Hamilton et al (1) conducted a study to assess strength, power and aerobic capacity of transgender athletes. They conclude the results may be useful for sports governing bodies and inform sports policy. However, policy should be informed by accurate scientific information and, unfortunately, this study contains fundamental errors in design, methodology and interpretation. In this letter, we focus on the incorrect interpretation of respiratory testing, the inappropriate definition of ‘athlete’, and group matching.
The study compares respiratory function of transgender and non-transgender individuals using cardiopulmonary exercise testing, as well as conventional lung function testing (spirometry, lung volumes and gas transfer). The authors report that transgender women (TW - male individuals who identify as women) had greater forced expiratory volume in 1s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) and a reduced FEV1/FVC ratio relative to cisgender women (CW - female individuals without a differing gender identity). From this data, the authors conclude that TW have decreased lung function, increasing their work of breathing relative to CW.
Firstly, the methodology employed to measure lung function does not appear to conform to accepted, published testing guidelines (ATS/ERS) (2). Lung function is typically measured repeatedly within 150mL, with the highest numeric value for each variable recorded, to ensure...
Hamilton et al (1) conducted a study to assess strength, power and aerobic capacity of transgender athletes. They conclude the results may be useful for sports governing bodies and inform sports policy. However, policy should be informed by accurate scientific information and, unfortunately, this study contains fundamental errors in design, methodology and interpretation. In this letter, we focus on the incorrect interpretation of respiratory testing, the inappropriate definition of ‘athlete’, and group matching.
The study compares respiratory function of transgender and non-transgender individuals using cardiopulmonary exercise testing, as well as conventional lung function testing (spirometry, lung volumes and gas transfer). The authors report that transgender women (TW - male individuals who identify as women) had greater forced expiratory volume in 1s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) and a reduced FEV1/FVC ratio relative to cisgender women (CW - female individuals without a differing gender identity). From this data, the authors conclude that TW have decreased lung function, increasing their work of breathing relative to CW.
Firstly, the methodology employed to measure lung function does not appear to conform to accepted, published testing guidelines (ATS/ERS) (2). Lung function is typically measured repeatedly within 150mL, with the highest numeric value for each variable recorded, to ensure reproducible high-quality measures, and not until a ‘declining performance occurred’. Secondly, in the TW group, data was included from an individual with abnormal findings (FEV/FVC ratio of approximately 0.62), indicating an individual with probable obstructive airways disease (3,4), confounding interpretation of mean data. Thirdly, the authors fail to correct lung function data for factors known to influence these variables, in addition to sex, e.g. height, ethnicity and age (5,6). In this study, the TW group are older and taller, and male, and as such, would be expected to have a lower FEV1/FVC relative to CW. When the published mean values are considered relative to these factors and compared with internationally validated Global Lung Initiative (GLI) reference ranges, the FEV1/FVC values are within normal ranges for corresponding predicted values in all groups (including the TW). Within these normal ranges, these results do not reflect reduced lung function in the TW, as a group, and do not represent an increased challenge to the ‘work of breathing’ as presented and discussed in this paper (6,7). The reported difference of FEV1/FVC, 0.88 (CW) vs. 0.83 (TW), arises because CW have a disproportionately lower FVC, as is normal for female and shorter individuals. This difference is further exacerbated by the inclusion of one individual with probable pathological airflow obstruction in the TW group. The study also reports that TW have a higher FEV1, FVC and PEFR relative to CW and therefore, if hypothesising on exercise performance based on absolute respiratory test values, it would be appropriate to discuss that TW may have improved lung function for sports performance (8), precisely the opposite conclusion drawn by the authors.
Methodologically, there is also a significant grouping error. The stated primary aim was to ‘compare cardiorespiratory fitness, strength and body composition of transgender athletes to that of matched cisgender cohorts’. Yet groups in this study were not matched, with clear differences in height, body mass index, fat mass index, and relative V ̇O2 max, between TW and CW. The TW group have the highest BMI (26.2kg/m2), Fat Mass Index (8.2 kg/m2) and Fat Mass (31.5%) and lowest V ̇O2 Max (45.1ml/kg/min) of any group in the study. These values are not physiologically representative of an athlete cohort (9). The study defines participants as athletes based on self-reported participation in a sport (unspecified) or in any physical training (unspecified) at least 3-times per week. This is not aligned with study guidelines on the definition of an ‘athlete’ (10). The authors suggest their study should influence sporting governing bodies and athletic sports policy, providing ‘sports governing bodies with laboratory-based performance related data from transgender athletes’. Neither the questionnaire-based criteria nor the physiological parameters are consistent with this being an athlete cohort.
In conclusion, we recommend the paper by Hamilton at al undergoes significant revision. The interpretation of respiratory testing is inaccurate and should include discussion on FEV1/FVC in the context of age, sex and height and relative to normative data. If the discussion on respiratory testing values and their possible impact on exercise performance is then retained, the potential for improved exercise performance of an increased FVC, FEV1 and PEFR in the TW group, relative to the CW group, should be discussed. Erroneous conclusions regarding ‘decreased lung function and increased work of breathing’ in TW should be removed. The study did not effectively match groups and the TW group do not meet published recommendations or physiological criteria to support an ‘athlete’ designation. Accordingly, we advise the study title is changed, the discussion, conclusions and ‘summary box’ corrected, and references to this as an athlete group removed. This is a contentious area of sports policy (11,12) and the British Journal of Sports Medicine should ensure that published scientific work draws credible conclusions and accurately informs readers.
References
1. Hamilton B, Brown A, Montagner-Moraes S, Comeras-Chueca C, Bush PG, Guppy FM, Pitsiladis YP. Strength, power and aerobic capacity of transgender athletes: a cross-sectional study. Br J Sports Med. 2024 Apr 10;bjsports-2023-108029.
2. Graham BL, Steenbruggen I, Miller MR, Barjaktarevic IZ, Cooper BG, Hall GL, et al. Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70–88.
3. Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J [Internet]. 2019 May 1 [cited 2024 May 31];53(5). Available from: https://erj.ersjournals.com/content/53/5/1900164
4. Recommendations | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE [Internet]. NICE; 2017 [cited 2024 May 31]. Available from: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#objective-...
5. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999 Jan;159(1):179–87.
6. Cooper BG, Stocks J, Hall GL, Culver B, Steenbruggen I, Carter KW, et al. The Global Lung Function Initiative (GLI) Network: bringing the world’s respiratory reference values together. Breathe. 2017 Sep;13(3):e56–64.
