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23 décembre 2013

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Première étude randomisée contrôlée : minimalistes vs maximalistes / First published randomized controlled trial: minimalist vs maximalist running shoes

English follows
La première étude contrôlée randomisée prospective sur le risque de blessures et le type de chaussage (minimaliste vs traditionnel/maximaliste) vient juste d’être publiée. ENFIN une étude de ce type!
 
En résumé 

103 coureurs habitués aux chaussures traditionnelles ont été randomisés en trois groupes : chaussures neutres traditionnelles/maximalistes (Nike Pegasus 28), semi-minimalistes (Nike Free 3.0 V2) et ultra-minimalistes (Vibram 5-Finger Bikila). Les coureurs intégraient relativement progressivement  les nouvelles chaussures (10 minutes de plus par semaine) durant un programme de 12 semaines (préparation à une compétition de 10km). Les résultats mesurés étaient le nombre de blessures (23 au total) et les douleurs reliées à la course. La proportion de coureurs blessés était significativement plus importante pour le groupe ‘Nike Free’ que pour les 2 autres conditions (Pegasus et 5-Fingers).

La conclusion des auteurs

Cette étude a d’abord pris la forme d’un ‘short paper’ intitulé « Examining the potential role of minimalist footwear for the prevention of proximal lower-extremity injuries » et publiée dans Footwear Science.

Leurs conclusions étaient formulées ainsi : « courir en chaussures minimalistes semble augmenter la probabilité chez le coureur qui porte nouvellement ce type de chaussure d’avoir une blessure ou une douleur reliée à la course lorsque s’entrainant (12 sem) pour une compétition de 10k. L’utilisation de chaussures ultra- minimalistes, par contre, peut réduire les douleurs aux genoux, à la hanche, au bassin et au bas du dos… suggérant que leur utilisation serait bonne pour prévenir ces blessures si un pré-conditionnement approprié des périostes tibiaux et des mollets est pratiqué » (Puisque les douleurs à ces endroits étaient significativement plus importantes pour le groupe ultra-minimaliste)

Cette étude a ensuite été republiée dans un format complet, avec un nouveau titre (Examining injury risk and pain perception in runners using minimalist footwear) et dans un journal de renom, le British Journal of Sport Medicine. Cette fois-ci, les conclusions se résumaient ainsi :

- Les deux groupes chaussés de minimalismes ont eu un risque accru de blessure par rapport au groupe de la chaussure neutre.

- Les chaussures modérément minimalistes ont entrainé une proportion de blessures plus importante.

- Les coureurs en chaussures très minimalistes ont signalé plus de douleur tibiale ou du mollet que les coureurs dans les deux autres groupes.

- Il est recommandé que les cliniciens usent de précaution lorsqu’ils prescrivent l’utilisation de modèles de chaussures minimalistes vu le risque de blessures et de douleurs reliées à leur utilisation.

Cette étude est la meilleure actuellement publiée sur le sujet. Le devis expérimental n’est pas parfait, mais tout de même très bien fait. Ce qui me chatouille, par contre, c’est le manque de clarté dans leurs recommandations pratiques (encadré mis en évidence – ce que la majorité des cliniciens retiennent).

Après lecture détaillée de l’étude qui a formé 2 articles, je reformulerais leur conclusion (pour plus de justesse) de la sorte :

Les coureurs récréatifs habitués aux chaussures traditionnelles qui ont intégré une nouvelle chaussure semi-minimaliste (Nike Free 3.0, 10 minutes de plus par semaine durant 12 semaines) ont augmenté significativement le risque d’avoir une blessure (plus précisément des douleurs aux mollets et aux périostes tibiaux) … ET

Les coureurs récréatifs habitués aux chaussures traditionnelles, qui ont intégré une nouvelle chaussure ultra-minimaliste (5-Fingers, 10 minutes de plus par semaine durant 12 semaines) n’ont PAS augmenté significativement le risque d’avoir une blessure, mais ont augmenté leur probabilité d’avoir des douleurs aux mollets et aux périostes tibiaux.

