Injuries in Athletics: Causes and Consequences

INJURIES IN ATHLETICS: CAUSES AND CONSEQUENCES

INJURIES IN ATHLETICS: CAUSES AND CONSEQUENCES by

Semyon Slobounov The Pennsylvania State University University Park, PA, USA

Editor Semyon Slobounov The Pennsylvania State University University Park, PA 16802

ISBN: 978-0-387-72576-5

e-ISBN: 978-0-387-72577-2

Library of Congress Control Number: 2008921945  2008 Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com

DEDICATION To elite athletes all over the world who sustain both physical and psychological traumas throughout their athletic careers - it is for their love of sports, their achievements, and their pain and suffering that I am most indebted. Nothing more could influence my inspiration and effort in preparation of this book. Semyon Slobounov

ABOUT THE AUTHOR Semyon Slobounov, Ph.D., is a Professor in the Department of Kinesiology College of Health of Human Development, and Adjunct Professor of Orthopaedics and Medical Rehabilitation with Hershey Medical College at the Pennsylvania State University, with primary responsibilities to teach undergraduate and graduate courses in the areas of psychology of injury, neural basis of motor behavior, and psychophysiology. His coaching background and clinical work with numerous injured athletes for more than 25 years was instrumental for development of ideas and topics elaborated in this book. His research focused on the neural basis of human movements with special emphasis on rehabilitation medicine, psychology and neurophysiology, including traumatic brain injuries. Dr. Slobounov is an adjunct investigator with the National Institute of Health, National Institute of Neurological Disorders and Stroke. He also is an adjunct Professor of the Neuroscience and an affiliate Professor of Gerontology Center at Penn State. He received his first Ph.D. from the University of Leningrad, Department of Psychology, USSR in 1978 and his second Ph.D. from the University of Illinois at Urbana-Champaign, Department of Kinesiology in 1994.

CONTENTS

Dedication

About the Author

vii

Preface

Foreword

xvii

Acknowledgements

xix

Part I

Foundations of Injury in Athletics

Chapter 1.

Classification of Injuries in Athletics

Chapter 2.

Science of Training and Injury in Athletics

Chapter 3.

Balance as a Risk Factor for Athletic Injuries

Chapter 4.

Fatigue-Related Injuries in Athletes

Chapter 5.

Nutrition as a Risk Factor for Injury in Elite Athletes

Part II

Coaches and Athletes’ Perspectives of Injury

111

Chapter 6.

Injury in Athletics: Coaches’ Point of View

113

Chapter 7.

Injury from Athletes’ Perspectives

147

Chapter 8.

Interviews with Injured Athletes

161

Chapter 9.

Overuse Injuries: Students’ Points of View

197

Chapter 10.

Fitness Assessment in Athletes

217

Part III

Psychological Traumas in Athletes

241

Chapter 11.

Psychological Trauma: Unfortunate Experience in Athletics

243

Chapter 12.

Fear as Adaptive or Maladaptive Form of Emotional Response

269

Contents

Chapter 13.

Fear of Injury, Kinesiophobia & Perceived Risk

289

Chapter 14.

Multiple Facets of Pain due to Injury

311

Chapter 15.

Psychological Trauma: Case Studies

331

Chapter 16.

Psychological Trauma: Age & Gender Factors

357

Part IV

Concussion in Athletes

375

Chapter 17.

Concussion: Why Bother?

377

Chapter 18.

Concussion Classification: Historical Perspectives and Current Trends

399

Chapter 19.

Evaluation of Concussion: Signs and Symptoms

415

Chapter 20 .

Traumatic Brain Injuries in Children

447

Part V

Injury Rehabilitation

467

Chapter 21.

Integrated Injury Rehabilitation

469

Chapter 22.

EEG & Neurofeedback in Rehabilitation

493

Chapter 23.

Virtual Reality in Injury Rehabilitation

515

Index

541

PREFACE As the mud kicked up from the moist earth clung within his cleats, the pulse of his breath setting the rate of his stride, the distance between him and the goal narrowed. Hugging the sideline he kept pace looking towards the center to find aid, he stepped back and released. The rotation of his body contorting his spine sent radiating pains pulsing throughout his limbs. Collapsing, cushioned only by the soft earth, he fell to his knees reeling in pain. The game, though far from over, was now finished for him. Making his way to the sideline, the physical pain dulled by the psychological wounds, he braved through the torment. Unfortunately, the events of this day will haunt the memories of a once fearless athlete for a lifetime… Injury is an unfortunate risk that is still an unavoidable part of athletics today. Over the past decade, the scientific information on athletic injury in general, and integrative models of injury rehabilitation in particular, has increased considerably. As an example, a database search of peer-review articles from Medline, SportDiscus and PsycInfo between 1970 and 2006, using a variety of search items and combinations of terms (e.g., “return to sport,” “psychology of athletic injury,” “sport injury”) returned more than 2,000 sport injury articles. Using the search engine PubMed (National Library of Medicine) for the term “psychology of injury” there were 1,990 articles available between the years 1994-2005, compared to 930 for the years 1966-1993. In recent years, a number of models, theories and hypotheses describing the physical, biological, behavioral, cognitive and affective aspects interactively influencing the healing process have been developed. The feasibility of these models, although in most cases contradictory, has been overall justified in a clinical setting. That said, despite dramatic advances in the physical education of coaches, the fields of medicine, athletic training and physical therapy, sport-related traumatic injuries is our major concern. It is a matter of fact that athletic injuries, both single and multiple, have a tendency to grow dramatically. Accordingly, the prediction, prevention, and, if possible, reduction of sport-related injuries are among the major challenges facing the sports medicine world, research and clinical community to-date. The purpose of this book is to accumulate the latest developments in science of athletes’ training from “injury-free” perspectives, along with psychological analyses, evaluation, and management of sport-related injuries, including traumatic brain injuries. It is this author’s attempt to classify athletic injury with respect to its underlying causes and consequences. Clearly we are still far from a complete understanding of the major causes and multimodal consequences of sport-related injuries. The clinical significance of research into sport-related injures stems from the fact that the number and severity of injuries in athletes have a tendency to

xii

Preface

grow exponentially, despite advances in coaching techniques, and technological advances in sports equipment and protective devices. For example, it have has been estimated that just in high school football alone, there are more than 250,000 incidents of mild traumatic brain injury each season, which translates into approximately 20% of all boys who participate in this sport. The incidence of injury for men’s basketball games is 9.9 injuries per 1,000 athlete-exposures. The injury rate in gymnastics is about 15.19 injuries per 1,000 athlete-exposures. These are really “scary” statistics clearly indicating that modern sport is far from safe. Some details of injury epidemiology in athletics are depicted in this book. Currently, there is no consensus among medical practitioners in terms of a generic definition and classification of injuries in athletics. The existing diversity in definitions of the term “sports injury” is apparent in the relevant literature and most likely accounts for disagreements in reported research findings and clinical practices when dealing with injured individuals. The classification of injuries, such as acute, chronic, etc., should be defined in conjunction with the severity of the injury (mild, moderate, major, sport disabling, catastrophic) to be recognized and fully accepted by coaches, athletes and medical professionals. Obviously, psychological risk factors, athletes’ personalities, fear-related issues, adherence toward rehabilitation protocols and numerous other attributes of injury have never been considered within the scope of epidemiological research on the prevalence of certain injuries in certain sports. However, neither proper assessment nor appropriate treatment protocols could be developed unless multiple physical, biological, psychological and sociodemographic substrates are interactively considered when dealing with injured athletes. It is also important to stress the conceptual significance of basic science and clinical research on various perspectives of injury. This issue has been addressed in a number of chapters of this book. For example, the effects of improper balance as a fundamental skill, progressive muscle fatigue, fear of injury and pain issues from both basic neuroscience and clinical research viewpoints will be discussed within the scope of this book. The need for an advanced conceptualization of injury in athletics stems from the fact that no two traumatic injuries are alike in terms of mechanism, symptoms, or symptoms resolution. There is still confusion among coaches and medical personnel in terms the criteria for injured athletes’ readiness for sport participation versus readiness for competition. It is important to note that: “physical symptoms resolution of an injury is not an indication of injury resolution per se.” Although, the reality of athletics is that return-to-sport participation criteria are defined by presence and/or absence of symptoms of injury. Specifically, physical symptoms resolution (i.e., no evidence of residual tissue damage, restored anatomical integrity of joint, etc.) and functional symptoms resolution (i.e., ROM, strength, stamina) are two major criteria of return-to-

Preface

xiii

play. Regarding traumatic brain injury, athletes are allowed to return to play when common symptoms of concussion (i.e., headache, fatigue, light or sound sensitivity, etc) are resolved. Is this really the cornerstone for clearance of the athlete for sport participation? In fact, residual dysfunctions and structural damage may still be present, but not observed due to numerous factors, including both extrinsic (i.e., lack of sensitivity of the assessment tools) and intrinsic (i.e., the athlete’s desire to quickly return to sport participation because “… an injured athlete is worthless.”) Now, in terms of concussion in modern sport, that indeed should be treated as a “silent epidemic.” The need for further understanding of concussion stems from the fact that, according to Dr. Robert Cantu, injury to the brain is the most common cause of death in athletes. It is conventional wisdom that athletes with uncomplicated and single mild traumatic brain injuries (mTBI) experience rapid resolution of symptoms within one to six weeks after the incident with minimal prolonged consequences. However, there is a growing body of knowledge indicating long-term disabilities that may persist up to ten years post injury. Recent brain imaging studies have clearly demonstrated the signs of cellular damage and diffuse axonal injury, not previously recognized by conventional imaging and neuropsychological examinations, in subjects suffering from concussion. It is a most striking fact that progressive neuronal loss in concussed subjects, as evidenced by abnormal brain metabolites, may persist up to thirty-five days post-injury. Note that current clinical practice is that athletes suffering from mild to moderate forms of TBI are usually cleared for sport participation within ten days post-injury. As a result, athletes who prematurely return to play based upon subjective symptoms resolution may be highly susceptible to future and often more severe brain injuries. In fact, concussed athletes often experience a second TBI or even multiple concussions within one year post initial brain injury. Moreover, every athlete with a history of a single mild TBI who returns to competition upon symptoms resolution still has a risk of developing a post-concussive syndrome with potentially fatal consequences. Humans, in general, and athletes in particular, are able to compensate for mild or even severe physical and functional deficits because of redundancy in human neural, motor and cognitive systems. This in turn, allows for the reallocation of existing resources such that undamaged pathways and functions are used to perform cognitive and motor tasks. This functional reserve and overall capability to accomplish the testing protocols gives the appearance that an athlete has returned to pre-injury health status, while in actuality the injury is still present and hidden from the observer. As a result, premature return to sport participation based upon physical symptoms resolution may put athletes at high risk for recurrent injuries and the development of permanent psychological trauma. In fact, there is still no agreement upon a psychological diagnosis and definition of psychological trauma, and there is no known comprehensive treatment of psychological

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trauma in athletes. It is a growing concern among medical practitioners and coaches that athletes with an initial injury are prone to suffering from recurrent and more severe injuries. It is feasible to suggest that one of the major factors of recurrent injuries in athletes is premature return to sport participation based upon questionable assessment of symptoms resolution.

OUTLINE OF THE BOOK We will now provide a few more details on the organization of this book’s content. There are 5 main parts, which provide analysis of the most recent basic science and clinical research on sport-related injuries. This book is focused on both applied and conceptual issues regarding the classification of injuries, common coaches’ errors leading to injury, coaches’ and athletes’ viewpoints on injury, the development of psychological trauma in athletes, traumatic brain injuries and basic principles of rehabilitation. Currently accepted in clinical practice and research classification of injury, prevalence of injuries in different sports, athletic injuries from coaches’ and athletes’ perspectives constitute Part 1. Several chapters will discuss basic principles of elite athletes’ preparation and common coaches’ errors including problems associated with: • • • • •

Confusing classifications of injury; Improper planning and training periodization; Whole body postural control and balance; Progressive muscle fatigue and overloading; Nutritional aspects

Coaches and athletes’ viewpoints on injury, including psychological responses to injury, constitute Part 2. Numerous interviews with collegiate and professional coaches and athletes, and descriptions of psychological methods and diagnostic procedures well-accepted in clinical practice, case studies, current practices dealing with injured athletes and future challenges are the heart of this section. In addition, a discussion of overuse “abuse” injuries in athletics is included in this part of the book. It is important to note that one of the major coaching errors in modern sport is the lack of appreciation for the proper assessment of physical fitness. This issue will be also discussed within the scope of Part 2. Current psychological research within the conceptual framework of “psychological trauma” in athletes constitutes Part 3, which includes a number of chapters summarizing experimental research on fear of injury and different forms of pain resulting from sport-related injuries. Special emphasis will be given to the aspect of the development of fear of re-injury and fear of movement due to anticipated pain, i.e., “kinesiophobia,” as a predisposing factor for long-term psychological trauma in athletes. Behavioral indexes of fear/generalized anxiety and the development of

Preface

bracing behaviors as a result of injury will be discussed as well. Moreover, factors of age and gender as a predisposition for athletes’ individuated responses to injury will be discussed in a special chapter of Part 3. Part 4 of the book constitutes current information on traumatic brain injuries in athletes. Assessment scales and return-to-play guidelines that are well accepted and currently debated in clinical practice will be discussed within the scope of this section. Pediatric concussion, which is a major concern among medical practitioners today, will be also discussed within the scope of Part 4. Finally, basic concepts and principles of integrated rehabilitation aimed at a timely return to sport participation will be discussed in Part 5. The special chapters of this section will be focused on the specialized treatment and rehabilitation of injured athletes, including the feasibility and applicability of virtual reality (VR), goal-setting and neurofeedback protocols in a clinical setting. To my knowledge, multimodal perspectives of injury in athletics, including a discussion of the major causes and consequences of sport-related injuries with a special emphasis on coaches and athletes’ viewpoints, have never been accumulated in a single source. Since the topic of sport-related injuries is included in most of the Kinesiology, Sports Psychology, Exercise and Sport Science, Athletic Training, Physical Therapy and Neuroscience curricula, it is anticipated that this book will be considered for adoption as a valuable asset and/or supplementary reading source within kinesiology, exercise and medical sciences programs.

Professor Semyon Slobounov

FOREWORD Sport-related injury is one of the major factors preventing the realization of full potentials in high performance athletes. It is still an ongoing debate among sport medicine professionals and coaches whether athletic injuries are an inevitable part of athletics, or whether they may be predicted or even prevented by utilization of advanced coaching strategies and technologically safe equipment. To fully elaborate on the issues of injury among elite athletes it is necessary to consider multiple factors, both the external and internal causes and consequences of injury. Among external factors is the nature of specific sports, creating differential demands on athletes. For example, according to a recent report provided by FINA after the Olympic Games in Greece, injuries during competition are predominant in sport games (i.e., water polo), while injury during practices most often happened in complex coordination sports (i.e., springboard diving). An internal factor that is important to note is the athlete’s gender. Male athletes are more prone to injury than their female counterparts, partly due to hormonal differences. In addition, psychological factors, such as attitude toward risky activity, personality, level of fear and perception of pain are just a few things that contribute to injury in elite athletes. Consequences of injury in athletes are another tremendous concern among coaches and medical professionals. Of course, this depends on type of injury, musculo-skeletal, nerves, brain injury, etc. Nevertheless, it is no longer a secret that athletes who are not treated properly and who participate in sports again before their injury is fully healed, put themselves at tremendous risk for recurrent injury and often career-ending injuries. Most importantly, multiple improperly-treated injuries may develop fear syndrome with huge psychological/psychiatric consequences. Of course, dealing with injury in elite athletes requires proper attention, highly professional knowledge and active involvement of coaches, athletes and medical staff. This book by Professor Semyon Slobounov covering various issues of sport-related injuries from the perspective of athletes, coaches, medical practitioners and scientific researchers. It is a very timely addition and very much welcomed. Professor Eide Lübs Federation Internationale de Natation (FINA) Sport Medicine Committee Honorary Secretary China, Nan Jing FINA Diving World Series, 2007

ACKNOWLEDGEMENTS This book would not have been possible without the author’s inspiration from observing and working with numerous athletes, who, despite constant injuries and suffering throughout their athletic careers, still amaze us by their dedication and commitment to their loving sports. It is because of their commitment to sport, incredible achievements and suffering both physically and psychologically, that our knowledge of causes and consequences of sport-related injuries has advanced so far in recent years. I would like to thank numerous students at The Pennsylvania State University whom I had the privilege to teach and share my professional growth and maturation with. It is because of their urgent need to understand, not injury per se, but rather every single injured athlete’s response to injury, and the underlying causes and factors thereof, that this book was written. I would like to thank my numerous colleagues’ valuable suggestions and their insight on the problems associated with sport-related injuries during preparation of this book. My special thanks go to Dr. Karl Newell and Dr. Wayne Sebastianelli who have helped me mature both professionally and personally. In addition, I would like to thank all of the Penn State student athletes, coaching and medical staff that have given me the privilege of collaborating and taking part in their programs. I would like to acknowledge my academic departments of Kinesiology for allowing me to pursue the area of sportsrelated injuries. I am especially grateful to my growing family (Elena Slobounov, Vera & Craig Anderson, Kate, Stanley and Dalton Preschutti, and Anton Slobounov) for their unconditional love and support. My special thanks extended to Kate Contacos. This book wouldn’t be readable without her editorial effort, enthusiasm and commitment in ‘fine-tuning’ the chapters. Finally, I would like to thank the staff at Springer Publishing Company for their eagerness to see this book completed and their help in making this book possible.

CHAPTER 1 CLASSIFICATION OF INJURIES IN ATHLETICS 1. INTRODUCTION Injury is an unfortunate risk that, according to most coaches, athletes, and medical practitioners, is an unavoidable part of athletics. Most athletes that participate in high level sports experience some type of injury during their athletic careers. Ironically, despite significant advances in science of coaching, improvement in coaching techniques, technological progress in the design of athletic equipment, protective devices and facilities, the incidence of sport injury has actually increased during the past 15-20 years (Orchard & Powell, 2003). Clear conceptualization of the term “injury” is needed in order to fully appreciate existing research and clinical practice dealing with injured athletes. Accordingly, in the following text a number of approaches to define athletic injuries will be outline and discussed. It should be noted that diversity in definitions of the term “sport injury” is apparent in the literature and probably accounts for some disagreements in reported research findings (Pargman, 2007). The most common keyword searches used for research in popular Ovid MEDLINE and Pub Med among others are: “athletic injury”, “athletic injury reporting”, “injury definition”, “injury risk”, “injury rate”, “sports injury”, “injury surveillance”, “injury patterns”, etc., may come up with pretty diverse and controversial definitions of injury, and as a result, may imply confusing treatment procedures. Examination of various sources, including the National Electronic Injury Surveillance System, clearly shows that there is no single consensus on the definition of a reportable injury. For example, according to Pediatric Orthopedic Society of North America (2003) early sport injury surveillance studies primarily focused on traumatic brain (TBI) and catastrophic injuries. Unlike the definitions used in more recent studies that have been more inclusive as “any tissue damage”, including even minor bruises (Junge et al., 2002), any physical damage caused by a sport-related incident, where or not it is, results in any incapability to the participant (Finch, 1997), or “any time an athlete sought medical help” (Orchard, 1995; Beachy et al., 1997). Traditionally, injuries in athletics were classified based on events and associated symptoms, including: (a) acute traumatic injuries (i.e. contusions, sprains tears etc.), (b) chronic injuries (i.e. jumper’ knee, tennis’ elbow, thrower’s shoulder, etc.), and (c) overuse injuries (i.e. low back pain, spondylolisis, etc.). Acute injuries occur as a result of a single, sudden impact that creates tissue damage. Most often, the athlete becomes aware of the injury soon after it has occurred. This awareness, in fact, does not mean

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that the athlete and his/her coach have an accurate and complete comprehension of the impact on injury at the time of the accident. The full understanding of the initial injury may be achieved while monitoring various symptoms resolution (both physical/physiological and psychological) over the course of recovery. Interestingly, almost 60% of injured elite skiers indicated that they immediately realized that something was going wrong after the injury. The other 40% of injured skiers noted that they were not initially aware of the extent and severity of injury (Udry, 1999). Therefore it is important to understand that the process of mental awareness and cognitive appraisal of the injury may or may not follow the objective clinical assessment of injury. On the other hand, chronic and often referred overuse injuries are the accumulation of repeated and most often under-threshold injuries, due to exposure to small forces over time which ultimately result in serious damage. This type of injury is frequently manifested in conditions such as tendonitis and/or stress fractures. While acute injuries may be more recognizable because of their sudden impact and often associated obvious functional abnormalities and physical symptoms, chronic injuries often gradually develop, frequently not observable and their influence of athletes may be more insidious. Chronic injuries can play havoc with an athletes’ motivation and most often are major cause of burnout. It should be mentioned that physicians’ currently have a strong concern for non-traumatic injuries. For example the common non-traumatic cyclingrelated injuries include the knee, neck/shoulder, hands, buttock and perineum (Dettori & Norvell, 2006). This type of injury is often not severe enough to cause individuals to seek medical assistance. According to American College of Sport Medicine (1974), 117 cases of “handlebar palsy” were reported in athletes observed by a single physician over a four-year period; interestingly, most were not associated with tour riding. Two categories of non-traumatic injuries in cycling sport that may have the greatest impact on disability comparable with traumatic injuries include ulnar nerve palsy, and erectile dysfunctions. Moreover, according to a recent report by Dettori & Norvell (2006) the prevalence of non-traumatic cycling injuries can be as high as 85%. Overall, there are not a lot of records of non-traumatic injuries available to researchers. Accordingly, there is a lack of well-controlled reports regarding non-traumatic injuries in other than cycling sports. From intervention perspectives, at least 5 categories of injury severity were proposed (see also Hail, 1993) 1) Mild – an injury requiring treatment without interruption of training and participating in competitions with low risk of development of physical and/or psychological consequences. It should be noted that mild injuries sometimes are non-recognizable by athletes, coaches and even medical practitioners. This may put the mild injuries

Injury Classification

athletes at risk for re-current more severe injuries. It should be noted that multiple recurrent mild injuries may cause the development of “psychological trauma”. Therefore, medical practitioners should consider assessment of signs for psychological trauma in athletes with multiple minor injuries and referring these athletes to a qualified psychologist for further evaluation and treatment, if necessary. 2) Moderate – a relatively more severe injury that interferes with ongoing practices and potentially limiting participation in practices and competitions. This type of injury definitely requires referral to medical professional for comprehensive evaluation and treatment if necessary. Monitoring for any sings of psychological trauma is highly recommended. 3) Major – an injury requiring a long duration of inability to practice, often associated with surgery and/or hospitalization and may potentially lead to chronic and long term physical and/or psychological deficits. It is highly recommended that referral to a sport psychologist with expertise dealing with injured athletes should be made by medical practitioners. The athletes with even a single episode of major injury are highly susceptible for development of psychological trauma. 4) Sport disabling - an injury which, because of severity or timing, prevent an injured athlete from returning to prior level of functioning both physical and psychological. Involvement of a clinical psychologist with knowledge of sport-related injuries is critical for this category of injured athletes to predict and prevent potentials for post-traumatic psychological/psychiatric problems (i.e. post-traumatic stress disorder). 5) Catastrophic – an injury that causes permanent functional and/or psychological impairment and/or disability, typically from damage to the head and spinal cord, and other injuries of comparable severity. It should be noted that the occurrence of permanent functional disability due to catastrophic injury is infrequent relative to all sports. Care about psychological well-being of this category of athletes is mandatory. More recently, some consistency has emerged for four broadly acceptable classification/definitions based on: (A) Knowledge based approach to define injury, including the functional anatomy, an accurate patient history, diligent observation and a thorough examination. (B) Medical treatment, which incorporates injuries requiring any treatment by a team physician, whether or not they result in loss-of-time from competition or training.

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Loss-of-time, fully inclusive, which incorporates injuries that result in loss-of-time from competition and/or practices (Brooks & Fuller, 2006). Types of sports differentially dominating most common injuries in athletes

2. CLASSIFICATION OF INJURIES A correct diagnosis and proper classification of injury in athletes depends on knowledge of functional anatomy, an accurate patient history, diligent observation, thorough examination and standardized injury reports. It is critically important that the same research methodology is implemented to classify the injury in athletics. It should be noted that several reports attempt to analyze the incidence of injuries in a given sport but the results found in these reports cannot be compared with one another because of heterogeneous injury definitions, methods and data collection, observation format and design, and sample characteristics. Thus, the risk for injury in different sports can be compared because standardized research methodology is implemented. From this perspective, it is worth mentioning to review one study conducted by a team of experts who conducted comparative study of exposure-related incidences and characteristics of injuries of elite athletes during 2004 Olympic Games (see for details: Junge et al., 2006). Specifically, all team sport (n=14) tournaments (soccer, handball, volleyball and beach volleyball, basketball, field hockey, baseball, softball and water polo) were analyzed using standardized injury reports obtained from physicians. It should be noted that response rate was 93%. According to this comprehensive report, a total of 377 injuries were reported from 456 matches. The overall injury incidence of the team sport tournaments was almost 1 injury per game. Half of the injuries affected the lower extremities, specifically ankle sprain followed by knee injury. Interestingly, 24 % of injuries involved the head and neck; accordingly, the most prevalent diagnoses were head contusion. This report noted that the severity of head injuries were not always obvious. On average, almost 80% of injuries were caused by contact with another player. Half of these contact injuries were caused by foul play, as rated by the team physicians. However, a higher % of non-contact injuries prevented the players from participating in his or her sports. In terms of severity of tournament-related injuries, there were 16 fractures, 17 ligament ruptures, 4 meniscal lesions, and 2 dislocations. Not surprisingly, there was a high risk of non-contact ASL injuries in female athletes. However, injuries in male and female players were similar in location and circ*mstances but differed significantly in terms of type of

Injury Classification

injury. Moreover, there was the higher incidence of ligamentous knee injuries in female players, which is in agreement with numerous recent reports. In addition, concussions were diagnosed more frequently among female players, although, it should be noted that some concussions may be missed in male’s games and/or recorded as contusions. Classifying Injuries is multi-factorial by nature. Clinicians take into account the patient’s previous medical history which includes information related to the site of injury and general heath and well being. Through observation, clinicians are able to get an overall view of structural abnormalities, influences of posture, and determine the various signs associated with inflammation. Performing palpations provides information related to temperature changes, spasms, and most importantly painful areas. Integrity of the joints can be assessed through range of motion testing and various structural and functional testing. Often times, diagnostic images (i.e. x-ray, MRI CT scans) are used to determine location and sometimes severity of injuries. How we classify injuries depends largely on the anatomical structures and/or the specific areas involved. 1. Soft Tissue Injury Classification 2. Neurological Injury Classification 3. Low Back Injury Classification

2.1. Soft Tissue Injury Classification Soft tissue injuries involve structures such as muscles, tendons, and ligaments. Injuries that involve these structures typically are classified as 1st, 2nd, or 3rd degree in nature. Table 1 lists the difference associated with each grade. (Magee, 2008) One recent change is the classification of tendon. The term tendonitis has now been replaced with tendonopath; mainly due to the lack of inflammation present in the tendon.

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Table 1. Classification of Muscle Strains, Ligament Sprains and Tendonopathy. 1° Strain/Sprain

2° Strain/Sprain

Definition Few torn fibers ½ of fibers torn

MOI Onset

3° Strain/Sprain All fibers torn

Overstretch/Ove Overstretch/Overload Overstretch/Overload rload Acute Acute Acute

Weakness Minor

Disability Minor

Moderate to major (reflex inhibition)/Minor to moderate Moderate

donopathy Inflammation and/or degeneration of tissue Overuse Chronic, acute

Moderate to major/Minor to moderate

Minor to moderate

Major /Moderate to major Moderate/Minor

Minor to major Minor None

Spasm

Minor

Moderate to major/Minor

Edema

Minor

Moderate to major/Moderate

Moderate to major

LOF

Minor

Moderate to major

Major (reflex Minor to major inhibition)/Moderate to major (instability) No to minor/No Minor to major

Pain with Minor/No contraction

Moderate to major/No

Yes Pain on stretch Joint play Normal

Yes

Normal

Possible

Defect

Normal/Normal to excessive Yes

Crepitus

ROM

↓

May ↑ or ↓ dependent ↓ upon edema/May ↑ or ↓ dependent upon edema, dislocation or subluxation possible

Possible

2.2. Neurological Injury Classification Nerves can be challenging to evaluate from an injury standpoint. Typically trauma to nerves lends to radicular symptoms including numbness, tingling, and/or pain. Table 2 outlines some distinct differences associated with neurological injury.

Injury Classification Table 2. Classification of Nerve Injuries According to Seddon (1943). Grade of Injury

Definition

Neuropraxia (Sunderland 1°)

A transient physiological block caused by ischemia from pressure or stretch of the nerve with no wallerian degeneration

Axonotmesis (Sunderland 2° and 3°)

Neurotmesis (Sunderland 4° and 5°)

Signs and Symptoms

Pain No or minimal muscle wasting Muscle weakness Numbness Proprioception affected Recovery time: minutes to days Internal architecture of nerve Pain preserved, but axons so badly damaged Muscle wasting evident that wallerian degeneration occurs Complete motor, sensory and sympathetic functions lost Recovery time: months (axon regenerates at rate of 1 inch/month, or 1mm/day) Structure of nerve is destroyed by No pain (anesthesia) cutting, severe scarring, or prolonged Muscle wasting severe compression Complete motor, sensory and sympathetic functions lost Recovery time: months and only with surgery

2.3. Low Back Injury Classification Low back injury or pain is very common among the general and athletic population. It ranks #1 as the reason patients visit either an orthopedist or neurologist. It falls to #2 for reason that patients visit their primary care physician (Heck & Sparaon, 2000; Wipf & Deyo, 1995). Recently, it has been suggested that low back pain be classified in relation to the type of symptoms that a patient has instead of an actual pathology (Heck, 2000). This is mainly due to the fact that much pathology related to low back pain are not diagnosed or properly identified in over 2/3 of the patient population (Heck & Sparaon, 2000; Spratt et al., 1990). Table 3. Low Back Injury Classification (Heck, 2000). Level 1 2 3 4

Description Local low back pain only Radiating pain Neurological deficits Serious conditions

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3. COMMON PROBLEMS WITH EXISTING CLASSIFICATIONS After reviewing numerous papers on the relevant topic, a conclusion can be made that the definition of injury cannot be expressed in a few simple words, nor is just one definition agreeable to all experts in the field. Analysis of published literature shows that the definition of injury is very broad and diverse due to different criteria used to evaluate it such as activity, severity of injury, and circ*mstances resulting in injury. However, at least one common agreement is that the injury has to have happened during a sporting event whether it is a practice of performance or a game or competition. According to NEISS-AIP the definition of injury relates to “bodily harm resulting from exposure to an external force or substance”. This is exclusive needs to be further elaborated on definition of injury with respect to both physical and psychological factors associated with it. Indeed, perception of injury and its severity are multi-factorial and age, gender, fitness level etc. dependent phenomenon. It is more or less common opinion among sport injury professionals that a definition of injury needs to include at least one, if not more, of the following: severity of the injury, time loss due to the injury, injury type, and whether a professional examined the injury. A very detailed description defined injury as “any unintentional or intentional damage to the body caused by acute exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and ionizing radiation interacting with the body in amounts or at rates that exceed the threshold of human tolerance” (Baker et al., 1992). It is also agreed that injury is “an event requiring medical attention in which the time absent from participation is directly correlated to the severity of the injury.” However, an addition should be made that injury is “any incident that occurs during an athletic event which involves a blow or damage to the head or spine as well as any physical ailment ranging anywhere from minor to severe causes that result in an athlete being unable to perform at 100%.” Besides the physical aspects which define an injury, psychological factors also aide to describe what injury is. Injury is an individual experience that only the injured person truly knows how it feels and what needs to be done to get better. A doctor can determine exactly what is wrong and help diagnose the issue and physical therapists can suggest exercises to perform to get back to normal. However, ultimately a positive attitude and good outlook on the situation at hand can greatly affect the recovery period along with age and gender. Some researchers mention that psychology plays a huge part in the entire injury process. Specifically, injured athletes direction of thoughts, and content of the healing imagery are important factors to

Injury Classification

consider in order to facilitating the recovery from the injury as the injury and during the recovery and healing process. Clearly, after experiencing a traumatic injury, it is much more than just going to rehabilitation; it involves mental injury as well. Mental injury can be defined as a psychological trauma. One injured athlete reported that she felt both physical and psychological strains of the injury during her rehabilitation process. She declared that her mind wanted to be at a level that her body was not and felt less stressful when both mind and body were at the same recovering level. She also claimed that when she recovered, she was mentally stressed due to fear of re-injury. Generally, there are immense pressures to compete early in life. Added stress and overload is often a common predisposing risk factor of injury. Once injured, negative thoughts of becoming re-injured, the amount of stress on an injured athlete and reflecting on whether or not your body is strong enough to compete in a sport again can take over the mind of an athlete. With the rate of injury increasing, coaches and trainers really need to evaluate not only the injury spot itself, but the athletes mental state a lot more than they currently are. Considering the importance of psychological trauma and its consequences on athletes’ recuperation process, this topic will be specifically discussed elsewhere in this text. The National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) defines reportable injury as “an event that occurs during participation in intercollegiate athletics, requiring medical attention from the CAT or team physician and results in restriction of the athlete’s participation for greater than or equal to one day beyond the day of injury” (Goldberg et al, 2007). In addition, many concur that including time lost from participation in the definition effectively reduces the bias associated with the incidence estimate (Meeuwisse, et al, 2003). Prager, considering High School Football injuries, agrees that the definition should include both time factor and a severity component used by the research committee of the American Orthopedic Society for Sports Medicine and by the US National Athletic Injury Reporting System, be adopted by all sports injury surveillance studies (Prager et al, 1989). Some argue that this point leaves room for argument. However, there are disagreements with both of these definitions stating that one cannot base the definition of injury on time lost from activity because many athletes play through injury and in some cases, the injury is minor enough that it is all right to play through. Some athletes are more willing to fight through pain, recommended or not, than other athletes. One article claims that “70%-90% of all injuries sustained fall in the transient category—that is, by only recording injuries that result in missed matches, the majority of injuries are missed and therefore injury rates are underreported” (Hodgson, 2007). This brings up an interesting point about the frequencies and severity of injuries. Concussions, for example, occur

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less often than ankle injuries in basketball, yet should these two injuries have the same weight in the definition of injury? One is severe and could potentially result in death, while the other occurs often and is easily looked after. Some researchers document that it should be considered only if it was an emergency room visit, a complaint requiring the attention of an athletic trainer, time loss that restricted participation or if a consultation with a physician was required. According to the NCAA’s definition, an athlete would need to have time loss from play greater than one day (Godlberg, 2007). While other state only injuries including the head and a time loss of more than 48 hours if it occurred during a game or competition would count (Prager, 1989). The severity of the injury also relates to the amount of time a player is away from functioning properly at a game and/or practice. Interestingly, it is not clear how to classify the athletes who function properly and who do not using existing observational formats. One’s definition on injury is correlated with the amount of knowledge and exposure one has had with sports-related injuries. Coaches that are unaware about the importance of the recovery and rehabilitation process of the physical, functional and emotional aspects could allow an athlete back to play prematurely, which may result in more damage to the athlete. Anecdotal observation in general, and an injured student-athlete reported specifically, that while playing soccer, he was knocked unconscious and the coach put him back in not knowing that he had a mild concussion. This proves that a more experienced professional, like a trainer, would be knowledgeable about the injury and not allow the athlete to go back into the game knowing that he could have hurt himself more. The bottom line is that researchers need to be knowledgeable and come to a conclusion on a meaningful definition that allows for severity, time lost, and exposure of a sport. One researcher used bones as an example to explore the “science” of injury. “Bones in youth generate new tissue at growth plates positioned near the end of most bones. During puberty, a protective band of tissue that supports the growth plate begins to deteriorate so the bone can harden in preparation for adulthood. Without the protective band, the plate is particularly vulnerable to being abnormally compressed or possibly pulled apart. Research suggests that girls are up to eight times as likely to injure their ACL as males are. Knee joints tend to be looser in girls and their quadriceps are often stronger than their hamstrings, destabilizing the knee” (Hayco*ck, 1976). This is a very good example with valid points. It suggests that definition/classification of injuries in athletics must take into consideration the developmental aspects to properly assess the impact of injuries and to develop rehabilitation protocol. There are various levels of injury perception and attitude because the level of pain/perception of pain associated with this specific injury varies

Injury Classification

from person to person. One cannot set an exact timeline for the recovery process because everyone’s bodies are on different schedules and of different abilities. Many people feel that you cannot gauge severity by the time lost because some athletes heal faster than others do, while still more return to their sport prematurely. The knowledge of professionals is also responsible for treating and diagnosing those athletes who actually report that an injury has occurred. A sideline coach may have little to no knowledge of injury while specific sports teams need trainers on the sidelines because it is a high impact sport. Such a high number of athletes do not report injury in order to keep participating in the game, which may cause more damage to injured athlete. It is important to be able to identify an injury and its mechanism in order to classify it under specific definition and perform effective injury surveillance, which in turn could lead to better preventive ideas and methods.

4. EPIDEMIOLOGY OF INJURIES IN ATHLETICS It has long been know that sports and injuries go hand in hand. The sports medicine team consisting of physicians, athletic trainers, and coaches all need to be aware of sudden injuries, whether they are minor or catastrophic. Each sport is unique to injuries depending on the nature of the sport. This most current literature review section was elaborated with an intention to classify the sports into contact or non-contact, breakdown the epidemiology of injury, and provide some sport specific prevention strategies. Both baseball and softball had relatively low injury rates as compared with the other sports examined. According to a 16 year study done by the NCAA, Dick et al. (2007) reported 5.78 baseball injuries per 1,000 athleteexposures during games whereas Marshall et al. (2007) reported 4.3 softball injuries per 1,000 athlete-exposures during games. Those same studies reported 1.85 baseball injuries per 1,000 athlete-exposures for practices and 2.7 softball injuries per 1,000 athlete-exposures for practices, respectively. Of those injuries baseball games produced the most upper leg muscle-tendon strains at 11% followed by ankle ligament sprains at 7.4% (Dick, 2007). Baseball practices produced shoulder muscle-tendon strains at10% of total injuries followed by ankle ligament sprains at 8.5% (Dick, 2007). Softball game injuries varied slightly by producing the most ankle ligament sprains at 10.3% of total injuries and practices resulted in the 9.5% of ankle ligament sprains making them the most common injury (Marshall et al., 2007). One common prevention strategy for both baseball and softball is to use breakaway bases. Many ankle ligament sprains occur from sliding feet first into the base. Throughout the 16 year study, Dick et al. (2007) found there were 439 injuries resulting from sliding into stationary bases and only 40

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injuries from breakaway bases. Another similar prevention strategy is proper off season conditioning to acclimatize the athlete to a new training regiment. Ankle ligament sprains are seen in all sports; however, the sport most accountable for this type of injury is basketball. According to Dick et al. (2007) their data collection resulted in 26.2% of all game injuries resulting in an ankle ligament sprain. The same can be said about practices with 26.8% of all injuries being ankle ligament sprains. Agel et al. (2007) reported women’s basketball had 24.6% of all game injuries as ankle ligament sprains and 23.6% of practice injuries consisted of a sprained ankle. The incidence of injury for men’s basketball games is 9.9 injuries per 1,000 athlete-exposures and for practices the incidence drops to 4.3 injuries per 1,000 athlete-exposures (Dick et al., 2007). The same can be said for women’s basketball which had an incidence of injury of 7.68 per 1,000 athlete-exposures for games and 3.99 injuries per 1,000 athlete-exposures for practices (Agel et al., 2007). Some common prevention strategies focus directly on the ankle. Further research is warranted on proprioception training to control the ankle upon landing. Also, the efficacy of prophylactic taping and bracing needs to be discussed. Does one work better than the other to prevent recurrent ankle sprains? Improving off season conditioning to prevent fatigued play during preseason may also help prevent injuries. Fencing is considered to be a low risk sport when it comes to injury. There are, however, several injuries that can occur from this sport. Murgu (2006) reported the most common lower extremity acute injuries are ligament sprains, meniscus tears, Achilles’ tendon ruptures, muscle strains, and nail contusions. The most common upper extremity acute injuries are finger, wrist, and elbow sprains and strains and muscle cramps. Overuse injuries can also happen to a fencer. Prolonged periods of time in the fencing stance can lead to patellofemoral pain syndrome, IT Band friction syndrome, and low back pain. A few suggested prevention strategies are adequate warm up, the use of orthotics, properly checked equipment, and a health care professional who can properly assess injury to prevent recurrent injury. Golf is closely related to fencing as it is considered a low risk sport in terms of incidence of injury. Theriault and Lachance (1998) reported there to be between 1.19 and 1.31 injuries per golfer. Depending on the swing and level of play, the most commonly injured body part varies from study to study, although the several top injuries remains constant. Parziale and Mallon (2006) reported low back pain is the most common ailment of golfers. Theriault and Lachance (1998) reported that professional golfers most often injure their wrist and amateur golfers most often injure their thoracic spine. Gosheger et al. (2003) found the most common injury to professional golfers was lumbar spine (21% of injuries) followed by wrist (20%) and the most common injury to amateurs is elbow (24.9% of injuries)

Injury Classification

followed by lumbar spine (15.2%). Prevention for golf injuries has a commonality between all the studies. Proper technique of the golf swing is reiterated throughout these studies (Theriault and Lachance, 1998; Parziale and Mallon, 2006; Gosheger et al. 2003). Quality equipment, proper warm up, flexibility, good aerobic training, and not carrying your golf clubs can all decrease the overuse injuries experienced. Gosheger et al. (2003) also performed a study with one group performing a ten minute warm up as compared to no warm up. The incidence of injury dropped from 1.02 injuries per player (no warm up) to 0.41 injuries per player for those who performed a ten minute warm up. Another non contact sport growing in popularity is gymnastics. The gymnastics injury rate is substantially higher than previous non-contact sports reported. Marshall et al. (2007) found 15.19 injuries per 1,000 athlete-exposures during competition and 6.07 injuries per 1,000 athleteexposures in practice. Kilt and Kirkby (1999) reported 5.45 injuries per gymnast or 3.31 injuries per 1,000 hours of training. It is important to note that sub-elite gymnasts were also included in these studies, therefore increasing the injury rates by trying more advanced skills. Of the high incidence of injury Marshall et al (2007) reported, during competition knee internal derangement consisted of 20.6% of injuries followed by ankle ligament sprains at 16.4%. During practice Marshall et al. (2007) found 15.2% of injuries consisted of ankle ligament sprains, followed by knee internal derangement at 8.7%. Kolt and Kirkby (1999) studied 64 gymnasts reported 349 injuries. A majority of the injuries (31.2%) were located in the foot and ankle followed by the low back (14.9%), and the knee (13.5%). Gymnastics injuries can be decreased with some specific prevention strategies. Ensure amateur gymnast only try more difficult routines after many hours of practice. A sting mat can be used to decrease the amount of force generated upon landing. Alter rules for competition to discourage harder routines with a higher risk of injury. Also, neuromuscular training, core stability, constant mental focus throughout practice, and condition so fatigue does not alter routines during enduring practices. Rowing injuries are often due to overuse, repetitive motions. Rumball et al. (2005) found the most common site of injury in male rowers was the lumbar spine, followed by the forearm and wrist, then the knee. In females, Rumball et al. (2005) found the most common site of injury was the chest, lumbar spine, followed by the forearm and wrist. In this study, spine injuries consisted of 15-25% of all injuries. The reason for the spine injuries is the force generation caused by hyper flexion and twisting motion causing a 4.6fold increase in body weight. McNally, Wilson, and Seiler (2005) also reported low back pain is the most common site of injury among rowers. This could possibly be due to the new rowing equipment which was made stiffer. McNally, Wilson, and Seiler (2005) reported one in eight rowers will have a rib stress fracture. Rib stress fractures are more common in sweep

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rowers and women. Rumball et al. (2005) found rib stress fractures account for 6.1-22.6% of all rowing injuries. Rib stress fractures could be caused by muscle weakness leading to less shock absorption and muscle imbalance. Some prevention strategies used in rowers are to strengthen core stabilizers, stretch, ease into strength training and provide the rowers with adequate rest and recovery after a training bout. Another sport causing a majority of overuse injuries is running. Common injuries as noted by Strakowski and Jamil (2006) and Cosca and Navazio (2007) are shin splints, Achilles’ tendonitis, plantar fasciitis, patellofemoral pain syndrome, IT band friction syndrome, and patellar tendonitis. These overuse injuries can be caused by numerous things such as: improper footwear, a sudden increase in mileage or intensity, pes cavus or pes planus, tibial varum, or leg length discrepancy (Strakowski and Jamil, 2006). There are many prevention strategies for runners to use to decrease the amount of overuse injuries or recurrent injuries. Stretching, taping, strengthening, and cross training are some easy ways to help prevent overuse injuries. Also, a runner can take NSAIDS (non-steroidal anti-inflammatory drugs). Rest, ice, properly prescribed orthotics, proper footwear, and heel lifts will also help. Swimming is a non-contact sport involving a lot of upper body strength. Muscle imbalance can lead to injury, specifically at the shoulder. Johnson (2003) reported that shoulder injuries are about 30% of all injuries, followed by back at 20% and knee injuries comprise 10% of all swimming injuries. With up to 1 million shoulder revolutions per year, it is easy to understand why shoulder injuries are so common in swimmers (Johnson, 2003). Weldon and Richardson (2001) reported that 90% of complaints from swimmers are about the shoulder. Overuse in swimming causes a muscle fatigue which can lead to decreased rotator cuff effectiveness and decreased scapular positioning during each stroke (Weldon and Richardson, 2001). Another big risk factor for swimmers and shoulder injury is muscle imbalance which leads to shoulder instability which results from ligamentous laxity and increased range of motion (Weldon and Richardson, 2001). There are ways to prevent so many overuse injuries in swimmers. Increasing shoulder stability and muscle imbalances is a key factor to decreasing the incidence of shoulder injuries. General rotator cuff exercises and scapular positioning will attribute to a decrease in injury. Attention to proper technique and, if injured, cross training exercises will be most beneficial. As with many non contact sports, tennis comes with a lot of overuse injuries. Perkins and Davis (2006) reported on the most common types of injuries among tennis players. Of them, muscle strains and ligament sprains were the most frequent. They found the most common shoulder injury to be rotator cuff tendonitis. Lateral epicondylitis of the elbow can occur frequently. De Quervain’s tenosynovitis is one of the most common tendon

Injury Classification

problems facing tennis players. The most common wrist problem as described by Perkins and Davis (2006) is ulnar wrist pain secondary to extensor carpi ulnar tendonitis. Jumper’s knee and patellofemoral pain syndrome are the two most common knee ailments in tennis players. Overuse treatment and prevention strategies are very similar no matter what sport causes the injury. Conservative treatments work well such as rest, ice, and NSAIDS. Strengthening and stretching the injured area can also be effective to relieve some discomfort after an injury. One more non contact sport to include is volleyball. The incidence of injury in volleyball players as reported by Agel et al (2007) is 4.58 injuries per 1,000 athlete-exposures in a game and 4.1 injuries per 1,000 exposures in practice. The incidence of injury does not change much from practices to games because of the activities in both. Ankle ligament sprains make up almost half of all game injuries and almost 30% of al practice injuries. Most ankle sprains occur from landing on another player’s foot. Proprioceptive training and strength training should be of utmost importance to volleyball players especially if he/she has suffered an ankle sprain previously. Agel et al. (2007) did report that the rate of ankle sprains over the 16 year period decreased by 1.8% in games and 3% in practices. Prophylactic taping and bracing should be considered once further studies are conducted to support the efficacy for it. The number of injuries sustained in a contact sport rapidly increases compared with most non contact sports previously mentioned. One example of this is ice hockey where Flik, Lyman, and Marx (2005) reported the incidence of injury for men’s ice hockey to be 13 injuries per 1,000 athleteexposures in games but only 2.2 injuries per, 1,000 exposures for practices. This is very similar to Agel et al. (2007) who reported 16.27 injuries per 1,000 exposures for games and 1.96 injuries per 1,000 athlete exposures for practices. Flik, Lyman, and Marx (2005) found concussions to be the most common injury happening 18.6% of the time, while Agel et al. (2007) found concussion to take only 9% of total injuries during games and 5.3% of all injuries during practices. The most common injury reported in the 16 year study was knee internal derangements consisting of 13.5% of all game injuries and in practice, 13.1% of the injuries were pelvis and hip muscle tendon strains (Agel et al., 2007). Agel et al. (2007) also reported on women’s ice hockey showing slightly different injury patterns. Here game injuries consisted mostly of concussions happening 21.6% of the time. In practice, concussions lead all injuries in women’s ice hockey taking up 13.2% of all injuries. The incidence of injury for women’s ice hockey was as similar as men’s ice hockey. Agel et al. (2007) reported 12.6 injuries per 1,000 athlete-exposures in games and 2.5 injuries per 1,000 athleteexposures in practices.

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Women’s ice hockey likely causes more concussions because of the no checking policy making players unprepared for accidental contact. Also, some women grow up playing on a men’s team so they are used to the physical contact, however, the women who are not used to it don’t know how to absorb a hit and sustain a concussion. Prevention strategies should focus on decreasing the amount of brain injury in ice hockey. Making rule changes to increase the size of the ice may decrease the amount of contact a player has with another player and may help decrease the concussion rate (Agel et al, 2007). Increasing the penalty time for elbows and illegal hits to the head may also help decrease the concussion rate (Flik et al, 2005). Men’s lacrosse is very similar in the incidence of injury as ice hockey. Dick et al. (2007) reported an injury rate of 12.58 injuries per 1,000 athleteexposures during games and an incidence of injury of 3.24 injuries per 1,000 exposures. Concussions also ranked evenly with ice hockey concussion rates comprising 8% of all injuries, the third most common following ankle ligament sprains (11.3%) and knee internal derangement (9.1%). The most common practice injury Dick et al. (2007) reported ankle ligament sprains, accounting for 16.4% of all injuries. Dick et al. (2007) also showed that women’s lacrosse had similar concussion injury rates as men’s lacrosse, but a substantially greater number of ankle ligament sprains in games, totaling 22.6% of all injuries. Ankle ligament sprains comprised 15.5% of all injuries in practice. Another study on women’s lacrosse by Matz and Nibbelink (2004) show almost identical injury rates for games and practices for ankle ligament sprain being the most common injury. An interesting note Dick et al. (2007) reported was that a new kayaking style helmet was introduced in the 1996-97 season for the women’s lacrosse team to wear, and it actually increased concussion rates most likely because the helmet was meant to withstand one blow and not multiple blows throughout the course of a competition. Women’s lacrosse just implemented a mandatory goggle rule in hopes of decreasing the amount of eye injuries, but no head protection is yet required as is the case in men’s lacrosse. A similar sport and incidence of injury to women’s lacrosse is women’s field hockey. Dick et al. (2007) reported 7.87 injuries per 1,000 athleteexposures in games and 3.7 injuries per 1,000 exposures in practices. The most common injury in games was ankle ligament sprains (13.7% of injuries) followed by knee internal derangement (10.2%) and concussions was not far behind comprising 9.4% of all game injuries. The study also reported upper leg muscle strains made up over one fourth of the total number of injuries in practice. A few rule changes half way through this study decreased the amount of injuries. The sticks were made of different materials, incorporated some protective equipment, increased play on artificial turf, eliminated off sides, and moved the corner shot to the sideline (Dick et al, 2007). Some more steps can be taken to prevent more injury

Injury Classification

such as mandatory helmet and padded glove wear, change rules to decrease congestion around the goal area, and prophylactic taping and bracing to decrease ankle ligament sprains. Soccer is an endurance type sports, however, soccer athletes sustain a high incidence of injury. Manning and Levy (2006) reported 10-15 injuries per 1,000 athlete-exposures. Dick et al. (2007) reported an incidence of injury for women’s soccer at 16.4 injuries per 1,000 athlete-exposures for games and 5.2 injuries per 1,000 exposures for practices. Agel et al. (2007) reported an incidence rate for men’s soccer slightly higher at 18.75 injuries per 1,000 athlete-exposures for games and 4.34 injuries per 1,000 exposures for practice. Ankle ligament sprains are the most common injury to men and women soccer player. In a men’s soccer game they make up 17% of the total injuries in games (Agel, 2007) and in a women’s soccer game ankle sprains make up 18.3% of the total injuries (Dick et al., 2007). Manning and Levy (2006) reported a higher incidence of injury playing indoors as compared to outdoors. Prevention of soccer injuries is primarily concentrated on ankle ligament sprains such as strength and neuromuscular training. Properly fitted shoes are also important. A rule change for tackling should be considered to prevent tackling type injuries. Water polo is a sport more popular overseas but one that is growing in popularity in the United States. Franic, Ivkovic, and Rudic (2007) reported the most common water polo injury is shoulder pain. Shoulder pain is directly correlated with the level of competition in the athlete and the number of years competing. Hand and wrist injuries, facial lacerations, and swimmer’s ear are all common because of the nature of water polo. Early identification and treatment of these injuries is paramount to prevent recurrent injuries. Wrestling is seen by many as a dirty sport consisting of only skin diseases. Agel et al. (2007) reported the injury rate to be 26.4 injuries per 1,000 athlete-exposures for a match and 5.7 injuries per 1,000 exposures for practice. Knee internal derangement was the most common injury at 22.9% of all injuries for matches. In practice, skin infections consisted of 17.2% of all injuries followed closely by knee internal derangements at 14.8% of the total number of injuries. Weekly, wrestlers deprive their bodies of proper nutrition to make weight for a match. One prevention strategy for wrestlers is proper hygiene and nutrition. Because of the high rate of skin infections during practice, a clean and sterile environment to wrestle on is a key element in decreasing the likelihood of spreading skin infections. A rule change for specific submission holds should be considered to decrease match injuries. Rugby is a violent contact sport consisting of anywhere form 10.6 injuries to 19.8 injuries per 1,000 athlete-exposures (McIntosh, 2005). The University of New South Wales (McIntosh, 2005) reported 35% of match injuries were to the lower extremity, 23% were to the upper extremity, 23%

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to the shoulder, and 20% to the head. Concussions comprised 14-17% of all injuries sustained in this study. Carson, Roberts, and White (1999) studied a women’s rugby team for one season and reported the incidence of injury to be 23.2 injuries per 1,000 athlete-exposures for matches and 2.5 injuries per 1,000 exposures for practices. The most common injury was ankle sprains. Four out of the 35 total injuries were concussions. Almost half of all injuries occur at the lower extremity. Rugby is a tough sport for injury prevention because of the nature of the game. No helmets, or pads are worn by the athletes so everyone involved needs to be clear on the procedures for injury, especially catastrophic injury. An extensive injury surveillance system needs to be set up for rugby teams so more injury prevention programs can be specific to the nature of the sports. Along the same lines as rugby is football where injury rate is 35.9 injuries per 1,000 athlete-exposures in games and 3.8 injuries per 1,000 exposures in practice (Dick et al., 2007). Knee internal derangements were the most common injury for fall games, fall practices, and spring practices at 17.8% of total injuries, 12% of total injuries, and 16.4% pf total injuries, respectively (Dick et al., 2007). Proper techniques are the most important injury prevention programs for football. Heat acclimatization before preseason is also important. The athletes need to come into preseason practices in condition to train in the heat and endure grueling practices. Prophylactic knee bracing is also a prevention strategy to decrease the number of knee internal derangements.