7. Haynes JM, Stumbo RW. The Impact of Using Non-Birth Sex on the Interpretation of Spirometry Data in Subjects With Air-Flow Obstruction. Respir Care. 2018 Feb;63(2):215–8.
8. McNeill J, Chernofsky A, Nayor M, Rahaghi FN, San Jose Estepar R, Washko G, et al. The association of lung function and pulmonary vasculature volume with cardiorespiratory fitness in the community. Eur Respir J. 2022 Aug;60(2):2101821.
9. Degens H, Stasiulis A, Skurvydas A, Statkeviciene B, Venckunas T. Physiological comparison between non-athletes, endurance, power and team athletes. Eur J Appl Physiol. 2019 Jun 1;119(6):1377–86.
10. McKinney J, Velghe J, Fee J, Isserow S, Drezner JA. Defining Athletes and Exercisers. Am J Cardiol. 2019 Feb 1;123(3):532–5.
11. IOC. IOC Framework on Fairness, Inclusion and Non-Discrimination on the basis of Gender Identity and Sex Variations [Internet]. IOC; 2021. Available from: https://stillmed.olympics.com/media/Documents/News/2021/11/IOC-Framework...
12. Lundberg TR, Tucker R, McGawley K, Williams AG, Millet GP, Sandbakk Ø, et al. The International Olympic Committee framework on fairness, inclusion and nondiscrimination on the basis of gender identity and sex variations does not protect fairness for female athletes. Scand J Med Sci Sports. 2024 Mar;34(3):e14581.
The "healthy worker effect" is an obvious explanation for the authors' findings. In this case, they have compared the extreme winners of the genetic lottery (sub 4-minute mile male runners) with the general population, a mixed bag of healthy and non-healthy people. The outcome of all-cause mortality also presents issues, as the reason of death may or may not be health-related.
The steep decline in the longevity advantage over time indicates that this advantage may not last as the general population becomes healthier (and possibly more active). It is plausible that there may even be an opposite effect (sub 4-minute mile male runners live shorter lives) in the coming decades.
While general population statistics are easier to obtain, comparing them with those of elite athletes to make conclusions about lifespan does not answer the question of whether extreme exercise has a detrimental effect on health. A more fair comparison group would be marathoners, short-distance runners, or even runners who have not broken the 4-minute mark.
I must fully concur with Dr McCrory's assessment of youth
sport. Here in the US, we have a great many fathers find enjoyment in
coaching their children-however there are far more whom become engulfed in
the desire to win at all cost, pushing their children, dramatizing local
saturday morning football as if it were the Super Bowl or World Cup. I
find it highly objectionable to their behavior and the role...
I must fully concur with Dr McCrory's assessment of youth
sport. Here in the US, we have a great many fathers find enjoyment in
coaching their children-however there are far more whom become engulfed in
the desire to win at all cost, pushing their children, dramatizing local
saturday morning football as if it were the Super Bowl or World Cup. I
find it highly objectionable to their behavior and the role models they
provide. It is a shame that we have so many good sports, but not so many
good sports to play them.
We appreciate the efforts of the authors of Strength, power and aerobic capacity of transgender athletes: a cross-sectional study (1) to provide data on transgender athletes. However, we have several concerns regarding the study design and analysis which we opine severely compromise the conclusions reached by the authors.
First, the inclusion criteria were that participants must “participate in a sport at a competitive level or undergo physical training three times per week”, which includes all forms of health promoting physical fitness or sports participation. We are fully aware of the difficulties recruiting suitable research participants, and particularly those from a small demographic group, but we think that much more specific inclusion criteria would have ensured more uniformly trained and comparable research participants.
The descriptive data did not provide enough information on the frequency, intensity, duration, or exercise mode of the participants to determine what type of athletes had been evaluated. While the authors state that 36% of the participants were endurance athletes, 26% team sports athletes, and 38% power sports athletes, there was no breakdown of sports participation within each comparison group. Therefore, it is not possible to know if this was a comparison of similar groups of athletes.
The data for the cisgender women and transgender women demonstrate great dissimilarity. Based on the data for body composition, muscle strength,...
We appreciate the efforts of the authors of Strength, power and aerobic capacity of transgender athletes: a cross-sectional study (1) to provide data on transgender athletes. However, we have several concerns regarding the study design and analysis which we opine severely compromise the conclusions reached by the authors.
First, the inclusion criteria were that participants must “participate in a sport at a competitive level or undergo physical training three times per week”, which includes all forms of health promoting physical fitness or sports participation. We are fully aware of the difficulties recruiting suitable research participants, and particularly those from a small demographic group, but we think that much more specific inclusion criteria would have ensured more uniformly trained and comparable research participants.
The descriptive data did not provide enough information on the frequency, intensity, duration, or exercise mode of the participants to determine what type of athletes had been evaluated. While the authors state that 36% of the participants were endurance athletes, 26% team sports athletes, and 38% power sports athletes, there was no breakdown of sports participation within each comparison group. Therefore, it is not possible to know if this was a comparison of similar groups of athletes.
The data for the cisgender women and transgender women demonstrate great dissimilarity. Based on the data for body composition, muscle strength, and aerobic fitness, the cisgender women were very fit, rating above the 80th percentile in these variables with average VO2max values on par with elite endurance athletes (2, 3). However, the body composition, muscle strength, and aerobic fitness of the transgender women were not what would be expected of trained athletes. The transgender women had a body fat percent in the 40th percentile for comparably aged men (2) and higher than previously researched non-athletic transgender women (4-6). The transgender women were well below average (scoring in the 20th percentile) in handgrip strength compared to men (3) but were on par with previously researched non-athletic transgender women (4, 7). And the VO2max measurements of the transgender women were in the 60th percentile when compared to men (3) and were above what has been previously observed in non-athletic transgender women (6). Taking all of this together, it is very reasonable to conclude that Hamilton et al. studied a group of transgender women who may have engaged in health promoting aerobic exercise but were certainly not engaged in vigorous strength training or other exercise necessary for competitive athletic success. We reiterate that no data are presented in this paper to demonstrate that these are equally trained comparison groups. Furthermore, no data are presented regarding the physical fitness, exercise, or sports habits of the transgender participants before GAHT making it impossible to determine the magnitude of effects of GAHT on any of the measured physical performance variables.
