Golfers are physically more active and have greater health associated quality of life than non-golfers following lower limb arthroplasty

N.D. Clement; P.G. Robinson; I.R. Murray; A.D. Murray; D. MacDonald; P. Gaston; M. Moran; G.J. Macpherson

doi:10.1016/j.jor.2024.03.029

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54 (); 158-162

doi:

10.1016/j.jor.2024.03.029

Golfers are physically more active and have greater health associated quality of life than non-golfers following lower limb arthroplasty

N.D. Clement^a,b,, P.G. Robinson^a,b, I.R. Murray^a, A.D. Murray^b,c, D. MacDonald^a, P. Gaston^a, M. Moran^a, G.J. Macpherson^a

a Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK

b PGA European Tour Health and Performance Institute, Virginia Water, UK

c Medical and Scientific Department, R&A, St. Andrews, UK

⁎Corresponding author: N.D. Clement. nick.clement@nhslothian.scot.nhs.uk

Received: 2024-3-16, Accepted: 2024-3-26, Published: 2024-3-28

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

The health benefits of physical activity are well recognised. This study assessed whether golfers were more physically active after lower limb arthroplasty when compared to those that did not play golf (primary outcome). In addition pre and postoperative changes in health-associated quality of life (HAQoL) and joint specific outcomes between golfers and none golfers were assessed (secondary outcomes).

There were 304 patients [THA (n = 155) or TKA (n = 149)] prospectively registered during a 4-month period undergoing lower limb arthroplasty. The mean age was 70.0 (range 37–92, standard deviation 10.2) years and included 188 (61%) females and 120 (39%) males. They completed pre and postoperative questionnaires assessing recreational activity, physical activity, HAQoL (EuroQol [EQ]), joint specific health (Oxford scores), and satisfaction.

Golfers (n = 33, 10.9%) were more likely to achieve longer than 3 hours of moderate activity during a week (48.5% vs 38.0%, odds ratio (OR) 3.4, p = 0.045) and achieved their recommended activity level (96.8% vs 77.7%, OR 8.6, p = 0.015) compared to non-golfers following arthroplasty. Postoperative EQ5D (p = 0.034) and EQVAS (p = 0.019) were significantly greater in golfers. The joint specific Oxford hip score was greater in golfers compared to non-golfers (mean difference 5.6, p = 0.022), however no difference was observed in the Oxford knee score following TKA (p = 0.495).

Golfers were more likely to achieve their weekly recommended level of physical activity and had a greater HAQoL relative to those that did not play golf following lower limb arthroplasty. More specifically after THA golfers also had a greater postoperative joint specific outcome, but no such advantage was observed in those following TKA.

Level II, diagnostic study.

Abstract

Highlights

•Golfers are more likely to achieve recommended levels of physical activity.•There was no difference in satisfaction according to golf participation.•Golf could be recommended after surgery to maintain physical activity.

Keywords

Arthroplasty

Golf

physical

Activity

Outcome

Health

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1 Introduction

Osteoarthritis affecting the hip and knee joints is common and those affected can have significant levels of debilitating pain with an associated decline in function and physical activity that can often be improved with joint replacement surgery.^1–4 Lower limb arthroplasty of the hip (THA) and the knee (TKA) are being performed in increasingly larger volumes,⁵ which is predicted to continue to grow.⁶^,⁷ As the burden of arthritis grows, so does the number of patients awaiting surgery which negatively impacts quality of life.⁸ Total joint arthroplasty can allow patients to get back to physical activity and patients who have previously been active prior to arthritis typically expect to achieve pre-arthritis mobility following surgery.⁹ Golf is a popular leisure activity in those undergoing TKA and THA with up to 20% of patients reported to be golfers.¹⁰^,¹¹ A recent study showed that an inability to play golf has a negative impact on a golfer's well-being and it is likely that this also applies to golfers unable to play secondary to arthritis.¹²

Guidelines from the World Health Organization (WHO) suggest that a person's physical activity should include 75 min of vigorous or one hundred and 50 min of moderate physical activity each week.¹³ A scoping review by Murray et al. concluded that golf was an excellent sport for persons of all ages to achieve these benchmarks.¹⁴^,¹⁵ Evidence suggests that playing golf is associated with living 5-years longer than a similar population who do not play golf when matching for demographics variables.¹⁶ The most common activities and hobbies undertaken by patients undergoing joint arthroplasty are swimming, cycling, walking, soccer, jogging, downhill skiing and golf.¹⁷^,¹⁸ It is currently unknown whether those who consider golf as their primary leisure activity are more physically active than those who do not, following hip and knee arthroplasty.

