key: cord-0964974-7clmy0gk authors: Nikaido, Motoshige; Arai, Sadao; Fujino, Keiji; Hayashi, Shohiro title: JCOA The Japanese Clinical Orthopaedic Association the questionnaire survey on the physical changes after the self-restraint of outdoor activities with the COVID-19 crisis- corona locomo and corona stress() date: 2021-11-09 journal: J Orthop Sci DOI: 10.1016/j.jos.2021.10.010 sha: cc6256b1b9057eaafdace1fdc633fda29a72543a doc_id: 964974 cord_uid: 7clmy0gk BACKGROUND: Problems with COVD-19 are not limited to the infection itself, but also include the secondary health damage arising from the prolonged self-restraint, which has affected all age groups in the Japanese population. Numerous studies have reported clear evidence of the secondary health damage. Published reports cover a wide range of damages, from locomotive dysfunction caused by decreased physical activity to decreased cognitive function and changes in eating and oral functions, and further to decreased opportunities for social participation. Such damage can also lead to worsening of so-called frailty. Under this circumstance, orthopedic surgeons conducted a questionnaire survey to determine the physical changes observed after the start of the COVD-19 self-restraint period. In this article, we report findings of the survey, along with some literature considerations. METHODS: The survey was started two months after the state of emergency in Japan was lifted, July 20 to August 12, 2020 (16 days total). And the analysis was conducted by simple and cross tabulation. RESULTS: Valid responses to the questionnaire were obtained from 12,254 participants. Approximately 40% of the subjects felt a lack of physical strength (Corona stress), with the percentage peaking in high school, in the elderly it remained rather below average. On the other hand, locomotive dysfunction (Corona locomo) increased with age, independent of physical activity, and was not correlated with Corona stress. CONCLUSIONS: Japanese citizens need to change their behaviors for the purpose of improving their exercise and lifestyle habits towards shifting to a new lifestyle norm. Looking ahead to the ``With Corona’’ era, it is considered necessary by selecting a tailor-made training method suitable for each age group. The spread of COVID-19 has forced people to restrict their activities in a wide range of areas. Even with the lifting of the selfrestraint, social activities appear to be headed for a new norm. In order to verify the impact of the prolonged self-restraint of activities on the motor functions of individuals, we conducted a survey to evaluate the physical changes associated with such restriction in all ages of patients who visited our orthopedic outpatient clinics and their family members. The questionnaire survey was conducted in patients who visited member institutions of the Japanese Clinical Orthopaedic Association (JCOA) and their families. The intent of the survey was explained to these subjects by the survey manager. After obtaining their informed consent, while they were seated in the waiting room, the survey staff, etc., asked them to fill out a form in a fill-inthe-blank format with answer choices on the website using their smartphone or a fill-in form, containing the following 18 questions. After all the questionnaires were collected, the answers were reentered on the website at a later date. All participants provided written informed consent and all procedures used in this research were approved by the Ethical Committee of JCOA. The 18 question items were as follows. We conducted a survey particularly over the impact of the time spent exercising or playing smartphones/games on physical stress and pain of school students before and during school closure (total 10 items) (9) The time spent playing on smartphones or games ( none <1hr 1~3hr 3hr<). (10)Poor posture ( Yes No) Valid responses to the questionnaire were obtained from 12,254 participants. The male: female ratio was 2:3. By age group, in their 70s accounted for the highest number, and more than half of all were in their 60s or older (Fig. 1 ). 1) By age group, a higher proportion of school students and the elderly engaged in exercises, as compared to the significantly lower proportion in 20se50s. The proportion in 20se30s who exercised was greater D.R. than B.R. On the other hand, the proportions of school students and 70se80s who exercised was lower D.R than B.R (Fig. 2) . 2) Walking, strolling and jogging exercises were the most common types of exercises throughout all age groups, the proportion increasing with 20s and older, and exceeding 50% in 70s (Fig. 3) . 30% of all reported that they had pain somewhere in the body. The proportion who had pain was consistent across age groups, except for being lower in elementary school students (E.S) and 20s. In regard to affected area, more than half of each age group, except children, complained of neck and lower back pain. On the other hand, 40% of E.S and 30% of J.H complained of feet and ankles pain (Fig. 6 ). The proportion of any changes in locomotive function increased with age, and changes in dynamic balance control ability exceeded in static balance control ability in all age groups (Fig. 7) . 