The transgender women exhibited greater body height, body mass, fat-free body mass, strength, and power than the cisgender women, all of which are male pattern sporting advantages when compared to equally aged, talented, and trained females. However, the authors calculated ratios of strength and power relative to body size and fat-free body mass and then used these ratios to demonstrate some parity between the transgender and cisgender women. But this type of statistical deception denies important sex-based dimorphic differences in the bodies of males and females and has no real-world application in sports.
Overall, Strength, power and aerobic capacity of transgender athletes: a cross-sectional study provides information on some physical performance variables in transgender individuals, but does not provide sufficient information to discern if these transgender and cisgender athletes should be reasonably compared to one another.
References
1. Hamilton B, Brown A, Montagner-Moraes S, Comeras-Chueca C, Bush PG, Guppy FM, and Pitsiladis YP. Strength, power and aerobic capacity of transgender athletes: a cross-sectional study. Br J Sports Med 2024.
2. Imboden MT, Welch WA, Swartz AM, Montoye AH, Finch HW, Harber MP, and Kaminsky LA. Reference standards for body fat measures using GE dual energy x-ray absorptiometry in Caucasian adults. PLoS One 12: e0175110, 2017.
3. ACSM's Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Wolters Kluwer, 2021, p. 480.
4. Lapauw B, Taes Y, Simoens S, Van Caenegem E, Weyers S, Goemaere S, Toye K, Kaufman JM, and T'Sjoen GG. Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone 43: 1016-1021, 2008.
5. Van Caenegem E, Wierckx K, Taes Y, Schreiner T, Vandewalle S, Toye K, Kaufman JM, and T'Sjoen G. Preservation of volumetric bone density and geometry in trans women during cross-sex hormonal therapy: a prospective observational study. Osteoporos Int 26: 35-47, 2015.
6. Alvares LAM, Santos MR, Souza FR, Santos LM, Mendonca BB, Costa EMF, Alves M, and Domenice S. Cardiopulmonary capacity and muscle strength in transgender women on long-term gender-affirming hormone therapy: a cross-sectional study. Br J Sports Med 56: 1292-1298, 2022.
7. Scharff M, Wiepjes CM, Klaver M, Schreiner T, T'Sjoen G, and den Heijer M. Change in grip strength in trans people and its association with lean body mass and bone density. Endocr Connect 8: 1020-1028, 2019.
We thank Brown and O'Connor (1) for their interest in our research (2) and we welcome their constructive criticism, especially regarding our study design, analysis and interpretation. We consider such exchanges equally important as the dissemination of the original research and hence, we wish to address all concerns. Concerns were raised about the need for more specific inclusion criteria to ensure comparability among research participants. Specifically, Brown and O’Connor (1) raised valid concerns about the lack of detailed information on the frequency, intensity, duration, and mode of exercise among our research participants. While we appreciate and totally agree with these comments, the task of recruiting suitable research participants, mainly from small demographic groups such as transgender athletes, is challenging. Many transgender athletes, especially those with high profile, feel too intimidated to come forward in the current polarised climate. Given this, we had to balance the need for stringent inclusion criteria with the necessity of obtaining a representative sample of transgender athletes to better understand their physiological and performance characteristics. We aimed to strike a balance between providing an informative overview of the participants' sporting backgrounds and protecting the anonymity of the transgender athletes involved in the study. We fully acknowledge that a more granular breakdown would have been beneficial for assessing comparab...
We thank Brown and O'Connor (1) for their interest in our research (2) and we welcome their constructive criticism, especially regarding our study design, analysis and interpretation. We consider such exchanges equally important as the dissemination of the original research and hence, we wish to address all concerns. Concerns were raised about the need for more specific inclusion criteria to ensure comparability among research participants. Specifically, Brown and O’Connor (1) raised valid concerns about the lack of detailed information on the frequency, intensity, duration, and mode of exercise among our research participants. While we appreciate and totally agree with these comments, the task of recruiting suitable research participants, mainly from small demographic groups such as transgender athletes, is challenging. Many transgender athletes, especially those with high profile, feel too intimidated to come forward in the current polarised climate. Given this, we had to balance the need for stringent inclusion criteria with the necessity of obtaining a representative sample of transgender athletes to better understand their physiological and performance characteristics. We aimed to strike a balance between providing an informative overview of the participants' sporting backgrounds and protecting the anonymity of the transgender athletes involved in the study. We fully acknowledge that a more granular breakdown would have been beneficial for assessing comparability among groups, and we recognise the value of more specific data and will continue to prioritise this in all our future research endeavours. Without a doubt, this balancing act, while essential for the advancement of knowledge in this field, will have contributed to some of the variability in training backgrounds among participants and may have influenced the findings of this research. For example, some of the differences between cisgender men, cisgender women and transgender women in terms of body composition, muscle strength, and aerobic fitness may be the result of variations in training backgrounds and the specifics of their chosen athletic pursuits. We attempted to reduce the impact of this important limitation by imposing the inclusion criteria of training three times per week and participating in competitive sport. Therefore, it can be inferred that all volunteers participating in our study were actively engaged in competitive sports, which would involve a variety of different training modalities. Given the status quo of almost no published data from transgender athletes, we opted to do the best we could in recruitment and design, appropriately analyse the data and present the findings while stressing the limitations of the research. As a result, our paper includes a detailed limitations section which addresses most of the concerns raised by Brown and O’Connor and others. For instance, in our limitations, we declared that the composition of the study cohort may not fully represent the diversity of athletes in elite sports from worldwide populations, and the study may suffer from selection bias (2, 3). While we acknowledge that this research we present is meant to encourage larger subject numbers and better methods in participant selection to improve the generalizability of research findings, there is a notable absence of studies that can establish an optimal sample size to determine whether transgender athletes possess unfair advantages. We acknowledged the limitations of our research but at the same time celebrate the uniqueness of our study and its strengths, which also include appropriate methods to assess the subjects’ strength, power and aerobic capacity, not to mention that all transgender participants have undergone years of hormonal treatment and have consistently maintained hormone levels within acceptable ranges; strengths that have received almost no attention. We believe that our research, despite its limitations, is a significant step towards better understanding the physiological and performance characteristics of transgender athletes, and we are committed to furthering this understanding through more collaborative research.
