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Bibby K, Kenny IC, Cahalan R, Purtill H, Comyns TM. Contact Breast Injuries Among Female Athletes: A Systematic Review. Sports Med 2024:10.1007/s40279-024-02027-y. [PMID: 38693460 DOI: 10.1007/s40279-024-02027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Robust surveillance of injury aetiology and epidemiology is recognised as fundamental for effective injury reduction and management programmes. However, while sex-specific differences in injury type and nature are noted in the literature, it is unclear if these are reflected in surveillance practices, and how the athlete is affected. OBJECTIVE Therefore, this study aimed to systematically review contact breast injuries (CBIs) among adult female athletes. METHODS The following databases were searched: PubMed, EMBASE, SPORTDiscus including MEDLINE, Web of Science and Scopus. The literature search was conducted in May 2023 and the search was limited to articles in the English and German language. Studies including female athletes, aged 18 years and above, in any sports (team or individual) at any level (amateur, semi-professional and professional), where an occurrence of CBI was documented were included. Studies were included irrespective of their investigated timeframes (e.g. the whole career, one or multiple seasons). Findings were categorised (e.g. sport, level of competition and investigated timeframe of the study) to enable possible comparisons. Case studies were excluded due to the non-generalisability of findings. RESULTS Of the six studies included, rugby codes (rugby union, rugby league and rugby sevens) had the highest occurrence rate (62.0%) of CBIs among eight different investigated sports (rugby codes 62.0%, softball 59.5%, Australian Football League (AFL) 51.0%, water polo 50.0%, soccer 46.7%, basketball 27.6-48.8%, volleyball 34.6%, boxing 0.0%). Between 25.6% and 62.0% of participants reported incurring a CBI and between 0.0% and 42.9% of CBIs were reported to a medical professional or support staff. The reported treatment rate for CBIs ranged between 0.0% and 2.1%, The main mechanisms for CBIs (where reported) were contact with another athlete (AFL 37.6%, rugby codes 56%) the ball (AFL 31.6%, rugby codes 25.5%) and the ground (AFL 6.6%, rugby codes 22%). Between 18.2% and 48% of the participants reported that CBIs negatively affected their performance. Risk factors increasing CBIs were positional differences, larger breast size and higher body mass index (BMI). In-season injury data collection and surveillance supported through education of both players and medical staff were identified to be of relevance for future CBI prevention. None of the studies reported incidence rate. CONCLUSION Despite the frequent occurrence of CBIs among female athletes, reporting and treatment remains low. Awareness and education of all stakeholders are fundamental to ensuring better breast safety in female sport. Identifying the mechanics, severity and risk factors of CBIs through thorough injury surveillance must be a focus of further research. REGISTRATION The study was preregistered on Open Science Framework (OSF).
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Affiliation(s)
- Kilian Bibby
- Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland.
- Sport and Human Performance Research Centre, University of Limerick, Limerick, Ireland.
- Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Ian C Kenny
- Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
- Sport and Human Performance Research Centre, University of Limerick, Limerick, Ireland
- Health Research Institute, University of Limerick, Limerick, Ireland
- Lero, The Science Foundation Ireland Centre for Software Research, University of Limerick, Limerick, Ireland
| | - Róisín Cahalan
- Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, University of Limerick, Limerick, Ireland
- Physical Activity for Health Research Cluster, University of Limerick, Limerick, Ireland
| | - Helen Purtill
- Health Research Institute, University of Limerick, Limerick, Ireland
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Tom M Comyns
- Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
- Sport and Human Performance Research Centre, University of Limerick, Limerick, Ireland
- Health Research Institute, University of Limerick, Limerick, Ireland
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2
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Melguizo-Ibáñez E, Ubago-Jiménez JL, Sanz-Martín D, Alonso-Vargas JM. Health-Related Quality of Life and Injuries in Physical Education Students: A Multi-Group Model According to the Degree of Adherence to the Mediterranean Diet. Eur J Investig Health Psychol Educ 2024; 14:1140-1152. [PMID: 38785573 PMCID: PMC11120319 DOI: 10.3390/ejihpe14050075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/25/2024] Open
Abstract
The Mediterranean diet is considered a healthy eating pattern. It has been shown to improve people's quality of life. When a person suffers injuries, their quality of life suffers. This research aims to accomplish the following: (a) to study the differences in the effect of the health-related quality of life on injuries according to the degree of adherence to the Mediterranean diet, (b) to analyse the existing differences in the variables that make up the health-related quality of life according to the degree of adherence to the Mediterranean diet, and (c) to analyse the degree of adherence to the Mediterranean diet according to whether the participants have suffered any injury. The study was descriptive, cross-sectional, and exploratory in a sample of 556 physical education students. The PREDIMED questionnaire, the SF-36 questionnaire, and a self-administered questionnaire were used. The results showed that high adherence to the Mediterranean diet was associated with higher quality of life and lower injury rates. It was also observed that high adherence to the Mediterranean diet improved the effect of the quality of life on injuries. In conclusion, the Mediterranean diet is beneficial for the quality of life of young university students.
