Body composition and bone mineral density in athletes with a physical impairment

Increased Risk of Fracture after Traumatic Amputation: A Nationwide Retrospective Cohort Study

The physiological changes and alterations in gait following amputation may increase the risk of fractures. However, there is insufficient research on fracture risk in amputees. Therefore, this study intended to analyze whether the risk of new fractures increases after traumatic amputations. This population-based, retrospective cohort study used data from the Korean National Health Insurance System database. The study included 19,586 participants who had undergone an amputation and 76,645 matched controls. The incidence of any fracture and site-specific fractures (vertebral, hip, and others) according to amputation site(s) and severity of disability due to amputation were evaluated using Cox proportional hazard regression analysis. During the mean follow-up of 4.2 years, amputees had a higher incidence rate (IR) of any fracture (adjusted HR [aHR] 1.47, 95% CI 1.36-1.60), vertebral fracture (aHR 1.63, 95% CI 1.44-1.85), hip fracture (aHR 1.85, 95% CI 1.39-2.46), and other fracture (aHR 1.34, 95% CI 1.20-1.49) compared to that of controls. In the presence of disability, the risks were further increased and were highest among amputees with severe disabilities. All fracture risks were higher in amputees than they were in controls, regardless of lower limb or upper limb amputation. This cohort study demonstrated that traumatic amputees experienced higher incidence of all fractures than did individuals without amputations, and this risk increases with severity of disability. This finding underscores the importance of early screening and lifestyle interventions to address fracture risk in traumatic amputees.

Do Paralympic athletes suffer from brittle bones? Prevalence and risk factors of low bone mineral density in Paralympic athletes

Background

Bone health may be a concern in Paralympic athletes, given the presence of multiple risk factors predisposing these athletes to low bone mineral density (BMD). Objective: We aimed to assess the prevalence of low BMD among Paralympic athletes participating in various sport disciplines, and to identify potential risk factors for low BMD.

Methods

Seventy Paralympic athletes, of whom 51 % were wheelchair-dependent, were included in this cross-sectional study. BMD of the whole-body, lumbar spine, total hip, and femoral neck were assessed by dual-energy x-ray absorptiometry. Comparisons between groups were conducted by one-way ANOVA, and regression analyses were conducted to identify potential risk factors for low BMD.

Results

The prevalence of low BMD (Z-score < -1.0) was highest at femoral neck (34 %), followed by total hip (31 %), whole-body (21 %), and lumbar spine (18 %). Wheelchair-dependent athletes had significantly lower BMD Z-scores compared to the non-wheelchair-dependent athletes at whole-body level (-0.5 ± 1.4 vs 0.2 ± 1.3; P = 0.04), total hip (-1.1 ± 1.2 vs 0.0 ± 1.1; P < 0.01), and femoral neck (-1.0 ± 1.3 vs -0.1 ± 1.2; P < 0.01). At the lumbar spine, low BMD was completely absent in wheelchair basketball and tennis players. Regression analyses identified body mass, wheelchair dependence, and type of sport, as the main risk factors for low BMD.

Conclusions

In this cohort of Paralympic athletes, low BMD is mainly present at the hip, and to a lesser extent at the whole-body and lumbar spine. The most prominent risk factors for low BMD in Paralympic athletes are related to mechanical loading patterns, including wheelchair use, the type of sport, and body mass.

Heterogeneity in regional changes in body composition induced by androgen deprivation therapy in prostate cancer patients: potential impact on bone health-the BLADE study

BACKGROUND

It is not clear whether changes in body composition induced by androgen deprivation therapy (ADT) in prostate cancer (PC) patients are uniform or vary in the different body districts and whether regional lean body mass (LBM) and fat body mass (FBM) could have an impact on bone health.

OBJECTIVE

To prospectively evaluate the regional changes in LBM and FBM in PC patients submitted to degarelix; to explore the relationship of regional body composition and bone mineral density (BMD) and bone turnover markers.