CONCLUSION Proper classification, assessment and definition of injury in athletes are important components to the development of a treatment plan. Unfortunately, the diversity in definitions of the term “sport injury” is apparent in the literature and probably accounts for some disagreements in reported research findings and clinical practices dealing with injured athletes. Classification of injuries, such as acute, chronic, etc., should be defined in conjunction with severity of injury (mild, moderate, major, sport disabling, catastrophic). This combination makes the definition of injuries extremely complex and confusing not only for athletes but also for medical professionals and coaches. In addition, rarely psychological status of injured athletes, athletes’ selfperception of injury and attitude towards injury are within the scope of definition of traumatic injuries. It is important to note that there are basically NO definitions of psychological trauma that can or cannot be directly related with physical injury in athletes. Moreover, psychological risk factor, and athletes’ personality have never been considered within the scope of epidemiological research on prevalence of certain injuries in certain

Injury Classification

sports. Neither proper assessment nor appropriate treatment protocols can be elaborated unless both physical and psychological impacts are considered when dealing with injured athletes.

Acknowledgments This chapter was prepared with great help of numerous Penn State undergraduate students who took my “Injury in Athletics, KINES 497 class”. My special thanks to Dusty Lang, AT graduate assistant in Fall 2007. A also appreciate contribution of Dr. Nicole McBrier to this chapter.

REFERENCES Orchard, J.W., & Powell, J.W. (2003). Risk of knee sprains under warious weather conditions in American football. Medicine and Science in Sports and Exercise, 35, 11181123. Pargman, D. Psychological Bases of Sport Injuries. 3rd Edition. Morgantown: Fitness Infomation Technology, 2007. Junge, A., Rosch, D., Peterson, L., et al., (2002). Prevention of soccer injuries: A prospective intervention study in youth amateur players. American Journal of Sports Medicine, 30(5), 652-659. Finch, C.F. (1997). An overview of some definitional issues for sports inury surveillance. Sports Medicine, 24, 157-163. Orchard, J. (1995). Orchard sports injury classification system (OSICS). Sports Health, 11, 39-41. Beachy, G., Akau, C.K., Martinson, M., et al., (1997). High school sports injuries: A longitudinal study in Punahou School: 1988 to 1996. American Journal of Sports Medicine, 25(5), 675-681. Udry, E. (1999). The paradox of injurie: Unexpeted posititive consequences. In D. Pargman (Ed.), Psycholgoical bases of sport injuries. (pp.79-88). Morgantown, WV: FIT. Detorri, N., & Norvell, D. (2006). Non-traumatic bicycle injries.: A review of the literature. Sports Medicine, 36(1), 7-18. Hail, J. Psychology of Sport Injury. Champaign: Human Kinetics, 1993. Brooks, J., & Fuller, C. (2006). The influence of methodological issues on the results and conclusions from epidemiological studies of sports injuries. Sports Medicine, 36(6), 459472. Junge, A., Langevoort, G., Pipe, A., et al. (2006). Injuries in team sport tournaments during the 2004 Olympic Games. American Journal of Sports Medicine, 34(4), 565-576. Magee, D. Orthopedic Physical Assessment. 5th ed. Philadelphia, Elsevier, 2008. Seddon, H.J. (1943). Three types of nerve injury. Brain 66, 17-28. Heck, J.F., & Sparaon, J.M. (2000). A classification system for the assessment of lumbar pain in athletes. Journal of Athletic Training, 35(2), 204-211. Wipf, J.E., & Deyo, R.A. (1995). Low back pain. Medicine Clinical in North America, 79(23), 1-246. Spratt, K.F., Lehmann, T.R., Weinstein, J.N., Sayre, H.A. (1990). A new approach to the low-back physical examination.: behavioral assessment of mechanical signs. Spine, 15, 96-102. Baker, S.P, O’Neill, B., Ginsburg, M.J., et al. The Injury Fact Book, 2nd ed. New York: Oxford University Press, 1992.

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Goldberg, A.S., et al., (2007). Injury Surveillance in Young Athletes, A Clinician’s Guide to Sports Injury Literature, Philadelphia, PA. Sports Medicine, 37 (3): 265-278. Meeuwisse, W.H., et al. (2003). Rates and Risks of Injury During Intercollegiate Basketball. American Journal of Sports Medicine, 31(3), 379-385. Prager, B.I., et al. (1989). High School Football Injuries: A Prospective Study and Pitfalls of Data Collection” American Journal of Sports Medicine, 17(5), 681-865. Hodgson et al. (2007). For Debate; Consensus Injury Definitions in Team Sports Should Focus on Encompassing All Injuries. Clinical Journal of Sports Medicine, 17, 188-191. Hayco*ck, C.D., & Gillette, J.V. (1976). Susceptibility of women athletes to injury: myths vs. reality. JAMA, 236, 163-165. Dick, R., Sauers , E.L., Agel , J., Keuter, G., Marshall, S.W., McCarty, K., et al. (2007). Descriptive epidemiology of collegiate men's baseball injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 183-193. Marshall, S.W., Hamstra-Wright, K.L., Dick, R., Grove, K.A., & Agel, J. (2007). Descriptive epidemiology of collegiate women's softball injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 286-294. Dick, R., Hertel, J., Agel, J., Grossman, J., & Marshall, S.W. (2007). Descriptive epidemiology of collegiate men's basketball injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 194-201. Agel, J., Olson, D.E., Dick, R., Arendt, E.A., Marshall, S.W., & Sikka, R.S. (2007). Descriptive epidemiology of collegiate women's basketball injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 202-210. Murgu, A.I. (2006). Fencing. Physical Medicine and Rehabilitation Clinics of North America. 17, 725-36. Thériault, G., & LaChance, P. (1998). Golf injuries. Sports Medicine. 26, 43-57. Parziale, J.R., & Mallon, W.J. (2006). Golf injuries and rehabilitation. Physical Medicine and Rehabilitation Clinics of North America. 17, 589-607. Gosheger, G., Liem, D., Ludwig, K., Greshake, O., & Winkelmann, W. (2003). Injuries and overuse syndromes in golf. American Journal of Sports Medicine. 31, 438-443. Marshall, S.W., Covassin, T., Dick, R., Nassar, L.G., & Agel, J. (2007). Descriptive epidemiology of collegiate women's gymnastics injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 234-240. Kolt, G.S., & Kirkby, R.J. (1999). Epidemiology of injury in elite and subelite female gymnasts: a comparison of retrospective and prospective findings. British Journal of Sports Medicine. 33, 312-318. Rumball, J.S., Lebrun, C.M., Di Ciacca, S.R., & Orlando, K. (2005). Rowing injuries. Sports Medicine, 35, 537-555. McNally, E., Wilson, D., & Seiler, S. (2005). Rowing injuries. Seminars in Musculoskeletal Radiology. 9, 379-396. Strakowski, J.A., & Jamil, T. (2006). Management of common running injuries. Physical Medicine and Rehabilitation Clinics of North America. 17, 537-552. Cosca, D..D., & Navazio, F. (2007). Common problems in endurance athletes. American Family Physician. 76, 237-244. Johnson, J.N. (2003). Competitive swimming illness and injury: common conditions limiting participation. Current Sports Medicine Reports. 2, 267-271. Weldon, E.J., & Richardson, A.B. (2001). Upper extremity overuse injuries in swimming: A discussion of swimmer's shoulder. Clinics in Sports Medicine. 20, 423-38.

Injury Classification

Perkins, R.H., & Davis, D. (2006). Musculoskeletal Injuries in Tennis. Physical Medicine and Rehabilitation Clinics of North America. 17, 609-631. Agel, J., Palmieri-Smith, R.M., Dick, R., Wojtys, E.M., & Marhsall, S.W. (2007). Descriptive epidemiology of collegiate women's volleyball injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 295-302. Flik, K., Lyman, S., & Marx, R.G. (2005). American collegiate men's ice hockey: An analysis of injuries. American Journal of Sports Medicine. 33, 183-187. Agel, J., Dick, R., Nelson, B., Marhsall, S.W., & Dompier, T.P. (2007). Descriptive epidemiology of collegiate women's ice hockey injuries: National collegiate athletic association injury surveillance system, 2000-2001 through 2003-2004. Journal of Athletic Training. 42, 249-54. Agel, J., Dompier, T.P., Dick, R., & Marhsall, S.W. (2007). Descriptive epidemiology of collegiate men's ice hockey injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training, 42, 241-248. Dick, R., Romani, W.A., Agel, J., Case, J.G., & Marshall, S.W. (2007). Descriptive epidemiology of collegiate men's lacrosse injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 255-61. Dick, R., Lincoln, A.E., Agel, J., Carter, E.A., Marshall, S.W., & Hinton, R.Y. (2007). Descriptive epidemiology of collegiate women's lacrosse injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 262-269. Matz, S.O., & Nibbelink, G. (2007). Injuries in intercollegiate women's lacrosse. American Journal of Sports Medicine. 32, 608-11. Dick, R., Hootman, J.M., Agel, J., Vela, L., Marshall, S.W., & Messina, R. (2007). Descriptive epidemiology of collegiate women's field hockey injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2002-2003. Journal of Athletic Training. 42, 211-220. Manning, M.R., & Levy, R.S. (2006). Soccer. Physical Medicine and Rehabilitation Clinics of North America. 17, 677-95. Agel, J., Evans, T.A., Dick, R., Putukian, M., & Marshall, S.W. (2007). Descriptive epidemiology of collegiate men's soccer injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2002-2003. Journal of Athletic Training. 42, 270-277. Dick, R., Putukian, M., Agel, J., Evans , T.A., & Marshall, S.W. (2007). Descriptive epidemiology of collegiate women's soccer injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2002-2003. Journal of Athletic Training. 42, 278-285. Franić, M., Ivković, A., & Rudić, R. (2007). Injuries in water polo. Croatian Medical Journal. 48, 281-8. Agel, J., Ransone, J., Dick, R., Oppliger, R., & Marshall, S.W. (2007). Descriptive epidemiology of collegiate men's wrestling injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 303-310. McIntosh, A.S. (2005). Rugby injuries. Medicine and Sports Science. 49, 120-139. Carson, J.D., Roberts, M.A., & White, A.L. (1999). The epidemiology of women's rugby injuries. Clinical Journal of Sports Medicine. 9, 75-78. Dick, R., Ferrara, M.S., Agel, J., Courson, R., Marshall, S.W., Hanley, M.J. et al. (2007). Descriptive epidemiology of collegiate men's football injuries: National collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. Journal of Athletic Training. 42, 221-233.

CHAPTER 2 SCIENCE OF TRAINING AND INJURY IN ATHLETICS 1. INTRODUCTION Over the past 45 years or so, we have achieved significant scientific understanding of many physical factors involved in the development of various aspects of training, including specific strength and conditioning training. This has allowed more effective programs to be used for athletes’ safety and preparation for competitions. Specifically, several components of training, such as skills, speed, strength, stamina and psychological skill training have been a focus of numerous text and research. The current conceptualization of science of training, basic principles of training theories as well as specific safe methods of strength and conditioning for athletes, have been summarized in Science and Practice of Strength Training (Zatsiorsky, 1995). The major theme of this book aims to provide scientific basis for the concept of adaptation as a law of training. Indeed, proper exercise, sport-specific drills and/or regular physical and psychological load is a very powerful stimulus for adaptation (i.e., organisms’ adjustment in its environment). Accordingly, the major objective of athletes’ preparation should be inducing specific adaptations in order to improve sport performance via: (a) carefully planned; (b) skillfully executed; and (c) goaloriented training programs. From practical perspectives, at least four important features of the adaptation process should be considered by a coach in order to make training programs effective and most importantly safe for the athletes. Otherwise, athletes may experience and express various forms of maladaptive responses to training and associated performance saturation/deterioration with high risk for sport-related traumatic injuries. Athletes’ adaptive responses are usually characterized by an increase in both physical properties, such as strength, speed, etc., and associated psychological indices, including emotional stability, proper level of motivation and vigor. According to Zatsiorsky (1995) there are four essential features of adaptation process as outlined below: (1) Overload. The most challenging issue that coaches face daily is to provide an opportunity for maximal performance enhancement and secure a safe and injury free coaching environment. There is always a possibility of injury due to the nature of athletic activity that coaches should constantly be aware of. Due to coaches’ primary responsibilities, which are an achievement of maximal performance and secure winning, positive (but not negative) training effect should be their major goal. However, positive

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training effect may take place only if training load is above the habitual level. In other words, if training load in terms of the volume and intensity is the same over an extensive period of time, there will be no additional adaptation resulted in physical fitness saturation. If the training load and intensity are too low, detraining may occur, meaning that an athlete may not improve his/her physical status despite continuous training. On the other hand, if the training load and intensity are too high, an athlete may experience maladaptive responses to training and an increase in risk of injury. Athletes’ individual responses (both adaptive and maladaptive) should be carefully monitored by the coaches in order to achieve progressive improvement and most importantly, to prevent overload-related injuries. Specific signs and symptoms of athletes’ overtraining will be discussed elsewhere in this book. Overall, training load can be roughly classified according to three important principles: (a) progressive stimulating : when the training volume and intensity are above individually defined neutral zone allowing for adaptation to occur; (b) retaining : when the magnitude of the load remains the same in the individually defined neutral zone, so the level of fitness may maintain for a long time; (c) detraining : when the magnitude of the load tends to decrease and associated performance deterioration and/or functional capacities of the athlete may be observed. It should be noted however, that the aforementioned principles should be considered with regards to hierarchy and duration of the periodical training units (i.e., general preparation period, competitive preparation period and transition period). In addition, it is important to note that these principles are also athletic fitness/skill level dependent. The aspect of individualization in terms of novice versus elite athletes’ responses to training load will be discussed in more details in the following text. (2) Accommodation. Positive training effect and associated positive psychological responses to the training load may take place if accommodation is prevented via proper training programs. In essence, accommodation refers to the training program when the same training program and type of exercise remains constant over a prolong period of time. For example, a diver that just performed optional dives (regardless of degree of difficulty) and ignores fundamental dry land, gym and conditioning training, a decrease in performance level will ultimately be observed. This is kind of a manifestation of biological law of accommodation. According to this law, an organisms’ response to a given constant stimulus saturate or even decrease over time. Not surprisingly, experienced coaches always vary their exercise programs by (a) constantly replacing exercise routine; (b) switching from aerobic to anaerobic types of activity; and (c) balancing specificity and generalization of training sessions. It is also advisable for coaches to schedule flexibility and relaxation exercises between heavy resistance

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strength drills to speed up recovery, prevent loss of flexibility and overall to avoid accommodation. According to Zatsiorsky (1995), training programs should satisfy at least two demands to avoid accommodation and to preserve specificity via: (a) quantitative modification (changing training loads in terms of the volume and intensity of exercise); and qualitative modification (replacing the exercises aimed at developing the athletes’ specific functions such as strength, coordination/flexibility, and endurance). (3) Specificity. Training adaptation is highly specific in nature. Success and injury free in particular sports require that the athletes posses specific qualities. What would be essential for a long distant runner could de detrimental or even harmful for a long jumper. Well developed upper body for a gymnast may not be beneficial for a springboard diver. Even among divers, depending on the event (springboard versus platform diver) current practices tend to provide differential training in order to develop sport diving specific qualities. As an illustration, excessive muscular development of the lower body compared to the upper body in springboard divers is an obvious necessity that needs to be achieved via specific strength training (see also Figure 1 below).

Figure 1. World Best Divers body compositions most likely influenced/selected for the platform (left, both female and male) and springboard (right, both male and female) events.

Current trend in diving is to achieve excessive body mass and explosive power of the lower body allowing the improvement of the jumping skill and height of the dives. As can be seen from this picture, top world springboard divers (right Pictures) are “more developed” and have larger leg muscles compared to the platform divers (left Pictures). Both males and females are most likely to encounter differential and special training programs, even

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within the same sport of diving. [Pictures were taken during FINA 2007 Diving World Series, Nan Jing, China, with permission from divers]. Another way to consider specificity of training program is to select sportdemand-specific routines. Clearly, fish can swim because they swim, birds can fly because they fly, frogs can jump because they jump, divers can dive because they dive, and so on. Thus, strength, flexibility and endurance training are highly specific in various sports. Unfortunately, this important principle of specificity of training programs is often ignored by the coaches. For example, it is a common practice in collegiate athletics that divers and swimmers utilize similar heavy resistance workouts for upper body, particularly during preparation period. This is inconsistent, at least, with the principle of specificity. Coaches should be aware that “what is honey for a swimmer could be poison for a diver”. Similarly, in the field of athletic training dealing with injured athletes, at an early stage following acute injury, it is important to control inflammation and regain the pre-injury range of motion. Accordingly, a specific exercise rehabilitation program should be utilized for this purpose to reduce probability of slow recovery and/or risk for re-injury. At the later stage of acute injury recovery, the muscle strength should be a major target for rehabilitation, thus, specific strength training drills must be utilized at this stage of recovery. Finally, preparation for the execution of specific drills should be a focus of rehabilitation. Accordingly, more sport-specific rather than general conditioning, strength and flexibility exercise should be incorporated into rehabilitation sessions. Another aspect of specificity may be considered from perspectives of identical-elements theory (see also theories of transfer initially developed by Thorndike back in 1914 and further elaborated within the scope of current motor control and learning research). In essence, in order to achieve positive transfer of learning between various skills and exercise routines, the main elements underlying different skills or situations surrounding performance must be identical and similar in nature. In other words, a major assumption of this theory is that positive transfer between skills is not based upon any general and unrelated performance, but rather very specific in nature. Similarities between stimuli (type of exercise) and responses (developed skills) are complementary in nature. The use of dry-land and gymnastic training aimed at practicing complex exercise maneuvers complement (positively transfer) to the springboard diving. Conversely, as the degree of similarity between stimuli and responses are declined, conflicting consequences may be experienced. For example, because of the dissimilarity between diving and gymnastic somersaulting techniques, athletes’ transition from gymnastic to diving may not likely foster any positive transfer. Similarly, because of the dissimilarity between the two sports, tackle techniques in football may not be applicable (but rather difficult to transfer) for rugby. In fact, a vast majority of concussive injury in rugby is due to

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tackle techniques that the rugby players adopted from their past experience playing football. Coaches, who understand basic principles of specificity, may avoid numerous problems and most importantly, may provide an optimal injury free training environment for their athletes. (4) Individualization. Due to genetically predisposed and environmentally influenced individual differences among people, the same exercise routines and training program may elicit differential effect among athletes. Indeed, people are different in terms of anthropometric dimensions (larger/smaller; stronger/weaker; more or less flexible; more or less fatigable; emotionally stable/unstable; risk taker/risk avoider; etc.). Therefore, any attempts to mimic performance style and or techniques of world best athletes have proven to be useless or even harmful. For example, numerous attempts to “copy” Greg Louganis’ diving style by novice divers led to significant deterioration of their own styles and overall performance. Similarly, mimicking the best Chinese divers’ clean entry and/or fast somersaulting techniques (which was a tendency a few years ago among USA diving coaches), has proven to be devastating. However, the acquisition of fundamental skills and coordination patterns should be essential regardless of aforementioned individual differences among athletes. Fundamentally correct posture and basic skills should be trained regardless of sports, whether it be complex coordination, games and/or cyclic in nature. Not surprisingly, apparatus gymnastics is called the “mother of all sports” and required as an essential training method for youngsters. With coaches’ creativity based on solid fundamental skills and qualities, injury controlled training methods proved to be successful. No average methods exist for exceptional athletes. “Only average athletes, those who are far from excellent, prepare with average methods. A champion is not average, but exceptional” (Zatsiorsky, 1995).

2. TRAINING PERIODIZATION One of the common errors leading to athletic injury is improper planning of both athletes training sessions and competitive activities. In essence, “…Failure to plan is planning to fail” (Balui, 1995). Poor planning and inadequate duration of preparatory season and lack of general conditioning prior to competitive season are the major causes of injury in athletics. Both lack of proper planning aimed to reach peak performance at proper time and lack of flexibility in planning aimed at correcting training programs, if necessary, may have severe consequences not only from performance enhancement but also from injury prevention perspectives. For example, adding another challenging competition in prior planned competitive calendar forces athletes and coaches to reconsider not only preparation for

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this specific event, but also modify the whole competitive season. Premature transition from general preparatory to specific preparatory phases is another coaching error leading to injury early in the season. The most common challenges facing coaches and other sport practitioners may be summarized as: (a) how to design a rational plan for a sufficiently long as well as for short-time training period; (b) how to skillfully execute a well-designed plan in an optimal manner in order to satisfy the general law of training (e.g., adaptation), reduce the risk of overtraining and potential injuries; and (c) how to reach the optimal peak of athletes best abilities precisely at the time of major events/competitions of the season, not before/and or after. The whole concept of training periodization is to address these challenges. It should be noted that there is still a lack of clarity, complete with controversy, in terms of how to define the concept of periodization, and most importantly, how to properly plan a training load. Generally speaking, periodization is “…a sensible and well planned approach to training, which maximizes training gain and performance enhancement.” (Dawson, 1996). Training periodization can also be defined as “…the purposeful sequencing of different training units (long-, mediumand short-term training cycles and sessions) for the attainment of the athlete’s desired state and planned results” (Issurin, 2003). This definition is similar to Nadori and Granek (1989) suggesting that “…periodization is the predetermined sequence of training sessions and competitions.” The following text contains a summary of the most general current notions and ideas regarding the training periodization with respect to the classic approach (Matveev et al., 1977). This issue is presented based on materials and documents kindly offered by Dr. Issurin (with permission from the author). It should be noted that a “classic approach” has been predominant for decades, particularly with regard to the block composition design.

2.1. Training Periodization: Looking Back and Current Trends Training periodization as a sport scientific concept and theory of athletes’ preparation was elaborated during the 1950s-1970s in the former USSR by Russian scientists Matveyev (1977), Ozolin (1970) and many other prominent leaders in the field at that time. This theory was adopted and propagated in Eastern Europe and more recently in Western countries (see Bompa, 1984; 1999; Dick, 1980) and has developed as a core foundation of planning in high-performance Olympic sports. In general, the training periodizaion theory exploits the periodical changes of all biological systems and social activities typical to human beings. Specific to sport reality, at

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least four rationales should be considered as the factors that determine the periodical changes in the context of athletes’ training: a) Repetitive patterns of nature: Exogenous (external) and endogenous (internal, or circadian) rhythms are one of the fundamentals of biological systems, including humans. The seasonal changes as well as the daily changes experienced by living systems predetermine all biological activities both in terms of volume and intensity. The months and weeks naturally divide social and economic life into historically and traditionally consolidated cycles, which are incorporated into general adaptation: the weekly resting rhythm. Clearly, all biological, social, industrial and other activities are subordinate to exogenous rhythms of nature; it would be strange if sport and athletic activities were an exception to these patterns of nature. b) Adaptation as a general law: As mentioned in the previous text of this chapter, the law of adaptation dictates and determines the athletes’ training and preparation for competitions. To reiterate, athletes should avoid excessive accommodation to habitual loads in order to improve desired qualities (i.e., general conditioning, specific strength, flexibility and stamina). Accustomed (habituated) stimuli, such as a constant training load and intensity, cannot continue to be effective. In order to regenerate the adaptability of the athletes, their training program and exercise repertory must be periodically changed and renewed according to demands and individual goals of an athlete. In other words, an excessively stabilized and fixed training program leads the athlete to an adaptation barrier, where he/she is forced to dramatically increase the magnitude of habitual workloads in order to increase the positive body response. From this point of view, periodic changes of the training program should be considered, and carefully planned within the scope of adaptation law. c) The sequencing of different training aims: Training in any sport is characterized by complexity, diversity, and variety. General and sport specific motor abilities, both technical and tactical skills/drills, cannot be developed simultaneously and maintained throughout the entire season. A more specific technical skill, for example, should be based on the appropriate level of motor fitness functional and psychological readiness of the athletes. In fact, a great number of injuries that an athlete suffers are from improper techniques and movement forms, which may be a result of improper physical fitness, or forcing the athletes to sacrifice movement fundamentals for the sake of performing the required drills. Fundamental skills and techniques (i.e., proper balance/posture and movement basic forms) must be acquired prior to acquisition of more specific skills. Similarly, excessive range of motion and joint stability/flexibility must precede the learning of advanced skills. Repetitive sequence of various training properties, individually defined and goal-oriented in nature, should be designed within both short and long-term training programs.

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d) Competition schedule: A vast number of injuries in athletics occur due to multiple peak performance problems. The number of “most important events” dramatically increased over the past decade pushing the athletes to force their readiness for each event, skip fundamental training and ignore under-recovery symptoms. Having said that, overall there is established events (competitions) that take place periodically both nationally and internationally. Specifically, various bodies such as the International Olympic Committee and a number of international, national, and domestic sport associations control the frequency and timing of competitions. Thus, the competition calendar established by these bodies determines and dictates preparation, competition and recuperation cycles of athletes’ training programs. The quadrennial cycle of Olympic preparation provides an excellent example of periodic changes which affect and dictate the activities of top world athletes. Traditional specification of periodic cycles of training/competition/recuperation phases in world class athletes’ preparation is presented in Table 1 below. Table 1. An Example of Hierarchy and Duration of the Periodical Training Units in Olympic Athletes Training units

Time duration

Quadrennial (Olympic) cycle

Four years – period between Olympic Games One year or a number of months

Macrocycle , may be annual cycle Training period Mesocycle Microcycle Workout or training session Training exercise

A number of months as part of the macrocycle A number of weeks One week or a number of days A number of hours (usually not more then three) A number of minutes

Mode of planning Long-term

Mediumterm Short-term

Training cycles of medium duration, called mesocycles, were traditionally proposed by classic theory, although there are several authors who do not consider these training units in their research (see, e.g., Bompa, 1999; Letzelter, 1978). The modes, specific aims, and content of mesocycles have been considered by many sport researchers who have suggested up to ten types and sub-types with more or less convincing argument (e.g., Harre, 1982; Matveyev, 1977; Platonov, 1997). The microcyles, as the small training cycles, are the most comprehensive, commonly accepted and least disputable terms, and are mostly defined as weekly cycles.

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It should be noted that there is a current tendency to reconsider the major assumption of the training periodization outline in Table 1, due to various practical reasons, such as: • increased number and level of competition throughout the entire season; • increased complexity of routines, especially in complex coordination sports; • earlier maturation of athletes, requiring to consider developmental aspect of athletes preparation; • increased total volume and intensity of training load the whole year around; • current practices and attempts to simultaneously develop motor abilities and functions such as strength, flexibility and stamina; • increased number of alternative views on the nature of training periodization; • progress in training methods and sport technologies, and protective devices, such as helmets, mouth guards, pads, braces, etc.; • increase in the financial and other extrinsic sources for motivation to compete constantly at their peak level. Periodical training units afford a great deal of freedom for creativity for coaches and athletes. However, the competitions calendar in most cases dictates the selection of the appropriate sequences, content, and duration of the training cycles. Specifically, the competition calendar dictates different modes of planning in order to reach the peak performance at the right time of the most important event of the season. Thus, this is the direct responsibility of coaches to design the plan of the training program focusing on principal features such as timing, peaking and training load distribution. The general conceptual framework for periodization of training programs, including preparatory, competitive and transition periods, was initially proposed by Matveev (1977) and Harre (1982) and more recently modified by Issurin (1985-2004). It is important to note that within the preparatory period, there is: (a) an initial stage aimed at developing and enhancing the general motor abilities and functions, and (b) a later stage aimed at developing and enhancing more specific motor abilities and functions. Similarly, within the competitive period, there is also: (a) a general preparatory stage and (b) an acute and most immediate precompetition stage characterized by different aims and should be achieved by various properties/features of training loads. Finally, the most common coaching error associated with training load and planning is the underestimation of the transition period aimed at the restoring of physical, psychological and functional resources. Some additional details for coaches to fully appreciate the modern approach to periodization of training program can be found in Table 2 below.

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Table 2. Goal-Oriented Stages of Training Periodization

Period

Stage

Preparatory

Competitive

Aims

Workloads’ features

General preparatory

Enhancing the level of general motor abilities. Enlarging the potential for various motor skills

Relatively large volume and reduced intensity of main exercises; high variety of training tools

Special preparatory

Development of the special training level; enhancement of more specialized motor and technical abilities

The loads' volume reaches their maximum; the intensity increases selectively

Competitive preparation

Enhancing event-specific motor fitness, technical and tactical skills; formation of the model of competitive performance

Stabilization and reduction of the volume; increase of intensity in eventspecific drills

Immediate precompetitive training

Accomplishing eventspecific fitness and reaching readiness for main competition

Low volume, high intensity; the fullest modeling of forthcoming competition

Transitory

Recovery and recuperation of physical, functional, and psychological spheres properties

Active rest; use of pleasant, attractive, and variable activities

Transitory

3. TRAINING EFFECTS A Coaches’ knowledge about differential training effect is fundamental in terms of proper planning of workout load, selection of exercise, its duration and intensity, timing of administration and timing of recuperation. Currently well-accepted in sport science community taxonomy of training effects (Zatsiorsky, 1995) includes: (a) acute effect, referred to changes induced by a single bout of exercise; (b) immediate effect, referred to changes induced by one workout session or training day; (c) cumulative effect, the result of a series of workouts overall certain time frame; (d) delayed effect, referred to changes that occur over a given time interval after a certain goal oriented specific program;

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(e) residual effect, which operates with the retention of changes induced by systematic workloads after the cessation of training beyond a certain time period. The residual training effect is well-observed but the least studied phenomenon of the athletes’ response to the training load. In 1991 Counsilman & Counsilman (1991) introduced and conceptualized residual training effect, however, this effect still is not well-accepted and understood among sport practitioners today. The following paragraph contains a few details regarding this effect with respect to “injury-free” planning of training programs as discussed. Overall, the phenomenology of the residual training effect is closely related with the process of detraining, which in the past was defined as saturation of progress or “loss trained functions” when training is stopped and/or interrupted for some reason. In fact, detraining in elite athletes from different sports may occur selectively and “targeted” toward only certain abilities (i.e., loss of strength) when it does not receive sufficient strength input. For example, it is well-documented that in elite and highly trained endurance athletes the maximum oxygen uptake decreases when the total weekly volume is reduced below a certain level (Steinacker, 1993; Steinacker et al., 1998). Interestingly, Wilmore & Costill (1993) reported a considerable decrease of swimming-specific strength after four weeks off practice. It was suggested that the risk of detraining, in general, and loss of aerobic endurance may occur despite the large volume of highly intensive exercises (Mijika, 1999). To reduce potential detraining, the consecutive rather than simultaneous development of sport-specific abilities approach should be utilized in elite athletes (Bondarchuk, 1981; Issurin & Kaverin, 1985). Proper prediction of duration and amount of residual effect of previous training should be taken into account in order to define the rational sequencing and timing of different training cycles. From this perspective, it is extremely important to know which factors and in what manner may influence the duration of training residuals. Some details in terms of duration and underlying physiological mechanisms associated with residual effect of sport-specific abilities are summarized in Table 3. It should be noted, however, that more search is still needed to justify the advantages of consecutive approach for development of sport-specific abilities.

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Table 3. The Duration and Underlying Physiological Mechanisms of the Residual Training Effect for Different Physical (Motor) Abilities (Issurin & Lustig, 2004) Physical (motor) ability

Residual’s duration, days

Physiological background

30 ± 5

Increased amount of aerobic enzymes, mitochondria number, muscle capillaries, hemoglobin capacity, glycogen storage, higher rate of fat metabolism

30 ± 5

Improvement of neural mechanism, muscle hypertrophy mainly due to the muscle fibers’ enlargement

Anaerobic glycolitic endurance

18 ± 4

Increased amount of anaerobic enzymes, buffering capacity and glycogen storage, higher possibility of lactate accumulation

Strength endurance

15 ± 5

Muscle hypertrophy mainly in slow-twitch fibers, improved aerobic/anaerobic enzymes, better local blood circulation and lactic tolerance

Maximal speed (alactic)

5±3

Improved neuromuscular interactions and motor control, increased phosphocreatine storage

Aerobic endurance

Maximal strength

The coaches’ knowledge about training residuals and temporal detraining is extremely important for planning transition at some stage of athletes’ preparation from simultaneous to consecutive development of the sport-specific fitness components and abilities. The overall rule of thumb is that coaches should remember the necessity of transition from simultaneous to successive/consecutive development of the training program allowing the enhancement of the residual effect of exercise and prevent detraining. By doing so, the principle of variability of training programs can be implemented and aimed at achieving injury-free peak performance at proper time with no indication of over-training. The lack of appreciation of training effects may have serious consequences for elite athletes’ well-being. On a final note, the general principle of differential effects of training may also be applicable for rehabilitation programs of injured athletes. It is well-accepted in the clinical practice that several important steps should be utilized during sport injuries rehabilitation programs for athletes suffering from various orthopedic injuries. Specifically, control of inflammation after knee injury should precede specific exercise aimed at increasing range of motion (flexion first and then extension). The next consecutive step should

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be specialized strength training followed by endurance and implementation of sport specific drills to restore pre-injury functional capacities. A simultaneous approach aimed at recovering multiple functions may be detrimental for athletes’ recovery protocol, prolong reacquisition of sport specific functions and, most importantly, may put athletes at high risk for recurrent injuries. Within the conceptual framework of rehabilitation residuals, comprehensive research is needed to examine the type of exercise, its duration and physiological mechanisms underlying maximal positive effects for various sport-related injuries. “How much is not enough and how much is too much” in terms of the volume, intensity and duration of breaks between rehabilitation sessions should be a primary concern of medical professionals to fully rehabilitate injured athletes. It should be noted that this important principle of training/rehabilitation residuals has not been seriously considered and appreciated in the clinical setting.

4. BLOCK COMPOSITION CONCEPT: OVERVIEW There are many contradictions and controversies in current practice and sport science regarding the issue of periodization, in general, and specifically in differential training effects. In attempts to resolve these existing contradictions and to achieve at least some consent among sports science experts and coaches in charge of elite athletes preparation, the revised approach to training periodization has been recently proposed (Issurin, 2004). This approach, so-called the Block Composition Concept (BCC), summarizes the general principles of elite athletes preparation and provides guidelines for alternative training periodization, with specific focus on short-term planning. Specific focus of the training workloads is the most important fundamental principle of the BCC. Indeed, empirical evidence and anecdotal facts suggest that only highly-focused training workloads can produce sufficient stimulation for the development of required functional properties and the acquisition of skills/motor abilities in elite athletes. The concept of block-mesocycles implies that at least three differential effects of training load should be considered and carefully controlled by the coaching staff. The first one is accumulation, where acquisition of basic fundamental motor skills and abilities should be a main focus of the training session. Specifically, basic jumping skills, proper body alignment and posture, and hand-torso-leg coordination should be acquired and consolidated first before transition for acquisition of more complex skills such as forward and backward somersaults in gymnastics. The lack of aforementioned basic skills and premature transition to more advanced motor modalities may put athletes at higher risk for injury due to improper techniques.

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The second effect is transmutation, characterized by creating a training environment which affords maximal positive transfer and utilization of previously acquired fundamental skills to sport-specific drills. For example, proper arm swing techniques synchronized with proper upright posture during the initiation of vertical jumps should benefit skillful execution of back single and double somersaults in gymnastic and springboard diving. Another example from the sport of gymnastics is that the proper head position during a vertical jump may significantly help to prevent disorientation and potential serious injuries during multiple somersaults, which is a well-known phenomenon. As discussed in the previous text, the identical-elements theory (Thorndike, 1914) and principal of similarities between stimuli (type of exercise) and responses (developed skills) may maximally foster positive transfer of basic to more specific skills. Also, the dissimilarity between acquired basic and sport-specific skills may induce numerous improper movement forms and techniques which are detrimental for athletes’ growth and development. Finally, realization effect of the training load assumes that an athlete should utilize his/her acquired fundamental and sport-specific potentials and skills and reach the optimal plan results at the peak of performance targeted on the most important event of the season. Again, this is the so-called “medium-size training cycles” or “block-mesocycles” characterized by the successively/consecutively focused development of fundamental (earlier in the cycle) and more sport specific (later in the cycle) abilities/skills. The training effects with respect to residuals can be illustrated in the following manner (See Figure 2 below).

Competition

Accumulation

Transmutation

Realization

Residual training effects Figure 2. Superposition of the residual training effects induced by the sequenced blocksmesocycles (adapted from Issurin & Shkliar, 2002 with permission the primary author)

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4.1. The Annual Cycle Compilation Similar to the classic approach, the annual cycle planning starts with the selection of major target-competitions of the season usually determined by international and national sport authorities. The specific item of the revised training approach is the subdivision of the entire annual cycle into a number of training stages. Each stage should contain a consecutive combination of extensive work on fundamental skills/abilities at the beginning of the season and more intensive work on sport-specific abilities with reduced volume as competitive stage approaches. Types of workout within the BCC aimed at achieving the accumulation, transmutation, and realization effects are shown in Table 4. Table 4. The Main Characteristics of the Three Types of Blocks Meso-cycles Main characteristics

Accumulation

Mesocycle Transmutation

type Realization

Targeted motor and technical abilities

Basic abilities: aerobic endurance, muscular strength, basic coordination

Sport-specific abilities: special endurance, strength endurance, proper technique

Integrative preparedness: modeled performance, maximal speed, event specific strategy

Volume-intensity

High volume, reduced intensity

Reduced volume, increased intensity

Low-medium volume, high intensity

Fatigue-restoration

Reasonable restoration to provide morphological adaptation

No possibility to provide full restoration, fatigue accumulated

Full restoration, athletes should be well rested

The tests' battery

Monitoring of the level of basic abilities

Monitoring of the level of sport-specific abilities

Monitoring of maximal speed, event-specific strategy, etc.

The rational sequencing of the meso-cycles within the training stage allows the optimal superposition of the residual training effects to be obtained, if properly planned. Figure 1 above shows the principal possibility of obtaining optimal interaction of the training residuals allowing high level of competitive performance of previously acquired both fundamental motor and specific technical abilities. It should be noted from Table 4 that training

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residuals of fundamental skills and abilities last much longer then residuals of more specific abilities, while the residuals of maximal speed and eventspecific readiness are the shortest ones (Table 4). Following this knowledge, the duration of the training stage is determined by the length of the training residuals and should be close to two months. In fact, the training stages can be shorter (near to peak season, for instance), or longer (at the season's beginning or due to specific needs). Proper control of athletes’ responses to the training load is an essential attribute of the science of training, allowing the prediction/prevention of athletic injuries. Accordingly, it is strongly recommended that the test battery should be reproduced in each stage of athletes’ preparation for competition. In conjunction with actual results of competition, proper testing of athletes’ physical, functional and psychological parameters may provide important monitoring and feedback information that can be used for future training corrections. As suggested, the number of training stages in an annual cycle is a sport-specific decision and depends on the number of external (i.e., number and location of major competitions) and internal (i.e., psychological status, predisposition for injuries, age and gender) factors. Clearly, the high volume and intensity of the training load required by modern sports is one of the major causes of injury in elite athletes. Thus, proper realization of BCC may provide a number of benefits, including the fact that the Block Composition model allows the total mileage and time expenses for training to be reduced, without substantially changing the total number of workouts. The other benefits of BCC include: - monitoring the detraining effect and focusing on a reduced number of abilities/skills successively acquired at each stage; - providing appropriate tests, the so-called “dose-response-effect” analysis to control for maladaptive physical/physiological responses; - providing psychological climate allowing a focus on the reduced number of targets; consequently the mental concentration and motivation level can be maintained more effectively throughout the entire season; - controlling nutritional aspects requiring a high protein diet in order to enhance the anabolic effect of strength training; carbohydrate nutrients are particularly important in meso-cycles for special and strength endurance (Wilmore & Costill, 1993).

4.2. Bases of the Short-term Planning The general propositions of BCC make more sense when considering short-term planning and properly designing the training micro-cycles and several workouts. At least two basic prepositions of the BCC immediately affect both the process and outcome of the short-term planning, namely:

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specific focus and concentration of the training loads on the minimum abilities-targets; - consecutive step-by-step development and maintenance of abilitiesspecific targets. That said, there are three major aspects of the short-term planning that should be considered by coaches when planning individual workouts to control for fatigue and maintain athletes’ high level of motivation, including: (a) load-related differentiation of workouts; (b) compatibility of different training loads in several and adjacent workouts; and (c) basics of the training micro-cycle compilation. Load-related differentiation emphasizes the importance of both physiological adaptation and mental concentration. For practical purposes, it is necessary to point out three general functions of workouts: development, retention, and restoration. The appropriate load level should be selected corresponding to these aims. Compatibility of the specific training modalities within the single workout and within the workout series emphasizes possibility of both negative (interferences) and positive interaction of several immediate training effects. The BCC allows the prevention or at least reduction of negative interactions by the use of a compatible combination of exercise routines within certain training modalities (i.e., strength, flexibility, endurance).

Basics of the training micro-cycle compilation contain a number of specific statements including (a) no more than three training modalities (usually one dominant, the second – compatible with the main purpose, the third – modalities of restoration exercises) should be implemented simultaneously; it is postulated that 65-70% of the entire training time within one training session should be allocated to one or two purposed training modalities; (b) high intensity of workout depends on the context and outcome of the previous session focused on key targets. For example, the session with primary focus on strength training should be followed by a high intensity session focused on flexibility training and significant reduction of workout targeting the strength training; (c) minimizing the number of training modalities is particularly important and typical for elite athletes. The daily program for less experienced and particularly for junior athletes may be more diversified in order to maintain a high level of motivation and attractiveness.

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CONCLUSION There is always a trade-off between high-achievement and probability of overtraining as well as high risk of injury among elite athletes. Proper planning, specificity and individualization of the training program are key factors to consider. There are tendencies in modern sports to (a) standardize the training program within certain sports; and (b) modify the exercise content to achieve maximal adaptation and reduce the probability of accommodation. The first tendency proposes the use of more or less standardized workload combinations within meso- and micro-cycle programs. The positive aspect of this tendency is the possibility of comparing the results and responses obtained in different training cycles with the same (or similar) workload combinations. This provides prerequisites for a current training control and improvement of sport specific training technology. The negative aspect is that the possibility of excessive accommodation when the athletes’ response to a continuing stimulus decreases followed by a decrease in the training effect as well. This may force the coaches to reconsider the initial training routine with emphasis on an increased training load and ultimately putting athletes at high risk for overtraining and injury. The second tendency relates to the effect of novelty when the unaccustomed exercises induce more pronounced adaptive responses. However, there is still a problem as to how to increase the effect of stimulus novelty when an athlete is accustomed to repetitive sport-specific exercises. Indeed, additional research, enhanced coaches’ experience and quality observations are necessary to overcome existing controversies in training programs aimed at maximizing performance enhancement without jeopardizing the safety and well-being of athletes.

Acknowledgments This chapter was prepared based on ideas and writings of Professor Vladimir Zatsiorsky and Dr. Issurin with further elaboration by the author. Personal consultations with these prominent leaders in the field of athletes training are highly appreciated.

REFERENCES Zatsiorsky, V. M. ( 1995). Science and practice of strength training. Champaign, IL: Human Kinetics. Thorndike, E. L. (1914). Educational Psychology: Brief course. New York: Columbia University Press.

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Balui, I. (1995). Planning, periodization, integration and implementation of annual training programs. Presentation to and in proceedings of the Australian Strength and Conditioning Association National Conference, (pp. 40-66). Gold Coast, Australia. Dawson, B. (1996). Periodization of speed and endurance training. In P. Reaburn & D. Jenkins (Eds.), Training for speed and endurance, (pp.76-96). St. Leonards, Australia: Allen & Unwin. Issurin, V. (2003). Aspekten der kurzfristigen Planung im Konzept der Blockstruktur des Training. Leistungsport, 33, 41-44. Nadori, L., & Granek, I. (1989). Theoretical and methodological basis of training with special considerations within a microcycle. Lincoln: National Strength and Conditioning Association. Matveyev, L. (1977). Fundamentals of sport training. Moscow: Progress Publishers. Ozolin, N. G. (1970). The modern system of sport training. Moscow: FIS Publishers. (Russian). Bompa, T. (1984). Theory and methodology of training. The key to athletic performance. Boca Raton, FL: Kendall/Hunt. Bompa, T. (1999) Periodization: Theory and methodology of training (4th ed.). Champaign, IL: Human Kinetics. Dick, F. (1980). Sport training principles. London: Lepus Books. Letzelter, M. (1978). Trainingsgrundlagen. Training. Technik. Taktik. Rowolt Verlag GmbH, Hamburg. Harre, D. (Ed.). (1982). Principles of sport training. Berlin: Sportverlag. Platonov V.N. (1997). General theory of athletes’ preparation in the Olympic sports. Kiev: “Olympic Literature”. (Russian). Issurin, V., & Kaverin, V. (1985). Planning and design of annual preparation cycle in canoeing. In “Grebnoj Sport” (Rowing, Canoeing, Kayaking), Ph.S.; Moscow, p. 25-29. Issurin, V., & Lustig G. (2004). Klassification, Dauer und praktische Komponenten der Resteffekte von Training. Leistungsport. 34, 55-59. Issurin, V., & Shkliar, V. (2002). Zur Konzeption der Blockstuktur im Training von hochklassifizierten Sportlern. Leistungsport, 6, 42-45. Counsilman, B. E., & Counsilman, J. (1991). The residual effects of training. Journal of Swimming Research , 7, 5-12 . Steinacker, J. M., Lormes, W., Lehman, M., & Altenburg, D. (1998). Training of rowers before world championships. Medicine and Science in Sports and Exercice, 30, 1158-63. Wilmore, J. H., & Costill, D. L. (1993). Training for sport and activity. The physiological basis of the conditioning process. Champaign, IL: Human Kinetics. Mujika, I. (1999) The influence of training characteristics and tapering on the adaptation in highly trained individuals: a review. International Journal of Sports Medicine, 19, 439446. Bondarchuk, A. P. (1981). The physical preparation designing in power disciplines of track and field. Kiev: Health Publisher (Zdorovie, Russian).

CHAPTER 3 BALANCE AS A RISK FACTOR FOR ATHLETIC INJURIES 1. INTRODUCTION Human upright posture is one of the fundamental skills necessary for successful acquisition of “super-postural activities” such as grasping, reaching, walking, jumping, catching, etc. Most importantly, postural stability allows proper balance preventing numerous health-related problems including traumatic injuries. Charles Darwin pointed out that one of the most important implications of the attainment of uprightness was that it freed the hands from locomotion function, so that they became available for sustained use in other directions, such as implementing instrumental activities. Nevertheless, our bodies are still subject to what Arthur Keith (1923) called the “illness of uprightness”. Although the upright posture has been the subject of considerable research, our knowledge about balance and human postural control, in general, and poor balance as predisposing factor for athletic injuries, in particular, is still incomplete. In this chapter, a brief perspective of some key issues in the postural control of humans will be provided. An emphasis will be given to current research on the role of cortical function, specifically the cerebral cortex in balance control. Finally, current perspectives on links between improper balance and sport-related injuries will be discussed.

2. POSTURE AS A FUNDAMENTAL HUMAN ACTIVITY 2.1. Posture Definition Human upright posture, traditionally defined as “…body segments” configuration at any given time (Thomas, 1940), has been extensively studied, but is still a poorly understood phenomenon. There are several reasons why existing models of posture (i.e., genetic, hierarchical etc.) are unable to explain the enormous complexity of mechanisms of human postural control. One reason is that there is still a strong notion, similar to classical Cartesian dualism, of considering human posture as the “…genetically determined reference posture or, integration of all stretch reflexes of the body…” in order to maintain equilibrium (see Massion 1992; Horak & Macpherson, 1996 for review) on one side, and “…voluntary goaldirected movement, as the activity of higher centers superimposed on the

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bodily mechanisms” (Magnus, 1925; Sherrington, 1910), on the other side. There is still a debate in the literature whether a single central control process is responsible for both movement and its associated postures or alternately, whether there is a dual coordinated control system for voluntary movement and posture (Massion et al., 2004). Human posture is a product of an extremely complex dynamical system with many degrees of freedom, which like any other fundamental activity, undergoes dramatic changes throughout the life span (Bernstein, 1967). As such, the classical question as to how the performer constrains the many degrees of freedom to preserve and coordinate various body segments’ configuration while performing goal-oriented movement is still unclear. In other words, the nature of postural dynamic is extremely complex, since posture includes not only the antigravity control (e.g., under static conditions, the center of gravity should remain within the support surface, Winter, 1990) but also the interface between perception and action via fine postural adjustments associated with super postural activity, stability control during locomotion and the ability to assess the body’s spatial-temporal orientation in the surrounding environment (Riccio, 1993). Accordingly, the primary objective of upright stance performer is to explore the dynamical properties of perceptual-motor workspace and to avoid the actions that exceed its operational limitations (Newell et al., 1989).

2.2. Sources of Information for Postural Control Considering posture as a complex dynamical assemblage, it is reasonable to assume that all sensory systems can contribute information relevant to the control of posture. It was hypothesized that processes within the postural control system involve organizing, integrating and acting upon redundant visual, vestibular and surface-somatosensory inputs to provide orientation information to the postural control system (Bechterev, 1882). The contribution of sensory information to providing the maintenance of stable posture has been characterized as a hierarchical process in which the congruence of both support surface somatosensory and visual inputs is compared to an inertial-gravitational reference, established by vestibular reference inputs. Thus, balance is a multidimensional ability in which a range of factors such as eye-motor coordination, kinesthetic response, ampular sensitivity, vertical semicircular canal function, and so forth, are crucial (Klack & Watkins, 1984). In cases of inter-sensory inconsistencies, inputs not congruent with vestibular reference inputs are suppressed and greater perceptual significance is attached to those inputs in accord with vestibular sources (Shumway-Cook & Woollacott, 1985). Overall, human upright posture is a product of a complex dynamical system that relies on integrating input from

Posture

multimodal sensory sources, including: (a) visual system; (b) vestibular system; and (c) a great number of sensory receptors embedded in the muscles, tendons, joint capsules and skin that we commonly refer to as proprioceptive systems (see Mergner et al., 2003 for review presenting a multi-sensory postural control model based on experiments with normal subjects and those with vestibular loss).

2.3. Neural Basis for Multi-sensory Sources of Balance A neural basis for the multi-sensory influences on postural motion and the whole body orientation has been proposed. Specifically, convergence of vision, audition, somatosensation and proprioception at the cellular level in the vestibular nuclei has been shown by Costikova (1939). Also, cells have been identified in the vestibular nuclei where whole discharge rates were influenced by both body motion, as signaled by vestibular end organs, and visual motion (Gurfinkel et al., 1965; DiZio & Lackner, 1987). Recent evidence suggests that the cortex, in some way, plays a role in processing multisensory information and modifying human postural control (Quant et al., 2004a&b; Adkin et al., 2006). Moreover, it has been suggested that vestibular and somatosensory input may be integrated within a distributed cortical network, including the temporal-parietal cortex supplementary motor area and prefrontal cortex, in order to process input related egomotion and counteract a loss of balance (de Waele et al., 2001). A more recent study with young controls has also identified fMRI correlates of selfperceived postural instability (Slobounov et al., 2006). Specifically, significant activation of several brain areas, including the parietal cortex, anterior cingulate and cerebellum was observed when young subjects visually recognized gravitational vertical via computer animated model of stable versus unstable postures. Indeed, several studies investigating the effects of human cerebral lesions on posture suggest that perception of the visual vertical involves the insula (Brandt et al., 1994), and perceived gravitational vertical requires healthy function of the thalamus (Karnath et al., 2000, 2005), superior parietal cortex (Blanke et al., 2000; Johannsen et al., 2006), and insula (Johannsen et al., 2006). In addition, lesions of the temporal-parietal junction (a region of multi-modal sensory integration) lead to poor equilibrium control on an unstable support (Perennou et al., 2000).

3. UPRIGHT POSTURE CONTROL 3.1. Assessment of Postural Stability There are several ways to define the stability limits during postural stances. One is to estimate the area of the base of support defined by the

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lateral edge of a subject’s feet. This approach is recommended while considering the issue of postural stability with respect to the vertical projection of the center of mass on the base of support. In other words, there is a notion that stable posture is maintained while gravito-inertial forces are in alignment with direction of balance. Accordingly, when the body orientation deviates from the direction of balance, the torque is produced to restore the appropriate body orientation with respect to gravity. The vertical projection of the center of mass to the base of support roughly may be assessed by calculating the center of pressure derived from the force platform according to the following approximations. The center of pressure (CP) motion is calculated from the moment of force about the given axis (Mx) and (My) divided by the vertical ground reaction force (Fz). Instantaneous locations of the center of pressure on the base of support are computed independently for X and for Y coordinates as shown in Fig. 1 below:

CPy=Mx/Fz, CPx=My/Fz Index of Stability = [CPymax-CPymin]/[length of feet] Subject Facing Y direction

Figure 1. Basic schematics for parameters derived from the force platform and calculation of the center of pressure and stability index.

Most common, the area of the center of pressure (CP-area) in addition to CP displacement and CP velocity are considered in clinical practice to estimate the subject’s postural stability. There is another way to define postural stability boundary during upright stances. In particular, standing space is structured by stability limits that are invariant with respect to a body position. These stability limits vary as a function of the body’s morphology and the base of support. Furthermore, stability limits depend on mechanical properties of the body, its environment

Posture

and on response latency to external perturbations. Thus, the strategy to maintain balance is to reduce the movement space needing the exploration from multiple degrees to one degree of freedom, and varying only one parameter at a time. More specifically, strategy to estimate stability limits during upright stances is to monitor the forward/backward and side-to-side translation of the center of pressure derived from the force plate. Maximal deviation of the center of pressure trajectory for the Y and X coordinates during whole body postural movement is supposed to reflect the subject’s limits of postural stability. It should be noted that there are numerous reports, papers and book chapters written and can be considered for details.

