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How exercise medicine has evolved from sports medicine
... [6] SM is only one component of SEM, the other being the EM. SM mainly focuses on diagnosis and treatment of SE-related medical issues and musculoskeletal (msk) disorders with an ultimate aim to optimise and enhance athletic performance, whereas EM deals with PA and Ex for optimal physiological and psychological health promotion and maintenance, preventive health measures, treatment, complication minimisation, rehabilitation of many chronic diseases, etc. [1,[7][8][9] The main components and domains of SEM [6] are illustrated in [ Figure 1]. ...
... With far exceeding number of physically inactive individuals compared to active ones, EM is more relevant and beneficial for the entire population, surpassing and dwarfing its parent speciality, SM. [8,10] The importance of clinical exercise physiology (CEP) and CIP are thus increasingly realised. Based on this, British Association of Sports Medicine has already changed its name to British Association of Sport and Exercise Medicine in 1998. ...
... [3,14,15,[18][19][20] The majority of the training is undertaken outside hospital setting unlike the traditional medical specialities, making SEM an unconventional medical branch, and hence, SEM doctors are more familiar with the dayto-day presentations of the common as well as sports and exercise-related medical conditions, illnesses and injuries. [8] ...
Sports and exercise medicine (SEM) is a relatively new medical speciality that comprises sports medicine (overall medical care of active and exercising individuals for performance optimisation and improvement) and exercise medicine (use of physical activity and exercise for health and fitness promotion and illness and injury management). Physicians with specialisation in SEM and clinical and interventional physiology (CIP) have key roles to play in combating physical inactivity and non-communicable diseases which are threatening to become epidemic proportions on the one hand, and dismal sports performance and rising doping menace on the other hand. This review provides information regarding SEM as an emerging medical speciality, its domains, key roles of the SEM and CIP physicians and future prospects of this field. CIP along with exercise physiology, as the foundation of SEM, is discussed in this review.
Background:
Arthroscopic sub-acromial decompression (decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically) is a common surgery for subacromial shoulder pain, but its effectiveness is uncertain. We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression.
Methods:
We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. We did the randomisation with a computer-generated minimisation system. In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat. The sample size calculation was based upon a target difference of 4·5 points (SD 9·0). This trial has been registered at ClinicalTrials.gov, number NCT01623011.
Findings:
Between Sept 14, 2012, and June 16, 2015, we randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). 24 [23%], 43 [42%], and 12 [12%] of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a small benefit over no treatment (mean 29·4 points [SD 11·9], mean difference vs decompression 2·8 points [95% CI 0·5-5·2], p=0·0186; mean difference vs arthroscopy 4·2 [1·8-6·6], p=0·0014) but these differences were not clinically important. There were six study-related complications that were all frozen shoulders (in two patients in each group).
Interpretation:
Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process.
Funding:
Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).
Tendinopathies represent one of the most frequent sport injuries and their correct treatment is a crucial issue in sport medicine practice. In most of the cases, these multifactorial conditions are related to overuse and it is characterized by activity-induced pain, local tenderness and swelling. Although tendinopathies are common, their treatment is not easy. Currently, it is generally accepted that the management of tendinopathies should include early functional exercises. Eccentric Exercise (EE) is considered a fundamental therapeutic resource, especially for the treatment of Achilles and patellar tendinopathy. In our review we analyze the use of EE for the treatment and prevention of the lower limb tendinopathies, evaluating the adopted programs and efficacy, the possible mechanisms of the healing process and the action of EE on tendon structure. Treatments with EE are useful to improve symptoms and function in lower limb tendinopathies, but more evidences are necessary to establish the adequate dose-response and to determine long-term effects.
To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease.
Systematic review and meta-analysis.
Pain and physical function.
Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms.
Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed.
The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death.
The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.
PROSPERO CRD42014009145.
© Thorlund et al 2015.
Objective
To determine, for adults with chronic low back pain, which exercise interventions are the most effective at reducing pain compared to other treatments.
Data sources
A search of MEDLINE, CINAHL, EMBASE, SPORTDiscus, PsycINFO and The Cochrane Library was conducted up to October 2014.
