The value of cross legged sitting: Virtue or vice for health.A review from sports medicine, physiology and yoga.Implications in joint arthroplasty.

Abstract

The value of cross legged sitting: Virtue or vice for health. A review from sports medicine, physiology and yoga. Implications in joint arthroplasty. Dr. Pavankmar Kohli, Dr. Poorv Patel, Dr. Hanumant Waybase, Dr. Satishchandra Gore and Dr. Sunil Nadkarni DOI: https://doi.org/10.22271/ortho.2019.v5.i3k.1596 Abstract Background: Despite the large volume of knee replacements carried out the world over, three very pertinent questions regarding the basic act of sitting & its relevance to Knee Arthroplasty have not yet been given adequate thought. Objectives: 1). whether sitting cross legged is healthier than chair sitting, 2). does sitting cross legged impact quality and longevity of life, 3.) Does it affect durability of the Arthoplasty implant whether total or partial knee Arthoplasty. This Pilot Analysis may lead to change in the habitual practice of doing total knee replacements without considering a more functional, less invasive & more cost friendly option. Methods: This study was conducted in accordance with the MOOSE (meta-analysis of observational studies in epidemiology) and PRISMA (preferred reporting items for systematic reviews and Meta analyses) guidelines. Results 1. 2. 3. Sitting cross legged is scientifically proven healthier way to sit compared to chair sitting on all counts…Body &Mind as reported by studies from Yoga, Sports medicine & human physiology. It increases fitness & enhances longevity of life too. Only Unicondylar knee Arthroplasty gives the ability to sit cross legged (most Total knees are not allowed to sit cross legged for fear of exaggerated wear and those that are have a unacceptable percentage of spin offs or dislocation of polyethylene inserts) In almost all lab studies, the mean wear rate of the medial & lateral bearings combined as a Total knee Replacement are significantly lower than a comparable fixed bearing as TKR under the same kinematic conditions. Unicondylar knees last longer too. Conclusions: Sitting cross legged is an important function for health & longevity. It is culturally an unalienable part of Indian/Asian lifestyle. UKA provides these advantages and lasts longer in In vitro studies. Keywords: UKA/UKR (unicondylar or partial knee replacement), TKA (total knee replacement), cross leg sitting, Sukhasana, arthroplasty, health, fitness, longevity

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International Journal of Orthopaedics Sciences 2019; 5(3): 607-610
ISSN: 2395-1958
IJOS 2019; 5(3): 607-610
© 2019 IJOS
www.orthopaper.com
Received: 01-05-2019
Accepted: 03-06-2019
Dr. Pavankmar Kohli
Professor, BKL Walawalkar
Rural Medical College, Sawarda,
Ta. Chiplun Dist. Ratnagiri,
Maharashtra, India
Dr. Poorv Patel
Secondary DNB Resident,
BKL Walawalkar Rural Medical
College, Sawarda, Ta. Chiplun
Dist. Ratnagiri, Maharashtra,
India
Dr. Hanumant Waybase
Arthroplasty Fellow BKL
Walawalkar Rural Medical
College, Sawarda, Ta. Chiplun
Dist. Ratnagiri, Maharashtra,
India
Dr. Satishchandra Gore
Professor, BKL Walawalkar
Rural Medical College, Sawarda,
Ta. Chiplun Dist. Ratnagiri,
Maharashtra, India
Dr. Sunil Nadkarni
Professor, BKL Walawalkar
Rural Medical College, Sawarda,
Ta. Chiplun Dist. Ratnagiri,
Maharashtra, India
Correspondence
Dr. Poorv Patel
Secondary DNB Resident,
BKL Walawalkar Rural Medical
College, Sawarda, Ta. Chiplun
Dist. Ratnagiri, Maharashtra,
India
The value of cross legged sitting: Virtue or vice for health.
A review from sports medicine, physiology and yoga.
Implications in joint arthroplasty.
Dr. Pavankmar Kohli, Dr. Poorv Patel, Dr. Hanumant Waybase, Dr.
Satishchandra Gore and Dr. Sunil Nadkarni
DOI: https://doi.org/10.22271/ortho.2019.v5.i3k.1596
Abstract
Background: Despite the large volume of knee replacements carried out the world over, three very
pertinent questions regarding the basic act of sitting & its relevance to Knee Arthroplasty have not yet
been given adequate thought.