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Affiliation(s)
- Eduardo Melguizo-Ibáñez
- Department of Didactics Musical, Plastic and Corporal Expression, Faculty of Education Science, University of Granada, 18071 Granada, Spain; (E.M.-I.); (J.L.U.-J.); (J.M.A.-V.)
| | - José Luis Ubago-Jiménez
- Department of Didactics Musical, Plastic and Corporal Expression, Faculty of Education Science, University of Granada, 18071 Granada, Spain; (E.M.-I.); (J.L.U.-J.); (J.M.A.-V.)
| | - Daniel Sanz-Martín
- Faculty of Humanities and Social Sciences, Universidad Isabel I, 09003 Burgos, Spain
| | - José Manuel Alonso-Vargas
- Department of Didactics Musical, Plastic and Corporal Expression, Faculty of Education Science, University of Granada, 18071 Granada, Spain; (E.M.-I.); (J.L.U.-J.); (J.M.A.-V.)
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3
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Huebner M, Lavallee ME. Arthralgia in female Masters weightlifters. BMC Musculoskelet Disord 2023; 24:670. [PMID: 37620827 PMCID: PMC10464145 DOI: 10.1186/s12891-023-06814-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/19/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Arthralgia or joint pain is a heterogeneous condition including organic and nonorganic joint pain. It is common in older populations, particularly in females. There is evidence that menopausal changes are associated with increased prevalence of arthralgia. While physical activities have been recommended to mitigate osteoarthritis (OA) and arthralgia, sport participation also carries risk factors due to excessive loading of some joints and possible injuries. The aim was to evaluate the association of training patterns, prior injuries, and severity of menopausal symptoms with arthralgia in female Masters weightlifters. METHODS Competitive female Masters weightlifters (n=868, 30-78 years) from 30 countries completed an online survey including joint pain for different anatomical sites, weightlifting training and performance, sport history, and menopausal symptoms. Logistic regression models were used to estimate the association of training patterns, prior sport participation, and menopausal symptom severity with arthralgia separately for shoulders, spine, hips, knees, ankles, elbows, and hands. RESULTS Arthralgia was most reported in knees (38.8%), shoulders (29.8%), hands/wrists (28.8%), and hips (24.9%). The prevalence of arthralgia was 51.5% in pre-menopausal women, 62.4% in women post natural menopause and 73.3% in women post medical or surgical menopause. Lifting heavier weights was associated with arthralgia in hips (OR=1.05, p=0.03), knees (OR=1.06, p=0.01), and hands/wrists (OR=1.05, p=0.04), but prior strength training was protective for arthralgia in the shoulders (OR=0.66, p=0.02). Prior injuries and psychological menopausal symptom severity were associated with an increased risk for arthralgia (p<0.01). CONCLUSIONS Arthralgia was common in competitive female weightlifters. Training frequency was not associated with arthralgia, but lifting heavier weights relative to age and body mass was. Prior injuries and menopausal symptoms were associated with arthralgia, but prior strength training was protective of arthralgia in the shoulders. Athletes, coaches and sports medicine professionals should be aware that prevalence of polyarthralgia increases in post-menopausal athletes.
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Affiliation(s)
- Marianne Huebner
- Department of Statistics and Probability, Michigan State University, East Lansing, MI, USA.
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA.