Review methods
Databases were searched for published reports of randomised trials that investigated the treatment of chronic low back pain of non-specific origin with an exercise intervention. Two authors independently reviewed and selected relevant trials. Methodological quality was evaluated using the Downs and Black tool.
Results
Forty-five trials met the inclusion criteria and thirty-nine were included in the meta-analysis. Combined meta-analysis revealed significantly lower chronic low back pain with intervention groups using exercise compared to a control group or other treatment group (Standard Mean Deviation (SMD) =-0.32, CI 95% -0.44 to -0.19, P<0.01). Separate exploratory subgroup analysis showed a significant effect for strength/resistance and coordination/stabilisation programs.
Conclusions
Our results found a beneficial effect for strength/resistance and coordination/stabilisation exercise programs over other interventions in the treatment of chronic low back pain and that cardiorespiratory and combined exercise programs are ineffective.
ABSTRACT From December 12-14, 2007, UK Sport held a think tank on "muscle strains" in London. This brought together many of UK Sport's top sports medicine clinicians along with three invited international experts. Many issues of muscle strains were discussed over the three days, but the aspect which attracted the most attention was the early management of strains in the elite athlete. A consensus summary of conclusions on this specific topic from the think tank is presented here.
Objectives: This study aims to describe how a negative reimbursement decision—based on the health technology assessment (HTA) report of a nondrug intervention—affects healthcare providers in Germany.
Methods: Knee arthroscopy was chosen as an example, because as of April 2016 this procedure is no longer reimbursed for osteoarthritis, but is still covered for other indications, including meniscal lesions. The exclusion followed an HTA report prepared by the Institute for Quality and Efficiency in Health Care (IQWiG). Here, we examine how the decision to revoke reimbursement for arthroscopy was perceived by the surgical community. Information was collected from official hospital statistics, the internet, and informal interviews with orthopedic surgeons.
Results: In 2015, a total of 37,920 arthroscopic procedures were performed for knee osteoarthritis in Germany. Several surgical societies were unhappy with the negative decision, which was issued as a directive in November 2015, and they challenged the decision-making process as well as the underlying scientific evidence. In March 2016, fifteen societies issued joint recommendations on how to differentiate osteoarthritis from other knee diseases and how to document other diseases in a way that inspections by representatives of health insurance funds would not detect any deficiencies. In informal interviews, orthopedic surgeons indicated that miscoding of the principal diagnosis (meniscal tear rather than knee osteoarthritis) is to be expected, especially in the hospital sector.
Conclusions: HTA can have a significant impact on the provision of health services, but various loopholes allow physicians to undermine policy decisions. Therefore, it is important to involve all stakeholders in HTA and to convince them of the benefits of evidence-based medicine.
Importance
Synovitis is common and is associated with progression of structural characteristics of knee osteoarthritis. Intra-articular corticosteroids could reduce cartilage damage associated with synovitis but might have adverse effects on cartilage and periarticular bone.
Objective
To determine the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain.
Design, Setting, and Participants
Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients. Mixed-effects regression models with a random intercept were used to analyze the longitudinal repeated outcome measures. Patients fulfilling the American College of Rheumatology criteria for symptomatic knee osteoarthritis, Kellgren-Lawrence grades 2 or 3, were enrolled at Tufts Medical Center beginning February 11, 2013; all patients completed the study by January 1, 2015.
Interventions
Intra-articular triamcinolone (n = 70) or saline (n = 70) every 12 weeks for 2 years.
Main Outcomes and Measures
Annual knee magnetic resonance imaging for quantitative evaluation of cartilage volume (minimal clinically important difference not yet defined), and Western Ontario and McMaster Universities Osteoarthritis index collected every 3 months (Likert pain subscale range, 0 [no pain] to 20 [extreme pain]; minimal clinically important improvement, 3.94).
