Running and Physical Activity in an Air-Polluted Environment: The Biomechanical and Musculoskeletal Protocol for a Prospective Cohort Study

ar too little attention has been paid to health e ects of air pollution and physical (in)activity on musculoskeletal health. The purpose of the Healthy aging in industrial environment study (4HAIE) is to investigate the potential impact of physical activity in

Amherst, MA 01003, USA *Correspondence: daniel.jandacka@osu.cz Received: 23 October 2020; Accepted: 4 December 2020; Published: 7 December 2020 Abstract: Far too little attention has been paid to health e ects of air pollution and physical (in)activity on musculoskeletal health. The purpose of the Healthy aging in industrial environment study (4HAIE) is to investigate the potential impact of physical activity in highly polluted air on musculoskeletal health. A total of 1500 active runners and inactive controls aged 18–65 will be recruited. The sample will be recruited using quota sampling based on location (the most air-polluted region in EU and a control region), age, sex, and activity status. Participants will complete online questionnaires and undergo a two-day baseline laboratory assessment, including biomechanical, physiological, psychological testing, and magnetic resonance imaging. Throughout one-year, physical activity data will be collected through Fitbit monitors, along with data regarding the incidence of injuries, air pollution, psychological factors, and behavior collected through a custom developed mobile application. Herein, we introduce a biomechanical and musculoskeletal protocol to investigate musculoskeletal and neuro-mechanical health in this 4HAIE cohort, including a design for controlling for physiological and psychological injury factors. In the current ongoing project, we hypothesize that there will be interactions of environmental, biomechanical, physiological, and psychosocial variables and that these interactions will cause musculoskeletal diseases/protection. Int. J. Environ. Res. Public Health2020,17, 9142; doi:10.3390 /ijerph17239142 /journal/ijerph

Int. J. Environ. Res. Public Health2020,17, 9142 2 of 20 Keywords: MRI; running; walking cutting; environment; knee; ankle; ACL; cartilage; achilles tendon 1. Introduction The health e ects of poor air quality are unlikely to be limited to cardiovascular and respiratory problems. Far too little attention has been paid to the health e ects of air pollution on the musculoskeletal system. Musculoskeletal problems represent a global threat to healthy aging and can lead to the development of musculoskeletal diseases [1]. Reduced physical function often leads to mental health decline, increased risk of developing other chronic diseases, and increased all-cause mortality [1,2]. Recently, the English Longitudinal Study of Aging described a possible link between air pollution exposure and cartilage damage in the English population [3]. Therefore, the health e ects of air pollution on the musculoskeletal system need further investigation. The English Longitudinal Study of Aging did not directly measure tissue quality, air pollution associated with participants' physical activity, or the biomechanical load of musculoskeletal system [3]. To understand the e ect of air pollution on the musculoskeletal system, it may be helpful to examine regularly physically active and inactive individuals permanently living in an air-polluted versus una ected (control) regions. Air pollution and health: Active transportation provides a substantial health bene t because of increased physical activity (PA) [4]. However, active travel may increase the intake of air pollution leading to negative health consequences [5]. A recent study found that the severity of osteoarthritis could be promoted by air pollution via systemic in ammatory mechanisms [6]. In addition, pollution from tra c may be an environmental risk factor for rheumatoid arthritis [7]. An increased risk of rheumatoid arthritis in participants exposed to PM2.5 and NO2was detected in a retrospective study in Taiwan [8]. Air pollution has been associated with the incidence of arthritis. However, whether this environmental factor is causally linked with osteoarthritis in humans, still remains a matter of debate. Muscular skeletal diseases such as knee osteoarthritis may develop over several decades and have been shown to be associated with biomechanical load during gait [9]. It has been shown

