Recent eLetters

Dear Editor,

We read with interest the commentary piece by McCrory et al. in the recent online edition of BJSM 1. It raises an important issue - that sports physicians who work with professional teams may be under pressure to favour fashion over science. One of the treatment regimes from a commentary piece of ours 2 was cited by the authors 1 as their primary example of a 'flawed approach'. A full read of our original article 2 can assure those who are interested in this topic that we are advocates of evidence based medicine (EBM) and consider it fundamental to specialist Sport and Exercise Medicine practice, as it is nowadays to all areas of medicine.

We attempted to summarise the level of evidence, which we characterised as 'low', to support injection therapy in general and the Traumeel/Actovegin regime in particular. We believe that the Mueller-Wohlfahrt experience at least qualifies as an unpublished but large size case series over three decades by a doctor with a sub-specialty practice in muscle strains. This should be distinguished from 'snake oil' treatments, which purport to treat 'every' condition and draw up images of unregistered practitioners. If elite athletes report impressive results from a Traumeel/Actovegin regime, which they have in continental Europe for many years, then there are at least three possible explanations: (1) that Actovegin and/or Traumeel have a beneficial therapeutic effect on injured muscle (2) that injection therapy in general, potentially with many substances, has a beneficial therapeutic effect on injured muscle (the rationale of glucose 'prolotherapy' (3) that injection therapy (or even perhaps travelling abroad) has a beneficial placebo effect. A further confounder with Dr Mueller-Wohlfahrt's personal management regime is that he tends to advise against the use of anti-inflammatory medications (cortisone and NSAIDs). As these are commonly taken by elite athletes for soft tissue injuries, a management regime which removes them may be beneficial if anti-inflammatories are in fact harmful for healing muscle.

As we did, McCrory et al. referenced the Wright-Carpenter et al. paper 3 which was a trial comparing Traumeel/Actovegin and autologous serum injections. It is worth noting that in this small nonrandomised study, the autologous serum group had superior results and that neither group exhibited any adverse effects. Our conclusion statement that injection therapy is "an important part of the landscape of management options for muscle strains", which McCrory et al. have taken issue with, is implicit in the very design of the Wright-Carpenter et al. trial.

We also made it clear that we did not advocate any doctor breaching his or her relevant national laws for drug regulation and nor would we recommend any treatment to an elite athlete which was in breach of WADA regulations. For a country in which Traumeel and Actovegin are not registered for injection use, perhaps glucose (prolotherapy) would be the closest legal substitute in an athlete subject to WADA regulations.

We hope that our original commentary paper brought further attention to a management option that is in common usage by elite athletes, stimulating further debate and calling for further study. If there were any advocates at the recent British conferences, referenced by McCrory et al. 1, who asserted that Traumeel/Actovegin were either 'proven' or 'essential' treatments for muscle strains in elite athletes, then we would similarly advise caution by re-iterating that the scientific level of evidence is currently 'low'. We hope our article helped team physicians with the dilemma of "what to do when the scientific evidence is unclear". It is a completely valid viewpoint to recommend no treatment over a treatment option that has a low level of scientific evidence. We think it is also currently a valid viewpoint that some practitioners may reach that the potential benefits of injection therapies for muscle strains in elite athletes outweigh the potential risks. Before coming to their own conclusions, we would trust the readers of the BJSM to read our commentary in full 2 rather than to assume from the McCrory et al. article1 that we had advocated it as proven best-practice.

We would also caution against any fear that sports medicine is about to collapse as a specialty because some team physicians choose to use treatments which have not been validated in high quality trials. Orthopaedic surgery has survived very well as a specialty without requiring all operations to be subjected to RCTs. Whilst general physicians have a far larger knowledge base of published trials, it is worth bearing in mind that a huge number of these have been funded by the companies profiting from the medications being tested. One of the unique aspects of specialist team physician practice is that elite athletes are different to the general population, with one of the differences being that they would always want the so-called 'active' agent and hence would not be interested in being part of an RCT. This doesn't mean we should avoid all research on elite athletes or ignore high quality research on members of the general population, but it does represent a challenging environment in which to practice. In fact, if the definition of a medical specialty includes a criterion that the area must be distinct from other medical specialties, then the unique elite athlete environment makes a very good argument as to why sports medicine must be considered a stand-alone medical specialty.

Yours sincerely,

John Orchard, Tom Best, Glenn Hunter, Bruce Hamilton

1. McCrory P, Franklyn-Miller A, Etherington J. Sports and exercise medicine - new specialists or snake oil salesmen? Br J Sports Med Online First: 29 November 2009 doi:10.1136/bjsm.2009.068999

2. Orchard JW, Best TM, Mueller-Wohlfahrt HW, Hunter G, Hamilton BH, et al. The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis Br J Sports Med 2008;42:158-159

3. Wright-Carpenter T, Klein P, Schauferhoff P, Appell HJ, Mir LM, Wehling P. Treatment of muscle injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle strains. Int J Sports Med. 2004 Nov;25(8):588-93

Conflict of Interest:

None declared

The article by Tillett and Loosemore describes guidelines for the prevention and management of travellers' diarrhoea (TD) based on their experience with the elite athletes and noncompeting members of Team England during the 2008 Youth Commonwealth Games in India. The authors recommended that all team members receive oral and written advice regarding prevention of TD, that all team members are issued alcohol hand gel and instruction for its use, and that all noncompeting team members receive ciprofloxacin for TD prophylaxis. As ciprofloxacin use in elite athletes is considered controversial because of a possible association with tendon rupture, the authors recommended that elite athletes consider the nonabsorbable antibiotic rifaximin as a prophylactic for TD. However, none of the elite athletes on Team England actually received rifaximin as a prophylactic therapy for TD. Further, the authors stopped short of recommending rifaximin for the treatment of TD, simply recommending treatment with empiric antibiotics per local advice and the results of stool culture.