2) Corona stress 38.5% of respondents across age groups perceived loss of physical strength. It was especially high in S.H (55.1%), whereas slightly below average in the elderly (37.5%). In most age groups, 35%e40% of all were aware of weight gain. In their 70s or older, the proportion reporting it decreased (Fig. 8 ). Percentage of respondents who exercised before and during self-restraint by age group. The proportion of people who exercised was slightly greater D.R than B.R. The rate increased by 8.9% among 20s and 11.0% in 30s, while it decreased by 5.4% among school children and by 2.2% in 70s and 80s. Loss of physical strength was the most common change in all the children, and peaked in S.H. A similar profile was also observed for having painful areas. Poor posture was more common in E.S, and weight gain was almost consistent across all the school students ( Fig. 9) . In D.R, " never exercise'' group was the most frequently selected option in E.S, both "exercising for 3 h or more a day'' group and "spending 3 h or more a day playing on smartphones/games'' group were the most frequent in S.H. In each group, loss of physical strength was the most frequent in extreme under-exercising group, whereas in extreme over-exercising group, J.H accounted for the highest proportion in any physical conditions, including easily fatigued (Fig. 10 ). This survey showed that despite 2 months having elapsed since the lifting of the call for self-restraint to the start of the survey, the physical condition had not recovered to the normal state in nearly 40% of the respondents. Yamada [1] conducted a web-based urgent questionnaire survey on the physical changes in 5000 people before the state of emergency was declared. She reported that the amount of physical activities decreased by 48% from the previous year in participants aged 60 years and older. Our survey revealed that predominantly children had Corona stress and predominantly elderly people had Corona locomo (Fig. 11) . The quality and quantity of exercise were deeply associated with the extent, specific to each age group, of locomotive dysfunction and physical stress. The proportion of respondents suffering from``Corona stress'' was extremely high (55.1%) among high school students. Both the frequency of exercise before the self-restraint period and the duration of exercise during the self-restraint period were higher in the order of high school students to junior high school students. The time spent in playing with smartphones/games for 3 h per day was greater in the order of high school students to junior high school students. It has been suggested that the stress in high school students is attributable to the rapid change in their daily exercise habits, 7 . Corona locomo. All three signs of early decline in locomotive function increased with age, and the dynamic balance control ability Ave.28.3% was greater than the static balance control ability 18.0% in all age groups. resulting from polarization of the amount of exercise ('`lack of exercise vs. excessive exercise'') during the COVID-19 pandemic. In addition, 40% of E.S complained of pain around feet and ankles. Stiffened joints during the school closure period affect especially feet and ankles among the weight-bearing joints. As a result, a situation may develop wherein resumption of exercise leads to inconceivable injuries under normal circumstances, such as``breaking ankle when jumping rope''. Muramatsu [2] states that the incidence rate of fractures in J.H has trebled from 1.0% to 3.0% in 40 years. Hayashi et al. [3] gave the term`C hild locomo'' for locomotive dysfunction without a clear underlying disease in children. They have been widely conducting Child locomo prevention and awareness raising activities, through conducting school medical examination of locomotive organs in Saitama Pref., under multidisciplinary cooperation of parents, school doctors, classroom teachers, school nurses, and dietitians. Also, a survey conducted by the Japan Sports Agency in 2018 [4] revealed that the physical strength and athletic ability of school students declined over time. The incidence of Child locomo has been rising steadily year after year. Many young and middle-aged people, who are supporters of society, were forced to change their lifestyles, such as long-term teleworking from home, due to the call for self-restraint for a period of about seven weeks. As a result, they were exposed to various health hazards. This survey also revealed that more than 70% of their 20s and 30s complained of stiff neck and lower back pain, and that at least 40% in 40s and 50s were aware of weight gain. The increase in the proportion of respondents engaging in exercise D.R, especially 20s and 30s, as compared to that B.R, is considered to reflect the sense of danger that young and middle-aged people felt regarding their health. Therefore, this finding is very interesting. After the declaration of the state of emergency, all sports facilities were closed, and group sporting events were cancelled. In addition, due to the limited medical care provided by medical institutions and closure of outpatient rehabilitation and long-term care facilities, elderly people were also forced to change their daily lifestyles rather suddenly. However, there was almost no change in the proportion of people who were engaged in habitual exercise, either before or during the self-restraint