Quelques points critiques

Pour les passionnés :

- Les coureurs déjà minimalistes avant l’étude ou ayant moins de 5 ans d’expérience étaient exclus. Cette publication étudie donc le risque de changement de chaussure, de coureurs habitués aux chaussures traditionnelles/maximalistes vers 2 types de chaussures minimalistes, bien avant le risque de blessures relatif au minimalisme lui-même.

- Les données statistiques de ces études ne nous permettent pas actuellement de dire (comme leur premier article faisait mention) que les Free ou 5F réduisent vraiment les douleurs de genou, de hanche et du lombaire. (Même si c’est une hypothèse à laquelle je crois)

- Il est clair par contre que lors d’une transition de ce type (10min de plus par semaine), plus la chaussure est minimaliste plus les douleurs au périostes tibiaux et aux mollets sont probables. (Est-ce que cette transition est encore trop rapide?)

- Nous sommes surpris que les 5F n’aient pas montré plus de blessures.

- Le suivi était très court (12 sem)… le plus intéressant aurait été la suite… la consolidation dans l’une ou l’autre de ces chaussures, une fois le coureurs bien adapté, a-t-elle un rôle protecteur ou délétère sur l’incidence des blessures?

 Pour les scientifiques :

- Les groupes étaient plutôt petits pour en tirer des conclusions solides.

- Les valeurs confondantes identifiées au préalable pour s’assurer de l’homogénéité des groupes, ne devraient pas inclure les mesures antropométriques inutiles (angle Q et index de la posture du pied) mais plutôt certains paramètres cinétiques et cinématiques (loading rate, cadence, foot strike) et physiologique (VO2max).

- Les risques de biais sont résumés ainsi : High risk of bias for blinding of participants and other sources of bias (industry partnership grant) ; Unclear risk of bias for Allocation concealment and selective outcome reporting; Low risk of bias for sequence generation and imcomplete outcome data.

Nous savons avec plusieurs études maintenant (2013-RyanA, 2013-RyanB, 2013-Cauthon, 2013-Ridge, 2012-Salzler, 2011-Giuliani) que migrer rapidement d’une chaussure maximaliste vers une chaussure minimaliste est risqué. Les 2 questions scientifiques sans preuve solide, mais à répondre à l’avenir, sont les suivantes : 1. Un débutant devrait-il débuter en chaussures minimalistes ou maximalistes? 2. Quelle est l’incidence des blessures chez le coureur habitué aux chaussures minimalistes ou maximalistes?

… Nous avons nos hypothèses… et vous?

 

English

At last, the first randomized controlled trial on the risk of injury with relation to shoe type (minimalist vs. traditional/maximalist) has just been published!

Summary

A total of 103 runners used to wearing traditional/maximalist shoes were randomly assigned a neutral traditional/maximalist (Nike Pegasus 28), partial minimalist (Nike Free 3.0 V2), or full minimalist shoe (Vibram 5-Fingers Bikila). Runners started a 12-week training program in preparation for a 10 km event and progressively increased the proportion of their training time with the new shoes. The outcome measures included the number of injury events (23 in total) and running-related pain. The proportion of injured runners was significantly higher for the Nike Free compared with the two other conditions (Pegasus and 5-Fingers).

Conclusion of the Authors

This study started as a short paper published in Footwear Science entitled “Examining the potential role of minimalist footwear for the prevention of proximal lower-extremity injuries.

Their conclusions were as follows: “Running in minimalist footwear appears to increase the likelihood of experiencing an injury and running-related pain in runners otherwise new to this footwear category while training for a 10 km event (12 weeks). Using a full minimalist design; however, may reduce pain at the knee, hip and pelvis, and lower back suggesting there is merit in using a full minimalist design for injury prevention with appropriate pre-conditioning of soft-tissue in the shin and calf.” (Given the fact that the experience of pain was significantly more important in the case of the ultra-minimalist group.)

This study was subsequently published once more in a more thorough format in the British Journal of Sports Medicine under a new title (Examining injury risk and pain perception in runners using minimalist footwear). This time, the conclusions were as follows:

- Both partial and full minimalist footwear designs resulted in a greater risk of injury compared with the neutral footwear group.

- The partial minimalist shoe resulted in a greater overall injury rate.

- Runners in the full minimalist shoe reported greater shin and calf pain than runners in both other footwear groups.

- It is recommended that clinicians use caution when prescribing the use of minimalist running shoe designs in light of the greater risk of injury and pain with their use.