The main (primary) aim of this study was to evaluate whether playing golf was associated with level of physically active following lower limb (hip and knee) arthroplasty relative to those not playing golf. In addition, the study assessed pre and postoperative differences in walking ability, health associated quality of life, joint specific outcomes and level of satisfaction according to preoperative golfing participation.

2 Methods

A prospective study was undertaken. Regional ethics committee approval was obtained prior to commencement (16/SS/0026). Patients undergoing primary THA or TKA were recruited during a 4-month period. All patients undergoing THA had a cemented Exeter V40 femoral component and either a cementless (Trident, Stryker Corporation) or cemented acetabular component (Contemporary, Stryker Corporation). For patients undergoing TKA a cemented cruciate retaining implant was employed (Triathlon, Stryker Corporation). The inclusion criteria consisted of: primary arthroplasty, single sided surgery, osteoarthritis as indication of surgery, and recorded outcome measures. Exclusion criteria included patients undergoing bilateral arthroplasty, were not willing to be follow up or those undergoing revision surgery. Patient demographics and comorbidity data were collected from the patients electronic notes. Patients were prospectively asked the sporting activities they participated in. Physical activity and patient reported outcomes were evaluated preoperatively and postoperatively (12 months), with the exception of satisfaction which was only assessed postoperatively.

2.1

2.1 Assessment of physical activity

Assessment of physical activity was assessed across four separate areas: physical movement over 7-days, period spent undertaking physical activity at a moderate and/or vigorous level, and walking ability pre and post arthroplasty. Patients were asked:1.During the last seven days how many of these days would you have been physically active for a TOTAL of 30 min or more? The response was recoded from 0 to 7 days.2.During the last seven days how many hours have you spent undertaking MODERATE physical activity? Moderate physical would include the level of effort to leave you breathing somewhat harder than normal. The responses to this were: 1 h or less, between 1 and 3 h, and 3 h or more.3.In the past seven days how many hours have you spent doing VIGOROUS physical activity? Activities that take hard physical effort and leave you breathing much harder than normal. Options to select were: less than 1 h, 1–3 h, and more than 3 h.4.Before your surgery how was your walking? Were you able to ….5.After your surgery how was your walking? Were you able to ….

Options to select for questions 4 and 5 were: hill walk and hike, walk easily on the flat, walk for short distances on the flat, or unable to walk.

Patients achieving either more than 3 h of moderate activity, more than 1 h of vigorous activity, or a combination of both for more than 1 h were defined to have achieved their recommended activity level.

2.2

2.2 Patient reported outcomes measures

Joint health outcomes were assessed preoperative and at 12-months postoperatively using the Oxford hip score (OHS) or Oxford knee score (OKS) for THA and TKA patients, respectively. The Oxford scores are joint specific outcome measures and includes of twelve questions that are assessed on a scale (Likert) which ranges from 0 (worst) to 4 (best) and a summative score is then calculated form all questions from zero (worst) to 48 (best). The Minimal clinical important difference, the difference in the score that is clinically meaningful to the patients, in the OHS and OKS is 5 points.¹⁹

The EuroQoL (EQ) general health questionnaire was employed to assess health associated quality of life and was recorded preoperatively and at 12-months postoperatively. The EQ questionnaire produces two outcomes of the patient's health. The EQ five domains (5D) assesses: anxiety and depression, selfcare, mobility, level of usual activities, and pain.²⁰ These 5D were assessed using the 3-level (3L) response scale version of the EQ questionnaire, where responses are recorded as: no, some or unable/extreme problems. Specific to the United Kingdom (population at risk) this index ranges from minus 0.594, which is the worst health, to one, which is perfect health. Values less than zero are thought to perceived a health state that is worse than death.⁸ The second part the EQ questionnaire employs a standardised vertical twenty cm visual analogue scale (EQVAS) to assess their current health-associated quality of life which is assessed on a scale of zero to one hundred, being worst and best health respectively. In addition, a pain VAS was also employed using a 15 cm straight scale from zero (no pain) to 100 (worst pain imaginable).

