1. “Should team doctors encourage, discourage or be neutral about treatment modalities with limited evidence?”
2. “Should sports physicians treat their team/elite athletes differently to their regular patients?”
BJSM readers will have strong opinions about these questions. Recent BJSM articles by McCrory, Cook and Maffulli and colleagues provide a physician, physiotherapist, and surgical opinion on the issue. But in reality each author is writing as a clinician-scientist. Orchard has responded with the letter below. This is a difficult issue at both the community and the professional level.
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 We believe that the Mueller-Wohlfahrt experience at least qualifies as an unpublished but large size case series over three decades by a doctor with a sub-specialty practice in muscle strains.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 non- randomised 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 full2 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
References
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, Schäferhoff 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