This study represents the best work published thus far on the subject. While the experimental protocol is not flawless, it is very well designed. What bugs me though is the lack of clarity in their clinical recommendations (text box highlighting what the majority of practitioners will remember).

After a careful reading of this study published in two parts, I would formulate their conclusion differently (for more accuracy):

Recreational runners used to wearing traditional shoes and who were assigned a new partial minimalist shoe (Nike Free 3.0, 10 minutes more per week for 12 weeks) showed a significantly higher risk of injury (more precisely at the calf and shin) … AND

Recreational runners used to wearing traditional shoes and who were assigned a full minimalist shoe (5-Fingers, 10 minutes more per week during 12 weeks) did NOT show a significantly higher risk of injury, but rather a higher likelihood of developing pain at the calf and shin

Here are a few critical points

For research addicts:

- Runners who already wore minimalist shoes before the study or with less than five years of running experience were excluded. Thus, this publication studied the risk associated with the integration of new running shoes, in runners used to traditional/maximalist footwear switching to two different types of minimalist shoe models, well before assessing the actual injury risk related to minimalism per se.

- The statistical data relative to these studies as they stand right now do not allow us to conclude (as was stated in their first article) that the Free or 5F actually reduce pain at the knee, hip, and lower back. (Even though I do believe in this hypothesis.)

- On the other hand, it is clear that in the case of such a transition (10 minutes more per day), the more minimalist the shoes, the more likely the pain at the shin and calf. (Is this transition still too aggressive in terms of time?)

- We are surprised to see that the 5F have not caused more injuries.

- The follow-up period was very short (12 weeks)… a longer follow-up would have been very interesting: once runners are well adapted to their new running shoes, is there a protective or deleterious effect of either footwear on the incidence of injuries?

For scientists:

- The groups were too small to draw solid conclusions.

- The confounding variables previously identified in order to ensure group homogeneity should not include useless anthropometric measures (Q angle and foot posture index), but rather specific kinetic and kinematic parameters (loading rate, cadence, foot strike pattern) as well as physiological parameters (VO2 max).

- The risk of bias is summed up as follows: High risk of bias for blinding of participants and other sources of bias (industry partnership grant); Unclear risk of bias for allocation concealment and selective outcome reporting; Low risk of bias for sequence generation and incomplete outcome data.

Thanks to a wide range of studies (2013-RyanA, 2013-RyanB, 2013-Cauthon, 2013-Ridge, 2012-Salzler, 2011-Giuliani), we now know that a quick transition from a maximalist shoe model to a minimalist design represents a certain degree of risk. Be that as it may, there are still two scientific issues that would need stronger evidence: 1. Should beginners start with minimalist or maximalist running shoes? 2. What is the incidence of injury for runners used to minimalist or maximalist running shoes?

… We have a few hypotheses in mind… do you?

Blaise and Jean-Francois

 

24 Comments Post a comment
  1. déc 23 2013

    I definitely think starting with minimalist shoes will prevent weakness and develop better proprioception. I would like to learn about body weight/mileage/years of experience/running during pregnancy and how these parameters affect injury rate/rate of adaptation. Thank you for the information! Happy Holidays, Dawn

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  2. déc 23 2013

    Des résultats constant avec ce qu’on sait déjà, si je ne m’abuse. Est-ce l’étude sur laquelle vous avez travaillé? Si oui, bravo!
    Je me permet une petite question : quelle est la différence entre des douleurs au mollet/tibia et une vraie blessure, comme la périostite tibiale. En gros, pourquoi est-ce que ces douleurs ne sont pas considérées comme des blessures?
    Ps. je pense qu’il y aurait encore moins de blessures pieds-nus.

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    • déc 23 2013

      C’est pas la notre mais le protocole est assez ressemblant. (Le goupe de Taunton et Ryan à Vancouver)

      Les douleurs sont un paramètre qu’il ont suivi au même titre que les blessures (3 jours d’entrainement manqué pour douleur. Donc certaines douleurs devenaient des blessures si elle interféraient avec l’entrainement.