period. In regard to walking, which was the most common exercise, 51.1% of people in their 70s and 1 in 4 people in their 80s walked by way of exercise every day. This result suggests that it is possible, even during the COVID pandemic, to continue walking, as part of elderly's daily activities, without worrying about``denseness'' (Fig. 3) . The result showing an increase in the incidence of Corona locomo with age, despite no reduction in the amount and frequency of exercise during the self-restraint period, suggests the following: walking for exercise is a typical aerobic exercise, and is considered to be effective for the prevention of not only metabolic syndrome and dementia, but also of mental stress. For elderly people who are highly health conscious, moderate exercise appears to be more effective for preventing mental deterioration than physical deterioration. Therefore, preventive measures against Corona locomo, which is more likely to develop with increasing age, involving not only aerobic exercise, but also low-intensity muscle strengthening exercises interspersed with locomotion-training, aimed at improving the static balance control ability. The results of the present survey showed that the proportion of respondents who perceived changes in the static balance control ability, which is an early sign of locomotive dysfunction, was lower than the dynamic balance control ability, across all age groups. This finding is inconsistent with Frankenberg's theory, which states that the balance control ability is established first for dynamic balance, followed by static balance during infancy, and with aging, static balance deteriorates first, followed by dynamic balance. Murray MP [6] states that``one-leg standing'', that is, the single-limb support period, accounts for 80% of the gait cycle at normal walking speed. In addition, Dai, et al. [7] states that the static balance control ability plays a supportive role by supporting and stabilizing the dynamic balance control ability (walking). It is difficult to assess the subjective judgment that deterioration of the static balance control ability leads to unstable walking and easy stumbling. Moreover, also from Ono's report [8] suggesting that the dynamic balance control ability markedly deteriorates with increasing age, it is considered that the ability to pay attention to stumbling also diminishes with increasing age. We still cannot see the convergence towards the end of the covid-19 crisis. Therefore, Japanese citizens need to change their behaviors for the purpose of improving their exercise and lifestyle habits towards shifting to a new lifestyle norm. Looking ahead to the``with corona era'', which is likely to last longer, it appears necessary for school students to build a regular lifestyle and to include proper stretching before and after physical exercises. For young and middle-aged people, it may be necessary to incorporate active training sufficient to overcome a chronic lack of sufficient daily physical activities. For elderly people, it may be necessary not only to encourage them to walk for exercise as they had done so far, but also to include an intervention with daily locomotive-training to prevent``Locomo-frail'' [9] . Thus, it is considered necessary to improve exercise and lifestyle habits by selecting a tailor-made training method suitable for each age group. In the era of accelerating aging of the society with a declining birthrate, in order to obtain a treasure for a lifetime, a``healthy locomotive system'', it is necessary to make efforts to extend healthy life expectancy by carrying out locomotive syndrome prevention and awareness raising activities suitable for all ages. We orthopedists have a significant role as key persons in conducting these activities. Ethics approval and consent to particle Written informed consent was obtained from all participants in advance. Application for approval of this study made to the Ethics Committee of the Japanese Clinical Orthopaedic Association. This work was supported by the research project of JCOA The Japanese Clinical Orthopaedic Association. All authors agreed to submit it and will agree to transfer the copyright. The corresponding author has full access to all data in the study and assumes final responsibility for the decision to submit for publication. There are no conflicts of interest to declare. The COVID-19 outbreak limits physical activities and increases sedentary behavior : a possible secondary public health crisis for the elderly Disaster under the control of the school authorities-annual basic statistics'' nissei fundamental research laboratory letter Child locomotive syndrome and school medical examination of locomotive organs Summary of the annual survey on physical strength and athletic ability in 2018 by the Japan Sports Agency. 6. Analysis of investigation results Gait as a total pattern of movement Development of exercise program of improving dynamic balance function for elderly people A comparative study of static and dynamic postural control characteristics in healthy younger and elderly people Frailty and locomotive syndrome. prospect and rearranging of the concepts We thank all of the orthopaedic surgeons, their staff members of JCOA, further patients and their families who participated in this study.