DESIGN, SETTING, AND PARTICIPANTS

29 consecutive non metastatic PC patients enrolled from 2017 to 2019. FBM, LBM and bone mineral density (BMD) evaluated by dual-energy x-ray absorptiometry (DXA) at baseline and after 12-month of ADT. Alkaline phosphate (ALP) and C-terminal telopeptide of type I collagen (CTX) assessed at baseline, 6 and 12 months.

INTERVENTION

All patients underwent degarelix administration.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

T-test or sign test and Pearson or Spearman test for continuous variables were used when indicated.

RESULTS AND LIMITATIONS

Median percent increase in FBM ranged from + 14.5% in trunk to + 25.4% in the left leg after degarelix. LBM changes varied from + 2% in the trunk to - 4.9% in the right arm. LBM in both arms and legs and their variations after degarelix directly correlated with ALP and inversely correlated with CTX. Lean mass of limbs, trunk and legs significantly correlated with BMD of the hip, lean mass of the trunk significantly correlated with spine BMD. These are post-hoc analysis of a prospective study and this is the main limitation.

CONCLUSIONS

an heterogeneous change in body composition among body district is observed after ADT and bone turnover is influenced by lean mass and its variation. A supervised physical activity is crucial to maintain general physical performance and preserving bone health.

High prevalence of low bone mineral density but normal trabecular bone score in Norwegian elite Para athletes

Background

Low bone mineral density (BMD) increases the risk of bone stress injuries (BSI) and is one of several clinical concerns in Para athlete sports medicine. However, whether bone microarchitecture is altered in Para athletes is not known.

Objective

We aimed to investigate BMD, bone microarchitecture and incidence of bone stress injuries in Norwegian elite Para athletes.

Design

In this cross-sectional study in Para athletes, Dual energy x-ray absorptiometry (iDXA, Lunar, GE Health Care) derived areal BMD, trabecular bone score (TBS), a surrogate marker for bone microarchitecture, and body composition (body weight (BW), lean body mass (LBM), fat mass (FM), fat percentage) were investigated and compared between ambulant and non-ambulant athletes. Also, the association between BMD, TBS and body composition variables was investigated. Incidence of BSI was assessed with a questionnaire and confirmed by a sports physician in a clinical interview. BMD Z-score <-1 was defined as low and ≤-2 as osteoporotic. TBS ≥ 1.31 was normal, 1.23-1.31 intermediate and <1.23 low.

Results

Among 38 athletes (26 ± 6 yrs, 14 females), BMD Z-score was low in 19 athletes, and osteoporotic in 11 athletes' lumbar spine (LS) or femoral neck (FN). BMD was lower in non-ambulant vs. ambulant athletes both in LS (1.13 ± 0.19 vs. 1.25 ± 0.14 g/cm2, p = 0.030) and FN (0.90 ± 0.15 vs. 1.07 ± 0.16 g/cm2, p = 0.003). TBS was normal for all athletes. BMD Z-score in LS was positively associated with TBS (r = 0.408, p = 0.013), body weight (r = 0.326, p = 0.046) and lean body mass (r = 0.414, p = 0.010), but not with fat mass or fat percentage. None of the athletes reported any BSI.

Conclusions

Half of the Norwegian elite Para athletes had low BMD, and 29% had BMD Z-score <-2 suggesting osteoporosis. Non-ambulant athletes were more prone to low BMD than ambulant athletes. However, despite high prevalence of low BMD, TBS was normal in all athletes, and BSI was absent in this young population.

The bone mineral density and isokinetic knee strength in amputee soccer players

OBJECTIVE

The aim of this study was to examine the isokinetic knee strength, H/Q ratio (%), and bone mineral density values between amputees (n=14; amputee soccer players) and healthy football players (n=14; non-amputee soccer players).

METHODS

A total of 28 amputee soccer players and non-amputee soccer players participated in the study. An isokinetic dynamometer was used to determine the knee flexion/extension forces of the dominant legs of the athletes at 60, 180, and 240°/s. Bone mineral density scans were performed using dual-energy X-ray absorptiometry.