In response to the comment by Brown and O'Connor (1) that transgender women in our study exhibited a higher body fat percentage compared to comparably aged men (4) and previously researched non-athletic transgender women (5, 6), it is essential to consider the influence of hormonal factors, specifically in the case of Alvares, Santos (5), who did not report any oestradiol findings, and Scharff, Wiepjes (6), who reported oestradiol (Range 225-257 pmol·L-1). Transgender women in our present study had oestradiol concentrations sixfold higher (742 pmol·L-1) than those of cisgender men (104 pmol·L-1), double that of cisgender women (336. pmol·L-1) and threefold higher than was reported in Scharff, Wiepjes (6). Given that oestradiol is known to be positively associated with fat mass accumulation (7), it is unsurprising that transgender women athletes presented with higher fat mass levels. However, as our research is cross-sectional, we cannot establish that causation. The result of higher oestradiol concentrations may be caused by athletes self-medicating with gender-affirmation hormone treatment, as we did not recruit from a clinic, which means that the gender-affirming treatment of transgender athletes in our study (2) was not controlled. Longitudinal studies tracking transgender athletes over time are crucial to better understanding the relationship between hormone levels, body composition changes, and athletic performance. An important limitation of cross-sectional studies, as we declare in our study (2), is the inability to determine causality, making it impossible to determine whether the lower performances (e.g., relative maximal aerobic capacity) we report in transgender women athletes compared to cisgender women are due to gender-affirmation hormone treatment or simply due to a lower training status. Likewise, the higher absolute fat mass observed in transgender women athletes may be influenced by oestrogen therapy, which can lead to increases in both visceral and subcutaneous fat. Therefore, longitudinal studies are crucial to provide a more comprehensive understanding.
Our study, which focuses on physical performance aspects such as strength, power, and aerobic capacity, should serve as a primer to the broader discussion of gender inclusion, highlighting the importance of recognizing the differences between groups, especially between cisgender men and transgender women. There is also a call for a more comprehensive approach to research on sports performance across diverse sports, utilizing specific metrics to gain deeper insights into the priorities of each sport. Additionally, studies focusing on physiological aspects such as metabolic, hormonal, and biomarkers are essential to address questions like the residual effects of testosterone in relation to the "muscle memory mechanism" (8); the current focus of our research on this topic.
Unfortunately, the issue of integration of transgender athletes into elite sport has generated so much negative and polarised discussion that no matter what design is employed, subjects recruited, and intervention applied, no amount of research would change the entrenched position of those who are vehemently either pro- or anti-inclusion. In short, this issue is now political and only scientific data, with its acknowledged limitations, can best inform the debate, not that scientists themselves are immune from contributing to the politics of this debate. Below are some examples of the social media critiques our paper has received that were addressed in the limitations of our paper (2).
1) “19 transgender women, 20 cisgender women, 19 cisgender men and 11 transgender men. Such low numbers, even for an experimental or preliminary study, is laughable and can hardly be taken seriously.” (9)
2) “When I first read it, it made me think that the IOC and their researchers simply could not find enough transgender athletes to study over time, and so instead, they’ve just taken whatever they could find, and then compared to them a group of whatever females they could find, and tried to portray it as a valid comparison.” (10)
3) “This study has numerous problems, including self-selection of participants, wide variation in ages of the participants, and no control over hormone treatment of its transgender participants.” (10)
4) “If you read the baseline characteristics of the study groups you see that the trans athletes have a BMI in the overweight range while the women are lower BMI. Basically the research is comparing fat blokes with athletic women. This is not a serious piece of research and seems designed to confirm the IOC bias that men can compete in women’s events.” (9)
5) “These demographic characteristics should already make us pause – these groups may not be comparable for reasons that really matter. We have a group of females who are on the higher end of cardiovascular capacity along the female spectrum, and there is a group of transgender women in the middle of that range, even the lower side of it. One group is overweight, the other is not.” (10)
We encourage all who read our paper to pay particular attention to our declared limitations and engage with generating original data rather than dismissing the work of others. So heated is the debate on transgender inclusion that we have received threats and emails that are too vulgar to be presented and constitute abuse and, in some countries, a criminal offence. We hope that publication of original studies such as our imperfect study, will encourage better funded collaborative research in this area to keep the emphasis on science and not politics.
References
1. Gregory A Brown, Mary I O'Connor. Concerns with Strength, power and aerobic capacity of transgender athletes: a cross-sectional study. Published on: 3 May 2024 https://bjsm.bmj.com/content/early/2024/04/10/bjsports-2023-108029.respo...
2. Hamilton B, Brown A, Montagner-Moraes S, Comeras-Chueca C, Bush PG, Guppy FM, et al. Strength, power and aerobic capacity of transgender athletes: a cross-sectional study. British Journal of Sports Medicine. 2024.
3. Tripepi G, Jager KJ, Dekker FW, Zoccali C. Selection bias and information bias in clinical research. Nephron Clinical Practice. 2010;115(2):c94-c9.
4. Imboden MT, Welch WA, Swartz AM, Montoye AH, Finch HW, Harber MP, et al. Reference standards for body fat measures using GE dual-energy x-ray absorptiometry in Caucasian adults. PloS one. 2017;12(4):e0175110.
5. Alvares LAM, Santos MR, Souza FR, Santos LM, de Mendonça BB, Costa EMF, et al. Cardiopulmonary capacity and muscle strength in transgender women on long-term gender-affirming hormone therapy: a cross-sectional study. British journal of sports medicine. 2022;56(22):1292-9.
6. Scharff M, Wiepjes CM, Klaver M, Schreiner T, t’Sjoen G, Den Heijer M. Change in grip strength in trans people and its association with lean body mass and bone density. Endocrine connections. 2019;8(7):1020-8.
7. Al-Ghadban S, Teeler ML, Bunnell BA. Estrogen as a Contributing Factor to the Development of Lipedema. Hot Topics in Endocrinology and Metabolism: IntechOpen; 2021.
8. Pitsiladis Yannis, Harper JMS, Betancurt JO, Martinez-Patino MJ, Parisi A, Wang G, Pigozzi F. Beyond Fairness: The Biology of Inclusion for Transgender and Intersex Athletes. Current Sports Medicine Reports 15(6):p 386-388, 11/12 2016.
9. Dineen, Robert. "Transgender sportswomen 'at a disadvantage' study claims." The Telegraph, 11 April 2024, https://www.telegraph.co.uk/sport/2024/04/11/transgender-sportswomen-at-...
