The International Olympic Committee framework on fairness, inclusion and nondiscrimination on the basis of gender identity and sex variations does not protect fairness for female athletes.

The International Olympic Committee (IOC) recently published a framework on fairness, inclusion, and nondiscrimination on the basis of gender identity and sex variations. Although we appreciate the IOC's recognition of the role of sports science and medicine in policy development, we disagree with the assertion that the IOC framework is consistent with existing scientific and medical evidence and question its recommendations for implementation. Testosterone exposure during male development results in physical differences between male and female bodies; this process underpins male athletic advantage in muscle mass, strength and power, and endurance and aerobic capacity. The IOC's "no presumption of advantage" principle disregards this reality. Studies show that transgender women (male-born individuals who identify as women) with suppressed testosterone retain muscle mass, strength, and other physical advantages compared to females; male performance advantage cannot be eliminated with testosterone suppression. The IOC's concept of "meaningful competition" is flawed because fairness of category does not hinge on closely matched performances. The female category ensures fair competition for female athletes by excluding male advantages. Case-by-case testing for transgender women may lead to stigmatization and cannot be robustly managed in practice. We argue that eligibility criteria for female competition must consider male development rather than relying on current testosterone levels. Female athletes should be recognized as the key stakeholders in the consultation and decision-making processes. We urge the IOC to reevaluate the recommendations of their Framework to include a comprehensive understanding of the biological advantages of male development to ensure fairness and safety in female sports.

Implementation of a Community-Based Mind-Body (Tae-Bo) Physical Activity Programme on Health-Related Physical Fitness in Rural Black Overweight and Obese Women with Manifest Risk Factors for Multimorbidity.

Non-communicable diseases (NCDs) are the leading cause of death globally, particularly impacting low- and middle-income countries and rural dwellers. Therefore, this programme aimed to investigate if a community-based mind-body PA programme implemented in a low-resource setting could improve health-related physical fitness outcomes. Black overweight or obese adult women (25 ± 4.7 years) with a body mass index (BMI) > 25 kg·m-2 recruited from a rural settlement in South Africa with manifest risk factors for multimorbidity were assigned to a 10-week waiting-to-treat non-exercising control group (n = 65) or a community-based mind-body programme (n = 60) consisting of 45-60 min, thrice-weekly Tae-Bo. The intervention resulted in significant (p ≤ 0.05) improvements in body weight (p = 0.043), BMI (p = 0.037), and waist (p = 0.031) and hip circumferences (p = 0.040). Flexibility was found to be significantly increased at mid- and post-programme (p = 0.033 and p = 0.025, respectively) as was static balance (mid: p = 0.022; post: p = 0.019), hand grip strength (mid: p = 0.034; post: p = 0.029), sit-up performance (mid: p = 0.021; post: p = 0.018), and cardiorespiratory endurance (mid: p = 0.017; post: p = 0.011). No significant change was found in sum of skinfolds following the programme (p = 0.057). Such a community-based mind-body programme presents an opportunity to level health inequalities and positively improve health-related physical fitness in low-resource communities irrespective of the underlying barriers to participation.

Hip and Knee Osteoarthritis, Not Nonsteroidal Anti-Inflammatory Drugs, are Linked to Cardiac Disease.

BACKGROUND: In 2005, the Food and Drug Administration placed a black-box warning (the most stringent warning for drugs) on all nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) stating that these agents may cause heart attacks and/or strokes. No level I evidence demonstrates that nonselective NSAIDs increase cardiovascular risk. An alternative hypothesis is that hip and knee osteoarthritis (OA) indirectly causes cardiovascular disease (CVD) through decreased activity and NSAIDs are correlated with CVD as an arthritis treatment. METHODS: Systematic reviews were conducted to find observational studies evaluating the association of hip and/or knee OA, CVD, activity, walking, and step counts. The systematic review found studies correlating hip and/or knee OA and CVD morbidity incidence (n = 2); CVD morbidity prevalence (n = 6); odds ratios, relative risks, or hazard ratios of CVD morbidity (n = 11); relative risk, standardized mortality ratios, or hazard ratios of CVD mortality (n = 14); and all-cause mortality hazard ratios associated with NSAID use (n = 3). RESULTS: Hip OA (5 studies), knee OA (9 studies), and hip and knee OA (6 studies) are linked to an increased risk of CVD morbidity and mortality. Cardiac risk increases with validated disability scores, use of walking aids, walking difficulties, longer follow-up times, younger ages of OA onset, numbers of joints involved, and OA severities. No study linked NSAID use to cardiac disease. CONCLUSIONS: All studies with more than 10-year follow-up linked cardiac disease with hip and knee OA. No study linked nonselective NSAID use to CVD. The Food and Drug Administration should reconsider the black-box warnings on naproxen, ibuprofen, and celecoxib.

