and great to see you including dog ownership in your COI statements! A plea from a veterinary surgeon interested in dog walking though: please collect and report data about the dogs. A dog isn't a standardised intervention like a Fitbit. Their exercise capacity and exercise desire will vary with breed, age, comorbidities, body condition score, behaviour yet no data about the dogs is included in this publication. In addition, research suggests that owning an ill or behaviourally problematic dog can be very stressful. These canine attributes may have introduced a level of unaccounted for heterogeneity into your intervention arm which may have confounded your results. I'd be happy to point any researchers in this field towards the relevant canine literature, or assist with dog aspects of a study design.
Dear authors, I have read your paper with interest, and I have a couple of remarks that I think needs to be discussed to hopefully stimulate to more studies in this important field.
Show MoreIt is a weakness that there are very few randomised trials on surgical treatment of tendinopathy. To then draw conclusions from few studies is difficult and not always possible.
From this systematic review it is shown that 10 out 12 trials are on tendinopathy in the upper extremities (shoulder and elbow-althogether 998 tendinopathies) and only 2 on tendinopathy in the lower extremities (patellar and Achilles-althogeteher 60 tendinopathies). The authors have unfortunately missed to include 2 randomised studies on surgical treatment of patellar tendinopathy, published by Dr Willberg et al. Althogether, most information is about the shoulder and elbow, and very little about the Achilles and patellar tendons. Anyhow, when conclusions are drawn I get the impression that the authors put all tendinopathies in one group. This might be strongly misleading since there is very little information about the lower extremity tendons (only 2 studies), and conclusions cannot be drawn for Achilles and patellar tendinopathy. Furthermore, such conclusions might lead to that we miss possible differences in load response between upper and lower extremity tendons? The upper extremity non weight-bearing tendons might respond different compared to the lower extremity weight bearing tendons, as it is fo...
In their recent viewpoint and article, Stöllberger and Finsterer 1 2 criticize the inadequate regulation of “whole body-electromyostimulation” (WB-EMS), potentially responsible for a variety of adverse effects recently reported. 3-6 Indeed, in contrast to locally applied EMS, the stimulation of all, or at least most, major muscle groups characterizes WB-EMS. Consequently, given that even locally applied EMS might cause severe rhabdomyolysis and hospitalization 7, it is obvious that a technology able to stimulate simultaneously up to 2600 cm2 of muscular area entails a much larger risk of triggering unintended side effects 3-6 at least when inadequately applied. 8
Show MoreParticularly with regard to the WB-EMS safety guidelines published in 2016 by our national WB-EMS consortium8, Stöllberger and Finsterer2 complain that the enquiring about contraindications and the requirements for a licensed WB-EMS trainer are not adequately specified. Overlapping with the publication of the article of Stöllberger and Finsterer, however it should be noted, that a German standard (DIN 33961-5, 9) was recently released which includes both contraindications for WB-EMS application in commercial, non-medical settings 10 and the requirements for the qualification of EMS trainers. Of importance, the latter was also specified by the 2019 revised German Radiation Protection Statutes (NiSV) a mandatory guideline published by the German “Bundesministerium für Umwelt, Naturschutz und nukleare Sicherhei...
The article Mortality of Japanese Olympic athletes: 1952 – 2017 cohort study currently fails to account for a probable source of non-negligible bias. Whilst the main finding, stating that there is a decreased mortality rate among Japanese Olympians appears to be methodologically reliable, the authors also state that “higher mortality was observed among those who participated in the Olympics twice and three times or more compared with those who participated just once,” which we believe to be a potentially inaccurate finding.
Show MoreA delayed entry exists at baseline, as those with longer careers tend to be older than those with shorter careers. For instance, someone who has participated in 3 Olympic Games started her/his Olympic career 12 years before those who have participated only once. Thus, there might be an important period effect underlying these findings. Even if the authors have adjusted the analysis by age, this is not equivalent to adjusting for period, as earlier periods in time are related with higher mortality rates, which could explain the findings.
Additionally, another problem often seen in survival studies is ignoring when a death event occurs. This is problematic because deaths will be observed more frequently in subjects with longer follow-up times. In the presence of time-dependent bias, the hazard ratio is artificially underestimated and the length bias leads to an artificial underestimation of the overall hazard [2]. Therefore, faulty interpretat...