In addition to the EQ the Short Form (SF-) 12 questionnaire was also used as a further measure of health-associated quality of life, to assess both the mental and physical health of patients prior to and following surgery. The SF-12 is a validated and reliable tool and reports two outcomes: the physical component summary (PCS) and the mental component summary (MCS).²¹ Each component is scored from 0 (worst) to 100 (best) and a mean average summary score is around 50 for a standard population.²²

Patients were asked at 12-months how satisfied they were with their THA/TKA. Their answer was documented using a 5-point scale (Likert) from very satisfied to very dissatisfied. Their level of satisfaction was categorised into either ‘satisfied’ (satisfied and very satisfied) or ‘dissatisfied’ (neutral, dissatisfied or very dissatisfied).

2.3

2.3 Statistical analysis

All data analysis was undertaken using Statistical Package for Social Sciences (version 17 SPSS Inc). Simple descriptive statistical analysis were undertaken to describe the means, standard deviation and percentage distribution. Scalar variables (age, BMI, OHS/OKS, EQ-5D, EQ-VAS and pain VAS) were assessed using an unpaired Student's t-test for comparison of between group (golfers and non-golfers) differences. A Chi square test or a Fisher's exact test (one group less than 5) were used to assess gender, co-morbidity, level of activity and satisfaction differences between groups. Significance was set as a p-value of <0.05. A power calculation was performed to achieve an odds ratio (OR) of 1.5 (for risk of achieving a moderate activity level postoperatively between golfer and non-golfers), 2-tailed analysis, and an alpha of 0.05 with a power of 90% deemed a need for a minimum of 270 patients.

3 Results

3.1

3.1 Study cohort characteristics

A total of 304 patients undergoing THA (n = 155) or TKA (n = 149) with complete pre and postoperative data that met the inclusion criteria were recruited to the study. This encompassed 123 (40%) males and 181 (60%) females. The mean age of the cohort was seventy (age range 37–92, standard deviation (SD) 10.2) years. The average BMI was 29.2 (range 18.8–55.9, SD 5.6). Patients reported their activity of choice as: walking (n = 63); golf (n = 33); swimming (n = 27); and lawn bowls (n = 19) (Fig. 1). 70 patients reported no participation in physical activities. There was a greater prevalence of males (p < 0.001) and of gastric ulcer (p = 0.025) in golfers preoperative. Furthermore, golfers had better EQ5D (p = 0.001), EQVAS (p = 0.012), pain VAS (p = 0.032), SF-12 MCS (p < 0.001), and joint specific Oxford scores (p ≤ 0.022) preoperatively (Table 1).

Word cloud for activity prior to hip and knee arthroplasty. The larger the word the more prevalent the activity.

Table 1 Preoperative demographics and functional outcomes between those playing golf preoperative and those not.