      Pour les 5F je reste surpris qu’il n’y ai pas plus de douleur/blessure générale… mais pas surpris de la tendance (non significative par contre) du moins de douleur aux genou et dos…

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  3. déc 23 2013

    Did the trials subjects run on grass/dirt or asphalt/concrete during the trials or was that not part of the control? I would think that the running surface/conditions would play a role in injury rates. Having run/raced at a high level for 30+ years and coached for 13 it seems we are back to the shoes of the 1970s with cushioning but not excessive cushioning and the « new »minimalist shoes are like the racing flats we wore all the time. The Nike Free were offered to our group in 2005/6 in the UK and definitely added stress to your foot, so many of us chose not to wear them after a week as they caused pain even then! Looks like we can start to put this to rest now?

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    • déc 23 2013

      About surfaces : variable and no significant difference between the 2 groups.

      Agree about normal shoes in 1970 vs minimalist shoe in 2013

      Minimalism is « risky » now because our feet are becoming « weak, fragile, less tolerant to stress » because the constant protection we have with our modern running shoes.

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  4. déc 24 2013

    If you want another version of the interpretation of this study… from big bulky shoe / orthotics defenders… or rhetoric and propaganda of the orthotics fan boys, see http://www.runresearchjunkie.com/examining-injury-risk-and-pain-perception-in-runners-using-minimalist-footwear/

    Normally this blog is credible and serious and I respect the author… just think he has something against minimalism because his « podiatry bias ». See another post where « his own filter » make some statement that are just part of the truth… including cherry picking of scientific articles http://www.runresearchjunkie.com/foot-strike-pattern-and-injury-rates/

    Whatever, I recommend you to subscribe to his e-mail newsletter to receive updates!!

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  5. petit-pied
    déc 24 2013

    bonjour,

    1- surpris pour les blessures de périostites tibiales car suite à deux semaines de courses en running traditionnel, je me suis fait une périostite phénoménale que j’ai solutionné en courant… pieds nus (pas guérie d’ailleurs car si je cours à « l’ancienne » -talon- je peux de suite lui redire coucou) je cours donc, depuis avril 2012, pieds nus avec une périostite mais qui !! grâce à la course pieds nus !! ne se manifeste plus
    bon comme quoi on est tous fait différemment ;)
    2- même incompréhension sur l’étude pourquoi prendre des cobayes en transition ??? on le sait que tout changement dans une foulée est un risque de blessures potentiel
    Il serait très intéressant de prendre des coureurs confirmé dans leur manière de se chausser (ou pas) et de niveau identique (courant de même distance) et là voir l’évolution des blessures et douleurs sur une période prolongée d’au moins une saison.
    3- vitesse de transition : je la trouve effectivement élevée perso lorsque j’ai appris à courir pieds nus, par séance je ne faisais que 10 % de plus du timing précédent !!
    et en faisant un calcul arondis, les débuts ce n’était donc que deux trois minutes par semaine

    bon ne critiquons pas trop non plus pour une fois qu’il y a une étude et que j’arrive à avoir le compte rendu en français en + !! ^_^

    De bonnes fêtes de fins d’années à tous !

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    • déc 24 2013

      1. il y a 2 types de périostites (crête tibiale antérieure causée par l’attaque talon et les grosses chaussures à talons surélevés :: et la crête tibiale postéro-médiale qui pourrait être dans certain cas causée par une attaque nouvelle avant pied ou des chaussures plus minimalistes)
      2. d’accord… mais le mieux serait de prendre des coureurs sans habitude, totalement débutant… là on saurait vraiment si les chaussures traditionnelles/maximalistes préviennent vraiment l’incidence des blessures.

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  6. déc 24 2013

    Another critics of this article from Peter Larson on Runblogger (very accurate like always) http://runblogger.com/2013/12/do-minimalist-shoes-increase-injury-risk-merry-christmas-vibram.html

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  7. Cody R.
    déc 24 2013

    yea, the minimalist footwear like Nike frees are basically a traditional shoe, but less

    that causes more damage due to doing the same thing (form and all that) as with traditional shoes and have less protection therefore more likely to cause injuries

    that’s why i never recommend them, only barefoot shoes or zero drop footwear at least if they are older and had more time in traditional footwear but perform barefoot exercises to get them as close to the ground as they can, as safely as they can

    no one’s been injured on my watch :)

    hope i can keep it up

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  8. déc 24 2013

    We have developed a way to make the concept behind running shoes simpler by determining “where each shoe model stands in terms of minimalism or maximalism” (in relation with “the probability that a specific shoe impacts running kinetics and kinematics”). To that extent, we have built a formula based on specific characteristics (TRC rating/minimalist index). We actually know (some interesting paper on that) that TRC rating < 70% is often not enough to change biomechanics and TRC rating > 75% often enough… (barefoot: 100%, VFF Bikila: 86%, Nike 3.0 version 5: 72%, Nike Pegasus 28+ : 54%)… all is question of probability!