| | - Mark E Lavallee
- Department of Orthopedics, UPMC Central Pennsylvania, Harrisburg, PA, USA
- USA Weightlifting Sports Medicine Society, Colorado Springs, CO, USA
- Executive Medical Committee, International Weightlifting Federation, Lausanne, Switzerland
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4
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Mohamed AA, Zhang X, Jan YK. Evidence-based and adverse-effects analyses of cupping therapy in musculoskeletal and sports rehabilitation: A systematic and evidence-based review. J Back Musculoskelet Rehabil 2023; 36:3-19. [PMID: 35848010 DOI: 10.3233/bmr-210242] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cupping therapy has been used to treat musculoskeletal impairments for about 4000 years. Recently, world athletes have provoked an interest in it, however, the evidence to support its use in managing musculoskeletal and sports conditions remains unknown. OBJECTIVE To evaluate the evidence level of the effect of cupping therapy in managing common musculoskeletal and sports conditions. METHODS 2214 studies were identified through a computerized search, of which 22 met the inclusion criteria. The search involved randomized and case series studies published between 1990 and 2019. The search involved five databases (Scopus, MEDLINE (PubMed), Web of Science, Academic Search Complete PLUS (EBSCO), and CrossRef) and contained studies written in the English language. Three analyses were included: the quality assessment using the PEDro scale, physical characteristic analysis, and evidence-based analysis. RESULTS The results showed that most studies used dry cupping, except five which used wet cupping. Most studies compared cupping therapy to non-intervention, the remaining studies compared cupping to standard medical care, heat, routine physiotherapy, electrical stimulation, active range of motion and stretching, passive stretching, or acetaminophen. Treatment duration ranged from 1 day to 12 weeks. The evidence of cupping on increasing soft tissue flexibility is moderate, decreasing low back pain or cervical pain is low to moderate, and treating other musculoskeletal conditions is very low to low. The incidence of adverse events is very low. CONCLUSION This study provides the first attempt to analyze the evidence level of cupping therapy in musculoskeletal and sports rehabilitation. However, cupping therapy has low to moderate evidence in musculoskeletal and sports rehabilitation and might be used as a useful intervention because it decreases the pain level and improves blood flow to the affected area with low adverse effects.
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Affiliation(s)
- Ayman A Mohamed
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA.,Department of Basic Sciences, Faculty of Physical Therapy, Beni-Suef University, Beni Suef, Egypt.,Faculty of Physical Therapy, Nahda University, Beni Suef, Egypt
| | - Xueyan Zhang
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Yih-Kuen Jan
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA
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5
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Moo EK, Al-Saffar Y, Le T, A Seerattan R, Pingguan-Murphy B, K Korhonen R, Herzog W. Deformation behaviors and mechanical impairments of tissue cracks in immature and mature cartilages. J Orthop Res 2022; 40:2103-2112. [PMID: 34914129 DOI: 10.1002/jor.25243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/12/2021] [Accepted: 12/11/2021] [Indexed: 02/04/2023]
Abstract
Degeneration of articular cartilage is often triggered by a small tissue crack. As cartilage structure and composition change with age, the mechanics of cracked cartilage may depend on the tissue age, but this relationship is poorly understood. Here, we investigated cartilage mechanics and crack deformation in immature and mature cartilage exposed to a full-thickness tissue crack using indentation testing and histology, respectively. When a cut was introduced, tissue cracks opened wider in the mature cartilage compared to the immature cartilage. However, the opposite occurred upon mechanical indentation over the cracked region. Functionally, the immature-cracked cartilages stress-relaxed faster, experienced increased tissue strain, and had reduced instantaneous stiffness, compared to the mature-cracked cartilages. Taken together, mature cartilage appears to withstand surface cracks and maintains its mechanical properties better than immature cartilage and these superior properties can be explained by the structure of their collagen fibrous network.
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Affiliation(s)
- Eng Kuan Moo
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Yasir Al-Saffar
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Tina Le
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Ruth A Seerattan
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Rami K Korhonen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Walter Herzog
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Bullock GS, Mylott J, Hughes T, Nicholson KF, Riley RD, Collins GS. Just How Confident Can We Be in Predicting Sports Injuries? A Systematic Review of the Methodological Conduct and Performance of Existing Musculoskeletal Injury Prediction Models in Sport. Sports Med 2022; 52:2469-2482. [PMID: 35689749 DOI: 10.1007/s40279-022-01698-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND An increasing number of musculoskeletal injury prediction models are being developed and implemented in sports medicine. Prediction model quality needs to be evaluated so clinicians can be informed of their potential usefulness. OBJECTIVE To evaluate the methodological conduct and completeness of reporting of musculoskeletal injury prediction models in sport. METHODS A systematic review was performed from inception to June 2021. Studies were included if they: (1) predicted sport injury; (2) used regression, machine learning, or deep learning models; (3) were written in English; (4) were peer reviewed. RESULTS Thirty studies (204 models) were included; 60% of studies utilized only regression methods, 13% only machine learning, and 27% both regression and machine learning approaches. All studies developed a prediction model and no studies externally validated a prediction model. Two percent of models (7% of studies) were low risk of bias and 98% of models (93% of studies) were high or unclear risk of bias. Three studies (10%) performed an a priori sample size calculation; 14 (47%) performed internal validation. Nineteen studies (63%) reported discrimination and two (7%) reported calibration. Four studies (13%) reported model equations for statistical predictions and no machine learning studies reported code or hyperparameters. CONCLUSION Existing sport musculoskeletal injury prediction models were poorly developed and have a high risk of bias. No models could be recommended for use in practice. The majority of models were developed with small sample sizes, had inadequate assessment of model performance, and were poorly reported. To create clinically useful sports musculoskeletal injury prediction models, considerable improvements in methodology and reporting are urgently required.