10. Ben Rumsby. “IOC accused of new low by funding study that claims trans women are at a disadvantage” The Telegraph, 12 April 2024, https://www.telegraph.co.uk/olympics/2024/04/12/ioc-accused-new-low-fund...
We have reviewed Dr McCrory’s sole authored content for plagiarism as we described in our prior editorial.[1] The University of Melbourne asked for a review of several other articles.
This has resulted in the retraction of four ‘warm up’ editorials [2 3,4,5 ] and one book review in BJSM [6] due to plagiarism. A letter in BJSM [7] has been retracted due to duplicate publication. A research article [8] and a review article [9] in BJSM have also been corrected due to inappropriate reuse of content.
Dr McCrory agrees with our decisions. No further concerns have been raised to us about content authored by Dr McCrory. This concludes our planned investigation. If further allegations are made about Dr McCrory’s work published in BJSM or in other BMJ journals, we will investigate them.
This investigation has been conducted by the Editor-in-Chief of BJSM in conjunction with the integrity team of BMJ. BJSM is published by BMJ.
BMJ Content Integrity Team, Dr Helen Macdonald and Ms Helen Hardy
BJSM Editor-in-Chief, Prof. Jonathan Drezner
1. Macdonald H, Ragavooloo S, Abbasi K, et al. Update on the investigation into the publication record of former BJSM editor-in-chief Paul McCrory. British Journal of Sports Medicine 2022;56:1327-1328.
2. McCrory P. “Elementary, my dear Watson”. British Journal of Sports Medicine 2006;40:283-284.
3. McCrory P. Cheap solutions for big problems? British Journal of Sports Medicine 2007;41:545.
4....
We have reviewed Dr McCrory’s sole authored content for plagiarism as we described in our prior editorial.[1] The University of Melbourne asked for a review of several other articles.
This has resulted in the retraction of four ‘warm up’ editorials [2 3,4,5 ] and one book review in BJSM [6] due to plagiarism. A letter in BJSM [7] has been retracted due to duplicate publication. A research article [8] and a review article [9] in BJSM have also been corrected due to inappropriate reuse of content.
Dr McCrory agrees with our decisions. No further concerns have been raised to us about content authored by Dr McCrory. This concludes our planned investigation. If further allegations are made about Dr McCrory’s work published in BJSM or in other BMJ journals, we will investigate them.
This investigation has been conducted by the Editor-in-Chief of BJSM in conjunction with the integrity team of BMJ. BJSM is published by BMJ.
BMJ Content Integrity Team, Dr Helen Macdonald and Ms Helen Hardy
BJSM Editor-in-Chief, Prof. Jonathan Drezner
1. Macdonald H, Ragavooloo S, Abbasi K, et al. Update on the investigation into the publication record of former BJSM editor-in-chief Paul McCrory. British Journal of Sports Medicine 2022;56:1327-1328.
2. McCrory P. “Elementary, my dear Watson”. British Journal of Sports Medicine 2006;40:283-284.
3. McCrory P. Cheap solutions for big problems? British Journal of Sports Medicine 2007;41:545.
4. McCrory P. Is it all too much? British Journal of Sports Medicine 2007;41:405-406.
5. McCrory P. You are a better man than I am, Gunga Din. British Journal of Sports Medicine 2006;40:737.
6. McCrory P. Boxing: medical aspects. British Journal of Sports Medicine 2006;40:561.
7. McCrory P, Davis G. Paediatric sport related concussion pilot study. British Journal of Sports Medicine 2005;39:116.
8. McCrory P, Heywood J, Coffey C. Prevalence of headache in Australian footballers. British Journal of Sports Medicine 2001;35:286-287.
9. McCrory P, Meeuwisse WH, Echemendia RJ et al. What is the lowest threshold to make a diagnosis of concussion? British Journal of Sports Medicine 2013;47:268-271.
In responding to the comments raised in the letter to the editor regarding the recommendation of the VISA-G questionnaire for gluteal tendinopathy, we first want to acknowledge qualified agreement with the points raised while also emphasising the practical considerations and guidelines that informed our recommendation.
1. A key conclusion of our recent publication was that we were not able to form a Core Outcome Set as no outcome measure had sufficient clinimetric properties (1). For a measure to be selected for a Core Outcome Set, it should have at least high-quality evidence of good content validity (2 3). As part of the COS-GT consensus process, we completed a systematic review that collected and evaluated measurement properties of all outcome measures used to evaluate patients with gluteal tendinopathy. (4) No outcome measures met this threshold. Of the ICON disability domain outcome measures that had been validated in people with gluteal tendinopathy (the VISA-G and the two HOS outcome measures), the VISA-G had, albeit low, the best available evidence for content validity (low-quality evidence of sufficient comprehensibility and very low-quality evidence of sufficient comprehensiveness and relevance). (4) After much consideration the final recommendation for interim use was based on consideration of the impact of not providing a recommendation and the COSMIN systematic review guidelines for formulating recommendations. (p45, 4.2 Step 9) (5)
In responding to the comments raised in the letter to the editor regarding the recommendation of the VISA-G questionnaire for gluteal tendinopathy, we first want to acknowledge qualified agreement with the points raised while also emphasising the practical considerations and guidelines that informed our recommendation.
1. A key conclusion of our recent publication was that we were not able to form a Core Outcome Set as no outcome measure had sufficient clinimetric properties (1). For a measure to be selected for a Core Outcome Set, it should have at least high-quality evidence of good content validity (2 3). As part of the COS-GT consensus process, we completed a systematic review that collected and evaluated measurement properties of all outcome measures used to evaluate patients with gluteal tendinopathy. (4) No outcome measures met this threshold. Of the ICON disability domain outcome measures that had been validated in people with gluteal tendinopathy (the VISA-G and the two HOS outcome measures), the VISA-G had, albeit low, the best available evidence for content validity (low-quality evidence of sufficient comprehensibility and very low-quality evidence of sufficient comprehensiveness and relevance). (4) After much consideration the final recommendation for interim use was based on consideration of the impact of not providing a recommendation and the COSMIN systematic review guidelines for formulating recommendations. (p45, 4.2 Step 9) (5)
2. We acknowledge the limitation for the lack of uni-dimensionality of the VISA-G and the need to address this in future.
3. Please see point 1 as to why VISA-G was ultimately recommended. With respect to the reflexivity statements – we acknowledge that our reflexivity statements failed to reflect the steering committee’s discussion and concerns about the conflicting recommendations from patients and healthcare providers. Indeed, the full author group did wrestle with this question. Ultimately, it was decided on balance – and with consideration to the matters raised above in #1 – to recommend it rather than not.