Demographic		Golfer		Difference/Odds Ratio (95% CI)	p-value
Demographic		No (n = 271)	Yes (n = 33)	Difference/Odds Ratio (95% CI)	p-value
Sex (n, %)	Male	95 (35.1)	28 (84.8)	Reference
Sex (n, %)	Female	176 (64.9)	5 (15.2)	0.1 (0.0–0.3)	<0.001^a
Arthroplasty (n, %)	THA	139 (51.3)	16 (48.5)	Reference
Arthroplasty (n, %)	TKA	132 (48.7)	17 (51.5)	1.1 (0.5–2.3)	0.761^a
Mean age (years, SD)		70.2 (10.4)	68.4 (9.6)	1.8 (−2.0 to 5.5)	0.350^b
Mean BMI (SD)		29.2 (5.7)	29.1 (4.7)	0.1 (−2.2 to 2.3)	0.948^b
Co-morbidities (n, %)	IHD	30 (11.1)	4 (12.1)	1.1 (0.4–3.4)	0.856^a
	HT	118 (43.5)	16 (48.5)	1.2 (0.6–2.5)	0.589^a
	COPD	16 (5.9)	3 (9.1)	1.6 (0.4–5.8)	0.475^a
	Diabetes	14 (5.2)	5 (15.2)	3.3 (1.1–9.8)	0.025^a
	Gastric ulcer	24 (8.9)	1 (3)	0.3 (0.1–1.0)	0.250^a
	Kidney disease	7 (2.6)	2 (6.1)	2.4 (0.5–12.2)	0.266^a
	Anaemia	21 (7.7)	1 (3)	0.4 (0.1–2.9)	0.323^a
	Back pain	96 (35.4)	8 (24.2)	0.6 (0.3–1.30	0.201^a
	Depression	34 (12.5)	3 (9.1)	0.7 (0.2–2.4)	0.567^a
PROMS (mean, SD)	EQ5D Index	0.405 (0.312)	0.577 (0.238)	0.171 (0.078–0.264)	0.001^b
	EQ VAS	66.8 (19.0)	75.6 (14.0)	8.8 (2.0–15.6)	0.012^b
	Pain VAS	51.1 (19.5)	59.1 (20.6)	8.0 (0.7–15.4)	0.032^b
	SF-12 PCS	31.7 (7.4)	33.0 (10.5)	1.3 (−1.6 to 4.2)	0.389^b
	SF-12 MCS	49.1 (11.7)	56.0 (8.8)	7.0 (3.5–10.5)	<0.001^b
	OHS	20.3 (7.0)	25.9 (7.5)	5.6 (1.4–9.9)	0.010^b
	OKS	20.0 (7.9)	24.4 (7.6)	4.3 (0.6–8.0)	0.022^b

a Chi square test.

b Unpaired Students t-test.

3.2

3.2 Physical activity

Golfers were more likely to achieve more than 3 h of moderate activity during a week compared to non-golfers following arthroplasty (odds ratio (OR) 3.4, p = 0.045) although only 48.5% of golfers achieved this level of activity (Table 2). When moderate and vigorous physical activity were combined 96.8% of golfers achieved their recommended activity level, which was significantly more likely (OR 8.6, p = 0.015) when compared to non-golfers (77.7%) (Table 2). The number of days of activity per week (p = 0.339) or hours of vigorous activity were not significantly (p ≥ 0.499) different between the groups (Table 2). Golfers had a significantly greater walking ability preoperatively (p = 0.004) and postoperatively (p = 0.046) relative to those not playing golf (Table 3).

Table 2 Physical activity assessment following lower limb arthroplasty between those playing golf and those not.

Physical Activity Assessment		Golfer		Difference (95% CI)	p-value^a
Physical Activity Assessment		No (n = 264)	Yes (n = 33)	Difference (95% CI)	p-value^a
Days of activity per week (mean, SD)		6.1 (1.9)	5.8 (2.0)	0.4 (−0.4 to 1.1)	0.339^b
		No (n = 266)	Yes (n = 33)	OR (95% CI)
Hours of moderate activity over a week (n, %)	<1 Hour	65 (24.4)	3 (9.1)	Reference
	1 to 3 Hours	100 (37.6)	14 (42.4)	3.0 (0.8–11.0)	0.077^a
	>3 Hours	101 (38.0)	16 (48.5)	3.4 (1.0–12.2)	0.045^a
		No (n = 252)	Yes (n = 31)	OR (95% CI)
Hours of vigorous activity over a week (n, %)	<1 Hour	148 (58.7)	17 (54.8)	Reference
	1 to 3 Hours	74 (29.4)	10 (32.3)	1.2 (0.5–2.7)	0.699^a
	>3 Hours	30 (11.9)	4 (12.9)	1.2 (0.4–3.7)	0.499^α
		No (n = 251)	Yes (n = 31)	OR (95% CI)
Moderate and vigorous activity (n, %)	<1 Hour	56 (22.3)	1 (3.2)	Reference
Moderate and vigorous activity (n, %)	≥1 Hour	195 (77.7)	30 (96.8)	8.6 (1.10–64.6)	0.015^α

a Chi square test.

b Unpaired Students t-test.