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Affiliation(s)
- Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, 475 Vine St, Bowman Gray Medical Building, Winston-Salem, NC, 27101, USA. .,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.
| | - Joseph Mylott
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, 475 Vine St, Bowman Gray Medical Building, Winston-Salem, NC, 27101, USA.,Baltimore Orioles Baseball Club, Baltimore, USA
| | - Tom Hughes
- Manchester United Football Club, Manchester, UK.,Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Kristen F Nicholson
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, 475 Vine St, Bowman Gray Medical Building, Winston-Salem, NC, 27101, USA
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Gary S Collins
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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7
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Migliorini F, Vecchio G, Pintore A, Oliva F, Maffulli N. The Influence of Athletes' Age in the Onset of Osteoarthritis: A Systematic Review. Sports Med Arthrosc Rev 2022; 30:97-101. [PMID: 35533061 DOI: 10.1097/jsa.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Whether sport participation is a risk factor for osteoarthritis (OA) development or progression is controversial. Mechanical overload, injuries, genetics, and acquired disorders concur to the onset of OA, with high variability between sports and participants. This study investigated the association between participation in specific sports and the risk of developing knee and hip OA in athletes at different ages. We hypothesized that young athletes who are exposed to high levels of physical activities have a greater risk of developing OA. MATERIALS AND METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Google scholar, EMABSE, and Web of Science were accessed in October 2021. No time constrains were used for the search. All the published clinical studies reporting data about relationship between physical activity, OA, and age were included. RESULTS The Newcastle-Ottawa Scale resulted in a final score ≥7 for all studies, attesting good quality of the methodological assessment. Data from 27,364 patients were retrieved. The mean age was 48.2±16.7 years. In all, 21.8% were women. CONCLUSIONS Our systematic review suggests an association between high levels of physical activities and knee and hip OA in men younger than 50 years. People who practice intense physical activity, such as professional athletes or heavy workers, are more prone to develop early-onset OA.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Gianluca Vecchio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy
| | - Andrea Pintore
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, England
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Filbay SR, Bullock GS, Sanchez-Santos MT, Arden NK, Peirce N. A Higher Playing Standard, Bowling, and Intermittent Helmet Use Are Related to a Greater Odds of Injury or Concussion in Cricket. Clin J Sport Med 2022; 32:e300-e307. [PMID: 34009794 DOI: 10.1097/jsm.0000000000000933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if playing position, a higher playing standard, and nonhelmet use are related to an increased odds of joint-specific injury and concussion in cricket. DESIGN Cross-sectional cohort. PARTICIPANTS Twenty-eight thousand one hundred fifty-two current or former recreational and high-performance cricketers registered on a national database were invited to participate in the Cricket Health and Wellbeing Study. Eligibility requirements were aged ≥18 years and played ≥1 cricket season. INDEPENDENT VARIABLES Main playing position (bowler/batter/all-rounder), playing standard (high-performance/recreational), and helmet use (always/most of the time/occasionally/never). MAIN OUTCOME MEASURES Cross-sectional questionnaire data included cricket-related injury (hip/groin, knee, ankle, shoulder, hand, back) resulting in ≥4 weeks of reduced exercise and self-reported concussion history. Crude and adjusted (adjusted for seasons played) odds ratios and 95% confidence interval (CIs) were estimated using logistic regression. RESULTS Of 2294 participants (59% current cricketers; 97% male; age 52 ± 15 years; played 29 ± 15 seasons; 62% recreational cricketers), 47% reported cricket-related injury and 10% reported concussion. Bowlers had greater odds of hip/groin [odds ratio (95% CI), 1.9 (1.0-3.3)], knee [2.0 (1.4-2.8)], shoulder [2.9 (1.8-4.5)], and back [2.8 (1.7-4.4)] injury compared with batters. High-performance cricketers had greater odds of injury and concussion than recreational cricketers. Wearing a helmet most of the time [2.0 (1.4-3.0)] or occasionally [1.8 (1.3-2.6)] was related to higher odds of self-reported concussion compared with never wearing a helmet. Concussion rates were similar in cricketers who always and never wore a helmet. CONCLUSIONS A higher playing standard and bowling (compared with batting) were associated with greater odds of injury. Wearing a helmet occasionally or most of the time was associated with higher odds of self-reported concussion compared with never wearing a helmet.
