THE FEMALE ATHLETE TRIAD

The "female athlete triad" is a term used to describe three distinct but interrelated conditions, including, low energy availability, menstrual dysfunction and low bone mineral density. Low energy availability is a term that is used to describe the condition that occurs if a female has low stored energy (low body weight for height), and/or low energy intake (insufficient calorie intake) and/or high levels of energy expenditure (lots of physical activity and/or exercise). The state of low energy availability can result in disruption of the normal menstrual cycle or delay the onset of a female’s first menstrual period. This is referred to as delayed menarche. Delayed menarche is defined as not having had your first menstrual period by age 15. In those females who have had their first period, but have low energy availability, their periods may get farther apart, or they may go away completely. Periods that occur every 35-90 days are referred to as “oligomenorrhea”. Periods that are farther than 90 days apart, or completely absent, are referred to as “amenorrhea”.

Low energy availability may occur unintentionally as a result of inadequate dietary intake relative to very high levels of exercise training. More often, it occurs as a result of intentional dietary restriction in the setting of disordered eating or an eating disorder such as anorexia nervosa or bulimia nervosa. A number of health problems can occur as a result of low energy availability leading to disrupted menstrual function. Infrequent or absent menstrual periods can result in low estrogen levels in the blood, which in turn leads to lower than expected bone mineral density. Amongst athletes, especially those that perform a weight bearing and/or impact sport like long distance running or basketball, the combination of these activities and low bone mineral density increases the likelihood of getting bone stress fractures. Stress fractures are serious injuries and can be a season ending and in some, a career ending injury.

Any female athlete is at risk for the female athlete triad. However, athletes who participate in aesthetic sports like gymnastics, figure skating, diving and dance, or in sports where leanness confers a competitive advantage like long distance running, are more likely to be affected by any component of the triad. We recommend that female athletes in high school and college undergo yearly preparticipation screening with a team physician or sports medicine physician who screens for the triad with the questions listed in Table 1.

Table 1: Female Athlete Triad Preparticipation Physical Evaluation Questions

• Have you ever had a menstrual period?
• How old were you when you had your “first menstrual period ?"
• When was your most recent menstrual period?
• How many periods have you had in the past 12 months?
• Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?
• Do you worry about your weight?
• Are you trying to or has anyone recommended that you gain or lose weight?
• Are you on a special diet or do you avoid certain types of foods or food groups?
• Have you ever had an eating disorder?
• Have you ever had a stress fracture?
• Have you ever been told you have low bone density (osteopenia or osteoporosis)?

Athletes identified as having any one component of the triad, should be carefully screened for the other aspects. While disruption of the menstrual cycle is a relatively common consequence of low energy availability, it’s important to make sure that other conditions are not resulting in menstrual disruption, specifically pregnancy and thyroid disease. Similarly, there are other conditions that can result in lower than expected bone mineral density. These conditions should be considered by a healthcare provider when evaluating an athlete with low bone mineral density.

Comprehensive evaluation of the athlete affected by the triad includes a physical and laboratory evaluation by a healthcare provider. Usually, an evaluation of dietary intake by a registered sports dietitian, and oftentimes an evaluation by a mental health professional, is done, especially if there is evidence of disordered eating or an eating disorder. Bone mineral density is often assessed using a tool called a dual-energy x-ray absorptiometry (DEXA)scan. The DEXA scan provides a number of scores. In the high school, college and young adult female, the “Z-Score” is used to make clinical decisions and NOT the “T-Score”. A Z-Score greater than 0 is normal. A Z-Score between -1 and 0 is still considered normal, but in the setting CONTINUED FROM PAGE 1 of the Triad should prompt discussion about the relationship between low energy availability, menstrual function and bone health – this is especially true if a prior DEXA is available for comparison and was previously greater than 0. A Z-Score between -1 and -2 in a weight bearing athlete is concerning and would indicate that bone health has been negatively affected. A Z-Score less than -2 indicates significant bone loss. Treatment of the triad should be focused on establishing adequate energy availability to meet energy demands of exercise, activities of daily living and in the younger athlete, growth. Although every person’s energy (or calorie) needs are different, research has found that achieving energy availability of 45 kilocalories per kilogram of fat free mass per day is associated with regular menstrual cycles. Fat free mass can be calculated (by measuring body fat percentage) or estimated. An example of this is provided in Figure 1.

Figure 1 : Calculating Energy Availability to Achieve Menstrual Regulation

18 years old
120 lb female
120 lb ÷ 2.2 = 54.5 kg
18% body fat
Fat Mass = 54.5 X 0.18 = 9.8 kg
Fat Free Mass = 54.5 – 9.8 = 44.7 kg
45 kcal X 44.7 kg = 2011 kcal/day

In this example of a 120-lb 18-year-old female, she would require 2011 kcal per day to support healthy reproductive function. A recent paper (2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad) written by members of the Female Athlete Triad Coalition, and published in the British Journal of Sports Medicine, Clinical Journal of Sports Medicine and Current Sports Medicine Reports, and endorsed by several medical professional societies also outlines the use of medications that may be considered in the treatment of women and girls who are affected by the Triad. However, it bears repeating that the primary treatment efforts should be focused on achieving adequate energy intake and adequate stored energy relative to energy expenditure. Medications such as birth control pills to initiate or regulate menstrual function should be used in those cases as outlined in the consensus statement.