Coaching, Separate from Mentoring, May Provide Skill Acquisition, Improved Well-Being, and Career Advancement in Orthopaedic Surgery: AOA Critical Issues.

ABSTRACT: Coaching is separate from mentoring, and can include life coaching, skills coaching, and behavior coaching. Life coaching can focus on purpose, work-life balance, well-being, and career path. Skills coaching encourages mastery and promotes autonomy. Behavior coaching may be mandated for a disruptive surgeon. Coaching has been shown to reduce burnout and promote well-being and can potentially advance a surgeon's career trajectory and leadership skills.

How much water is in a mouthful, and how many mouthfuls should I drink? A laboratory exercise to help students understand developing a hydration plan.

Preventing impairments in athletic performance is an important concept for students that are preparing for careers that involve working with athletes. Gaining hands on, laboratory-based experience in measuring exercise induced dehydration can help students understand how to help athletes prevent dehydration induced impairment in performance. This article describes a laboratory exercise for junior and senior students in a sports nutrition class, in which the students measure changes in body mass (as a measure of dehydration) due to 40 min of moderate-intensity exercise and 40 min of vigorous-intensity exercise. The students also measure how much water is in a mouthful from a sports bottle and from a drinking fountain. The students then calculate how many mouthfuls are necessary to replace exercise induced fluid losses. This laboratory exercise has been well received by students and has improved performance on the test regarding hydration.

Thermal Nerve Radiofrequency Ablation for the Nonsurgical Treatment of Knee Osteoarthritis: A Systematic Literature Review.

BACKGROUND: There are roughly 14 million adults in the United States presenting with symptomatic osteoarthritis (OA) of the knee. Nerve radiofrequency ablation (RFA) is a nonsurgical procedure for the management of knee OA symptoms, and no previous systematic review has been performed comparing geniculate nerve RFA to other nonsurgical treatments. QUESTIONS/PURPOSES: (1) How does geniculate nerve RFA compare with other nonsurgical modalities for patients with knee OA about pain, function, quality of life, and composite scores? and (2) How does geniculate nerve RFA compare with other nonsurgical modalities for patients with knee OA about adverse events (AEs)? METHODS: A systematic literature review was conducted within PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to identify all studies from 1966 to 2019 evaluating the relative effectiveness of geniculate nerve thermal (heated or cooled) RFA compared with other nonsurgical treatments for knee OA. Two independent abstractors reviewed and analyzed the literature including comparators such as intra-articular (IA) corticosteroids, IA hyaluronic acid, NSAIDs, acetaminophen (paracetamol), and control/sham procedures. Inclusion was based on the following criteria: English language, human subjects, symptomatic knee OA, and patient-reported outcomes. RESULTS: Five high-quality and two moderate-quality randomized controlled trials (RCTs) met the inclusion criteria for this review. The results showed consistent agreement across all RCTs in favor of geniculate nerve thermal RFA use for nonsurgical treatment of knee OA. One high-quality RCT and one moderate-quality RCT found geniculate nerve RFA to provide statistically significant outcome improvement compared with control or sham procedures regarding pain, function, quality of life, and composite scores. When compared with IA corticosteroids and hyaluronic acid, geniculate nerve RFA also provided notable improvement in pain, function, and composite scores (visual analog scale, Western Ontario, and McMaster Universities Arthritis Index, and Oxford Knee Score). RFA was markedly favored for all pain and composite outcomes (Western Ontario and McMaster Universities Arthritis Index and visual analog scale). The included RCTs did not report any serious AEs related to geniculate nerve RFA. DISCUSSION: These results demonstrate geniculate nerve thermal RFA to be a superior nonsurgical treatment of knee OA compared with NSAIDs and IA corticosteroid injections. None of the RCTs reported any serious AEs with geniculate nerve thermal RFA, as opposed to known cardiovascular, gastrointestinal, and renal AEs for NSAIDs and accelerated cartilage loss and periprosthetic infection risk for IA corticosteroid injections. LEVEL OF EVIDENCE: Level I.

Management of Surgical Site Infections.