in Taiwan [8]. Air pollution has been associated with the incidence of arthritis. However, whether this environmental factor is causally linked with osteoarthritis in humans, still remains a matter of debate. Muscular skeletal diseases such as knee osteoarthritis may develop over several decades and have been shown to be associated with biomechanical load during gait [9]. It has been shown that the knee adduction moment during gait leads to higher knee cartilage degeneration [10]. In addition, it has been shown that higher walking cadence is associated with less cartilage osteoarthritis progression [11]. Especially given that biomechanical data processing is challenging, the biomechanical research to date has tended to focus on small samples rather than multidisciplinary epidemiological research. Multidisciplinary epidemiological research can help control for psychosocial, physiological, or behavioral potentially biasing variables. Active transport movements, air pollution, and health: A form of vigorous active transport is recreational running. Runners have a 30–45% lower risk of mortality and a reduced risk of cardiovascular, cancer, metabolic, mental, and neurodegenerative diseases [12]. However, not all people in the world have favorable conditions for physical activity such as running. In contrast with running health bene ts, air pollutants have been proven to reduce life expectancy and induce respiratory, cardiovascular, cancer, lung and brain, diabetes, and dementia diseases [13]. A signi cant proportion of the active population is exposed to air pollution, particularly in large cities. Despite the increasing concentrations of air pollutants, nearly 30% of the male population and 20% of the female population participate in running as a form of exercise in the 18–29 age range. However, less than 2% of males and less than 0.7% of females continue to run past 65 years of age [14]. The causes of this decline in running participation, which is the most e ective means of achieving longevity [12], remain unclear. Current investigation has shown that the doses of particulate matter exposure are a key factor for osteoarthritis severity under the jogging condition in rats [6]. In this context, the degradation of the musculoskeletal system may be one of the main reasons for the decline in participation

participation, which is the most e ective means of achieving longevity [12], remain unclear. Current investigation has shown that the doses of particulate matter exposure are a key factor for osteoarthritis severity under the jogging condition in rats [6]. In this context, the degradation of the musculoskeletal system may be one of the main reasons for the decline in participation in regular running in older age. In addition, prospective cohort studies show that a minimum of 18% and a maximum of 92% of runners incur injuries during this activity [15]. The risk of injury and illness associated with

Int. J. Environ. Res. Public Health2020,17, 9142 3 of 20 running limits the use of the potential o ered by this activity in health management for the current population. There are only a few prospective biomechanical studies focusing on running [15–20]. None of these studies apply control group, multidisciplinary approaches and the number of test subjects investigated is lower than 500. A prospective cohort study of a large number of runners, combined with a multidisciplinary approach (epidemiology, biomechanics, physiology, psychosociology), has the potential to reveal the causes of the most common chronic injuries in relation to air pollution. Among the most common injuries associated with running are Medial tibial stress syndrome, Achilles tendinopathy, Plantar fasciitis, Patellar tendinopathy, ankle sprains, and Iliotibial band syndrome [15]. All these injuries lead to a cessation of regular motion activity, and they may negatively in uence adherence to physical activity. During locomotion, it is often necessary to change direction or alter the direction of motion resulting from some external stimulus. However, such movements, often referred to as `cutting', result in injuries particularly to the knee. A prominent knee injury, anterior cruciate ligament (ACL) rupture frequently occurs in non-contact, rapid movement situations such as cutting maneuvers in sport [21]. Females show greater ACL injury rates than males [22–24] and the prevalence of ACL injury increases over time in the female population [25]. Previous investigations [26,27] have shown that air pollution is associated with a decrease in neuro-behavioral functions and the level of gross and ne motor skills in children. Changes in neuro-behavioral function and the level of motor skills could in uence associative risk factors of the ACL injury as well as movement coordination and its variability. Successfully negotiating a high ACL injury risk requires complex neuromuscular control strategies for dynamic joint stabilization [28]. Moreover, situational awareness, arousal, and attentional resources of the individual may in uence areas of neurocognitive function, a ecting the complex integration of vestibular, visual, and somatosensory information needed for neuromuscular control [28]. Aims of the Study: The general aim of the 4HAIE study is to investigate the in uence of air