RESULTS

H/Q ratio and 60º/s flexion and 180 and 240º/s flexion/extension strength (p<0.05) were found to be high (180º/s, p=0.03; 240º/s, p=0.048) in the non-amputee soccer player group. Accordingly, the bone mineral density values of the lumbar vertebra, femoral neck, proximal metaphysis of the femur (p<0.01), tibia/fibula proximal metaphysis, and tibia/fibula distal metaphysis (p<0.05) were found to be high. A correlation was observed between the 60º/s knee extension strength and tibia/fibula diaphyseal bone mineral density (p=0.025; r=0.594) and tibia/fibula distal metaphysis bone mineral density (p=0.017; r=0.623) values in the amputee soccer players group. The Z-scores of the amputee soccer players and non-amputee soccer players were in the expected range according to age (>-2).

CONCLUSION

The bone mineral density, H/Q ratio, and all measured angular velocities of isokinetic strength were high in non-amputee soccer players. This finding made us think that lower extremity amputation may also be associated with losing strength. However, it was observed that the relationship between strength and bone mineral density in amputee athletes might vary according to different angular velocities. It is recommended that isokinetic strength measurement can be evaluated together with bone mineral density in athletes.

Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls

Individuals with lower-limb amputations, many of whom have type 2 diabetes, experience impaired musculoskeletal health. This study: (1) compared residual and intact limbs of diabetic and non-diabetic post-mortem individuals with amputation to identify structures vulnerable to injury, and (2) compared findings to diabetic and healthy control groups to differentiate influences of amputation and diabetes on musculoskeletal health. Postmortem CT scans of three groups, ten individuals each, were included: (1) individuals with transtibial or transfemoral amputations, half with diabetes (2) diabetic controls, and (3) healthy controls. Hip and knee joint spaces, cross-sectional thigh muscle and fat areas, and cross-sectional bone properties (e.g. area, thickness, geometry) were measured. Wilcoxon Signed-Rank and Kruskal-Wallis tests assessed statistical significance. Asymmetry percentages between limbs assessed clinical significance. Residual limbs of individuals with amputation, particularly those with diabetes, had significantly less thigh muscle area and thinner distal femoral cortical bone compared to intact limbs. Compared to control groups, individuals with amputation had significantly narrower joint spaces, less thigh muscle area bilaterally, and thinner proximal femoral cortical bone in the residual limb. Diabetic individuals with amputation had the most clinically significant asymmetry. Findings tended to align with those of living individuals. However, lack of available medical information and small sample sizes reduced the anticipated clinical utility. Larger sample sizes of living individuals are needed to assess generalizability of findings. Quantifying musculoskeletal properties and differentiating influences of amputation and diabetes could eventually help direct rehabilitation techniques.

Impact of Prolonged Cessation of Organized Team Training Due to the COVID-19 Pandemic on the Body Composition of Japanese Elite Female Wheelchair Basketball Athletes

Studies on the effects of training confinement on athletes with physical impairments are limited. Hence, in this retrospective cohort study, we aimed to investigate the impact of prolonged cessation of organized team training due to the coronavirus disease 2019 pandemic on the body composition of elite female Japanese basketball athletes. Fourteen female wheelchair basketball athletes (aged ≥20 years) were enrolled. The primary outcomes were lean and adipose indices measured using whole-body dual-energy X-ray absorptiometry. The impact of prolonged organized team training cessation on body composition was investigated by comparing the body composition at baseline and post-training confinement. A reduced whole-body lean mass (p = 0.038) and percent lean mass (p = 0.022), as well as an increased percent body fat (p = 0.035), were observed after the confinement period. The regional analysis revealed reduced percent lean and increased percent fat masses in the trunk (p = 0.015 and p = 0.026, respectively) and upper limbs (p = 0.036 and p = 0.048, respectively). In conclusion, prolonged organized team training cessation reduced lean mass and increased body fat percentage, primarily in the trunk and upper limbs. Individualized training programs targeting these body regions should be implemented to improve body composition and physical conditions in athletes during and after prolonged cessation of organized team training.