As rightly pointed out by Thorborg et al rapid response, there is an urgent need for a new PROM that addresses the shortcomings of existing measures. In the absence of such a measure, our interim recommendation of the VISA-G aligns with COSMIN guidelines as the outcome measure with the best available content validity. (p45, 4.2 Step 9) (5) It's noteworthy that this pragmatic approach was endorsed by 100% of healthcare professionals in the consensus process. This approach addresses the immediate need for a measure for clinicians and researchers while acknowledging its deficiencies.
In conclusion, we agree that there is a pressing need for a new PROM for gluteal tendinopathy disability – as well as measures for other ICON tendinopathy domains for which measures in this condition do not exist. We remain committed to ongoing research and development aimed at addressing the limitations of existing PROMs in this field.
Sincerely,
The Author Team
References
1. Fearon AM, Grimaldi A, Mellor R, Nasser AM, Fitzpatrick J, Ladurner A, et al. ICON 2020-International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy. Br J Sports Med. 2024;58(5):245-54.
2. Terwee CB, Prinsen CAC, Chiarotto A, de Vet HCW, Bouter LM, Alonso J, et al. COSMIN methodology for assessing the content validity of PROMs User manual 2018 [Available from: https://www.cosmin.nl/tools/guideline-conducting-systematic-review-outco....
3. Terwee CB, Prinsen CAC, Chiarotto A, Westerman MJ, Patrick DL, Alonso J, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual Life Res. 2018;27(5):1159-70.
4. Nasser AM, Fearon AM, Grimaldi A, Vicenzino B, Mellor R, Spencer T, et al. Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties. Br J Sports Med. 2022;56(15):877-87.
5. Mokkink LB, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, de Vet HCW, et al. COSMIN methodology for systematic reviews of
Patient‐Reported Outcome Measures (PROMs) 2018 [Available from: https://www.cosmin.nl/finding-right-tool/conducting-systematic-review-ou....
Dear Editor,
First, we commend the efforts of the International Scientific Tendinopathy Symposium Consensus (ICON) group in defining health-related core domains for tendinopathy treatment outcomes. However, in this rapid response, we want to share our concern with the conclusion from the ICON 2020 statement concerning the development of a core outcome set for gluteal tendinopathy, written by Fearon et al. and published in the British Journal of Sports Medicine.(1)
Our primary concern relates to the suggestion that the Victorian Institute of Sport Assessment-Greater trochanteric pain syndrome (VISA-G) questionnaire, as the only condition/region-specific patient-reported outcome measure (PROM), should be considered in clinical trials - and that this measure currently is the best measure of relevant tendinopathy domains. Presently, we do not find any evidence from the literature(2,3,4) or the ICON consensus process(1) that supports such a strong statement, and we would like to support our claim in three main points:
1. The development of the VISA questionnaires has not sufficiently included patients, and the content validity of the VISA questionnaires is therefore questionable.(2,3,4) The Delphi process from the ICON paper by Fearon et al. also seems to question the content validity of the VISA-G questionnaire, as only 14% of patients (1 in 7 patients) considered the VISA-G an appropriate measure concerning gluteal tendinopathy core-domains.(1) As content...
Dear Editor,
First, we commend the efforts of the International Scientific Tendinopathy Symposium Consensus (ICON) group in defining health-related core domains for tendinopathy treatment outcomes. However, in this rapid response, we want to share our concern with the conclusion from the ICON 2020 statement concerning the development of a core outcome set for gluteal tendinopathy, written by Fearon et al. and published in the British Journal of Sports Medicine.(1)
Our primary concern relates to the suggestion that the Victorian Institute of Sport Assessment-Greater trochanteric pain syndrome (VISA-G) questionnaire, as the only condition/region-specific patient-reported outcome measure (PROM), should be considered in clinical trials - and that this measure currently is the best measure of relevant tendinopathy domains. Presently, we do not find any evidence from the literature(2,3,4) or the ICON consensus process(1) that supports such a strong statement, and we would like to support our claim in three main points:
1. The development of the VISA questionnaires has not sufficiently included patients, and the content validity of the VISA questionnaires is therefore questionable.(2,3,4) The Delphi process from the ICON paper by Fearon et al. also seems to question the content validity of the VISA-G questionnaire, as only 14% of patients (1 in 7 patients) considered the VISA-G an appropriate measure concerning gluteal tendinopathy core-domains.(1) As content validity is the prerequisite for developing a patient-reported outcome questionnaire,(5,6) it seems contradictory to refer to VISA-G as the best measure.(1)
2. The structural validity of the VISA questionnaires has previously been questioned.(2,3,7) The internal structure of the original VISA questionnaires (VISA-A and VISA-P) was never evaluated in the initial development studies.(2,3) Still, a 2-factor structure (pain/function and sporting activity) exists across the initial VISA questionnaires,(2,3) and in the VISA-G (pain/function and weight-bearing activities).(2,3) Modern Test Theory, a collection of statistical models including confirmatory factor analysis and item response theory,(8) will be able to shed more light on PROMs used in patients with gluteal tendinopathy in the future. This approach is considered the gold standard for validating patient-reported outcomes and their structural validity(8)—and has recently shown that an inconsistent underlying structure for the VISA questionnaires seems to exist.(7) This questions the assumption that the VISA questionnaires are unidimensional measures, meaning that computing VISA scores as a total sum score of all VISA items should be avoided.(2,3,7,8)
3. It is difficult for us in the ICON paper(1) to decipher how the VISA-G was recommended as a relevant interim outcome measure when patients did not find it relevant.(1) According to ICON authors, a reflexive practice was adopted where all authors identified and discussed their potential bias and addressed this continuously, which was shared in a supplementary file.(1) This reflexive practice report did not include any specific reference to the disagreement between patients and health practitioners on the relevance of the VISA-G.(1) Such a reflection could have given valuable and transparent insights as to why the patients’ initial judgment of the VISA-G was disregarded in the final part of the consensus process.(1)
Thus, in summary, we hope that the ICON authors can provide more clarity and transparency to their interim recommendation that the VISA-G, as the only condition/region-specific PROM, should be considered in future clinical trials – when empirical evidence of its superiority is lacking. Our concern is that this statement may end up guiding future trialists, peer-reviewers, and journals, in a way that may be counterproductive to the common goal - namely, to understand and use relevant and best available PROMs (existing, interim, or future ones) in patients with gluteal tendinopathy.
