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Preview: British Journal of Sports Medicine current issue

British Journal of Sports Medicine current issue



British Journal of Sports Medicine RSS feed -- current issue



 



24 issues per year, 25 member societies, 1.5 million podcast listens and 6.5 million YouTube views

2017-11-16T23:20:27-08:00

When the current editorial team was given the privilege and responsibility of leading the BJSM into the 2010s, part of the job description was to write a ‘Warm Up’ for each of the 12 annual issues. We have dodged that responsibility pretty consistently and still get paid. However, at the end of our 10th year in the role we share 10 Level 5 opinions.

  • BJSM aims to serve the clinical community. This resulted from our ‘listening for direct’ consultations in 2008.  It meant that BJSM differentiated itself from leading physiological journals such as Journal of Applied Physiology and also from surgical journals such as the American Journal of Sports Medicine. BJSM was for clinicians who treat those in the physical activity, exercise and sporting community and those who use physical activity, exercise and sport as medicine.

  • 25 member societies make up the current ‘BJSM family’ without including ‘the special’...




  • Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3

    2017-11-16T23:20:27-08:00

    Introduction

    The aetiology of patellofemoral pain (PFP) is a complex interplay among various anatomical, biomechanical, psychological, social and behavioural influences. Numerous factors associated with PFP have been reported in the literature, but the interaction between these proposed risk factors and the clinical entity of PFP remains unclear (figure 1).

    The goal of this consensus document is to place known associated factors within the context of a pathomechanical model of PFP. An underlying assumption of the proposed pathomechanical model is that PFP is associated with abnormal loading of the patellofemoral joint (elevated joint stress). In this model, abnormal loading could affect the various patellofemoral structures that can contribute to nociception (ie, subchondral bone, infrapatellar fat pad, retinaculum and ligamentous structures); however, the specific tissue sources related to PFP are not known.

    The experience of PFP is not just nociception.1 Persons with persistent PFP exhibit abnormal nociceptive processing (ie,...




    Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4--Recommendations for future research

    2017-11-16T23:20:27-08:00

    Background

    This is Part 4 in the series of reviews from the International Olympic Committee (IOC) expert committee on exercise and pregnancy in recreational and elite athletes. Part 1 focused on the effects of training during pregnancy and on the management of common pregnancy-related complaints experienced by athletes;1 Part 2 addressed maternal and foetal perinatal outcomes;2 Part 3 reviewed the implications of pregnancy and childbirth on return to exercise and on common illnesses and complaints in the postpartum period.3 Parts 1–3 are all open access papers.

    In Part 4, we recommend future research based on Parts 1–3. The systematic reviews, on which the previous Parts were based, revealed many gaps in knowledge relating to strenuous exercise during pregnancy and in the postpartum period, in both regular recreational exercisers and elite athletes. Important research questions are listed below, in relation to the foci...




    Rocking the shoulder surgeons world

    2017-11-16T23:20:27-08:00

    Dr Schrøder and colleagues1 are to be congratulated on performing a high-quality study to address this controversial topic. Randomised surgical trials are difficult to perform, particularly with such a convincing ‘control’ group.

    As they point out, the enthusiasm for SLAP repairs has waned over recent years, but it remains a commonly performed operation, which makes this study very relevant.

    From a design and performance perspective, the study has many strengths. It was a double-blinded, randomised design with an adequate sample size to detect a clinically relevant difference. The CONSORT flow chart appropriately tracks the screening process and only 14 out of 445 screened patients declined to participate. This rules out significant selection bias. All patients failed a non-operative programme (that included formal therapy) and an experienced subspecialist shoulder surgeon performed all surgeries. This reduces the risk of a performance bias.

    Post-operative rehabilitation was standardised for all patients...




    Lessons to be learnt from the study 'Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

    2017-11-16T23:20:27-08:00

    ‘Real surgery is no better than sham surgery in isolated type II SLAP lesions’. That is the first interpretation the reader may make based on the study published by Schröder et al in BJSM.1 First, let us congratulate the authors for conducting such a well-designed study on a large sample of patients, with a research question that is extremely relevant to patients and to payers.

