Sports After Total Joint Replacement
Technologic advancement during the last several decades in both implant design and component manufacturing has allowed surgeons to offer total joint replacement (TJR) to a wider range of patients. These include young active patients with posttraumatic osteoarthritis, aging athletes who want to continue exercising, and elderly patients who have had multiple revisions of joint replacements but want to remain active.
Minimally invasive techniques and limited incisions, along with reduced surgical dissection, have decreased recovery times and allowed earlier return to activities. However, the outcome of TJR and return to sport has not been well studied.
Pain and decrease in activity level are the primary reasons that individuals seek joint replacement surgery. Postoperatively, however, recommendations/restrictions for return to activity vary among surgeons, as well as in the literature. The authors note that patients often disregard the recommended restrictions, creating increased risk of loosening and failure of the implant.
This article provides a guide to activity after TJR that stratifies risks by level of impact loading (low to high) by sport, as well as participation in specific sports based on anatomic location of the arthroplasty. For example, golf has a low impact level, but orthotics and activity modifications can further reduce impact loads, whereas basketball has a high impact level and has a significant probability of injury that can necessitate revision. Horseback riding, cross-country skiing, and bicycling are all acceptable for patients with hip, shoulder, or knee replacements, but karate and lacrosse are not recommended for patients with any of these joint replacements. These guidelines are covered in two helpful tables.
Returning to competition after TJR is extremely difficult. Return to recreational sport can present a challenge also and depends to a great degree on the stability and strength of the joint preoperatively. Repetitive motion of a particular sport wore out the original joint and will have a similar effect on the replacement joint. Patient education, both preoperatively and postoperatively, is essential to helping patients choose appropriate exercise after TJR.
Clifford, P. E., & Mallon, W. J. (2005). Sports after total joint replacement. Clinics in Sports Medicine, 24(1), 175-186.
Vitamin D and Bone Health
Vitamin D and calcium are essential components of osteoporosis management strategies. This review article discusses the role of vitamin D in bone health and summarizes current information about high prevalence of inadequate serum levels of vitamin D and recommendations for supplementation.
Vitamin D is a steroid hormone. It was mistakenly classified as a vitamin because of early findings that cod liver oil (a dietary source of vitamin D) prevented rickets in children. The active form of vitamin D has numerous physiologic activities, including upregulating intestinal calcium and phosphate absorption. Inadequate vitamin D levels impair calcium absorption, leading to increased bone resorption and accelerated bone loss.
Data from a range of studies (epidemiologic, clinical, and laboratory) also suggest a direct effect of vitamin D on muscle strength, and several studies have demonstrated a correlation between low serum vitamin D and age-related muscle weakness, musculoskeletal pain, increased body sway, increased risk of falls, and fall-related fractures. Refer to the article for the specific study references.
There is no consensus on the optimal level of vitamin D. Serum levels of hydroxylated vitamin D [25(OH)D] are the most reliable indicator of vitamin D status. Levels of 25(OH)D <20 ng/mL have been associated with decreases in bone density, decreases in intestinal calcium absorption, and decreased lower extremity function. It is suggested therefore that >30 ng/mL of 25(OH)D are essential for maximal calcium absorption.
Sources of vitamin D are limited and include diet (oily fish, fish oil, and fortified milk in the United States) and synthesis in skin from exposure to ultraviolet light. Skin synthesis is hindered by factors that reduce ultraviolet light penetration and intensity. These include sunscreen use, clothing, darkly pigmented skin, season, and latitude. However, a global study has suggested that latitudinal association is overwhelmed by other factors.
Epidemiologic data document the continued and widespread high prevalence of inadequate serum levels of vitamin D among osteoporotic patients and the elderly. This is a global problem, irrespective of latitude. Several studies have found that more than 50% of patients with osteoporosis have inadequate levels of vitamin D. Despite that supplementation is the simplest and most effective means of obtaining adequate vitamin D levels, few patients with osteoporosis currently take vitamin D supplements.
The U.S. Food and Drug Administration, as well as the Scientific Committee for Food established by the Commission of the European Communities, recommends 400 IU of vitamin D daily for all adults, irrespective of age. The Institute of Medicine Adequate Intake for the United States and Canada recommends 400 IU of vitamin D daily for people aged 70 and under and 600 IU for those over 70 years. Vitamin D toxicity has not been reported from overexposure to sunlight and has only been associated with intake when daily doses exceed 10,000 IU.