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Affiliation(s)
- Stephanie R Filbay
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Department of Physiotherapy, Centre for Health Exercise and Sports Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Garrett S Bullock
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Maria T Sanchez-Santos
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Nigel K Arden
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Nicholas Peirce
- England and Wales Cricket Board, Lord's Cricket Ground, London, United Kingdom ; and
- National Centre For Sports and Exercise Medicine and National Cricket Performance Centre, Loughborough University, Loughborough, United Kingdom
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Bullock GS, Nicholson KF, Waterman BR, Niesen E, Salamh P, Thigpen CA, Shanley E, Devaney L, Collins GS, Arden NK, Filbay SR. Health Conditions, Substance Use, Physical Activity, and Quality of Life in Current and Former Baseball Players. Orthop J Sports Med 2021; 9:23259671211056645. [PMID: 34881341 PMCID: PMC8647246 DOI: 10.1177/23259671211056645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023] Open
Abstract
Background: A comprehensive understanding of lifestyle (health conditions and substance use), health-related quality of life (HRQoL), flourishing (holistic representation of health), and physical activity can inform stakeholders (players, coaches, and clinicians) and help improve long-term health across the life span. Purpose: To describe health conditions (comorbidities or diagnoses), substance use, physical activity, HRQoL, and flourishing in current and former collegiate and professional baseball players and to assess the relationship between playing position and HRQoL/flourishing in former baseball players. Study Design: Descriptive epidemiology study. Methods: Eligible participants were those ≥18 years old with ≥1 season of collegiate or professional baseball experience. Participants completed a survey on health conditions (asthma, diabetes, hypertension, hypercholesterolemia, and depression), substance use (tobacco, alcohol, and energy drinks), physical activity (International Physical Activity Questionnaire–Short Form), HRQoL (Veterans Rand 12-Item Health Survey [VR-12] physical and mental component scores), and flourishing (Flourishing Scale). Adjusted multivariable regressions were performed for HRQoL and flourishing. Results: Overall, 260 baseball players opened the survey, and 214 (current players, 97; former players, 117) participated for an 82% response rate. Of the former players, 32% had hypertension or hypercholesterolemia. In addition, 26% of current players had used smokeless tobacco (median, 3 years; interquartile range [IQR], 1-5 years) as compared with 34% of former players (median, 15 years; IQR, 5-25 years). In addition, 14% of current players had used electronic cigarettes (median, 2 years; IQR, 0-4 years) as opposed to 3% of former (median, 3 years; IQR, 2-4 years). Energy drinks were consumed by 31% and 14%, respectively, of current and former players on at least a weekly basis. Current baseball players performed 8667 metabolic equivalents per week of physical activity as opposed to 3931 in former players. Pitching was associated with worse VR-12 Mental Component Scores (–5.0; 95% confidence interval, –9.0 to –1.0). Playing position was not related to VR-12 Physical Component Scores or flourishing in former baseball players. Conclusion: The similar smokeless tobacco prevalence between current and former baseball players suggests that they may start using tobacco products during baseball participation and continue after retirement. Similar reported HRQoL as compared with the general US population and high flourishing and physical activity levels suggest that baseball players may present with good musculoskeletal and psychological health.
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Affiliation(s)
- Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
| | - Kristen F Nicholson
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Eric Niesen
- Houston Astros Baseball Club, Houston, Texas, USA
| | - Paul Salamh
- Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, Indiana, USA
| | | | - Ellen Shanley
- ATI Physical Therapy, Greenville, South Carolina, USA
| | - Laurie Devaney
- Department of Kinesiology, College of Agriculture, Health, and Natural Resources, University of Connecticut, Storrs, Connecticut, USA
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nigel K Arden
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephanie R Filbay
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.,Centre for Health, Exercise and Sports Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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10
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Panagodage-Perera NK, Bullock GS, Arden NK, Filbay SR. Physical activity and sedentary behaviour in current and former recreational and elite cricketers: a cross-sectional study. BMJ Open 2021; 11:e052014. [PMID: 34732485 PMCID: PMC8572389 DOI: 10.1136/bmjopen-2021-052014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Former sports participants do not necessarily maintain high levels of physical activity (PA) across their lifespan. Considering physical inactivity in former athletes is associated with an increased susceptibility to inactivity-related chronic diseases, research into PA behaviours in cricketers of all playing-standards is needed. The objective was to (1) describe PA and sedentary behaviour in current and former cricketers, and (2) determine the odds of current, former, recreational and elite cricketers meeting PA guidelines and health-enhancing PA (HEPA) compared with the general population. STUDY DESIGN Cross-sectional survey. SETTING Questionnaire response, UK. PARTICIPANTS 2267 current and former cricketers (age: 52±15 years, male: 97%, current: 59%, recreational: 45%) participated. Cricketers were recruited through the Cricket Health and Wellbeing Study and met eligibility requirements (aged ≥18 years; played ≥1 year of cricket). PRIMARY AND SECONDARY OUTCOMES Age-matched and sex-matched data from Health Survey for