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Tricia Majewski-Schrage and Kelli Snyder

Clinical Scenario:

Managing edema after trauma or injury is a primary concern for health care professionals, as it is theorized that delaying the removal of edema will increase secondary injury and result in a longer recovery period. The inflammatory process generates a series of events, starting with bleeding and ultimately leading to fluid accumulation in intercellular spaces and the formation of edema. Once edema is formed, the lymphatic system plays a tremendous role in removing excess interstitial fluid and returning the fluid to the circulatory system. Therefore, rehabilitation specialists ought to use therapies that enhance the uptake of edema via the lymphatic system to manage edema; however, the modalities commonly used are ice, compression, and elevation. Modalities such as these may be effective at preventing swelling but present limited evidence to suggest that the function of the lymphatic system is enhanced. Manual lymphatic drainage (MLD) is a manual therapy technique that assists the lymphatic system function by promoting variations in interstitial pressures by applying light pressure using different hand movements.

Focused Clinical Question:

Does MLD improve patient- and disease-oriented outcomes for patients with orthopedic injuries?

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Anna Melin, Monica Klungland Torstveit, Louise Burke, Saul Marks and Jorunn Sundgot-Borgen

Disordered eating behavior (DE) and eating disorders (EDs) are of great concern because of their associations with physical and mental health risks and, in the case of athletes, impaired performance. The syndrome originally known as the Female Athlete Triad, which focused on the interaction of energy availability, reproductive function, and bone health in female athletes, has recently been expanded to recognize that Relative Energy Deficiency in Sport (RED-S) has a broader range of negative effects on body systems with functional impairments in both male and female athletes. Athletes in leanness-demanding sports have an increased risk for RED-S and for developing EDs/DE. Special risk factors in aquatic sports related to weight and body composition management include the wearing of skimpy and tight-fitting bathing suits, and in the case of diving and synchronized swimming, the involvement of subjective judgments of performance. The reported prevalence of DE and EDs in athletic populations, including athletes from aquatic sports, ranges from 18 to 45% in female athletes and from 0 to 28% in male athletes. To prevent EDs, aquatic athletes should practice healthy eating behavior at all periods of development pathway, and coaches and members of the athletes’ health care team should be able to recognize early symptoms indicating risk for energy deficiency, DE, and EDs. Coaches and leaders must accept that DE/EDs can be a problem in aquatic disciplines and that openness regarding this challenge is important.

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Scott O. McDoniel

With the number of individuals becoming overweight or obese, health care professionals are in need of accurate, reliable, and convenient tools to help personalize weight-loss programs. Recently, a new handheld indirect calorimeter (i.e., MedGem/BodyGem; also know as “Gem”) was introduced as a convenient way to assess resting metabolic rate (RMR) to determine daily energy needs. Several validation and comparison studies were conducted to determine whether the Gem device is accurate and reliable, and results from these studies are mixed. Fourteen human studies (12 adult, 2 pediatric) were conducted, and 12 met the established criteria for this review. In all Douglas-bag (DB; n = 4) validation studies, the Gem device was not significantly different than the DB (mean difference adult ±1%, pediatric ±1%). The intra class reliability of the Gem ranged from 0.97 to 0.98, and the interclass reliability to the DB ranged from 0.91 to 0.97. Although few (n = 2) studies have demonstrated that the Gem device measures RMR significantly lower (–8.2% to 15.1%) than traditional metabolic carts, it performs very comparably (RMR values 0.1–4.0%, interclass reliability 0.76–0.92) to traditional metabolic carts in most (n = 6) of the comparison studies. Based on these data, the Gem device is a valid and reliable indirect calorimeter for energy assessment in most adults and children.

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Cora Lynn Craig


Low levels of physical activity (PA) and fitness have long been a government concern in Canada; however, more than half of adults are inactive. This article examines factors influencing policy development and implementation using Canadian PA policy as a case study.


Current and historical PA policy documents were amassed from a literature review, audit of government and non government websites and from requests to government officials in each jurisdiction directly responsible for PA. These were analyzed to determine policy content, results, barriers, and success factors.


The national focus for PA policy in Canada has devolved to a multilevel system that meets most established criteria for successful strategies. Earlier PA targets have been met; however, the prevalence of PA decreased from 2005 to 2007. Annual per capita savings in health care associated with achieving the earlier target is estimated at $6.15 per capita, yet a fraction of that is directed to promoting PA.


Evidenced-based strategies that address multiple policy agendas using sector-specific approaches are needed. Sustained high-level commitment is required; advocacy grounded in metrics and science is needed to increase the profile of the issue and increase the commitments to PA policies in Canada and internationally.

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Brent C. Mangus

The number of wheelchair-bound athletes training for and competing in local, state, national, and international sporting events increases every year. As participation increases, sports injuries associated with the training and competition of these athletes also increase. Medical attention for wheelchair athletes during training and competition should be provided by competent professionals. However, even with competent professionals providing medical attention to wheelchair athletes, injuries do occur. Typical injuries experienced by the wheelchair-bound athlete include carpal tunnel syndrome, various shoulder problems, numerous problems with the hands, and lacerations, abrasions, and contusions to all parts of the body. The ability of the wheelchair athlete to thermoregulate his or her own body is also an area of concern for those providing health care during practice and competition. More researchers are studying injuries and injury rates to the wheelchair athlete, and the body of literature in this area is becoming larger. Future research can begin to document the effects of strength training, nutrition, various conditioning strategies, the biomechanics of the wheelchair motion, and the psychological impact of athletic injuries. Although some physiological factors have been studied, many remain to be addressed in an effort to shed light on the injuries experienced by wheelchair athletes.

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Robert M. Kaplan, Alison K. Herrmann, James T. Morrison, Laura F. DeFina and James R. Morrow Jr.