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  9. Michael Ryan
    déc 24 2013

    Blaise,

    Thanks for the discussion on our paper, always nice to see our work being considered by clinicians and trainers.

    Please be careful with your interpretation of the findings re risk of injury. I think our clinical recommendations were actually quite clear and well founded based on the outcomes within the study. Both minimise shoe models showed a higher relative risk of injury compared to wearing the Pegasus and I would consider a 160% higher likelihood to being injured in the 5f was clinically meaningful inspite of the ‘non significant’ survival analysis (which is simply one approach of statistically treating this data).

    That being said I think minimalist shoes have a place in running to help supplement training on a variety of levels that we were unable to measure. Concurrent motion analysis with kinetics on a sample this size would be a massive study and $$$$ but would greatly complement our findings vis a vis mechanisms of injury or prevention.

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    • déc 25 2013

      Hi Michael,
      Many thanks for this RCT. Many thanks also to drop a line on our blog. The goal is to transfer the knowledge of science into clinical guidelines for clinicians and coaches.

      About the result of your study:
      I was surprise that the 5Fingers group was not more injured than the Free and the Pegasus group (we speak here about transition to new « very minimalist shoes » and with just 12 weeks of adaptation to run 115min per week with this new shoes).

      About your stats:
      The Kaplan-Meier plot as well as in the tables presented in the supplementary data, risk of injury in the Vibram Fivefingers was not significantly different from the Pegasus (we are both agree with that)…
      It means that confidence interval for absolute risk reduction in VFF compared to Pegasus overlaps zero, confidence interval for relative risk in VFF relative to Pegasus overlaps 100% or 1.

      Therefore, I don’t understand your interpretation. We cannot say that 160% is « clinically meaningful » if it’s « not significant »…
      « Not significant » means that the chance that this difference is not a real difference exist… in a proportion that make us to conclude that there is not a difference between groups. (The sample size at that point is very important. 160% for a groupe of 3 runners cannot be significant and has no value on « clinical meaningful »… 160% for a groupe of 300 runners is certainly significant… and after we can say that this difference is clinically meaningful). The opposite is different. If you have a lot of people in your study you can have significant difference (ex: 105%) but decide that this difference is not clinically meaningful.
      Huuuummm … I will ask to statisticians, maybe I’m wrong on my interpretation.

      About your clinical recommendations:
      So, I had a hard time with your sentence « Both partial and full minimalist footwear designs resulted in a greater risk of injury compared with the neutral footwear group. » Both combined (statistically) or the Free only are the 2 ways to say that « Minimalist shoes group(s) resulted in a greater risk of injury ».

      Sorry for my bad english. Hope you understand me. And again, my hypothesis goes on the same way that what you say: transition to minimalist shoe is more dangerous than not changing habits… and (I would add): be used to wear minimalism less injurious that big bulky shoes.

      Best
      Blaise

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    • déc 25 2013

      I have to agree with Blaise here. Non-significant is non-significant, it’s why we use stats. If you ran the study again the results could be reversed.

      If we believe that a non-significant result is meaningful, then we could go ahead and say that we should be concerned about the Pegasus increasing risk of low back pain, or the Free increasing risk of knee pain. But the results are non-significant so we don’t.