3.2. Virtual Reality for Assessment of Postural Stability Perceiving optic flow (structural pattern of visual motion) contributes to balance control because it specifies changes in body position or postural sway relative to gravity (Gibson, 1966). It is well known since Mach (1985) that a moving visual scene may induce a sensation of ego-motion. Adult normal subjects perceive their direction of heading from optic flow to within 1 deg under a variety of circ*mstances (Keshner & Kenyon, 2000), and they are similarly sensitive to variations in optic flow in controlling balance (Lee & Lishman, 1975). This phenomenon has been attributed to a conflict between the changing visual input and vestibular and proprioceptive information (Lestienee et al., 1977) and has been extensively studied using the so-called “moving room paradigm” (Lee & Lishman, 1975; Stoffregen & Smart, 1998). Subjects’ exposure to optic flow with different visual stimulus patterns consistently induces an increase in postural sway not only in humans (van Asten et al., 1988; Ehrenfried, 2003) but also in animals (Ikeda & Takahashi, 1977). Therefore, concurrent analysis of optic flow variables and subjects’ self-motion may help understand the visual control of posture (Beer et al., 2002). Our recent research clearly demonstrated that the moving room paradigm using 3-D VR technology proved to be effective in inducing subjects’ self motion or postural adjustments when exposed to manipulations of visual scenes (Slobounov et al., 2006). This is consistent with other numerous studies reporting that the body tends to tilt and/or rotate in the direction of moving visual field (Lee & Lishman, 1975; Lestienne et al., 1977; Ehrenfried et al., 2003). Postural effects were most pronounced when low frequency (0.2 Hz) visual scene motion was introduced, which supports the notion of “exploratory response” to possible destabilizing visual input implying a perturbation of stance. Also in replication, self-motion and “selfpresence” were reported by all subjects who experienced actual whole body postural adjustments as evidenced by the center of pressure and trunk kinematics data. This finding is consistent with previous studies suggesting

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that an immersive dynamic visual field induces a postural reorganization as reflected in the subjects’ head, trunk and ankle responses (Keshner & Kenyon, 2000). This specific issue of postural control as assessed by Virtual Reality technologies may be found in a number of recently published reports and beyond the scope of this chapter. Overall, the feasibility of Virtual Reality technologies (virtual room experiments) to examine the postural stabilization responses to optical flow is now documented; and behavioral data suggest that healthy subjects adjust their postural movement to direction of the optic flow and thus are capable of preserving the balance in a visually confused virtual environment. Figure 2 below shows the VR experimental set-up used for assessment of postural stability in our laboratory.

Figure 2. Virtual reality (VR) set-up for assessment of visuo-kinetsthetic integration involved in the control of upright postures. Subjects’ postural responses are obtained from force plate and Flock of Birds whole body postural movement while viewing 3D motion of the “virtual room”.

3.3. Quiet Stance Domain During quiet stance the body experiences some very small variations in its position. It oscillates in anterior-posterior (AP) and medial-lateral (ML) direction. This oscillation is quantified by different methods such as image recording where the whole body movement is compared along the time dimension or by the use of the force platform. By using a force platform one can record the time-to-time position of the center of pressure (COP). COP movements are commonly used to assess the body oscillation during stance. Normally in stance, COP migrates approximately 0.4 cm in AP direction and 0.18 cm in ML direction (Winter et al., 1998) while COM displacements are

Posture

somewhat smaller. The differences in migration of COP and COM in AP direction have been associated with the generation of torques at the ankle joints, while ML displacements have been associated with activity of hip muscles (Winter et al., 1996). Several models have been suggested to explain and describe COP migration in quiet stance. Three of these models are now briefly described.

3.4. Models Upright human posture has been frequently modeled as an inverted pendulum (Fitzpatrick et al., 1992b; Winter et al., 1993; Winter et al., 1998; Morasso & Schieppati, 1999). Modeling the human body as an inverted pendulum is based on the assumption that joint motion is only at the ankle joints, body sway is very small and that the feet do not move (Zatsiorsky & King, 1998). Since the stability of the system requires that the center of mass (COM) falls within the base of support it is believed that the COM is the controlled variable of the unstable body system. COM is regulated through a continuous movement of the COP and stabilized around a fixed reference point. In a single pendulum model the difference between the COM and center of pressure (COP) will be proportional to the acceleration of the body COM. A two-process random-walk model was suggested by Collins and De Luca (1993), where the maintenance of vertical posture could be viewed as part of a stochastic process. This model assumed the movement of the COP as a correlated random walk and determined at which time intervals COP displacements are either positively or negatively correlated. It was found that for short time intervals (less than 1 second) COP displacements were positively correlated. That is, displacements of the COP in one particular direction were followed by displacements in the same direction. At longer time scales, negative correlations were found. Overall it was suggested that these COP characteristics correspond to an open loop control at short time scales and a closed loop control at longer time scales. A more recent model for the control of posture has been formulated by Zatsiorsky and Duarte (1999). They introduced a method of decomposing COP trajectories into two components, termed rambling and trembling. The decomposition first identified instant equilibrium points (IEP). An IEP is the position of the COP when the horizontal forces are zero. At these moments, the projection of the COM onto the base of the support coincides with the COP position. The individual IEPs, connected through a spine fitting function, form the rambling trajectory, while the difference between rambling and COP trajectories is called the trembling trajectory. The authors suggest that the rambling trajectory describes the motion of a moving reference point with respect to which the body’s equilibrium is

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instantly maintained, while the trembling trajectory describes body oscillation around the reference point trajectory.

3.5. Preprogrammed Reactions To date, a vast body of research in human posture has focused on neural organization, or muscular contraction synergy associated with postural control (Diener et al., 1988; see also Horak et al., 1994, for review). Theoretical insights have suggested that a pattern of organization is preprogrammed by executive commands according to the particular motor task in order to constrain the large number of functionally related muscle synergy (Arutyunyan et al., 1969). Following the imposition of brief surface displacement, the automatic postural adjustments were recorded and characterized by relatively fixed temporal and structural patterns of ankle and thigh muscle activity (Forssberg & Nashner, 1982). Preprogrammed reactions consist of a combination of muscle activation patterns specific for a given perturbation and act at a time delay of about 50-100 ms. They are different from simple reflexes in the sense that they depend on the instruction to the subject and that their magnitude can be independent from the length changes in the muscle (Latash, 1993). A vast literature exists on the regulation of posture under external perturbations and the modulation of preprogrammed reactions (see: Nashner, 1976; 1977; Nashner & Woollacott, 1979; Nashner et al., 1989; Horak et al, 1986-1990).

3.6. Anticipatory Posture Adjustments (APA) It should be noted that Hess (1943) first pointed out that a proactive (i.e., anticipatory) postural stabilization is required for performance of goaloriented volitional movement producing an internal disturbance of equilibrium. It was shown that the ensemble of the sequential postural adjustments obey certain rules (i.e., flexible postural synergy) that are modifiable in order to optimize the balance. Since that time, the preparatory nature of postural responses is considered to be centrally programmed and independent of any feedback from the moving limb. These preparatory (i.e., anticipatory) postural adjustments associated with volitional movement were intensively studied in relation to dynamic asymmetry and muscle forces generating movement that can perturb postural equilibrium (Bouisset & Zattara, 1987; Ramos & Stark ,1990; Massion, 1992). The disturbing effects of voluntary movement seem to be anticipated by the CNS. This anticipation is clearly demonstrated in studies revealing muscle activation about 50-150 ms prior to the movement initiation when no reflexes can be triggered (i.e. absence of external stimulus). Anticipatory postural adjustments have been described considering different movements

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performed by arm, leg, trunk and head (Belinkiy et al., 1967; Cordo & Nashner, 1982, Gurfinkel et al., 1988, Vander Fits et al., 1998), including those for forearm loading and unloading tasks (Aruin & Latash, 1995a, 1995b; Aruin & Latash, 1996; Shiratori & Latish, 2000). It has been suggested that APA are generated by the CNS in a feed-forward fashion in an attempt to predict the upcoming postural perturbation and to generate approximate corrections.

4. CORTICAL CONTROL OF HUMAN POSTURE The role of the cerebral cortex, in general, and contribution of higher cortical functions in human postural control has been less studied and thus, controversial. Historically the neuromuscular control of “automatic” postural responses was thought to arise from brainstem and spinal circuit with limited consideration for the role of cerebral cortex (Magnus, 1926; Sherrington, 1910). The original proposition that “the whole righting apparatus is arranged sub-cortically in the brainstem, and in this way made independent of direct voluntary influences” (Magnus, 1926), has persisted with time. The idea that postural responses are regulated subcortically was based upon the notion that postural responses are triggered automatically, without any voluntary intent, and therefore, are initiated more quickly and with less variability then cued voluntary movement (Diener et al., 1984; Keck et al., 1998). However, the onset of postural responses occurs at longer latencies than those of stretch reflexes (Matthews, 1991), indirectly suggesting that postural responses exhibit greater potential for modulations and modifications by neural centers hierarchically residing higher along the neural axis (Jacob & Horak, 2007). Moreover, unlike stretch reflexes, postural responses involve synergistic activation of muscle throughout the whole body, and these are also more context-specific, flexible and adaptable than spinal proprioceptive reflexes (Horak & Macpherson, 1996).

4.1. Behavioral Studies There is considerable behavioral evidence suggesting the contribution of the cerebral cortex and higher cognitive functions in the control of upright posture. Indeed, postural response have been shown to be modified by various cognitive-motor processes “represented” in the cerebral cortex, including those involved in anticipatory postural adjustments (Bouisset & Zattara, 1981). Postural responses are modified by: (1) changes in cognitive load and attention when performing dual postural tasks (Brown et al. 1999; Carpenter et al. 2004; McIlroy et al. 1999; Maki et al. 2001; Brauer et al. 2002; Norrie et al., 2002; Quant et al., 2004a), (2) changes in a subject’s intentions to respond with a specific strategy (Burleigh et al. 1994; Burleigh

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& Horak 1996; McIlroy & Maki 1993; 1995), (3) learning and modification of postural responses with prior experience (Horak & Nashner, 1986; Horak et al., 1989; McIlroy & Maki 1993; Quintern et al., 1985); and (4) with changes in initial conditions (Chong et al., 1999; Henry et al., 2001; Tjernstrom et al., 2002). Considering that attention, mental calculation and memory properties have been attributed to represent high-order cognitive functions controlled by the cerebral cortex (Dehaene et al., 2004; Kaiser & Lutzenberger, 2005; Naghavi & Nyberg 2005), it is reasonable to suggest the direct cortical involvement in control of postural equilibrium (Jacobs & Horak, 2007).

4.2. Brain Imaging Studies There are several lines of research that have directly demonstrated the involvement of cerebral cortex in human postural control. Variation of slow negative potentials in the primary motor cortex preceding the onset of postural adjustment was observed in Saitou et al. (1996) EEG study. A more recent EEG study by Slobounov et al., (2005) has also documented that the initiation of self-paced postural movement is preceded by slow negative direct current (DC) shift, similar to movement-related cortical potentials (MRCP) accompanying voluntary goal-oriented movement. Also, a brief burst of gamma (40Hz) EEG activity preceded the initiation of compensatory postural movement when balance was in danger (see Fig.1A). The spatial distribution of EEG patterns in postural actions approximated that during previously observed postural perceptual tasks (Slobounov et al., 2000). Similarly, change in cortical excitability, revealed by slow negative DC potentials just prior to the anticipated postural perturbations has been reported by Jacobs and Horak (2007). Similar to DC potentials that observed 1-2 s prior to a voluntary self-initiated postural movement (Saitou et al., 1996; Slobounov et al., 2005), they reported EEG readiness potentials with significant negative variation only in the cue condition. In this study, the cue-related differences in the subjects’ readiness potentials were highly correlated with the cue-related improved postural stability. Experimental set-up to record EEG collectively with postural response is shown in Fig. 3B.

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Figure 3. (B) Burst of EEG 40 Hz gamma activity associated with prediction of postural instability; (A) Experimental set-up to record brain electrical activity in conjunctions with whole body postural movement.

Overall, EEG studies support the hypothesis that cerebral cortex may play a role in the optimization of postural responses to external perturbations thorough changes in anticipatory central set. Therefore, the postural movement once considered to be automatic, might be susceptible to voluntary cortical control. There are several EEG studies examining the role of cerebral cortex on triggered postural responses after a perturbation (Dietz et al., 1985; Ackermann et al., 1986; Dimitrov et al., 1996; Quant et al., 2004; Adkin et al., 2006). These studies have shown that EEG potentials following postural perturbations (known as perturbation-evoke responses, PER) become altered with changes in the central set, such as with changes in the predictability of a perturbation (Adkin et al., 2006) or with a secondary motor task (Quant et al., 2004). The PER are thought to represent cortical processing of sensory input related to the balance disturbance (Dietz et al., 1985) that arises as an error-or conflict-related signal (Adkin et al., 2006). Specifically, the first negative peak between 100 and 150 ms (N1) may represent sensory disturbance, and late PERs may be linked to the sensorimotor processing of balance correction, similar to the error-related negativity responses observed for incorrect responses in decision-making paradigms (Pailing & Segalowitz, 2004; Yasuda et al., 2004). These studies clearly demonstrate that postural set influences the characteristics of the cortical contribution to the control of balance after perturbation.

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Evidence suggests that the cerebellar-cortical loop is responsible for adapting postural responses based on prior experience and the basal gangliacortical loop is responsible for pre-selecting and optimizing postural responses based on current context. Thus, the cerebral cortex most likely influences longer latency postural responses directly via corticospinal loops and shorter latency postural responses indirectly via communication with the brainstem centers that harbor the synergies for postural responses, thereby providing both speed and flexibility of pre-selecting and modifying environmentally appropriate responses to a loss of balance (Jacobs & Horak, 2007). Finally, the neural substrates for maintaining standing postures in humans have been investigated using the mobile gantry PET system (Ouchi et al., 1999). Interestingly, compared with the supine posture, upright standing with feet together activated the cerebellar anterior lobe and the right visual cortex, while standing in tandem was accompanied by activation within the visual association cortex and cerebellar vermis. This finding is consistent with previous research suggesting that the human cerebellar vermis may coordinate the timing in keeping the center of gravity within the stability margins, therefore, it may provide a control of postural scaling and central set in stance (Horak & Diener, 1994).

5. ABNORMAL POSTURAL CONTROL 5.1. Impaired Postural Control in Mild Traumatic Brain Injury (MTBI) Several previous studies have identified a negative effect of MTBI on postural stability (Lishman, 1988; Ingelsoll & Armstrong, 1992; Wober et al., 1993). Generally, balance problems in MTBI subjects have been attributed to disruption of various CNS functions responsible for postural stability (Guskiewicz et al., 2003; Slobounov et al., 2002; 2005; Thompson et al., 2005). A growing body of experimental studies has demonstrated postural stability deficits, as measured by the Balance Error Scoring System (BESS, a clinical test that uses modified Romberg stances on different surfaces) on post-injury day 1 (Guskiewicz et al., 2001; 2003). An increased velocity of the center of pressure and an overall weight-shifting speed indicating both static and dynamic instability in concussed subjects has also been shown by Geurts et al (1999). It was suggested that the recovery of balance occurred between day 1 and day 3 post-injury for most of the MTBI subjects (Peterson et al., 2003). The initial 2 days after MTBI are the most problematic for subjects standing on the foam surfaces, which was attributed to sensory interaction deficits in the use of visual, vestibular and somatosensory systems (Valovich

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et al., 2003; Guskiewicz, 2003). However, Cavanaugh et al. (2005 a, b; 2006) have shown that the Approximate Entropy (ApEn) method may detect changes in postural control in subjects with “normal” postural stability as determined by conventional balance testing long after a cerebral concussion. This is consistent with other recent studies demonstrating long-lasting residual balance abnormalities in MTBI subjects (Slobounov et al. 2005), which is most evident during dynamic postural tasks.

5.2. Virtual time-to-contact (VTC) Recently, the notion of virtual time-to-contact (VTC) that specifies the spatial-temporal proximity of the center of pressure to the stability boundary, as an informational property in the regulation of posture was proposed (Slobounov et al. 1997). The original speculation that VTC may be a lowdimensional informational control variable in postural regulation (Carello et al., 1985) was supported in a serious of experiments (Martin, 1990; Riccio, 1993; Haibach et al., 2007). This new approach to understanding the nature of posture regulation places the emphasis on information for control not on departures from a stability point within the equilibrium region of the potential base of support, as in inverted pendulum models of posture (Mergner et al. 2003), but rather on the temporal safety margin, as specified by the virtual time to collision with the stability boundary (Lee, 1976). A significant consequence of this approach is that the control variable for posture is defined over the organism-environment-task interaction, rather than simply a product of the organism (Newell 1986; Riccio, 1993). Slobounov et al. (1997) labeled the measure they created as virtual time to contact (VTC) which is the instantaneous time to the functional stability boundary defined on the dynamics of each point in the time series. The word virtual was used because the individual does not want to make contact with the stability boundary. Thus, VTC is an estimate of the time to the boundary should it occur, which would only happen in the case of a loss of stability as in a fall. In this approach a time series of the virtual time to contact can be determined that is based on the dynamics of the time to contact relative to the boundary rather the relative position of the center of pressure to the stability boundary. See Fig. 4 below for details of computation of VTC.

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Figure 4. Schematic of VTC computation with respect to two-dimensional physical stability boundary. Clearly, it is temporal-spatial properties of the instantaneous COP values and combination of position, velocity and acceleration vectors rather than just position of the COP within the stability boundary are important fully appreciate VTC as an informational variable in control of posture. As can be seen, the virtual trajectory (VT) has a parabolic shape if the direction of the initial velocity and acceleration vectors is not collinear. However, the VT is linear if the initial velocity and initial acceleration have the same direction or if either of them is equal to zero.

In a series of recent studies, VTC has been shown to be a more sensitive index of postural stability than other traditional COP-based measures in aged and traumatic brain injured subjects (Haibach et al., 2007; Slobounov et al., 2008). Van Wegen and colleagues using a variation of this virtual-time to contact measure have shown similar age-related properties of time-to-contact in the control of postural stability (Van Wegen et al., 2001; 2002). Hertel et al. (2005) have shown the robustness of the virtual time to contact measure in control of uptight posture in human single leg quiet standing. More recently, Hertel and Olmsted-Kramer (2007) revealed alterations of time-toboundary measures (TTB) in subjects suffering from chronic ankle instability (CAI), and suggested that TTB measures may detect postural control deficits related to CAI that traditional measures (i.e., COP range and velocity etc.) do not. Clearly, further research is needed to examine neurocognitive and physiological basis of VTC in control of human posture.

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5.3. Abnormal VTC in Concussed Athletes VTC methodology has been recently applied to detect long-lasting residual postural abnormalities in concussed athletes. It appears that both ApEn and VTC measures can detect postural abnormalities that cannot be observed using traditional balance testing. The concussed subjects were able to accomplish dynamic postural tasks in the presence of signs of altered measures of postural control and may be explained by enormous brain plasticity to control movement in spite of deficiency. Again, residual postural abnormalities in concussed individuals may be undetected using conventional research methods. Indeed, VTC measures were altered in the absence of signs of postural instability based on traditional measures of postural control. Most importantly, VTC alterations were more prominent when postural stances were challenged by introducing dynamic stability tasks that utilize more of the functional reserve. Both minimal/mean and mode values of VTC increased along with enhanced VTC variability in subjects suffering from concussion. This may imply that following concussion the subjects conserved enlarged “temporal safety margin” (Carello et al., 1985) in the regulation of posture in order to preserve balance in dynamic situations. Collectively, recent research shows that the residual deficits of concussion are most sharply revealed when the postural system is challenged by more demanding tasks. Previous research has provided support for the proposition that VTC, which specifies the spatiotemporal proximity of the center of pressure to the stability boundary, is an informative variable in the regulation of human posture (Slobounov et al., 1997; Haibach et al., 2007). A more recent study provides additional evidence for this proposition (Slobounov et al., 2007). Specifically, the nominal values of VTC regardless of subjects’ injury status were significantly lower during dynamic postural tasks compared to static quite stances. This may indicate a reduced “safety margin” (Corello et al., 1985; Hertel et al., 2006; van Wegen et al., 2002) associated with more complex postural tasks resulting in less time available to initiate compensatory postural adjustments (Riccio, 1993) to preserve balance. This interpretation is in agreement with recent conceptualization of anticipatory postural adjustment (APA) reversals that emphasizes the important role of safety in generation of postural adjustments associated with voluntary movement. It should be noted that the shape and structure of VTC time series distribution during A-P sway before concussion is similar to those after concussion. VTC consistently increased with enhanced variability as a subject approached the stability boundary (see Fig. 5), meaning that the same strategy was implemented to preserve balance in the dynamic task regardless of injury status. Finally, it should be emphasized that although

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VTC values were reduced during dynamic postural tasks with respect to those during quite stance, these were significantly increased after concussion. This suggests that concussed subjects may be more conservative in terms of preserving a larger “safety margin” in order to avoid “collision” with stability boundary and fail to accomplish the task. That the overall shape of VTC distribution was preserved after concussion, though its nominal values and variability were increased, provide further evidence that VTC may serve as a low dimensional controlled variable in regulation of upright posture (Slobounov et al., 1997).

Figure 5. The VTC time-series with respect to COP position.

Collectively, the current findings suggest that the alteration in the regulation of postural movement in concussed individuals may not be detected using conventional assessment tools. Whether this alteration is relatively transient resulting in the acquisition of more conservative compensatory strategies to preserve balance, or a long-term persistent residual postural abnormality is yet to be determined. The clinical implication of our findings is in agreement with Cantu (2006) that the athletes who prematurely return to play based solely on conventional symptom resolution criteria may be highly susceptible to future and possibly more severe brain injuries. Indeed, a combination of various assessment methods and tools should be used by clinicians in order to make an accurate decision in terms of return to play and to identify athletes at risk for recurrent concussions.

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6. BALANCE-RELATED TRAUMATIC INJURIES IN ATHLETICS Well preserved balance and proper whole body posture are important fundamental components for all sports and recreational activities. Clearly, the demands imposed by various sports (i.e., execute complex drills on the narrow, slippery and inclined bases of support, such as gymnastics, figure skating, skiing and a number of X-sports) require that athletes should possess highly developed postural control. On the other hand, specificity of training programs in these sports, in general, and specific drills and routines, in particular, may contribute to the acquisition of advanced balance system in those athletes. In fact, in our early work (Slobounov & Newell, 1994), a number of postural stability tasks were administered to athletes (i.e., gymnast; figure skaters, divers) and non-athletes. Interestingly, differences in balance measures were observed only during more challenging tasks (i.e., single-leg stance with closed eyes). More recently, the results of our early work have been confirmed by Bressel et al. (2007) study. This study focused on comparison of static and dynamic balance among collegiate athletes competing or training in soccer, basketball, and gymnastics. To assess static balance, participants performed 3 stance variations (double leg, single leg, and tandem leg) on 2 surfaces (stiff and compliant) using the Balance Error Scoring System. For assessment of dynamic balance, participants performed multidirectional maximal single-leg reaches from a unilateral base of support, using normalized leg reach distances from the Star Excursion Balance Test. In fact, these clinical tests are commonly used by AT practitioners to assess balance problems after traumatic injuries to low extremities. Interestingly, Balance Error Scoring System error scores for the gymnastics group were 55% lower than for the basketball group. This was also true for the Star Excursion Balance Test scores. This clearly indicates that gymnasts have more advanced postural control, probably due to specificity and training and demands imposed by gymnastics. Another interesting finding from this study is that the Star Excursion Balance Test scores were 7% higher in the soccer group than the basketball group. Overall, gymnasts and soccer players did not differ in terms of static and dynamic balance, which is quite surprising. In contrast, basketball players displayed some signs of less advanced postural stability that may be a predisposing factor for the ankle instability/injury. Clearly, further research is needed to examine differential effect of sport activities on balance and postural control. Improper balance is most dangerous in extreme X-sports, requiting execution of complex drills on the narrow base of support. A recent pilot study by Major et al. (2007) examined the effect of the skater experience and lower extremities biomechanics on energy absorption and observed balance

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strategies used during two basic tricks. In these tricks, the skater is required to jump onto an elevated rail and maintain balance while standing in a single position (stall) or sliding along the rail (grind). Lower extremity joint kinematics, impact force characteristics and general movement behavior were examined during landing and balance phases. The vertical impact force was found to decrease with increasing skater experience in stalls and grinds. Similar to drop landing experiments, peak impact force decreased with increasing knee flexion during stalls in experienced skaters. During stalls, skaters demonstrated classic balance maintenance strategies (ankle, hip, or multi-joint) depending on trick length. During grinds, the skater’s centre of mass never passed over the rail base of support, suggesting the use of momentum produced from obliquely approaching the rail. Overall, experienced skaters have more advanced techniques to prepare body positioning prior to impact to prevent falls and more importantly to reduce the risk of severe injuries. Interestingly, the less-experienced skaters were more concerned with maintaining balance than refining the technique to minimize impact force. This means that dual-task requirements (i.e., maintenance of proper balance and pure execution of drills) may be a limiting factor of novice skates. Consequently, proper balance training is crucial for injury prevention among X-sport athletes.

6.1. Balance Impairment as a Result of Traumatic Injury Postural control deficits and abnormal balance after traumatic injuries in athletes have been a focus in a number of recent studies. As can be concluded from the previous discussion, there are multiple contributions to postural stability from visual, somato-sensory and vestibular systems. Any damage to these systems may directly contribute to impaired postural control. For example, in the case of sport-related traumatic brain injury, athletes with TBI may experience short-term deficits in the visual system (i.e., blurred vision). Not surprisingly, abnormal balance is the major symptom of MTBI. In fact, as mentioned in the previous text, there is growing evidence of long-lasting postural abnormalities in athletes who suffered from even mild TBI. Another example is empirical evidence of impaired balance as a result of reduced muscle strength, muscle sensitivity (e.g., proprioceptive sense) and developed functional joint(s) instability in athletes with traumatic injury to lower extremities. Specifically, a recent study by Docherty et al. (2006) has examined the postural control deficits in athletes suffering from functional ankle instability among Division 1 collegiate athletes by means of Balance Error Scoring System (BESS). In this study, the BESS test battery requires participants to stand unsupported on two different surfaces (firm and foam) in three different stances (double stance, single-one-leg stance, and in

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tandem). The major findings from this study is that athletes with functional ankle instability had poorer balance on all testing conditions and had lower BESS scores compared to normal controls. In other words, postural control deficits were identified in athletes suffering from functional ankle instability using the BESS test batteries. It was suggested that these deficits could be a contributing factor to the repeated episodes of instability and giving way that often occurs following an inversion ankle sprain in athletes. Balance deficits in athletes with low extremities injury also are assessed by the Biodex Balance System. Akbari et al. (2006) examined the effect of acute lateral ankle sprain on postural stability using two clinical tests: the Functional Reach Test and the Star-Excursion Balance Test under both vision conditions (eyes open versus eyes closed). More severe balance impairment as a result of acute lateral sprain was observed when vision was not available regardless of clinical tests. This implies that the impaired proprioceptive sense as a result of ankle sprain was a major contributing factor influencing abnormal balance in injured athletes. Therefore, proprioceptive sense training in addition to strength training and conditioning should be implemented as soon as possible to speed up the recovery of balance and to prevent recurrent injuries.

6.2. Abnormal Balance as a Risk Factor for Injury There is growing evidence that abnormal balance may be a predisposing factor for injury, especially, the lower extremities injuries. It seems reasonable to expect that preseason ankle instability due to a) residual effect from previous injuries, b) reduced range of motion following injury, c) diminished strength of the joint, and d) reduced joint position sense may put athletes at risk for recurrent injuries not only to the low extremities but also to the other parts of the body. An athlete may develop abnormal movement patterns/techniques and “bracing behavior” which is an act of preparing or positioning for impact or danger during execution of athletic drills. For example, in track, a hurdler may land differently on the less “stable” leg out of subconscious fear of re-injury due to impact forces with the track surface. In springboard diving, a diver may initiate a somersault by differentially pressing the board by “stable” versus “unstable” legs producing asymmetric rotational whole body motion. This is not only detrimental in terms of diving technique but most importantly is extremely dangerous putting the diver at high risk to hit the board. All of these examples represent “abnormally acquired movement patents” and possibly long-term “bracing behaviors” which are extremely harmful for athletes’ physical and psychological well-being. Psychological factors, including the fear of injury, will be discussed elsewhere in this text.

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Another important factor, indirectly related with poor balance as a risk factor for injury, is muscle fatigue. A few recent studies examined the effect of fatigue and balance level in athletes. According to Rose et al (2000), athletes are not differed in balance levels at pre-fatigue levels, but there are differences between fatigued and non fatigued athletes at the post-fatigue level. Balance due to fatigue still does not pose a major problem for athletes, since peripheral muscle fatigue, and accordingly balance, usually restore within 20 minutes post extensive exercise program (Susco, 2004). On the contrary, balance usually becomes a problem for most injured athletes. It is obvious, and as discussed in the previous text, that lower extremity injuries cause balance deficits. But the same negative effect may occur for injuries of the upper body since the athletes’ center of mass is controlled and maintained by both the core and the upper/lower extremities. Not surprisingly, even a broken arm could cause deficit in balance (Rose et al, 2000). As athletes recover from their injuries, as evidenced by increased range of motion, strength and endurance, the balance improved as well (Rose, 2000). Although abnormal balance has been proposed as a risk factor for sportrelated injuries, few well-controlled studies have been conducted to examine this relationship. Sporadic evidence suggests that Star Excursion Balance Test (SEBT) may detect the risk of low extremities injury among high school basketball players (Plisky et al., 2006). Logistic regression models

used in this study indicated that players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury. Interestingly, female athletes with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury. In fact, this is consistent with numerous recent studies clearly indicating higher risk for ACL injuries in female athletes. Overall, it was suggested that the SEBT can be incorporated into pre-season physical examinations to identify players at higher risk for injury due to impaired balance. There were very few prospective studies focusing on identifying the risk factors that predispose an athlete to ankle-ligament trauma. According to Beynnon et al., (2002) review, there is some agreement among researchers regarding the risk factors for ankle-ligament injury. However, considerable controversy remains. Although female athletes are at a significantly greater risk of suffering a serious knee sprain, such as disruption of the anteriorcruciate (ACL) ligament, this does not appear to be the case for ankleligament sprains. Specifically, according to According to Vrbanic et al. (2007), Croatian female athletes participating in high-risk sports (volleyball and handball) suffer anterior cruciate ligament (ACL) knee injury at a 4- to 6-fold greater rate than do male athletes. ACL injuries in females result either from contact mechanisms or from certain unexplained non-contact mechanisms occurring during daily practices. The occurrence of non-

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contact injuries points to the existence of certain factors intrinsic to the knee that can lead to ACL rupture. When knee joint movement overcomes the static and the dynamic constraint systems, non-contact ACL injury may occur. Certain recent results suggest that balance and neuromuscular control play a central role in knee joint stability, protection and prevention of ACL injuries. These authors suggest the Sport KAT 2000 testing system may be used to monitor balance and coordination systems and to estimate risk predictors in athletes who withdraw from sports due to lower sports results or ruptured ACL. Balance and injury in elite Australian footballers was also a focus of Hrysomallis et al (2007) research. Consistent with other studies, low preseason balance ability was shown to be associated with an increased risk of ankle ligament injury. Moreover, successful prediction of susceptibility to ankle sprain injury by means of a single leg balance (SLB) test prior to season was reported by Trojian & McKeag (2006). Specifically, high school varsity and intercollegiate athletes with positive SLB test results not taping the ankle imposed an increased risk of sprain over the season. Overall, gender does not appear to be a risk factor for suffering an ankle-ligament sprain. In addition, athletes who have suffered a previous sprain have a decreased risk of re-injury if a brace is worn, and the consensus is that generalized joint laxity and anatomical foot type are not risk factors for ankle sprains. However, the literature is divided with regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical alignment, muscle strength, muscle-reaction time and postural sway are risk factors for ankle sprains.

6.3. Balance Training/Retraining Following Injury Low extremities injuries are common among athletes both in contact and non-contact sports. This results in postural instability, asymmetry and probability of further residuals. Upon the general assumption that the maintenance of proper upright posture is essential not only for competing at a high level but also for prevention of injury in athletics, it is reasonable to suggest that a) coaches should implement balance training programs for prevention of injuries, and b) medical practitioners should seriously consider rehabilitation programs aimed at restoring balance after injury. In fact, several recent studies have clearly demonstrated a beneficial effect of balance training in athletes suffering from various injuries. Specifically, the Star Excursion Balance Training (SEBT) implemented with both eyes open and eyes closed paradigms was shown to be more effective to restore functional stability than conventional therapy after ankle sprain (Chaiwanichsiri et al., 2005). Similarly, a 4 week balance specific training program may benefit the athletes suffering from chronic ankle instability

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(Hale et al., 2007). In addition, 6 weeks of balance training using either a mini-trampoline or a dura disc tool may improve postural stability in athletes suffering from lateral ankle sprain (Kidgell et la., 2007). More recently, balance training has been adopted to try and prevent injuries to the ankle and knee joints during sport activities (Hrysomallis, 2007). As a single intervention, balance training has been shown to significantly reduce the recurrence of ankle ligament injuries in soccer, volleyball and recreational athletes; however, it has not been clearly shown to reduce ankle injuries in athletes without a prior ankle injury. Balance training on its own has also been shown to significantly reduce ACL injuries in male soccer players. Taking into consideration growing concern regarding the high risk of major knee injuries in female soccer players and overuse knee injuries in female volleyball players, it is reasonable to suggest that specialized balance training along with conventional conditioning may benefit female athletes at high risk for low extremity injuries. A high body mass index and previous ankle sprains have been shown to increase the risk of sustaining non-contact inversion ankle sprains in high school football players (McHugh et al., 2007). Accordingly, it was hypothesized that stability pad balance training (SPBT) may reduce the incidence of these injuries. Players balanced for 5 minutes on each leg, 5 days per week, for 4 weeks in preseason and twice per week during the competitive season. Post-intervention injury incidence was compared with pre-intervention incidence (107 players-seasons) for players with increased risk. Interestingly, injury incidence for players with increased risk was 2.2 injuries per 1000 exposures before the intervention and 0.5 after the intervention. This represents a significant (77%) reduction in injury incidence as a result of implemented balance training for athletes at risk for ankle sprains. Goal-oriented and task specific training has been shown to improve diminished functions. However, it is often a challenging task to maintain patients’ motivation and stick with rehabilitation routines. One way to meet this challenge is to employ the game-based exercise rehabilitation programs. In fact, this was implemented by Betker et al (2007), who used game-based exercises for dynamic short-sitting balance rehabilitation of patients with chronic spinal cord and traumatic brain injuries. The patients in this study exhibited increases in practice volume and attention span during training with the game-based tool. In addition, they demonstrated substantial improvements in dynamic balance control. Similarly, upright balance function can be improved following balance specific training performed in a supine position in the Virtual Reality (VR) environment providing the perception of an upright position with respect to gravity (Oddson et al., 2007). Overall, a supervised goal-oriented balance training program should not only be used after injuries to low extremities but also as a preventive intervention for athletes at high risk for injuries.

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CONCLUSION This chapter presents a brief perspective of previous work with special emphasis on (a) current research regarding the role of cerebral cortex in human postural control, (b) balance assessment tools, (c) abnormal postural control in athletes suffering from various injuries, and (d) benefits of specific balance training. Considerable behavioral evidence clearly suggests the contribution of the cerebral cortex and higher cognitive functions in the control of upright posture. This was documented “indirectly” via modification of postural responses induced by various high-order cognitive functions and/or learning that are thought to be “represented” in the cerebral cortex. There is also a growing body of more recent research “directly” demonstrating the involvement of cerebral cortex in postural movement, similar to many other voluntary movements under study. This was primarily documented via EEG patterns preceding (movement-related cortical potentials, MRCP) self-initiated postural movement and following (perturbation-evoke responses, PER) postural perturbation. It should be noted, however, that this newly evolving understanding of the role of cortical processes in the control of posture in humans is still in its infancy. Future research implementing current advances in cellular recording and brain imaging techniques may be warranted to further explore differential contribution and functional connectivity of various brain structures in control of human posture. Clearly, abnormal balance is present as a result of traumatic injury to peripheral structures and/or to the brain (MTBI). On the other hand, abnormal posture and improper body orientation may result in impairment of overall movement form and athletic techniques. This may contribute to higher risk of injuries in the athletics. The residual postural abnormalities may not be clearly seen and most often are overlooked when traditional posture assessment tools are implemented. Therefore, advanced methods, including brain imaging studies and Virtual Reality (VR), should be implemented to assess balance in athletes. If postural abnormalities are warrant, appropriate balance training/retraining is highly recommended to prevent high possibilities of traumatic injuries.

Acknowledgments This chapter was inspired by long-term collaboration with Dr. Karl Newell, who introduced me to the field of human postural control. Some empirical evidence provided in this chapter has been collected and published with Karl in numerous journal and book chapters.

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CHAPTER 4 FATIGUE-RELATED INJURIES IN ATHLETES 1. INTRODUCTION During a maximum contraction of many mixed muscles, it is common to see a 50% reduction of force over a period of a few seconds. This is known as fatigue (Rothwell, 1994). The term fatigue though can refer to both physical and mental exhaustion due to prolonged stimulation or exertion. As such, it is a phenomenon that is of interest to many scientific disciplines, including the science of coaching, as is used in a variety of contexts. Of particular interest is localized progressive muscle fatigue which has been defined as an inability to maintain required force level after prolonged use of muscle (Gandevia et al. 1998). While reduction in force production is obviously detrimental in many circ*mstances, progressive muscle fatigue has also been shown to impair postural stability (Johnston et al., 1998), muscle coordination (Carpenter et al., 1998) and control of limb velocity and acceleration (Jaric et al., 1997). Fatigue has traditionally been attributed to the occurrence of a “metabolic endpoint”, where muscle glycogen concentrations are depleted, plasma glucose concentrations are reduced and plasma free fatty acid levels are elevated (cf: Meeusen et al., 2006). However, one of the major complications that arise in studying muscle fatigue is that both peripheral and central mechanisms contribute to the manifestations of muscle fatigue (Enoka & Stuart, 1992). These mechanisms are highly interactive in nature, and should both be acknowledged as a complex phenomenon. Unfortunately, both their independent and collective contributions to progressive muscle fatigue are still poorly understood. One of the problems with conceptualization of fatigue is research methodology. In a clinical practice most often fatigue is assessed based on subjects’ self-reports (SR)/responses to questionnaires. Some of the traditional instruments to measure fatigue include: Rhoten Fatigue Scale (RFS, one-item 11 point scale), Profile of Mood States (POMS, having vigor, 8-item and fatigue, 7-item subscale with 5 point scales), Multidimensional Fatigue Inventory (MFI, 20-item, 7-point scale, 6 dimensions), Fatigue Symptom Inventory (FSI, 13-item, 0-10 scale, 2 dimensions), Piper Fatigue Scale Revised (PFS, 22-item, 0-10 scale, 4 dimensions), Multidimensional Fatigue Symptom Inventory (MFSI, 83-item, 5 point scale, 5 dimensions) and Brief Fatigue Inventory (BFI, 9-item, 0-10 scale, single dimension). One of the common shortcomings of these scales is the lack of test-re-test validity; they are lengthy and often confusing to the

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patients. It should be noted that there is NO single standard accepted as a clinical practice instrument today. Moreover, no single SR instrument has been shown to correlate with other biological/physiological and/or neural markers of fatigue. For example, Dimeo et al. (1997) evaluated a correlation between fatigue assessed by POMS and the Symptoms Check List (SCL-90R) and physical performance of 78 patients. They observed a week correlation (r= -0.30) between the SP rating and physical performance (stress test on treadmill). However, there was stronger correlation between SR fatigue rating and depression (r=0.68) and/or anxiety (r=0.63). Similarly, low correlation between SR fatigue rating and physical performance (walking) was also reported by Simmonds (2002). Clearly, biological markers in conjunction with commonly accepted clinical practice indices of fatigue should be considered for pure assessment of fatigue. Numerous anecdotal facts and observations in sport environment indicate a negative effect of fatigue on performance of athletic drills. Clearly, fatigue induces performance deterioration due to reduction force production, lack of accuracy and reduced speed of motor responses. Possible degradation of the aiming precision of a whole-body pointing task as evidenced by impaired movement coordination due to selective muscle fatigue has been shown by Schmid et al., (2006). Another recent study of the instep football kick have shown significantly slower ball velocity observed in the fatigue condition due to both reduced lower leg swing speed and poorer ball contact (Apriantono et al., 2006). This well-controlled study that reduced leg swing speed, represented by a slower toe linear velocity immediately before ball impact and slower peak lower leg angular velocity, was most likely due to a significantly reduced resultant joint moment and motion-dependent interactive moment during kicking. These results suggest that the specific muscle fatigue induced in the present study not only diminished the ability to generate force, but also disturbed the effective action of the interactive moment leading to poorer inter-segmental coordination during kicking. Moreover, fatigue obscured the eccentric action of the knee flexors immediately before ball impact. Interestingly, this might increase the susceptibility to injury. However, initial sign of fatigue may be overlooked due to enormous compensatory strategies that athletes may employ to achieve the goal despite the fatigue. For example, a swimmer may switch from predominant arms to predominant legs work intensity to be able to maintain required speed of propulsion. Gymnasts often switch practices from “swinging” (i.e. high bar) to supporting (i.e. parallel bar) apparatuses to floor exercise in order to distribute work load and use different muscle groups to continue the workout despite fatigue. In other words, “re-allocation of resources” is one of the strategies to maintain the motor task productivity despite progressive muscle fatigue.

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In fact, this “resources re-allocation” concept was supported by empirical research on progressive muscle fatigue (Johnston et al. 2001). Specifically, it was shown that the initial stage of muscle fatigue associated with non-significant reduced force along with increased the amount of muscle activation allowing production of the required force level. Interestingly, progressive muscle fatigue was also accompanied with significant enhancement of motor cortical activation (as revealed by the brain electrical activity, EEG) enabling the subject to accomplish the force production accuracy task despite fatigue. Considering this fact, it is reasonable to suggest that compensatory adjustment occurred at the central nervous system. On the one hand, it allowed the athletes to “keep going” to meet the sports/coaches requirements. On the other hand, this may put athletes at risk for injury due to exhaustion of both physical (i.e. central and peripheral) and psychological resources. In the following sections, first (a) current conceptualization of central and peripheral mechanism of progressive muscle fatigue; and second, (b) fatigue-injury relationship in athletic environment will be discussed.

2. MECHANISMS OF MUSCLE FATIGUE

2.1. Peripheral Fatigue There at least three major reasons why muscle fatigue might occur following a sustained muscle contraction. Namely: (a) failure in transmission at the nerve-muscle junction, on in conduction at the fine terminal branches of motor axons, (b) failure of the contractile machinery in the muscle, and (c) reduction in the central drive to motoneurones below that necessary to sustain maximal muscle activity. The relative roles of these three phenomena depend on the type of contraction, the muscle group under study and some psychological factors (these will be considered in the appropriate section of this chapter, see also Rothwell, 1994). Factors thought to be important in the development of peripheral fatigue during sustained muscle contractions include the depletion of muscle glycogen, which results in limiting the rate of adenosine diphosphate rephosphorylation, and the progressive loss of body fluids. This, in turn, results in increased cardiovascular, metabolic and thermoregulatory strain (Bergstrom et al., 1967). However, failure of neuromuscular transmission was believed to be a major factor in the development of fatigue for many years. In humans, such failure was demonstrated by supramaximal electrical stimulation of a motor nerve inducing a mass muscle action potential (the socalled M-wave) due to synchronous activation of all the units in the muscle (Merton, 1954). Repeated electrical stimulation after 20 seconds produced a significant decline in the amplitude of M-wave, indicating that action

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potentials are not longer generated in all units of the muscle under study. It should be noted however, that the amplitude of M-waves during supramaximal electrical stimulation of the muscle may not be equal to those during maximal voluntary contraction of the same muscles. This indicates that neuromuscular transmission may be retained during progressive muscle fatigue. But, fatigue is most probably caused by the failure in the production of contractile force (Rothwell, 1994). In fact, the anaerobic metabolisms can cause the decline in contractile function of muscles during intensive exercises. For a long time, the accumulation of lactic acid was believed to be an important factor of muscle fatigue. However, recent discoveries challenged the role of lactic acid as an important cause of muscle fatigue. Reduced pH may have little effect on contraction of mammalian animal muscles. Inorganic phosphate rather than lactic acid appears to be a major direct cause in the decline of contractile functions of muscles. The increased pH may affect muscle fatigue in several ways. It may act directly on the myofibrils and decrease cross-bridge force production and myofibrillar Ca2+ sensitivity. The pH may also act directly on the SR Ca2++ release channels, increase their open probability and increase the tetanic Ca2++ in the early stage of fatigue, and inhibit the ATPdriven SR Ca++ uptake and reduce tetanic calcium in late fatigue by entering the SR, precipitating with Ca2+, and thereby decreasing the Ca2+ available for release. A more detailed discussion of the muscle contractile function may be found in other texts and far beyond the scope of the chapter.Peripheral muscle fatigue can be assessed by an experimental procedure using electrical stimulation-evoked twitch force (TF) elicited before (fresh state) and immediately after (fatigue state). The first classical study using TF procedure was performed by Merton in 1954 and later used by other researchers (e.g. Marsden et al., 1983) to study muscle fatigue. The stimulation is usually applied to the biceps brachii muscle, a major elbow flexor (of course, depending on the research protocol). The stimulus parameters (i.e. amplitude and frequency of stimulation) are kept the same before and after sustained motor task (SMT) and all twitch force values are normalized with respect to maximal voluntary contraction obtained from a subject before SMT. Since muscle fatigue is reliably indicated as a decline of its ability to generate force (see Gandevia, 2001 for review), the amount of twitch force reduction immediately after the SMT is considered as physiological index of peripheral muscle fatigue. Another line of research within the scope of peripheral fatigue is related with properties of, (a) groupIII afferents that are sensitive to changes in both the mechanical state and the metabolic environment of the muscle, and (b) group-IV afferents that are most responsive to the chemical milieu in the muscle (Enoka & Stuart, 1992; Gandevia, 1998). The common research methodology used in the studies of the influence of fatigue on the feedback delivered by group III-IV afferents is to compare

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the recovery of function, when blood flow is normal and when it is impeded. During ischemia, the metabolites that accumulate in the fatigued muscle will continue to stimulate the group III-IV afferents. Moreover, the depression of discharge rate for motor units in the biceps brachii after a sustained maximal voluntary contraction (MVC) did not recover during the 3 minutes that blood flow was occluded but did recover to control values within 3 minutes after blood flow was restored. This result may suggest that a peripheral reflex mediated by group III-IV afferents from the fatigued muscle contributed to the decrease in the discharge rate. It should be noted however that the central connections of group III-IV afferents can evoke diverse responses. Todd et al., (2007) investigated the contribution of feedback by group III-IV afferents to the fatigue experience during a sustained 2 minutes MVC with the elbow flexor and extensor muscles as the end-effectors. The research protocols involved comparing the amplitude of potentials evoked in muscle with TMS of the corticospinal tract during the MVCs and during recovery, when blood flow to the muscle was occluded and when it was not. When the fatiguing contraction was performed with the triceps brachii muscle, the amplitude of the evoked response decreased during the MVC and remained depressed during ischemia, but recovered within 15 seconds after the removal of ischemia. The amplitude of the evoked potentials in triceps brachii also decreased after the fatiguing contraction was performed with the elbow flexor muscles. In contrast, the amplitude of the evoked potentials in biceps brachii increased after a fatiguing contraction with triceps brachii. These results indicate that group III-IV afferents depressed the excitability of the motor neurons of triceps brachii, but facilitated those that innervate biceps brachii. Overall, the contribution of feedback from group III-IV afferents to the decline in motor unit activity during a fatiguing contraction probably differs for flexor and extensor muscle. Additional research is needed to further explore differential contribution of feedback from group III-IV afferents to progressive muscle fatigue.

2.2 . Central Fatigue The central fatigue is a form of fatigue that is associated with specific alterations of the CNS functioning that may influence, (a) the central neural drive to the muscles, (b) mood and sensation of effort, and (c) tolerate pain and discomfort. The notion that the central neural system (CNS) contributes in the development of muscle is not new. Pioneering work by Alessandro Mosso (1904) clearly demonstrated a reduced capacity to perform sustained muscle contractions following a mental activity/effort, resulting in the development of the term “mental fatigue” (cf: Meeusen et al., 2006).

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The currently accepted “central fatigue hypothesis” is based on the assumption that during prolonged exercise the synthesis and metabolism of central monoamines, specifically serotonin, dopamine and noradrenalin (norepinephrine) are influenced. It was initially proposed by Newsholme et al. in 1987 that during prolonged exercise, increased brain serotonergic activity may augment lethargy and loss of drive, resulting in a reduction in motor unit recruitment at the peripheral level. This, in turn, may influence both physical and mental efficiency of the person performing the exercise, referred to as a central fatigue. While there have been many other neurobiological mechanisms proposed to explain reduced neural drive referred to as “central” fatigue, the neurotransmitter hypothesis has received the greatest recognition to date. In recent years, a number of studies have attempted to alter the central serotonin levels via various dietary supplementations with specific nutrients. This issue will be discussed elsewhere in this book. It is also possible that the interaction between brain serotonin and dopamine during sustained exercise could play a regulative role in the onset of fatigue (Davis & Bailey, 1997). Since dopamine was known to influence CNS functioning in terms of alteration of mood, memory, attention, and motivation, it is reasonable to accept the revised central fatigue hypothesis that an increase in the brain ratio of serotonin to dopamine is associated with feelings of tiredness and lethargy, accelerating the onset of fatigue. In contrast, a low ratio of serotonin to dopamine may favor improved performance via the maintenance of high levels of motivation and anxiety (Davis & Bailey). While substantial support exists for metabolic and biomechanical changes in motor units recruitment and firing rates, changes in reflex mechanisms occur with muscle fatigue. Evidence has been provided as changes in cortical excitability (e.g. central fatigue). For example, to assess the excitability of the motor cortex, transcranial magnetic stimulation (TMS) has been applied to the brain and changes in both the motor evoked potential (MEP) in the muscle and the ensuing silent period (SP) seen in the EMG after an MRP has been examined (Taylor et al., 1996). More recently, the contribution of central and peripheral fatigue during sustained low intensity elbow flexion in healthy subjects using TMS has been reported (Sogaard, 2006). The sustained contraction induced both muscle and progressive central fatigue. This was reflected in subjects’ inability to maximally contract the muscles. Surprisingly, the central fatigue recovered much faster (10min versus 25 min) compared to the peripheral fatigue as evidenced by recovery of resting twitch force. Despite apparent contradictions, the rather broad conclusion drawn from numerous TMS studies are that changes occurring in the MEP amplitude and SP duration associated with muscle fatigue are due to complex interactions of both excitatory and inhibitory processes in the motor cortex.

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There are several lines of research aimed at investigating the origin of central fatigue, in general, and chronic fatigue syndrome (CFS), in particular (see Bailey, 2007 for review). Reduced post-exercise motor cortical excitability along with observed perfusion defects in the frontal and temporal lobes was documented. Evidence for central fatigue was also provided based on observed impairment of cerebral blood flow abnormalities in white matter signal intensity associated with slower reaction time. Central fatigue may be also studied by Electroencephalography, using both subdural electrodes and by means of surface-recording EEG signals (Johnston et al., 2001). For example, researchers used implanted electrodes in the motor cortex of monkeys and observed a direct link between motor cortical cells and motor unit activity as EEG post spike effects in the target muscle. This finding provided direct evidence regarding the involvement of motor cortical cells in motor unit recruitment during fatigue. The changes in electro-cortical activity both in time and frequency domains associated with global and local muscle fatigue have also been observed in humans (Ivanova, 1990). Specifically, reduction of EEG alpha power (8-12 Hz) in fronto-central areas and an increase in amplitude of movement-related potentials was documented at early stages of progressive muscle fatigue. These EEG findings are consistent with other research on the effect of muscle fatigue on movement-related potentials (Freude etla., 1987) and more recently replicated by Johnston et al. (2001). A significant increase in motor-related cortical potentials was accompanying progressive muscle fatigue as evidenced by reduction of force production and reduced EMG responses. More recently, these EEG results were supported by fMRI findings indicating the contribution of central mechanisms to muscle fatigue (Liu et al., 2003). Considering the fact that movement-related cortical potentials reflect cortical output neurons (Kristeva, 1990) that are recruited to strengthen the descending commands, it is reasonable to suggest that modulation of brain activation patterns reflect compensatory central mechanisms to overcome the muscle fatigue. However, it should be mentioned that a contradictory report by Shibata et al. (1997) claimed no increase of electro-cortical activation preceding muscle contraction. Shibata et al. used an arterial occlusion technique to induce both metabolic changes in the muscle and force deficits in task performance similar to that seen in muscle fatigue. The team reported a significant increase in brain activation during the maintenance phase of the isometric contraction associated with increased EMG activity under condition of arterial occlusion. It was suggested that changes in brain activation patterns under arterial occlusion may reflect the recruitment of additional motor units to compensate for the reduction of force production. Other researchers have also reported NO alteration of EEG signals associated with planning phase of force production, but reduction of alpha (8-12 Hz) and beta (14-18 Hz) during the sustained phase of force

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production (Lui et al., 2005a). In other words, these researchers suggested that maximal force production induced fatigue has differential effects on cortical signals during the motor task execution compared to its maintenance. Overall, regardless of directionality of changes in patterns of brain activation (increase versus decrease) there is convincing evidence in the literature that progressive muscle fatigue has central sources and mechanisms. Additional information regarding the alteration of cortical activities during muscle fatigue was received from the fMRI studies by Liu et al. (2005b). These researchers observed that during a sustained (2-minute) maximal-effort handgrip, handgrip force and EMG signals declined in parallel during the course of muscle fatigue, the fMRI-measured BOLD signals first substantially increased and then decreased. The brain areas involved in such activities include primary sensorimotor areas and the secondary and association cortices (supplementary motor, prefrontal, and cingulate areas). This fMRI study shows the nonlinear changes of brain activation patterns that may reflect an early adjustment to strengthen the descending command for force-loss compensation and subsequent inhibition by sensory feedback as fatigue became more severe. It could explain at least to some extent why in TMS studies the excitability and inhibition in motor cortex both increase and the voluntary drives from the motor cortex continuously decreased during fatiguing exercise and did not recover after exercise if the blood flow was occluded. There are limited reports in the literature on the cortical modulation of muscle fatigue and/or fatigue related cortical dysfunctions in clinical populations. For example, abnormal EEG findings (both event-related desynchronization “ERD” and event-related synchronization “ERS”) have been reported by Zamarian et al. (2006) studying Parkinson patients. Similar findings have been reported by Babiloni et al. (2000) studying Alzheimer patients. Assuming that these clinical populations usually suffer from chronic fatigue syndrome (CFS), it is reasonable to suggest that EEG abnormalities observed in these patients may somehow reflect alteration of central drive to control muscle contractions. Abnormal cortical activation during fatiguing voluntary movement in Multiple Sclerosis (MS) was also reported by Leocani et al. (2001). Indeed, prevalent fatigue is the most common clinical symptom of patients suffering from MS. Normal controls and MS patients with and without fatigue symptoms performed self-initiated extensions of the thumb for prolong period of time. Post-movement ERS within high beta frequency band (18-22 Hz) was found to be significantly lower in the MS fatigue group compared to the MS non-fatigue patients. Moreover, ERD at the same frequency band (18-22 Hz) was more widespread in the frontal area of the brain for the MS fatigue group. Overall, it was suggested that the alteration of ERS/ERD patterns may be a result of inhibitory circuits acting on the motor cortex after termination of

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movement and/or decrease connectivity between cortical neurons causing reduced capability for producing synchronized oscillation of brain signals. Depressive symptoms are the strongest predictor of fatigue in clinical population. However, fatigue cannot solely be explained by depression (Bower, 2005). Clearly, chronic fatigue is an important problem in cancer survivors. However, the extent to which the incidence and prevalence of fatigue among these patients differ from similar adults without cancer history remains an important question. A recent epidemiological study has reported that chronic fatigue, sometimes even in severe forms of exhaustion, along with persistent symptoms of depression are the most common consequences of cancer (Reyes-Gibby et al., 2006). In a prospective study of breast cancer patients undergoing radiation, pretreatment fatigue, depressed mood and anxiety scores were solid predictors of fatigue 2.5 years after treatment (Geinitz, et al., 2004). Similarly, women with higher levels of depressive symptoms in the five years after diagnosis were at greater risk for chronic fatigue, even after being able to control the initial fatigue (Bower et al., 2006). Overall, this link between depression and fatigue found in clinical populations should be of particular concern in athletes suffering from traumatic injuries and those who had experienced various forms of psychological trauma. Specifically, the stress athletes induced by traumatic injury may be associated with greater immune dysregulation, provoking the maladaptive effects of stress and depression on inflammation (there are current trends to propose that inflammation may be one mechanism underlying chronic fatigue in clinical populations). It should be noted that a number of health-related behaviors are associated with both fatigue and higher levels of proinflammatory cytokines, including pain, physical activity, body mass, sleep, diet, and comorbid health conditions (Bower, 2005).

