In “past, present, future”, we ask clinical or academic experts to reflect on selected Sports & Exercise Medicine topics. Today Ian Shrier on Research Methods & Statistics in Sports & Exercise Medicine




Tell us more about yourself

After finishing training in medicine, I spent 3 years practising sport and exercise medicine and emergency medicine. To fulfil my creative needs, I started a PhD in basic science physiology, followed by a post-doc in Epidemiology and clinical research. After a few more years, I started using injury data and found that this field’s methods often failed to follow standard principles. For example, methods didn’t account for repeated measures on participants and often lacked appropriate calculations for confidence intervals. I was very fortunate to find a statistician who was willing to become “invested” in improving the application of appropriate methods. I have learned a great deal through our collaborations over the last 20 years. The most important lesson I have assimilated is not to overestimate the value of my own experiences and always seek out appropriate expertise to answer research questions.


What was hip and happening 10 years ago?

Surveillance databases in sport and exercise medicine started to become available about 10-15 years ago. That was hip because sports medicine clinicians and researchers could track large groups of athletes over time. There was great promise and excitement, and it was a great first step. As the databases from the last 10 years have matured, investigators can now address important questions that were simply not possible to answer before. At the same time, there were important limitations. Our field simply did not keep up with the methodological advances being made, and despite good intentions, some investigators proposed methods without fully understanding the mathematical principles of the methods. This led to some sub-optimal practices becoming widely used.


What are we doing now?

In recent years, there has been a push towards using modern methods to estimate causal effects rather than just predictors of outcomes (mix of causal and non-causal effects). This is a positive move. However, this comes with a caution. Causal effects provide answers to only some of the important clinical questions. Some journals and reviewers do not appear to understand that some non-causal questions are also very important. I think this is unfortunate. Non-causal questions may require simple or advanced methods depending upon the question being asked. The pendulum swings back and forth. So we must always keep in mind that we start with an important question and then choose methods that will answer that question. My favourite sport growing up was tennis. I think we are still trying to figure out where the “sweet spot” of the racquet is regarding the optimal methods for different types of causal and non-causal questions.


Where do you think we will be 10 years from now?

I am hopeful that we can continue to improve methods used in both consensus statements and original research. I recently published an article in BJSM (“Consensus statements that fail to recognize dissent are flawed by design: a narrative review with 10 suggested improvements”) explaining why I think the current process to create consensus statements is seriously flawed even though they follow “recommended” practices. My paper highlighted some concrete examples where recommendations were sub-optimal and ideas on how to improve the process. Most importantly, organizers need to encourage dissent in both actions and words. This requires inviting collaborators with a full range of scientific opinions and methodological expertise. Organizers also need to report the level of agreement for each recommendation and the major dissenting opinions. For original research papers, our field would improve greatly if every paper with a quantitative analysis included a statistician as a co-author responsible for (1) the data analysis and (2) ensuring that the results are properly reported and interpreted. There is an old joke that the definition of an epidemiologist is someone who everyone calls a statistician, except the statisticians. Alternatively, in the words of Andrew Vickers, PhD, “A mistake in the operating room can threaten the life of one patient; a mistake in statistical analysis or interpretation can lead to hundreds of early deaths. So it is perhaps odd that, while we allow a doctor to conduct surgery only after years of training, we give SPSS to almost anyone”. [Vickers A. Interpreting data from randomized trials: the Scandinavian prostatectomy study illustrates two common errors. Nat Clin Pract Urol, 2005]”