    Superior labral tear from anterior to posterior(SLAP) lesions have been much written about and likely been overdiagnosed and overtreated.2 Numerous papers presented new diagnostic tests3 and postoperative outcome after SLAP repairs,4 and a few studies explored the benefit of conservative, non-operative treatment.5–7

    Sham surgery proves as successful as real surgery

    Schröder and colleagues show that surgery consisting of labral repair or biceps tenodesis provides no benefit over sham surgery for isolated...




    Designed by the food industry for wealth, not health: the 'Eatwell Guide

    2017-11-16T23:20:27-08:00

    Introduction

    The Balance of Good Health, a picture of a segmented plate, was launched by the UK Department of Health in 1994. In September 2007, this was relaunched by the Food Standards Agency as the Eatwell Plate. The changes were cosmetic. In March 2016, the Eatwell Plate was relaunched as the Eatwell Guide. Many of the changes were, again, cosmetic (figure 1).

    The Eatwell Guide was formulated by a group appointed by Public Health England, consisting primarily of members of the food and drink industry rather than independent experts.

    What changed?

    The Eatwell Plate became the Eatwell Guide; the knife and fork disappeared; the segment names were tweaked and the images on the plate became drawings, not photographs—looking even less like real food. None of this would have any impact on epidemics of obesity or type 2 diabetes.

    The segment proportions changed: starchy foods...




    Sports concussion research, chronic traumatic encephalopathy and the media: repairing the disconnect

    2017-11-16T23:20:27-08:00

    A tragic case

    Todd Ewen was a National Hockey League (NHL) ‘tough guy’ who accumulated over 1900 penalty minutes in 518 games across 12 NHL seasons. He recently committed suicide after bouts of depression at the age of 49. Before an autopsy had been performed, the media pre-emptively wrote about how his depression and suicide were most likely the result of a career in the NHL, repetitive head trauma and the inevitable onset of chronic traumatic encephalopathy (CTE).1 Ewen himself was convinced he had developed CTE, as his wife recalled him being terrified by the thought of a future living with a neurodegenerative disease.2 Ewen's brain was examined by neuropathologists at the University of Toronto—they found no evidence of CTE. So we ask, how did a professional athlete who had treatable depression, come to believe that he had an untreatable condition and committed suicide?




    The new concussion in sport guidelines are here. But how do we get them out there?

    2017-11-16T23:20:27-08:00

    The 2016 Consensus Statement on Concussion in Sport has recently been published in BJSM, as the major conduit for informing sports medicine practitioners and clinicians worldwide about the importance of this condition, its assessment and management.1 This information dissemination strategy has worked well for previous concussion statements and has certainly raised the profile of the issue in sports medicine circles.2

    Successful dissemination of guidelines needs to consider the relevant implementation context

    But publishing guidelines only in sports medicine journals means they only reach a particular target group, especially if no consideration is given to implementation and dissemination strategies more widely.2 There is no doubt that sports medicine practitioners should be one of the major target groups for this information, but there are many other stakeholder groups (eg, coaches3) that are overlooked with this approach. Ensuring effective and sustained sports safety...




    Evidence from prospective cohort studies did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review

    2017-11-16T23:20:27-08:00

    Objectives

    National dietary guidelines were introduced in 1977 and 1983, by the USA and UK governments to reduce coronary heart disease (CHD) mortality by reducing dietary fat intake. Our 2015 systematic review examined randomised controlled trial (RCT) evidence available to the dietary committees at the time; we found no support for the recommendations to restrict dietary fat. What epidemiological evidence was available to the dietary guideline committees in 1983?

    Methods

    A systematic review of prospective cohort studies, published prior to 1983, which examined the relationship between dietary fat, serum cholesterol and the development of CHD.

    Results

    Across 6 studies, involving 31 445 participants, there were 1521 deaths from all-causes and 360 deaths from CHD during the mean follow-up of 7.5±6.2 years. The death rates were 4.8% and 1.1% from all-causes and CHD respectively. One study included men with previous heart disease. The death rate from CHD for those with, and without previous myocardial infarction was 20.9% and 1.0% respectively. None of the six studies found a significant relationship between CHD deaths and total dietary fat intake. One of the six studies found a correlation between CHD deaths and saturated dietary fat intake across countries; none found a relationship between CHD deaths and saturated dietary fat in the same population.