We report here that, in 2008, some elite athletes from the United States received rifaximin either for the prophylaxis or treatment of TD while in Beijing, China. In this small sample of elite athletes, rifaximin was safe and well tolerated, and no adverse events were reported. Rifaximin has been found safe, well tolerated, and effective for both the prophylaxis and treatment of TD in other populations1-8. Based on our experience and the excellent safety profile of rifaximin for the treatment of TD, the use of rifaximin as an antibiotic therapy for the treatment of TD in elite athletes deserves further consideration.

REFERENCES 1. DuPont HL, Ericsson CD, de la Cabada FJ, et al. Prevention of travelers' diarrhea with rifaximin- a phase 3 randomized double-blind placebo-controlled trial in U.S. students in Mexico [abstract]. Am J Gastroenterol. 2006;101(suppl):S197-S198. 2. DuPont HL, Ericsson CD, Mathewson JJ, et al. Rifaximin: a nonabsorbed antimicrobial in the therapy of travelers' diarrhea. Digestion. 1998;59(6):708-714. 3. DuPont HL, Haake R, Taylor DN, et al. Rifaximin treatment of pathogen- negative travelers' diarrhea. J Travel Med. 2007;14:16-19. 4. DuPont HL, Jiang ZD, Ericsson CD, et al. Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33(11):1807-1815. 5. DuPont HL, Jiang Z-D, Belkind-Gerson J, et al. Treatment of travelers' diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide, and loperamide alone. Clin Gastroenterol Hepatol. 2007;5:451-456. 6. DuPont HL, Jiang Z-D, Okhuysen PC, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med. 2005;142(10):805-812. 7. Steffen R, Sack DA, Riopel L, et al. Therapy of travelers' diarrhea with rifaximin on various continents. Am J Gastroenterol. 2003;98:1073- 1078. 8. Taylor DN, Bourgeois AL, Ericsson CD, et al. A randomized, double- blind, multicenter study of rifaximin compared with placebo and with ciprofloxacin in the treatment of travelers' diarrhea. Am J Trop Med Hyg. 2006;74:1060-1066.

Conflict of Interest:

no

Dear Sir

May I register a plea on behalf of all your British readers? To us, the sport of football is synonymous with soccer. To Americans, it refers to a completely different sport involving major collision. I'm not at all sure what it means to Antipodeans.

I read the otherwise excellent article by Davis et al on cervical canal stenosis in a "footballer" in your December 2009 issue with increasing irritation. It became clear that the authors were referring to the sport we British readers call "American football"- the precise term used correctly by Caine in your January 2010 editorial.

I know it is totally unrealistic to expect North American authors and journals to adopt clearer terminology, but I contend that the British Journal of Sports Medicine should be setting the gold standard as part of its editorial policy and house style.

Yours faithfully

Dr Richard Hardie Consultant Neurologist Frenchay Hospital BRISTOL BS16 1LE UK

Conflict of Interest:

None declared

I read your fascinating article with much interest. Do you think that in simple terms that anticipatory regulation may be an aspect of the decision-making the athlete makes before execution of an action. In the instance of longer duration exercise eg a marathon a decision is made then physiological systems amongst others come into action as you have described. Prior learning and adaptation may be involved as well as genetic and environmental factors. The particular learning aspects include; cognition, perception and affection. The knowledge to be gained from this study could have particular importance to injury prevention in sport, notably when fatigue is an issue. Central fatigue and peripheral fatigue. Henare Broughton PhD candidate School of Psychology Trinity College Dublin Ireland.

Conflict of Interest:

None declared

I read the review article on the anticipatory regulation of performance and pacing strategies by Dr R Tucker in the June edition of BJSM with great interest. The idea that there is a part of the brain, as yet undiscovered,which enables one to judge the optimal work rate for a given task, is an intriguing one. From a Darwinian view point, the idea of there being a template in the brain that one could draw upon in determining pacing strategy, carries great merit. Anthropologists have learnt of a hunting strategy used by Bushmen from Southern Africa in which the prey, such as a Kudo, is chased for many hours until it collapses in exhaustion. The Bushmen pace themselves, such that they do not succumb to exhaustion, and are able to follow the tracks of the animal when they lose sight of it. The same principle can be seen with the hunting behaviour of wolves. Having spotted a weak member of a herd of elk or other deer, they will chase it for hours on end if necessary. It is obvious that the most successful hunters will be those who can judge their pace the best. The genes of these hunters are more likely to be passed through to the next generation. An athlete's ability to judge pace is therefore likely to be the consequence of millions of years of mammalian evolution.