Nutritional Practices and Body Composition of South African National-Level Spinal Cord-Injured Endurance Hand Cyclists

Nutritional practices and body composition of para-athletes can impact their health and athletic performance. There is a paucity of research on the nutritional practices, including dietary and supplement intake, body composition and bone health of spinal cord-injured (SCI) endurance hand cyclists. This study assessed the body composition and dietary and supplement intake of 12 national-level SCI endurance hand cyclists (age: 44.0 ± 9.3 years). Bone mineral density (BMD) was assessed in a sub-sample of participants (n = 4) using dual-energy x-ray absorptiometry (DXA). Estimated body fat percentage was healthy (18.4 ± 5.1%) and lumbar spine BMD for the sub-sample was adequate, however hip BMD was low (Z-score and/or T-scores < −2). Carbohydrate intake for male and female participants was below the recommended intake (3.8 (2.9−4.1) and 2.4 (2.0−2.7) g/kg BW, respectively). Overall protein intake was adequate, whilst fat intake was high for both males and females (39.7 (37.7−41.6) and 42.1 (39.0−45.3)% of total energy, respectively). The reported intakes for a few key micronutrients were also below the recommended dietary allowance (RDA) and/or adequate intake (AI) for males (vitamin D, calcium). The prevalence of supplement use before, during, and after training was 40%, 100%, and 60%, respectively. In conclusion, the hand cyclists could benefit from nutritional guidance to match their daily carbohydrate intake with exercise requirements and optimise their fat intake. Optimal vitamin D and calcium intake is also important especially in the light of poor bone health below the lesion level.

Sporting activity does not fully prevent bone demineralization at the impaired hip in athletes with amputation

There is lack of information about bone mineralization at the lumbar spine and bilateral hips of athletes with unilateral lower limb amputation. The present study assessed for the first time the areal bone mineral density at the lumbar spine and at the hip of the able and impaired leg by means of Dual-Energy X-Ray Absorptiometry using a large sample (N = 40) of male athletes. Results showed that bone demineralization in athletes with unilateral lower limb amputation is found at the impaired hip but not at the lumbar spine and may therefore be site-specific. The extent of hip demineralization was influenced by the level of amputation, with about 80% of athletes with above knee amputation and 10% of athletes with below knee amputation showing areal bone mineral density below the expected range for age. Nevertheless, a reduced percentage of fat mass and a lower fat-to-lean mass ratio in the residual impaired leg as well as a greater amount of weekly training was positively associated with bone mineralization at the impaired hip (partial correlation coefficients = 0.377–0.525, p = 0.040–0.003). Results showed that participation in adapted sport has a positive effect on bone health in athletes with unilateral lower limb amputation but is not sufficient to maintain adequate levels of bone mineralization at the impaired hip in athletes with above-knee amputation. Accordingly, physical conditioners should consider implementing sporting programs, according to the severity of the impairment, aimed at improving bone mineralization at the impaired hip and improve body composition in the residual impaired leg.

Physique and performance in male sitting volleyball players: implications for classification and training

Background

This study assessed whether anthropometry, physical fitness and sport-specific sprint performance vary across the three groups of sitting volleyball (SV) athletes (athletes with a disability (VS1), athletes with a minimal disability (VS2) and able-bodied SV athletes (AB)) in order to explore the validity of the current system of classification. This study also investigated how the anthropometric and physical fitness characteristics of athletes relate to their sprint performance.

Methods

Thirty-five SV male athletes aged 37.4 ± 10.8 years and practicing SV at a national/international level volunteered for this study. Testing consisted in the evaluation of linear anthropometry, physical fitness (body composition by-means of dual-energy X-ray absorptiometry and upper-body strength) and sprint performance (5-meter sprint tests, agility test and speed and endurance test).