    Conclusions

    1983 dietary recommendations for 220 million US and 56 million UK citizens lacked supporting evidence from RCT or prospective cohort studies. The extant research had been undertaken exclusively on males, so lacked generalisability for population-wide guidelines.




    Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis

    2017-11-16T23:20:27-08:00

    Objectives

    National dietary guidelines were introduced in 1977 and 1983, by the US and UK governments to reduce coronary heart disease (CHD) mortality by reducing dietary fat intake. Our 2016 systematic review examined the epidemiological evidence available to the dietary committees at the time; we found no support for the recommendations to restrict dietary fat. The present investigation extends our work by re-examining the totality of epidemiological evidence currently available relating to dietary fat guidelines.

    Methods

    A systematic review and meta-analysis of prospective cohort studies currently available, which examined the relationship between dietary fat, serum cholesterol and the development of CHD, were undertaken.

    Results

    Across 7 studies, involving 89 801 participants (94% male), there were 2024 deaths from CHD during the mean follow-up of 11.9±5.6 years. The death rate from CHD was 2.25%. Eight data sets were suitable for inclusion in meta-analysis; all excluded participants with previous heart disease. Risk ratios (RRs) from meta-analysis were not statistically significant for CHD deaths and total or saturated fat consumption. The RR from meta-analysis for total fat intake and CHD deaths was 1.04 (95% CI 0.98 to 1.10). The RR from meta-analysis for saturated fat intake and CHD deaths was 1.08 (95% CI 0.94 to 1.25).

    Conclusions

    Epidemiological evidence to date found no significant difference in CHD mortality and total fat or saturated fat intake and thus does not support the present dietary fat guidelines. The evidence per se lacks generalisability for population-wide guidelines.




    Exercise to prevent falls in older adults: an updated systematic review and meta-analysis

    2017-11-16T23:20:27-08:00

    Objective

    Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.

    Design

    Update of a systematic review with random effects meta-analysis and meta-regression.

    Data sources

    Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.

    Study eligibility criteria

    We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.

    Results

    99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I2 47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson's disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I2 65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I2 21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital.

    Summary/conclusions

    Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.




    Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

    2017-11-16T23:20:27-08:00

    Background

    Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions.

    Methods

    A double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.

    Results

    There were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI –5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI –5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI –5.9 to 7.0), p=0.86. Similar results—no differences between groups—were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.

    Conclusion

    Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.

    Trial registration number

    ClinicalTrials.gov identifier: NCT00586742




    The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canadas national body checking policy change

    2017-11-16T23:20:27-08:00

    Background

    In 2013, Hockey Canada introduced an evidence-informed policy change delaying the earliest age of introduction to body checking in ice hockey until Bantam (ages 13–14) nationwide.

    Objective

    To determine if the risk of injury, including concussions, changes for Pee Wee (11–12 years) ice hockey players in the season following a national policy change disallowing body checking.

    Methods

    In a historical cohort study, Pee Wee players were recruited from teams in all divisions of play in 2011–2012 prior to the rule change and in 2013–2014 following the change. Baseline information, injury and exposure data for both cohorts were collected using validated injury surveillance.

    Results

    Pee Wee players were recruited from 59 teams in Calgary, Alberta (n=883) in 2011–2012 and from 73 teams in 2013–2014 (n=618). There were 163 game-related injuries (incidence rate (IR)=4.37/1000 game-hours) and 104 concussions (IR=2.79/1000 game-hours) in Alberta prior to the rule change, and 48 injuries (IR=2.16/1000 game-hours) and 25 concussions (IR=1.12/1000 game-hours) after the rule change. Based on multivariable Poisson regression with exposure hours as an offset, the adjusted incidence rate ratio associated with the national policy change disallowing body checking was 0.50 for all game-related injuries (95% CI 0.33 to 0.75) and 0.36 for concussion specifically (95% CI 0.22 to 0.58).

    Conclusions

    Introduction of the 2013 national body checking policy change disallowing body checking in Pee Wee resulted in a 50% relative reduction in injury rate and a 64% reduction in concussion rate in 11-year-old and 12-year-old hockey players in Alberta.




    University of Bath: Internationally renowned Master of Science (MSc) programmes in Sport and Exercise Medicine and Sports Physiotherapy for the busy clinician (Continuing Professional Development Series)

    2017-11-16T23:20:27-08:00

    Institution

    Department for Health, University of Bath, Bath, UK.