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  10. Michael Ryan
    déc 25 2013

    Guys,

    There were two different approaches to analysing the injury data in the study, one is through calculating relative (and absolute) risk of wearing the minimalist shoe models compared to the Pegasus, the other is the survival analysis of onset of injury across the three footwear groups over time. These are independent analyses, so you can’t directly interpret findings from the survival analysis to the relative risk statistic.
    We did not perform significance testing on the relative risk as this is simply an expression of the number of injuries experienced by the minimalist groups relative to the neutral shoe.
    The survival analysis is an significance test on the onset of injury over the course of the training period.
    Relative risk is overall comparison, survival analysis is really looking at the time to an event: it takes less time to get an injury in the Free than the other shoes, but the overall injury risk is 160% and 300% for the 5F and Free

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    • déc 25 2013

      But the confidence interval for your relative risk value for the Vibrams is 0.51-4.96. It includes 1, so thus is non-significant. A value of 1 means no difference in risk between the two conditions. Same for absolute risk reduction, the condfidence intervals for the Vibram group (-25.1-11.0) here overlap 0, so again non-significant.

      My background is in multivariate morphometrics so epidemiological analysis is a bit outside my area of expertise, but this is my understanding of how these statistics work. Please correct me if I’m wrong (I have been wrong before!).

      For the Frees you have 1.12-8.57. Does not include 1, so elevated risk is indeed significant in the Frees, not in the Vibrams.

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    • déc 25 2013

      Even with survival analysis, even if the overall risk is 160% or 300%, even if it’s can be clinically meaningful or not… we need to be sure that this difference is significant (significant = the probability that an effect is not likely due to just chance alone)…
      And, in your study the difference between 5F and Pegasus is NOT significant… so the 60% of difference is maybe just the chance alone.
      I will contact biostatistician to have precision on that part.
      Thanks again Pete an Michael for the discussion.

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    • déc 26 2013

      After discussion with a biostatistician from Laval University, it’s clear that the results of this study don’t show a significative difference between the 5F and pegasus groups… and it’s not appropriate to say « Both partial and full minimalist footwear designs resulted in a greater risk of injury compared with the neutral footwear group. »

      My personal opinion : if you do the same study with more subjects to be sure to have significant results… My hypothesis is that your 5F group will have more injuries (because it’s a change) than the pegasus (closer to the habits of the subjects)… and more also than the Free.

      Happy Christmas everybody
      Blaise

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  11. Lynne Moore
    déc 26 2013

    I have a few comments on the statistical analysis. The log-rank test tests the null hypothesis that there is no difference between groups so a p-value below 0.05 indicates that there is a statistically significant difference (without specifying which groups are different). Figure 2 appears to indicate that you performed two tests – one comparing partial minimalist and neutral and one comparing full minimalist and partial minimalist (surprising since the comparison that appears to be of interest is the minimalist versus neutral one). Performing two comparisons would require an adjustment for multiple comparisons (e.g. Bonferroni alpha/2). As far as the relative risks go, it’s not clear to me whether you present a ratio of incidence proportions or of incidence rates (neither the rates nor the proportions presented in Table 3 lead to the given RR). In any event, as mentioned in earlier comments, the confidence interval indicates that the difference between the neutral and full minimalist groups is compatible with zero (and the risk compatible with 1). That just means that due to low sample size, you were unable to detect a clinically significant difference (if you consider a 60% increase in risk to be clinically significant). It’s surprising that sample size calculations were based on differences in the pain scale rather than differences in injury incidence since the latter is presented as your main outcome.

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  12. déc 29 2013

    Hi Blaise, Pete and Michael
    Firstly, great research Michael, some great information for researchers and clinicians alike – hopefully some follow up to come?
    Secondly, great piece Blaise and very good to put both forms of the paper in the one forum.

    I will leave the stats aside >> important but essentially made up arbitrary cut off values for which total agreement will never occur :)

    For me the key findings/messages from this paper are
    1. That change = increased risk of injury. This is not isolated to footwear – e.g. running volume, running intensity, terrain, etc.
    2. Conditioning and form may be (probably is) more important than footwear itself (the importance of this is speculated in the recommendations)
    3. Clinicians should use caution when changing patients footwear (covered in recommendations) and don’t rely on recommendations made by a commercially drive company (e.g. VFF)

    Going forward, I think we still need to learn more about the influence of footwear properties on injury risk and treatment. However, perhaps more importantly, we need to learn more about the influence of other changes on injury risk (i.e. run volume and intensity). I think this is the most common reason I see running injuries clinically, yet it is a factor that is poorly researched. If this is proven in research, patients may actually listen to activity modification advice. Additionally, understanding the influence of changing running mechanics on injury (for better or worse) may be more valuable than the influence of footwear, orthotics, etc. These external devices are probably just a tool which may or may not facilitate changes to mechanics.