Despite benefits of physical activity (PA), exercise is also associated with risks. Musculoskeletal injury (MSI) risk increases with exercise frequency/intensity. MSI is associated with costs including medical care and time lost from work.


To evaluate the economic costs associated with PA-related MSIs in community-dwelling women.


Participants included 909 women in the Women’s Injury Study reporting PA behaviors and MSI incidence weekly via the Internet for up to 3 years (mean follow-up 1.89 years). Participants provided consent to obtain health records. Costs were estimated by medical records and self-reports of medical care. Components included physician visits, medical facility contacts, medication costs, and missed work.


Of 909 participants, 243 reported 323 episodes of expenditure or contact with the health care system associated with PA. Total costs of episodes ranged from $0–$18,934. Modal cost was $0 (mean = $433 ± $1670). Costs were positively skewed with nearly all participants reporting no or very low costs.


About 1 in 4 community-dwelling women who are physically active experienced a PA-related MSI. The majority of injuries were minor, and large expenses associated with MSI were rare. The long-term health benefits and costs savings resulting from PA likely outweigh the minor costs associated with MSI from a physically-active lifestyle.

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Barry D. McPherson

With the aging of the population, an increasing sex ratio of women to men, the potential for increased disability-free life expectancy, and increasing health-care costs, health promotion and physical activity personnel engaged in research, policy, or practice need a full understanding of the physical, cultural, and social context in which consecutive age cohorts move through life. This paper integrates research information from health promotion, the physical activity sciences, social gerontology, and demography; it is divided into six sections focusing on demographic and cultural diversity, the cultural meaning of physical activity, active lifestyles, catalysts and barriers to the emergence of an active older population, and promoting lifelong active living. Employing a macro (societal) rather than a micro (individual) level of analysis, the paper emphasizes that aging is a lifelong social process leading to diverse lifestyles in middle and later adulthood, that there is considerable heterogeneity in physical and social experiences and capacities within and between age cohorts, and that aging is a women’s issue, particularly with respect to health and activity promotion.

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Christina Tsitsimpikou, Nastasia Chrisostomou, Peter Papalexis, Konstantinos Tsarouhas, Aristidis Tsatsakis and Athanasios Jamurtas

Although the use of nutritional supplements by professional athletes and the benefits thereof have been extensively studied, information on recreational athletes’ use of supplements is limited. This study investigated the consumption of nutritional supplements, source of information and supply of supplements, and level of awareness with regard to the relevant legislation among individuals who undertake regular exercise in Athens, Greece. A closed-ended, anonymous questionnaire was answered by 329 subjects (180 men, 149 women), age 30.6 ± 12.1 yr, from 11 randomly selected gym centers. Preparations declared as anabolic agents by the users were submitted to a gas chromatographic analyzer coupled to a mass spectrometric detector. Consumption of nutritional supplements was reported by 41% of the study population, with proteins/amino acids and vitamins being the most popular. Age (r = .456, p = .035), sex (χ2 = 14.1, df = 1, p < .001), level of education (χ2 = 14.1, df = 3, p < .001), and profession (χ2 = 11.4, df = 4, p = .022) were associated with the subjects’ decision to consume nutritional supplements. Most (67.1%) purchased products from health food stores. Only 17.1% had consulted a physician or nutritionist, and one third were aware of the relevant legislation. Two preparations were detected containing synthetic anabolic steroids not stated on the label. In conclusion, use of nutritional supplements was common among recreational athletes in Athens, Greece. A low level of awareness and low involvement of health care professionals as sources of information and supply were observed.

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Mei Du, Mee-Lee Leung, Frank H. Fu and Lynda Ransdell

While job stress in various occupations has gained the attention of experts in both academic research and occupational health care, there is a dearth of information about stress levels among managers in the sport and recreation industry, especially in women and in the Asian culture. Because managers are an important force in delivering sport and recreation services to citizens, the purposes of this study were to examine the job stress and job satisfaction of sport and recreation managers in Hong Kong, and to discern the relationship between stress and job satisfaction. Sport and recreation managers experienced moderate stress (M = 3.63, SD = 0.67) and were satisfied with their jobs (M = 3.79, SD = 0.64). Work relationships (Beta = −.44, p <.001), organizational climate (Beta = −.36, p <.001), home/work balance (Beta = .26, p <.01), and personal responsibility (Beta = .23, p <.01) were important determinants of their job satisfaction. A comprehensive understanding of job stress and job satisfaction is important for minimizing the impact of potential stressors on today’s workforce.

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Jennifer L Kuk, Shahnaz Davachi, Andrea M. Kriska, Michael C. Riddell and Edward W. Gregg

This article briefly summarizes the “Pre-Diabetes Detection and Intervention Symposium” that described ongoing and past pre-diabetes interventions, and outlined some considerations when deciding to target specific populations with pre-diabetes. The success of type 2 diabetes (T2D) prevention clinical trials provides clear evidence that healthy lifestyle change can prevent the development of T2D in a cost effective manner in high risk individuals. However, who to target and what cut-points should be used to identify individuals who would qualify for these T2D prevention programs are not simple questions. More stringent cut-offs are more efficient in preventing T2D, but less equitable. Interventions will likely need to be adapted and made more economical for local communities and health care centers if they are to be adopted universally. Further, they may need to be adapted to meet the specific needs of certain high-risk populations such as ethnic minorities. The Chronic Disease Management & Prevention Program for Diverse Populations in Alberta and the Pre-diabetes Detection and Physical Activity Intervention Delivery project in Toronto represent 2 examples of specialized interventions that are targeted at certain high risk populations. To reverse the current T2D trends will require continued efforts to develop and refine T2D prevention interventions.