Objectives: 1). whether sitting cross legged is healthier than chair sitting, 2). does sitting cross legged
impact quality and longevity of life, 3.) Does it affect durability of the Arthoplasty implant whether total
or partial knee Arthoplasty. This Pilot Analysis may lead to change in the habitual practice of doing total
knee replacements without considering a more functional, less invasive & more cost friendly option.
Methods: This study was conducted in accordance with the MOOSE (meta-analysis of observational
studies in epidemiology) and PRISMA (preferred reporting items for systematic reviews and Meta
analyses) guidelines.
Results
1. Sitting cross legged is scientifically proven healthier way to sit compared to chair sitting on all
counts…Body &Mind as reported by studies from Yoga, Spo rts medicine & human physiology. It
increases fitness & enhances longevity of life too.
2. Only Unicondylar knee Arthroplasty gives the ability to sit cross legged (most Total knees are not
allowed to sit cross legged for fear of exaggerated wear and those that are have a unacceptable
percentage of spin offs or dislocation of polyethylene inserts)
3. In almost all lab studies, the mean wear rate of the medial & lateral bearings combined as a Total
knee Replacement are significantly lower than a comparable fixed bearing as TKR under the same
kinematic conditions. Unicondylar knees last longer too.
Conclusions: Sitting cross legged is an important function for health & longevity. It is culturally an
unalienable part of Indian/Asian lifestyle. UKA provides these advantages and lasts longer in In vitro
studies.
Keywords: UKA/UKR (unicondylar or partial knee replacement), TKA (total knee replacement), cross
leg sitting, Sukhasana, arthroplasty, health, fitness, longevity
Introduction
Background
There has till date been no scientific evaluation of the health benefits of sitting cross legged
from various sciences although it has been an ingrained part of the Indian / Asian cultures for
Millenia. But is it healthier from evidence based medicine point of view?
The normal lifestyle of Asians, where sitting cross legged has passed down the generations as
a cultural and healthier lifestyle. In fact in India & Japan, where the two fore most systems of
meditations flourished i.e Yoga & Zen, it was found to have other advantages too like
development of calm, steadiness & equanimity of mind. It is noteworthy that almost all the
Gods of the east from early documented times, have been potrayed in the sitting cross legged
or Sukhasana posture. These were meant to serve as role models for the large populations
which understood pictoral characters more than words. Essence was in the sitting cross legged.
Sitting cross legged promoted balance, proprioception, enhanced parasympathetic rest & digest
response and led to a more integrated & calmer state of mind in asanas, work & during
eating& prayer, the most essential acts of any human life [3, 4].

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Thus, in a frequent condition of knee osteoarthritis, where
arthroplasties are increasing by the day, the most major
advantage of UKA over TKR i.e. of sitting cross legged… is
sacrificed thoughtlessly. Total knee replacement sacrifices the
normal lateral compartment and most importantly, the
proprioceptive ligaments and framework of the intercondylar
notch [9, 10, 12].
We thought this particular question which is so important to
the health, cultural & functional needs of the patient, needed
specific redressal.
In addition, we also tried to address the question that does this
sitting cross legged and UKA affect the life of the implant?
It would be safe to presume that an implant, which helped
resumption of normal cultural lifestyle, adoption of a healthier
life, lasted longer, increased the life span of the patients and
had shorter hospital stay and less morbidity, was definitely the
procedure & implant of choice!
Of course, about 25% of patients have very severe
deformities, bilateral compartmental affection, this study is
for the remaining 75% who have primarily medial
compartment affection, with or without some patellofemoral
arthritis & who are slated ad hoc for TKR, thereby giving
them pain relief, but taking away function, longevity &
fulfillment in the passing.
This question, we felt deserved sincere addressal.
To our knowledge, this is the first time that such a pilot
review & Analysis study has been attempted.
Material & Methods
A detailed review was made for the advantages of cross
legged sitting for health.
Studies considered were of how cross legged sitting impacted
longevity, mental health and a fulfilling life from journals of
Physiology, Yoga & Sports Medicine.
Another review was made for the in vitro mechanical lab tests
regarding longevity of UKA vs TKR implants.
Finally, Studies were also reviewed on the the ease of
recovery, lesser costs, lesser morbidity & earlier discharges
from hospital in Biateral UKA vis a vis Bilateral TKA.
Satisfaction index post UKA was also considered.