3. FATIGUE-INJURY RELATIONSHIP

3.1. Injuries due to Central Fatigue There are numerous well-documented reports and anecdotal facts clearly indicating both direct and indirect links between fatigue and various forms of injury both in athletes and non-athletes. For example, it is very common and well-known that a driver’s fatigue is a major risk for road accidents that can often result in injury and death. However, considerable debate still exists concerning factors associated with driver fatigue. Recently, a study investigated both physiological and psychological determinants of the drivers’ fatigue (Wijesuriya, et al., 2007). Three fatigue outcome measures were used, including a physiological, psychological, and a combined physiological and psychological measure. Significant factors associated

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with physiological fatigue included higher levels of baseline EEG delta activity (i.e. an index of generalized slowness of brain functions and sleepiness) and an extraverted personality. Factors related to the psychological fatigue outcome measure included sleepiness, low healthy lifestyle status, an extraverted personality, tension-prone personality, and negative mood states. The combined fatigue outcome measure was associated with factors such as a tension-prone and extraverted personality, low systolic blood pressure and negative mood states. Another relevant recent study examined the prevalence of fatigue in an outpatient spinal cord injury population, as well as the additional clinical variables contributing to that fatigue (Fawkes-Kirby et al., 2007). In this study, data was collected from 76 individuals admitted to the GF Strong Outpatient SCI Program (Vancouver, British Columbia) using the Fatigue Severity Scale (FSS). A majority of these patients were admitted for medical reasons and had pain, spasticity, incomplete injuries and/or were on more that one medication with a known side effect of fatigue. Fatigue among individuals with spinal cord injury who are seeking outpatient rehabilitation is very common. The authors concluded that the severity of fatigue was greater for individuals with incomplete lesions. Moreover, pain was also a potentially important covariate of fatigue. The effect of fatigue on the functional recovery of patients with spinal cord injury is unknown at this time. Signs of chronic fatigue are also prevalent in patients with traumatic brain injuries. In a recent study, Bushnic et al. (2007) have evaluated the association between neuroendocrine findings (testing including thyroid, adrenal, gonadal axes and growth hormone (GH) after glucagon stimulation) and fatigue after traumatic brain injury using Fatigue Severity Scale (FSS) and Global Fatigue Index (GFI). Higher GH levels were significantly associated with higher FSS scores. There was a noted trend between lower basal cortisol and higher scores on both the FSS and GFI. It was concluded that an observed relationship between higher GH levels and greater fatigue contradicted the prevailing hypothesis that post-acute TBI fatigue is associated with GH deficiency. However, the relationship between lower basal cortisol and greater fatigue was in the expected direction. Overall, the fatigue derived from neuroendocrine abnormalities alone may be masked by fatigue induced by other factors commonly experienced following TBI. Again, the exact contribution of GH deficiency to diminished quality of life post-TBI remains unclear. Fatigue injury relationships can also be mediated by impaired cognitive functions associated with prolonged exercise leading to mental exhaustion. For example, the athletes’ diminished ability to focus on key elements of drills, make fast and timely decisions, predict and anticipate forthcoming events, particularly at the end of practice/competition, may result in impairment of movement forms and technique, putting these athletes at high

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risk for injury. In fact, this was partly documented in a number of recent studies. For example, combined effect of fatigue and decision making on female athletes risk for the anterior cruciate ligament (ASL) injury due to improper landing has been shown by Borotikar et al (2007). Specifically, fatigue caused significant increases in initial contact hip extension and internal rotation, and in peak stance knee abduction and internal rotation and ankle supination angles. Fatigue-induced increases in initial contact hip rotations and in peak knee abduction angle were also significantly more pronounced during unanticipated compared to anticipated landings. Overall, the integrative effects of fatigue and decision making may represent a worst case scenario in terms of ASL injury risk during dynamic single leg landings, by perpetuating substantial degradation and overload of central control mechanisms. Injury may be caused by the lack of anticipation and prediction of possible collision and/or impact with objects or players due to progressive central and peripheral fatigue. For example, warning prior to lifting helps to properly prepare appropriate muscle groups to prevent injury. It was shown that warning did not alter the level of trunk muscle activity prior to sudden loading when subject experienced progressive fatigue (Mawston et al., 2007). These findings indicate that warning prior to sudden loading may enhance postural responses, reduce ranges of joint motion and increase stability. However, the benefits of prior warning for reducing ranges of joint motion may not be present when a person is fatigued. In other words, fatigue may induce the athlete’s ability to predict and anticipate the amount of impact and exact timing of landing (for example landing in gymnastics after multiple somersaults). In fact, numerous ankle injuries in gymnasts are caused by improper landing. The author’s numerous personal interviews with injured gymnasts clearly indicate that most of these injuries happened at the end of the practice sessions and were linked to fatigue and an unprepared landing on hard surface. The lack of prediction of the impact forces (i.e. cognitive appraisal and appropriate readiness to initiate proper preparation) during lifting the weight is another example of fatigue/cognition/injury link in athletes. In addition, fatigue generally increases initial and peak knee adduction, abduction, and peak knee internal rotation, with the later being more pronounced in female athletes (McLean et al., 2007). Specifically, female athletes usually landed with more initial ankle plantar flexion and peak-stance ankle supination, knee abduction and knee internal rotation compared to male athletes. Females also demonstrate greater quadricepshamstrings co-activation ratios than males, regardless of the fatigue condition. There are the muscle mass (or strength) and associated level of vascular occlusion, substrate utilization, muscle composition as well as neuro-muscular activation hypotheses to explain gender differences in muscle fatigability (see also Lariviere at al., 2006 for details).

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Only females showed increased knee flexion at initial contact after fatigue during hopping/landing (Padua et al., 2006). Fatigue induced alteration of low-limb control during landing may be a contributing factor to alteration of knee stabilization resulting in higher risk of ASL injuries in female athletes. Several other EMG studies differentiated landing strategies in female athletes with low and high risk for ASL injuries (see Nyland et al., 1997 for review). Fatigued recreational athletes (especially females) have also demonstrated the altered motor control strategies, which may increase anterior tibial shear force, and cause strain on the anterior cruciate ligament (Chappell et al., 2005). Clearly, regardless of gender, constant monitoring for any signs of mental fatigue, especially at the end of the practice sessions may benefit athletes in terms of predicting/preventing injuries. Lack of prediction of timing during drop landing due to fatigue may also alter the agonist/antagonist muscle co-activation patterns, which play an important role for stabilizing the knee joint (Kellis & Kouvelioti, 2007). Localized muscle fatigue (including contribution of central mechanisms) may alter the tibial response parameters, including peak tibial acceleration, time to peak tibial acceleration and the acceleration slope, measured at the knee during unshod heel impacts (Holmes & Andrews, 2006). These facts should be also considered while plyometric drop-jump training which is currently used in numerous sports. A recent study examining effect of fatigue on tibial impact properties and knee kinematics in drop jump have clearly shown that neuro-muscular fatigue induced by treadmill running protocol caused a significant increase in tibial impact acceleration and peak angular velocity in drop jump (Moran & Marshall, 2006). This, in turn, may considerably increase the risk for chronic and overuse injuries of low extremities. The reduced leg swing speed, represented by a slower toe linear velocity immediately before ball impact and slower peak lower leg angular velocity, was most likely due to a significantly reduced resultant joint moment and motion-dependent interactive moment during kicking (Apriantono et al., 2006). These results suggest that the specific muscle fatigue induced in the present study not only diminished the ability to generate force, but also disturbed the effective action of the interactive moment leading to poorer inter-segmental coordination during kicking. Moreover, fatigue obscured the eccentric action of the knee flexors immediately before ball impact. This might ultimately increase the athletes’ susceptibility to injury. Finally, a sudden unexpected loading (i.e. lack of preparatory activities) and fatigue arising from manual handling practices in the workplace have been identified as contributing factors to the risk of low back injury (Mawston et al., 2007). Fatigue-induced reduction in active muscle stiffness necessitated increased antagonistic co-contraction to maintain stability resulting in increased spinal compression with fatigue. Also, fatigueinduced reduction in force-generating capacity limited the feasible set of

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muscle recruitment patterns, thereby restricting the estimated stability of the spine (Granata et al., 2004). In this study, Electromyographic (EMG) and trunk kinematics from healthy participants were recorded during suddenload trials in fatigued and un-fatigued states. Empirical data supported the model predictions, demonstrating increased antagonistic co-contraction during fatigued exertions. Overall, warning prior to sudden loading may enhance preparation for postural responses, reduce ranges of joint motion and increase whole-body postural stability resulting in better control for fatigue-related injuries.

3.2. Abnormal Postural Control and Injury due to Fatigue In the previous text we discussed abnormal postural control and balance deficiency as both, (a) predictor for high risk of injury, and (b) significant factor of residual deficit due to injury. In the following discussion it is an intention to provide additional evidence that progressive muscle fatigue may contribute to postural control abnormalities, ultimately putting athletes at high risk for injury. It should be noted that balance and stability is not restricted to whole body postural stability but may involve any joint(s) contributing to execution of movement. Clearly, control for whole body and selective body segments for stabilization during movement is affected by intact proprioception and joint position sensitivity. Therefore it is feasible to suggest that sustained and prolong physical activity may reduce proprio-sensation along with joint position sensitivity. As a result, the lack of sensitivity due to fatigue may be a contributing factor for joint(s) instability and associated injuries. There are several recent studies in support of this assumption. Specifically, the contribution of impaired stretch reflex responses in conjunction with fatiguerelated ankle injuries was warranted by Jackson et al. (2007) recent study. This finding clearly indicates that reducing dynamic stability of the ankle joint is due to alteration of reflexive response. Thus, the lack of sensitivity of ankle joint stability during landing (e.g. floor exercise in gymnastics) and/or impact with moving objects (catching the springboard in diving) may cause frequently observed ankle sprain injury in these sports. In another relevant study, the effect of muscular fatigue on knee joint proprioception was examined (Lattanzio et al., 1997). In this study, subjects were instructed to perform a two-legged squat to specific knee flexion angles. There was significant decline in proprioceptive function after the fatiguing exercise (e.g., 80% VO2max until maximal exhaustion). Interestingly, female athletes experienced more trouble to reproduce required range of knee motion under fatigue condition. Similarly, the lack of sensori-motor control between upper extremity stability and mobility due to fatigue not only deteriorated overhead throwing

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movement in athletes, but also may be considered as a contributing factor to overused types of shoulder injuries (Tripp et al., 2007). These researchers reported that fatigue occurred after an average of 62 +/- 28 throws and increased 3-dimensional variable error scores (i.e. decreased acuity) of the entire upper extremity and all joints in both positions. Fatigue increased errors (ranging from 0.6 degrees to 2.3 degrees) at arm co*ck for scapulothoracic internal-external rotation, upward rotation, and posterior tilt, glenohumeral internal-external rotation and flexion-extension, elbow flexion-extension, wrist ulnar-radial deviation and at ball release for scapulothoracic internal-external rotation and upward rotation, glenohumeral horizontal abduction-adduction, elbow pronation-supination, and wrist ulnarradial deviation and flexion-extension. Also, deceleration time was shown to be significantly increased by the fatiguing intervention in the Bowman et al., (2006) study. It was suggested that the decreased ability to decelerate may be an adaptive response by the subjects to dissipate a lower percentage of force per second. Although, this adaptive response may cause impaired overhead motion and ultimately lead to injury. Overall, this suggests that functional fatigue affects the acuity of the entire upper extremity, each individual joint and multiple joint motions in overhead throwers. Clinicians and coaches should definitely consider the deleterious effects of upper extremities fatigue when designing the injury prevention training and rehabilitation programs. There are few direct reports suggesting the negative effect of fatigue on whole body postural control ultimately linking to injury in athletes. Specifically, baseline and post-fatigue postural stability scores were assessed using the isokinetic fatiguing contractions protocol (Harkins et al., 2005). Postural sway velocity, as an index of postural instability, was significantly higher when the 30% fatigue protocol (70% of decrease in strength) was introduced compare to 50% (50% of decrease in strength) fatigue protocol. In another relevant study, deficits in static postural control as a result of fatigue in conjunction with chronic ankle instability was examined (Gribble et al., 2004a). The Star Excursion Balance Tests clearly indicated disrupted dynamic postural control, most notably by altering control of saggital-plane angles proximal to the ankle as a function of progressive fatigue. These overall findings were replicated by Gribble & Hertel (2004b) using a singleleg stance research protocol. Specifically, fatigue about the hip and knee had great adverse effect on postural control properties. Moreover, it was shown that fatigue and deficits in postural control may predispose musculoskeletal injury, with greater effect of localized fatigue of the frontal plane movers of the hip compared to the ankle on maintenance of postural control in a single-leg stance (Gribble & Hertel 2004c). Clearly, more wellcontrolled research is needed to fully elaborate on moderating effect of fatigue on injury in athletes due to abnormal postural control.

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CONCLUSION Despite significant advances in understanding fatigue associated with sustained exercise, there are still controversies regarding the contribution of peripheral (pure muscular) and central (super-spinal factors) to progressive muscle fatigue. The rate of progress in the field of muscle fatigue has not matched expectations expressed in the early 1990s, since the paper published by Enoka & Stuart (1992) and the international symposium in Miami (Gangevia et al., 1995). Clearly, peripheral mechanisms including muscle glycogen concentration, transmission at the nerve-muscle junction and contractile machinery in muscles have been well-documented. However, significant progress associated with advanced brain imaging technologies, such as fMRI and TMS, clearly demonstrated differential contribution of various brain regions to this phenomenon. The question whether the mechanisms predominantly responsible for fatigue is located in the exercising muscle or somewhere else in the CNS remains to be answered. As was stressed by Nybo & Secher (2004 sf: Barry & Enoka, 2006), due to the mutual interaction of central and peripheral mechanisms, the dichotomy is not particularly useful and should be avoided. Another point to be made regarding muscle fatigue is the “research methodology”. As was mentioned in the previous text, subjective scales and numerical categories used to assess the contribution of central mechanisms are most often lacking ecological validity, they are confusing to patients and rarely match other biological and neural markers of fatigue. These numerous confounding factors, such as task dependency, subjects’ perception of exhaustion, individual differences in terms of tolerance to pain, current mental status and nutritional factors may bias the results of “pure” experimentation of muscle fatigue. That said, impairment of motor skill production, multiple compensations in terms of techniques used to achieve the desired goal due to progressive muscle fatigue, is a serious predisposing factor for injuries in athletics. There are more questions than answers, such as, (a) how to reduce the risk factor for injury due to fatigue, (b) what are pure markers of threshold for progressive muscle fatigue when it is time to stop the loading to prevent injury, (c) how to reduce fatigability of the muscle to meet the demands of current sports, and (c) how to speed-up recuperation of athletes between practice sessions, just to name a few. Indeed, multidisciplinary effort of exercise physiologists, psychologists, coaches and medical practitioners is needed to properly address these and many other important questions related to reducing the risk of injury in athletes due to fatigue. On the final note, according to Dr. O’Brien, dealing with elite athletes, coaches and medical practitioners need to constantly monitor the fatigue level, including both muscle and mental fatigue to determine the training

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load, intensity and volume of proposed exercise programs. The lack of recuperation control may lead to the cumulative effect of fatigue which is a direct cause of injury in elite athletes.

REFERENCES Rothwell, J. Control of human voluntary movement. Second edition. Chapman & Hill, 1994. Gandevia, S.C., Enoka, R.M., McComas, A.J., Stuart, D.G., Thams, C.K. (Eds.), Fatigue: neural and muscular mechanisms. New York: Plenum Press, 1998. Johnston, J., Rearick, M. Slobounov, S. (2001). Movement-related cortical potentials associated with progressive muscle fatigue in a grasping task. Clinical Neurophysiology, 112, 68-77. Carpenter, J.E., Blasser, R.B., Pelizzon, G.G. (1998). The effects of muscle fatigue on shoulder joint position sense. American Journal of Sports Medicine, 26, 62-65. Jaric, S., Radovanovic, S., Milanovic, S et al. (1997). A comparison of the effects of agonist and antagonist muscle fatigue on performance of rapid movement. European Journal of Applied Physiology, 76, 41-47. Meeusen, R., Watson, P., Hasegawa, H., Roelands, B., Piacentini, M. (2006). Central fatigue: The serotonin hypothesis and beyond. Sports Medicine, 36)10), 881-909. Enoka, R.M, Stuart, D.G. (1992). Neurobiology of muscle fatigue. Journal of Applied Physiology, 72, 1631-48. Dimeo, F., Stieglitz, R.D., Novelli-Fischer, U., Fetscher, S., Mertelsmann, R., Keul, J. (1997). Correlation between physical performance and fatigue in cancer patients. Annals of Oncology, 8, 1251-1255. Simmonds, M.J. (2002). Physical function in patients with cancer: Psychometric characteristics and clinical usefulness of a physical performance test battery. Journal of Pain Symptom Management, 24, 404-414. Schmid, M., Schieppati M., & Pozzo, T. (2006). Effect of fatigue on the precision of a wholebody pointing task. Neuroscience, 139 (3), 909-20. Apriantono, T., Nunome, H., Ikegami, Y., & Sano, S. (2006). The effect of muscle fatigue on instep kicking kinetics and kinematics in association football. Journal of Sports Science, 24(9), 951-60. Bergstrom, J., Hermansen, L., Hultman, E. et al. (1967). Diet, muscle glycogen and physical performance. Acta Physiologica Scandinavia, 71(2), 140-150. Merton, P.A. (1954). Voluntary strength and fatigue. Journal of Physiology, 123, 553-564. Marsden, C.D., Meadows, J.C., & Merton, P.A. (1983). ‘Muscular wisdom’ that minimizes fatigue during prolonged effort in man: peak rates of motoneuron discharge and slowing of discharge during fatigue. Advanced Neurology, 39, 169-211. Gandevia, S.C. (2001). Spinal and supraspinal factors in human muscle 309-14 fatigue. Physiological Review, 81 (4), 1725-89. Todd, G., Taylor, J.T., Butler, J.E., Martin, P.G., Gorman, R.B., Gandevia, S.C. (2007). Use of motor cortex stimulation to measure simultaneously the changes in dynamic muscle properties and voluntary activation in human muscle. Journal of Applied Physiology, 102(5), 1756-1766. Mosso, A. Fatigue. London. Swan Sonnenschein, 1904. Newsholme, E.A., Acworth, I., Bloomstrand, E. (1987). Amino acids, brain neurotransmitters and a function link between muscle and brain that is important in sustained exercise. In: Benzi G (Ed). Advances in myochemistry. pp. 127-133. London: John Libbey Eurotext. Davis, J.M. & Bailey, S.P. (1997). Possible mechanisms of central nervous system fatigue during exercise. Medicine in Science Sports Exercise, 29(1), 45-57.

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Taylor. J.L., Butler, J.E., Allen, G.M., Gandevia, S.C. (1996). Changes in motor cortical excitability during human muscle fatigue. Journal of Physiology, 490, 519-529. Sogaard, K., Gandevia, S.C., Todd, G., Petersen, N.T., Taylor, J.L. (2006). The effect of sustained low-intensity contractions on supraspinal fatigue in human elbow flexor muscles. Journal of Physiology, 573(Pt 2), 511-523. Bailey, A. (2007). Chronic fatigue syndrome: a tiresome illness. British Journal of Nursing, 16(16), 967. Ivanova, M. Cortical control of voluntary movement. Moscow: Academy of Science, 1990. (Russian). Freude, G., Ullsperger, P. (1987). Changes in bereitschaftpotential during fatiguing and nonfatiguing hand movement. European Journal of Physiology, 56, 105-108. Liu, J.Z., Zhang, L.D., Shan, Z.Y., Sahgal, V., Brown, R.W., Yue, G.H. (2003). Brain activation during sustained and intermittent submaximal fatigue muscle contractions. Journal of Neurophysiology, 90, 300-312. Kristeva, R., Cheyne, D., Lang, W., Lindenger, G., Deecke, L. (1990). Movement-related potentials accompanying unilateral and bilateral finger movements with different inertial load. EEG and Clinical Neurophysiology, 75, 410-418. Shibata, M., Oda, S., Moritani, T. (1997). The relationship between movement-related cortical potentials and motor unit activity during motor contraction. Journal of Electromyography and Kinesiology, 7(2), 79-85. Liu, J.Z., Yao, B., Siemionow, V., Sahgal, V., Wang, X.F., Sun, J., Yue, G.H. (2005a). Minimal changes in cortical command but substantial declines in muscular output during severe muscle fatigue. Brain Research, 1057, 113-126. Liu, J.Z., Zhang, L.D., Yao, B., Sahgal, V., Yue, G.H. (2005b). Fatigue induced by intermittent maximal voluntary contractions is associated with significant losses in muscle output but limited reductions in functional MRI-measured brain activation level. Brain Research 1040, 44-54. Zamarian, L., Visani, P., Delazer, M., Seppi, K., et al., (2006). Parkinson’s disease and arithmetics: the role of executive functions. Journal of Neurological Sciences, 25(248), 124-130. Babiloni, F., Babiloni, C., Carducci, F. et al. (2000). Movement-related electroencephalographic reactivity in Alzheimer disease. Neuroimage, 12(2), 139-146. Leocani, L., Colombo, B., Magnani, G. et al. (2001). Fatigue in multiple sclerosis is associated with abnormal cortical activation to voluntary movement: EEG evidence. Neuroimage, 13(6Pt 1), 1186-1192. Bower, J.E. (2005). Prevalence and causes of fatigue after cancer treatment: the next generation of research. Journal of Clinical Oncology, 23(33), 8280-2. Reyes-Gibby, C.C., Aday, L.A., Anderson, K.O., Mendoza, T.R., Cleeland, C.S. (2006). Pain, depression, and fatigue in community-dwelling adults with and without history of cancer. Journal of Pain and Symptom Management, 32(2), 118-128. Geinitz, H., Zimmermann, F.B., Thammm, R., Keller, M. Busch, R., Molls, M. (2004). Fatigue in patients with adjuvant radiation therapy for breast cancer: long-term followup. Journal of Cancer Research and Clinical Oncology, 130(6), 327-333. Bower, J.E., Ganz, P.A., Desmond, K.A. et al. (2006). Fatigue in long-term breast carcinoma survivors: A longitudinal investigation. Cancer, 106(4), 751-8. Wijesuriya, N., Tran, Y., Craig, A. (2007). The psychophysiological determinants of fatigue. International Journal of Psychophysiology, 63 (1), 77-86. Fawkes-Kirby, T.M., Wheeler, M.A., Anton, H.A., Miller, W.C., Townson, A.F., Weeks, C.A. (2007). Clinical correlates of fatigue in spinal cord injury. Spinal Cord Bushnik, T., Englander, J., Katznelson, L. (2007). Fatigue after TBI: association with neuroendocrine abnormalities. Brain Injury, 21 (6), 559-66.

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Borotikar, B.S., Newcomer, R., Koppes, R., McLean S.G. (2007). Combined effects of fatigue and decision making on female lower limb landing postures: Central and peripheral contributions to ACL injury risk. Clinical Biomechanics. Sep 21. Mawston, G.A., McNair P.J., Booco*ck, M.G. (2007). The effects of prior warning and liftinginduced fatigue on trunk muscle and postural responses to sudden loading during manual handling. Ergonomics, 1-14. McLean, S.G., Felin, R.E., Suedekum, N., Calabrese, G., Passerallo, A., Joy, S. (2007). Impact of fatigue on gender-based high-risk landing strategies. Medicine & Science in Sports & Exercise, 39 (3), 502-14. Larivière, C., Gravel, D., Gagnon, D., Gardiner, P., Bertrand Arsenault, A., Gaudreault, N. (2006). Gender influence on fatigability of back muscles during intermittent isometric contractions: a study of neuromuscular activation patterns. Clinical Biomechanics, 21 (9), 893-904. Padua, D.A., Arnold, B.L., Perrin, D.H., Gansneder, B.M., Carcia, C.R., Granata, K.P. (2006). Fatigue, vertical leg stiffness, and stiffness control strategies in males and females. Journal of Athletic Training, 41 (3), 294-304. Nyland, J.A., Caborn, D.N., Shapiro, R., Johnson, D.L. (1997). Fatigue after eccentric quadriceps femoris work produces earlier gastrocnemius and delayed quadriceps femoris activation during crossover cutting among normal athletic women. Knee Surgery Sports Traumatology, Arthroscopy, 5 (3), 162-7. Chappell, J.D., Herman, D.C., Knight, B.S., Kirkendall, D.T., Garrett, W.E., Yu, B. (2005). Effect of fatigue on knee kinetics and kinematics in stop-jump tasks. American Journal of Sports Medicine, 33 (7), 1022-9. Kellis, E., Kouvelioti, V. (2007). Agonist versus antagonist muscle fatigue effects on thigh muscle activity and vertical ground reaction during drop landing. Journal of Electromyography and Kinesiology. Holmes, A.M., Andrews, D.M. (2006). The effect of leg muscle activation state and localized muscle fatigue on tibial response during impact. Journal of Applied Biomechanics, 22(4), 275-84. Moran, K.A., Marshall, B.M. (2006). Effect of fatigue on tibial impact accelerations and knee kinematics in drop jumps. Medicine & Science in Sports & Exercise, 38 (10), 1836-42. Granata, K.P., Slota, G.P., Wilson, S.E. (2004). Influence of fatigue in neuromuscular control of spinal stability. Human Factors, 46 (1), 81-91. Jackson, N.D., Gutierrez, G.M., Kaminski, T. (2007). The effect of fatigue and habituation on the stretch reflex of the ankle musculature. Journal of Electromyography and Kinesiology. Lattanzio, P.J., Petrella, R.J., Sproule, J.R., Fowler, P.J. (1997). Effects of fatigue on knee proprioception. Clinical Journal of Sports Medicine, 7 (1), 22-7. Tripp, B.L., Yochem, E.M., Uhl, & T.L. (2007). Functional fatigue and upper extremity sensorimotor system acuity in baseball athletes. Journal of Athletic Training, 42 (1), 908. Bowman, T.G., Hart, J.M., McGuire, B.A., Palmieri, R.M., Ingersoll, C.D. (2006). A functional fatiguing protocol and deceleration time of the shoulder from an internal rotation perturbation. Journal of Athletic Training, 41 (3), 275-9. Harkins, K.M., Mattacola, C.G., Uhl, T.L., Malone, T.R., McCrory, J.L. (2005). Effects of 2 ankle fatigue models on the duration of postural stability dysfunction. Journal of Athletic Training, 40 (3), 191-4. Gribble PA, Hertel J. (2004a). Effect of lower-extremity muscle fatigue on postural control. Archives of Physical Medicine and Rehabilitation, 85(4), 589-92. Gribble, P.A., Hertel, J. (2004b). Effect of hip and ankle muscle fatigue on unipedal postural control. Journal of Electromyography and Kinesiology, 14(6), 641-6.

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Gribble PA, Hertel J, Denegar CR, Buckley WE. (2004c). The Effects of Fatigue and Chronic Ankle Instability on Dynamic Postural Control. Journal of Athletic Training, 39(4), 321-329. Gandevia, S.C., Allen, G.M., & McKenzie, D.K. (1995). Central fatigue: critical issues, quantification and practical applications. Advanced Experimental Medical Biology, 384, 281-294. Barry, B., Enoka, R. (2006). The neurobiology of muscle fatigue: 15 years later. Integrative and Comparative Biology, 47, 465-473.

CHAPTER 5 NUTRITION AS A RISK FACTOR FOR INJURY IN ELITE ATHLETES 1. INTRODUCTION During the past two decades there have been scientific breakthroughs in understanding the role human metabolism plays in exercise, physical performance and athletic injuries. Studies have shown that specific forms of dietary behaviors may potentially be linked to health benefits or problems and their association to athletic performance. The field of sports nutrition has indicated that athletes have greater demands for macro and micronutrients than inactive humans. These findings have dictated the dietary recommendations of individuals participating in sports. This innovative and intergraded science has shifted from practical studies investigating the effects of dietary restrictions and supplementation, to the direct investigation of the biochemical basis of specific nutritional demands for elite performance and injury mechanics. This review chapter is based on sports nutrition and its association with sports injuries. Various topics of the nutritional demands of exercise are reviewed in their biochemical and metabolic relationships to athletic performance. As sport induced injuries are on the rise, sports medicine specialists and sports nutritionists have been trying to determine how nutrition is related to injury. On the contrary, many exercise physiologists believe “fuel is fuel” and it doesn’t matter what comes in. As human performance becomes more advanced and elite athletes are becoming more dependent on their team nutritionist, it is becoming evident that proper nutrition is essential for proper performance during practice and competition. Specific nutrients are critically important for enhancing the quality of performance, conditioning, practice time, recovery from fatigue, and avoiding sports induced injuries. For an athlete, improving biomechanical performance and avoiding the disturbance of homeostasis by strenuous demands by their specific sport is crucial. Since athletes require more nutrients than the recommended daily allowances (RDAs), it is important that they not only eat a well-balanced diet consisting of carbohydrates, protein, fat, vitamins, and minerals, but meet the nutritional demands and supplementation required before and after rigorous exercise.

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2. NUTRITIONAL SUPPLEMENTATION AND INJURY 2.1. Carbohydrates Carbohydrate metabolism is one of the most energy contributing biochemical pathways. Although the exchanging of carbohydrates and lipids for fuel utilization plays a role in endurance exercise, regulating the consumption of these two substrates can be a determinant in exhaustion and fatigue times. Glycogen, liver and skeletal muscle glycogen is an obligatory substrate for sprinting, jumping, lifting and other high power outputs demands. Skeletal muscle glycogen becomes a limiting factor in strenuous exercise due to its limited storage amounts and rapid utilization. Fatigue occurs when glycogen levels are significantly depleted in active muscles. Strenuous exercise may also exhaust liver glycogen, leading to a low blood glucose concentration and impaired endurance performance. Therefore, an effective way to improve endurance while prolonging the effects of fatigue is to increase glycogen stores in liver and glycogen muscle prior to initiating prolonged exercises, such as a marathon and/or long distance swimming. This may be achieved by ingesting carbohydrates, preferably monosaccharides or oligosaccharides, due to their rapid absorption and transport to peripheral tissues, either before or during exercise. For instance, it has been reported that glycogen stores can be increased by eating a lowcarbohydrate diet for 3 to 6 days prior to competition. It was reported that following by a high-carbohydrate diet during the final 3 days results in the storage of 1.5 times more glycogen than normal (Evans, 1985).

2.2. Protein L-carnitine in the form of a nutritional supplement is believed to have potentially positive effects on muscle injury. The lysine-derivative is synthesized in the body and is obtained from red meat. Its primary role is to transfer fatty acids across the mitochondria matrix for beta-oxidation of fatty acid. It also plays a role in synthesis of adenosine triphosphate (ATP). Volek et al. (2002) conducted a study on trained males who were supplemented with 2 grams of L-carnitine or a placebo prior and during a 4 day long training session. Muscle-damage markers were measured to evaluate the effects of L-carnitine. Results showed that the L-carnitine subjects experienced less DOMS, lower blood CK concentrations and less muscle damage according to MRI imaging.

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2.3. Carbohydrates and Protein With an estimated 80,000 Anterior Cruciate Ligament (ACL) tears in the United State and 56,000 of them occurring during sport, athletes are prone and unfortunately expected to experience just an injury. ACL damage is the major and prominent injury in most contact sports, such as football, basketball and ice hockey. Foremost, a rehabilitation specialist’s top priority is to restore muscle mass, strength, and flexibility, along with a full range of motion. In conjunction with physical therapeutic interventions, oral supplementations have been recognized as rehabilitation sessions. Muscle mass and strength is enhanced by increasing the protein synthesis to breakdown ratio in muscle. This is accomplished through resistance training, protein intake, as well as carbohydrate intake. If no nutrients are endogenously ingested, then the net protein balance will remain negative. A positive net balance is required for significant protein syntheses. Holm et al. (2005) conducted a twelve-week rehabilitation session on patients with ACL injuries who had experienced quadriceps and hamstring atrophy and weakening. The patients were supplemented with a mixture of protein and carbohydrate immediately after rehab sessions. Results conclude that there where greater hypertrophic responses in the distal region of the quadriceps muscle. This site of the large muscle is associated with kneejoint stability and maximal function.

2.4. Antioxidants Mild traumatic brain injuries (MTBI), commonly referred to as concussions, are considered the least serious type of traumatic brain injury. Yet, repetitive MTBI can lead to neurodegenerative diseases by means of axonal injury and even death. Traumatic head injury studies have incorporated the use of animals to determine the effects of traumatic injuries. This is due to the importance of neuronal function and degeneration as factor for head injuries in humans. One theory of damage is based on the effects of reactive oxygen species (ROS), which are a major cause of secondary neuronal tissue damage following physical head trauma. Research has indicated that ROS are capable of damaging or altering the expression of numerous genes, proteins and macromolecules (Halliwell & Gutteridge, 1999). ROS directly affect the brain following injury through oxidation of DNA and proteins, and inducing peroxidation of membrane lipids. ROS also activates pathways which lead to different cascades of cellular messengers and transcription factors that promote axonal inflammation and apoptosis. In addition, they are believed to be involved in the aging process causing neurodegenerative diseases such as Alzheimer's and Parkinson’s.

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A nutritional intervention currently being used to speed the recovery process, increase the oxygen concentration in the brain and prevent further damage after a traumatic head injury is the supplementation of antioxidants. Clinicians are now supplementing patients and rats in animal models with Vitamins A, C, E, all B vitamins, and minerals such as selenium and zinc to confirm their positive effects against free- radicals. Studies performed to prove the free-radical theory have determined that antioxidant enzymes, such as superoxide dismutase (SOD), catalase and glutathione peroxidase (Gpx) are altered in head-injured patients. The evidence suggests that polyunsaturated fats are a major constituent and substrate for lipid peroxidation, which results in free radicals. High levels of iron in the substantia nigra are shown to promote radical formation. Furthermore, the human brain contains significantly low concentrations of catalase, glutathione, glutathione peroxidase and vitamin E. The oxidative metabolism of dopamine also has the potential to generate radicals. Neuronal tissue has cellular and extracellular defense mechanisms against ROS. These mechanisms including enzymes such as superoxide dismutase and glutathione peroxidase, catalase to reduce the overall load of oxidative stress (Halliwell & Gutteridge, 1999). Supplementation of large doses of Vitamin E, Vitamin C, Selenium (as part of glutathione peroxidase) and cysteine (as part of glutathione) have shown to protect axonal tissue from the further damage caused by reactive species.

2.5. Skeletal Muscle Injury Most muscular injuries are caused by high counteracting forces and/or high resistance bouts. As the availability of athletic events increase at the amateur, high-school, collegiate and professional level, individuals are experiencing more injuries resulting in everyday muscular pain and impaired physical performance. In a society where the norm seems to be an “easy fix”, many Americans are turning to nutritional supplementation to eliminate the negative feeling experienced due to muscle injury. Although there are hundreds of beneficial claims reported by consumers, many of these claims are due to placebo effects. The recommendations and scientific evidence of these supplements are being manipulated by the fitness industry and athletics media, causing false beliefs. To date, there have been numerous studies on the effects of vitamins (antioxidants) on exercise-induced skeletal muscle injury. Damaged skeletal muscle can be measured by several direct and indirect markers. These markers include magnetic resonance imaging (MRI), a decreased range of motion (ROM), delayed-onset muscle soreness (DOMS), increased 3methylhistidine in urine (3-MH), increased creatine kinase (CK) and lactate

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dehydrogenase (LDH) levels in the blood and increased inflammatory biomarkers such as C-reactive protein and interleukin-6 (Bloomer, 2004). According to scientific experiments, the water-soluble vitamin C (ascorbic acid) and the fat-soluble vitamin E (alpha-tocopherol) have shown to effectively reduce certain signs and symptoms or degree of muscle injury, not eliminate it. Over a decade ago, Kaminsky and Boal (1992) studied the effects of ascorbic acid on delayed muscle soreness (DOMS). In this double-blind, cross-over study, subjects were supplemented with vitamin C or placebos for 3 days before and after their prescribed exercise. DOMS was measured by a visual scale. Results showed that DOMS was lower in the vitamin C individuals than the placebo group. Other experiments on vitamin E alone had negative results, meaning that the vitamin did not have significant effects on muscle damage and pain. However, after failing to conclude positive effects of vitamins C and E individually, researchers began to combine the two antioxidants to treat muscle injury. At the molecular level, vitamin C helps vitamin E maintain its reduced and most biologically active form. Bloomer et al. (2004) performed a study on untrained women who were supplemented a antioxidant mixture composed of 1 gram of vitamin C, 400 IU of vitamin E, and 90 micrograms of selenium or a placebo before and after their prescribed exercise. Results showed that both CK and DOMS levels were lower in the antioxidant group.

2.6. Creatine Creatine supplementation in athletes has had a negative stigma. Creatine monohydrate has been associated with dehydration, bloating, water retention and kidney strain. Yet, no studies have concluded such results. Some studies demonstrate that creatine supplementation increases sprinting performance, fat-free mass and the rate of muscle contractions. Greenwood et al. (2003) examined the effects of creatine supplementation on cramping, dehydration and various musculoskeletal injuries in NCAA Division 1 football players during the 1999 season. Results indicated that athletes who utilized creatine experienced less cramping and injury than the non-creatine users. Creatine users also improved their work capacity. In another creatine-based study, Franaux et al. (2001) measured maximum power output of knee extensions in males and females. The results were also beneficial in creatine users. Mean power output in knee extensions was increased and time to fatigue was also improved in both sexes. However, females were significantly favored.

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3. VITAMIN SUPPLEMENTATION AND PERFORMANCE Since vitamins do not directly provide immediate energy as carbohydrate and fats do, it would be controversial and highly debatable to ask the question “does vitamin supplementation improve performance?” The true question should be “do vitamin deficiencies impair athletic performance?” Exercise alone can increase an individual’s resting metabolic rate (RMR). In contrary, diet alone decreases an individual’s RMR. By increasing one’s RMR, the demands for energy expenditure and protein synthesis are increased. Therefore, metabolic pathways that utilize B vitamins such as thiamine (B1), riboflavin (B2) and Pyridoxine (B6) are stressed and in turn, elevate vitamin demands of an athlete. Studies displayed in table 1 indicate that active individuals tend to have inadequate vitamin statuses. This might be due to high energy demands and low nutrient dense foods. Nutritional researchers have performed studies on clinically vitamin depleted individuals to observe if vitamins deficiencies affect the ability to physically perform at maximal capacity. van der Beek et al. (1994) depleted men of thiamine, riboflavin and pyridoxine. Results showed a 12% decrease in maximal work capacity (VO2 max) and a 7% increase in blood lactate accumulation. Suboticance et al. (1990) assessed teenage boys with poor vitamin B6 and riboflavin levels. Their physical performance on a bicycle ergometer improved after being supplemented with vitamin B6 and riboflavin. With existing studies, it is safe to say that vitamin deficiencies negatively affect maximal work capacity and athletic performance.

4. ORIENTAL SUPPLEMENTS AND PEROFRMANCE For many years now, Americans in the athletic world have had a sense of wonder about Asian dietary habits. Both how they eat and what they eat. Countries like China and Japan seem to lack the epidemics, such as cancer and obesity, occurring in the United States. Yet their elite athletes tend to follow that path in reference to fatiguing and recovery. Chen et al. (2002) studied the effects of Huangqi Jianzhong Tang, a medication used to treat peptic ulcers and convulsions in the ancient oriental regions, on fatigue time in athletes. The athletes were supplemented with the herb in powdered form and a placebo. Results confirmed that Huangqi Jianzhong Tang effectively reduced muscular fatigue in the herb group. Because of this, muscular strength also increased. The scientists believe Huangqi Jianzhong Tang reduces fatigue by increasing the oxygen uptake in aerobic systems.

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Ma-huang, commonly called ephedra or ephedrine, has been used by the Chinese for centuries. Purposes have been for respiratory medications and weight loss through its thermogenic effects. Its alkaloid form stimulates the central nervous system. Ginseng is another commonly used herb. It is known for its adaptogenic effects on the sympathetic nervous system. It is believed to reduce stress, increases immunity, decrease the sensation of fatigue,and improve reaction time.

Incidence of Athletes Worldwide With Low Nutritional Intakes Table 1. Studies conducted on athletes worldwide to determine if dietary recommendations were met.

Authors

Gender/Sport

Clark et al. Rico-Sanz et al. Rankinen et al. Zieglar et al.

Females/Soccer Males/Soccer Males/Skiing Females/Figure Skating

Lower than Required Recommendation Vitamin E, Folate, Copper, Magnesium

Country United States

Calcium Vitamin D and E, Zinc and Magnesium

Puerto Rico

Unites States

USA Korea

Papadopou lou et al.

Females/Volleyball

Beals et al.

Volleyball

Folate, Iron, and calcium Calcium, Iron, folate, magnesium, Zinc, and Vitamin A and E Folate, B vitamins, vitamin C, Iron, Calcium, Magnesium, and Zinc

Kim et al.

Females/Judo

Calcium and Iron

Finland

Greece

5. NUTRITION AND FATIGUE Rothwell (1994) defined the term fatigue as both physical and mental exhaustion due to prolonged stimulation or exertion. Fatigue resulting from exercise and physical activity has been related to central and peripheral factors. These factors have been indentified to be influenced by the intensity and duration of the activity, the athlete’s physiological status and nutrition intake. Most text books and studies concentrate on peripheral factors and known biochemical pathways that lead to fatigue, such as the depletion of muscle and liver glycogen, the inhibition of Calcium ions in muscle physiology by hydrogen proton from the accumulation of lactic acid, water loss and impaired electrical impulses in muscle during performance. Ovulation in females has also been associated with exercise fatigue (Drake, 2004). However, neurobiological factors that directly and/or indirectly influence central fatigue are less known and lack scientific proof (Nybo,

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2004). Amino acids and 5-hydroxytryptamine (5-HT), known as serotonin, have been closely identified to be influential factors in causing central fatigue.

5.1. Serotonin (5-HT) Fluctuations in serotonin levels in the brain have been involved in the control of sleeping patterns, arousal and clinical depression. 5-HT has been suggested to play a role in mental fatigue during physical activity. The first study to demonstrate that serotonin is influenced by exercise was published in the early 1960’s by Barchas and Freedman (1963). After exhausting laboratory rats with exercise protocols, they determined an increased concentration of 5-HT in the rats’ brains. Several other studies have indicated that 5-HT is released in the hippocampus and frontal cortex during and after intense exercise (Frusztajer et el., 1990; Kim et al., 2002; Kirby et al., 1995). The controversy about serotonin being involved in exercise is currently being debated. However, the relationship between serotonin release and central fatigue during exercise has been supported by animal studies where animal brain 5HT levels have been pharmacologically manipulated. Running performance in rats was improved by the administration of a peripheral 5-HT antagonist (Bailey, 2003). Experiments with human subjects are controversial. Some indicate the involvement of 5-HT in fatigue and some do not. Differences in pharmaceutical agents and their time of administering, differences in frequency, intensity and duration of exercise, or individual variation in neuroendocrine responses, might explain opposing results (Blomstrand, 2006).

5.2. Amino Acids During the past decade, the ingestion of branched chain amino acids (BCAAs) and their influence on the transportation of tryptophan and 5-HT metabolism has been investigated. Several studies on BCAAs have focused on their plasma concentrations and increasing effects of free tryptophan. In theory, the supplementation of BCAAs, decrease the transport of tryptophan into the brain, 5-HT synthesis and the perception of fatigue (Bromstrand, 2006). The intake or administration of tryptophan is predicted to elevate free tryptophan levels and accelerate the perception of mental fatigue. Supporting the involvement of tryptophan was the administration of tryptophan to rats and horses by Farris et al. (1998) and Soares et al. (2002). The increased free and total blood tryptophan concentration in the animals

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was associated with a reduction in performance, thus supporting the involvement of tryptophan and 5-HT in fatigue. Blomstrand et al. (1997) conducted a study where human subjects were supplied with a mixed dose of BCAAs. Results concluded that perceptions of exhaustion and mental fatigue were decreased. In another study conducted by Mittleman et al. (1998), physical performance in a warm environment was evaluated as time to exhaustion. Human exhaustion was improved from 137 to 153 minutes. However, the debate between whether BCAAs should be supplemented with carbohydrates is still under research. BCAAs supplementation has also shown to be DOMS in females (Shimomura et al. 2006).

6. NUTRITION AND FEMALE ATHLETES Since Title IX of the Education Amendments of 1972 (20 United States Code section 1681) was enacted in 1972 by the Office of Civil rights (NCAA), high school females have increased their participation in sports by 904% and college females have increased their participation by 456% (WSF, 2007). Although these statistics show advancement in our fight for gender equality in athletes, it also demonstrates a growing field of possible gender specific injuries and trends. A common diagnostic tool and unfortunate issue that female athletes are being regularly recognized as having is the famous female athlete triad. It is a syndrome composed of anorexic behaviors, amenorrhea and osteopenia, early stages of osteoporosis. The signs and symptoms include decreased appetite, irregular periods, stress fractures, re-injuries, chronic fatigue and impaired endurance. The female athlete triad is commonly recognized in females who frequently are involved in disordered eating by restricting calories and protein (meat) in their diet, and often lack rest. Specific sports have physical requirements, such as obtaining a smaller body frame and less body fat. Gymnastics, track and field and competitive cheerleading fall under that category. Dieting is common in competitive dancers and results in amenorrhea (Warren, 1986). Frusztajer et al. (1990) conducted a study on ballet dancers with similar endocrine profiles to determine if stress fractures differed with respect to nutrition. Results indicated that dancers with stress fractures were more likely to consume diets meeting less than 85% of the RDA. This trend in dieting was to avoid high fatty foods while consuming more low-calorie substitutes. Several studies have also shown that female athletes with higher incidences of stress fractures have been associated with lower intakes of calcium and less frequent usage of oral contraceptives (Kiningham, 1996). The importance of calcium is observed in bone metabolism. While the recommended dietary allowance of calcium is 1,200 to 1,500 milligrams per

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day for females within the age range of 11 to 24 years of age, national surveys of teenage females have indicated that average daily intakes of calcium if less than 900 milligrams per day. Benefitting calcium metabolism is vitamin D. An additional daily supplementation of 400 to 800 international units (IU) is believed to facilitate the absorption of calcium (National Institute of Health). Vitamin K supplementation has also shown to improve bone metabolism in amenorrhoeic female athletes (Craucuin, 1988). When analyzing the female triad, one must strongly consider the culture and background of the athletes. Okano et al. (2005) concluded there is a lower prevalence of disordered eating in Chinese female athletes than Japanese. Still, both nations have significantly lower indices of eating disorder than that of the United States. This is partly explained by the lack of socioculturally desire to be thin and low frequency of dieting during their lifetime.

CONCLUSION There is no doubt whether nutrition plays a crucial role in athletic performance. Research has proven that macromolecule and vitamin metabolism is intertwined with elite performance. If such scientific fact was debatable, Olympic and professional teams would not be competing with highly trained and educated nutritionists on their sidelines. Manipulating what metabolic fuels to utilize, which cellular components to improve and which recovery substances to ingest has allowed physically active individuals to enhance their quality of athletic performance and better prevention of injury at the physical and psychological levels. In general, the purpose is to provide an athlete with easily digestible food to provide adequate energy and carbohydrates for glycogen replacement and ensure proper recovery. Introducing proper nutrition and its contribution to training and optimal performance should be a top priority for all coaching staff. Especially in sports requiring low body weight and a lean body composition such as gymnastics, cross-country, diving and swimming and competitive cheerleading and dance. Vegetarian athletes must comprehend the reality of being at risk due to their low protein intakes and low-density foods consumption. In regards to the female triad, some of its components are often undetected and misdiagnosed. Prevention is crucial and recognizing the syndrome’s risk factors is a key. Clinicians should be cautious with symptoms such as anemia, electrolytes imbalances, fatigue and signs of depression. One must also understand that young athletes, especially female athletes, are prone to adapt maladaptive eating behaviors when body image and composition are emphasized by their coaches or instructors. Therefore, diagnosing such problems may play a role in managing this condition. For

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optimal treatment of the female triad, physicians and other professionals with subspecialties in nutritional counseling should not be the only individuals running the rehab plan. Coaches, trainers and family members closest to the athlete should also partake in the process. Although human performance can be benefitted through nutrient supplementation, an athlete’s heredity is still the greatest factor in determining elite, and most importantly, injury-free performance.

Acknowledgments This chapter was written by Julio Cezar Gomes, Penn State undergraduate student with double major in Kinesiology & Nutritional Science under the author’s direct supervision and guidance.

REFERENCES Evans, W.J. & Hughes, V.A. (1985). Dietary carbohydrates and endurance exercise. American Journal of Clinical Nutrition, 41, 1146–1154. Volek, J.S., Kraemer, W.J., Ruben, M.R., et al. (20020). L-carnitine L-tartrate supplementation favorably affects markers of recovery from exercise stress. American Journal of Physiology-Endocrinology and Metabolism, 282, E474-82. Holm, L., Esmarck B., Mizuno, H., Hansen H., Suetta, C., Holmich, P., Krogsgaard M., Kjaer M. (2005). The Effect of Protein and Carbohydrate Supplementation on Strength Training Outcome of Rehabilitation. Halliwell, B., Gutteridge, J.M.C. Free Radicals in Biology and Medicine, third ed. Oxford University Press, Oxford, 1999. Bloomer, R.J., Goldfarb, A.H., McKenzie, M.J., et al. (2004). Effects of antioxidant therapy in females exposed to eccentric exercise. International Journal of Sport Nutrition and Exercise Metabolism, 14, 377-88. Kaminsky, M., Boa, L. R. (1992). An effect of ascorbic acid on delayed-onset muscle soreness. Pain, 50, 317-21. Greenwood, M., Kreider, R.B., Greenwood, L., Byars, A. (2003). Cramping and Injury Incidence in Collegiate Football Players Are Reduced by Creatine Supplementation. Journal of Athletic Training, 38(3), 216-219. Franaux., M., Louis, M., Sturbois, X., & Poortmans, J. R. (2001). Effects of creatine supplementation in males and females. Medicine and Science in Sports and Exercise, 33, 5. van der Beek, E.J., van Dokkum, W., Wedel, M., Schrijver, J., van den Berg, H. (1994). Thiamin, riboflavin and vitamin B6: impact of restricted intake on physical performance in man. Journal of the American College of Nutrition., 13(6), 629-640. Suboticanec, K., Stavljenić, A., Schalch, W., Buzina, R. (1990). Effects of pyridoxine and riboflavin supplementation on physical fitness in young adolescents. International Journal for Vitamins and Nutrition Research., 60(1), 81-88. Chen, K.T., Su, C.H., Hsin, L., Su, Y. (2002). Reducing fatigue of athletes following oral administration of Huangqi Jianzhong Tang. Acta Pharmacologia, 23(8), 757-761. Clark, M., Reed, D.B., Crouse, S.F., et al. (2003). Pre- and post-season dietary intake, body composition,and performance indices of NCAA division I female soccer players. International Journal of Sport Nutrition and Exercise Metabolism, 13(3), 303–319.