    Courses

    Master of Science (MSc) in Sport and Exercise Medicine (SEM) and MSc in Sports Physiotherapy (both by distance/blended on-line learning).

    Why?

    A Masters qualification in SEM or Sports Physiotherapy provides the foundation for specialisation. The Master’s graduate gains a considerable depth of academic knowledge, clinical skills and experience while also honing his or her understanding of professional practice and service development.1 Such expertise is increasingly demanded of clinicians who work with high-performance athletes, such as those competing in national and Olympic teams.2

    Overview

    Both MSc programmes (SEM and Sports Physiotherapy) are delivered in an integrated way under the stewardship of the current Director of Studies, Dr Polly McGuigan. She is supported by experienced Clinical Directors for SEM (Dr Julian Widdowson) and Sports Physiotherapy (Beenish Kamal) and approximately 15 other experienced...




    What is a symptomatic SLAP II tear? It is all about inclusion and exclusion criteria

    2017-11-16T23:20:27-08:00

    We have read with great interest the article ‘Sham surgery versus labral repair or biceps tenodesis for type II superior labral tear from anterior to posterior (SLAP) lesions of the shoulder: a three-armed randomised clinical trial’.1 Although we highly appreciate the efforts of the authors to bring more understanding to the topic of treatment of SLAP II lesions, we have some comments and two questions concerning this high-quality and relevant study. We believe that the conclusions of the current trial have to be drawn in the light of these remarks.

    The diagnosis of a SLAP lesion based on clinical history and physical examination is difficult.2 Several tests have been described such as the active compression test or O’Brien test, Yergason test, Speed test, Habermeyer’s test and biceps load test,3 4 each with their documented specificity and sensitivity. As none of these tests...




    Treating SLAP II lesions with sham surgery

    2017-11-16T23:20:27-08:00

    We greatly enjoyed reading the most recent article by Shroder et al1 detailing their findings of a well thought out, executed and written-up randomised blinded trial of sham surgery versus labral repair or biceps tenodesis in the surgical management of a SLAP II lesion.

    The SLAP lesion, as detailed by the authors, was first described by Snyder et al in 1990.2 The original classification details four distinct lesions of the superior labrum found on shoulder arthroscopy. Since then the classification has been expanded by others but it should be noted that Snyder’s classification was based on a traumatic initiating episode causing the lesion, which was only diagnosed on arthroscopy, and not a degenerative process which may be akin to the difference between an acute and degenerative tear of the rotator cuff. Indeed, it should be noted that up to 72% of patients between the ages...




    Author response--sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

    2017-11-16T23:20:27-08:00

    We appreciate the comments on our study from Hong C-K and Su W-R, van Deurzen DFP and van den Bekrom MPJ, and Edwards D and Funk L.

    Letter 1

    While planning the study, about 10 years ago, we had lengthy discussions about the ethics of what was proposed. We all had reservations about this issue, in particular the shoulder surgeon, but our experience having completed the clinical trial is in agreement with previously published sham surgical studies.1 2 Patients in sham surgical groups have fewer complications than those who undergo repair or any other procedure.3 4 Hong and Su suggest that it was unethical to assign patients to sham surgery because the current literature does not suggest that shaving arthroscopy or arthroscopic irrigation is helpful for these patients.5 We do not understand the reference to ‘shaving arthroscopy procedure’ since...




    Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

    2017-11-16T23:20:27-08:00

    We read with interest the article by Schrøder et al1 on the clinical outcome among labral repair, biceps tenodesis and sham surgery for isolated type II superior labrum anterior posterior (SLAP) lesions in a double-blind randomised clinical trial.2 Patients 18–60 years of age who had shoulder pain for more than 3 months and were unresponsive to the conservative managements were candidates for this trial. Once isolated type II SLAP lesion was confirmed from the arthroscopic examination, each patient was randomly  assigned to either labral repair, biceps tenodesis or sham surgery. The authors concluded that neither labral repair nor biceps tenodesis had any superior benefit over sham surgery.

    We appreciated the authors’ great efforts on this randomised control study. However, we have several comments and concerns regarding the study design and conclusions:

  • We cannot believe that this study could be approved by their ethical committee. Patients enrolled in this...