England 2015 (n=3201) was used as the general population-based sample. The International Physical Activity Questionnaire Short-Form assessed PA. Logistic regression, adjusted for age, sex, body mass index, alcohol consumption, smoking, education and ethnicity were used to meet the second aim. RESULTS 90% of current and 82% of former cricketers met UK PA guidelines. Current (OR 1.26, 95% CI 1.06 to 1.49)) and elite (OR 1.35, 95% CI 1.01 to 1.78) cricketers had greater odds of meeting UK PA guidelines, and elite cricketers had greater odds of HEPA (OR 1.19, 95% CI 1.02 to 1.42), compared with the general population. Former cricketers had reduced odds (OR 0.78, 95% CI 0.62 to 0.99) of meeting the UK PA guidelines compared with the general population. CONCLUSIONS Elite cricketers had a greater odds of meeting the PA guidelines and HEPA, compared with the general population. Former cricketers demonstrated reduced odds of meeting the PA guidelines compared with the general population. Strategies are needed to transition cricketers to an active lifestyle after retirement, since former cricketers demonstrated reduced odds of meeting the PA guidelines compared with the general population.
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Affiliation(s)
- Nirmala K Panagodage-Perera
- Australian Institute of Sport, Canberra, Australian Capital Territory, Australia
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Latrobe Sports and Exercise Medicine Research Centre, Latrobe University, Bundoora, Victoria, Australia
| | - Garrett Scott Bullock
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
- Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nigel K Arden
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
| | - Stephanie R Filbay
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
- Department of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
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11
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Bullock GS, Perera N, Murray A, Orchard J, Arden NA, Filbay SR. The relationship between cricket participation, health and wellbeing: A scoping review. Int J Sports Med 2021; 43:401-410. [PMID: 34734400 DOI: 10.1055/a-1686-6632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Summarising and synthesising the evidence on cricket health and wellbeing can help inform cricket stakeholders and navigate future research directions. The purpose of this study was to investigate the relationship between cricket participation, health and wellbeing at all ages and playing standards, and identify research gaps in the existing literature. A scoping review was performed from inception to March, 2020. Studies were included if they assessed a construct related to health and/or wellbeing in cricketers, available in English. 219 articles were eligible. Injury incidence per 1,000 player exposures ranged from 1.8-5.7 injuries. 48% of former cricketers experienced persistent joint pain. However, former cricketers reported greater physical activity levels and mental-components of quality of life compared to the general population. Heat injury/illness and skin cancer are concerns and require further research. Cricket participation is associated with an inherent injury risk, which may have negative implications for musculoskeletal health in later life. However, cricket participation is associated with high quality of life which can persist after retirement. Gaps in the literature include prospective studies on health and wellbeing of cricketers, female cricketers, injury prevention strategies, and the impact of cricket participation on metabolic health and lifetime physical activity.
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Affiliation(s)
- Garrett Scott Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, United States.,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland
| | - Nirmala Perera
- Sport Medicine, Australian Institute of Sport, Belconnen, Australia
| | - Andrew Murray
- Physical Activity for Health Research Centre, University of Edinburgh Institute for Sport Physical Education and Health Sciences, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - John Orchard
- Medicine, University of Sydney, Sydney, Australia
| | - Nigel A Arden
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland
| | - Stephanie R Filbay
- Physiotherapy, The University of Melbourne Department of Physiotherapy, Melbourne, Australia
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12
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Intra-Articular Hybrid Hyaluronic Acid Injection Treatment in Overweight Patients with Knee Osteoarthritis: A Single-Center, Open-Label, Prospective Study. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11188711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: A BMI > 25 is the most decisive, albeit modifiable, risk factor for knee osteoarthritis (KOA). This study aimed at assessing the efficacy of intra-articular injections of hybrid hyaluronic acid (HA) complexes (Sinovial® H-L) for the treatment of KOA in overweight patients in terms of disease severity, cardiocirculatory capacity, and quality of life. Materials: In this single-site, open-label, prospective trial, 37 patients with symptomatic knee OA were assessed at baseline and 3 months after ultrasound-guided intra-articular injection of hybrid HA complexes (Sinovial® H-L). Results: Primary variables displaying a statistically significant improvement after treatment were pain (VAS), disease severity (WOMAC), and cardiopulmonary capacity (6 min walk test). Among secondary variables, quality of life (SF-12) improved significantly, as did analgesic intake for pain control. No statistically significant difference was observed in body fat and muscle mass percentage measured by bioelectrical impedance analysis. Conclusions: Intra-articular hybrid HA injections are significantly effective in improving OA-related disease severity, cardiopulmonary function, and analgesic intake. This supports the role of hybrid HA viscosupplementation as a nonpharmacological treatment to relieve pain, reduce disability, improve quality of life, and limit the risk of polypharmacy in overweight patients with knee OA.