The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria for the Management of Surgical Site Infections (SSIs) (website: http://www.orthoguidelines.org/go/auc/default.cfm?auc_id=225018&actionxm=Terms). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The Appropriate Use Criteria for the Management of SSIs were derived by identifying clinical indications typical of patients commonly presenting with a SSI in clinical practice. These indications were most often parameters observable by the clinician, including symptoms and diagnostic tests. The 264 patient scenarios and nine treatments were developed by the writing panel, which consisted of a group of clinicians who are specialists in this Appropriate Use Criteria topic. Next, a separate, multidisciplinary, voting panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a nine-point scale to designate a treatment as appropriate (median rating, seven to nine), may be appropriate (median rating, four to six), or rarely appropriate (median rating, one to three).

Comparison of Physical Activity during Zumba with a Human or Video Game Instructor.

Using a physically active video game presents an opportunity for a person to engage in exercise in the privacy of their own home, yet still receive some feedback on the quality of their exercise performance. The purpose of this project was to compare the physical activity between participating in a Zumba exercise class led by a human and using a Zumba video game. Eight women (33.0 ± 3.0 y, 34.8 ± 8.1 % body fat) who regularly participated in a Zumba exercise class were measured for heart rate, number of steps taken, and minutes of sedentary, light, moderate, and vigorous physical activity while participating in a 60-minute human led Zumba exercise class (HZ) or while playing Zumba on the Xbox Kinect video game system (VZ). There were no differences between HZ or VZ (respectively) in light intensity (11.0 ± 7.3 vs. 11.9 ± 9.6 minutes) or moderate intensity (24.7 ± 7.1 vs. 27.6 ± 8.1 minutes) physical activity, or number of steps taken (5337 ± 899 vs. 5001 ± 1141). HZ resulted in less (P<0.05) sedentary time and more (P<0.05) vigorous intensity physical activity (22.0 ± 12.0 vs. 14.2 ± 12.8 minutes) and higher (P<0.05) average heart rates (149.0 ± 14.8 vs. 125.0 ± 10.9 beats/minute) than did VZ (respectively). The present data indicate that participating in Zumba led by a human or played as a video game can contribute to health promoting moderate intensity physical activity, but human led Zumba produces more vigorous intensity physical activity.

Mixed Treatment Comparisons for Nonsurgical Treatment of Knee Osteoarthritis: A Network Meta-analysis.

INTRODUCTION: Knee osteoarthritis (KOA) is a significant health problem with lifetime risk of development estimated to be 45%. Effective nonsurgical treatments are needed for the management of symptoms. METHODS: We designed a network meta-analysis to determine clinically relevant effectiveness of nonsteroidal anti-inflammatory drugs, acetaminophen, intra-articular (IA) corticosteroids, IA platelet-rich plasma, and IA hyaluronic acid compared with each other as well as with oral and IA placebos. We used PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to perform a systematic search of KOA treatments with no date limits and last search on October 7, 2015. Article inclusion criteria considered the following: target population, randomized controlled study design, English language, human subjects, treatments and outcomes of interest, ≥30 patients per group, and consistent follow-up. Using the best available evidence, two abstractors independently extracted pain and function data at or near the most common follow-up time. RESULTS: For pain, all active treatments showed significance over oral placebo, with IA corticosteroids having the largest magnitude of effect and significant difference only over IA placebo. For function, no IA treatments showed significance compared with either placebo, and naproxen was the only treatment showing clinical significance compared with oral placebo. Cumulative probabilities showed naproxen to be the most effective individual treatment, and when combined with IA corticosteroids, it is the most probable to improve pain and function. DISCUSSION: Naproxen ranked most effective among conservative treatments of KOA and should be considered when treating pain and function because of its relative safety and low cost. The best available evidence was analyzed, but there were instances of inconsistency in the design and duration among articles, potentially affecting uniform data inclusion.

Management of Osteochondritis Dissecans of the Femoral Condyle.

The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) document Management of Osteochondritis Dissecans of the Femoral Condyle. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC clinical patient scenarios were derived from patient indications that generally accompany osteochondritis dissecans of the femoral condyle, as well as from current evidence-based clinical practice guidelines and supporting literature. The 64 patient scenarios and 12 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Lastly, a separate, multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

Treatment of Anterior Cruciate Ligament Injuries.

The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) document Treatment of Anterior Cruciate Ligament Injuries. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC clinical patient scenarios were derived from patient indications that generally accompany an anterior cruciate ligament injury, as well as from current evidence-based clinical practice guidelines and supporting literature. The 56 patient scenarios and 8 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Lastly, a separate, multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

Mechanical and physiological analysis of minimalist versus traditionally-shod running.