Would you like to learn more on this topic? Here is a selection of consensus statements published in our journal.
  • Gian Nicola Bisciotti, Piero Volpi, Maurizio Amato, Giampietro Alberti, Francesco Allegra, Alessandro Aprato, Matteo Artina, Alessio Auci, Corrado Bait, Gian MatteoBastieri, Luca Balzarini, Andrea Belli, Gianandrea Bellini, Pierfrancesco Bettinsoli, Alessandro Bisciotti, Andrea Bisciotti, Stefano Bona, Lorenzo Brambilla, MarcoBresciani, Michele Buffoli, Filippo Calanna, Gian Luigi Canata, Davide Cardinali, Giulia Carimati, Gabriella Cassaghi, Enrico Cautero, Emanuele Cena, Barbara Corradini, Alessandro Corsini, Cristina D’Agostino, Massimo De Donato, Giacomo Delle Rose, Francesco Di Marzo, Francesco Di Pietto, Drapchind Enrica, Cristiano Eirale, LuigiFebbrari, Paolo Ferrua, Andrea Foglia, Alberto Galbiati, Alberto Gheza, Carlo Giammattei, Francesco Masia, Gianluca Melegati, Biagio Moretti, Lorenzo Moretti, RobertoNiccolai, Antonio Orgiani, Claudio Orizio, Andrea Pantalone, Federica Parra, Paolo Patroni, Maria Teresa Pereira Ruiz, Marzio Perri, Stefano Petrillo, Luca Pulici, Alessandro Quaglia, Luca Ricciotti, Francesco Rosa, Nicola Sasso, Claudio Sprenger, Chiara Tarantola, Fabio Gianpaolo Tenconi, Fabio Tosi, Michele Trainini, AgostinoTucciarone, Ali Yekdah, Zarko Vuckovic, Raul Zini, Karim Chamari.Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete
  • Gian Nicola Bisciotti, Piero Volpi, Giampietro Alberti, Alessandro Aprato, Matteo Artina, Alessio Auci, Corrado Bait, Andrea Belli, Giuseppe Bellistri, PierfrancescoBettinsoli, Alessandro Bisciotti, Andrea Bisciotti, Stefano Bona, Marco Bresciani, Andrea Bruzzone, Roberto Buda, Michele Buffoli, Matteo Callini, Gianluigi Canata, Davide Cardinali, Gabriella Cassaghi, Lara Castagnetti, Sebastiano Clerici, Barbara Corradini, Alessandro Corsini, Cristina D’Agostino, Enrico Dellasette, Francesco Di Pietto, Drapchind Enrica, Cristiano Eirale, Andrea Foglia, Francesco Franceschi, Antonio Frizziero, Alberto Galbiati, Carlo Giammatei, Philippe Landreau, ClaudioMazzola, Biagio Moretti, Marcello Muratore, Gianni Nanni, Roberto Niccolai, Claudio Orizio, Andrea Pantalone, Federica Parra, Giulio Pasta, Paolo Patroni, DavidePelella, Luca Pulici, Alessandro Quaglia, Stefano Respizzi, Luca Ricciotti, Arianna Rispoli, Francesco Rosa, Alberto Rossato, Italo Sannicandro, Claudio Sprenger, ChiaraTarantola, Fabio Gianpaolo Tenconi, Giuseppe Tognini, Fabio Tosi, Giovanni Felice Trinchese, Paola Vago, Marcello Zappia, Zarko Vuckovich, Raul Zini, Michele Trainini, Karim Chamari. Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)
  • G N Bisciotti, P Volpi, R Zini, A Auci, A Aprato, A Belli, G Bellistri, P Benelli, S Bona, D Bonaiuti, G Carimati, G L Canata, G Cassaghi, S Cerulli, G Delle Rose, P Di Benedetto, FDi Marzo, F Di Pietto, L Felicioni, L Ferrario, A Foglia, M Galli, E Gervasi, L Gia, C Giammattei, A Guglielmi, A Marioni, B Moretti, R Niccolai, N Orgiani, A Pantalone, F Parra, A Quaglia, F Respizzi, L Ricciotti, M T Pereira Ruiz, A Russo, E Sebastiani, G Tancredi, F Tosi, Z Vuckovic. Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete
  • Gavin Breslin, Andy Smith, Brad Donohue, Paul Donnelly, Stephen Shannon, Tandy Jane Haughey, Stewart A Vella, Christian Swann, Stewart Cotterill, Tadhg Macintyre, Tim Rogers, Gerard Leavey. International consensus statement on the psychosocial and policy-related approaches to mental health awareness programmes in sport
  • Daniel H Major, Yngve Røe, Margreth Grotle, Rebecca L Jessup, Caitlin Farmer, Milada Cvancarova Småstuen, Rachelle Buchbinder. Content reporting of exercise interventions in rotator cuff disease trials: results from application of the Consensus on Exercise Reporting Template (CERT)
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