The consensus statement also provides physicians with guidance regarding clearance and return to play for athletes affected by the triad. The paper developed a “Magnitude of Risk” tool that includes known risk factors that can be identified and scored leading to Risk Stratification and Recommendations. The risk factors included in this tool include: 1) presence or history of an eating disorder or disordered eating; 2) Current body mass index (BMI); 3) Age of first menstrual period; 4) Number of menstrual periods in the past 12 months; 5) Bone mineral density as measured by DXA scan; 6) History of bone stress fractures or stress reactions. Using the Magnitude of Risk and Risk Stratification tools, a physician can then inform the athlete where she lies on the continuum, and develop a plan to achieve health and guide safe participation in sports or exercise. In conclusion, exercise and sport participation improve health and quality of life for females of all ages.

The female athlete triad can be a consequence of participation, the same way that knee injuries can be a part of football participation. We should not discourage females from participating in sport, instead we should screen for risk factors and the conditions that make up the triad, and treat it appropriately.

BREAST-FEEDING CAN LIMIT MOM'S RISK OF HEART ATTACK, STROKES

You've heard before about how healthy breast-feeding is for your baby. But what if it could aid your long-term health, too?

The latest findings published Wednesday in the Journal of the American Heart Association suggest that breast-feeding could reduce a mother's risk for developing a heart attack and stroke later in her life. Specifically, the Chinese study discovered breast-feeding mothers lowered their heart disease or stroke risk by approximately 10 percent.

It's important to note that the study was just observational (i.e. no cause-and-effect conclusions are available).

While short-term health benefits have been known – think weight loss and lower cholesterol – the long-term effects haven't been clear when it comes to cardiovascular diseases in mothers. University of Oxford, the Chinese Academy of Medical Sciences and Peking University researchers took into account data from 289,573 Chinese women, average age of 51, for the study. 

That data came from another study, where women (almost all were mothers, and none of them had cardiovascular disease) provided details regarding their reproductive history and lifestyle factors. There were 16,671 cases of coronary heart disease (including heart attacks) and 23,983 cases of stroke within eight years of follow-up. Mothers who breast-fed saw a 9 percent lower heart disease risk and an 8 percent lower stroke risk, all compared to those who had never breast-fed. Those who breast-fed for two years or more saw an 18 percent lower heart disease risk and 17 percent lower stroke risk.

Researchers accounted for cardiovascular disease risk factors like smoking, obesity and diabetes when putting together these results. Live Science notes the study couldn't account for factors like women's diet that might contribute to heart disease risk.

As for what researchers hope comes out of this? More breast-feeding.

"The findings should encourage more widespread breast-feeding for the benefit of the mother as well as the child," Zhengming Chen, senior study author and professor of epidemiology at the University of Oxford, said in a statement. "The study provides support for the World Health Organization's recommendation that mothers should breast-feed their babies exclusively for their first six months of life.

"Although there is increasing recognition of the importance of exclusive breast-feeding, genuine commitment from policy makers is needed to implement strategies in the healthcare system, communities and families and the work environment that promote and support every woman to breast-feed," the authors wrote.

NON-OPIOID TREATMENT AFTER SURGERIES

The results of a recent consumer survey found that 79% of patients who have undergone surgery would choose a non-opioid option for treatment of pain over opioids. These findings make clear the high level of interest patients have in nonopioid treatment after surgery, despite the nation’s growing opioid epidemic.

The survey (Opioid Addiction and Dependence after Surgery Is Significantly Higher Than Previously Known- June 13, 2016) provides valuable insight into the issue, and suggests more patient education is needed.

The study polled 500 adults in the United States who had orthopedic surgery or soft tissue surgery in June 2016, and was conducted in support of the Plan Against Pain campaign, an effort designed to educate patients about their choices in managing pain following a surgical procedure. 

According to the Centers for Disease Control and Prevention (CDC), sales of prescription opioids have quadrupled in the United States. In response to the growing epidemic, the CDC released opioid prescribing guidelines in March 2016, urging prescribers to reduce the use of opioids in favor of safe alternatives like physical therapy.

Physical therapists partner with patients, their families, and other health care professionals to manage pain through movement and exercise.

The American Physical Therapy Association launched a national campaign to raise awareness about the risks of long-term use of opioids and the fact that physical therapy is safe alternative pain management. Learn more at our #ChoosePT page.

BODY MECHANICS AT THE OFFICE

Whether or not you realize it, you probably have a home office. You might not telecommute, and you might not have a corner, L-shaped desk or a computer with dual monitors, but most likely, there is a place in your home where you browse the web, check Facebook, answer emails, update your blog, or write the next chapter of your 200,000 word fan-fiction novel. There is a place in your home where you spend a lot of time sitting down, facing a screen. You’re thinking about it right now, aren’t you?