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Bullock GS, Nicholson KF, Waterman BR, Niesen E, Salamh P, Thigpen CA, Shanley E, Devaney LL, Tokish JM, Collins GS, Arden NK, Filbay SR. Persistent joint pain and arm function in former baseball players. JSES Int 2021; 5:912-919. [PMID: 34505105 PMCID: PMC8411053 DOI: 10.1016/j.jseint.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Baseball has specific sport and positional demands that may modify joint pain compared with other sports. Persistent joint pain reduces function and is an underlying reason for seeking medical care. The pain and functional status of players after they stop competitive play are unknown. Such knowledge can assist clinicians in creating personalized physical examinations and interventions for baseball players as they transition to retirement. The purpose of this study was to (1) evaluate persistent joint pain and arm function in former baseball players and (2) determine whether playing position is associated with increased odds of joint pain and reduced arm function in former baseball players. Methods A cross-sectional survey was performed. Eligibility criteria consisted of (1) played ≥1 collegiate baseball season, (2) aged ≥18 years, and (3) formerly played baseball (currently retired). Outcomes assessed included persistent joint pain and Single Assessment Numeric Evaluation (SANE). Explanatory variables included playing position (position, two-way, or pitcher). Multivariable logistic and linear regressions were performed. Models were adjusted for age, body mass index, arm dominance, playing standard, years played baseball, and injury and surgery history. Results A total of 117 former baseball players participated (age: 36.8 [13.7] years). The mean dominant SANE score was 70.2 (standard deviation 24.1), and the mean nondominant SANE score was 85.2 (standard deviation 19.4). There was no difference in dominant arm SANE scores when stratified by arm injury history (4.6 [95% confidence interval: −14.9, 5.8]) or arm surgery history (−3.8 [95% confidence interval: 13.4, 5.8]). The shoulders had the greatest persistent joint pain prevalence (28% of all participants) and elbows (21% of all participants). There was no relationship between dominant arm pain or function and playing position. Conclusion This is the first study to demonstrate an increase in dominant arm disability in former baseball players. The high prevalence of persistent arm pain and poor arm function among former baseball players is concerning considering participants were younger than 40 years of age. No differences were observed in arm function when stratifying by arm history, surgery, or position demonstrating the potential relationship between baseball participation and arm disability after cessation of play. Clinicians should consider working with baseball players to develop long-term strategies to maintain joint health, especially in the throwing arm, when baseball players are transitioning to retirement. Future research is needed to understand the long-term effectiveness of clinical treatments and the implications of specific arm injuries such as ulnar collateral ligament tears on persistent arm pain and function.
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Affiliation(s)
- Garrett S Bullock
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kristen F Nicholson
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Eric Niesen
- Athletic Department, University of Georgetown, Washington DC, USA
| | - Paul Salamh
- Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, IN, USA
| | | | | | - Laurie L Devaney
- Department of Kinesiology, College of Agriculture, Health, and Natural Resources, University of Connecticut, Storrs, CT, USA
| | - John M Tokish
- Orthopedics & Sports Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nigel K Arden
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Stephanie R Filbay
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Health, Exercise and Sports Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
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14
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Losciale J, Wayman K, Mansfield CJ, Rethman KK, Briggs MS. A preliminary analysis of physical therapist agreement regarding the perceived impairments in cases of runners with knee pain. Physiother Theory Pract 2021; 38:2938-2948. [PMID: 34315318 DOI: 10.1080/09593985.2021.1946876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: There is a scarcity of evidence describing how physical therapists use data from clinical examinations to inform the treatment of runners with knee pain.Objective: Our purpose was to examine the between physical therapist agreement on the selection of perceived impairments in runners with knee pain.Methods: Twelve physical therapists reviewed two cases of runners with knee pain. The cases included clinical subjective information, objective data, and review of videos of each participant running. Each rater selected up to three perceived impairments (from a list of eight) that each physical therapist would address at the next physical therapy session. Percent agreement was calculated to determine the between rater agreement on each individual perceived impairment selection and Fleiss Kappa was calculated for each unique combination of three perceived impairments per case.Results: Twelve raters with 51 (18-156) months of clinical experience participated. Percent agreement ranged from 8%-100% for both cases for individual impairments. When assessing the unique combination of three impairments selected, inter-rater agreement was less than what is expected due to chance alone (κ = -0.09, p = .92; κ = -0.09, p = .98) for both cases.Conclusion: The 12 physical therapists demonstrated poor to excellent levels of agreement when selecting an individual perceived impairment. Agreement was worse than chance when selecting a combination of three unique impairments.