Results

Athletes in the three groups differed in fat mass percentage (%FM) which was higher in VS1 versus AB at the sub-total level (+9%), in the arms (+15%) and in the non-impaired leg (+8%) regions. Greater hand span, greater length of the impaired lower leg, lower %FM at both the sub-total and regional level and a higher level of strength in the upper body are all associated with better performances in the considered sprint tests (P < 0.05 for all). These results do not confirm the validity of the current system of classification of athletes adopted in SV. Professionals dealing with SV athletes should include specific exercises aimed at improving whole-body and regional body composition and the strength of the trunk and upper limbs in their training programs.

Adaptive Sports in Spinal Cord Injury: a Systematic Review

Purpose of Review

Recent Findings

Summary

A review of musculoskeletal adaptations in individuals following major lower-limb amputation

Structural musculoskeletal adaptations following amputation, such as bone mineral density (BMD) or muscle architecture, are often overlooked despite their established contributions to gait rehabilitation and the development of adverse secondary physical conditions. The purpose of this review is to provide a summary of the existing literature investigating musculoskeletal adaptations in individuals with major lower-limb amputations to inform clinical practice and provide directions for future research. Google Scholar, PubMed, and Scopus were searched for original peer-reviewed studies that included individuals with transtibial or transfemoral amputations. Summary data of twenty-seven articles indicated reduced BMD and increased muscle atrophy in amputees compared to controls, and in the amputated limb compared to intact and control limbs. Specifically, BMD was reduced in T-scores and Z-scores, femoral neck, and proximal tibia. Muscle atrophy was evidenced by decreased thigh cross-sectional area, decreased quadriceps thickness, and increased amounts of thigh fat. Overall, amputees have impaired musculoskeletal health. Future studies should include dysvascular etiologies to address their effects on musculoskeletal health and functional mobility. Moreover, clinicians can use these findings to screen increased risks of adverse sequelae such as fractures, osteopenia/porosis, and muscular atrophy, as well as target specific rehabilitation exercises to reduce these risks.

Illness and injury among Norwegian Para athletes over five consecutive Paralympic Summer and Winter Games cycles: prevailing high illness burden on the road from 2012 to 2020

OBJECTIVE

To describe the illness and injury pattern of Norwegian Para athletes over five consecutive Paralympic Summer and Winter Games cycles and to identify which health problems should be targeted in risk management plans with respect to impairment types.

METHODS

We monitored athletes from 12 to 18 months prior to each Game using a weekly online questionnaire (Oslo Sports Trauma Research Center-H2 (OSTRC-H2)). We asked them to report all health problems they had experienced in the preceding 7 days, irrespective of their consequences on their sports participation or performance and whether they had sought medical attention.

RESULTS

Between 2011 and 2020, 94 candidate athletes were included in this monitoring programme and prepared to represent Norway; of these, 66 (71%) were finally selected for multiple Paralympic Games. The overall response rate to the weekly questionnaires was 87%. At any given time during the five observation cycles, 37% of the athletes (95% CI 36% to 38%) reported having at least one health problem. Athletes with neurological impairments (n=51) lost 10 days per year due to respiratory problems (95% CI 9 to 11) compared with 9 days (8-10) among those with musculoskeletal impairments (n=37). Gastrointestinal problems caused a time loss of on average 4 days per year in athletes with neurological impairments versus 1 day in athletes with musculoskeletal impairments (mean difference 2.7 days, 2.1-3.3). Musculoskeletal injuries generated a high burden for both athlete groups, in particular, to the elbow, shoulder and lumbosacral regions.

CONCLUSION

At any given time, nearly two out of five elite Norwegian Para athletes reported at least one health problem. Respiratory tract and other infections; gastrointestinal problems, injuries to the shoulder, elbow and lumbosacral regions represented the greatest health burden. Our findings can help guide the allocation of clinical resources, which should include a broad network of medical specialists, together with dieticians and physiotherapists, to meet the health challenges in Para athletes.