This study was conducted in accordance with the MOOSE
(meta-analysis of observational studies in epidemiology) [21]
and PRISMA (preferred reporting items for systematic
reviews and Meta analyses) guidelines [22].
Literature search and selection of studies
We conducted a systematic search of Medline, Embase,
PubMed, Google Scholar, Cochrane Controlled Register of
Trials (CENTRAL), and Clinical Trials. Gov., to identify
relevant studies published in English between 1 January 1997
and 31 July 2019. Studies were initially selected on the basis
of their title and abstract, we included randomised controlled
trials, retrospective analyses of large national or multicentre
databases or joint registries, and large cohort studies. The
search was limited to studies that directly compared outcomes
of UKA and TKA. Studies were excluded if the data
presented were insufficient to pool for statistical analysis.
Data extraction
Data were extracted by use of standardised forms, such as the
name of the lead investigator, year of publication, recruitment
period, and median duration of follow-up, number of
participants, and mean age and sex of the participants.
Furthermore, the primary outcome measures and adverse
event data were extracted.
A detailed pilot review was made for the advantages of cross
legged sitting for health. Studies considered were of how
cross legged sitting impacted longevity, mental health and a
fulfilling life. Another review was made for the in vitro
mechanical lab tests regarding longevity of UKA vs TKR
implants. Finally, Studies were also reviewed on the ease of
recovery, lessor costs, lessor morbidity & earlier discharges
from hospital in bil UKA vis a vis Bil TKA. Satisfaction
index post UKA was also considered.
Results
UKA is a superior alternative to TKR for a vast majority of
patients. It enables a more active lifestyle, enables more
function including cross legged sitting, both of which are
enabling for longevity of life [3, 4].
In UKA, Not only does the patient live longer, the implant
also lasts longer. And all this while enabling a more health
friendly lifestyle.
A study published in the European Journal of Preventive
cardiology noted that participants who lacked the ability to
rise from the floor without assistance were twice as likely to
die than those who were able do so (“How Well”, 2012).
Maintaining the ability to sit and stand from the ground is
valuable in long-term health and wellness, and this skill is not
currently being cultivated by sitting arrangements [1].
A similar study confirmed this sentiment, stating that
musculoskeletal fitness indicators such as the Sit to Rise Test,
i.e to stand up from sitting cross legged on floor, which
examine individuals for muscle strength and flexibility, is a
significant predictor of all-cause mortality (Chau J et al.,
2014) [2].
Some reference is shown that research performed on floor-
seated postures and their MET levels have been conducted by
Hagins, Moore, & Rundle in 2007, wherein the researchers
determined that while yoga alone cannot satisfy
recommendations for the intensity of physical activity to
maintain health and fitness, practicing yoga is akin to walking
on a treadmill at 2 mph and expends around 2.5 METs [3].
So, while it has been determined that sitting on the floor in
traditional Eastern postures such as the yogic Sukhasana
(easy, joyful pose),) expends more energy than sitting in a
chair is more calming & integrated state for the mind by
journals of Yoga & Human Physiology, it has also been
proven by inclusion of the above test in the American Council
of sports medicine that the action of rising frequently from the
ground, not only is a predictor of lifespan, but increases
longevity [1, 2, 4].
The health benefits of yoga have been studied by hundreds of
peer-reviewed scientific sources. One study published in the
International Journal of Orthopaedics Sciencesstates that
yogic meditation done in the sitting cross legged pose, is a
promising way to improve cardio-metabolic health and, in a
trial, found significant improvements in body-mass index,
systolic and diastolic blood pressure, both LDL and HDL
cholesterol levels, heart rate, weight, and triglyceride levels,
which are all traditionally biometrics that indicate lifestyle
disorders like obesity and CVD [6].
Study published in the International Journal of Cardiology,
which assessed “the effects of yoga & meditation done in
Sitting cross legged pose, impact modifiable biological
cardiovascular disease risk factors,” found that yoga also
improved biometrics like blood pressure, heart rate,
respiratory rate, waist circumference, cholesterol, and
triglyceride levels, revealing “evidence for clinically
important effects of yoga on most biological cardiovascular

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disease risk factors” [7].