Dear Editor,
We have read with interest the article by Radenkovic D et al. (1) As final year medical students having experienced both pre-clinical and clinical training, we agree that there is a significant gap in lifestyle medicine training. We appreciate the authors highlighting the gap in formal training and assessment of motivational interviewing. Evidence suggests there is a strong positive correlation in using motivational interviewing and the transtheoretical model of behaviour change as counselling strategies to achieve improved patient outcomes in lifestyle changes. (2)
While this study focused primarily on physical exercise guidelines, it is important to define lifestyle medicine holistically, as it incorporates not only physical exercise but also nutrition, sleep, smoking as well as stress management. It would also be interesting to see how well trained medical students are in these other aspects of lifestyle medicine and how that correlates to lifestyle habits of students across various years of training. This could be done in the form or student welfare surveys throughout the academic year which would allow a more longitudinal holistic analysis of the representation of lifestyle medicine knowledge and student lifestyle habits. This can further inform targeted changes to medical school curriculum and student wellness interventions to ensure students are well equipped to maintain their own well-being and increase their confidence in counselling p...
Show MoreTo the Editor,
We read the recent publication by Nathan, Davies & Swaine (2018) with great interest due to a mutual interest in the subject of Generalised Joint Hypermobility (GJH) and its influence on injuries within elite sport. The authors of this paper should be commended for undertaking a study with such good participant numbers over a range of sports. We believe that the findings of this study suggesting that GJH may be protective of joint ligament damage may be a very important initial paper leading to valuable further exploration within specific sports and specific joints. However despite this good work we would like to take the opportunity to raise a concern over one of their conclusions and how this may confuse readers of the article.
In the discussion section of this paper Nathan et al. (2018) suggest that the findings of this study may suggest that “regular stretching may increase flexibility, and this could subsequently reduce rates of injury in those that are less flexible.” We believe that this statement may lead to misunderstanding as the terms “flexibility” and “joint hypermobility” are two completely different entities.
GJH is a hereditary physiological entity whereby most synovial joints move beyond their normal limits (Pacey et al., 2010) and may, or may not be symptomatic. This entity is commonly classified by the use of the Beighton Scale, as in the Nathan et al. (2018) paper, whereby adult participants are deemed positive i...
Show MoreTo the Editor,
We read with great interest the systematic review by Joschtel et al.1 on the effects exercise training on physical and psychological health in children with pediatric respiratory diseases such as asthma, bronchiectasis, bronchopulmonary dysplasia and cystic fibrosis (CF). Undoubtedly, the authors should be commended for their effort that they have put into this systematic review on an important research topic. However, we would like to take the opportunity to express some methodological concerns related to the CF studies included in this review.
Joschtel et al.1 included studies on children, adolescents and young adults aged between 4 and 21 years and excluded those with a study population mean age of 21 years. These contradictory criteria have led to a false inclusion of one study 2 that included patients aged 12-40 years (although with a mean (SD) age of 19.5 (6.4) and 19.4 (5.3) for the intervention and control groups, respectively). Other studies 3 4, in which the mean age of the participants is <21 years were not considered for this review. Specifically, 3 out of 4 groups from the Kriemler et al. study 3 would qualify to be included in this review. Joschtel et al.1 did not publish a review protocol and therefore pre-specified inclusion and exclusion criteria cannot be verified.
Joschtel et al.1 have conducted a meta-analysis on peak oxygen uptake (VO2peak), despite substantial heterogeneity of study characteristics (i.e., study...
Show MoreThank you to the authors for emphasizing this topic. Physical inactivity remains the big problem and major pandemic in the world. Besides Sweden, many developing and developed countries have this serious problems. Researchers may suggest that physical inactivity cost lead to bigger healthcare cost and economic burden in the future. Physical inactivity is contributed to about 6-10% of ischaemic heart disease, stroke, diabetes, breast and colon cancer(1). Global physical inactivity cost is estimated $67.5 billions in total which consist direct cost around $53.8 billions and indirect cost around $13.7 billions (2). As for Europe and North America, it remains higher cost than in Asia. In China, the total cost of physical inactivity is estimated total about $6.7 billions (3). As for Korea, cost as much as 83.6 million was contributed to physical inactivity(4). While in North America and Europe, it remains high each $28.9 billions and $15.5 billions in total cost (2).
It is much appreciated that the research filling the gap of data especially in Sweden. Other countries especially developing countries, should have the same idea about calculating the economic cost of physical inactivity. The current data in developing countries are inadequate, both direct and indirect cost which are very important. So that, the government can realize the important and dangerous effects of physical inactivity. Implementation should be underlined more on promotive and preventive action rath...
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