neuromuscular control strategies for dynamic joint stabilization [28]. Moreover, situational awareness, arousal, and attentional resources of the individual may in uence areas of neurocognitive function, a ecting the complex integration of vestibular, visual, and somatosensory information needed for neuromuscular control [28]. Aims of the Study: The general aim of the 4HAIE study is to investigate the in uence of air pollution on the incidence of sports related injuries, physical activity related injuries, physical (in)activity, health, and quality of life across the lifespan. The speci c purpose of the biomechanical and musculoskeletal protocol of the 4HAIE study is to investigate the potential impact of a polluted environment on the biomechanics of human active transport including the quality of knee cartilage, Achilles tendon and ACL determined by magnetic resonance imaging (MRI). We hypothesize that there will be interactions of environmental, biomechanical, physiological, and psychosocial variables and that these interactions will cause musculoskeletal diseases/protection. 2. Material and Methods 2.1. Design A total of 1500 active runners and inactive controls aged 18–65 will be recruited for this study. Inactive controls are de ned as those who can run but choose not to run and do not meet public health recommendations for physical activity. In total, 900 physically active runners and 600 inactive controls, both men and women, will be recruited, with equal representation of those living in the experimental highly-polluted industrial region (n=750) and the control region with low pollution levels (n=750) (Figure). The available data on air pollution in Czechoslovakia, and later the Czech Republic, have been collected since the beginning of the 1950s. Due to long-term monitoring results of ambient benzo[a]pyrene and particulate matter pollutants, the Moravian-Silesian region of the Czech republic has been recognized as a European hotspot [29]. Exposure to benzo[a]pyrene in Ostrava–Radvanice has been the highest in the European union for a decades [30]. Muscular skeletal diseases such as osteoarthritis may develop over several decades [9]. We therefore chose the highly and long-term polluted region of Moravia-Silesia as the experimental region. Due to relatively low concentrations of pollutants in the air in the region of South Bohemia from 1950

benzo[a]pyrene in Ostrava–Radvanice has been the highest in the European union for a decades [30]. Muscular skeletal diseases such as osteoarthritis may develop over several decades [9]. We therefore chose the highly and long-term polluted region of Moravia-Silesia as the experimental region. Due to relatively low concentrations of pollutants in the air in the region of South Bohemia from 1950 to the present, this region was chosen as the control region [29–31]. The South Bohemian region has been shown to be signi cantly less polluted than Moravian-Silesian region from the long-term perspective [29,30]. Both regions are

Int. J. Environ. Res. Public Health2020,17, 9142 4 of 20 comparable with respect to ethnicity with the majority of population (ca. 95%) being White Caucasian and ascribing to either Czech or Moravian nationality (both speaking the Czech language and being of similar cultural and ethnical background) [32].Int. J. Environ. Res. Public Health 2020, 17, x 4 of 21 concentrations of pollutants in the air in the region of South Bohemia from 1950 to the present, this region was chosen as the control region [29–31]. The South Bohemian region has been shown to be significantly less polluted than Moravian-Silesian region from the long-term perspective [29,30]. Both regions are comparable with respect to ethnicity with the majority of population (ca. 95%) being White Caucasian and ascribing to either Czech or Moravian nationality (both speaking the Czech language and being of similar cultural and ethnical background) [32]. Figure 1. Field of annual average concentration of benzo[a]pyrene for 2018. The figure is modified according to Air Quality Information System—Czech Hydrometeorogical Institute [33]. Participants will be recruited through a professional social science and marketing research company. The sample will be recruited using quota sampling based on location, age, gender, and activity status (reflecting the sociodemographic distribution of the specific populations). Interested participants will be screened online and by telephone. Eligible participants complete online questionnaires and undergo a 2-day baseline laboratory assessment, including biomechanical, physiological, psychological testing, and imaging. Subsequently, participants will be monitored for one year after baseline testing. During this year, objective physical activity data will be collected through Fitbit Charge 3 monitors, along with data on incidence of injuries, air pollution, psychological factors, and behavior collected through surveys on a custom designed mobile application. Data collection began in April 2019 and is expected to be completed by April, 2021. Ethical approval was obtained from the Ethics and Research Committee of the principal author university and all participants are required to sign an informed consent form prior to data collection. 2.1.1. Inclusion Criteria for Active Runners Active runners must spend at least 150 min a week in moderate-intensity physical activity or 75 min in