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  13. déc 29 2013

    Thanks Christian,
    My comments
    1. Agree
    2. Agree http://www.therunningclinic.ca/blog/2013/12/debat-sur-la-prevention-des-blessures-1-debate-on-injury-prevention-1-debate-sobre-la-prevencion-de-lesiones-1/
    3. Agree (e.g. VFF OR ASICS …! all depending of the habit of the patient)

    About shoes/biomechanics
    If my goal is to increase impact moderating behaviour, I will personalized my prescription (of the intervention) in function of 4 things.
    1. Which intervention the patient is able to integrate easily?
    2. Which intervention works the most to moderate the impact force?
    3. Which intervention is the less « dangerous »?
    4. Which intervention is more durable?

    With these 4 questions I choosing the best intervention for my patient (personalization). In general the more frequent (in my practice) are (in order) : change for more minimal interface -minimalism-, increase cadence, do less noise, change your foot position (I’m more afraid about this last recommendations… very efficient but more dangerous)

    Best
    Blaise

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  14. Rich Willy
    déc 29 2013

    Blaise and Jean-Francois,
    Christian makes some great points and I agree fully with his takeaway points from the paper. I am also not going to comment on the stats.

    I’m left with a few additional thoughts on this blog’s post and from the Ryan paper:
    1. I think it brings up the argument of effectiveness vs efficacy. While there are clinical instances when changing shoe-type is done in a very controlled manner, it is safe to say that very few runners do so on their own. It seems that it is important to look at both approaches (controlled vs haphazard) and to consider both carefully.
    2. If change is truly bad, then we would expect higher injury rates in minimalist shoe runners when they are transitioned to highly cushioned shoes such as a Pegasus. Seems like an arm such as this should be included in footwear studies. Now, that would be an interesting study :-)
    3. I am unaware of any study that demonstrated better biomechanics (reduced impact loading, reduced ankle and knee joint power, reduced patellofemoral joint stress) in a minimalist shoe in novel minimalist runners… that also did not include at least some instruction in running mechanics (gait retraining) e.g. McCarthy 2013. In fact, we see quite the contrary (Willson, 2013, Willy and Davis, 2013). Yet, we see pretty profound reductions in these variables with gait retraining alone without changing shoes. What we don’t know is if retraining certain aspects of gait is easier in minimalist shoes.
    4. How we define an « injury » is important. For example, Ryan counted an injury if 3 consecutive days were missed. This is by no means a universal operational definition as some researchers count an injury as more or less time lost. No commentary here, just something that should be pointed out. As such, a runner could miss nonconsecutive runs due to pain and have it not counted as an injury. Something to consider for future studies.

    Best,
    Rich

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  15. jan 2 2014

    Hi Rich,
    See some of my comments
    1. Fully agree
    2. YES, I would expect higher injury rates in minimalist shoe runners when they are transitioned to big bulky shoes… and I predict that they will be injured at the knees, hips and lower back. (2 cases like that in our pilot study)
    3. HUUMMM… If the principal cause of « alteration of biomechanics » is the big bulky shoe… why just working on gait retraining? Maybe we can combine both, but I think the intervention will be more durable (2013-Giandolini) if the integration is made by unconscious changes (neuro-physiological) than with a complex intellectualization of the movement…
    If we do gait retraining, I will recommend general tips first (increase cadence, do less noise) and very rarely specific changes (more injurious, we don’t know if it’s working, difficult to integrate for many patients)
    4. Clear definition is coming. We have participated to a Delphi study (experts consensus around the world… you were probably in) on the definition of « running injury » with a researcher group from Brazil… hope to see the result soon.
    In our pilot study : a running related injury was defined as: 1) any period of three or more training days that were either missed or decreased by at least 50% because of pain, or 2) a diagnosis of running related injury following evaluation by the health professionals. In addition, runners reporting levels of pain ≥ 4/10 without being forced to miss or decrease training were also referred to the sport physician to establish whether a running related injury was present.

    See you in the CSM-APTA to continue the debate :)
    Blaise

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