Vitamin D is essential for optimal skeletal health, but inadequate levels are prevalent in many adults. Greater awareness of this problem by both healthcare providers and the public is necessary to maximize bone homeostasis.
Reginster, J. (2005). The high prevalence of inadequate serum vitamin D levels and implications for bone health. Current Medical Research and Opinion, 21, 579-585.
Multi-Ethnicity and Healthcare
The 2000 U.S. Census included changes allowing people to check more than one racial category, offering a total of 126 possible combinations of race and ethnicity. "Races" included White, Black, American Indian, Asian, Pacific Islander, and other. Individuals were also able to declare Hispanic ethnicity. Children were more likely to be categorized as multiracial (4.2% of children under 18) than were adults (1.9%), likely reflecting an increase in the number of interracial couples in the United States.
The option to declare more than one race is now being extended to all federal programs and is part of a larger societal awareness of the role of race, ethnicity, and culture in the United States and has important implications in the healthcare arena. The terms race, culture, and ethnicity are often used interchangeably, and their definitions have changed over time.
The American Medical Association (AMA) endorsed the multiple racial/ethnic categories of the 2000 Census, noting that examining genetic and cultural contributions to health and illness could better be achieved with more specific information. The Institute of Medicine (IOM) noted that the traditional conception of race rests on the false premise that natural distinctions grounded in significant biologic and behavioral differences can be drawn between groups. The IOM, therefore, argued that emphasis should be on ethnicity rather than race. This recommendation was based on the fact that racial categorizations used in this country are not discernible based on genetic information.
The importance of race as a health variable, however, should not be overlooked. It has been useful in helping to demonstrate long-standing health disparities. Also, because race is a factor in social inequality, failing to examine race as a variable in health research will make it difficult to examine racism and social inequality in healthcare and public health practice.
Within racial groups, ethnic and cultural distinctions have notable health implications. For example, Asian emigrants from China, Japan, Vietnam, and India have many genetic, dietary, and potentially health differences. Hispanics differ also: Puerto Ricans, Mexicans, and Cubans in the United States have important differences in education, income, and access to healthcare. Second- and third-generation emigrant families also differ from the first generation. Accurate data on racial identity are especially important in screening for genetic diseases (e.g., cystic fibrosis, sickle cell anemia, and Tay Sachs disease), for bone marrow donations, and in relation to drug reactions.
The increase in the number of interracial families and multiracial children in the United States has important implications for pediatric health professionals. First, accept family diversity. Second, be vigilant about assumptions based only on a child's appearance. Third, support positive identity development in children. Fourth, offer resource materials to interracial families and multiracial individuals who may wish to find literature or support groups. The author provides print recommendations and a table listing Internet-based resources for families and individuals.
Ahmann, E. (2005). Tiger Woods is not the only "Cablinasian": Multi-ethnicity and health care. Pediatric Nursing, 31, 125-129.
The Female Athlete Triad
Are Elite Athletes at Increased Risk?
A serious syndrome comprising three interrelated components-disordered eating, amenorrhea, and osteoporosis-has been termed the female athlete triad (the triad). It has been stated that all female athletes are potentially at risk of developing the triad but that athletes competing in sports in which leanness and/or low body weight is considered important may be at increased risk. It is unclear, however, to what extent girls and women engaged in physical activity at different levels are at risk for developing the triad. The purpose of this study was to look at risk factors for the triad components. The prevalence of disordered eating and eating disorders in young female athletes had been reported to be higher in athletes than in nonathletes, particularly in athletes competing in sports that emphasize leanness or low body weight. Few prevalence studies related to premature osteoporosis in young athletes and nonathletes have been published.
Each of the three disorders of the triad alone may result in serious medical health consequences. Because the triad is frequently denied, not recognized, and underreported, proper screening for numerous symptoms and risk factors has been recommended. Because disordered eating and most likely also menstrual dysfunction and osteoporosis are assumed to occur on a continuum, early detection and identification of females with at-risk behavior associated with these three components may prevent further development and worsening of triad symptoms.