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Affiliation(s)
- Justin Losciale
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katherine Wayman
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cody J Mansfield
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Jameson Crane Sports Medicine Institute, Columbus, OH, USA.,School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, OH, USA.,Ambulatory Rehabilitation, Ohio State Sports Medicine Care Point Gahanna, The Ohio State University Wexner Medical Center, Gahanna, OH, USA
| | - Katherine K Rethman
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew S Briggs
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Jameson Crane Sports Medicine Institute, Columbus, OH, USA.,School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, OH, USA.,Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Zhang J, Qi B, Liu M, Zhao T, Tan L. Influence of swimming exercise on the expression of apoptotic gene caspase-3 in chondrocytes in osteoarthritis. Am J Transl Res 2021; 13:2511-2517. [PMID: 34017409 PMCID: PMC8129308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/28/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study swimming exercise's effect on caspase-3 expression in chondrocytes in osteoarthritis (OA). METHODS 36 SD rats were randomly separated into normal group (n = 12), OA model group (n = 12) and swimming exercise group (n = 12). After modeling, rats received no intervention in model group and swimming exercise once a day (15 min/time) for 4 consecutive weeks in swimming exercise group. After intervention for 4 weeks, specimens were taken to analyze tissue morphology by H&E staining, caspase-3 expression by Western blot and qPCR, chondrocytes apoptosis by TUNEL assay. RESULTS HE staining revealed abnormal bone tissue morphology in model group and swimming exercise group with improved morphology after swimming exercise. Model group and swimming exercise group all showed significantly higher Caspase-3 protein level than normal group with lower level after swimming exercise (P < 0.05). Consistently, qPCR showed similar expression profile of caspase-3 mRNA level to the protein level. CONCLUSION Swimming exercise can inhibit caspase-3 level and chondrocytes apoptosis in OA, thus improving the joint morphology.
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Affiliation(s)
- Jiting Zhang
- Department of Traumatic Orthopedics, The First Hospital of Jilin University Changchun, Jilin, China
| | - Baochang Qi
- Department of Traumatic Orthopedics, The First Hospital of Jilin University Changchun, Jilin, China
| | - Mingxi Liu
- Department of Traumatic Orthopedics, The First Hospital of Jilin University Changchun, Jilin, China
| | - Tianhao Zhao
- Department of Traumatic Orthopedics, The First Hospital of Jilin University Changchun, Jilin, China
| | - Lei Tan
- Department of Traumatic Orthopedics, The First Hospital of Jilin University Changchun, Jilin, China
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16
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Hwang JJ, Rim YA, Nam Y, Ju JH. Recent Developments in Clinical Applications of Mesenchymal Stem Cells in the Treatment of Rheumatoid Arthritis and Osteoarthritis. Front Immunol 2021; 12:631291. [PMID: 33763076 PMCID: PMC7982594 DOI: 10.3389/fimmu.2021.631291] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/04/2021] [Indexed: 12/17/2022] Open
Abstract
Mesenchymal stem cell (MSC) therapies have been used as cell-based treatments for decades, owing to their anti-inflammatory, immunomodulatory, and regenerative properties. With high expectations, many ongoing clinical trials are investigating the safety and efficacy of MSC therapies to treat arthritic diseases. Studies on osteoarthritis (OA) have shown positive clinical outcomes, with improved joint function, pain level, and quality of life. In addition, few clinical MSC trials conducted on rheumatoid arthritis (RA) patients have also displayed some optimistic outlook. The largely positive outcomes in clinical trials without severe side effects establish MSCs as promising tools for arthritis treatment. However, further research is required to investigate its applicability in clinical settings. This review discusses the most recent advances in clinical studies on MSC therapies for OA and RA.
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Affiliation(s)
- Joel Jihwan Hwang
- College of Public Health and Social Justice, Saint Louis University, St. Louis, MO, United States
| | - Yeri Alice Rim
- Catholic Induced Pluripotent Stem Cell Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoojun Nam
- Catholic Induced Pluripotent Stem Cell Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Hyeon Ju
- Catholic Induced Pluripotent Stem Cell Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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