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Rico-Sanz, J., Frontera, W.R., Mole, P.A., et al. (1998). Dietary and performance assessment of elite soccer players during a period of intense training. International Journal of Sport Nutrition, 8(3), 230–240. Rankinen, T., Lyytikainen, S., Vanninen, E., et al. (1998). Nutritional status of the Finnish elite ski jumpers. Medicine & Science in Sports & Exercise, 30(11), 1592–1597. Ziegler, P.J., Jonnalagadda, S.S., Nelson, J.A., et al. (2992). Contribution of meals and snacks to nutrient intake of male and female elite figure skaters during peak competitive season. Journal of the American College of Nutrition, 21(2), 114–119. Papadopoulou, S.K., Papadopoulou, S.D., Gallos, G.K. (2002). Macro- and micro-nutrient intake of adolescent Greek female volleyball players. International Journal of Sport Nutrition and Exercise Metabolism, 12(1), 73–80. Beals, K.A.. (2002). Eating behaviors, nutritional status, and menstrual function in elite female adolescent volleyball players. Journal of the American Dietary Association, 102(9), 1293–1296. Kim, S.H., Kim, H.Y., Kim, W.K., et al. (2002). Nutritional status, iron-deficiency-related indices, and immunity of female athletes Journal of the American Dietary Association 18(1), 86–90. Rothwell, J. (1994). Control of human voluntary movement. Second edition. Chapman & Hill. Drake, S.M., Evetovich, T.K., Eschbach C., Webster, M., Whitehead, T. (2004). The effect of menstrual cycle on electromyography and mechanomyography during fatigue. Medicine and Science in Sports and Exercise, 36, 5. Nybo, Z. & Secher, N.H. (2004). Cerebral perturbations provoked by prolonged exercise. Progress in Neurobiology, 72, 223-261. Barchas, J.D., Freedman, D.X. (1963). Brain amines: response to physiological stress. Biochemical Pharmacology, 12, 1232-1235. Frusztajer, N.T., Dhuper, S., Warren, M.P., Brooks-Gunn, J. & Fox, R.P. (1990). Nutrition and the incidence of stress fractures in ballet dancers. American Journal of Clinical Nutrition, 5(1), 779-783. Kirby, L.G., Allen, A.R., Lucki, I. (1995). Regional differences in the effects of forced swimming on extracellular levels of 5-hydroxytryptamine and 5-hydroxyindole-acetic acid. Brain Research, 682, 189-196. Bailey, S.P., Davis, J.M., Ahlborn, E.N. (1993). Serotonergic agonists and antagonists affect endurance performance in the rat. Internaitonal Journal of Sports Medicine, 14, 330-333. Blomstrand, E. (2006). A Role for Branched-Chain Amino Acids in Reducing Central Fatigue1-3. The Journal of Nutrition, 136(2), 544-548. Farris, J.W., Hinchcliffe, K.W., McKeever, K.H., Lamb, D.R., Thompson, D.L. (1998). Effect of tryptophan and of glucose on exercise capacity of horses. Journal of Applied Physiology, 85, 807-816. Soares, D.D., Lima, N.R., Coimbra, C.C., Marubayash,i U. (2002). Evidence that tryptophan reduces mechanical efficiency and running performance in rats. Pharmacological Biochemistry Behavior, 74, 357-362. Blomstrand, E., Hassmén, P., Ek, S., Ekblom, B., Newsholme, E.A. (1997). Influence of ingesting a solution of branched-chain amino acids on perceived exertion during exercise. Acta Physiologica Scandinavica, 159, 41-49. Mittleman, K.D., Ricci, M.R., Bailey, S.P. (1998). Branched-chain amino acids prolong exercise during heat stress in men and women. Medicine in Science, Sports & Exercise, 30, 83-91. Shimomura, Y., Yamamoto, Y., Bajotto, G., et al. (2006). Nutraceutical effects of branchedchain amino acids on skeletal muscle. Journal of Nutrition, 136(2), 529S-32S. www.womenssportsfoundation.org www.ncaa.org

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Warren, M.P., Brooks-Ounn, J., Hamilton, L.H., Warren, L.F., Hamilton, W.O. (1986). Scoliosis and fractures in young ballet dancers: relation to delayed menarche and amenorrhoea. New England Journal of Medicine, 314, 1348-1353. Kiningham, R.B., Apgar, B.S., Schwenk, T.L. (1996). Evaluation of amenorrhea. American Family Physician, 53, 1185-1194. National Institiute of Heatlth Consensus conference. (1994). Optimal calcium intake. NIH Consensus Development Panel on Optimal Calcium Intake. JAMA, 1272, 1942-1948. Cracuin, A.M., Wolf, J., Knapen, M.H., Brouns, F., Vermeer, C. (1988). Improved bone metabolism in female elite athletes after vitamin K supplementation. International Journal of Sports Medicine, 19, 479-484. Okano, G., Holmes, R.A., Mu, Z., Yang, P., Lin, Z., Nakai, Y. (2005). Disordered Eating in Japanese and Chinese Female Runners, Rhythmic Gymnasts and Gymnasts International Journal of Sports Medicine, 26, 486-491.

CHAPTER 6 INJURY IN ATHLETICS: COACHES’ POINT OF VIEW 1. INTRODUCTION There are numerous causes and a variety of physical, behavioral and psychological consequences of athletic injuries. Coaching errors are commonly cited as one of the major causes of athletic injuries. Generally speaking, there are two types of coaching styles that make a tremendous impact on the physical and psychological atmosphere in the training/ competition environments. As identified by Greg Louganis, three time Olympic Champion, the first one is judgmental and critical, which is characterized by the situation when coaches are trying hard (maybe with good intention) to identify as much error in performance as possible, then present these errors in a critical manner. “You are not listening…, how many times have I told you to keep your eyes on the ball…, you are still not doing that…, you’ll never get this, why don’t you try to play golf instead…,” to name just a few examples of this coaching style. It could be expected that tremendous tension can be anticipated in the coach-athlete relationship over time. Inevitably, the breaking point will be reached and the relationship will end due to a deficient coaching style. (Personal communication with Greg Louganis, 2007 US Diving National Training Camp, Indianapolis, Ind.) The second style of coaching is characterized by the atmosphere where the coaches observe and assess an athlete’s performance, with the intention to identify both progress and still existing errors in performance. “Good effort…, right direction to think..., you should feel better than yesterday…, keep trying.., still losing contact with the ball…,” to name just a few comments within this style of coaching. Not surprisingly, this second coaching style creates an extremely positive learning/training environment benefiting both the physical and mental well-being of the athletes. In addition to issues with the overall coaching styles identified above, there are several fundamental coaching problems that directly and/or indirectly cause high risk for injury in athletic environments. Specifically, inadequate assessment of athletes’ physical skills, misunderstanding of psychological coping resources, rushing with acquisition of new techniques, overtraining and overloading causing accumulated muscle and mental fatigue, and early return to sport participation after injury are just a few examples of coaching errors that increase the risk of injury/re-injury in athletics. The following text contains some common coaching mistakes identified by clinical sport practitioners and psychologists, including:

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*Overreacting when the athlete makes an error or does not perform according to the coach’s instructions and expectations. It should be noted that there are at least two types of errors of overly observed performance: (a) error of execution of skill, when a clear picture of an ideal performance is intact but physical capacities are not adequate and/or sufficient enough to meet high demands of performance; and (b) error of planning, when a clear image of an ideal performance is lacking due to inadequate cognitive assessment of the situation and demands, but the athlete’s capacity in terms of strength, flexibility and endurance is intact. Accordingly, clear identification of overall performance is critical to avoid coaches overreacting, which in fact an indication of inefficient judgment and/or too critical a style of coaching. *Demanding too much time or commitment from athletes so that they are continually injured. Clearly to be competitive at the collegiate level to say nothing of Olympic level, it is necessary to allocate enormous amounts of time and effort to practice and work outs. For example, currently elite Chinese Olympic divers practice on average eight hours a day, six days per week. My personal observation of the Chinese divers’ training session during the 2007 Diving World Series revealed that they performed on average 120 competitive dives per day in addition to post-practice conditioning training for almost two hours. Suffice it to say that this observation took place during the high peak competitive season; one may wonder how many dives the Chinese divers perform and/or for how many hours they practice during the pre-competitive preparatory phase of training program. Thus, in order to be competitive in the international sporting arena, coaches must demand that athletes commit most of their time to sport. One thing to consider is all the competing, confounding factors (i.e., financial compensation, professional versus collegiate status, cultural/societal differences, etc) before demanding excessive time and/or commitment to sport to meet its growing demands. *Relentlessly putting a high amount of pressure on the athletes, causing every practice to become a life-or-death situation or requiring that athletes are constantly at boundary level of being over-trained and/or burnout. There is common “goal-oriented philosophy” that sport psychologists call “outcome orientation”. Rarely do coaches encourage the amount of effort an athlete puts into action to accommodate his/her coaches’ demands. Accordingly, so-called “mastery orientation,” which emphasizes the importance of the process of skill acquisition and step-by-step improvement, is a rare practice in a coaching environment. As Greg Louganis believes, “… it is not necessary to be perfect every time performing the dives both at practice and even at competitions. Everybody makes mistakes, nobody is perfect. There is always room for improvement and this is an endless process. Thus, coaches should focus on progress, even non-significant, rather than on ideal performance routines. This coaching style may reduce

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a lot of pressure even if the demands of the sport are exhausting.” (Personal communication, August 2007, US Diving Training Camp, Indianapolis). *Specifically for collegiate athletics, NOT respecting that studentathletes need to have balance in their life – time for school, work, family, friends and rest. Despite the regulation imposed by NCCA which restricts the time for practices/competitions, and promotes the balanced life and wellbeing of student-athletes, external demands/expectations as well as the selfimposed high achievement attitude of collegiate athletes may put these athletes at risk for burn-out and injuries. Sporadic evidence and numerous observations suggest that the transition from high school to college frequently induces a higher risk for injury due to a disrupted life-style. This factor should be taken into consideration, especially when dealing with freshman collegiate athletes who just left their home, parental support, friends, etc. As Penn State gymnastic coach Randy Jepson stressed, “… it is really difficult to work with incoming freshman athletes. They do not have realistic expectations and do not have enough confidence in us as coaches. It takes time to develop a relationship and demonstrate that our major concern is their safety and well-being, not what they can or cannot do in the gym.” *Overemphasizing body weight, especially in complex coordination sports with female athletes can lead to self-image problems and even serious eating disorders. This is a tremendous concern not only for females but also for male athletes. My personal view is as follows: it is not body weight that should be used as a possible limiting factor for performance enhancement but rather an athlete’s ability to control his/her body and possess enough strength, flexibility and endurance to properly perform all necessary drills and routines. It is more important to emphasize healthy nutrition and eating habits than to be preoccupied with body weight. Coaches must focus on fitness and body shape rather than body weight. That stated, it is important to note that if any signs of eating disorders are present this should be considered as a serious clinical problem requiring treatment by specialists. It is essential that coaches acquire the knowledge to be able to detect signs of eating disorders in order to prevent the possibility of catastrophic consequences. *Mistreating the athletes for being lazy, not trying hard enough or not placing high enough and dragging the whole team down the slope is another detrimental style. Athletes are human and should be treated accordingly. As stressed by coach Jepson, “People should be treated as people, not like machines and robots having a goal to be best in their sport. I treat gymnasts on my team as people and sport is just a part of their life.” Truly, this coaching philosophy may be an instrumental part of the success of the Penn State Men’s gymnastic program, which won three National Championships over the last ten years under the leadership of coach Randy Jepson.

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*Losing perspective on the whole purpose of sports and being completely preoccupied with winning at any cost and putting athletes under tremendous pressure and stress. As stressed by the coach Ron O’Brien, who has been coaching multiple Olympic Champions for more than 40 years, “… there are too many unfortunate circ*mstances that are far beyond our control influencing a winning versus losing situation. So, why bother? Wouldn’t it be better to spend our time more productively focusing on technical details and ways to improve an athlete’s skill and experience?” This so called “mastery orientation approach” is rewarding and a mutually beneficial approach from both athletes’ and coaches’ perspectives. This motive is a driving force of numerous great coaches who think of the wellbeing of the athletes. Similarly, as clinicians, we are not treating generalized anxiety disorder, or ACL per se, but rather we are taking care of people with physical and/or mental problems. Another important problem to consider in terms of the coaches’ role in prevention of injury in athletes is the “knowledge-attitude relationship issue”. Clearly, there is a differentiation of function in modern sports. Coaches are coaching, fitness experts are taking care of athletes’ conditioning and doctors are involved if injuries happened. Not surprisingly, the primary concern of coaches is to stay current in the areas directly related to performance enhancement. There are different sources to improve professional qualification of coaches. Not surprisingly, huge problems appear when coaches’ ignorance meets with arrogance. That said, the content of the coaches’ knowledge should be spread to some extent to understand the causes and consequences of injuries in athletes. As was described in the previous chapters of this book, there are common overuse injuries in certain sports due to their nature that could be predicted or maybe prevented by using appropriate training programs. For example, the knowledge of the causes of chronic ankle dislocations in gymnastics (i.e., improper landing after somersaults) may develop the proper attitude in the coaches, who would then employ specific exercise routines to prevent this problem. There is some relevant research examining the relationship between knowledge and attitude in other domains. A few previous studies (Simonds, 2005; Sefton, 2003; Livingston & Ingersoll, 2005; Kaut et al., 2004) have examined the knowledge of and/or attitudes about concussion in college athletes, and only one study has examined the prevalence of the underreporting of concussion in athletes (McCrea et al., 2004). Although the specifics of these studies can be found in greater detail elsewhere in the relevant literature, the findings generally show that athletes’ knowledge and attitudes about concussion vary. There are some domains that athletes are proficient in and others that they appear to be deficient in (Simonds, 2005; Sefton, 2003; Livingston & Ingersoll, 2005). Additionally, there is a subset of athletes whose attitudes about concussion appear to be unsafe (Simonds,

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2005; Sefton, 2003). Finally, the behavior of a significant portion of athletes in reaction to concussion appears to be congruent with this unsafe attitude, as about half of the high school athletes surveyed by McCrea et al. (2004) failed to report a concussion after it occurred. Thus, although there has been some data from various studies about concussion knowledge, attitudes, and risky behaviors (i.e., playing while experiencing the symptoms of concussion), there have been no studies conducted that have examined the relationships between concussion knowledge, attitudes, and risky behaviors occurring after concussion. Research focusing on “knowledge-attitude” relationships within the scope of prevention may be sufficiently similar to known literature pertaining to sexual behavior in adolescents. For example, Kirby (2002) reviewed the literature pertaining to outcomes of educational interventions intended to decrease unprotected sex and pregnancy rates. The researcher reviewed seventy-three studies conducted in the United States and Canada that were conducted using adolescents ages 12-18. Each study evaluated the effectiveness of a sex and/or HIV education program. These programs were intended to increase knowledge, alter attitudes and influence behavior. A number of indicators of program effectiveness were examined in the review: initiation of intercourse, frequency of sexual intercourse, number of sexual partners and contraceptive/condom use. Participants in the studies were exposed to a particular intervention and were followed up for a period of time after the end of the intervention. The results of the interventions were promising in that about one-third of the programs measuring the initiation of intercourse contributed to a delay in the initiation of intercourse. No changes in initiation of intercourse were seen in most of the other studies. About 25% of programs resulted in reduced frequency of sex, and most of the other studies showed no change in the frequency of sexual intercourse. In 30% of the studies examining the number of sexual partners, the number of partners decreased. As with other outcome indicators, no changes were seen in the other studies in the frequency of sexual intercourse. Participants in about two-thirds of the studies that measured changes in condom use after the end of the educational program reported significant increases in condom use, and most of the other studies reported no change in condom use. It should also be noted that the vast majority of these seventy-three studies either reported reductions in risky sexual behavior or no change in the frequency of the sexual practices. The lack of change in sexual practices is considered to be an indicator of an effective educational program because it is believed that the knowledge gained by students likely contributes to their decision to maintain their current sexual practices, rather than increasing the likelihood of pregnancy or the transmission of HIV due to an increase in number of sexual partners or an increase in unprotected sex (Kirby, 2002).

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This review begins to establish a link between the knowledge gained from the educational programs and the influence that this information may have on the diminution or stabilization of potentially unsafe and, therefore, risky sexual behaviors. However, because the study lacked direct information about the relationships between knowledge, attitudes and behaviors, the nature of these relationships is unclear. An additional study was conducted to address this relationship and further establish a connection between sex and HIV education programs and changes in risky sexual behavior (Kirby, Laris, & Rolleri, 2007). The researchers reviewed eighty-three studies, many of which were conducted in the United States. Moreover, several studies were conducted in other developed and underdeveloped countries. Thus, this study included a more diverse and, potentially, representative sample of adolescents and young adults. The age range of participants involved in the studies included in the literature review was between nine and twenty-four years of age. The findings pertaining to risky sexual behavior were roughly similar to those found in the Kirby (2002) review. More importantly, almost all of the studies examining knowledge about sexual intercourse and safe sex practices reported increases in knowledge and about two-thirds of the studies examining attitudes about sex reported safer attitudes towards sex. About 40% of the studies examining student perceptions of sexual behavior in peers (an influential factor in the decision making of adolescents; Millstein & Halpern-Felsher, 2002) reported that students tended to believe that their peers were engaging in safer sexual behaviors. The authors concluded that the educational programs tended to increase knowledge and alter attitudes about sex and change perceptions of peer sexual behavior. These cognitive and emotional changes then influenced changes in risky behavior (Kirby et al., 2007). These literature reviews suggest that the likelihood of engagement in a risky behavior is associated with the knowledge that an individual possesses about that behavior. Furthermore, the evidence points to a link between an individual’s attitudes about risky behavior and engagement in the behavior. Although it is unclear as to how knowledge and attitudes about sport-related injuries affect the likelihood of reporting an injury upon recognition of the symptoms or how these factors influence adherence with medical treatment recommendations after injury, it seems possible that either knowledge or attitudes, or both, may lead to higher injury reporting rates and greater adherence among injured athletes. Overall, it is the responsibility of clinical practitioners to expand the athletes’ and coaches’ knowledge of the causes of athletic injury.

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2. INTERVIEW WITH ELITE COACHES Personal interviews with several world class Olympic coaches as well as with collegiate coaches were conducted, and aimed to explore their perspectives on causes and consequences of injuries in elite athletes. Upon request, and due to the sensitivity of the issues, some of the last names of the coaches are omitted. Q1. Injury is a common risk and unfortunately an unavoidable part of athletics. Most athletes, regardless of sport, experience some type of injury during their athletic careers ranging from mild to severe. Despite technological advances and improved sports equipment, advanced coaching expertise and knowledge about particular sports, understanding nutritional and psychological factors contributing to athletes’ progress and well-being, the number of injuries continues to rise. Could you please elaborate on why injury is still an unavoidable part of athletics today? What elements do you feel are most essential in coaching elite athletes to prevent risk of injury? Coach Ron O’Brien (USA Diving): Dr. O’Brien has coached nineteen different Olympians to twelve Olympic medals (five gold, three silver, four bronze) and produced US National Champions for twenty-four straight years. In Olympic, World Championship, World Cup, Pan Am, University, USA Diving and NCAA, his divers won 196 gold, 113 silver and 106 bronze medals. He coached Greg Louganis to four Olympic gold medals. Responding to the questions, Dr. O’Brian thinks coaches need to continuously monitor the fatigue level, including both muscle and mental fatigue, and determine the training load accordingly. The two most common contributors to injury are overtraining and inadequate use of rest which would allow the athletes to recover from previous training loads. In other words, the lack of recuperation control may lead to the cumulative effect of fatigue which is a direct cause of injury in elite athletes. Coach Yembo (China): In China, we have the luxury to select, not recruit, children at an early age for particular sports. We believe that prevention of injury starts from the selection of children with proper physical and psychological properties, allowing us to work hard and create an injury free environment. First, the most essential component of our training program is that every single kid selected for elite programs would go to a two-to-three year gymnastic program in order to acquire fundamental motor skills, such as body awareness, coordination, flexibility and strength. Second, we are fully aware that if an athlete suffers an injury requiring surgery, there is no way for this athlete to be fully functional, even after recovery, despite advanced medicine. For this reason we do everything possible, including proper nutrition, to prevent injury. Finally, over the years of training hard, Chinese coaches have acquired the knowledge and experience of how to

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control for overtraining and proper recuperation. Of course, injury may happen as bad luck, but not due to coaching errors. Coach Georgeo (Italy): I have been coaching elite athletes for more than twenty years and believe that injury can and should be prevented. My injury prevention strategy is “trusting” my athletes’ feelings. I encourage them to “listen and feel their body,” and as early as excessive muscle soreness happens, they should let me know. Then we immediately switch to other types of activities, without reduction of volume or intensity of the preplanned training session. Another aspect of injury prevention is to “overload” the body in the preparation phase so when major competitions start, there won’t be any pressure due to fatigue. At this time, we basically flatten the load and intensity of the training program and constantly control for possible drop of conditioning. Whenever it happens, we stop specific training and return to basic skills. Finally, emotional happiness of the athlete is critical to prevent over-training despite current demands in elite sports. Coach Michail (Russia): There is one way to reduce injury in elite sports to date: Reduce training volume to simplify exercise routines and to reduce the longevity of athletes’ careers. By doing so, however, there won’t be elite sports anymore. In other words, every single athlete who achieved world class level is at high risk for severe injuries or multiple injuries, including catastrophic injuries. They should accept it or quit; there is no way around it. That said, we do everything possible to make sure to maintain and control high levels of fitness the whole year around, to reach the flexibility level up to two times higher than necessary and to perform competitive routines five times more than required at the competition. The other important factor to consider in terms of injury prevention is proper warm up prior to the main part of the training session. In fact, boys are needed for a longer time and require more effort than girls because they are bigger and stronger. Again, injury is an unavoidable part of elite athletes. They should acquire experience to compete with injuries, because injury can happen at any time, even during the Olympic Games and there is no way to miss the most important event in an athlete’s life. Coach Julio (Cuba): Due to excessive pressure from international elite athletes and tremendous pressure from our society to win at all cost, we have to practice harder and harder. Unfortunately, there are limits of human resources, then these limits are ignored and the injury happens. It should be stressed that we often know there is a limit of athletes’ capacities but voluntarily take a risk to explore it. If we are lucky, we are at the top of the world, if not, that is our destiny. Coach Josean (Spain): Injury happens often in elite athletes mostly because coaches are not patient. They force the athletes to higher standards before they are ready to meet new challenges, both physical and most importantly psychological. I believe that 90% of injuries in elite athletes happen because of an abnormal mental status of the athletes, when they get tired at the end of

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season. As coaches, we know how to “load” athletes and make them physically strong. Unfortunately, we do not know how to “load” athletes mentally to make them psychologically strong. Unless we get this knowledge, injury will be a part of elite athletics. Coach Ganter (PSU, Football): I think the injuries are inevitable because in contact sports things have to happen. There has to be some give and something is going to give when you are dealing with a contact sport. Obviously, the knowledge of the game is an important contributor to injury. It is important to make sure that athletes are in proper position. The strength training is the most essential element in coaching college athletes in order to prevent the risk of injury. I think conditioning and strength training probably outweigh the other two, because you could be out of position or you could be in an awkward position and still your strength training should carry you through any serious injury, at least as far as prevention goes. So, I think strength training, including its proper gain and control, is the key element in terms of prevention of injury in football. Coach Jepson (PSU, Gymnastics): I would like to address the questions regarding the injury as an unavoidable part of athletics in gymnastics, and what we can do in order to prevent traumatic injuries in our sport. It is my strong belief that physical preparation of gymnasts is the most essential factor of injury and injury prevention. Functional abilities, general strength and conditioning and flexibility and specific skills are most important. The lack of these athletic properties is a predisposing factor for injury. Especially in my sport, you have to have general strength and specific flexibility in order to be injury free. So, you as a coach are going to set up the situation when injury should be under control. The second thing, looking from an injury prevention perspective, is the selection of elements that a given gymnast can learn, consistently perform and be comfortable with in his competitive routine. Athletes and coaches should have realistic expectations of demands and personal capacities to meet these demands. You need to prepare athletes both physically and emotionally so that expectations should be reasonably adequate and acceptable both from coaches’ and athletes’ perspectives. Do not expect good performance from athletes who are well prepared physically, but not ready emotionally for upcoming events. Even the amount of work load would be differentially accepted and perceived by athletes with different levels of “emotional” readiness. I would say that you can avoid injury if you train properly. As far as risk is concerned, there is no question that gymnastics is a risky sport by mother’s nature, however, proper training of gymnasts is a key factor of injury-free environment in gymnastics. Coach Shephard (PSU, Women Gymnastics): Every time the body is in motion, it needs to overcome the inertia, which is difficult to control. Especially in my sport of gymnastics, as soon as the gymnast left the base of support, it is really difficult to change the movement trajectory. So,

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inappropriate take-off, slight errors in movement initiation may lead to an unavoidable risk of injury. In addition, you must stop the movement fast, the hard landing, deceleration and all other mechanical properties of required skills are difficult to control, which is another major reason of injury, including traumatic brain injury. In other words, objective demands for the sport of gymnastics, high risk associated with skill performance and the necessity to maintain focus on what is supposed to be done – all these are predisposing factors for injury in modern gymnastics. You subject your body to abnormal forces all the time which lead to overuse injuries as well to traumatic injuries. You land incorrectly, you land hard on one leg, you fall, and this will be always present in gymnastics. Therefore, I agree that risk of injury is unavoidable and an inherent part of athletics in general, and in gymnastics in particular. There is no way totally to eliminate it. However, if you train smart and correctly, you can definitely reduce the number of injuries, especially overuse injury, by appropriate planning and controlling the training process. The planning of training programs, the assessment of physical skill and psychological status of an athlete are important, but the most important issue, at least in our sport of gymnastics is body composition. Overall physical fitness and conditioning and the lack of these properties must be the most important priority of gymnastic coaches. If you take care of it, you can dramatically reduce the number of injuries. Second, systematic approach, periodization, knowing how to smartly push athletes to achieve their potentials are also crucial. Overall, we can in some way control the injury, but in terms of avoiding the injury, this is a big question for me. Coach Battista (PSU, Ice Hockey): Size and strength, F=MA. They are simply pushing the limits. Equipment is lighter but not necessarily more protective. I also feel seasons are too long and both mentally and physically it is taking its toll on these kids. Coaches need to work closer than ever with strength coaches, nutritionists, sport psychologists and trainers. Hydration issues, recovery issues, relaxation techniques, flexibility training, curbing over training, time management, stress related issues – there are so many more stressors today. Coach Ross (PSU, Women’s Volleyball): I have two thoughts on why injuries occur, and the first is that players come in to college unprepared for the physical demands of practice, and the frequency and intensity of preparing at the next level. The second is that some injuries occur because the sport is demanding. For example, hand injuries occur from blocking (vs. bigger, stronger, more experienced hitters), and ankle or foot injuries may occur from the repetitions, which increase the chance of trauma. A goal would be for the players to come in to college healthy and prepared for the demands both physically and mentally. Coach Kaidanov (PSU, Fencing): As coaches, we should face the reality that injury is indeed a real problem in athletics. The demands of the sport

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are so high that it is beyond the abilities of athletes to meet these demands. We have to train harder and harder to be competitive and athletes’ effort is so high that this at one time or another may lead to traumatic injury. I should stress that both physical effort, related with volume and intensity of the training program as demand of the sport is so high, as well as psychological perceived effort are contributing factors to injury. In other words, physical demands of the sport are much higher than athletes’ capacities and capabilities to meet these demands. Therefore, I should say that unfortunately, traumatic injuries in sports are still an unavoidable part of athletics today. That said, I should stress that coaching strategies aim to at least reduce the risk of injury, including appropriate all-season strength training, flexibility and endurance. Athletes should not only be physically ready at the beginning of the competitive season, but most importantly, should maintain this level of physical conditioning throughout the entire season. This is a direct responsibility of coaches which is definitely a crucial factor for the prevention of injury. In other words, the stronger the athlete is physically, the less probability of injury we should expect. Q2. According to a survey of 482 athletic trainers, almost 50% responded that they believed every single injured athlete suffered psychological trauma (Larson et al., 1996). The survey also indicated that 24% of trainers referred an athlete to counseling for situations related to their injury. Recent studies demonstrated that the probability of psychological problems dramatically increases in athletes suffering from three or more minor injuries. Do you agree that every injury may cause psychological trauma and therefore athletes should seek psychological counseling shortly after injury? Coach Ganter: My overall answer to this question is NO. This is coming from my personal experience and based on what I have seen when kids were coming back from serious injury. The majority of cases in football players are able to find ways out from injury by their own. For the most part, I have been surprised by how reckless athletes are when they come back. I remember one of our players throwing his knee brace over the fence which he had to wear till the end of the season after injuring his ACL. He wore it for about ten minutes in practice then took it off and threw it over the fence and would never put it on again. So, I look at a guy who was coming back eleven months after an ACL surgery and notice that there is no psychological problem there. No fear, no intimidation at all. Another player was recovering from a knee injury. On the first day when he was allowed to participate, he went out on the field and yelled across to Coach Joe Paterno. He then did zigzag exercises for about fifty yards, planted his knee down and then shrugged his shoulders to show that it was nothing. There are far more guys that lack concern as to whether they are going to experience injury again. It is interesting that the trainers feel the other way; it surprises me.

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Coach Jepson: I disagree that every single injury induces psychological trauma; it depends of the type of injury. For example, in gymnastics we have a lot of minor injuries, inducing bruises, scratches, etc., that are not traumatic, but induce more discomfort, unlike serious traumatic injuries requiring both medical and psychological attention. If an athlete has only discomfort or muscle soreness, it should not be recommended to see a psychologist. However, if an athlete has traumatic injury, psychological services could definitely help. My approach is to recommend injured athletes for psychological evaluation and possible treatment if the injury is classified as moderate and severe, otherwise, the athlete should be able to fully recover as the symptoms of physical trauma are resolved. Coach Shephard: Most athletes are mature enough to deal with injury and fully recover through physical rehabilitation programs without extra psychological attention. Injury is a part of the sport. However, serious, season ending injuries can be very psychologically demanding and damaging. This situation is often associated with a severe psychological impact requiring the involvement of psychological personnel to deal with this issue. It definitely depends on the severity of the injury; athletes may or may not be referred for psychological evaluation, counseling and even treatment. So, referring athletes with mild injury to a psychologist may create even more problems, since athletes may develop the symptoms of preoccupation with injury. Coach Battista: Each athlete will react differently, but the question should be approached. Athletes who are afraid of losing their spot on the depth chart due to injury, spending the extra time needed to rehabilitate and experiencing loneliness due to an extended rehabilitation all play a role. I would caution against the “self-fulfilling prophecy mentality” of some athletes looking for an excuse to get out of practice and/or games which may mask bigger issues. My generation was taught to “suck it up” at any cost and sacrifice everything for the team. The pendulum may have swung too far in the other direction and now we are being overly cautious. Coach Ross: Career-ending injuries need to be evaluated with the assistance of counselors. Players understand the expectations of their participation and are accountable for their physical and mental health. The occasions that we did seek external help was for eating disorders. I seek tough players with endurance and weed out the players who are dependent on psychological stroking. Coach Kaidanov: It depends on the classification of injury. Severe injuries should definitely be treated differently from a psychological perspective, than mild or moderate injuries. The overemphasis or preoccupation with injury and the overestimation of the impact of injury may cause even more negative mental consequences. Fencing athletes are extremely mentally strong and can handle the emotional consequences of injury. They would be frustrated, but strong enough to overcome the temporary emotional

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problems. Overall, different approaches should be used on different athletes for the psychological recovery from injuries. As coaches, we should do our best to prevent multiple injuries or at least to predict athletes at risk for multiple injuries rather than consider how an athlete can cope psychologically from injuries. Q3. Injured athletes usually return to sport participation based upon clinical symptoms resolution and upon recommendation of medical staff. However, there is a notion among medical practitioners that clinical symptoms resolution may NOT be the injury resolution. Incomplete rehabilitation following injury may lead to the development of so-called bracing (selfprotecting) behavior. This is a dangerous situation that may lead to more severe injuries. Through your coaching experience could you describe the signs and symptoms of bracing behavior among your athletes? What would be your coaching strategies to prevent, and if observed, to eliminate the symptoms of bracing behavior? Coach Ganter: Some players are self-protective. As a coach, you can tell when an athlete is not ready to return; I have told doctors and trainers that an athlete is not ready even after they considered the athlete ready to return. If an athlete is not 100%, then I do not allow his return. It is also important to believe the athlete; if he tells me he is hurt, then I believe him. Some guys need to be pushed to get back onto the field, but if an athlete tells me he is hurt, or cannot play at 100%, then I respect that. It is hard for me to believe that a kid at this level would not want to be out there, so when they say they are hurt I usually believe they are hurt. Coach Jepson: This type of behavior in gymnastics occurs a lot. It happens most often when there are still residual physical symptoms that occupy the gymnast’s attention. So the question is when does the injury resolve completely and when is the athlete ready for 100% participation? The presence of bracing behavior is an indication that we have to be careful to prevent re-injury. Due to bracing and protecting, it is damaging to movement dynamics and the abnormal techniques that ultimately develop and causes chronic, long-term problems. Gymnastics is a very conservative process and the coaches must develop the relationship of trust. It is a fundamental element in my philosophy of coaching, and I will not allow an athlete to perform if not at 100%. My relationship with the medical staff is also important, and sharing a mutual understanding to eliminate confusion is a goal that everyone shares. Coach Shephard: Physical symptoms resolution does not necessarily mean that an athlete is ready to compete and is fully recovered from injury. In gymnastics, we re-train injured athletes. After a leg injury, an athlete would have the tendency to land on the non-injured leg, putting more pressure on it during a landing. This creates danger of the overuse syndrome and leads to further injury. This situation can also develop bad habits and lead to a serious predisposition for further injuries. So, we do progressive skills of

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gradually landing gradually increasing the height of the blocks, or changing the surface of support from soft to hard, etc. So, they know that the injured leg can “take it”, so we build the confidence that no injury would happen if done properly. This is just one coaching strategy to deal with negative effect of “bracing behavior”. Coach Battista: A perfect example would be a former standout athlete in hockey, four-time first team all-American Josh Mandel, broke his foot blocking a shot and was casted in early December. It was the second year in a row for the same foot at the same time of the year. Although cleared to practice and play in early January at 100%, he skated gingerly on his foot for the first two days of practice and was ineffective. We had to decide whether to take him on a trip to Arizona or to take someone else. We met with Josh, asked him to do a few non-contact drills and to not think about the foot and just go all out. He slowly gained confidence and by the end of practice was essentially back to his normal level of play. The psychological barrier had to be overcome. Basically we want the athlete to be honest and give us feedback. If we can do testing to reassure them that they are indeed okay, then we should. Eventually they have to “get back in the pool” and give it a try. I have found that over the years most athletes tend to come back too soon, but usually don’t do further damage. When it takes them longer to recover they face the inevitable questioning by teammates with regard to their commitment and toughness especially in the more physical sports. It’s all about communication with the coaching and medical staffs and developing that level of trust that the athlete feels they are not going to be put into a harmful situation. Coach Ross: The question is how we determine if a player is 100% ready to return to full participation without getting them into the competitive arena. The only way to tell is to test them at game speed and this may result in a reinjury, or players risking a new injury because they are afraid to go hard. We try to have the players increase their effort and push the injured body part in small group settings before we return them to full group participation. A sign of bracing in volleyball would be a player returning from a leg injury, and either hurting the other leg, or a different lower body joint by compensating. We have had players try to change their mechanics because of their rehab regimen, and they not only lose power, but confidence in their ability to succeed. Coach Kaidanov: Frankly, I underestimated this particular aspect of consequences of injury, until I start recently thinking about it. First of all we should be certainly sure that no physical signs of injury present before we allow our athletes to practice again. Though, it is important to note that upon return to practices it is reasonable to suggest that non-injured body parts should be “activated” first, to gradually regain athletes’ confidence that they are fully ready for new challenges. This is very important issue, and I saw in my practice that a lot of athletes “brace” or protect their used-to-be

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injured leg, leading to enormous technical problems, new skills learning, and possibly to injury. Overall, full rehabilitation is a key to prevent possibility of development of bracing behavior. And as soon as the injured athlete returns to participation, we need to start again from fundamentals and gradually re-learn all pre-injury skills. The other interesting thing, the use and/or abuse of actual braces, cast for example also should be considered within the scope of this question. Actual braces are necessary to protect injured joint from overuse. This may also enhance athletes’ psychological confidence. Although, these braces should be removed as soon as athletes are fully physically recovered from injury. Otherwise, athletes could develop abnormal dependence on these braces, which may create numerous problems. Q4. Holistically, sport medicine specialists as well as most coaches have been concerned primarily with physical aspects of injury and injury rehabilitation. Thus, athletes who attained a pre-injury physical level are assumed to be fully prepared for safe return to practices and competitions. Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free, post-injury athletes are fully ready for 100% sport participation? Please elaborate. Coach Ganter: There are two parts to this question. The last part, are they usually ready, I would say yes. That is just based on my coaching experience. Yes, even just looking at one of our offensive linemen, in the training room just coming off of ACL surgery, I do not think there is any question that psychology will play a role in how he recovers and how he approaches his rehabilitation and whether he is ever going to play again. I think that is psychological and that would help either make him rehab at a higher rate versus taking his time and maybe not doing it at all. I do not think there is any question about that. Coach Jepson: I really believe that psychological adaptation to injury plays a very important role in athletes’ rehabilitation post-injury. It is important in order to prepare athletes for the work load as well as for demands of sport requirement both physical readiness, confidence, in believe in their own abilities to meet high demands of the sport. Without this adaptation, athletes will be frustrated, coaches will be frustrated with lack of achievement and accomplishment. It has happened a lot in gymnastics. We use in this case a lot of spotting techniques, set-back and return to fundamental skills, re-learn every single element of their used-to-be automatic skills. Basically, I understand psychological adaptation as the return to basics, and gradually regain the confidence in ability to perform the pre-injury routines. Coach Shephard: Psychological adaptation is an important component in injury rehabilitation in sport. For example, you can be physically ready from medical doctor’s perspective, but athletes may be afraid of performing the certain skills that cause previous injury. So, regardless of physical

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symptoms resolution, athletes should acquire psychological status as well to be fully ready to compete. I can give you example, two years ago, one of my gymnasts dislocated her elbow during “Tkachev” vault. After completed treatment and rehabilitation, she was capable of doing this vault again, though, she was so afraid of doing that, we were forced to change her vault to less a complex vault, so she would be comfortable with it. Again, the psychological part of it is huge, so, you go back to fundamentals to regain the confidence of doing it consistently, and sometimes, as in this case, you should change the routine. Coach Battista: I firmly believe that athletes must feel they are ready to go mentally as well as physically. Whether it’s the concern of reinjuring or further injuring they must feel safe and feel they have the support of the staff and team. However I think there simply needs to be that extra communication which establishes the level of trust between the staff and the athlete. They must be psychologically ready to engage the competition. Coach Ross: I think the severity of the injury and the athlete’s previous exposure to injury has a significant impact on how they perceive their readiness to return to full participation. I think it is important for the medical professionals to be familiar with the demands of the sport in question. It is possible that a player is cleared to play because she is functional, but that may not be adequate for the player to fully compete at a high level. Coach Kaidanov: This decision definitely should be made by experienced professional, that is a coach. However, medical professionals should be also involved in this process, they should be familiar with demands of our sport and help the coach with final call in terms of level of recovery from the injury. I should say that full physical recovery may not be indication of athletes’ 100% readiness. Other aspects of preparation, including athletes’ responses to training demands, attitude, motivation and emotions are important factors to consider as well. I believe that sports psychologist may play important role in estimation of athletes’ psychological readiness. Also, sports psychologist can help athlete to regain his status as full-time fully recovered individual. Q5. Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions? Coach Ganter: I would say, first the player, and second the doctor, in no way the coach. As long as there is good judgment used in practice, I can see a green cross routine (where a green cross indicates a partial level of activity). I think that is fine. I think getting a kid ready for participation means all out 100%. I had used the old adage about it: “Do what you can and go till you cannot go any more, until it hurts or whatever; if it starts to bother you, then get out”.

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Coach Jepson: As I said before, I have great relationships with physicians and trainers. This is mutual decision, and I trust our medical staff, because they are well aware of our sport of gymnastics. They attend our practices and competitions and they know some specifics of the sport that allow them to make accurate decision when athletes are ready to return to sport participation. There is no way I push athletes to do something they are not ready to do. Now, it is my responsibility to communicate with medical staff, so athletes have good representation from both sides. It should be noted that sometimes medical staff do not fully understand our sport. So, they should be educated as well. They have to know the actual mechanisms involved in movement, so the decision in terms of return to play will be made according to this knowledge. So, this is a responsibility of coaches to educate medical personnel about specificity of sport. If physician knows the medicine, but does not know the sport, it could be difficult to make appropriate decision. On the other, I am not a doctor, and do not know a lot of medical aspects of injury. Thus we have to work together for the safety of our athletes. In fact, as I mentioned before, our medical staff are in the gym with us, and this creates a lot of trust, which is critical in terms of athletes’ rehabilitation from injury in general, and return to participation in particular. Coach Shephard: I think that the coach and the doctor should collaborate together and make a decision of return to participation based upon physical status of the athlete, first, and other athletic characteristics, second. Some doctors, especially in gymnastics, do not have enough knowledge what athletes can do after injury, and injury rehabilitation. For example, if a gymnast has ankle injury, she still can do full bar routine, except landing. She also can do a lot of conditioning exercise for upper body. That said, she was not allowed to participate in practices by medical personnel. They say “no participation”, and eliminate a lot of things that athletes could be doing for faster return to pre-injury status. This situation for sure may create conflict between medical doctors and coaches. So, doctors may be very knowledgeable in terms of physical aspects of injury, but at the same time, they could be ignorant in terms of understanding the sport and gymnastics and possibilities of compensatory training programs for injured athletes without aggravating the injury. So, the final call from a legal standpoint should be from a doctor, but from the practical standpoint, the coach should be responsible for final decision regarding the return to participation. Coach Battista: I really believe it needs to be a collaborative decision. But that the coach with the athlete and the doctor’s input should be given the opportunity to make the case for an athlete’s return. But, in this litigious day, I would have to say it is up to the team doctors, especially in cases involving serious injuries which could prove life threatening (hydration, weight issues, heart and lung, concussions, etc.). I believe the athletes should have some means by which we can “test” their mental and physical readiness for returning to action, whether practice or competitions.

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Coach Ross: I think that the final decision on whether a player is ready to play rests with the coach, however, the medical staff has to be comfortable that the player is capable of competing injury free. The physician should not release a player to a coach unless they are sure the player is ready. Too many times I see a player cleared to play, but nowhere near ready to truly compete. There is a difference between contributing and excelling, and in some situations a coach may want the contribution and they can limit the demands placed on the player until they are fully able to compete. Both parties share the same goal, and that is a healthy athlete who can offer their best effort. Coach Kaidanov: It should be definitely mutual decision. The medical doctor should clear the athlete for participation based on their clinical signs and regulation. However, coach should clear the athletes for specific types of activities without compromising the possibility of re-injury. Having said that, the medical doctor overall is responsible for final decision based upon clinical symptoms resolution and his or her knowledge and experience dealing with specific sport activities. The medical doctor should predict possibilities of re-injury and make their call accordingly. Q6. There are a number of interventions recommended by sports psychology practitioners -- including negative thought stoppage, cognitive restructuring, healing imagery, muscle relaxation, goal setting, etc. -- to speed up rehabilitation of injured athletes. What kind of coaching strategies would you recommend to enhance athletes’ readiness for returning to a full range of sports participation? Coach Ganter: I am an old school guy, and I do not have any knowledge or experience in any type of psychological rehabilitation. I think the greatest motivator is playing time and if they want to get back on the field and play, they are going to hurry up and get better. I think, if injured athlete is worried about regaining a position or playing time, sometimes that will speed the process up too. I have no experience with people giving psychological coaching or anything like that in rehabilitation of my kids. Coach Jepson: I do a lot of visualization, like I said, specifically focused on physical skills that were associated with injury. I truly believe that major cause of injury in gymnastics is improper techniques and errors in performance of complex skill. So, gymnasts should be clear minded in terms of understanding the fundamental mechanics of skills they perform. Also, skill progression, especially in case of injury, is critical to return to pre-injury status. We teach gymnasts to focus on the positive, rather than to think about possibility of re-injury. Coach Shephard: I think that properly framed, gymnastics-oriented and injury recovery-focused visualization is a tremendous coaching resource to speed up the rehabilitation of injured athletes. Visualization should include not only visual imagery per se but also skill imitation, feeling, sensing the recovery, feeling the pressure and tension in the injured joint producing

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required skills. We use this often in our program, not only for performance enhancement but also as a part of psychological intervention program for injured athletes. For example, we have a gymnast with Achilles tendon injury, so I required that she should do visualization every day at least ten minutes per session, with the accent on acquisition of feeling that her tendon get stronger and stronger every day, becoming more flexible. Positive thought process and positive thinking about progress of recovery is a great contributing factor speeding up the whole process. It is important to stress again, that it should be specific and recovery goal-oriented visualization. This should be trained similar to physical skill training. Coach Battista: First, I remind them that they are athletes and are in most cases in much better shape mentally and physically than the average person. Most doctors are going to err on the side of the conservative diagnosis. I try to keep them active in team meetings and activities so they look forward to getting back as soon as possible. I firmly believe in the importance of communication with all parties to develop both a written and verbal game plan that helps the athlete remain focused. We are big into goal-setting, imagery and relaxation exercises, and use our sports psychologist whenever the athlete is willing to participate. Coach Ross: I think that there is a full array of interventions that can assist with the development of an athlete. The use of these items may work with some athletes, and I would encourage their use. The player may have to deal with the fear of returning to full participation and I think anything that can reassure them that they are ready to go is valuable. My communication with my players is that they need to test for themselves before they can get full clearance from me. They need to feel comfortable and capable of reentering the sport. Coach Kaidanov: As a coach, I am in charge of modification of practices, considering the level of recovery from injury. I also change and modify the goals that athletes should set for themselves. They should be realistic, but challenging enough, so athletes would return to full participation sooner. We could also contract a certain routine of injury-free exercise that focuses primarily on involvement of non-injured parts of the body. For example, if an athlete is recovering from hamstring muscle pull, we could recommend a series of exercise programs related with abdominal conditioning. So athletes are fully involved in the training program but accent of the training is modified and shifted to the upper body conditioning. Q7. As ascertained in various studies, it is clear that gender differences in athletes are highly influential in shaping the psychological and emotional experience of injury. For example, females report higher levels of fear related to injury due to movement than males. Are there different coaching strategies for dealing with female athletes as opposed to male, particularly in regard to recovery from injury?

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Coach Ganter: I do not know, I do not have any experience with female athletes or how they are coached. I just know a little bit since I have been around the female coaches we have here at PSU. I know for sure, they are probably tougher than we are. You said that they have a little more fear of injury than the males. Maybe the good female coaches have to be tougher. Coach Jepson: It is clearly not my area of expertise, though I think that there are fundamental differences in coaching males versus female athletes. I guess female athletes are more emotional and sensitive, therefore coaching strategies in female sports should be oriented on creating extremely positive learning environment. Coach Shephard: Gender differences are absolutely essential issues to consider when coaching female athletes. They learn differently, they feel differently, they are more sensitive to critique and coaching styles. You have to be very sensitive towards the mentality of the female athletes. I think it is essential that they should have daily team meetings to discuss various aspects of their life, not only athletic life. They should be happy and psychologically well to respond to enormous pressure to be student-athletes. There are delicate issues such as body weight, body image, self-esteem, that extremely important for athletes, especially for female gymnasts. Thus, my primary responsibility is to maintain psychological well-being of my gymnasts in any way I can. Unfortunately, not much research is presently available for coaches on how to deal with female athletes, therefore we mostly orient on our personal experience and experience of my female assistant coach. Coach Battista: Certainly not my area of expertise, but definitely a factor since the culture of women’s sports is inherently different (cultural influences, relatively new and few female coaches who can relate). My gut feeling would be a higher need for communication and reassurance. Coach Ross: I am aware of some research claiming that female and male athletes display similar levels of confidence, psychological maturity and toughness when tasks are appropriate for females, when females and males have similar experiences and physical abilities, and when clear evaluation criteria and feedback are present. I fully agree and believe in enormous potential of female athletes in terms of dealing with training load, athletic demand, discipline and commitment to sport. This is at least the philosophy in our team at Penn State. It should be noted that concern about body image definitely affects all women including student-athletes. Athletes just as any other women are extremely sensitive to the general societal pressure towards unhealthy thinness. We as coaches should be also sensitive to how we communicate with female athletes about this issue. I suggest that we should follow nutritional guidelines and focus on healthy eating behavior rather than on weight issues. I also should say that the most important aspect of coaching is to treat the athletes with respect and dignity regardless of gender, race and social preferences.

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Coach Kaidanov: I should say that I agree with the notion that gender influences all aspects of coaching including practices, competition, and coaches’ interaction with athletes. Gender influences coaches’ interpretation of athletes’ responses to work load, their expectations and effects of psychological pressure. It is important to note that gender is an important individual characteristic. Accordingly, if you would like to follow the principle of individualization, you should directly tie this to gender. To my knowledge, there is not much research and recommendations how to deal with gender issues in coaching practice. Q8. Among athletes it is common to hide fear in order to avoid appearing weak. However, it is known that in previously injured athletes, fear of subsequent injuries may induce erratic emotional responses, avoidance reactions, and bracing behaviors. In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male vs. female athletes? Coach Ganter: I would have to say more attention is needed when you coach injured athletes. I can not picture an injury getting less attention, there is no motivation there, there is no “we got to get you back.” That is a tough one, but I would have to say more attention would help promote the quicker recovery. I think the better rehabilitation and more attention a guy would get and more encouragement would get them back quicker. I have no opinion regarding the gender differences. Coach Jepson: I think that fear is important protective mechanism and plays an important role in athletics. As I said, gymnastics is extremely risky sport and, not surprisingly, fear is present every time a gymnast is preparing for or performing a routine. Most importantly, however, to dissociate fear per se, from ability to control fear. Successful gymnasts, regardless of gender can control fear, trust their body and their coaches. I also believe that fear comes from uncertainty due to lack of consistency in performing the routines. Thus, the more consistent and reliable the skills, the less fear might be at place. Unlike other less risky sports, if there are less risky sports, we should think of fear in terms of fear of being hurt, versus fear of being embarrassed, or fear of failure. Coach Shephard: I agree that fear is necessary component of sports environment. Usually female athletes are more open in terms of expressing fear. They are honest and expressive if they are afraid to learn or to perform new skills. So, my responsibility as a coach to take into consideration the fear factor, and progressively reduce it though consistency of performance of risky routines and acquisition of confidence. Also important, is that athletes should know that we are good “spotters” and are able to protect the athletes in case of falling. In essence, fear can be controlled, if properly trained.

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Coach Battista: All players are different. Most players would respond better to a coach or trainer who gave positive feedback: “Looking better already,” “almost there,” “can’t wait to have you back.” Some however need to have it downplayed while others need to be told straight up that it’s not that bad, get over it! I definitely feel that females respond differently than males (some are tougher and more stubborn!!!). But the key is still communication. Generally, I would think the females like more than less information. Coach Ross: Fear of injury is not a common emotional reaction in volleyball, unlike fear of failure performing certain skills. My coaching approach to deal with fear of failure is to stress that I reward learning progress, commitment to sport and to team rather than winning or losing, issues that unfortunately dominate modern sport, including collegiate sport. On the other hand fear of re-injury as a result of premature return to play is an important factor to consider. Therefore, we have to explore the root of the problem rather than to treat the consequences of our erroneous assumptions about the injury and its impact on athletes’ well-being, both physical and psychological. In other words, we should be crystal clear about the severity of injury, its impact on athletes’ status and most importantly about the current emotional status of a previously injured athlete. An athlete should be not only physically injury free at the time to return to play, but also should not experience any signs of irrational thoughts, anticipated pain due to movement, etc. These observable signs of premature return to play should be used as red flags for coaches requiring termination of situations when these signs are present and maybe additional physical rehabilitation and/or psychological counseling. Coach Kaidanov: There should not be any behavioral signs of fear of injury, otherwise it could potentially lead to injury. Neither should there be any irrational thoughts and expectation of injury. This extremely negative emotional reaction distracts athletes from major focus of control, technical skills, competitive strategies and decision making processes, especially during competition. I guess, if an athlete may develop this emotional distraction, he or she should be referred to professionals dealing with this issue. Q9. Sport-related concussion has received significant attention in recent years. Despite some advances of studying concussions, important questions are still to be answered including: *Which concussion grading scale and return to sport participation guidelines are sufficient to prevent more severe secondary and multiple concussions? *After how many concussions should an athletic career be terminated? *Are there long-term cognitive and behavioral deficits after single and especially multiple concussions?