References
1: Fearon AM, Grimaldi A, Mellor R, Nasser AM, Fitzpatrick J, Ladurner A; COS-GT
consensus group; Vicenzino B. ICON 2020-International Scientific Tendinopathy
Symposium Consensus: the development of a core outcome set for gluteal
tendinopathy. Br J Sports Med. 2024 Mar 8;58(5):245-254. doi:
10.1136/bjsports-2023-107150. PMID: 38216320.
2: Korakakis V, Kotsifaki A, Stefanakis M, Sotiralis Y, Whiteley R, Thorborg K.
Evaluating lower limb tendinopathy with Victorian Institute of Sport Assessment
(VISA) questionnaires: a systematic review shows very-low-quality evidence for
their content and structural validity-part I. Knee Surg Sports Traumatol
Arthrosc. 2021 Sep;29(9):2749-2764. doi: 10.1007/s00167-021-06598-5. Epub 2021
May 21. PMID: 34019117; PMCID: PMC8384789.
3: Korakakis V, Whiteley R, Kotsifaki A, Thorborg K. Tendinopathy VISAs have
expired-is it time for outcome renewals? Knee Surg Sports Traumatol Arthrosc.
2021 Sep;29(9):2745-2748. doi: 10.1007/s00167-021-06596-7. Epub 2021 May 10.
Erratum in: Knee Surg Sports Traumatol Arthrosc. 2022 Aug;30(8):2880. PMID:
33970294; PMCID: PMC8384781.
4: Nasser AM, Fearon AM, Grimaldi A, Vicenzino B, Mellor R, Spencer T, Semciw
AI. Outcome measures in the management of gluteal tendinopathy: a systematic
review of their measurement properties. Br J Sports Med. 2022
Aug;56(15):877-887. doi: 10.1136/bjsports-2021-104548. Epub 2022 Apr 8. PMID:
35396205.
5: Terwee CB, Mokkink LB, Knol DL, Ostelo RW, Bouter LM, de Vet HC. Rating the
methodological quality in systematic reviews of studies on measurement
properties: a scoring system for the COSMIN checklist. Qual Life Res. 2012
May;21(4):651-7. doi: 10.1007/s11136-011-9960-1. Epub 2011 Jul 6. PMID:
21732199; PMCID: PMC3323819.
6: Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter
LM, de Vet HC. The COSMIN checklist for assessing the methodological quality of
studies on measurement properties of health status measurement instruments: an
international Delphi study. Qual Life Res. 2010 May;19(4):539-49. doi:
10.1007/s11136-010-9606-8. Epub 2010 Feb 19. PMID: 20169472; PMCID: PMC2852520.
7: Comins J, Siersma V, Couppe C, Svensson RB, Johansen F, Malmgaard-Clausen NM,
Magnusson SP. Assessment of content validity and psychometric properties of
VISA-A for Achilles tendinopathy. PLoS One. 2021 Mar 11;16(3):e0247152. doi:
10.1371/journal.pone.0247152. PMID: 33705412; PMCID: PMC7951845.
8: Christensen KB, Comins JD, Krogsgaard MR, Brodersen J, Jensen J, Hansen CF,
Kreiner S. Psychometric validation of PROM instruments. Scand J Med Sci Sports.
2021 Jun;31(6):1225-1238. doi: 10.1111/sms.13908. Epub 2021 Jan 22. PMID:
33341986.
What am I missing? The authors measured the number of steps taken by participants for only three days then they followed them for years to see who had better outcomes? Did the participants promise to keep the same level of activity until they died? Is it accurate to assume one’s level of activity will always be the same?
Have data from transgender women after GAS been included in the studies?
Surgeries undergone as part of GAS:
-Gives testosterone levels much lower than the reference values for cisgender women and much more stable than all other groups
- permanent and irreversible trauma to the muscular area (psoas, etc.) which generates losses of strength, mobility and flexibility
Dear Editor,
Hamilton et al (1) conducted a study to assess strength, power and aerobic capacity of transgender athletes. They conclude the results may be useful for sports governing bodies and inform sports policy. However, policy should be informed by accurate scientific information and, unfortunately, this study contains fundamental errors in design, methodology and interpretation. In this letter, we focus on the incorrect interpretation of respiratory testing, the inappropriate definition of ‘athlete’, and group matching.
The study compares respiratory function of transgender and non-transgender individuals using cardiopulmonary exercise testing, as well as conventional lung function testing (spirometry, lung volumes and gas transfer). The authors report that transgender women (TW - male individuals who identify as women) had greater forced expiratory volume in 1s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) and a reduced FEV1/FVC ratio relative to cisgender women (CW - female individuals without a differing gender identity). From this data, the authors conclude that TW have decreased lung function, increasing their work of breathing relative to CW.
Firstly, the methodology employed to measure lung function does not appear to conform to accepted, published testing guidelines (ATS/ERS) (2). Lung function is typically measured repeatedly within 150mL, with the highest numeric value for each variable recorded, to ensure...
Show MoreThe "healthy worker effect" is an obvious explanation for the authors' findings. In this case, they have compared the extreme winners of the genetic lottery (sub 4-minute mile male runners) with the general population, a mixed bag of healthy and non-healthy people. The outcome of all-cause mortality also presents issues, as the reason of death may or may not be health-related.
The steep decline in the longevity advantage over time indicates that this advantage may not last as the general population becomes healthier (and possibly more active). It is plausible that there may even be an opposite effect (sub 4-minute mile male runners live shorter lives) in the coming decades.
While general population statistics are easier to obtain, comparing them with those of elite athletes to make conclusions about lifespan does not answer the question of whether extreme exercise has a detrimental effect on health. A more fair comparison group would be marathoners, short-distance runners, or even runners who have not broken the 4-minute mark.
Dear Editor
I must fully concur with Dr McCrory's assessment of youth sport. Here in the US, we have a great many fathers find enjoyment in coaching their children-however there are far more whom become engulfed in the desire to win at all cost, pushing their children, dramatizing local saturday morning football as if it were the Super Bowl or World Cup. I find it highly objectionable to their behavior and the role...