Results
Among 140 randomized patients (mean age, 58 [SD, 8] years, 75 women [54%]), 119 (85%) completed the study. Intra-articular triamcinolone resulted in significantly greater cartilage volume loss than did saline for a mean change in index compartment cartilage thickness of −0.21 mm vs −0.10 mm (between-group difference, −0.11 mm; 95% CI, −0.20 to −0.03 mm); and no significant difference in pain (−1.2 vs −1.9; between-group difference, −0.6; 95% CI, −1.6 to 0.3). The saline group had 3 treatment-related adverse events compared with 5 in the triamcinolone group and had a small increase in hemoglobin A1c levels (between-group difference, −0.2%; 95% CI, −0.5% to −0.007%).
Conclusions and Relevance
Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.
Trial Registration
ClinicalTrials.gov Identifier: NCT01230424
Study Design
Systematic review and meta-analysis.
Background
Running is a healthy and popular activity worldwide, but data regarding its association with osteoarthritis (OA) are conflicting.
Objectives
To evaluate the association of hip and knee OA with running and to explore the influence of running intensity on this association.
Methods
PubMed, Embase, and Cochrane Library databases were used to identify studies investigating the occurrence of OA of the hip and/or knee among runners. A meta-analysis of studies comparing this occurrence between runners and controls (sedentary, nonrunning individuals) was conducted. Runners were regarded as “competitive” if they were reported as professional/elite athletes or participated in international competitions. Recreational runners were individuals running in a nonprofessional (amateur) context. The prevalence rate and odds ratio (with 95% confidence interval [CI]) for OA between runners (at competitive and recreational levels) and controls were calculated. Subgroup analyses were conducted for OA location (hip or knee), sex, and years of exposure to running (less or more than 15 years).
Results
Twenty-five studies (n = 125810 individuals) were included and 17 (n = 114829 individuals) were meta-analyzed. The overall prevalence of hip and knee OA was 13.3% (95% CI: 11.6%, 15.2%) in competitive runners, 3.5% (95% CI: 3.4%, 3.6%) in recreational runners, and 10.2% (95% CI: 9.9%, 10.6%) in controls. The odds ratio for hip and/or knee OA in competitive runners was higher than that in recreational runners (1.34; 95% CI: 0.97, 1.86 and 0.86; 95% CI: 0.69, 1.07, respectively; controls as reference group; for difference, P<.001). Exposure to running of less than 15 years was associated with a lower association with hip and/or knee OA compared with controls (OR = 0.6; 95% CI: 0.49, 0.73).
Conclusion
Recreational runners had a lower occurrence of OA compared with competitive runners and controls. These results indicated that a more sedentary lifestyle or long exposure to high-volume and/or high-intensity running are both associated with hip and/or knee OA. However, it was not possible to determine whether these associations were causative or confounded by other risk factors, such as previous injury.
Level of Evidence
Etiology/harm, level 2a. J Orthop Sports Phys Ther 2017;47(6):373–390. doi:10.2519/jospt.2017.7137
Aims:
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and have been associated with increased cardiovascular risk. Nonetheless, it remains unknown whether use of NSAIDs is associated with out-of-hospital cardiac arrest (OHCA).
Methods and results:
From the nationwide Danish Cardiac Arrest Registry, all persons with OHCA during 2001-2010 were identified. NSAID use 30 days before OHCA was categorized as follows: diclofenac, naproxen, ibuprofen, rofecoxib, celecoxib, and other. Risk of OHCA associated with use of NSAIDs was analyzed by conditional logistic regression in case-time-control models matching four controls on sex and age per case to account for variation in drug utilization over time.We identified 28 947 persons with OHCA of whom 3376 were treated with an NSAID up to 30 days before OHCA. Ibuprofen and diclofenac were the most commonly used NSAIDs and represented 51.0% and 21.8% of total NSAID use, respectively. Use of diclofenac (odds ratio (OR), 1.50 [95% confidence interval (CI) 1.23-1.82]) and ibuprofen (OR, 1.31 [95% CI 1.14-1.51]) was associated with a significantly increased risk of OHCA. Use of naproxen (OR, 1.29 [95% CI 0.77-2.16]), celecoxib (OR, 1.13 [95% CI 0.74-1.70]) and rofecoxib (OR, 1.28 [95% CI 0.74-1.70]) was not significantly associated with increased risk of OHCA; however, these groups were characterized by few events.