to be completed by April, 2021. Ethical approval was obtained from the Ethics and Research Committee of the principal author university and all participants are required to sign an informed consent form prior to data collection. 2.1.1. Inclusion Criteria for Active Runners Active runners must spend at least 150 min a week in moderate-intensity physical activity or 75 min in high-intensity physical activity (or an equivalent combination of moderate- and vigorous- intensity activity), including running [34]. They must run regularly for 6 weeks or longer, at least 10 km per week, and plan to continue running for another 12 months. Participants must also be between 18–65 years of age upon enrollment, reside in the given localities year-round for at least 5 years, and have no plan to move from the given locations in the next 12 months. Participants must have internet access and own a smartphone (with Android 5.0 or higher, or iOS operating systems) with a data connection (Wi-Fi or mobile data). Figure 1. Field of annual average concentration of benzo[a]pyrene for 2018. The gure is modi ed according to Air Quality Information System—Czech Hydrometeorogical Institute [33]. Participants will be recruited through a professional social science and marketing research company. The sample will be recruited using quota sampling based on location, age, gender, and activity status (re ecting the sociodemographic distribution of the speci c populations). Interested participants will be screened online and by telephone. Eligible participants complete online questionnaires and undergo a 2-day baseline laboratory assessment, including biomechanical, physiological, psychological testing, and imaging. Subsequently, participants will be monitored for one year after baseline testing. During this year, objective physical activity data will be collected through Fitbit Charge 3 monitors, along with data on incidence of injuries, air pollution, psychological factors, and behavior collected through surveys on a custom designed mobile application. Data collection began in April 2019 and is expected to be completed by April, 2021. Ethical approval was obtained from the Ethics and Research Committee of the principal author university and all participants are required to sign an informed consent form prior to data collection. 2.1.1. Inclusion

psychological factors, and behavior collected through surveys on a custom designed mobile application. Data collection began in April 2019 and is expected to be completed by April, 2021. Ethical approval was obtained from the Ethics and Research Committee of the principal author university and all participants are required to sign an informed consent form prior to data collection. 2.1.1. Inclusion Criteria for Active Runners Active runners must spend at least 150 min a week in moderate-intensity physical activity or 75 min in high-intensity physical activity (or an equivalent combination of moderate- and vigorous-intensity activity), including running [34]. They must run regularly for 6 weeks or longer, at least 10 km per week, and plan to continue running for another 12 months. Participants must also be between 18–65 years of age upon enrollment, reside in the given localities year-round for at least 5 years, and have no plan to move from the given locations in the next 12 months. Participants must have internet access and own a smartphone (with Android 5.0 or higher, or iOS operating systems) with a data connection (Wi-Fi or mobile data).

Int. J. Environ. Res. Public Health2020,17, 9142 5 of 20 2.1.2. Inclusion Criteria for Inactive Controls Inactive controls ful ll the same criteria as active runners, but, in spite of being otherwise capable of physical activity including running (i.e., having no limitations to physical activity diagnosed by their physician), they do not meet public health recommendations for physical activity (i.e., engage in physical activity for less than 150 min a week). 2.1.3. Exclusion Criteria Participants are excluded if they are smokers and/or report experiencing acute problems that hinder physical activity in the last six weeks (surgery, pain, injury) or experience any other acute illness. Those with other chronic disease conditions may participate only after presenting a written consent from their physician. Physician's consent is also required if indicated by the Physical Activity Readiness Questionnaire (PAR-Q) screening test. Additional exclusion criteria involve contraindications to magnetic resonance imaging or dual-emission X-ray absorptiometry (DXA) examination (e.g., pregnancy, radiological examination in the last 7 days using iodine/barium contrast agents, pacemaker, radioactive body, surgical staples, insulin pump, cochlear implant, other metal implants, and foreign bodies such as shrapnel, etc.). 2.2. Experimental Set-Up 2.2.1. Biomechanical Set-Up Overground walking, running, cutting and treadmill running kinematics of the lower extremities are recorded using a high-speed motion capture system. Treadmill running is acquired using a 9-camera motion capture system (8x Oqus 100 and 1x Oqus 510+, Qualisys, Inc., Gothenburg, Sweden). Overground walking, running and cutting is acquired using a 10-camera motion capture system (9x Oqus 700+and 1x Oqus 510+, Qualisys, Inc., Gothenburg, Sweden). Three force plates (Kistler 9286AA, 9281CA and 9287CCAQ02, Kistler Instruments AG, Winterthur, Switzerland) are used to collect ground reaction force (GRF) data. The force plates are built into a 17 m long runway. In addition, treadmill running GRF is recorded using a treadmill with an embedded force platform (Bertec, USA). Kinematics and ground reaction force data is sampled at a frequency of 240 Hz and 1200 Hz (treadmill) and 2160 Hz (force plates) respectively. Overground running speed is controlled using two photocells (OPZZ, EGMedical s.r.o., Brno, Czech Republic) located at intervals of 3 m along the

This study outlines a protocol to assess the effects of air pollution on musculoskeletal health in runners.