The fact is, people are spending more time in front of screens than ever before. According to a recent BBC article, adults in the UK are now spending more time on devices than sleep, and the New York Times reports that statistics in the U.S. are similar. Studies have shown, and it’s not too difficult to believe, that people are not just dependent on their devices, but also emotionally attached to the connectivity that they provide.

“But,” some might say, “I’m not wasting time on my device. I’m forced to be in front of my screen for work/school.” This may very well be true, but whether screen time is due to stacks upon stacks of paperwork or due to an unhealthy emotional attachment to connectivity with the virtual world, the result, at least for the human body’s ergonomic health, is the same. If we can’t tear ourselves away from our screens (for whatever reason), the very least we can do is make sure that our “home office” allows for the body posture that is least harmful to our health.

The Chair
Mayo Clinic says that the height of a chair should allow for feet to rest on the floor and for knees to be level with hips. A good chair also provides lumbar/lower back support. If your desk chair does not allow your feet to hit the floor, guess what - it's step-stool time for you! You should (preferably) have a desk chair with arm rests, and those arm rests should be used to keep your shoulders from lowering too far. What happens when you lower your arms too far for too long? It can, over time, lead to compression issues in the nervous structures in and around your neck, and stretch out muscles that need to be shorter to keep your shoulder joint mechanics on par. 

The Phone
Mayo Clinic also says that if one regularly uses a phone at the same time as a computer, the phone should have a headset so as to protect the neck from strain. Please, please, try not to hold your phone to your shoulder with your ear. We're all guilty of it sometimes, but efficiency comes at a cost.

The Monitor
The same article indicates that the monitor should be an arm’s length away and the top of the screen should be just below eye level. Where your keyboard should be depends on your diagnosis. Ask your PT for more information! 

Posture
No matter how flawlessly a workspace is set up, joint health still relies heavily on correct body posture. In other words, we can easily find ways to sit in our ergonomically correct home office that are not ergonomically correct. Three few helpful posture rules are:

1. Don’t slouch. It sounds obvious, but still difficult to remember!
2. Center your body in front of your monitor/keyboard.
3. Keep your thighs and knees level with your hips, if appropriate. And don't cross your legs! 

If your back pain occurs when your back is bent, you want to keep your knees below the level of your hips. If your back pain occurs when your back is too straight, you'll want to keep your knees above the level of your hips. A good general rule for those who are just correcting their posture for prevention's sake is to keep the knees level with the hips. 

Take Breaks
Taking a break to move around, even if it’s just to stand up and walk or stretch, is not only good for the body, but it’s been proven to increase the ability to focus, to decrease fatigue, and to improve mood.

So, do your best to separate yourself from your computer, phone, and television when possible, and when you can’t find enough willpower to say no to Facebook, or when deadlines are approaching, do your body a favor and relax or work in a position and location that optimize skeletal and muscular health. Get up and move around. Our social media gal, Anna, gets 10 minute breaks for every 50 minutes where the students are required to get up and walk around to refuel their bodies. We truly aren't meant to sit at a desk for 8+ hours per day. 

EXTRA STEPS CAN HELP REDUCE RISK OF DIABETES AND STROKE

Individuals at risk for diabetes can cut their risk for heart attack or stroke by 8% by taking an extra 2,000 steps a day—equivalent to about 20 minutes of moderately paced walking—according to a study of more than 9,000 adults performed by researchers at the University of Leicester and published in the Lancet.

"Two thousand steps seemed to be the magic number," TIME reported ("How Many Steps Does it Take to Avoid a Heart Attack? Researchers Find Out" - December 19, 2013). "Even before the study began, for every 2,000 steps a day one participant tended to walk on average compared to another, he enjoyed a 10% lower rate of heart problems by the end of the year."

Visit www.apta.org for more information! 

GUESS WHO IS AT A HIGHER RISK FOR OVERUSE INJURIES DURING HIGH SCHOOL?

According to the APTA, among high school athletes, girls are at greater risk for overuse injuries than boys, according to a recent national study published in the Journal of Pediatrics (“Epidemiology of Overuse Injuries among High-School Athletes in the United States” – March 2015).

In analyzing 3,000 male and female high school athletes participating in 20 different sports, researchers found that overuse injuries represented 7.7% of injuries overall, but rates among girls and boys differed significantly, with overuse injuries representing 13.3% of all injuries for girls compared to only 5.5% for boys.

Girls and boys also differed in terms of when the injuries were likely to occur, with the proportion of overuse injuries decreasing in females from freshman to senior year, while it increased in males.

The highest overuse injury rates for girls were seen in track and field, field hockey, and lacrosse.

"This finding may be solely due to differences between males and females or that these girls’ sports have larger teams with younger, skeletally immature girls who were not physically ready to handle the repetitive motion associated with these sports," the researchers summarized. "Athletes in these sports may benefit most from overuse injury assessment and prevention."

In a video produced by Ohio State University, lead author Thomas Best, MD, also theorized that single-sport specialization could be a contributing factor.

"Many of these youngsters are playing a single sport, and that may in fact be a major risk factor for these overuse injuries because their bodies are seeing the same repetitive blows with one sport," Best said.

What can you do? Preventative measures are your best option. Although there's no guarantee, you can make a significant impact on yourself by working against nature to prevent it.