Conclusion:
Use of non-selective NSAIDs was associated with an increased early risk of OHCA. The result was driven by an increased risk of OHCA in ibuprofen and diclofenac users.
Background:
The WHO recommends moderate physical activity to combat the increasing risk of death from chronic diseases. We conducted a meta-analysis to assess the association between physical activity and cancer mortality and the WHO recommendations to reduce the latter.
Methods:
MEDLINE and EMBASE were searched up until May 2014 for cohort studies examining physical activity and cancer mortality in the general population and cancer survivors. Combined HRs were estimated using fixed-effect or random-effect meta-analysis of binary analysis. Associated HRs with defined increments and recommended levels of recreational physical activity were estimated by two-stage random-effects dose-response meta-analysis.
Results:
A total of 71 cohort studies met the inclusion criteria and were analysed. Binary analyses determined that individuals who participated in the most physical activity had an HR of 0.83 (95% CI 0.79 to 0.87) and 0.78 (95% CI 0.74 to 0.84) for cancer mortality in the general population and among cancer survivors, respectively. There was an inverse non-linear dose-response between the effects of physical activity and cancer mortality. In the general population, a minimum of 2.5 h/week of moderate-intensity activity led to a significant 13% reduction in cancer mortality. Cancer survivors who completed 15 metabolic equivalents of task (MET)-h/week of physical activity had a 27% lower risk of cancer mortality. A greater protective effect occurred in cancer survivors undertaking physical activity postdiagnosis versus prediagnosis, where 15 MET-h/week decreased the risk by 35% and 21%, respectively.
Conclusions:
Our meta-analysis supports that current physical activity recommendations from WHO reduce cancer mortality in both the general population and cancer survivors. We infer that physical activity after a cancer diagnosis may result in significant protection among cancer survivors.
Objective:
The burgeoning rate of prescription opioid misuse, abuse, addiction, and opioid related overdose deaths has gained substantial professional and national media attention. This manuscript provides a narrative review and critique of the literature on prescription opioid misuse, abuse, addiction and opioid-related mortality and discusses future research needs in this area.
Design:
Current literature on misuse, abuse, addiction and opioid related fatalities was reviewed in patients with chronic noncancer pain receiving long-term prescription opioid therapy.
Results:
There have been inconclusive results on the efficacy of long-term opioid therapy in patients with chronic pain but moderate level evidence of dose-dependent risk of harm. The estimated prevalence of prescription opioid abuse and opioid use disorders ranges from <1% to 40% due to the paucity of uniform definitions of what constitutes misuse, abuse, and addiction but several recent studies have developed unique methodology to more accurately assess these states in the pain population. The rate of opioid-related overdose deaths is not inconsequential and a number of patient related and medication specific risk factors have been identified that may provide a basis for risk mitigation strategies.
Conclusions:
Accurately assessing the prevalence of misuse, abuse, and addiction in the pain population has been challenging due inconsistent definitions between studies. Additional high-quality research is needed in this area utilizing consistent definitions and in reducing the risk of opioid-related overdose fatalities.
To assess workload-related risk factors for injuries to particular tissue types in cricket fast bowlers.
235 fast bowlers who bowled in 14600 player innings over a period of 15 years were followed in a prospective cohort risk factor study to compare overs bowled in each match (including preceding workload patterns) and injury risk in the 3-4 weeks subsequent to the match. Injuries were categorised according to the affected tissue type as either: bone stress, tendon injuries, muscle strain or joint injuries. Workload risk factors were examined using binomial logistic regression multivariate analysis, with a forward stepwise procedure requiring a significance of <0.05.
High acute match workload and high previous season workload were risk factors for tendon injuries, but high medium term (3-month workload) was protective. For bone stress injuries, high medium term workload and low career workload were risk factors. For joint injuries, high previous season and career workload were risk factors. There was little relationship between muscle injury and workload although high previous season workload was slightly protective.