The use of yoga for alleviation of chronic lower back pain
(CLBP), one study in the American Journal of Lifestyle
Medicine found that yoga in a sitting cross legged posture
reduces functional disability and improves stress, depression,
and pain responses in patients. The authors state that their
study “suggests that yoga and meditation in Sukhasana has
the ability to reverse the interlinked downward spiral,
whereby CLBP causes depression, which gives rise to further
back pain, resulting in increased depression, and so on.” This
research indicates that potential health benefits of yoga extend
beyond just the physical realm [8].
Discussion
Sitting cross legged has been an integral part of the Indian
lifestyle since ancient times. It was adopted for studying,
eating, praying & meditating or in short any activity that
needed composure of mind & stability of body. Yoga has
propounded the advantages of Sukhasana or sitting cross
legged varying from stability of body needed for long
duration tasks to self-realization & self-actualization [6, 26].
Yoga says that body is the visible Mind & Mind the invisible
body. Both have an inextricable link & are interdependent on
the other. The stabler the body, the quieter the mind. Newer
studies have mentioned the positive impact on muscles for
core stability & pelvi sacral frame for proper breathing,
proper oxygenation & central & peripheral circulation [3, 26].
Even at its worst, the practice of sitting cross legged
consumes more calories than chair sitting or couch sitting [4].
More recently, the practice of getting up from the cross
legged position was included as one of the only two validated
tests to predict life expectancy by the American college of
sports medicine [5].
Other than walking up a flight of stairs, how long one will
live, will depend on how easily he gets up from a floor cross
legged sitting position. Thus sitting cross legged enhances
integration of mind & body & getting up from sitting cross
legged enhances longevity and balance & proprioception.
Of all the pills & medicine that modern science has invented,
Exercise remains the king of impact and efficiency in results.
(www.exerciseismedicine.org) (www.rciseismediccine.org)
Including exercise i.e sitting and getting up cross legged, into
an activity that all of us need for long time in the day, No
matter our nature of work, was the wise ancient way for
inculcating healthier & more efficient habits into our way of
life.
The only implant to allow sitting cross legged & getting up
from the floor, both of which are shown to enhance lifespan &
health is the UKA. Satisfaction, another important element
has always ranked higher in UKA than TKR [17].
This is due to a more active lifestyle, a more normal lifestyle,
and a feeling of normal knees Addition factors are ability to
operate on more morbid patients, lessor invasive surgeries,
quicker discharges, & still lessor medication & costs for the
patient & healthcare system [15].
The consideration of the final factor was the longevity of the
implant. Do we need to sacrifice on longevity to get so many
health & lifespan benifits?
Fortunately No. In vitro studies have shown significantly
lower wear rates under the same kinematic conditions of the
same implant with the same polyethylene when inserted in the
UKA mode vis a vis TKR mode [10] This may not directly
translate into longer survival in vivo due to a more active
lifestyle & sporting activities, but the fact remains that the
implants inserted in the UKA mode do last longer than the
same polyethylene inserted in TKR mode [14].
It does not come as a surprise that some centers in Europe
would rather do a bicompartmental UKA rather than a TKR
with excellent results & satisfaction [7, 23, 24].
From the above it is clear, whatsoever promotes a nature
friendly lifestyle, promotes more activity, including in sitting,
walking sports etc., will not only make the joint last long, the
patient will live longer & more fulfillingly [6, 7, 12].
Other advantages of UKA of long survivorship of upto 98% at
10 years, Lessor complications 11Restoration of normal knee
kinematics [11, 12, 13, 14]. Proprioception [14].
Nature respects those who respect nature. It is like most a
reciprocal arrangement. Whether we want to give up function
culture and time tested health practices, for sake of during a
more common procedure remains our individual choice. But
in all honesty, out patients must be made aware that a more
durable, health friendly & less morbid surgery does exist for
Indian /Asians patients.
Conclusion
1. Sitting cross legged is scientifically proven healthier way
to sit compared to chair sitting on all 3 counts Body,
Mind & Soul.
2. Only Unicondylar knee Arthroplasty gives the ability to
sit cross legged. Satisfaction level and resumption of
original lifestyle was a great satiety factor for
Unicondylar knees above total knee replacements.
3. In almost all lab studies, the same polyethylene lasted
MORE in the Unicondylar mode than in the Total knee
Arthroplasty mode under all petterns of straim testing.
The above are important factors for decision making in
Indian patients. Patients appreciate complete resumption
of original lifestyle, especially when it is healthier, costs
lessor (due to shorter hospital stay etc.) and lasts longer.
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