Table 3 Walking ability pre and post lower limb arthroplasty for those playing golf or not.

Timepoint	Walking Ability (n, %)	Golfer		p-value
Timepoint	Walking Ability (n, %)	No (n = 264)	Yes (n = 33)	p-value
Preoperative	Hill walk and hike	15 (5.7)	2 (6.1)	0.004^a
	Walk easily on the flat	31 (11.7)	11 (33.3)
	Walk short distances on the flat	195 (73.9)	20 (60.6)
	Unable to walk	23 (8.7)	0
		No (n = 261)	Yes (n = 33)
Postoperative	Hill walk and hike	23 (8.7)	8 (24.2)	0.046^a
	Walk easily on the flat	135 (51.1)	16 (48.5)
	Walk short distances on the flat	100 (37.9)	9 (27.3)
	Unable to walk	3 (1.1)	0

a Chi square test.

3.3

3.3 PROMS

Postoperative health associated quality of life was significantly greater in golfers, according to the EQ5D (p = 0.034) and EQVAS (p = 0.019), relative to those that did not play golf (Table 4). In contrast when assessing SF-12 PCS or MCS scores there were no differences observed (Table 4). The joint specific OHS demonstrated a better, postoperative functional outcome associated with golfers compared to those that did not play golf (p = 0.022). Whereas there was no (p = 0.495) differences found in the OKS (Table 4). Post-arthroplasty satisfaction did not significantly vary between the groups (p = 0.999). Twenty-eight golfers (90.3%) were satisfied following joint replacement compared to 214 those that did not golf (89.2%) (Table 5).

Table 4 Postoperative outcomes between those play golf or not.

PROMS (mean, SD)	Yes (n = 33)	No (n = 271)	Difference (95% CI)	p-value^a
EQ-5D Index	0.764 (0.194)	0.679 (0.287)	0.086 (0.008–0.166)	0.034
EQ VAS	81.5 (9.9)	72.8 (20.3)	8.8 (1.5–16.1)	0.019
Pain VAS	63.9 (33.7)	66.8 (28.7)	2.9 (−8.1 to 13.9)	0.601
SF-12 PCS	43.2 (10.9)	39.5 (11.1)	3.7 (−0.5 to 7.9)	0.081
SF-12 MCS	55.1 (9.0)	52.5 (10.1)	2.7 (−1.1 to 6.4)	0.166
OHS	16.4 (3.5)	22.0 (9.0)	5.6 (0.8–10.4)	0.022
OKS	23.9 (6.8)	25.5 (9.6)	1.7 (−3.1 to 6.4)	0.495

a Unpaired Students t-test.

Table 5 Comparison of postoperative satisfaction between those playing golf or not.

	Golfer		Odds ratio (95% CI)	p-value^a
	No	Yes	Odds ratio (95% CI)	p-value^a
Satisfied	214 (89.2)	28 (90.3)	Reference
Dissatisfied	26 (10.8)	3 (9.7)	OR 0.88 (0.25–3.10)	0.999

a Fishers exact test.

4 Discussion

This study has shown that golfers were more likely to achieve their weekly recommended level of physical activity compared to those that did not play golf after hip or knee arthroplasty. Furthermore, golfers were shown to have a greater health associated quality of life following lower limb arthroplasty. The joint specific Oxford score was significantly better postoperatively in golfers undergoing THA, whereas following TKA no differences was observed in their Oxford scores. Despite these differences there was no difference in the rate of satisfaction with joint replacement according to golfing status.