We appreciate the efforts of the authors of Strength, power and aerobic capacity of transgender athletes: a cross-sectional study (1) to provide data on transgender athletes. However, we have several concerns regarding the study design and analysis which we opine severely compromise the conclusions reached by the authors.
Show MoreFirst, the inclusion criteria were that participants must “participate in a sport at a competitive level or undergo physical training three times per week”, which includes all forms of health promoting physical fitness or sports participation. We are fully aware of the difficulties recruiting suitable research participants, and particularly those from a small demographic group, but we think that much more specific inclusion criteria would have ensured more uniformly trained and comparable research participants.
The descriptive data did not provide enough information on the frequency, intensity, duration, or exercise mode of the participants to determine what type of athletes had been evaluated. While the authors state that 36% of the participants were endurance athletes, 26% team sports athletes, and 38% power sports athletes, there was no breakdown of sports participation within each comparison group. Therefore, it is not possible to know if this was a comparison of similar groups of athletes.
The data for the cisgender women and transgender women demonstrate great dissimilarity. Based on the data for body composition, muscle strength,...
We thank Brown and O'Connor (1) for their interest in our research (2) and we welcome their constructive criticism, especially regarding our study design, analysis and interpretation. We consider such exchanges equally important as the dissemination of the original research and hence, we wish to address all concerns. Concerns were raised about the need for more specific inclusion criteria to ensure comparability among research participants. Specifically, Brown and O’Connor (1) raised valid concerns about the lack of detailed information on the frequency, intensity, duration, and mode of exercise among our research participants. While we appreciate and totally agree with these comments, the task of recruiting suitable research participants, mainly from small demographic groups such as transgender athletes, is challenging. Many transgender athletes, especially those with high profile, feel too intimidated to come forward in the current polarised climate. Given this, we had to balance the need for stringent inclusion criteria with the necessity of obtaining a representative sample of transgender athletes to better understand their physiological and performance characteristics. We aimed to strike a balance between providing an informative overview of the participants' sporting backgrounds and protecting the anonymity of the transgender athletes involved in the study. We fully acknowledge that a more granular breakdown would have been beneficial for assessing comparab...
Show MoreWe have reviewed Dr McCrory’s sole authored content for plagiarism as we described in our prior editorial.[1] The University of Melbourne asked for a review of several other articles.
This has resulted in the retraction of four ‘warm up’ editorials [2 3,4,5 ] and one book review in BJSM [6] due to plagiarism. A letter in BJSM [7] has been retracted due to duplicate publication. A research article [8] and a review article [9] in BJSM have also been corrected due to inappropriate reuse of content.
Dr McCrory agrees with our decisions. No further concerns have been raised to us about content authored by Dr McCrory. This concludes our planned investigation. If further allegations are made about Dr McCrory’s work published in BJSM or in other BMJ journals, we will investigate them.
This investigation has been conducted by the Editor-in-Chief of BJSM in conjunction with the integrity team of BMJ. BJSM is published by BMJ.
BMJ Content Integrity Team, Dr Helen Macdonald and Ms Helen Hardy
BJSM Editor-in-Chief, Prof. Jonathan Drezner
1. Macdonald H, Ragavooloo S, Abbasi K, et al. Update on the investigation into the publication record of former BJSM editor-in-chief Paul McCrory. British Journal of Sports Medicine 2022;56:1327-1328.
Show More2. McCrory P. “Elementary, my dear Watson”. British Journal of Sports Medicine 2006;40:283-284.
3. McCrory P. Cheap solutions for big problems? British Journal of Sports Medicine 2007;41:545.
4....
In responding to the comments raised in the letter to the editor regarding the recommendation of the VISA-G questionnaire for gluteal tendinopathy, we first want to acknowledge qualified agreement with the points raised while also emphasising the practical considerations and guidelines that informed our recommendation.
1. A key conclusion of our recent publication was that we were not able to form a Core Outcome Set as no outcome measure had sufficient clinimetric properties (1). For a measure to be selected for a Core Outcome Set, it should have at least high-quality evidence of good content validity (2 3). As part of the COS-GT consensus process, we completed a systematic review that collected and evaluated measurement properties of all outcome measures used to evaluate patients with gluteal tendinopathy. (4) No outcome measures met this threshold. Of the ICON disability domain outcome measures that had been validated in people with gluteal tendinopathy (the VISA-G and the two HOS outcome measures), the VISA-G had, albeit low, the best available evidence for content validity (low-quality evidence of sufficient comprehensibility and very low-quality evidence of sufficient comprehensiveness and relevance). (4) After much consideration the final recommendation for interim use was based on consideration of the impact of not providing a recommendation and the COSMIN systematic review guidelines for formulating recommendations. (p45, 4.2 Step 9) (5)
2. We ackno...
Show MoreDear Editor,
First, we commend the efforts of the International Scientific Tendinopathy Symposium Consensus (ICON) group in defining health-related core domains for tendinopathy treatment outcomes. However, in this rapid response, we want to share our concern with the conclusion from the ICON 2020 statement concerning the development of a core outcome set for gluteal tendinopathy, written by Fearon et al. and published in the British Journal of Sports Medicine.(1)
Our primary concern relates to the suggestion that the Victorian Institute of Sport Assessment-Greater trochanteric pain syndrome (VISA-G) questionnaire, as the only condition/region-specific patient-reported outcome measure (PROM), should be considered in clinical trials - and that this measure currently is the best measure of relevant tendinopathy domains. Presently, we do not find any evidence from the literature(2,3,4) or the ICON consensus process(1) that supports such a strong statement, and we would like to support our claim in three main points:
1. The development of the VISA questionnaires has not sufficiently included patients, and the content validity of the VISA questionnaires is therefore questionable.(2,3,4) The Delphi process from the ICON paper by Fearon et al. also seems to question the content validity of the VISA-G questionnaire, as only 14% of patients (1 in 7 patients) considered the VISA-G an appropriate measure concerning gluteal tendinopathy core-domains.(1) As content...
Show MoreWhat am I missing? The authors measured the number of steps taken by participants for only three days then they followed them for years to see who had better outcomes? Did the participants promise to keep the same level of activity until they died? Is it accurate to assume one’s level of activity will always be the same?
Have data from transgender women after GAS been included in the studies?
Surgeries undergone as part of GAS:
-Gives testosterone levels much lower than the reference values for cisgender women and much more stable than all other groups
- permanent and irreversible trauma to the muscular area (psoas, etc.) which generates losses of strength, mobility and flexibility
Pages