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*Collegiate athletes are at high risk for sport-related brain injuries. The likelihood of brain injury is a function of head impact (or sudden acceleration/deceleration) within the context of sport participation. The concussion may occur in any activity, regardless of the nature of this activity, and when the brain injury occurs, it has potential for a lasting effect on the athlete. What do you think the collegiate coach should know about concussions and what should be done from a coach’s point of view in order to prevent concussions? Coach Ganter: What they should know is the dangers of and what is a real concussion. I know even personally, I can think of times when I must have had a concussion and remained in the activity, went back out with severe headaches, you know either into the practice or even the next day. I could remember that. I think now, when our kids have severe headaches and maybe they got a blow on the head, it is worth to keep them out for a day or two. I am saying, jeez, I am sure we could have a lot of problems having concussed kids back in the field. Anyway, I think knowledge, what is a concussion, what are the dangers if he continues to participate with any symptoms of a concussion, is critical for coaches. What we can do to prevent concussion, is to make sure that we are doing safe drills when players do not have a helmet and just being smart and taking precautions. So that we do not have any unnecessary concussion because of lack of protection. We do too many things without a helmet. Our summer football camp is without a helmet drills. There are just so many things that worry me about that. Really, the more I think about it, the more I worry about it. I have become more knowledgeable about concussions, and what can happen down the road is really worries me. Coach Jepson: A couple of cases we had in our gymnastic team. I would like to stress that I am not a neurologist and, practically, have little knowledge about concussion. Therefore, I think that medical professionals should treat athletes with concussion, regardless the level of injury. I know that there are gradations in terms of mild, moderate or severe concussions. I think this is very serious injury and every single case of brain injury should be considered from our coaches’ perspectives as severe injury, requiring immediate medical attention and treatment. I am aware of possible consequences of concussion including learning problems in student-athletes suffering from single and multiple brain injuries. I think that we as collegiate coaches should be more educated about signs and symptoms of concussion, especially about long-lasting residual abnormalities. Coach Shephard: This is definitely a confusing injury not only for athletes but also for us as coaches, because unlike other injuries, you often do not observe obvious physical evidences of injury, such as broken arm, cast, etc. Unfortunately coaches do not have enough knowledge about this serious type of injury, the brain injury. My understanding was that this injury is temporary, at least in the mild form. Therefore, I thought that athletes

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suffering from concussion should be ready to start practices within one week post-injury. However, my recent experience with one of my gymnasts, who suffered mild concussion five weeks ago and still experiencing problems, has convinced me that this is more serious injury than I have ever thought. Therefore, more education is needed for coaches to fully realize the danger of brain injuries. I was not aware of procedures, scales, assessments etc., and still do not know the details about this injury. It is important for us to understand long-term consequences of concussion to realistically expect the injured athletes to be back for full participation. Coach Battista: We should be educated on all the most up to date information on concussions and recovery from concussions. As someone who has dealt with this both as a youth and adult athlete, it is a primary concern of mine. Any and all data should be collected and analyzed to help determine the short and long term effects of concussions as well as the appropriate time needed to recover. Until such a time that affordable, portable “EEG” machines that are capable of quickly giving feedback on brain patterns are available, we need to develop the best alternatives possible. Baseline testing prior to tryouts, “litmus” tests that give some sense of the magnitude of the concussion administered by trainers/doctors should be on hand. In general I favor a conservative approach. I do believe we have to be careful how the test is administered (e.g. the first question asked shouldn’t be “do you have a headache” or “do you remember what happened,” it should be generic like “how do you feel?”). I worry that sometimes we make suggestive comments that the athlete simply reacts to in an affirmative way. We had an athlete who answered, “I guess I have a headache,” and jokingly said, “I don’t know what hit me,” and it turned out he was fine. Coach Ross: The concussion issue is one that I feel needs to remain in the medical community. I don’t think the coaches are trained to evaluate this condition. Although it is rare for a volleyball player to suffer from this injury, I have had a few players that have, and they were monitored and regulated by the physicians and athletic trainers. Not much in my sport can be done to prevent the occurrence of this injury, but certainly adequate instruction in the floor skills area can reduce the exposure to hitting one’s head on the playing surface. Coach Kaidanov: I should say that concussion is a very unusual and seldom traumatic injury in fencing. But in case if concussion would happen in my sport, I would definitely refer concussed athletes to professionals. I truly believe that this is a serious trauma, regardless the grade, symptoms and/or symptoms resolution. I also suggest that coaches should be educated in advance about this type of injury, so, if it would happen, appropriate actions should be implemented. This is particularly important since we are dealing with student-athletes who should go to school, study, acquire a lot of intellectual knowledge that requires memory, concentration, and other

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mental abilities. Thus, overlooking the symptoms of concussion may cause dramatic consequences in terms of student-athletes’ ability to successfully graduate. Again, highly professional medical people should be involved in case of concussion in athletes. Q10. Many athletes who have had single concussions recover quickly and are able to return to play. However, athletes who have had a history of concussion may exhibit certain symptoms such as an episode of concussion, including headache, dizziness, nausea, emotional liability, disorientation in space, impaired balance and postural control, altered sensation, photophobia, lack of coordination and slowed motor responses. As a coach, do you think it is possible to discern these symptoms as irregular or abnormal in an affected athlete, and if so, how would you adjust your coaching methodology? Coach Ganter: I feel that at least personally, I am better educated in what a concussion is, what causes one and the symptoms of concussions, mostly because a previous player of mine had to give up football because of headaches. Because of the emphasis put on by the medical personnel, I think that most coaches are better educated about concussion, what causes one, and what are some of the symptoms. I do not know how you do it manually, but just visually you know the stories and interviews I have had with kids about headaches and inability to sleep, and the inability to concentrate when they study, having to get up in the middle of the night to take a shower just to get some heat on their head because their head was killing them, the headaches. I heard guys talk about blurred vision and I mean we have enough of them around here that I think by observation. If you notice any change in the way the practice and their performance and then you talk to them, I think most coaches would be able to discern that there is something wrong here. This kid maybe got dinged yesterday and better have a doctor look at him. Coach Jepson: Again, my expertise and experience dealing with concussions is limited. Therefore, I would follow directions from medical professional how to treat brain injured gymnasts. One thing I know for sure, I would be very careful coaching gymnasts with concussion, because of nature of our sport requiring abrupt change of direction of head motion, hard landing and possible falls. This may cause the situation when previous brain injured gymnasts could suffer from another and more severe concussion. Having said that, it should be noted, if an athlete with previous brain injury would be cleared for participation, I do not think that I would treat this athlete differently. I would keep eye on it, but would not overemphasize my concern. I would consider this as typical injury. I should be sure that their mind is clear, they know what they are doing, are in control of their body and mind, can focus and concentrate on skill performance etc. For example, I had gymnast who suffered from mild concussion and weeks later he could not remember what he did, and had long lasting memory problems. Of

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course, he was not ready to come back and we did not allow this from happening. So, I watched him very closely. Actually, I watch every single athlete very closely, regardless of whether s/he is injured or not. So, I know if something wrong with them, I just do not allow them to take the risk. This is my common procedure, concussion included. Coach Shephard: First of all, I would like to stress again that my expertise and experience are limited, therefore I would follow the recommendations of medical people regarding the treatment and coaching brain injured athletes. For sure, I would monitor these athletes very closely and will be watching for any signs of lack of concentration, attention, fatigue, reduced motivation. If this happens I would terminate their practices and refer these athletes to medical people for evaluation. I would not push these athletes further without proper assessment of impact of the injury. Again, most coaches have no idea about this type of injury. Therefore, coaches’ education is a critical factor in terms of prevention of multiple concussions in athletics. Coach Battista: Tricky area. I think it depends on your own background as both an athlete and how your coaches dealt with it. In the old days we simply said shake it off or you just got your bell rung you’ll be fine so there is a macho thing here. Someone bruises an arm or a knee we put ice on it and everyone feels sympathy for the athlete. Someone complains of a headache and they are either consciously or subconsciously considered a wimp. I do believe coaches who really know their players can spot differences in behaviors and motor skills but with a large squad it is not always possible to detect the smaller changes. Again communication is a priority. Working with the training staffs and having assistant coaches on the same page with regard to creating a safe and caring environment. Helping the athletes to feel comfortable about speaking up if they have a concern without fear of losing their spot in the line-up or having the confidential information become public. Educating the players about the potential long term effects without scaring the hell out of them and taking away the aggressive mind set. Coach Ross: As I mentioned in my previous responses, concussion is rare injury in our sport. I personally do not have enough experience and expertise to deal with concussed players. I truly believe that in general, this injury should be carefully treated, evaluated and re-evaluated in order to prevent residual long-term debilitating effects. It is known that symptoms of concussion may reappear long time after the accident, so close monitoring of these symptoms is important. Coach Kaidanov: As I mentioned in my responses to previous question regarding the concussion, I would be very conservative in terms of dealing with post-concussed athletes. I would closely monitor for any signs of abnormal movement patterns, such as occasional loss of attention, progressive fatigue, unexpected mood swing, inability to concentrate. If these symptoms are present, I would immediately terminate practice and

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send this symptomatic athlete for professional evaluation and possible treatment. Q11. Currently, it is still being debated whether concussions result in permanent neurological damage or in transient behavioral and psychological malfunctions. This controversy is due in part to the lack of assessment of the development of fear of re-injury, bracing reactions and overall avoidance behaviors. Is it obvious during practice or in competition, to you as a coach, if a previously injured athlete has developed bracing behaviors? Do you have particular strategies for dealing with athletes who exhibit this type of behavior in response to injury? Coach Ganter: In terms of concussion, I would say no. I have never noticed that from the guy coming back from a concussion. I definitely have seen guys who are ginger for a knee or maybe an ankle and who maybe selfbrace. Remember how I said that I think an athlete knows better when it is time to go all out. That is the way I feel, so I have noticed it from that standpoint, but not from the standpoint of the concussion. For the most part the kids almost, I can not think of anybody except for one player, really who said “I need a couple of days because of my head.” I can think of dozens that have said I need another week or I am not ready yet or this is not good for other parts of their bodies. I have had no experience with a guy saying my head still hurts or I am not all there or I am not ready. Coach Jepson: In my experience with concussed gymnasts, I observed some cases of “self-protecting” behaviors, similar to those following other traumatic injuries. I do not have enough experience in order to elaborate specific coaching strategies for concussed gymnasts, therefore I would treat these athletes similarly that I am treating gymnast with serious traumatic injuries. Coach Shephard: I guess I should study more about concussion and educate myself about this injury. One thing I know for sure, that from now on I would consider even mild concussion as severe injury, due to accumulated knowledge of long-term disabilities resulting from brain injury. Coach Battista: See my responses to Q10. There is a point where as a coach I think we need to simply put the kids’ long term health ahead of short term gains. I have experienced multiple concussions and have dealt with the aftermath. I am not sure of the long term effects of concussions that are spread out over time, but I have no doubt that short term effects can be a hindrance to performance as well as daily functions. Multiple concussions in a short term period of time are of even greater concern to me. Since I have experienced this firsthand I am more sensitive to the issue than others may be, thus my dealings with this issue are certainly biased. Some athletes are better than others at hiding their real feelings about things. Again fear of being removed from the line-up, being singled out as a wimp, factor in. Some athletes have a much higher threshold for pain so I really think this is more of an art than a science to some degree. Coaches get to know which

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athletes tend to cry wolf and which ones try to be tough guys. When I do come across the kids who are using bracing reactions we try to make them feel as confident as possible that they will be okay and that the idea of holding back or slowing down may actually put them in a more vulnerable position. Coach Ross: I do not know whether concussion induces permanent neurological damage, or transient functional abnormalities in brain and behavior. But I know for sure that improperly treated concussion, premature return to practices after concussion is not permissible, as in case of any other traumatic injuries in sport. Clear and accurate assessments performed by qualified medical personnel are essential to prevent risk of brain injury in athletics. Coach Kaidanov: Again, I do not have enough experience dealing with concussion in my sport of fencing. Therefore, I cannot further elaborate on this issue. Although, I guess, there certain types of protective patterns that athletes may develop to prevent the second or multiple concussions. Q12. What advice would you give to upcoming coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? Coach Ganter : I think the number one thing is the strength training. If you put a kid in the position where he is overmatched from a strength standpoint and any type of physical overmatch, you are certainly risking an injury. The second thing is position, especially for a young coach if he is coaching young people. You need to teach them proper hitting position, body position, how to fall -- just how to protect themselves. So, I think the strength training is first, conditioning is probably second, because if they get tired they probably are more vulnerable to an injury, and then position. Coach Jepson: The biggest thing is there is no short cut. Physical preparation, you have to learn groundwork. Important thing, if athlete is psychologically not ready to do certain things, do not over push. Again, you have to build good foundation. Athletes should understand what is proper way of their preparation, and this what we do as the coaches. If athletes understand this, it means they are coachable, and if so, they are learnable and can reach their potentials whatever it is. Holistic understanding, physical, mental, emotional, understanding that some injury may happen and if so, they should find some “advantages of it,” of being tougher and more knowledgeable as athletes and most importantly as individuals. At this point, I think athletes should know that they can trust me, because my primary responsibility is not to make national champions, but to develop quality people. I have their best interest in mind, and they know it. And if they believe that, I am accomplishing my mission as a coach properly. People should be treated as people, not like machines and robots having a goal to be best in their sport. I treat gymnasts in my team as people and sport is just a part of their life.

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Coach Shephard: Avoid overtraining and emphasize conditioning, especially pre-season when most of the athletes are not in good physical shape. You cannot do just gymnastics to be in good shape for gymnastics. You should do a variety of conditioning programs before you do gymnastics. You have first to prepare your body to absorb the impact during landing, you have to prepare your abdominal muscles to perform the bar routine. And most importantly you have to plan properly given the time you have for preparation. Physical readiness is not the only component of a successful season. Athletes should be ready psychologically as well. Proper motivation, psychological skill training, individual goal setting, stress management skill are just a few attributes of injury free training environment. There is large preparation prior to competition. You have to build proper confidence with proper progression of physical skills and general fitness. Slowly, brick by brick build various aspects of athletes’ progression, with no rush. You must build fundamentals and certain discipline and commitment. Coach Battista: First, knock off the old school macho stuff and be more concerned about safety, factoring in water breaks, taking into account environmental conditions (heat and humidity, lightning, air quality). Educate them about the value of mental training and help them buy into relaxation and feedback as a skill no different than skating or shooting. To be resourceful by utilizing school supplied or community volunteer experts that can help with nutrition, psychology, strength and condition (making sure you do background checks and follow-ups on suspicious behavior, e.g. a volunteer strength trainer recommending supplements without your knowledge). Teaching the kids the value of proper warm-up and flexibility (not just stretching!) is an essential issue. Urging the kids to play within the rules and to not “cheat” by hitting away from the play or pushing the rules to extremes which may incite retaliations (in the more physical sports and the stick yielding sports especially) is another fundamental rule. Educating parents about the new research and findings is crucial also. Numerous times we have had parents argue with us when we held their son out of competition due to concussions and in their minds the kids need to just “suck it up and tough it out.” Parents should understand the coaches’ and the team’s policies in advance. Coach Ross: I think my advice would be to monitor the amount of jumping used in training and instruction because I think many injuries occur because of lack of sufficient strength to handle the training level. When athletes tire, they become more susceptible to injury, and the coach needs to pull back their demands as opposed to pushing the players harder. There is no question that proper instruction in the performance of the necessary skills correlates with a safer environment, and coaches are responsible for making sure the training facility is safe and properly maintained. In closing, it is critical for the coaches to work with the health professionals in assuring that

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their athletes are ready to restart their participation and not listen only to the athlete. Coach Kaidanov: I would say that the most important thing in coaching is to be patient. Encourage challenge when athletes are ready to meet this challenge. Do not expect quick success rather than build fundamental skill, conditioning and character. Coach O’Brien: Through personal interaction at the beginning and end of each training day, coaches should determine the athlete’s fatigue level: extreme – high – moderate – low, and adjust the training plan for that day or the next day accordingly. If the coach sees a significant deterioration in the athlete’s performance level, use rest to allow recovery before injury occurs. We do not have a chance to risk, and every coaching mistake may lead to severe consequences for athletes’ well-being. My other advice to young coaches is that knowledge about your sport, care about your athletes and commitment to your coaching duties are among most important contributors to injury free environment.

3. COMMONALITIES AND DIFFERENCES Injuries are commonly blamed on the coaches. Inadequate assessment of athletes’ physical skills, misunderstanding of psychological coping resources, rushing with acquisition of new techniques, overtraining and overloading causing accumulated muscle and mental fatigue, early return to sport participation after injury are just a few examples of coaching errors that increase the risk of injury/re-injury in athletics. If a coach is being too critical of an athlete, this could result in a negative relationship and possibly even injury. These overly judgmental and critical coaches create an atmosphere that is detrimental for the athlete. They try too hard and present their errors in a critical manner. The second coaching style, which creates a positive training environment benefiting both physical and mental well-being of the athletes, is the observing and assessing one. This technique is more effective for collegiate athletes. When different Penn State athletic coaches were questioned about injuries, their responses were similar in some cases, yet different in others. This journal shows how there are common causes of injuries yet different opinions about them. Regarding the first question, many of the coaches had similar answers when it comes to the most essential aspects in coaching in a manner that prevents injury. Most of them stated that their athletes can avoid injuries by becoming physically ready for the demands of their sport. In order to become physically ready, they have to do training before, during and even after their season. One of the coach’s comments that I found interesting was when the women’s volleyball coach admitted that when her first year players

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start off in the program, they tend to get injured because they are not as physically and mentally prepared as the upperclassmen. When asked whether the coaches believed their injured athletes need to see a sports psychologist after each injury, the opinions were similar yet different. When Coach Ganter mentioned one of the players who threw his knee brace over the fence after ten minutes of practice, it reinforced my opinion of how mentally tough the football players are. The football coach was not hesitant to say “NO” to this question right away. The women’s volleyball coach stated something similar, “We weed out the players who need psychological stroking and seek the tough ones.” The general consensus of the coaches was that a sports psychologist is needed if it is a moderate to severe injury, but not for any of the minor ones. In response to the third question, regarding the bracing behavior once an athlete returns to his/her sport, there were some interesting responses. The women’s gymnastics coach explained the strategy of “progressive skills of landing,” by gradually increasing the height of the blocks, or changing the surface of support from soft to hard. This seems like an effective method and more coaches should use that type of approach if they do not do so already. The example from Coach Battista was interesting too, where the hockey player had to “break the psychological barrier” and ease back into the practice, starting with non-contact drills. Overall, the coaches at Penn State have similar responses to these questions. They all seem to have these answers because this is a Division One intercollegiate school, and therefore athletics are taken seriously. Some of the variations observed are due to the demands of the different athletic teams. If I were to give advice to a new coach for a collegiate athletic team, I would tell them that it is better to be safe than sorry when handling an injured athlete on their team. Even though an injury such as a concussion is not blatantly obvious, the athlete should be given enough recovery time and the proper treatment to prevent further problems in the future. It is known now that athletes can get even epileptic seizures for up to ten years after receiving many head injuries from their sport. If a coach were to make an injured athlete compete again too soon after an injury, they could be affecting their health in later years without realizing it and therefore it is better to be safe than sorry. On high school and professional athletic teams, the athlete can typically decide whether or note he or she is able to compete again after an injury. On collegiate teams, that is not always the case. When the coaches were asked when an injured athlete should return to play and competition, there were varied opinions on when the time was appropriate. Gender differences are another aspect that needs to be taken into account when handling injuries. For example, facial injuries are considered more traumatic for female athletes. Coaches need to be sensitive to the gender differences since there

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are many of them. In reading the Penn State coaches’ opinions, they seem to be sensitive to this subject. International coaches’ opinions regarding injury differed depending on what country they were from. As Coach Yembo from China stated, injury may happen as bad luck, but not due to coaching errors. This differs to what some experts in the US believe. They have the ability to select athletes when they are very young in order to train them for their sport, rather than waiting to recruit them at a later age. The most essential component of their training program is that every single kid selected for their program would do two-to-three years of gymnastics. This is very interesting, and they do this so the young athletes acquire fundamental motor skills, such as body awareness, coordination, flexibility and strength. Also, they believe that if an athlete suffers an injury requiring surgery, there is no way the athlete will be fully functional after recovery. Coach Georgeo emphasizes the importance of the athlete’s happiness to prevent over-training. He overloads the body in the preparation phase so that when major competitions start, there will not be any pressure due to fatigue. Georgeo also encourages them to “listen and feel their body”, and as soon as even excessive muscle soreness happens they should let him know. His techniques are different than those of the coach in China, and seem to work well for him considering he has worked with elite athletes for over 20 years. Coach Michail of Russia stated they do everything possible to make sure to maintain and control a high level of fitness the whole year around, to reach a flexibility level up to two times higher than necessary, and to perform a competitive routine five times more than is required at the competition. He mentioned how injury in elite athletics is unavoidable and being prepared to perform with an injury may be necessary, especially at the Olympic level. Another method for injury prevention Michail mentioned is a proper warm up prior to the main part of the training session. Coach Julio from Cuba stated how hard work is what contributes to injury prevention in his coaching. Knowing the limits of human capacity is important so that you do not push an athlete too hard. Coach Josean of Spain made a bold statement saying, “I believe that 90% of injuries in elite athletes happened because of abnormal mental status of athletes, when they get tired at the end of season.” Mental exhaustion could definitely have an impact on an athlete’s performance. He also mentioned that when coaches are impatient, athletes tend to get injured. Josean also blamed the inability to “load” athletes mentally to make then psychologically strong, for athletic injuries. All of these coaches described their personal techniques for preventing injuries for their athletes. They all mentioned different aspects and methods, which is very interesting. Some prevent injuries by gymnastics, happiness, hard work, overloading, and fitness. Where these coaches are influences their techniques and effectiveness on their athletes.

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Overall, I think that elite coaches’ opinions and perspectives on injury are important to consider when developing individualized training programs for athletes.

CONCLUSION Injury in athletics is a growing concern. Despite technological innovations, coaches’ advanced knowledge about their loved sports, progresses in scientific research on various aspects of athletes’ preparation, the number of injuries with long lasting consequences has a tendency to progressively increase. Premature return to sport participation based upon resolution of only physical injury symptoms considerably enhances the risk for re-injury. Moreover, multiple traumatic injuries induce psychological trauma that is often overlooked in making decisions regarding the return to participation. This psychological trauma is evidenced by cognitive impairment, sensory-motor disabilities, and overall behavioral properties that may lead to development of so-called “bracing reactions” or “selfprotective responses.” This is a dangerous symptom that ultimately may contribute to high risk of re-injury. Our current research and the interviews with elite coaches clearly support our previously formulated notion that resolution of only physical injury symptoms is not indicative of injury resolution (Slobounov & Sebastianelli, 2006) allowing the athletes to fully participate in their loved sports. Incomplete recovery of either physical/functional (i.e., strength, range of motion, endurance) or psychological (emotional status, irrational thoughts, preoccupation with possible injuries, motivational attributes, inadequate goals) functions are definite warning signs for possibility of reinjury. The most important message from the coaches’ responses is that education and knowledge about injuries is currently lacking. The most serious concern is lack of knowledge about brain injuries in athletics. Most coaches rely on professional opinions regarding the impact of brain injury and the time frame for return to play. Taking into account that symptoms of traumatic brain injury my reappear months after the incident, meaning that there are could be long-terms functional disabilities even after mild brain injuries, it is essential that coaches should be properly trained and educated in terms of the devastating effects of concussion. Overall, coaches’ advanced knowledge about injury is an important factor that may influence their athletes’ attitude toward safety and ultimately could reduce the risk of injury in athletics.

REFERENCES Simonds, C. B. (2005). Development of a questionnaire about concussion and return to assess knowledge and attitudes about concussion and return to play criteria in college

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athletes. (Doctoral dissertation, LaSalle University, 2004) Dissertation Abstracts International: Section B: The Sciences and Engineering, 65(7-B), 3724. Sefton, J. M. (2003). An examination of factors that influence knowledge of and reporting of head injuries in college football. Unpublished master’s thesis, Central Connecticut State University, New Britain, Connecticut. Livingston, S. C., & Ingersoll, C. D. (2004). An investigation of collegiate athletes’ knowledge of concussions. Journal of Athletic Training, 39(Suppl. 2), S-17-S18. Kaut, K. P., DePompei, R., Kerr, J., & Congeni, J. (2003). Reports of head injury and symptom knowledge among college athletes: Implications for assessment and educational intervention. Clinical Journal of Sports Medicine, 13(4), 213-221. McCrea, M., Hammeke, T., Olsen, G., Leo, P., & Guskiewicz, K. (2004). Unreported concussion in high school football players: Implications for prevention. Clinical Journal of Sports Medicine, 14(1), 13-17. Kirby, D. (2002). Effective approaches to reducing adolescent unprotected sex, pregnancy, and childrearing. Journal of Sex Research, 39(1), 51-57. Kirby, D. B., Laris, B. A., & Rolleri, L. A. (2007). Sex and HIV education programs: Their impact on young people throughout the world. Journal of Adolescent Health, 40, 206217. Millstein, S. G. & Halpern-Felsher, B. L. (2002). Perceptions of risk and vulnerability. Journal of Adolescent Health, 31(Suppl.) 10-27. Slobounov, S. & Sebastianelli W. (2006). Foundations of Sport-Related Brain Injuries. Springer Publishing Company.

CHAPTER 7 INJURY FROM ATHLETES’ PERSPECTIVES 1. INTRODUCTION: ATHLETES’ RESPONSES TO INJURY There are numerous predisposing factors for athletic injuries, both intrinsic (i.e., physical/biological/psychological status, including fitness level, personality type, availability of coping resources, history of stressors) and extrinsic (i.e., type of sport, coaching errors, psycho-social environment). Indeed, from a practical perspective, it is impossible to control these mutually dependent factors since there is no solid theoretical foundation for predicting or preventing sports-related injuries. There was an attempt to separate physical/biological and psychological factors related to injury and to develop a multi-component theoretical model of stress and injury (Andersen & Williams, 1988). This initial model implies a direct link between stress induced by sports participation and/or injury resulting from stress responses. Due to numerous critiques of the initial “stress-injury” model, these authors proposed a revised version of the model which emphasizes “bidirectional links” between the athlete’s personality and his/her coping resources (Williams, 2001, see also Figure 1).

Figure 1. Revised version of “stress-injury” relationship model (adopted form Williams, 2001, with permission from John Wiley & Sons, Inc.)

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The central core element of this revised model is a bidirectional relationship between the athlete’s cognitive appraisal of the situation and stress responses as evidenced by physiological changes. For example, selfperception of sports-related demands is challenging and realistically may consolidate an athlete’s resources both physically and psychologically. This can help him or her stay focused and creates an injury-free situation. When cognitive appraisal is inaccurate and distorted by irrational thoughts and there is the belief that resources are inadequate to meet the demands, the injury risk is increased due to “bad distress” (see: Williams, 2001 for details of this model). Stress, related to attention deficits in this model, is attributed to increased generalized tension, narrowing of the visual field, increased distractibility, reduced sustained attention and the reduced capability to extract meaningful information from background noise. Not surprisingly, sustained muscle tension in conjunction with reduced central resource mechanisms may result in fatigue. As discussed in the previous chapter, fatigue may be a serious risk factor for injury. Since controversy and confusion surround the classification/definition of injury, it is difficult to properly assess the clinical value of the “stressinjury” model. In fact, it was suggested that the “stress-injury” model is probably most appropriate for acute injuries. For injuries such as overuse injuries, the causes and the mechanisms are largely unknown (see: Williams, 2001 for details of this model). Unfortunately, multiple predisposing factors are never operating in isolation. The ways and manners in which these multiple factors are interacting and collectively influencing athletes’ responses are unknown for acute injuries as well. Similarly, it is almost impossible to make any reasonable comparisons between studies examining “stress-injury” relationships due to different research methodologies, types of injury under study, differential severity and the number of injuries experienced over time, age and gender.

1.1. Cognitive Responses to Injury Cognitive appraisal of the injury in general and its impact on athletes’ short and long-term responses to injury specifically, is highly individual. The same impact and amount of damage due to trauma for one athlete could be a career ending injury, but for another it could simply be an annoyance. Numerous times elite athletes have suffered a bone fracture during competition, finished the game and then gone to seek medical attention. At other times elite athletes have developed psychological trauma, even without a traumatic injury, and could not recover, forcing the termination of their athletic careers. It should be stressed that emotions play a critical role in athletes’ perception of injury. Despite individual differences, there is

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commonality in athletes’ cognitive responses to injury, as was previously identified by Beck & Emery (1985) and summarized in Heil’s (1993) text: Catastrophizing – exaggerating the severity of injury. A couple of common examples of irrational thoughts are: At the time of injury: “I’ll never be able to play again.” And then after a pain flare-up: “I’ll never get over this pain.” Overgeneralization – incorrectly extending the impact of injury to aspects of playing ability and/or daily activities that are not likely to be affected by injury. A few examples are: “Because of this shoulder injury I’ll probably never be swimming at full speed again,” or, “With this injury, my girlfriend will leave me.” Personalization – experiencing undue personal responsibility for injury or exaggerating the meaning in relation to other teammates or coaches. For example, injured athletes may be preoccupied with the idea, “Why me and not others,” or, “I was working harder than anyone in the team, but I am the one who always gets injured ”. Confusion, or, “mental block,” defined as an injured athlete’s acute response, characterized by the inability to cognitively comprehend the injury. “I was in the greatest shape of my entire career. I cannot believe this happened.” “Why did this injury happen when I was ready for the best?” Unfortunately, injuries always happen at unfortunate times. Selective abstraction – focusing on specific aspects of an injury that have little meaning in the overall context of the injury. For example, an irrational thought such as: “My team mate had an ACL and it was a career ending injury for him; it would be for me too.” Another example is: “If I were allowed to warm up longer this would not happen.” Absolutistic/dichotomous thinking – unreasonable and complex thoughts related to injuries of all categories. This is typically a reflection of injured athletes’ lack of appreciation for painful experiences. An athlete is often confused about real or neurotic types of pain and experiences, and has thoughts such as: “My painful injury is neither physical nor mental.” In should be noted that in addition to individual differences in cognitive responses to injury, the type and severity of injury, athletes’ positive versus negative experiences with previous injuries and recovery, gender and many other variables should be considered when examining the evolution of athletes’ responses to injury. For example, a successful rehabilitation and 100% return to sports participation after an ACL (e.g., severe and often season ending injury) injury is a significant factor in an athlete’s appraisal of acute ankle sprain.

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1.2. Affective Responses to Injury The cognitive appraisal of injury never occurs in isolation from its emotional content. Direction of thoughts, beliefs of prompt recovery and an athlete’s overall mental trends are hardly influenced by emotions. The feeling of guilt, uncertainty about the course of recovery and the fear of pain are all emotional responses which influence the self-perception of injury. That said, there was a proposal to consider the personal, emotional reaction to traumatic injury in isolation as a grieving process. (Hardy & Crace, 1990). This is similar to a series of stages experienced by terminally ill people (Kubler-Ross (1969). This initial seminal thinking was outlined in On Death and Dying and proposed that patients typically experience disbelief, denial and isolation, anger, bargaining, depression, acceptance and resignation. Similarly, injured athletes may follow a five stage grief response, including: 1. Denial, as a sense of disbelief as well as varying degrees of failure to accept the seriousness of the situation and severity of injury. 2. Anger, as mental and/or physical aggression/irritation due to various attributions. 3. Bargaining, as a sense of hope that injury is not as serious as it looks. 4. Depression, as a result of anxiety, fear of uncertainty and anticipation of trouble, often manifested in rapid mood swing. 5. Acceptance and reorganization, as a sense that reality is threatening life goals and personal values. Among other cumulative reactions to injury, as described by Petitpas & Danish (1995) may be the following: Feeling of identity loss and/or loss of an important social role such as not being recognized as an athlete any more and being disengaged from sport roles. This may have serious consequences affecting the athlete’s selfconcept. Fear and obsessive thoughts of not being able to recover to the pre-injury physical status and performance level. Since the injured athlete cannot practice or compete, there is plenty of time for worry and experience anxiety. Drop of confidence level, due to temporary and/or a prolonged restriction to practice. This in turn may result in decreased motivation for rapid recovery and return to sports participation. Performance decrement, especially evident upon initial return to sports participation, may be because of lowered confidence and missed practices.

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1.3. Signs and Symptoms of Poor Adjustment to an Injury There are possibilities that the long-term cumulative effect of previous injuries that may lead to a problematic adjustment to the current injury and recuperation process. Some common signs of poor adjustment to injury are identified by Petitpas & Danish (1995) and summarized as follows: • Evidence of situational anger, depression as evidenced by alteration of mood, confusion and/or apathy. • Obsessive thoughts of not being able to recover and obsessed with asking when s/he can return. • Denial, reflected in irrational remarks and thoughts, such as, ‘injury is just an annoying delay and not a big deal.’ It is a reflection of an athlete’s effort to convince him/herself or other people that the injury does not really matter. • An injured athlete’s desire to return to sports participation prematurely based on upon an irrational perception of the injury, and driven by fear and denial. • Exaggerated storytelling and/or bragging about past athletic accomplishments. Obsessive thoughts of fast, unrealistic recovery and ignorance of the severity of the injury. • Dwelling on minor somatic complaints, not mentioning restricted ability to move and accomplish basic skills. • Guilt, shown by constant remarks about not contributing to the team effort. • Becoming dependent on the therapist or on the therapy process; displaying a lack of involvement in the treatment process and being a passive recipient of the treatment protocol. • Isolation and withdrawal from teammates and coaches. Making excuses for skipping therapy and medical appointments. • Acting helpless and hopeless; asking “Why should I even try?” Both emotional and cognitive athletes’ responses and problematic adjustment to injury may be assessed by interviews, observations of athletes in various sports and their daily living environment, and by providing psychological tests. Only interviews performed by experienced professionals may have an implication for the clinical practice in dealing with injured athletes. Accordingly, in the following text, definitions, common strategies of effective interviewing techniques and basic procedures of initial interviews will be discussed.

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2. METHOD OF INITIAL INTERVIEW Clearly, the most direct approach to assessing the individual experiences of injured athletes is to interview these athletes about their feelings, behavior, attitude and the likes. However, in order to obtain valid information about athletes’ experiences with injury and their personal views on injury, robust interviewing techniques must be used. And most importantly, the manner and atmosphere while interviewing injured athletes must be preserved. It should be noted that injured athletes might have personal reasons to interpret certain questions in a variety of ways. She may want to please or displease the clinician for unknown reasons, and participate in the interviewing process accordingly. Therefore, biases and interviewing errors are important factors to consider before making any assumptions and conclusions regarding the effect of injury on both athletes’ physical status and their psychological well-being. First, it is important to provide a definition of “interview” and dissociate it from “conversation”. In general, interview can be defined as “…face-toface verbal encounters or exchange of ideas and opinions…but the interview interaction is designed to achieve a consciously specific purpose” (Wiens, 1983). The initial interview is more purposeful and organized than just conversation; however, it is less formalized than a pure psychological test which is aimed at revealing covert or hidden features that cannot be assessed by the interview or behavioral observations. In other words, a unique characteristic of the interview method is the wider opportunity it provides for an individualized approach that will be effective in eliciting data from a particular person (Pharez, 1988). That said, the relative flexibility represents both the strength and the limitations of many interviewing techniques. Not surprisingly, the interview method is regarded as a combination of art and science. Despite the flexibility of an interview as a method to elicit information about the patient, there are three common principles that dissociate it from conversation. The interview must be: (a) goal-oriented; (b) carefully planned; and (c) skillfully executed. In terms of goal-orientation of the initial interview, two things are important to consider. First, there are different types of interview that will be discussed in some details in the following text. Second, prior to the interview, an initial hypothesis should be formulated regarding the nature of the problem under study. For example, in dealing with injured athletes it may be hypothesized that: “Every single and moderate to severe acute traumatic injury results in the development of psychological trauma” “Only severe traumatic injury results in the development of psychological trauma”

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“Multiple even minor traumatic injuries result in the development of fear of re-injury” “Female athletes experience more severe psychological trauma than male athletes suffering from the same type of injury” “There are multiple symptoms of injury, which should be resolved prior to return to sport participation. The presence of some of the symptoms may result in more severe recurrent injuries.” Accordingly, while conducting the interview it is an intention of the clinical practitioner to rule out and/or confirm the initially formulated hypotheses. It is anticipated that at the end of interviewing session, the steps for solving the problem will be clearly formulated and intervention strategies are proposed. In terms of the necessity to carefully plan the interviewing session, it should be considered that: (a) It is inappropriate to conduct an interview without scheduling the time and place beforehand. Accordingly, depending on the place (i.e., office and/or training room) an appropriate surrounding atmosphere should be prepared. (b) It is the clinician’s responsibility to get knowledge about the sport the injured athlete is engaged in. Accordingly, not only general knowledge about this sport but also common terminology should be learned prior to conducting the initial interview with the injured athlete. (c) History of previous injuries should be requested from medical practitioners, upon receipt of the athlete’s consent, to consider the possibility of chronic cumulative abnormalities. (d) Background information about the actual incident of injury and an athlete’s initial response to injuries should be requested from the athletic trainer and the medical doctor. (e) If possible, team mates may be interviewed as well to get more information about the injured athlete.

2.1. Types of Initial Interview There are different types of initial interview commonly accepted in clinical practice. They differ less in techniques and methods than in goal and purposes, namely to elicit valuable information about the case prior to administering intervention strategies. As mentioned before, a quality interview is an essential part of the treatment protocol. As was noted by Berg (1954), “… it is no exaggeration to assert that a bungled intake interview can prolong treatment while an effective one can shorten it.” (cf: Pharez, 1988, p. 149)

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The intake-admission interview, aimed at: (a) determining why an injured athlete has come to the clinician; and (b) judging whether the clinician with his/her competence may meet the needs and expectations of the injured athlete; Case-history interview, aimed at acquiring concrete facts, dates, events, sites, type of competition/practice. Overall, as much information as possible should be obtained in the first initial session with the injured athlete; Diagnostic interview, aimed at provoking and assessing an injured athlete’s mental status. It is important to note both verbal and non-verbal (facial) expression, alteration of postural responses, present mood and emotional status, abnormal mental trends (preoccupation with the injury, hopelessness/ helplessness). Some examples cited from Phares (1988) are as follows: (a) Expression and Posture (e.g., mask-like expression, silly smile, grimacing, etc.) (b) Behavior during interview (e.g., hostility, lack of insight, cooperation, etc.) (c) Mood and emotions (e.g., flat affect, euphoria, excitement, etc.) Pre-test, post-test interview, aimed at exploring the preference and possibility of administering psychological inventories, if necessary, to assess the psychological profile of injured athletes in more details. For example, verbal or visual tests may be more appropriate to further assess the “covert” signs and symptoms of psychological trauma as a result of injury; Research interview, aimed at elicitation of information about this specific injury and/or athlete. The results of this interview may be presented as a case study describing the athlete’s unpredicted responses to injury; Pre-therapy interview, aimed at detecting the preferable psychological therapeutic techniques and/or intervention. For example, depending on the athlete’s direction of irrational thoughts, behavioral/physiological/ psychological symptoms of trauma discovered during the initial interview, a program consisting of one or more of the following should be recommended: behavioral modification, healing imagery, negative thought stoppage, or stress inoculation. Crisis interview, aimed at detecting the potential for disaster and preventing crisis. Most often this type of interview is conducted during severe, disabling and career ending injuries in athletes. Proper and immediate referral to a qualified clinical practitioner is necessary following the crisis interview. Obviously, the main goal of the crisis interview is to meet the problems as they occur and to provide an immediate resource.

2.2. Interviewing Skills: Types of Questions It should be noted that regardless of the types of interview identified in the previous text, a quality interview depends on the types of questions,

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which may become more structured as the interview proceeds. The type of question should be a priori designed and carefully formulated to facilitate clinician-injured athlete communication during the interview. In the following text types of questions aimed at assessing the status of the injured athlete, as initially proposed by Maloney & Ward (1976) for general clinical practice, are provided. Open-ended questions. Regardless of the type of initial interview, the interviewing session should start with a series of open-ended questions, basically to prevent “yes-no” answers, indicating that the interview is over before it gets started. These types of questions should provide a rich foundation for constructing a hypothesis and allowing the clinicians to observe the injured athlete’s cognitive and emotional status. A few examples of this type of question include: Why are you here? Tell me about your sport. Tell me about your experience with your sport-related injuries. Again, open-ended questions are the essential part of the whole interviewing process and should be planned accordingly. Facilitative comments and questions. These are also known as “supportive comments” used in the interview. For example, in order to encourage the athlete to elaborate on some details that may be critical to assess the impact of the injury, the following questions may be asked: Do you remember what happened prior to the collision with another athlete when you had concussion? I suspect that it is important…Could you expand on your feelings right after the injury? Did you experience different symptoms after the second concussion, than after the first one? It is important to note that facilitative comments and questions should be addressed in such manner that direct “yes or no” answers are prevented. Confronting questions. It is common for injured athletes to consciously or subconsciously provide inconsistent or even contradictory statements. In this case, to direct an interview in the right direction and to eliminate confusion, confronting questions may be asked, such as: “…Well, I must admit that I may misunderstand your previous statement, but you earlier said that ...”. That said, it should be noted that a contradictory statement may contain a lot of meaning and make a lot of sense and may suggest a desire to mislead the clinician. Thus, confronting questions should be used with great caution to maintain the proper psychological climate during the interview. Direct questions implying direct “yes or no” answers should be used primarily at the end of interview, or when the clinician has achieved a certain level of trust and sense of understanding of the situation and intends to terminate the interview. Here are some direct questions to consider: Did you see a neurologist after the concussion? Did you pass neuropsychological testing? Have you lost consciousness at the site of the injury? Does it still hurt? It is important to note that overuse of direct questions may tend to shift the entire responsibility for the course of the

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interview onto the clinician. This could result in an interview that evolves as a series of short questions and short answers of no use.

2.3. Rapport and Non-Verbal Communication 2.3.1. En rapport Apparently, the most important factor of a successful interview is the clinician’s ability to establish a mutually beneficial and supportive relationship with the injured athlete. Everything matters when it comes to injured individuals, because it is not the injury per se but the injured athlete as a whole that needs proper treatment and care. The special term used to characterize the clinician-patient relationship is rapport. Berg (1954) defined en rapport as the comfortable atmosphere surrounding the interview which is permissive, reasonably harmonious and characterized by mutual interest. It is not a requirement for the sake of rapport that every patient would become a friend, but it’s required that proper attitudes, understanding, sincerity, acceptance and empathy from both parties are achieved. When an injured athlete realizes that the major goal of the clinician is to understand the problem and provide help, then a solid background for rapport is established. In other words, en rapport assumes a relationship founded upon respect, trust and confidence that the problem will resolved with mutual effort from both clinician and injured athlete. It is important to realize that the injured athlete should be an active participant of the treatment protocol, rather then a passive recipient of the clinician’s instructions. There are several predispositions and ingredients that make en rapport possible. Clearly, the clinician’s values, background and experience are among the most important factors in good rapport and an overall effective interview. Among other factors of en rapport are the following: Maximally effective communication, both verbal and non-verbal aimed at bidirectional delivery and processing of the information and to achieve the goal of the interview; An Initiation of the interviewing session aimed at establishing a comfortable atmosphere and in which the plan of action is proposed. It is recommended to start the interview with some irrelevant issues to assess the injured athlete’s current mental and physical state and reduce anxiety and tension. The use of proper language, considering the injured athlete’s background, education and sport, is critical for a good rapport. As mentioned in the previous sections, it is the responsibility of the clinician to educate him/herself about the sport in which the injured athlete was involved and to get accustomed to sport-specific terminology. It is not recommended

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to use scientific jargon to demonstrate the clinician’s “competence” with the intention of getting respect from the patient. Silence may be indicative of the injured subject’s resistance, but also may have a lot of meaning. This may indicate the patient’s confusion and inability to think rationally. That said, prolonged silence may ruin the rapport and if this happens, it is recommended that clinician should introduce new line of inquiry. Effective communication is not a monolog but rather a dialog aimed at understanding, assessment and acceptance. Therefore, listening skills and evaluation of both the cognitive and emotional content of the injured athlete’s behavioral responses is one of the key ingredients of en rapport. In fact, the main reason for a “broken link” with the patient is the failure to listen due to multiple reasons, including: (a) distraction by irrelevant stimuli/information/memories; (b) preoccupation with irrelevant thoughts; (c) concern with appearance and the patient’s impression of the clinician. These are just a few elements that can cause the clinician’s inability to obtain and process the information valuable to the assessment of the situation. Therefore, it is important to develop a habit of being an “active” listener. 2.3.2. Non-verbal communication It was long time ago when Leather (1976) declared that non-verbal communication has great functional significance in our society, for several major reasons: 1. Non-verbal rather than verbal information is the major determinant of meaning and attitudes. Specifically, tone of voice, facial expression and whole body posture may provide more clues than an athlete’s expression “this hurts a lot”. Pain experienced as a result of injury can be better expressed by the facial expression of grimacing. 2. In addition, non-verbal means more accurately convey the intensity of feeling and emotions than do verbal expressions of being sad and/or frustrated by the injury. 3. It was well-know for centuries than non-verbal clues usually transmit meaning and intentions that are relatively free from deception, because these are less under the conscious control of the patient. Conceptualization and thinking about possible answers and their consequences distort and modulate the patients’ responses and create confusion about the situation. 4. Non-verbal clues may provide additional information, if properly assessed, and serve to clarify the patient’s intention, direction of thoughts and meaning of the words.

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5. There are less redundancy, repetitions and inconsistencies in nonverbal clues 6. Finally, non-verbal clues are highly suitable for suggestion. That said, it should be noted that non-verbal clues should be used with caution due to the element of subjectivity and biases. Overall, nonverbal communication is an important attribute in a successful interview, but the interpretation of the clues may vary from case to case. Clearly, since Dr. Leather’s declaration, the clinical value of non-verbal communication and skills to extract meaning have become even more appreciated. Indeed, the skilled clinician is one who has learned to extract meaning from signs and gestures, from facial expressions and grimacing, from whole body posture and tone of voice. It is a “marriage” of science and art that makes the clinician a valuable asset to an injured athlete’s treatment.

CONCLUSION Unfortunately, there is a lack of well-controlled research on athletes’ responses to injury. Numerous confounding factors well out of the control of the researchers basically make it impossible for clinical professionals to rely on speculations obtained by the researchers. For example, several signs of “poor adjustment to injury” were identified by sport psychology researchers. A list of symptoms as warning sings of poor adjustment to injury was proposed. It included: (a) (b) (c) (d) (f ) (g)

Feelings of anger and confusion; Obsession with the question of when one can return to play; Denial, as the direction of thoughts that injury is not a big deal; Guilt about letting the entire team suffe; Rapid mood swings, from hope to depression; Hopelessness that 100% recovery may happen.

Would it be feasible to propose that these aforementioned symptoms are not an indication of “poor adjustment to injury” but rather the common patterns of elite athletes’ responses to acute injury? Are there any “good adjustments” to injury? Over twenty years of coaching and dealing with injured athletes, I’ve never seen the symptoms of “good adjustment” to injury, especially if the injury requires prolonged treatment and rehabilitation. That said, with proper assessment of the impact of the injury, personality predispositions, and available coping resources, well-grounded interventions may be successfully administered.

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REFERENCES Andersen, M.B. & Williams, J.M. (1988). A model of stress and athletic injury: Prediction and prevention. Journal of Exercise & Sport Psychology, 10, 294-306. Beck, A.T., & Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books. Heil, J. (1993). Psychology of Sport Injury. Champaign, Ill: Human Kinetics. Hardy, C. J., & Crace, R. K. (1990). Dealing with injury. Sport Psychology Training Bulletin, 1(6), 1-8. Kubler-Ross, E. (1969). On death and dying. New York: Macmillan Petitpas, A., & Danish, S. (1995). Caring for injured athletes. In S. Murphy (Ed.), Sport Psychology Interventions (pp.255-281). Champaign, Ill: Human Kinetics. Wiens, A.N. (1983). The assessment interview. In I.B. Weiner (ed.), Clinical Methods in Psychology. (2nd ed.). New York: Wiley-Interscience. Pharez, J. (1988). Clinical Psychology. Concept, Methods, & Profession. Third Edition. Chicago, Illinois: The Dorsay Press. Berg, I. A. (1954). The clinical interview and the case record. In L.A. Pennington & Berg (eds.), An Introduction to Clinical Psychology. New York: Roland Press. Maloney, M.P. & Ward, M.P. (1976). Psychological Assessment: A Conceptual Approach. New York: Oxford University Press. Leathers, D.G. (1976). Nonverbal Communication System. Boston: Allyn & Bacon.

CHAPTER 8 INTERVIEWS WITH INJURED ATHLETES Interview 1: Baseball Tom T. a junior at Penn State University, has been playing baseball for more than fifteen years. Tom majors in Recreation and Tourism Management. He was the starting pitcher at his high school, Council Rock. During his career in baseball, he has suffered many injuries. Tom has broken his right wrist twice, left wrist once, and his right elbow twice. Altogether in his life he has incurred thirteen broken bones (note that some of the breaks were not sports-related). Unfortunately, during his last season of baseball in high school, Tom broke his elbow for the second time, eliminating him from being able to play for college. He told the story of how this occurred. He was running and slid into home plate, and the catcher fell on top of him and broke his elbow, ending his career. Even though Tom did go through rehabilitation, he felt that he could not pitch as fast and hard as he used to and removed himself from the sport. Still today, he cannot pitch in certain ways due to the injury that happened in his senior year. In this interview, as you will read, I focused on the aspects of what he endured during his season, obtain the view through his eyes as a coach and what he has seen from his coaches, and how still to this day he is dealing with not having the same ability he had once had. Q1: As you know, injury is a common risk and is an unavoidable part of sport. Can you elaborate on why injury is still an unavoidable part of athletics today? What elements do you feel are more essential in your training as a coach on how to prevent the risk of injury? Putting yourself in your coaching shoes, what do you feel are the more crucial elements in reducing this risk? Tom T: I strongly feel that injury in sport is inevitable. Most of injuries that do endure are mainly freak accidents. Take for example on how my last injury happened and ended with me not pursuing in baseball anymore. All I was doing was sliding into home plate and the catcher fell on me. He did not do it on purpose, but just by accident. We, as athletes, can only do so much to be cautious, but no one is perfect and can avoid the risk of injury. Participating in sports there is always that risk. The coaches can only teach and do so much to prevent this from happening. The elements that I feel are essential would be position, getting the technique down right and also, a training program. Having a program, such as strength training really helps build up the core areas of your body. Also, having the right state of mind during practice and competition, this can help eliminate the risk. Some

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injuries do happen, because athletes are not focusing on technique, or what others are doing around them. If I were to put myself in the coach’s shoes, I would strongly encourage my players to get into a great strength training program, teach them the basics with proper form and positioning, and get my players to have trust in me. Having trust is a major component, because if you did not have trust I strongly believe that will happen more frequently . As a coach, they are the ones who are aware of things, had different experiences, and have dealt with these situations. Q2: Psychological trauma has become a very important issue in sport today. Have you ever dealt with or seen another one of your team mates have sport-related psychological trauma? Do you feel that every single injury may cause some type of psychological trauma and that athletes need to seek counseling after injury? Tom T: In certain aspects, I felt like I did go through psychological trauma, but not to the extent that I needed to seek any counseling for it. After seeing physically, I could not throw a pitch as good as I once had really got to me. It did have the affect that had led me to end my baseball career, but still I don’t feel that I needed help for it. Everything happens for a reason. Yes, mine was due to injury, but as a look back on it I probably would have gotten burnt out from the sport and just quit later. I have seen some teammates go through psychological trauma, but it was not sportrelated, such as depression, bipolar and other disorders. To answer the second part of the question, I do feel that certain injuries due cause that psychological trauma. By having the top star in whatever sport have their talent taken from them in a matter of minutes and have nothing left, then I feel they need that counseling. The fact that something is taken away from you in the matter of moments does take a serious toll on the athlete, especially if they have nothing to fall back on in life. So, basically it depends on how much the sport weighs on the athlete that they would have to endure some type of counseling. Q3: Injured athletes who return to sports sometimes feel that they may not be psychologically ready to come back. They start to display a symptom called “bracing behavior.” Coming back from rehabilitation have you ever experienced yourself displaying this sort of behavior? What signs and symptoms could you identify in your behavior (if any) or in other athletes on your team? How would you prevent this behavior and how would the coaches deal with this problem? Tom T: I honestly have to say that I have never done or thought I had displayed that type of behavior. After all my injuries in baseball and any sport I did, I tried to come back early. By me coming back as early as I had done, they thought I had re-injured my arm. The main reason that I wanted to have a fast recovery is that I wanted to play. I always had the motivation to get right back into the swing of things. I loved baseball it just kept me wanting to get back in right away. Some “bracing behaviors” that I saw

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from my teammates would be just complaining that they were still hurt, therefore the coach would sit them for practice and not play them in the game. With the coach not allowing them to play in the game, they would complain of why they were not getting in at all. Since I don’t think I displayed the behavior, I would not know how to prevent. Seeing that my coach had to deal with some players like that, he would just go back to the basics, you practice before you play. Honestly if they did not practice after an injury, I feel that they are more prone to re-injury again. It all comes back to having that coach-athlete trust. You do not want to have the risk of reinjury and neither does your coach. The coach has to do what he feels is the best for you and the team. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you feel that if you are 100% symptom-free you are ready for sport participation? Tom T: Psychological adaptation does play a huge role in the rehabilitation process. If you are not mentally ready then physically you would not be either. These two comes hand-in-hand. If you are only physically ready, then you are probably more likely to milk the injury (or display that bracing behavior that we just talked about earlier). The more mentality you have the stronger you are going to be as a person and in the sport. You mental ability keeps you motivated. Always get you going in whatever you do. Now if you are 100% symptom-free in both physical and mental aspect, then yes you are absolutely ready to come back. The only thing that would hold you back if you lack one of those elements, but other than that I would think and feel that you are ready to get back into the game. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of an athlete’s readiness for retuning to practice versus returning to competition? Tom T: I feel that the decision should be made by the athlete, medical staff, and then the coach. In making my comeback in sport I made the decision to come back early, even though it may not have been the best decision made by me, but it’s solely up to the athlete. I mean we are the ones who know our own body and what it is capable of doing. The medical staff and coach can only see how you’re doing though what you tell them or what they see in rehabilitation or practice. For the criteria of coming back with the athlete’s readiness you have to perform well and let the coaches see and know that you are ready and are able to compete at the level you did before the injury had occurred. If you are not performing top notch then the coach would not let you start like you were before. You have to start from the basics and move your way up. My coach for baseball let me practice and in the beginning of making my way back to competition, he would only put me in for one or two games. The coach solely believed if I was in there too long, then the injury would emerge again.