BACKGROUND: It has been purported that minimalist running shoes allow runners to be more biomechanically and metabolically economical, but evidence supporting these claims remains equivocal. This study's aim was to measure oxygen consumption (VO2), heart rate (HR), pulmonary ventilation (VE) and electromyography (EMG) of gastrocnemius and tibialis anterior in 12 recreationally-trained, college-aged males during minimalist and shod running. METHODS: Participants ran at 70% VO2max on a treadmill in both minimalist and traditional shoes for six minutes each while VO2, HR, VE, EMG and steps taken were recorded. RESULTS: Results indicated no significant differences in VO2 (2.39±0.17 vs. 2.43±0.15 L/min), HR (156.59±2.99 vs. 157.13±3.86 bpm), VE (46.97±3.19 vs. 47.00±2.83 L/min), EMG in the tibialis anterior (2.02±0.28 vs. 1.79±0.20 mV), EMG in the gastrocnemius (1.97±0.36 vs. 2.03±0.37 mV) or steps taken (946.08±13.50 vs. 962.42±19.68 steps) between running in traditional and minimalist shoes, respectively. CONCLUSIONS: This study shows that there is no mechanical and physiological benefit when running wearing minimalist shoes as opposed to traditional shoes and warrants a cautious approach to transitioning to minimalist shoe use.

Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence.

BACKGROUND: The purpose of this analysis was to determine the clinical significance of injectable hyaluronic acid (HA) in the treatment of knee osteoarthritis, and to assess which trial-level factors influence the overall treatment effect of HA on pain (as measured by a VAS [visual analog scale] or the WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index]) and the WOMAC function and WOMAC stiffness subscales. METHODS: A comprehensive literature search of PubMed, EMBASE, the Physiotherapy Evidence Database, and the Cochrane Central Register of Controlled Trials was done to locate randomized controlled trials that compared HA with control treatment and had a minimum of thirty patients per subgroup. To be considered for inclusion, each article had to include VAS or WOMAC pain, WOMAC function, and/or WOMAC stiffness as outcomes because the minimal important difference (MID) has been established for these instruments. A "best-evidence" systematic review and meta-analysis of nineteen trials was performed; because of high heterogeneity among the trials, meta-regression analyses were conducted to determine the influence of trial characteristics on overall HA treatment effects for pain, function, and stiffness. RESULTS: The most consistent finding was that double-blinded, sham-controlled trials had much smaller treatment effects than trials that were not sufficiently blinded (p < 0.05). For double-blinded trials, the overall treatment effect was less than half of the MID for pain, function, and stiffness. Other significant associations were found for cross-linked HAs and follow-up duration. However, the effect sizes among double-blinded trials of cross-linked HAs were still less than half of the MIDs for pain and stiffness. The statistically significant effect of follow-up duration disappeared when the open-label trials were removed from the analysis. CONCLUSIONS: Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials.

Online quizzes promote inconsistent improvements on in-class test performance in introductory anatomy and physiology.

Review quizzes can provide students with feedback and assist in the preparation for in-class tests, but students often do not voluntarily use self-testing resources. The purpose of the present study was to evaluate if taking a mandatory online review quiz alters performance on subsequent in-class tests. During two semesters of a single-semester introductory anatomy and physiology course, students were required to complete brief online quizzes after each textbook chapter had been covered during lecture as well as the day before an in-class test. During the next two semesters, students were not required to take the online review quizzes. Overall scores on chapter specific in-class tests were higher (P < 0.05) during the semesters in which students took online review quizzes (82.9 ± 14.3%) compared with when they did not (78.7 ± 15.5%), but all in-class tests were not improved. Scores on comprehensive midterm examinations were higher (83.0 ± 12.9% vs. 78.9 ± 13.7%, P < 0.05) but not on final examinations (72.4 ± 13.8% vs. 71.8 ± 14.0%) between those with online review quizzes and those without, respectively. Overall scores on in-class tests and comprehensive examinations were higher (P < 0.05) during the semesters in which students took online review quizzes (83.4 ± 16.8%) compared with when they did not (80.3 ± 17.6%). These data suggest that an online review quiz taken the day before an in-class test increases performance on some in-class tests. However, online review quizzes taken after completion of each chapter do not consistently enhance performance on comprehensive examinations.