Participants
The total population of female elite athletes in Norway, 13-39 years of age (N = 938) and nonathlete controls in the same age group (N = 900) were invited to participate. In this study, an elite athlete was defined as one who qualified for the national team at the junior or senior level or who was a member of a recruiting squad for that team. The athletes represented 66 different sports/events. Seven different sport groups were formed and then divided into two groups: leanness sports and nonleanness sports. Athletes competing in sports in which leanness and/or a specific weight were considered important were included in the leanness group and sports in which these factors were considered less important were included in the nonleanness group.
Leanness sports included cross-country skiing, swimming, figure skating, gymnastics, boxing, weightlifting, pole vaulting, and the long jump. Nonleanness sports included fencing, golf, snowboarding, basketball, soccer, tennis, alpine skiing, and bobsledding.
Questionnaire
A questionnaire including a battery of assessment questions was sent to each of the eligible athletes and eligible controls. The response rate of the total sample was 88.3%. In addition to questions regarding menstrual history, oral contraceptive use, and pregnancy, the Body Dissatisfaction and Drive for Thinness subscales of the Eating Disorder Inventory and questions regarding weight history, training history, training time and physical activity patterns, dietary history, nutritional habits, use of pathogenic weight-control methods (e.g., diet pills, vomiting, diuretics, and laxatives), possible eating disorders, and injury history were included on the questionnaire.
Results
The athletes were younger than the controls and reported a lower body mass index (BMI). Athletes competing in aesthetic sports were younger with lower height and weight compared with all other sports. Athletes competing in nonleanness sports had lower weight and BMI compared with controls.
A higher percentage of controls (62.9%) than athletes (60.4%) were classified as at risk of the triad. The difference was still significant after adjustment for age (p <. 01). A higher percentage of controls reported use of pathogenic weight-control methods, whereas more athletes reported low BMI, menstrual dysfunction, and stress fractures compared with controls.
A higher percentage of athletes competing in leanness sports (70.1%) and controls (69.2%) were classified as at risk for the triad compared with athletes competing in nonleanness sports (55.3%) (p < .001). A higher percentage of athletes competing in leanness sports were underweight and reported menstrual dysfunction compared with both athletes competing in nonleanness sports (p < .001) and controls (p < .001).
Significant differences in at-risk percentage were found when comparing the different sport groups (overall, p < .01). A higher percentage of athletes competing in aesthetic sports were classified as at risk of the triad compared with athletes competing in ball game sports.
Discussion
The main findings in this study are as follows: (1) more than 6 of 10 females were classified as at risk of the female athlete triad, with small differences detected between normal active females and elite athletes, and (2) higher percentages of both athletes competing in leanness sports and controls were classified as at risk of the triad compared with athletes in nonleanness sports.
It is surprising that as many at 64% of the women included in this study were classified at risk of the triad. However, it is important to remember that previous studies focusing on at-risk subjects have mainly investigated undernutrition, weight loss, and risk of eating disorders and not asked for menstrual dysfunction or stress fractures. Because components of the triad presumably occur on a continuum, it was considered important to not only focus on the presence of symptoms of severe eating disorders, amenorrhea, and osteoporosis but go one step further and evaluate early warning signs.
In contrast to what was expected, the results show that a significantly higher percentage of nonathlete controls than of athletes were classified as at risk of the triad when including all risk factors. It appears there is little difference between the nonathlete controls and the athletes regarding disordered eating and eating disorders, whereas clear medical signs like a history of menstrual dysfunction and stress fractures is more common in the athlete population.
The results from this study are in accordance with other studies reporting a high prevalence of disordered eating and menstrual dysfunction in sports focusing on leanness and/or low body weight. A higher percentage of athletes competing in leanness sports classified as at risk of the triad was found when compared with athletes competing in nonleanness sports. A high percentage of athletes competing in endurance, aesthetic, and weight class sports reported menstrual dysfunction. This is in agreement with other studies and may reflect the consequences of competing in sports in which leanness and low weight are considered important.
Based on the high prevalence of exercising girls and women at risk of the triad, it is necessary to continue the ongoing education of athletes, coaches, leaders, and parents, as well as physically active girls and women in general, about the life-threatening health consequences of inadequate energy intake and excessive exercise habits. In turn, it may be possible to prevent more females from developing one or more of the components of the triad.
Torstveit, M. K., & Sundgot-Borgen, J. (2005). The female athlete triad: Are elite athletes at increased risk? Medicine and Science in Sports and Exercise, 37, 184-193.