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Q6: Sports psychology has come up with a number of interventions to help speed up the rehabilitation process of injuries. Have your coaches and medical staff ever used an intervention to help you return to full sport participation? Which technique did you feel worked the best for you? Tom T: Once my injury was healed, the rehabilitation staff sets certain goals and had me learn the basics again. You can not just jump right into the sport again. Everything needs to take time, especially dealing with an injury that has set you back for awhile. After the medical staff said I was good to go, it was then up to my coach. Coach still took it slow with me, because I was still getting used to things again. He had me go over the basics and use the imagery technique. Once I started to see it in my head, and start to show results on the field, he then started to make me set some goals during practice, which got me ready for competition. Having these interventions helped speed up the repairing process, but only to a certain extent, because having an injury can be either mental or physical. No one has the magic touch to be like; okay your arm is not broken or that you are not afraid to play again. We just need to take our time in the recovery process and not speed things up that could lead to problems later on in life. Q7: Studies have shown that there are clear gender differences among athletes dealing with the psychological and emotional aspects of an injury. Even though you have played in male sports all your life, do you feel that there are different strategies that coaches take for female athletes verses male athletes? Do you feel that female athletes express different emotions than male athletes do? Tom T: I have no prior experience in this area, since I have been only playing with all male athletes. Maybe there can be different strategies that coaches give to female athletes, because they do tend to be more moody and emotional than males. I mean females do go through more psychological barriers, such as eating disorders, image, self-esteem issues, whereas male athletes do not usually see this type of barrier besides trying to perform their best. For male athletes, we hardly ever show emotion or affection, because if we did, we would be made fun of or be labeled as the weak one on the team. I feel that coached towards female athletes might be a little harder to eliminate these biases against them. If you really think about it, in the end it might make the female athlete stronger and come over these drawbacks. Q8: In your opinion, and in terms of psychological recovery, do you as an injured athlete think you would recover better or faster if given more attention or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male verses female athletes? Tom T: In dealing with my injury it helped that the coach and medical staff gave me the attention that was needed. It helped me pull through the process better, but I wouldn’t say faster. The reason for that is, because I think I got myself motivated come back faster since I wanted to bad so badly. Obviously, getting attention helps even more, because it gives you

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more motivation to do better and hopefully comeback fully recovered. When coaches, medical staff, or even parents show attention to the injured it creates a sense of trust. Trust is a major issue that comes along with sport. If you don’t have trust than what do you have? Makes you feel that you don’t have a stable person to fall back on. I don’t feel that there is a difference response to attention paid females verses males. There are certain coaches respond to situations differently. Dealing with female athletes, you just have to watch what you say and not treat them like babies. Q9: Another issue that concerns many athletes and coaches is braininjuries, mostly concussions. Have you ever dealt with a head trauma? Did your coaches ever talk to you about concussions and were they well informed? Do you feel that coaches can try and prevent concussions? Tom T: I am lucky enough to say I have never dealt with any concussions or severe head traumas. The coaches did talk to us about certain injuries, but did not discuss specifically about concussions. He made it very general, and instructing to be safe during practice and competition. They talked about the risk and dangers involved, but that was summing up all physical injury that could transpire. When the coach was talking about the risks involved I would assume that they are well-informed in some situations, but they are not part medical staff so how much should they know? I mean you hear of injuries all the time when you’re growing up, so some just assume that you are aware of the risk. Coaches can try and prevent concussions, but can only do so much. Make sure they wear proper equipment for protection, and make sure they are paying attention and focusing. Other than what I said, I do not think there is much more that can be done. Q10: Some athletes exhibit certain symptoms after having a history of concussions, including headache, dizziness, nausea, emotional liability, disorientation in space, impaired balance and postural control, altered sensation, photophobia, and lack of coordination and slowed motor responses. Do you feel that your coach labeled these symptoms as irregular or abnormal in the affected athlete? Tom T: I do not personally feel that I have that ability or knowledge about these symptoms, because I’m not a medical doctor and have not experienced a concussion before in my life. If I recall, I do not think that the coach would label it some of those symptoms as irregular or abnormal, because half those symptoms are common in any sport atmosphere. If you run too much, you may feel nausea or dizzy. Not hydrating yourself can lead you with some of these symptoms. So basically, I feel the trust issue comes back into play. Honestly if the athlete feels that they are not acting like themselves or talking about how their habits have changed, then I would think that the coach would see it as abnormal. Q11: Since you haven’t endured a concussion, do you feel that it is obvious during practice or competition that a previously injured athlete has

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developed “bracing behaviors?” Did your coach have particular strategies for dealing with athletes who exhibit this type of behavior in response to injury? Tom T: I have never seen one of my teammates milk a concussion, but I’m sure some do. They probably feel that there could be some physiological damage that could happen. If the athlete feels like they are not ready to come back, because they had a previous concussion maybe they need to take more caution in their sport. If I was showing that behavior, I probably would go and talk to my coach and see what he has to say to me. He would probably send me to the medical staff, which I guess they would do some tests to see if I was alright, but I can’t really give you an answer since I have no prior history of having a concussion. The strategies coaches might exhibit to the athlete might include some psychological interventions or just have the athlete taken over to the medical staff, so that they can discuss the fear the athlete has about this issue. Q12: What advice would you give athletes to identify risk of injury or prevent injuries to happen? Tom T: Listen to what your coaches tell you. Also, drink lots of milk, and have a balanced diet. You need a well-balanced diet to get all the vitamins and minerals to help with injury and the healing process. Stay positive and always keep your head up even in the worst situations, because you have the ability to recover and give it all you have. I would emphasize having a good training program, so that you are physically able to meet the demands from your coach, because as you move up in life and start to play at a higher level the demands become more complex and enduring than when you were little. Q13: Do you regret your choice of ending your career in baseball? Tom T: I do not regret the choice I’ve made, solely because I can still play for fun. I played baseball for fifteen years and I feel if I would of when further that the fun and thrill would be taken out of the sport for me. So, I have no regrets, but just maybe coming back into the season too soon that my range of motion is not back to normal. Every athlete just needs to realize that it takes time and you just need to wait and be patient, because you will be able to play the sport again whether it’s at a collegiate level or just for fun.

Interview 2: Lacrosse No matter what sport the athletes play, they are more than likely to suffer some sort of injury during their career. The recovery process can be more demanding, painful and psychologically difficult than the actual injury. This is particularly true for traumatic injuries. To examine some of the effects a serious injury has on an individual with a history of severe injury, a

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Penn State student and club lacrosse team member Jeremy E. (juniorChemical Engineering) was interviewed. Q1: What was your injury and how did it happen? Could you see it coming? Jeremy E: During the fall of my sophom*ore year (2001) I tore my left ACL and MCL playing football. I played running back and was getting tackled. I don’t remember any of the details except I was running and I got hit from behind. Next thing I know is that I am lying on the ground with extreme pain and then my knee went numb. I was helped off the field and the trainers looked at it. I ended up going to the hospital and having an MRI which is when I found out the extent of the injury. Q2: When did you have your surgery and were there any complications during rehab? How long did you have to wait before you could rehab? Jeremy E: I had to wait until the swelling went down to have surgery. I hurt my knee in September and had surgery in October. It sucked though, because I began rehab for about a month after the surgery and then I had a complication since my MCL did not heal right the first time. So I had to go in and have that fixed and rehab for another 5 ½ months. I was able to get back in a little under 6 months and play in some of my lacrosse games. Q3: Wow, that seems fast to be fully recovered from an ACL. How did your rehab go and what did you have to do? Jeremy E: Nah, it seemed like it was forever. I’ve always been an athletic and competitive person and couldn’t wait to play again. I played football and lacrosse in high school and I still play lacrosse for the PSU club team. I just couldn’t stand not playing. In rehab I just had to get my strength and flexibility back after the surgery. It was very painful and sucked a lot. The physical therapist and medical staff was very nice though. I had exercises with weights and a woman sat on my leg to bend it to regain motion and strength. Probably was one of the most painful experiences in my life. I hope I don’t have to do it again. My knee still hurt some when I was cleared, but I just figured I had to play through it to get back in shape. Q4: While rehabbing did you have a specific goal in mind? Jeremy E: I just wanted to get back as fast as I could to full speed 100% and I think I’ve done that. Q5: Did you have any problems getting back into sports physically or psychologically? Did you have to “brace” yourself or compensate for the injury? If so, how? Jeremy E: Physically it hurt a little bit when I started running again. I was hesitant to plant and cut like I used to for a bit. I just wore a knee brace for a year after the injury and then I realized I didn’t need it anymore and it just got in the way. If I ever got hit the right way it stung some, but now it is basically back to what it was before I got hurt. It does hurt now though sometimes when I run on pavement a lot. I’ll always have sort of permanent tendonitis for the rest of my life.

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Q6: But no major psychological difficulty? Jeremy E: I just tried to forget about it for a bit when I was cleared to play and tried to play normal. However, that’s much easier said than done. It probably took me a year to get fully comfortable again. My stats suffered some because I was not as aggressive. I decided I was never going to play football again. I just couldn’t do it. With lacrosse I figured I had less of a chance since there is less contact. I have to admit though, I was a little bit worried I could get hurt again, but I was like ‘it happens.’ If it’s gonna happen, it will… I can’t do anything about it. I struggled a bit with my conditioning for a while when I got back, but not from any major psychological fear or anything. I never went to see a psychologist or anything. I don’t even think about my knee now. Q7: How did your personality change during this traumatic time and how did your family react? Jeremy E: My family was real supportive and helped me out a lot and I thank them. I was probably real annoying to my mom. I complained a lot and was real stubborn since I really couldn’t do anything other than sit around. I pushed myself too hard at some points I think. Luckily since it was my left leg I was able to still drive. Otherwise, I would have been a pain in the ass for her having to chauffeur me around all the time. I just learned to appreciate the limited opportunities I had in sports more than before. Q8: How did your coaches help you through your knee injury? Were they well informed about your injury? Jeremy E: Well it happened during football season and those coaches just told me to take as much time as possible and were understanding. They knew about knee injuries from coaching clinics, but they let the trainer and doctors take care of it. They just offered encouragement mainly. I still went to practice during the season and they let me take part in film sessions. After a while I was able to lift upper body with the team. However, I never played football again after the injury so after the season I didn’t have much interaction with them. But my lacrosse coach was very nice. He called me once a week at home to see how I was doing and always offered help if I needed it. I was captain of the lacrosse team and luckily I was able to get back for some of the season. I never felt rushed by any of them. I think I put more pressure on myself than they did. Q9: Do you think this injury will affect you in your future plans? Jeremy E: Eh, maybe, but not a lot. Like I said before, I am doing club lacrosse and that is fine. I am also doing Officer Candidate School for the Marines in the summer. I was able to pass all their tests and have my knee cleared to participate. Hopefully, it stays that way. I’ll worry about that if it happens. Q10: If you had to rehab again from this injury, would you treat it the same way?

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Jeremy E: Absolutely, I had no problems and I am fine now. I just wish there was a way to get back faster. Q11: Do you have any suggestions for athletes, or for coaches, friends and family members of athletes who may suffer a significant traumatic injury in the future? Jeremy E: I would just have to say to keep positive. Everything will work out in the end if you put enough effort into the rehab and don’t get discouraged if there are any setbacks. As for the coaches, family and friends of an athlete I’d just say to be supportive and include the patient in activities. Q12: Many athletes suffer from concussions in sports and they can have severe side effects if not properly diagnosed, how do you think they should be handled by coaches and doctors? Jeremy E: I think concussions should be treated safely and with extreme caution. Severe memory loss or psychological effects could occur in the future. Coaches should be informed of concussion symptoms and err on the side of caution rather than risk an athlete’s health even if they still can physically compete. After interviewing Jeremy I found that he reacted to his ACL and MCL tear like I would expect any athlete to. He was in the prime of his career and wanted to recover as quickly as possible to resume playing lacrosse. I got the feeling he is kind of co*cky, stubborn and does not like to show any weaknesses. However, he experienced a few setbacks that required additional surgery on his knee. He took them in stride and dealt with them. When he was cleared to return to the playing field, he was hesitant to go 100%. At first, he was unsure of his abilities, but he was able to quickly regain confidence to be an effective contributor to his team. Eventually, he was able to run, cut and plant with full strength. Jeremy did not have any major or unique psychological fear that required any extra attention or help. He has no noticeable psychological effects from the injury now. Jeremy’s responses were very candid and truthful. His personality has not changed much since the injury. However, he seems thankful that he was able to recover fully.

Interview 3: Cheerleading The subject interviewed was Ashley F. Ashley participates on the Penn State Club Cheerleading team and has done so for the past three years. Her position on the team is a base, which is the support for stunting and certain poses. Ashley currently has a torn ligament in her left ankle which happened during stunting. She has had previous cheerleading-related injuries, however not this type of injury. Ashley was asked a number of questions similar to the coaching questions, but from her point of view as an athlete.

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Q1: Could you elaborate on why you believe injury is unavoidable in athletics? Ashley F: Injury is unavoidable because when practicing to your full ability, one is not thinking about injury or being cautious. In my sport, girls are being tossed up into the air and caught; without proper techniques and perfect timing injuries can result. Q2: Do you agree that every injury could cause psychological trauma and that injured athletes should receive psychological counseling? Ashley F: replied that she does not think athletes should receive counseling and that not every injury could result in a psychological trauma. She thinks that athletes should realize that there is a chance of injury and there is a low probability that it will happen again. Q3: Do you have any sign of bracing behavior yourself as an injured athlete that you are aware of? Ashley F: agreed that she does have bracing behaviors for her injured ankle. She said, “I favor my ankle and try to land more to the right side to take weight off my left injured ankle.” Q4: Do you think if you are medical symptom-free post-injury that you are fully ready for 100% sport participation? Ashley F: did not agree with this statement, instead she replied, “I am not fully ready to go back to competition. I need to rebuild my strength and get back into shape before competing again.” Q5: Who should be responsible for the final decision in terms of your return to full sport participation: coach or medical doctor? Ashley F: responded, “In my situation it should be the doctor’s final decision because he knows more about my injury than my coach and the specifics of re-injury to my ankle.” Q6: What kind of strategies do you do to enhance your readiness to return to sport participation? Ashley F: believes that her readiness was enhanced by knowing her position on the team was in jeopardy because there are two teams for the club cheerleading team and the coach could easily pull another base from the other team to fill her position. Q7: Do you think there are differences in female athletes versus male athletes coming back from injury? Ashley F: believes that females are stereotyped of being more emotional and coaches believe that they will not have the mentality to return to competition. She believes men have to it easier when returning to sports without the hassle from coaches. Q8: Do you think you would recover faster or slower with more or less attention given to your injury? Ashley F: responded, “I think less attention is better because then you are not constantly thinking about injury while practicing or competing. I

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also think if more attention was paid to the injury it could increase the risk for re-injury.” Q9: Do you think your coach knows enough about concussions? “I do not think he knows a lot,” Ashley replied. “I believe he knows about symptoms of concussions and what to look for if an athlete is concussed since concussions are likely if a flyer falls from a stunt.” Q10: Can you see bracing behaviors within your own teammates? Ashley F: replied, “I can definitely see teammates favoring one side over another side. Athletes also wear a lot of braces such as an ankle brace or wrist brace to prevent injury or re-injury.” Q11: Do you have any advice for other collegiate athletes in preventing injury or injury in general? Ashley F: believes that student-athletes should not let coaches push them beyond their limits when they are injured. She also believes that athletes should not jump back into full participation if they are not ready.

Interview 4: Football There are many factors linked to this increase in sport related injury, but to get a better opinion of why these injuries still continue to the haunt the lives of many athletes, a formerly injured collegiate athlete was interviewed and asked to elaborate on the question asked by many, “How can one prevent injury in sport?” Christopher B: is a talented freshman Penn State varsity football player. He was a highly recruited wide receiver coming out of the state of Virginia. He has played the game of football for a number of years and is definitely no stranger to football related injuries. Christopher has had a number of sprained ankles, several broken bones and a concussion. So he is definitely one who has his share of injuries and has worked with different medical doctors, trainers, and coaches. With his varied personal experience, Christopher has developed a multitude of opinions on proper techniques for preventing and treating sports related injuries. Q1: Could you please elaborate with your opinion on why injury is still an unavoidable part of athletics today? What elements do you feel a coach needs to hold most essential when coaching collegiate athletes to reduce the risk of injury? Christopher B: There are a lot of factors that go into why sport related injuries continue to increase, like fatigue, flexibility and experience. But one of the most important factors I believe is the physical condition of a player. The player may not be in a good physical condition and just because you have very expensive and technologically advanced equipment on does not mean that you are exempt from any possibility of injury. Another factor that most people do not realize is very important is the ability of a player to

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remain as balanced as possible in all situations in competition. For example, the more balanced you are as a wide receiver, the less likely that you will hit the ground awkwardly and cause an injury. Because I find these two factors to be the most important in preventing physical injury, I think that it would be in the best interest of many coaches to enforce physical health and balance in practice and competition. Q2: Do you agree that every single injury may cause psychological trauma and therefore athletes should seek psychological counseling shortly after injury? Christopher B: No, I do not believe that every single injury causes psychological trauma, but I do believe more severe injuries may cause it. If an athlete shows signs of psychological trauma after a severe injury, like broken bones or ligaments, or concussions then I do believe that the athlete should seek psychological counseling shortly after injury. Q3: Through your experience as an athlete could you describe the signs and symptoms of bracing behavior among yourself or other athletes? What would you think a coach would need to do to prevent or eliminate these symptoms of bracing behavior? Christopher B: Signs of bracing behavior could range from reduced speed to athletes showing less effort in completing plays that may have involved the injured body part. Signs of fear are common predictors of bracing behavior. As an athlete I think that if a coach observes any bracing behavior in an athlete, he or she should personally talk to the athlete and explain to him or her that the bracing behavior is negatively affecting their performance and if he or she does not let go of it their performance will affect their play and cause re-injury or even a loss of their position on the team. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free post-injury athletes are fully ready for 100% sport participation? Christopher B: I believe that an athlete’s psychological adaptation to injury can play a role in the rehabilitation process. It all depends. Some athletes have the ability to speed up the rehabilitation process by mentally motivating themselves and others do not. I also so not believe that medical symptom-free post-injury athletes are always ready for 100% sport participation. Athletics for the most part need to be both mentally and physically ready before they can return to 100% sport participation. An athlete can be physically ready 100% but only 50% mentally ready and only 75% ready for sport participation. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions?

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Christopher B: I believe that neither the coach nor the medical doctor should have the final decision in terms of an athlete’s return to full sport participation. I believe that the athlete should have the final decision, because the athlete is the one who knows his or her body the most. The athlete is the one who is going to be returning to the game, not the coach or the medical doctor. But after the athlete’s decision, the next important decision is the medical doctor’s and then the coach’s. I do think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions. This is a strategy that is already implementing on the Penn State football team. Q6: What kind of coaching strategies would you recommend to enhance athletes’ readiness for returning to a full range of sport participation? Christopher B: I believe that the coaches should not do anything because it is not their job to come up with strategies that enhance the athletes’ readiness for returning to a full range of sport participation. I believe that this job is for the physical therapists and trainers. I think that the coaches should stay out of it because they would only complicate things, especially if they are telling the athlete something that is not parallel to what the physical therapist and trainer is saying. Q7: In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Christopher B: I think on a broader scale the more attention you pay to an athlete and their injury the more likely that the athlete is going to recover faster than an athlete who has the same injury and received less attention. But on a much narrower scale it actually depends on the athlete. Sometimes the recovery of an athlete has no significant correlation to the amount of attention given to the player. Q9: What do you think the collegiate coach should know about concussions and what should be done from a coach’s point of view in order to prevent concussions? Christopher B: I am really not an expert when it comes to concussions and therefore have no idea of how any concussion grading scales and return to sport participation guidelines can be used to determine how to prevent more severe secondary or multiple concussions, but I do believe that after three mild concussions or one very severe concussion an athlete should consider ending his or her athletic career. I also really do not have enough information about concussions to know if there are any long-term cognitive and behavioral deficits after single concussions, but I do believe that there is a far greater chance of these effects happening in people who have multiple concussions. I also believe that collegiate coaches should know everything there is to know about concussions, because they happen so often and can cause both short term and long term harm. I do not know what coaches can do to prevent concussions from happening because I really do not know how

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much research has been done on what causes concussions to happen in the first place. Q10: Is it obvious during practice or in competition, to you as an athlete, if a previously injured athlete with concussion has developed bracing behaviors? Christopher B: I believe that it can be obvious at times to coaches and athletes at practice when a member of a team has developed bracing behaviors, because the athlete will change up his style of play. For example, an athlete who is normally runs fast at every practice begins to run noticeably slower after recovering from a concussion and a leg injury. Q12: What advice would you give to uprising coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? Christopher B: The only advice that I can give uprising coaches is that they really cannot prevent injuries completely but once they notice that a player is injured he or she needs to provide all necessary physical and psychological treatments to that player to ensure a 100% full mental and physical recovery.

Interview 5: Track and Field: Running The following interview was conducted with Meghan N., a current Penn State athlete. Meghan is a sophom*ore who runs for the cross country team and competes in long distance events for the track team. She also is a former high school field hockey player. Meghan suffered an injury to her hamstring muscle during her freshman year, keeping her from competition for a few weeks. She was forced to wear a brace as well. The following reflect her views on injury in collegiate sports. Q1: Could you please elaborate with your opinion on why injury is still an unavoidable part of athletics today? What elements taught to collegiate athletes do you feel are most essential to prevent risk of injury? Meghan N: Injury is still unavoidable because even with all the nutritional understanding and coaching expertise, athletes push their bodies to the limit each time they practice/compete. I feel that when athletes are taught to approach their coaches with any minor pains and to see their trainer for preventative physical therapy, they can prevent minor injuries from becoming major. I don't think college athletes are really “taught” any specific elements to prevent risk of injury other than to not let something minor become major. Q2: Do you agree that every single injury may cause psychological trauma and therefore athletes should seek psychological counseling shortly after injury?

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Meghan N: I do not agree that every single injury may cause psychological “trauma”. I feel that some injuries, even minor, may get an athlete down, however, I do not feel that every injury causes trauma. Q3: Through your athletic experience could you describe the signs and symptoms of bracing behavior among your fellow athletes? What strategies could your coach use to prevent, and if observed, to eliminate these symptoms of bracing behavior? Meghan N: I have seen this “bracing” activity a number of times. Basically, when I see it in runners, if they come back from an injury too early they typically run different because they are afraid to run on whatever part of the body was injured. I feel if a coach realizes an athlete is not quite ready to fully participate in workouts on the track they can have them run tempo runs outdoors where no one else is watching the athlete and the athlete can become comfortable with running again without the stress of having to run a certain repeat in a certain time. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free post-injury athletes are fully ready for 100% sport participation? Meghan N: Yes, I feel that medical symptom free post-injury athletes are ready for participation. However, with any injury regardless of physiological or psychological conditions, the athlete should never go into 100% participation right away. I do feel that an athlete’s psychological adaptation to the injury matters in rehab. For example, if they are more positive and able to take things day by day that will probably progress better. But still, regardless of their psychological adaptation, 100% is never good for an athlete right out of injury. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions? Meghan N: I think the doctor has the ultimate say. They know the athlete's condition and what is best. Yes, as stated above, I think there is a big difference between practicing and 100% competition such as full workouts and competitions. Like anything, after an injury an athlete needs to gain their fitness again. It’s like telling someone to go run a marathon without ever training for it. Yeah, I know I could run that marathon and probably finish it, but without training for it, I know I wouldn't be able to walk for many days afterward. Q6: What kind of strategies do you think coaches should utilize to enhance athletes’ readiness for returning to a full range of sport participation? Meghan N: I really don't think the above activities would work. I think it is more about readiness in training to return to full sport participation.

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Mentally, as an athlete, or at least in my personal case, when you get injured, you already set the goal of getting back. From your doctor and trainer, you get an idea of how long it will take to get better. Thus, when you are finally able to train again, you are mentally ready because you have been doing the active steps in physical therapy along the way to get back. Sometimes it is more important for coaches to set guidelines to hold athletes back though. Because I feel like mentally athletes think that they can start right where they left off, and it could be mentally defeating when they realize they can't. As a coach, I feel that the only strategy to maintain an athlete's readiness is to make sure that they have them do workouts and activities in which they can succeed, and to not throw them directly into the fire of competition. Q7: Do you think coaches use different strategies for dealing with female athletes as opposed to male, particularly in regard to recovery from injury? Meghan N: Maybe studies have shown this, but I don't personally see women being more fearful then men, at least on my team, so I don't feel there should be gender distinctions. Q8: In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male versus female athletes? Meghan N: I think that it is the right medium of “more and less attention” it's the “right attention.” If you look at an injury and don't overobsess or brush it off, and see it for what it really is, I feel psychologically, recovery will be best. NO, I don't feel there is a difference for male versus female. Q9: What do you think the collegiate coach should know about concussions and what should coaches do in order to prevent concussions? Meghan N: In my sport, this doesn’t really apply. Q10: Is it obvious during practice or in competition, if a previously injured athlete has developed bracing behaviors? Meghan N: Like I said, in track I can only see it if someone is running different. I was a field hockey player in high school, and I personally know after tearing my ACL that I played more tentatively. I think it is more obvious to see in team sports. Q11: What advice would you give to uprising coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? Meghan N: I would just tell coaches to make sure their athletes take care of their bodies and know when they should start rehabbing minor injuries. There are some things such as bruises that you just don’t do anything for, but at the same time, you shouldn't let a nagging injury turn into something much more serious.

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Interview 6: Soccer Interview with Jeff C., Penn State soccer player. History of Injury: 2 concussions Turf Toe Hematoma in both quads Needs surgery on femur Knee Cap does not track properly causing problem with cartilage in knee joint Steps to recovery: Ultra sound on knee and injected medicine Rehab Stretching Ice Surgery on femur Visits with trainer Q1: Could you please elaborate with your opinion on why injury is still an unavoidable part of athletics today? What elements do you feel are most essential in coaching collegiate athletes to prevent risk of injury? Jeff C: Athletics, despite certain advancements in equipment, which allow athletes to push their bodies to optimal levels, have remained the same throughout time. Speaking of soccer, equipment and rules have been the same since the turn of the century. Shin guards are actually smaller and the cleats are light weight and the ball plays better and is not as heavy. As we make advancements to be able to perform better and push the bodies to the limit, injuries are unavoidable when we push our bodies to this optimal performance level. The best thing a coach can do is not push the athlete past a certain point and realize when enough training is enough training. A coach that allows players to recover will have healthier athletes. Q2: Do you agree that every single injury may cause psychological trauma and therefore athletes should seek psychological counseling shortly after injury? Jeff C: No, not every single injury causes psychological damage. However, a string of injuries or an injury that will keep you away from the sport for a while definitely has a psychological element. I somewhat disagree that athletes should have to seek counseling after injury; possibly if the athlete will be out for a long period of time. Q3: Through your coaching experience could you describe the signs and symptoms of bracing behavior among your athletes? What would be your

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coaching strategies to prevent, and if observed, to eliminate these symptoms of bracing behavior? Jeff C: Bracing occurs often when a player is returning from injury. Oftentimes it is intentional to protect the athlete until he is positive he feels 100% fit. With knee injuries a player will have a no contact regulation put on him during practice. These players may shy away from tackles or situations that may cause contact. If this causes further bracing behavior you can sit the player for a longer period and allow him to practice outside team practices until he or she feels they are strong enough for contact. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free post-injury athletes are fully ready for 100% sport participation? Jeff C: No not right away because an athlete may not have his timing down or his confidence level may not be 100%. If you allow a player a longer recovery time and give him more practices before competition these things may return. Timing, I feel, is a large aspect of coming back from injury. Timing, meaning being able to flow with the speed of play, not late on tackles etc. If a player’s timing is off he or she could get re-injured easily. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions? Jeff C: Medical doctor. A medical doctor can look out for the athlete’s interests without his own interests involved. I have seen coaches push players to return because he needed a stronger squad even though that player was not fully fit. A coach may not always have the player’s interests at heart. There should be different criteria for return to practice and games. Q6: What kind of coaching strategies would you recommend to enhance athletes’ readiness for returning to full range of sport participation? Jeff C: As a coach, I feel that I would leave rehab up to the athletic trainer but advise the player to follow their instruction closely and push themselves hard in rehab sessions. Also I would advise the player to use his best judgment whether he is 100%. Trainers can sometimes baby the injury and not be aggressive enough during rehabilitation. Q7: Are there different coaching strategies for dealing with female athletes as opposed to male, particularly in regard to recovery from injury? Jeff C: I feel that injury and strategies are down to the individual’s attitude. I’ve seen women who can be pushed harder than some men and vice versa. In general however, I feel that you can be more aggressive with rehab for males, and females might take a little longer to recover or rehab both mentally and physically.

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Q8: In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male versus female athletes? Jeff C: I think that if you give too much attention to the injury that a player may respond differently when returning to competition. It is cemented into his mind when he is given excessive attention to the injury. If rehab is done and emphasis is put on getting healthy rather than the injury itself a player’s attitude changes from not getting hurt again to wanting to get back on the field as soon as possible. This attitude could change the confidence level of the athlete returning to the field. And, I feel, there is a difference between female and male athletes in regards to attention given. I feel women are given more attention. Q9: What do you think the collegiate coach should know about concussions and what should be done from a coach’s’ point of view in order to prevent concussions? Jeff C: Coaches should understand the severity that comes with brain injuries. Because you cannot see the injury i.e., swelling, bruising, a coach may not understand the medical implications of the injury. Also a player may appear fine and ready to return but he may be vulnerable to re-injury. Personally, I suffered two concussions on successive game weekends and the coach did not understand why I had to sit out as long as I did. Q10: Do you think it is possible to discern these symptoms as irregular or abnormal in an affected athlete, and if so, how should coach adjust his/her coaching methodology? Jeff C: No it is really hard to recognize these symptoms and a player may not always be truthful for fear of not playing, losing their starting position, or even being subjected to concussion testing (they are not pleasant and boring). Q11: What advice would you give to uprising coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? Jeff C: First of all, uprising coaches should learn that winning and losing a game is not what collegiate sport is about. They should understand the life of student-athletes and treat us accordingly.

Interview 7: Track and Field: Javelin Jesse H. is a member of the Penn State Track and Field team. He has thrown the javelin for eight years and is ranked sixth in the nation and third in Pennsylvania. He has suffered multiple injuries throughout his time as a javelin thrower. Some minor ones included shin splints, damaged back

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alignment, and turf toe. Some major injuries that added up and eventually ended Hershey’s career included orthoscopic cartilage trimming in 2002 due to pain in the shoulder when lifting and throwing. During his freshman year he had Tommy-John surgery on his elbow because he tore his UCL during a throw. Six months after that surgery he had Bankart lesion and capsule repair on his shoulder. Finally his last surgery was in November 2006, when his subscapular tendon burst and part of the Achilles tendon had to be attached because 30% of that tendon was missing. This last surgery was career ending. He is now in physical therapy trying to just gain back normal range of motion and activity in his shoulder. He has taken a coaching position for javelin on the Penn State Track and Field team. Q1: Could you please elaborate with your opinion on why injury is still an unavoidable part of athletics today? What elements do you feel are most essential to prevent risk of injury? Jesse H: Injury is an unavoidable part of sports because athletes or coaches do not have enough knowledge of the sport they are involved in. Some elements that are essential to prevent injury are to educate athletes and coaches about the sport and there should be people who know the technique or skills of the sport that can observe the athlete and correct any errors that could lead to injury. I know I was trained with speed before proper technique with the javelin and that is a huge component to why I am injured. Q2: Do you agree that every single injury may cause psychological trauma and therefore athletes should seek psychological counseling shortly after injury? Jesse H: Not every injury causes psychological trauma; it depends on its severity. My injuries were severe enough, so I actually went through psychological counseling because I lost confidence in myself and I was unsure of my abilities. I also did not know how to approach the situation I was in. Q3: Through your experience as an athlete could you describe the signs and symptoms of bracing behavior among athletes? What would be your strategies as an athlete to prevent, and if observed, to eliminate these symptoms of bracing behavior? Jesse H: After my first injury of my arm I noticed I was bracing when I would throw the javelin because I was not actually fully recovered yet, so I was changing my normal form to reduce chances of hurting myself again. However, that just led to more injury and another surgery. I believe the best strategy to prevent and eliminate bracing is to make sure the athlete is totally recovered and if bracing still occurs after clearance to play, the athlete needs to get psychological counseling or talk to the coach about their fear. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free post-injury athletes are fully ready for 100% sport participation?

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Jesse H: Yes, an athlete’s psychological adaptation to an injury definitely plays a role in rehabilitation. Some athletes adapt quicker to an injury and want to get back to playing as soon as they’re recovered and others may take a little more motivating if they cannot adapt to the situation well. I think that if the athlete has kept up with some kind of training throughout the injury then they should gradually get back into the sport. However, I would not say even though they are medical symptom-free that they should be back in a competitive situation right away. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of athletes’ readiness for returning to practices versus returning to competitions? Jesse H: I think that medical staff should have the first opinion on athletes’ return to full sport participation. Different criteria are necessary for return to practice versus return to competition. Q6: What kind of strategies would you recommend to enhance the athlete’s readiness for returning to full range of sport participation? Jesse H: To enhance readiness to return to full play I think you need to practice as soon as possible so you do not lose technique or regress too much. Gradually increase practice skills until recovery to a normal level of play. Q7: Are there different coaching strategies for dealing with female athletes as opposed to male, particularly in regard to recovery from injury? Jesse H: Gender does not matter. Every athlete has individual reactions to injury. Women tend to get injured less in javelin, but I do not know the reason behind that because they receive the same training aside from the distance they have to throw it. Q8: In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male versus female athletes? Jesse H: It is better to have more attention, so the athlete can stay motivated to recover quicker and with more confidence in playing again. I do not think there is difference about the response to attention paid to an injury in male or female athletes. Q9: What do you think the collegiate coach should know about concussions and what should be done from a coach’s’ point of view in order to prevent concussions? Jesse H: I do not know a lot about concussions but I would say it depends on the severity of the concussion and how many times it has occurred to terminate an athlete’s career. When I played football in high school, coaches gave their players bubble helmets after concussions and I

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felt that was a good way to prevent future concussions. I think coaches definitely need to know the severity of concussions and their symptoms. Q10: As an athlete, do you think it is possible to discern psychological symptoms as irregular or abnormal in an affected athlete? Jesse H: Experiencing a concussion before, I would say those symptoms are normal right when you have the concussion initially but if they persist it would be abnormal. I would refer an athlete to a doctor if I noticed these symptoms much later after the concussion. Q11: Is it obvious during practice or in competition, to you as a coach, if a previously injured athlete has developed bracing behaviors? Do you have particular strategies for dealing with athletes who exhibit this type of behavior in response to injury? Jesse H: Since I am currently coaching javelin because I cannot participate, I would say that as a coach, if I were dealing with an athlete who suffered a concussion and they continue to brace themselves I would have a talk with them about confidence in playing. If they need more time to recover I would opt for that, but if they just cannot reduce their fear I might just tell them that maybe playing right now is not the best decision. Q12: What advice would you give to uprising coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? Jesse H: Coaches definitely need more knowledge about the sports they are coaching. I know my coaches definitely did not know everything about javelin to show me what was being done wrong. I feel that I have suffered from their lack of knowledge.

Interview 8: Football Name: Ross M. Sport: Penn State Football, Center Year: Sophom*ore Eligibility, Junior Academically Like many collegiate athletes, Ross M.’s love for the game of football evolved at a very early age, and by age nine he had begun his journey and love affair with the sport that brought him here to Pennsylvania State, University Park. When asked why he loves the game so much he responded, “It’s the only remaining team sport besides basketball that you can really individualize.” Throughout high school he faced minor thumb injuries and three lumbar fractures in his junior year, all injuries he considered trivial. However, during his first year on the team he tore his right MCL and sprained his left MCL only one year later. Both injuries he considers himself to be fully recovered from, and besides a couple of cases of plantar

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fasciitis (in the right and left feet), his body sees to be in working condition for next season. Q1: Could you please elaborate with your opinion on why injury is still an unavoidable part of athletics today? What elements do you feel are most essential in coaching collegiate athletes to prevent risk of injury? As a member of a collegiate team with a big reputation, do you feel that there is additional pressure that leads to injury? Ross M: Injury is an unavoidable part of athletics because in an ideal world technique would be perfect every play, but unfortunately we don’t live in a perfect world. As a lineman, you never know what you’ll be working with. Different teams with different movements will always be present to challenge you to adjust. You can practice all you want, but you have to work with what is thrown your way the best way you can. Also, I believe that when players start to fatigue, technique is compromised and injuries occur. At points in the game, you will become tired. It’s as simple as that. As far as prevention goes, coaches are accountable for their team’s cardiovascular fitness and should harp on technique as much as possible. Our team has great flexibility, strength, and core stability programs to keep us as injury-free as possible. I believe that flexibility is essential for prevention of injury as well as very useful during rehabilitation for an injury. I think the biggest thing as far as injury goes on this type of team is the amount of risk taken when technique is compromised in order to make big plays. Everyone wants to be that person who made that great play, and that’s where a lot of injuries occur. Plus, once a player is injured there is so much pressure to come back as quickly as possible. Q2: In your opinion, what types of injuries qualify athletes for psychological counseling? Do you think that psychological counseling is the best way to facilitate a recovery and if not what do you think is? Ross M: Not necessarily. Slight injuries cause apprehension, but not every single injury requires psychological counseling. Injuries that are pretty major, including every degree of a concussion, should require some psychological counseling. While counseling can be very important to some injury cases, physical rehabilitation is the best way to come back from an injury, hands down. Regardless of full recovery or restoration to the exact skill level you were at pre-injury, rehabilitation is essential for you to carry on other areas of your life. You may not be able to play your sport as well as before you were hurt, but you will still want to be able to do other activities without complications. Q3: Injured athletes usually return to sport participation based upon clinical symptoms resolution and upon recommendation of medical staff. However, there is a notion among medical practitioners that clinical symptoms resolution may NOT be the injury resolution. Incomplete rehabilitation following injury may lead to development of so-called bracing (self-protecting) behavior. This is a dangerous situation that may lead to

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more severe injuries. Through your experience could you describe the signs and symptoms of bracing behavior among athletes in your sport? What would be your strategies to prevent and eliminate symptoms of bracing behavior? How do your coaches respond to signs of bracing behavior? Why do you think some athlete’s develop this behavior while others do not? Do you have any first hand experience with bracing behaviors? If yes, why do you think they occurred? Ross M: Everyone is a competitor at this level so as soon as an athlete is physically cleared, most are mentally cleared as well. If you are told you are physically ready, I believe that something in your head just clicks and lets you know you can do this. If bracing does occur, it is usually not noticeable during plays especially because of the pace of plays. However, you may see a teammate who has come back from an injury favoring the uninjured side of the body after a play has occurred. As far as my injury, I thought a lot about my knee on the field and in training making sure if was safe at all times. Even when I tried not to, I couldn’t help it. I always worried if it was feeling looser than usual and whether or not it would make it more vulnerable during training or in competition. Coaches definitely can pick up on obvious bracing behaviors. They usually respond by pulling the athlete aside and privately asking them what’s going on. I believe that whether or not an athlete develops these bracing behaviors depends specifically on the athlete and the severity of their injury especially if the injury has negative implications for their lives and playing time. Full rehabilitation is the key to avoiding these behaviors. Q4: Do you think that athletes’ psychological adaptation to injury may play a role in the rehabilitation process? Do you think that medical symptom-free post-injury athletes are fully ready for 100% sport participation? What do you think completely qualifies an individual to return to sport after an injury? How do your coaches approach this concept? Ross M: It definitely takes the right mindset to successfully complete your physical rehabilitation. You need to want to work really hard to get through your injury because without rehabilitation you have to know that you won’t 100% recover. With my injury, they made me do heal slides that hurt like hell. I worked my MCL out with so much pain but forced my way through it because I knew I had to. If an athlete is symptom-free and physically cleared, the medical professionals have done their part and the athlete should be 100% ready for sport participation. Only the individual can tell if they are mentally ready for a return so if they don’t speak up that is their own fault. It will only hurt them and create the possibility of reinjury. An athlete must be physically and mentally back to where they were before they were injured to return to play. They need to be especially mentally prepared for the hard work. As far as a coach’s role in an athlete

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returning to play, I believe they leave all of the physical clearance to the professionals. Mentally speaking, coaches ask the players if they are feeling okay and if the answer is yes then they consider that player good to go. Q5: Who should be responsible for the final decision in terms of an athlete’s return to full sport participation: coach or medical doctor? Do you think that there should be different criteria in terms of an athlete’s readiness for returning to practice versus returning to competition? How much of a role should the athlete play in deciding when to return play? Is the coach or the medical doctor always right in their assumption that an athlete is ready to return? When do you mostly see flaws in this decision? Ross M: One hundred percent the medical doctor. The coaches want their best players on the field, and if the doctors say they are ready, the coaches listen. The coach is always right in their assumption that an athlete is always ready to return to play because they are at the doctor’s mercy, and any poor decisions would be in the hands of the doctor. In my particular sport, the coaches really trust their medical staff. As far as a difference in criteria in terms of an athlete’s readiness for a return to practice versus competition, I would have to say there is none. Our team goes by the motto, “You practice like you play.” If you can practice at the high levels, you are definitely ready for competition based on the conditions. An athlete’s role in this decision requires that they work hand in hand with the doctor. Together with feedback from the doctor they should decide when returning is appropriate. Q6: What strategies do you recommend to enhance an athlete’s readiness for returning to full range of sport participation? What strategies have you found work the best for you? Are you open minded about different types of intervention suggested to you and if not, why the apprehension? Ross M: Goal setting is number one. Set little goals such as coming back 10% or 20%, doing a few more squats next time, or adding the treadmill to your workout. Your goals can’t be general like “I want to play next week.” I also think that a positive attitude is everything. The more optimistic you are about your rehab, the better and faster the end result. The strategies that have worked best for me have been goal setting and focusing on clearing my mind during rehabilitation. I used the mentality that nothing else mattered when I was at rehab accept for getting better so I forgot about everything else for the time being. I am very open-minded about trying different types of intervention. With returning to the field as a main goal, anything that might help get me there faster is something I will consider. Whether or not it actually works is up for debate. Q7: Do you think there are different strategies for dealing with female athletes as opposed to male, particularly in regard to recovery from injury? Why do you think this is so? Do you think some of the different coping methods hold athletes back severely?

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Ross M: I don’t think there is necessarily a difference between females and males, but the strategies for dealing with athletes in general must be very specific to the individual as well as their mental capacity. It is silly to have a cookie cutter rehab program for men and women, especially because each injury is very different and must be cared for in different ways. Certain injuries will affect people more than others, but overall I think any type of negative thoughts will hold any athlete back from rehabbing correctly. The athlete needs to be accountable for a positive attitude and dedication to recovering from their injury. Q8: Among athletes it is common to hide fear in order to avoid appearing weak. However, it is known that in previously injured athletes, fear of subsequent injuries may induce erratic emotional responses, avoidance reactions, and bracing behaviors. In your opinion, and in terms of psychological recovery, do you think that athletes recover better or faster from an injury if the injury is given more attention or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male versus female athletes? How do your coaches respond to athletes in the “recovery phase”? Do you agree or disagree with how your coaches respond to injured athletes on your team, and if not what would you do differently? Ross M: Recovery is very individual specific. However, the more attention given to an athlete, I believe, the better the rehab will go. If coaches aren’t paying as much attention to a player during the rehab process, athletes are limited in recovery and are not getting all that they need. I think that if an athlete feels that they are getting all of the attention of a coach they will believe the coach is dedicated to getting them back on the field and will recover quicker. During the recovery phase, coaches are supportive but not as connected to you as they are to their players that are out their making the plays. Football is a business, and they care a lot more about their competing athletes, as much as I hate to say it. I agree with this method only to an extent because at this level I understand that is how things need to be handled. It would be nicer if coaches did actually care more about the psychological factors of the team. From personal experience, during my freshman year when I was out with my first MCL injury, I wished the coaches had more time to pay attention to my injury, especially because I was so worried about coming back. Q9: Sport-related concussion has received significant attention in recent years. Despite some advances in studying concussions, important questions are still to be answered including: Which concussion grading scale and return to sport participation guidelines are sufficient to prevent more severe secondary and multiple concussions? After how many concussions should an athletic career be terminated?

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Are there long-term cognitive and behavioral deficits after single and especially multiple concussions? Collegiate athletes are at high risk for sport-related brain injuries. The likelihood of brain injury is a function of head impact (or sudden acceleration/deceleration) within the context of sport participation. The concussion may occur in any activity regardless of the nature of this activity, and when the brain injury occurs, it has potential for a lasting effect on the athlete. What do you think the collegiate coach should know about concussions and what should be done from a coach’s point of view in order to prevent concussions? How should team members respond to their fellow concussed players? If there were a seminar held for PSU collegiate coaches to obtain extensive knowledge to help deal with concussed players, do you think your coaches would attend? Ross M: The general rule of thumb requires an athlete to be symptom free for a week starting from the time that all symptoms were gone, although this was not followed in Anthony Morelli’s case. I guess there is a lot of politics involved. Concussions are very serious injuries and should be monitored carefully. Our team undergoes a standard concussion test once a year. This test and the close monitoring of concussed athletes is essential because reports have said that depression, fear of getting hit, negative thoughts, and even thoughts of suicide can result from this injury. Collegiate coaches should understand exactly what a concussion is, what its ramifications are. They need to know how serious this injury is and use this knowledge so as not to push their concussed athletes in any way. Athletes need to be symptom-free and coaches should be aware of the severity of each and every concussion they encounter (based on the medical report). Our brains are incredibly sensitive. When a concussed player returns to the field, the rest of the team is very supportive. Those who have had them can relate on another level. Extra caution is taken in practice and concussed athletes are not allowed to get hit. They take it easy at first. If there was a seminar held for PSU coaches, I do not think any of our coaches would attend. This is a business and coaches don’t want to hear it. They believe that doctors and trainers have the responsibility of knowing every aspect of the concussion. Q10: Do you think it is possible, as an athletic coach, to discern concussion symptoms as irregular or abnormal in an affected athlete and if so, how do you think a coach should adjust methodology? What are your coach’s general guidelines with concussed players? Ross M: The coach really would not adjust his methodology because without the clearance of a medical doctor, the athlete should not be back on the field. Coaches generally acknowledge options/symptoms that are voiced. If a doctor or player does not speak up, the coach usually will not bring it up. Guidelines for dealing with concussed players involve the one

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week rule that I talked about before. Basically coaches feel that you should not come out on the field until you are ready because when you do come out you are expected to be able to give 100%. Q11: Is it obvious during practice or in competition to a coach or even fellow players if a previously injured athlete has developed bracing behaviors? Are there particular strategies that coaches have when dealing with athletes who exhibit this type of behavior in response to injury? In your opinion what are the biggest consequences an athlete could face with an injury of this severity? Ross M: Yes! It is usually pretty obvious if the athlete is showing clear signs. If there is an issue, coaches pull the athlete aside so as not to make a big deal out of it in front of the rest of the team. Coaches will oftentimes talk about strategies to deal with the issue and make sure that they athlete is doing okay. Also, if a coach is concerned he may go to the medical doctor or trainer and ask what is going on with the athlete privately. I feel that concussions are very serious injuries with BIG consequences that can include loss of memory, depression, and anger, with the biggest consequence being suicide. It is so frightening because in one day your life can be completely changed from the sport you love. Q12: What advice would you give to uprising coaches today regarding how to identify athletes at risk for injury and ultimately to prevent injuries among student-athletes? If you were the coach of your team, how would you handle injury prevention during practice, competition, preseason, and postseason? Ross M: The best advice a coach can receive is to hire a good training and medical staff for the technical stuff and take the responsibility to harp on technique, technique, technique. Coaches need to talk to their players about the risks of this sport. If I were the coach of my team I would make sure I have the best medical staff possible and spend lots of time on technique. To handle injury prevention I would make sure my team was in good shape year round (which we generally are). In season is the time to keep yourself in shape to prevent injury but off season is key for making improvements in flexibility and strength.

Interview 9: Cheerleading Coaches and athletes can sometimes overlook the importance of understanding the psychology behind injuries and this can lead to more serious issues that are clearly seen in the following interview with two Penn State cheerleaders. Both Alison B. and Devon C. are sophom*ores here at Penn State, University Park. They both have been involved in various sports throughout their athletic careers, which made them appropriate to interview.

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Alison and Devon have both witnessed and dealt with traumatic athletic injuries. Q1: Could you please give me a brief background of your athletic career up to and including being the Penn State Cheerleaders. Alison: I started going to gymnastics when I was three years old and competed from the time I was five years old until tenth grade. When I stopped gymnastics I was at level nine, which is highly competitive. Our gymnastics team required us to take dance classes from preschool until tenth grade. I began cheerleading in third grade when I joined a “midget” squad. I started competitive all star cheerleading when I stopped gymnastics in tenth grade. In high school, I was on the track team sophom*ore through senior year. In April of my senior year in high school, I tried out for the Penn State cheerleading team. Freshman year of college, I was on Small Coed and this year I made Large Co-ed. I compete for Penn State cheerleading currently. We went to the UCA collegiate nationals in Orlando, Florida over winter break but did not place in the top five teams in our division. Our squad was content with just being accepted to participate in this national championship which some of the best teams in the nation go to. Devon: I took dance class for one year when I was three. I began gymnastics when I was four years old and began competing when I was six. I was on the diving team my freshman year in high school. When I stopped competitive gymnastics in tenth grade, I became a cheerleader at my high school for eleventh and twelfth grade. In April of my senior year of high school, I tried out for Penn State Cheerleading. I made Small Co-ed both years and competed with Small Co-ed last year. I always seemed to like individual sports more throughout my athletic career. Q2: As a Penn State student athlete, I am sure that you have seen different sport-related injuries in college, as well as on teams when you were younger. Do you feel that coaches you have had in the past, as well as in the present, have been knowledgeable about the psychology behind the sports injuries that you and your team mates had? Are there any specific examples or instances that you can remember? Alison: From what I remember, in gymnastics when I was younger, my coaches had a better psychological understanding and approach than my current coach. Our coach would rarely make our injuries seem extremely serious when they would occur, and if they actually were he would explain it to us after the initial shock. Typically when we would get injured, we would just get it iced/taped, take some Ibuprofen and just continue on our way. Now our Penn State cheerleading coach has the “better safe than sorry” mentality. He probably has to act this way because if someone were to sue Penn State, there would be much more liability and complications involved. I understand this point of view most of the time, but disagree when he somewhat “babies” injuries that aren’t as serious.

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Devon: When I was a gymnast, the coaches definitely understood the psychology behind our injuries because when someone would get injured, they would downplay it and make it seem less serious than it actually was. They would do this in order to avoid mentally “freaking us out” and would later on explain how serious the injury was. Now, our coach does not handle injuries in the same manner. He does not attempt to explain the seriousness of the injury in most of the cases and a lot of times will blatantly ignore the injured athlete and just tell us see the trainer right away. Q3: Most athletes that participate in high level sports experience some type of injury during their athletic careers. What sports injuries have you had throughout your athletic career as a gymnast and as a cheerleader? Alison: I have sprained both of my ankles multiple times. I broke my left arm when I freaked out in the middle of a back hand spring. I broke my right hand and dislocated my toe. -Did you find that you had more injuries when you had one particular coach or set of particular coaches? Not necessarily, I had different coaches all throughout my gymnastics career and I was not more likely to get injured with one of them opposed to another. Since I have been a cheerleader at Penn State, I have gotten one serious concussion. This happened when I fell backwards off of one of my team mates’ shoulders and hit my head extremely hard on our competition mat. I also sprained my ankle one time since being on the cheerleading team here. Devon: I sprained my right ankle three times, got a concussion from gymnastics in seventh grade, and popped my bursa sac in my knee in eighth grade. Last year on the Penn State cheer team, I got two concussions. The first concussion was less severe and resulted from falling out of a stunt that came down wrong and hitting one of my other male team mates in the head. The second, and much more severe, concussion I got resulted from falling out of a back tuck basket toss, straight onto the ground. I have never broken a bone and hope that I never will. Q4: A number of previous studies have examined athletes’ emotional responses to injury (McDonald & Hardy, 1990; Smith et al., 1990), painting an intricate picture of an injured athlete’s personal status. Do you feel that sport injuries affect student athletes emotionally and/or psychologically? Can you think of a specific injury you or a team mate had when you were able to observe this? Alison: Definitely psychologically, especially when it is a recurring injury. When I was doing an “overshooting” on the parallel bars for gymnastics, I hit my toe on the low bar and dislocated it, I flew out of control, and landed on the mat. This accident hurt very badly, but the initial shock of it was traumatic. Since I have a strong emotional memory of this incident, I feel that it did affect me greatly.

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Devon: After an injury, student-athletes can definitely be psychologically affected. Diving was the most psychologically-oriented sport I tried. I was doing fine learning how to dive when I first started and the transition from gymnastics made it easier, but one day that all changed. I dove and hit my legs on the board, and as soon as it happened I thought to myself, “I am never doing that again.” Something just clicked and my mentality towards diving changed. This was weird to me because in gymnastics similar incidences happened many times and I would keep on doing it. I am not sure if I thought different because I was older [ninth grade as opposed to five years old] when it happened, but it definitely mentally freaked me out. “Wiping out” messes with your head at the time of the injury and afterwards. It also is emotionally frustrating when you get hurt because when you are sitting out, you have to watch your team mates progress as you can not. Q5: Do you feel that every injury an athlete gets may cause psychological trauma and therefore require seeing a sports psychologist? Alison: If an athlete were to see a sports psychologist for every single injury it would get ridiculous. I feel that it is necessary if it is a careerending injury, but not for less serious injuries. If an athlete is having a particularly painful time with rehab, then it also may be necessary to talk to a sports psychologist. Seeing one would help them discuss their frustrations that come along with the injury. Devon: No. Being an athlete requires certain toughness in your character. You have to understand that getting injured is a risk when you are a collegiate athlete. I feel that a person can determine for themselves whether it would be appropriate to seek help or not after getting injured. Q6: Do you think that the psychological mindset of an athlete going through rehabilitation after an injury has an impact on the recovery time? Alison: Yes. Definitely, the more determined the person is to getting better soon, the faster their recovery would be. I feel that it is hard to sit and watch while being injured, especially when it is a team sport. I feel like it is my fault when I am sitting out and not participating. Devon: I think that with a positive attitude towards recovery, an athlete can speed up their time in rehabilitation. When children are younger, they feel that it is “cool” to sit out at a practice for a week or two and enjoy the attention. At this level, it is definitely not the same. The faster the athlete wants to and tries to return, the speedier the recovery will be. Q7: Premature return to sport participation based upon just physical injury symptoms resolution considerably enhances the risk for re-injury. Do you think that the coach or medical doctor should decide when an athlete can return to full sport participation? Is your answer the same when it comes to practices and competitions?