The level of injury risk for some tissue types varies in response to preceding fast bowling workload, with tendon injuries most affected by workload patterns. Workload planning may need to be individualised, depending on individual susceptibility to various injury types. This study supports the theory that tendons are at lowest risk with consistent workloads and susceptible to injury with sudden upgrades in workload. Gradual upgrades are recommended, particularly at the start of a bowler's career to reduce the risk of bone stress injury.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Background:
Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines.
Objectives:
To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.
Search methods:
Five electronic databases were searched, up until May 2013.
Selection criteria:
All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group.
Data collection and analysis:
Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).
Main results:
In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup.
Authors' conclusions:
High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.
Non‐communicable chronic diseases ( NCDs ), such as cardiovascular disease, diabetes, and cancer, are currently responsible for 65% of all deaths worldwide and are projected to cause over 75% of all deaths by 2030. A substantial accumulation of epidemiological and experimental evidence has established a causal relationship between NCDs and well‐known yet preventable risk factors (e.g., physical inactivity and obesity). Given that physical activity has both direct and indirect effects on the mortality and morbidity of NCDs via other risk factors (e.g., obesity, diabetes, and hypertension), it is now undeniable that sedentary lifestyles are one of the most significant public health problems of the 21st century.
In 2007, the A merican C ollege of S ports M edicine ( ACSM ) and A merican M edical A ssociation ( AMA ) launched the E xercise is M edicine® ( EIM ) initiative in recognition of the fundamental importance of physical activity to health and well‐being. EIM is on the forefront of a global movement to reduce sedentary lifestyles, foster implementation of exercise counseling into clinical practice, and disseminate exercise therapy on a global scale. If the devastating human losses and financial burden of inactivity‐induced chronic disease are to be ameliorated, the wide‐ranging cost‐effective health benefits and financial feasibility of physical activity interventions must be appreciated and promoted.
Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.
We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported.
3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise.
Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy.
None.
Current international treatment guidelines recommending therapeutic exercise for people with symptomatic hip OA report are based on expert opinion only.
To determine whether land-based therapeutic exercise is beneficial for people with hip OA in terms of reduced joint pain and/or improved physical function.
Five databases were searched from 1966 up until August 2008.
All randomised controlled trials (RCTs) recruiting people with hip OA and comparing some form of land-based therapeutic exercise (as opposed to exercises conducted in the water) with a non-exercise group.
Three reviewers independently extracted data and assessed methodological quality. All analyses were conducted on continuous outcomes.
Combining the results of the five included RCTs demonstrated a small treatment effect for pain, but no benefit in terms of improved self-reported physical function. Only one of these five RCTs exclusively recruited people with symptomatic hip OA.
The limited number and small sample size of the included RCTs restricts the confidence that can be attributed to these results. Adequately powered RCTs evaluating exercise programs specifically designed for people with symptomatic hip OA need to be conducted.
To identify sports medicine-related clinical trial research articles in the PubMed MEDLINE database published between 1996 and 2005 and conduct a review and analysis of topics of research, experimental designs, journals of publication and the internationality of authorships.
Sports medicine research is international in scope with improving study methodology and an evolution of topics.
Structured review of articles identified in a search of a large electronic medical database.
PubMed MEDLINE database.
Sports medicine-related clinical research trials published between 1996 and 2005.
Review and analysis of articles that meet inclusion criteria.
Articles were examined for study topics, research methods, experimental subject characteristics, journal of publication, lead authors and journal countries of origin and language of publication.
The search retrieved 414 articles, of which 379 (345 English language and 34 non-English language) met the inclusion criteria. The number of publications increased steadily during the study period. Randomised clinical trials were the most common study type and the "diagnosis, management and treatment of sports-related injuries and conditions" was the most popular study topic. The knee, ankle/foot and shoulder were the most frequent anatomical sites of study. Soccer players and runners were the favourite study subjects. The American Journal of Sports Medicine had the highest number of publications and shared the greatest international diversity of authorships with the British Journal of Sports Medicine. The USA, Australia, Germany and the UK produced a good number of the lead authorships. In all, 91% of articles and 88% of journals were published in English.
Sports medicine-related research is internationally diverse, clinical trial publications are increasing and the sophistication of research design may be improving.