The benefits of golf on health have are well established.¹⁴ These include physical, social and mental benefits which are recognised by the United Kingdom's National Health Service, to such an extent that some now ‘prescribe’ patients to play golf to achieve such benefits.²³ Moderate physical activity can be enjoyed while playing golf due to both the cardiovascular demands of walking on the golf course and has been shown to reduce sedentary behaviour.^24–26 Furthermore, the physical demands of swinging the golf club lead to improvements in both strength and balance.²⁷ No study to the authors knowledge has previously reported the likelihood of golfers undergoing hip or knee arthroplasty achieving such physical parameters postoperatively. In the current study, those who were golfers were more likely to achieve in excess of 3 h moderate activity per week postoperatively and were more likely to hill walk/hike both pre and post operatively compared to non-golfers. These findings demonstrate encouraging support for golf as a sport for older individuals to maintain and achieve national physical activity goals following their arthroplasty.¹³ In addition, the findings from this study may also suggest the pre-habilitation benefits of golf prior to arthroplasty.²⁸

The WHO recommendation of weekly physical activity of 75 min of vigorous or one hundred and 50 min of moderate physical activity may be difficult to quantify in the context of playing a round of golf.^{13 15} A recent study assessing the activity expenditure during golf by Kasper et al. demonstrated that a single round of golf, taking on average 200–210 min, would be a significant contribution to achieving these recommended activity levels.²⁹ They demonstrated the energy used during a round of golf to be approximately 700 kcal and therefore concluded that golf is a valuable activity to enhance an individual's step-count and increases physical activity levels. In addition, they also highlight that the modes of transporting golf clubs (carrying, manual or electric trolley) did not have a meaningful effect on activity energy expenditure. Golf has been suggested as a novel exercise treatment regime for patients with Parkinson's disease and is associated with a lower risk of falls in the community.³⁰ Therefore, to suggest golf as an activity to patients presenting with hip or knee arthritis following arthroplasty may be acceptable. Participation in the sport could help improve their activity levels while also helping them to optimise their health preoperatively, as part of prehabilitation,²⁸ and/or postoperatively to potentially achieve a better HRQoL.

A previous study assessing the pre and post-surgical functional outcomes of golfers after THA, consistent with the current study, found those playing golf had more of an improvement in their Oxford score compared to those that did not play golf.¹¹ A meta-analysis of studies assessing return to golf following arthroplasty demonstrated that those undergoing THA had a higher return to golf (90%) when compared to TKA (70%).³¹ In the present study, knee-related functional outcomes did not reflect those of the hip with no difference found in the OKS between golfers and non-golfers. This may be due to different demands from the golf swing on the biomechanics of the knee joint following surgery compared to the hip.

This study has limitations that should be acknowledge when interpreting the results. There was a predominance of males in the golfing group, but this is what might be expected of the demographic of golfer with previous authors highlighting no influence on gender following THA.³²^,³³ The pattern of osteoarthritis and radiographic severity/grade within the hip or knee joint prior to arthroplasty was not evaluated, and it is possible that superior preoperative functional scores may reflect less severe disease. In addition, it is unknown if the physical activity reported in the golfing cohort was achieved through directly playing golf itself or other leisure activities.

5 Conclusion

Golfers were more likely to achieve their weekly recommended level of physical activity and had a greater health association quality of life following lower limb arthroplasty relative to those that did not play golf. THA in golfers was associated with a greater postoperative joint specific functional outcome, but no such advantage following TKA. Despite these differences satisfaction with joint replacement was not influenced by golfing status.

Informed consent

All patients included in this study were aware and agreed that data collected as part of this study may lead to peer reviewed publication in the medical literature.

Ethical approval and consent to participate

Ethical approval was obtained from the regional ethics committee (Research Ethics Committee, South East Scotland Research Ethics Service, Scotland [16/SS/0026]) for analysis and publication of the presented data. The data collection was carried out in accordance with the GMC guidelines for good clinical practice and the Declaration of Helsinki.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

CRediT authorship contribution statement

N.D. Clement: Research idea, data collection, data analysis, writing manuscript. P.G. Robinson: Read and approved the final manuscript. I.R. Murray: Read and approved the final manuscript. A.D. Murray: Writing manuscript, Read and approved the final manuscript. D. MacDonald: Data collection, Read and approved the final manuscript. P. Gaston: Read and approved the final manuscript. M. Moran: Read and approved the final manuscript. G.J. Macpherson: Read and approved the final manuscript.

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