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Alison: I think that it is a decision the medical doctor should make, not the coach. My opinion doesn’t change when it comes to practices and competitions. Devon: I feel that it should be up to the medical doctor. When it comes to practices and competitions, the decision should go for both, not one or the other. Q8: From your personal experiences in the past, what would you say would be the most common injury in gymnastics? What are some of the more common injuries when it comes to cheerleading? What precautions could be taken to make these injuries avoidable? Alison: When it comes to gymnastics and cheerleading, ankle sprains are probably the most common type of injury. Sprains also occur in cheerleading, but not as often as concussions. At the collegiate level, I see many more concussion injuries. I personally have been dropped on my head multiple times. This may result in the fact that we now have males on our team who have never been a part of a cheerleading team of any sort. We also do a lot of basket tosses and stunts in which we are very far from the ground and increasing our chances of getting seriously injured. There are not many precautions that can be made since as long as you are going to have sport you are going to have injuries. Devon: In gymnastics, ankle sprains were very common among me and my teammates. Now that I am a collegiate cheerleader, it seems that sprains as well as concussions seem to be the most common. In order to prevent serious injuries, the guys on our team could go through mandatory training at which they are taught how to properly throw and catch us when stunting. This would prevent girls being dropped when stunting, which is a main cause of injuries seen on our team. Q9: There are a number of interventions recommended by sport psychology practitioners including: negative thought stoppage, cognitive restructuring, healing imagery, muscle relaxation, goal setting, etc., to speed up rehabilitation of injured athletes. How could a coach make returning to practices and competitions after an injury a smooth transition? Alison: It would be helpful for the coach to be aware that there may be some difficulty for them at first and to be understanding. It would not be beneficial for a coach to be extremely mean or hard on the athlete right away, especially if it is a psychologically impacting injury. Devon: If a coach were to avoid placing the blame of the injury on the athlete it would ease the process. They shouldn’t baby the injured athlete too much but understand that they did not try to get hurt on purpose. Q10: Does the amount and type of attention an injured athlete receives from a coach impact the amount of time that athlete will need to recover? Alison: If an injury is treated like it is a big deal, the athlete will begin to believe that as well. Mind over matter theory – the way the coach interacts

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with the injured athlete will have an impact on their mentality when it comes to getting better. Devon: If a coach acts like their injured athlete is “dying” that athlete will believe they are “dying.” Inversely, if a coach acts like the injury is not a big deal, the athlete may believe that as well. This could be detrimental if the athlete returns into practice or competition too soon and gets injured again. The coach should be neutral when handling their injured athlete in order to get the best recovery time. Q11: As you stated earlier, concussions are common among collegiate cheerleaders. “The problem with concussion is that with the exception of the unconscious athletes or someone who is severely dazed, it is often very difficult to identify who has sustained a concussion and who has not” (Cantu, 2006). Do you think that it is easy to tell if someone has suffered from a concussion? Alison: Yes, most of the time. If the concussion is mild it may be more difficult to tell. When I had my serious one earlier this season, I was told how out of it I seemed. When we arrived to the hospital I became very easy going and emotional and even began to cry. I went to the HUB the next day, left and walked to the wrong class. Devon: It depends on the severity of the concussion when it comes to telling if someone has one. When I got mine for example, I didn’t feel that bad until I went home and dry heaved into the toilet. Q12: What do you think collegiate cheerleading coaches should know about concussions and what can be done to prevent them? Alison: A coach should know that a concussion is more psychological than physical in most cases. You have to trust your team mates enough to have them throw you in the air and catch you, and that may have to be regained after a traumatic injury. You want to make sure they will be there next time, and not have to wonder. When I got my serious concussion, my coach happened to be the only person standing behind the stunt. I therefore think that the coach should know and practice the ability to catch/spot us while stunting. Devon: In order to prevent athletes from getting concussed, they should make sure our male team mates know what they are doing. Spotters should be ready when necessary, and be able to do their job correctly. Overall, Alison and Devon’s responses were very similar for many of the questions. This was not very surprising, considering they both have a background of gymnastics and cheerleading, but was interesting to observe. Their responses gave an insight on the opinions and knowledge cheerleading team members have concerning injuries. One of the important messages from these team mates’ responses was that education about traumatic brain injury is currently lacking.

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CONCLUSIONS According to athletes with a history of sport-related injuries, most of these injuries can be avoidable if coaches try to increase their knowledge about the skills and techniques of the sports they coach. They know for a fact if they were not trained to be powerful instead of having correct form with javelin throwing, initiating stunts, somersaulting etc, they may still be participating in the sport. Collegiate coaches get so caught up in their team or athlete ranking that they lose sight of what is more important than just winning or losing – which is the athletes’ health. They push the athletes too hard or move them through recoveries at such a rapid pace that they end up doing more harm than good for the team and their bodies. Proper training about their sport for coaches, who can then show their athletes correct techniques, is the most essential way to reduce injuries in sports. It is an unfortunate fact that coaching errors, including inability to properly assess the level of skill and/or fatigue and change the loading level, ended up with career ended injuries of their athletes. Clearly, there was also agreement among injured athletes that bracing can occur after injuries and athletes need to either be completely healthy to return or very confident in returning to avoid further injury. Psychological counseling can be very helpful when an injury is severe enough because it definitely can help athletes get over insecurities and fears. However, athletes are tough enough to overcome psychological problems and emotions when injuries are mild. As for concussions, most of the athletes did not have a great deal of experience but find it essential for coaches to know the extent and symptoms. That said, a kind of interesting statement was proposed as “… If there was a seminar held for PSU coaches, I do not think any of our coaches would attend. This is a business and coaches don’t want to hear about it.” Coaches’ knowledge about bodily injuries goes hand-in-hand with their attitude towards brain injuries. In closing, through athletes’ eyes we can gather the importance of both technique, flexibility, and strength programs and psychological attributes to build a better prepared and injury free athlete. With insight into coaching views, strategies, and guidelines, we are able to have a better understanding of how both coaches and players manage injury and injury prevention. Whether injury is just a part of athletics or a controllable sport-related phenomenon still requires further discussion.

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Acknowledgments This chapter wouldn’t be possible without the contribution of my Penn State undergraduate students, who learned about dealing with injured athletes and conducted these interviews via my class, KINES 497, “Psychology of Injury,” in the Spring, 2007.

CHAPTER 9 OVERUSE INJURIES: STUDENTS’ POINTS OF VIEW 1. INTRODUCTION Injuries occur in every sport, at all levels of the game, in various venues across the world. Whether it is an ACL tear in a soccer player in Real Madrid’s stadium in Spain or an eleven-year-old Pennsylvanian boy breaking his collar bone on a beat-up field behind his school during a football game, unexpected and often devastating injuries occur. Overuse injuries, or those injuries that occur due to overuse of key body parts necessary to perform skills associated with specific sports, are extremely common among today’s athletes. Current notion is that repetitive stress disorder, repetition strain injury, and cumulative trauma disorder are synonyms that are used for an overuse injury. It is important to note that overuse injuries are not caused by a specific injury or accident, but rather by repeated stresses on the body (Difiori, 1999). Due to the prevalence of overuse injuries both in professional sports and recreation activities it is important to increase students’ awareness about this issue. Accordingly, the author proposed an assignment for Penn State students majoring in Kinesiology to explore common mechanisms and elaborate on causes and psychological consequences of overuse injuries in sports and recreational activities. This chapter was elaborated by Penn State University KINES 497 “Psychology of Injury” students aimed at discussing overuse injuries in various sports/recreational activities, including tennis, soccer, baseball, football, lacrosse, running, swimming, water polo, and skiing. In addition, some relevant issues related to overuse injuries, such as gender differences and psychological aspects of the recovery process will be also the topic of discussion in this chapter.

2. TYPES OF OVERUSE INJURIES 2.1. Tennis Elbow The first sport discussed is tennis, a popular sport played across the world, including in France, Australia, and the United States. Tennis originated in the nineteenth century and can be played on grass, clay, or a hard court. Injuries in tennis involve the use of muscles of the arm and

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forearm and small tears of the tendons. This can often lead to tennis elbow, which includes varying degrees of pain or point tenderness at the origin of the wrist extensor muscles near the lateral epicondyle of the humerus (Fedorczyk, 2007). Other factors that contribute to tennis elbow include lack of strength, poor technique, increased time or intensity of play. Symptoms of tennis elbow include pain on the outside of the elbow, usually during or after intense use. Lifting or grasping can become difficult and pain can sometimes radiate down the arm. Treatment for this injury would initially be rest, since there have been signs of overuse of the wrist extensors, which are muscles that pull the hand up and down. Activities that cause pain should be discontinued and the R.I.C.E. method (rest, ice, compression and elevation) is helpful to reduce pain and swelling. Icing the elbow for 10-15 minutes and wrapping the forearm near the elbow may help protect the injured muscles as they are healing. Another treatment includes changing stroke mechanics and racquet type and/or size. From injury prevention perspectives it is important that the racquet is sized properly, including grip size. Also observe whether the player is hitting the ball in the center of the racquet and make sure they do not lead the racquet with a flexed elbow, which is a common technical error of recreational tennis players. Anti-inflammatory medications are an easy solution to control pain and inflammation. Cortisone injections are the next option if the antiinflammatory medications are insufficient. If more than two injections are taken and there is no relief, additional injections will not benefit the player. According to a study, patients who received steroid injections were statistically significantly better for all outcome measures at follow up. That said, it is a proper technique and prevention, rather than control for pain and medication after the injury has developed, should be recreational players’ primary concern. The researchers advocate a steroid injection as the first line of treatment for athletes with tennis elbow demanding quick return to daily activities. Surgery is the final and unfortunate treatment of tennis elbow. This is rarely necessary because about 95% of patients with tennis elbow can be treated without surgery. Simple exercises, in general, can be performed just to control symptoms of tennis elbow, and light to moderate muscle strength routines, in particular. Because recurrence of this condition is common, return to activity should not occur too quickly, and preventive exercises that stretch and strengthen the muscles should be done consistently. Some examples of exercise routines are shown in a Figure 1 below. It is important to stress that the volume and intensity of exercise should be prescribed by medical professionals to avoid negative effects and worsening the symptoms.

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Figure 1. Wrist exercise with some weight prescribed for treatment athletes with tennis elbow.

2.2. Overuse Injury in European “Futbol” (Soccer) Defined as “futbol” in Europe and South America and “soccer” in the USA, soccer is known as the sport that unites fans across the globe in the World Cup. This is used to be the most popular male sport and recreation activity in Europe and South America, and has now become an extremely popular female sport as well. To date, boys and girls play soccer across the world. Unfortunately, there are a lot of lower body injuries that can occur in soccer, such as ankle sprains, contusions, muscle strains/pulls, and back pain, to name just a few. A more recent concern with soccer is of undetected multiple concussions due to heading the ball. There is current debate in the relevant literature as to whether heading the ball is safe or may cause traumatic brain injury. Clearly, there are particular injuries that relate to overuse of the muscles and joints. Two injuries occurring in young athletes, due to periods of rapid growth, include Osgood-Schlatter disease and Sever’s disease. OsgoodSchlatter's (see Figure 2 below) is characterized by chronic pain at the top of

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the shinbone. Ultimately a severe form of tendonitis which comes about from excessive forces on the patellar tendon from jumping and running, Osgood-Schlatter’s can lead to separation of the tendon from the bone. Addressed with appropriate rest and modification of training, it usually will resolve (Levengood, 2007).

Figure 2. Sources of pain associated with Osgood-Schaletter disease.

Sever’s disease (see picture below) is characterized by a chronic pain at the heel where the Achilles tendon attaches. It is an inflammation of the growth plate in the heel bone. X-rays will show a bony change at the site of the Achilles insertion. Appropriate training, shoe modification, and activity modification will be necessary to prevent and treat this common injury in soccer.

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Figure 3. Source of pain associated with Sever’s disease.

Older soccer players usually deal with the following common chronic or overuse injuries: patellar tendonitis, stress fractures and shin splints. Patellar tendonitis is a chronic inflammatory response in the patellar tendon secondary to overuse. The athlete will complain of pain just below the kneecap and it is usually very tender to touch. Most often a biomechanical disadvantage due to inflexibility and/or weaknesses is to blame. A good biomechanical evaluation may find what is responsible for the tendonitis, and a specific program set up by a physical therapist can eliminate the pain. Performing an ice massage regularly will also be helpful. Most stress fractures in athletes occur in the lower limbs and they usually have a slow onset of about two to three weeks, starting with pain only during activity, but then progressing to resting pain. The fractures result from a failure within the bone to adapt to the repetitiveness of certain activities and the torque of the muscles acting across the bone. Many times the fracture cannot be picked up by X-ray, and a bone scan or MRI (a better choice for children) is used for diagnosis. Rest of the area integrated with alternative exercising is essential for the proper healing of this injury. Pain on the middle, inside, or outside of the lower leg with activity can indicate shin splints. Often shin splints are caused by a rapid increase in running mileage, improper footwear, running on hard surfaces, or poor flexibility. There are many ways to reduce the susceptibility to these chronic injuries. One way is avoiding the over training syndrome. Many athletes mistakenly think more exercise is better and they fail to get adequate rest. Not returning to soccer too soon is a way to give the injury time to heal. Working on poor techniques or biomechanics is always important because usually these injuries are related to something not working correctly with the muscles or joints. Incorrect footwear is also a huge deal in soccer. Players

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can play up to ninety minutes a game, so shoes definitely have to be comfortable, supportive, and fit right in order to perform without injury. There are simple treatments that can eliminate most of these chronic injuries. An inexpensive method is to ice massage the area before and after exercise, stretching the calf muscles. Players may also try inserting cushions in the shoe and having a biomechanical evaluation by a physical therapist who can recommend appropriate shoe inserts and flexibility exercises (The Stone Clinic). Following Hughston Sports Medicine Foundation’s idea of P.R.I.C.E., similar to the R.I.C.E. method, involves prevention, rest, ice, compression, and elevation. Prevention is the most important part of the equation. Rest involves giving the injured tissue adequate time to repair itself. Ice is used to decrease inflammation and should be applied before and after practice or games over the injured body part. Compression involves applying an elastic wrap over the injured part to help reduce swelling. Elevation helps to decrease swelling by using gravity to assist in the process. If this method does not relieve the pain players can try nonsteroidal antiinflammatory drugs (NSAIDs), such as Ibuprofen and Aspirin, to reduce swelling. During periods of acute pain, athletes definitely should consider a stop in play and allow time for the injury to heal.

2.3. Overuse Injuries in Baseball Popular in North and South America, baseball is known as “America’s pasttime” and is played and watched by the young and old alike. In baseball, injuries involving the shoulder are highly prevalent and oftentimes potentially career ending. To understand the mechanisms behind such injuries it is important to look at the actions involved in throwing a baseball. Throwing can be broken down into four specific phases. These include: the wind up, co*cking, acceleration and deceleration. These actions performed on a routine basis stress the shoulder and soft tissue stabilizers in the joint. Tears or dislocation are common, especially in pitchers. In the figure 4 below the actions involved in throwing a baseball can be viewed:

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co*cking

Acceleration

Deceleration

Figure 4. Actions involved in the throwing the ball inducing shoulder injury.

The reason that shoulder injuries are so prevalent in baseball is because the shoulder ball fits loosely in the arm socket and is largely unrestricted in movement. While this is beneficial for allowing a wide range of motion, it can lead to significant injury and strain for the player. Treating this type of injury is often complicated, since it is hard to determine if damage has occurred until a debilitating injury takes place. A case study example for a career ending shoulder injury can be considered by examining Robb Nen. Nen is one of the most famous relief pitchers in baseball, but in 2002 he had surgery to “clean up loose particles in his shoulder” after experiencing pain. However, during surgery a torn labrum, part of the soft tissue in the shoulder, was found. After discovery of this injury, Nen underwent three other surgeries and sat out for a total of eighteen months in order to fix this injury. The reason that this type of shoulder injury is so serious is that doctors have no way to completely fix a torn labrum, and no way to detect it visually without opening up the shoulder because the labrum is located between two bones, making it difficult to X-ray. Below, an image of the labrum of the shoulder can be viewed.

Figure 5. Intact labrum (left image) and damaged labrum (right image)

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The best way that athletes can avoid this type of injury is for them to be conscious of a sore shoulder, a loss of velocity, stamina, and poor form when throwing. Coaches should also be aware of these signs and ask players if they are experiencing any pain during play. Shoulder injuries are serious and often career ending for these athletes and should be avoided at all costs. Early signs of shoulder injury must be treated immediately so as to benefit the player.

2.4. Overuse Injuries in American Football Football, a high impact, highly demanding and physical sport is worth discussing due to its extreme vulnerability to injury in general and overuse injuries in particular. Each year, hundreds of football players on the college and professional levels are injured. In fact, the sport is infamous for generating injury. Sufficient is to stress that the NCCA was created back in 1917 due to the growing concern of injuries in collegiate football. While many injuries are common to football players, including those to the shoulder, leg, and head, injuries to the knee, specifically damage to the ACL, are the most debilitating. The ACL, or anterior cruciate ligament, is the ligament in the knee used to stabilize the leg and help a player change direction quickly. When damage to the ACL occurs a popping sound can usually be heard, and following it, immense pain. One study which examined the frequency of this type of injury in college students found that of those playing Division One football during their collegiate career, approximately 16% have a chance of experiencing this type of injury. The risk of this injury in players is one hundred times higher than in the general population. Below, a figure of the ACL can be viewed.

Figure 6. Damaged (left image) and normal (right image) ACL

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Increase in age and activity level seem to be the main determinants of an increased risk for this type of injury. These factors also determine the methods for recovery from such an injury. Usually athletes who experience damage to the ACL require rest and physical rehabilitation. The injury usually takes at least six to nine months to heal, which makes it even more devastating to the athlete. Often, surgery is needed to reconstruct the ACL, resulting in a longer rehabilitation and healing process. Because of the prevalence of ACL injuries in football players, many studies have been conducted to further investigate the consequences of ACL damage. Most of these studies revealed that ACL injury may affect both the physical and psychological well-being of injured athletes. Because of the severity of this injury, significant emotional distress is common. Feelings of fear and depression are also evident in most athletes experiencing this type of injury. Due to the severity of the impact, behavioral treatment such as physical therapy should be accompanied by psycho-therapy interventions to speed up both physical and psychological recovery. Psychological counseling sessions are also recommended, including positive self-talk, imagery, relaxation training and goal setting. It is important that injured athletes should be “actively” involved in the treatment process, for example by constantly monitoring and assessing their psychological status and emotional responses to the rehabilitation process. An example of an ACL injury on the professional level can be viewed with Chad Jackson, who played for the Patriots. This injury ended this athlete’s 2006 season and (as of the writing of this book) no set return is scheduled for this player. Another example can be seen with Javon Walker of the Denver Broncos, who was kept out of the NFL for twelve months due to an ACL injury. A list of elite athletes suffering from an ACL injury might be endless, as ACL injuries continue to occur each year on the professional and collegiate levels. More research should be done on this type of injury and different methods for rehabilitation, including psychological recuperation should be explored. Overall, it is suggested that psychological counseling and emotional support beyond the standard physical therapy and rehabilitation are critical for athletes. In other works, it is highly recommended that every single case of ACL injury should be referred to a qualified sports and/or clinical psychologist for further evaluation and treatment. Interestingly, one student used a personal experience in his life to explain a different overuse injury that occurred to him several years ago in football. “When I was around fifteen years old about seven years ago I suffered from shin splints. I was a star linebacker for my school and part of my training was running two to three miles a day about three to four days a week. I was a fast, hard hitting line backer who had no problem with putting my shoulder into someone. Then one day at practice while the team and I were running drills I started complaining to the coaches about pain in my

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shins. The coaches sent me home and I told my parents about the pain. They took me to the doctor and the doctor told me to make an appointment to get X-rays. So I did and the X-rays showed that I had shin splits. I remember asking the doctor how this happened and he told me that my injury was due to stress on my tibia. In other words all the running I was doing led to an overuse injury. The doctor then told me I had to sit out and keep from any physical activity for at least three weeks; I winded up having to stay off the field for only the minimum three weeks. I recovered fully and retuned to play and never lost a step. That was from that injury, but I had many more. I am now twenty-two and am still suffering from a long-term overuse injury. From all the sports I played and the fact that I was a hard hitting linebacker who had no problem putting my shoulder into a person to make a tackle, I now have bursitis […the inflammation of a bursa” (Castinel & Prat, 2007)] in both my shoulders. I tell you this because most people think of overuse injuries as a quick fix; where you sit out for a two to six week period and after that you suffer from no more symptoms. When in fact there are many overuse injuries that can stay with you through out the rest of your life. Some of these injuries are bursitis, tendonitis, and forms of arthritis. I can tell you that bursitis is a very painful and uncomfortable injury, and because of it I have been in and out of the doctor for this problem since I was seventeen years old.

1.5. Face and Head Traumas in Lacrosse One of the more recent sports to gain national attention, lacrosse is a popular sport in the United States. Injuries are common in this sport, most often to the face and head. Because of this, protective gear is required to guard the head and upper body from damage. The sport itself is classified “a collision sport” but the prevalence of injuries is estimated at only 4.7 for every 1000 practice sessions and games. According to the NCAA this sport is ranked seventh for number of injuries per game. Several studies examine the impact of head and face injuries in lacrosse players (see: McCulloch & Bach, 2007, for review). A study conducted by the University of Virginia surveyed athletes on the number of injuries per player. It was found that 85% of lacrosse players experienced some type of injury during the season. Though helmets and facemasks are required during play, concussions are very common in the sport. Diamond and Gale studied the impact of head injuries in lacrosse players and found that collisions with other players are the cause for most of these injuries. In the past, lacrosse players were allowed to play even after a minor concussion, which is dangerous and increases the risk for further damage to the athlete and the risk for re-injury.

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A study conducted by the American Alliance for Health in 2000 looked at injury rates in female lacrosse players during a two-year period. Injury reports were given to athletes, trainers, and coaches. Injuries were examined by determining the athlete’s position and the amount of protective gear worn during games and practice. This study concluded that the number of head injuries could be reduced by approximately 16.5% if protective head gear were worn (Sherman, 2000). To reduce the prevalence of these injuries, it is recommended that protective gear be worn at all times for lacrosse players. It also may be beneficial to research the type of gear worn and determine if alternative material might decrease the severity and prevalence of head and face injuries in lacrosse players. Though the number of injuries in this sport may be lower than in others, with the increase in popularity of lacrosse an increase in injuries may be seen in the future.

1.6. Overuse Injury in Running Tibial Stress Fractures are common among all types of runners. This injury can be very serious in nature and has the potential to be career threatening. A recent study conducted by Milner (2007) titled: “Are knee mechanics during early stance related to tibial stress fractures in runners?” had as its focus common mechanisms and ways of tackling this injury. The authors examined twenty-three runners who had a history of tibial stress fractures. They were compared to a control group that consisted of twentythree individuals who matched them for age and mileage with no previous bone related injuries. All the subjects were to run 3.7 miles and the data were collected at the foot-strike to the impact peak of the vertical ground reaction force. Subjects were excluded if they had any current injuries or had not yet returned to 50% of their pre-injury mileage, had cardiovascular pathology, had abnormal menses, or were pregnant or suspected they might be pregnant. The results of this study showed that sagittal plane knee stiffness was significantly greater in individuals who reported having tibial stress fractures. Stiffness was also positively correlated with shock. Knee excursion, knee angle at foot-strike and shank angle at foot-strike were not different between the control group and the group of stress fracture individuals. Knee flexion stiffness was greater in the group who had previous stress fractures than in the control group. The positive relationship between stiffness and tibial shock was more pronounced in the stress fracture group. This difference in knee stiffness, and the lack of betweengroup differences in the other variables tested, may indicate a role in tibial stress fracture risk.

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The findings of this study indicate that there is a positive relationship between mechanics during initial loading and tibial stress fractures in runners. This relationship is important because if you were to retrain the runner in the mechanics of his or her gait, the potential for more stress fractures may decrease. In general, a stress fracture occurs when the forces being exerted are lower than normal, but over time the repetition of these forces causes fractures on the shin, or tibia. Stress fractures can occur in any bone but are usually seen in the foot and shin and occur with athletes that run and jump on hard surfaces, such as runners, ballet dancers, and basketball players. Knowing the history of injury of an athlete plays a key role in diagnosing a stress fracture. X-rays don’t usually show a stress fracture; however they will show bony growths around where a stress fracture may have occurred. This would show a healing process. Below are figures of some common exercises to “treat” the runner’s overuse injuries: (a) quadriceps strengthening: isometrics; (b) quadriceps strengthening: straight leg lift; (c) hamstring stretch; (d) calf stretch; to name just a few. (Adopted from American Family Physician.) Again, the volume, intensity and duration of these exercises should be defined on an individual basis upon consultation with physicians.

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Figure 7. Set of exercise for treatment the runner’s overuse injuries.

1.7. Swimmer Shoulder Another common type of overuse injury is called “swimmer’s shoulder.” As the name states it is commonly seen in swimmers but also affects springboard divers. Swimmer’s shoulder is a condition caused by an impingement of the soft tissues against the coracoacromial arch. This injury, like the others that have been discussed, is most often caused by excessive repetition. The repetitive overhead arm motion of the freestyle stroke is an example of this. Multiple entries into the water in diving are another cause of this injury. Most commonly, this happens at the end of practices when athletes are suffering from progressive muscle fatigue. Often in swimming and diving sports, shoulder injuries occur due to lack of proper warm-up, especially when practices and/or competitions are held in outdoor pools. There are two types of impingement that may result in swimmer’s shoulder. The first occurs in the pull-through phase. At the beginning of the pull-through phase, when the hand enters the water, if the swimmer’s hand is across the midline of the body this places the shoulder in a position of horizontal adduction which mechanically impinges the long head of the biceps against the anterior part of the coracoacromial arch. The second type of impingement occurs during the recovery phase of the stroke. As a swimmer fatigues it gets hard to lift the arm out of the water and the muscles of the rotator cuff, which work to externally rotate and depress the head of the humerus against the glenoid, become less efficient. When this happens the supraspinatus becomes impinged between the greater tuberosity of the humerus and the middle and posterior portions of the coracoacromial arch. Numerous recent studies have been focused on the causes and symptoms of swimmer’s shoulder as well as on treatment protocols. Some treatment protocols for pain management were offered including: (a) avoiding painful

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activities; (b) two weeks of non-steroidal anti-inflammatory medications and ice; (c) decreased anterior capsule stretching and increased posterior capsule stretching; (d) increased rotator cuff exercise with an emphasis on external rotators; (e) scapular-positioning muscle exercises and increasing body-roll (see Weldon & Richardson, 2001 for details). Increased range of motion is an important factor in minimizing injury in swimmer’s shoulders. By allowing the arm more forward elevation, a shoulder with increased range of motion allows the arm and the body to achieve a 180 degree angle. This angle permits the body to be parallel to the surface, minimizing the forward axial surface area and reducing dragging (Weldon & Richardson, 2001).

1.8. Overuse Injuries in Water Polo Water Polo is a sport that combines swimming and stamina with strength and accuracy. It demands an athlete who possesses both quickness and stamina. To stay above the water, the lower body and core must be very strong and have great stamina. To battle the opposition in order to win the ball or win a shooting lane, the upper body must be equally strong. Finally, and most importantly, the upper extremities must be able to shoot a water polo ball with both speed and accuracy. The ball weighs 400-450 grams (14-16 ounces), and can be either 0.7 or 0.65 meters in circumference, for men or women (Wikipedia, May 4, 2007). Rarely is a shot in water polo truly on balance, like a baseball throw. This is a contributing factor to injuries of the throwing arm, since an off-balance throw will place undue stress on the shoulder and elbow. These injuries might occur because of either overuse or acute trauma (Colville, 1999), depending on the situation. Overuse trauma could occur strictly because of the shooting motion, whereas acute trauma could occur because of the contact element of the game. An arm stopped suddenly in mid-throw could overstress a ligament suddenly and cause acute trauma. The stress on the muscles attempting to internally rotate the shoulder will increase greatly at contact with a resistant force, and overload these muscles even more than they were originally. This mirrors how many injuries are suffered in football, where contact is the source of the injury, not the actual throwing motion.

1.9. Overuse Injuries in Volleyball Volleyball is a sport that, while it uses overhead motion, is not a throwing sport. Its overhead motion, or “spike” is one in which the “spiker” does not have possession of the ball at any time. The only contact made is at the end of the acceleration stage, when the volleyball is struck with a closed fist. Also, this contact is generally made with the body suspended in the air.

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The contact is much more over the top than other sports, which generally demand the throw to be made with the shoulder abducted at 90 to 120 degrees. The best spike in volleyball is made at the highest point, so the contact is made with the shoulder abducted more than 120 degrees. With this level of abduction, not only is the humerus in an unstable position with the supraspinatus pressed against the acromion, but the scapula has moved laterally to accommodate the movement of the shoulder. This places the scapula in an unstable position also, possibly creating a greater stress on the shoulder. In a study of volleyball players of the Danish Elite Division during the 1993-1994 seasons, 15% of injuries were overuse injuries to the shoulder. Most of the injuries were acute, such as blows to a finger when blocking (Aagaard & Jorgensen, 1996). Volleyball players are susceptible to overuse because of the constant spiking, but there are also other overuse injuries. In a study conducted of world-class beach volleyball players, there were other overuse injuries noted: the most common being back pain and knee pain, followed by shoulder problems. The study concluded that overuse injuries represented a significant source of disability (Bahr & Reeser, 2003).

1.10. Overuse Injury in Skiing A sport many people may not think of as having an overuse injury associated with it is skiing. Skiing accidents are the most common causes of damage to the ligament, among others, that cause the injury known as skier’s thumb. When a skier falls on an outstretched hand with a ski pole in the palm it creates the force necessary to stress the thumb and stretch or tear the ligament. Some symptoms of skier’s thumb include swelling, inability to grasp, and thumb pain, tenderness, or discoloration. A study was done observing skiers. Within twenty-eight skiing injuries, seventeen were ulnar collateral ligament injuries. The most common cause of this was an uncontrolled fall, associated with failure of the ski pole to be separated from skier’s hand forcing the pole to be driven into the web space, causing thumb abduction and hyperextension. To relieve pain the thumb should be iced and movement should be avoided as much as possible (Srittmatter, 2005). If there is a partial rupture of the ulnar collateral ligament it can be treated with four weeks of immobilization. If there is a total rupture, surgery is used to repair the ligament, but there is potential for complications and only partial recovery afterwards (Strittmatter, 2005). The summary of common overuse injuries in sport and recreational activities is shown below in the Table 1.

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Types of Overuse Injuries

Symptoms of Overuse Injuries

Jumper’s Knee

Soreness below the knee or above the shin

The patellar tendon in the knee is repeatedly pulled

Little Leaguer’s Elbow or Shoulder

Pain in the shoulder or elbow area

Repeated over head throwing

Osteochondritis Dissecans

Pain and swelling to the knee

Sever’s Disease

Pain to the heel of the foot

Jumping or running activities

Shin Splints

Pain and soreness to the shin

Running on a hard surface

Causes of Overuse Injuries

It can run in families or can be caused by a metabolic problem

Knee pain

Due to a fracture of the knee cap caused by over extension of the patellar tendon

Spondylolisthesis

Pain to the back

Caused by over flexion and extension of the lower back

Spondylolysis

Pain to the back

Caused by over flexion and extension of the lower back

Sinding-LarsenJohansson Disease

The chart below shows some risk factors that contribute to overuse injuries, adopted from: www.physsportsmed.com/issues/1997/05may/oconnor.html.

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Instrinsic

Extrinsic

Malalignment

Training Errors

Muscle Imbalance

Equipment

Inflexibility

Environment

Muscle Weakness

Technique

Instability

Sports-acquired deficiencies

Finally, below is the Nirschl Pain Phase Scale of Athletic Overuse Injuries adopted from: www.ultrunr.com/painphase.html Phase 1. Stiffness or mild soreness after activity. Pain is usually gone within 24 hours. Phase 2. Stiffness or mild soreness before activity that is relieved by warmup. Symptoms are not present during activity, but return afterward, lasting up to 48 hours. Phase 3. Stiffness or mild soreness before a specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity, but does not cause the athlete to alter activity. Phase 4. Similar to phase 3 pain but more intense, causing the athlete to alter performance of the activity. Mild pain occurs with activities of daily living, but does not cause a major change in them. Phase 5. Significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living, but does not cause a major change in them. Phase 6. Phase 5 pain that persists even with complete rest. Pain disrupts simple activities of daily living and prohibits doing household chores. Phase 7. Phase 6 pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity.

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3. PSYCHOLOGICAL RESPONSES TO OVERUSE INJURIES The psychological consequences of an overuse injury can be devastating. Most athletes have the ability to fight through pain, while their mind tells them they can but their body says differently. The mindset of an athlete usually follows the saying, “no pain, no gain”. For an athlete injury is not allowed, pain is ignored and unacceptable, and there should be no complaints. If an athlete is experiencing pain and it decreases during training, the athlete believes they have worked through the pain; they may even assume that their initial pain was imaginary. Also athletes who are trained to endure pain have difficulty distinguishing normal aches and pains from pain signaling the onset of a possible injury. A study was done among 280 NCAA athletes using an impact of event scale (IES) to measure the distress of these athletes. Out of all the athletes sampled, 48% were classified as injured. Most of these injured athletes were still participating in their sport (Shuer, 1997). This is really frustrating evidence documenting that motivated athletes, due to numerous reasons, pretend that they are fully functional and capable of making a contribution to team success despite the presence of injury symptoms. This fact raises another question as to how define return-to-sport participation based on athletes’ self-perception of injury or the presence of physical evidence of residual damage. Athletes dread injuries; it places them in a world with no guarantees or predictable outcomes in terms of return-to-play/competition. After an injury, athletes will typically respond with a range of emotions such as denial, shock, anger, and depression, to mention just a few. Athletes are generally committed to their sport; they strive to improve and get stronger. Once an injury sets in some may stay committed to overcoming the injury. In this case they will work hard at every rehab session and maintain a positive attitude. This type of athlete does not view the injury as a crisis but rather a challenge that must be conquered. It is good for an athlete to set goals and develop strategies to reach them. This gives them something to focus on, encouraging motivation and determination. For example, Tim Willoughby, 48, a right-handed tennis player who suffered from a severe case of tennis elbow, decided to learn to hold his racket in his left hand. He taught himself to play in reverse where his backhand became his forehand and vice versa. Tom suffered from a bad case of tennis elbow from playing every day and instead of giving up he re-taught himself the fundamentals of tennis on his left side. Once his arm healed he went back to playing with his right arm but when his elbow begins to flare up he rests it and switches the racket over to the other side (Bateman, 2005).

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Some athletes are over confident and have a tendency to try to speed up recovery by going above and beyond, but this ultimately leads to too much too soon for the injured body part. Some athletes may isolate themselves from their teammates and friends, feeling left out and helpless. Others will continue to be an active member of the team by attending practices and competitions. Most endurance athletes are going to experience an overuse injury. Athletes do not want to be told to rest. So instead the best way to recover from an injury is to continue training without using the injured part. Athletes can cross train to maintain fitness and to heal the injury. If a runner who usually runs eight miles a day is now suffering from runner’s knee and is unable to run, they should instead replace the usual running with swimming. This will help to maintain endurance and strength. Athletes are exposed to the potential for injury every day and this is beyond anyone’s control. For new swimmers the danger is a rotator cuff or other shoulder injury. Though all these injuries are different they do have one thing in common: they’re caused by overuse. If the athlete is unable to cope with the injury they should seek psychiatric help to reconsider their short and long-term goals and to adjust to the trauma. Another factor that has been researched regarding overuse injuries is the variation between races and genders. Although race is not a determining factor for who will or will not have an injury related to overuse, gender does play a small role in distinguishing overuse injuries. This can be caused by hormonal differences, anatomical differences, and differences in the activities done by men and women. Carrying angles, Q-angles, and bodymass are several other implications of sex differences on overuse injuries (Laker, 2006).

CONCLUSION Chronic injuries are hard to avoid and prevent; however, most are treatable. Coaches can help to prevent and avoid chronic injuries by being aware of which chronic injuries are specific to their sport. They can also adjust practice duration and frequency to lower the risk of chronic injuries. With chronic injuries, as with any injury, there is a risk of developing a psychological trauma. It is also the coach’s job to try and prevent or reduce the risk of a psychological trauma with the help of a sports psychologist. After observing multiple sports and participating in multiple sports over the years, it is clear to me that chronic injuries are an on-going problem. More research is needed to better prevent and treat these injuries.

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Acknowledgements This chapter summarizing some current research and characterization of overuse injuries in sport and recreational activities wouldn’t be possible without the significant effort and commitment of my numerous students. I would like to acknowledge the special contribution of Mary-Kate Courtney to this chapter.

REFERENCES Difiori, J. (1999). Overuse Injuries in Children and Adolescents. The Physician and Sports Medicine www.med.umich.ed/1libr/sma/sma_overuse_sma.htm. Fedorczyk, J. (2007). Tennis Elbow: Blending Basic Science with Clinical Practice. Journal of Hand Therapy, 19 (2), 146-152. Levengood, G. ( 2007). Goal! To Recognize and Prevent Overuse Injuries in Soccer. Hughston Health Alert. Hughston Sports Medicine Foundation. 2, http://www.hughston.com/hha/a.soccer.htm. Castinel, A., Prat, A. (2007). Stress Fracture in the Lumbar Spine in a Professional Rugby Player. British Journal of Sports Medicine, May pubmed.com: www.orthopedics.about.com/cs/sportmedicine/a/blbursitis.htm. McCulloch, P. & Bach, B. ( 2007). Injuries in Men’s Lacrosse. Orthopedics, 1 (30), 29-35. Sherman, N. (2000). Head Injuries and protective eyewear in women’s lacrosse. Journal of Education, Recreation and Dance, 71, 2-9. Milner, T. (2007). Are Knee Mechanics During Early Stance Related to Tibial Stress Fracture in Runners? Clinical Biomechanics, 6, 17-26. Weldon, E.J., & Allen B. Richardson, A. (2001). Upper extremity overuse injuries in swimming: A discussion of swimmer’s shoulder. Clinics in Sports Medicine 20 (6), 119129. Wikipedia; “Water Polo Ball.” 04 May 2007. http://en.wikipedia.org/wiki/Water_polo_ball. Colville, J.M. & Markman, B. S. (1999). Competitive Water Polo. Upper Extremity Injuries. Clinics in Sports Medicine, 18 (2) 305-312. Aagaard, H., & Jorgensen, U. (1996). Injuries in elite volleyball. Scandanavian Journal of Medicine & Science in Sports, 6 (4), 228-232. Bahr, R, &Reeser, J.C. (2003). Injuries among World-Class professional beach volleyball players. The American Journal of Sports Medicine 31 (1), 119-125. Strittmatter, J. (2005). Skier’s thumb. Emedicine Health, Denver Health Medical Center.http://www.emedicinehealth.com/skiers_thumb/article_em.htm. Shuer, M. (1997). Psychological effects of chronic injury in elite athletes. WJM, 166 (2), 997-2002. Bateman, N. (2005). Tennis elbow. Medical Encyclopedia. Healthwise Inc. http://health.msn.com/encyclopedia/healthtopics/articlepage.aspx?cpdocumentid=100068004. Laker, S.R. (2006). Overuse Injury. http://www.emedicine.com/pmr/topic97.htm.

CHAPTER 10 FITNESS ASSESSMENT IN ATHLETES 1. INTRODUCTION One of the major coaching errors in modern sports is the lack of appreciation for proper assessment of the physical fitness of elite athletes. Clearly, with all respect to coaches’ knowledge regarding “how to load” athletes to achieve peak performance at the right time, there is a common unsolved problem around and lack of knowledge about “how much is enough, and how much is too much,” which is directly related to high risk of injury. One recent well-controlled study among high school student-athletes conducted by Contos et al. (2006) clearly indicated that lack of physical fitness prior to the season is directly correlated with high risk for various traumatic sport-related injuries. There are numerous other studies in support of this observation. A high level of fitness achieved during pre-season must be maintained throughout the whole competitive season. Therefore it should be properly and systematically assessed, allowing for modification of the training program in the case of under-recovery and/or overtraining. It should be noted that fitness assessment among athletes must be sport-specific, since different sports (complex coordination, cyclic, endurance, games etc.) require sport-specific properties. Therefore, in the following text, various models and programs will be discussed within different categories of sport activities. Specific focus in this discussion is the situation with fitness assessment at Penn State Collegiate Athletics.

2. FITNESS ASSESSMENT IN COMPLEX

COORDINATION SPORTS Fitness, a measure of the combination of muscular strength, endurance, power, agility, speed, balance, and flexibility, is sport specific. Strength and power tests vary among different sporting contexts. Different aspects of fitness can also very from one sport to another. For example, a football player may have the capability to lift 150 lbs in a gym, but at the same time be incapable of lifting a 115 lb. girl with one hand as seen in cheerleading. The amount of time devoted strength training and power testing differs from sport to sport. Complex coordination sports such as gymnastics may focus a large portion of their time on flexibility, whereas sports like long distance swimming and running spend a majority of their effort on improving endurance.

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Due to sport specific differences in fitness, different sport specific physical assessment tests are useful in order to determine when an athlete has reached a necessary fitness level. These tests can also be helpful in determining when an athlete has fully recovered from an injury and when it is appropriate for him/her to safely return to play. In the next few paragraphs, different complex coordination sports such as gymnastics, figure skating, competitive dancing, and cheerleading will be discussed to varying degrees on topics such as injury, fitness, strength and endurance assessments.

2.1. Gymnastics The GFMT, which stands for gymnastics functional measurement tool, was developed by physical therapist Mark D. Sleeper to be used in assessing the overall fitness level of gymnasts. The GFMT can also be used to measure the fitness progress of a gymnast and is highly sport specific. In order to test a gymnast’s level of muscular strength, endurance, and flexibility, Sleeper designed a series of specific tests that are each awarded a certain number of points depending on how well the athlete performs the task. Sleeper developed a series of challenges to assess the muscular strength of gymnasts. He measured their strength by using rope climb challenges, hanging pikes, over-grip pull-ups, a push-up test, and a handstand hold. The rope climb tests the level of ability with which the athlete performs the task and also factors in time. For example, if a gymnast was able to climb the rope hand over hand with his/her hips at ninety degrees of flexion within the time frame of 0-10 seconds, he/she would be awarded ten points, the maximum score. However, if the gymnast was only capable of climbing the rope hand to hand, as opposed to hand over hand, and also enlisted the help of his/her legs and completed the climb in fourteen seconds, he/she would only earn five points. Two points for method and three for time. Another muscular strength challenge developed by Sleeper is the hanging pikes test. The hanging pikes test measures abdominal and hip flexor strength. This test begins with the gymnast hanging from a horizontal bar with his/her body in completely straight alignment. The athlete is then tested on the number of times he/she can touch his/her toes to the bar while keeping the legs straight. In order to prevent a momentum advantage, between each leg lift the gymnast must pause in a straight hanging position. 2.1.1. Endurance In order to test muscular endurance, Sleeper designed a series of six tests. The agility sprint is the first test of endurance. In addition to testing muscular strength, the rope climb, hanging pikes, over-grip pull-ups, the

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push-up test, and the handstand hold all test muscular endurance as well. The agility sprint is based on time. The gymnast is asked to sprint the diagonal of a regulation competition floor. Two cones are placed on opposite corners of the floor. The athlete must sprint to the cone, touch the cone, run back and touch the opposite cone five times before the clock is stopped. The athlete’s level of endurance is based on the speed in which he/she completes this task. The handstand hold tests strength and balance and is another endurance test. The gymnast is given two chances to hold a handstand on the beam for as long as possible. A handstand is defined as the gymnast’s total body weight being supported entirely by the hands. If any body part besides the hands touches the floor or beam or if the gymnast moves his/her hands from the original position, the time is stopped. 2.1.2. Flexibility Flexibility is another test of fitness. The GFMT flexibility tests include a shoulder flexibility test and a right and left leg and middle split test. The shoulder flexibility test measures shoulder flexion flexibility. First the athlete holds her arms out straight in front of her at a ninety degree angle while holding a wooden dowel. Then a measurement of arm length is taken from her AC joint to the dowel. After this measurement the gymnast lies face down on the mat with her nose and chin touching the floor and with her arms extended in front of her. The gymnast is then asked to hold the dowel with an overhand grip and thumbs touching and then is told to lift her arms as high as she can without her nose coming off the mat and without changing her grip. When the athlete reaches the peak, a measurement is taken from the dowel to the floor. The split test assesses pelvis and lower extremity flexibility. Specific positioning of the body is determined and the gymnast is asked to slide into a split. Different measurements are taken from where the highest point of body clearance is from the floor mat. This test is done for both legs and a middle split.

2.2. Competitive Figure Skating Competitive figure skating has evolved into a very physically demanding sport. Single skaters need to incorporate more double, triple and quadruple jumps into their routine, while pair skaters must execute more throws and lifts in order to impress judges and receive national recognition for their complex coordination skills. To accomplish such high levels of performance, in addition to training on ice, athletes are required to participate in weight training, dance and aerobic activities. This results in elite figure skaters training at least four to six hours per day, six times per week, for ten to eleven months per year. Such rigorous physical fitness demands leads to a number of acute and overuse injuries. Analyzing injuries

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in figure skating is a unique topic to evaluate because no other sport places the same diversity of forces on such a narrow base of support. In both studies, “Competitive Figure Skating Injuries” and “The Incidence of Injuries in Elite Junior Figure Skaters,” most of the injuries observed with single competitive skaters were of the overuse type and occurred in the lower extremities. This suggests that there might be a relationship between the long hours of training and the injury itself. With pair skaters and ice dance skaters, on the other hand, most of the injuries were acute due to the fact that there are more lifts and throw jumps during their competitions. In general, pair skaters accounted for more injuries than single skaters and the injuries were mostly to the head and shoulder because of carries, throws and lifts. Women pair skaters were also more susceptible to injury because they are the ones being tossed in the air by their strong male counterparts. The research studies also concluded that single male skaters are more vulnerable to injury compared to single female skaters possibly because of the males’ older age, greater body weight, and perhaps, the greater height, velocity, and impact of their jumps. Since most competitive figure skaters begin training when they are physically immature, it is important for physicians, physiotherapists, and physical educators to advise, guide, and monitor the training of young skaters. Parents, coaches and administrators should also be aware of the overuse and acute injuries involved with competitive figure skating. As stated in the “Incidence of Injuries in Elite Junior Figure Skaters,” “Only through good postural alignment, adequate stretching and strengthening training programs, especially during the asynchronous development period of bone and soft tissue, can overuse syndromes be prevented and reduced.” Educating parents, coaches and administrators about the susceptibility for injury in such a complex coordination sport can help prevent injuries. The findings from both studies suggest that more research is needed in evaluating the predisposing factors for overuse and acute injuries and methods of rehabilitation. The predominance of lower extremity injuries calls for investigation of footwear materials (fit, alignment and stability) as well as a detailed biomechanical analysis of propulsion and jump landing mechanics. Hopefully, with such knowledge about the injuries involved in figure skating, we can reduce the number of injuries.

2.3. Competitive Dancing Competitive dancing is an activity that takes a lot of skill, physical strength, and flexibility in order to excel at it. Because of the specificity of the muscles that must be strong and the flexibility that is mandatory, acute and overuse injuries are a common factor during competitive dancing. Acute injury is defined as a sudden sharp pain or pop that a dancer could

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relate to a specific situation. Overuse injury is defined as a problem with insidious onset that continued to bother the dancer during a period of at least two weeks (Askling, 2002). A study was done to see how prevalent injuries were in ninety-nine students at a dancing academy. All of these students were educated about the definitions of acute injury and overuse injury before answering a questionnaire about their injury history. Every third dancer had a history of acute injury in the last ten years, while every sixth dancer had a history of overuse injury in the last ten years. Eighty-eight percent of the students that defined their injury as acute stated that the injury occurred during slow activities in flexibility training, while the other twelve percent said it was caused by a powerful movement. All of the students with the acute injury said that it occurred in the proximal part of the hamstring muscle. Sixty-six percent of the injuries occurred while doing some form of the splits, which is a slow flexible activity. After injury most of the students stopped the physical activity for an extended period of time while some continued in the same training routine as before the injury. When comparing the two groups, there was no significant difference in continued problems after the injury (Askling, 2002). Results from the study showed that extreme caution should be used while doing extensive stretching while in a competition or directly after. It was shown that a fatigued hamstring muscle is much more likely to be injured while stretching than a strong, rested muscle. The findings of the hamstring being injured during slow intense movements are contradictory to all other findings that showed hamstring injuries only occurred during high speed, high force activities. Many of the dancers in this study underestimated the time it would take for recovery. Most figured they would be back between a few weeks to a few months. The average recovery time was, however, was eight months with some lasting up to eighty months of problems after the initial injury. The study showed that dancers, and other participants in sports prone to acute hamstring injuries, should be more educated about the severity of the injury and the precautions that should be taken to prevent further injury. Educating athletes on how to treat the injury will minimize continuing problems (Askling, 2002).

2.4. Cheerleading Cheerleading was nowhere close to being considered a sport when it began in 1884 at Princeton University. It began with a group of men displaying college spirit at athletic events. Now, cheerleading is highly recognized as a competitive sport with more than 400 North American teams at the collegiate level and 230 teams around the world. The sport has now introduced cheerleading gyms to the world’s most famous cities, such as

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Bangkok, London, Mexico City, Moscow, New York, Sydney, and Hong Kong (cheerleading.net). There are also more than 170 cheerleading associations and companies conducting training programs and cheerleading competitions around the world. With cheerleading evolving into a contact sport with high demands of agility, strength and gymnastic skills, cheerleading-related injuries are now on the rise. Between 1982 and 2002, the National Center for Catastrophic Sports Injury Research had forty-two direct catastrophic cheerleading-related injuries reported. The injuries varied from serious to fatal. They included traumatic head injuries such as skull fractures, cervical (C5) spine fractures, spinal cord injuries, coma, and quadriplegia.

Figure 1. Penn State Cheerleading team is getting ready for national competition

Most injuries result from pyramid building, basket tosses, and floor routine performances (Boden, 2003). Unfortunately, the National Collegiate Athletic Association injury surveillance does not include cheerleading injuries. Therefore, knowledge about injured cheerleaders at the collegiate level is limited. In 2005, the NCAA Insurance program stated that twentyfive percent of money spent on student-athlete injuries resulted from varsity cheerleading. After the monetary concern, the NCAA and Varsity Brands formed an alliance to improve safety in collegiate cheerleading. The American Association of Cheerleading Coaches and Administrators (AACCA) developed a safety program that mandatorily required coaches

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and team members to receive training and certification at Varsity Brand training camps (NCCSI, 2006). 2.4.1. Injury Assessment Injuries experienced by athletes play influential roles in the their changes in behavior, self identity, performance, and adjustment to cognitive stress. However, injuries in competitive cheerleading can be perceived differently in the sense that they may have a greater influence on the concept of returning to play. Cheerleading has been determined as the sport with the highest average days lost to injury. Although football players experience the greatest number of injuries, cheerleaders lose more practice time than football players (Axe, 1991). This hard to believe phenomenon is due to the fact that all limbs are required to execute the required movements and stunts related to the sport. Many athletes of other sports experience injuries that do not limit their participation in practice. For example; a track runner with a strained bicep muscle still has the ability to run; however, a fractured arm or injured shoulder can easily prevent a cheerleader from participating for several weeks. Full recovery after injury is also negatively affected by the time frame of the sport. Cheerleading is a year-round activity involving football season when most teams prepare for nationals and finally ending in the spring while committing to basketball season. This circulating and overlapping schedule of many collegiate teams allows limited time to fully recover from injuries. Shields and Smith (2006) conducted a study where cheerleading-related injuries of an estimated 208,800 injured-cheerleaders ages five to eighteen, were analyzed and categorized into injury and body part types. Data was retrieved from the National Electronic Surveillance System (NEISS). Results are shown in Table 1. The authors also concluded that injuries to the lower extremities were more common in cheerleaders twelve to eighteen years of age. Table 1. Shows the categories and percentages of injury and types and body parts injured. *Abrasions, contusions, and hematoma **Foreign body, crushing injury, nerve damage, hemorrhage, dental injury, and anoxia. ***internal, pubic region, and (>25%) body. Injury Type

Percentage

Body Part Type

Percentage

Fractures/Dislocation

16.4%

Upper Extremity

26.4%

Laceration/Avulsions

3.8%

Lower Extremity

37.2%

Soft tissue Injury* Concussion/ Closed head injury

18.4%

Head/Neck

3.5%

Trunk

16.8%

Strain/Sprain

54.4%

Other***

.8%

Other**

5.5%

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The Consumer Product Safety Commission reported an estimated 16,000 emergency room visits in 1986. In 1999, the number of injuries increased to approximately 21,916 and in 2004, the number increased to 28,414. A major factor playing a role in this increase has been the progression in athleticism in cheerleading, which now involves elite acrobatic type stunts. Mueller and Cantu (2005) also reported that cheerleading is responsible for more than fifty percent of all high school and collegiate direct catastrophic injuries experienced by female athletes. A significant cause contributing to this increase in cheerleading injuries is coaching errors. A highly significant number of high school teams do not have qualified or certified coaching staff. Furthermore, athletics departments at the high school level do not consider cheerleading as a sport. Therefore, athletic trainers and medical staff are extremely limited. Other faults in coaching styles are inadequate training, overtraining, insufficient supervision, and practicing on inappropriate surfaces. 2.4.2. Fitness Assessment Although research on cheerleading injuries is now increasing in publications, limited knowledge is known about the physiological status of a competitive cheerleader. For both men and women, there are demands of flexibility, strength, agility, and balance. Thomas et al. (2004) assessed the physical status of NCAA Division I collegiate cheerleaders. The authors determined fitness levels by measuring VO2max, maximum heart rate, pushups, curl-ups, flexibility, quadriceps strength, and bench press. VO2max scores placed the men and women at the eightieth percentile of norms. Female cheerleaders’ VO2max scores were similar to those reported for female basketball, gymnastics, swimming, and volleyball athletes. Male cheerleaders were similar to male basketball, football, and tennis players. In flexibility, the men were placed at the seventieth percentile and the women beyond the ninetieth percentile. Both men’s and women’s bench press scores were similar those of their basketball playing counterparts. Push-up scores placed the men at the ninetieth percentile and women at the seventyfifth percentile. These demands for well above the norm of fitness levels demonstrate that collegiate cheerleaders match up to other collegiate athletes. Their high degree of fitness appears to reflect the demands of the sport.

3. FITNESS ASSESSMENT IN FOOTBALL In athletics today in general, and in football in particular, there are countless methods of training. Some of them are effective and some of them can be damaging to the athletes. In order to prevent further maladaptive responses in the athletes of our chosen sport, our task was to look in depth

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into the three fields of fitness and create testing procedures for each of them. These testing procedures would help players, coaches, and the training staff evaluate the physical condition, and based on that, create a safe and effective training program for each player. Due to Penn State’s rich history of success in the football program, the team sport that we chose to look at is football. In football, as in any sport, three major areas of physical fitness need to be focused on when training and testing. These three aspects are flexibility, endurance and, most importantly in football, strength. In football it is difficult to have a team-wide testing regimen due to the varying tasks that the many positions are required to do in competition. In order to overcome this we had to generalize testing procedures for the whole team. In the following paragraphs we will discuss within the three fields of fitness: the current trends in training, how the current trends could be made more efficient, and specific testing procedures for each of the three facets of fitness. Flexibility is the first aspect of physical fitness that we have focused on. And unfortunately it seems to be the most overlooked in football, including in our team at Penn State. Flexibility should not be overlooked because it can be very beneficial in preventing injuries to joints that often plague football teams. One benefit of being flexible is that you have increased length in both your muscles and tendons. This leads to an increased range of movement, which helps your limbs and joints move further prior to an injury occurrence, theoretically making a potential injury less damaging. A brief review of the situation discovered that not all football teams ignore flexibility as an aspect of fitness. The Denver Broncos employ a flexibility training program that includes three different types of stretching. The first, ballistic stretching, uses rapid bounce to stretch the muscle. However, these uncontrolled movements can easily result in excessive loading and can damage the connective tissue by extending it beyond its elastic capabilities. The second is static stretching, which is applying steady pressure at the extreme range of motion without bouncing. The final technique they use is passive stretching which is a slow, controlled stretch of the muscle. The technique of static stretching requires a slow, controlled elongation of the relaxed muscles; you feel a pull but no pain. This position is held for twenty seconds, and then the muscle is slowly allowed to shorten. We found an effective stretching regimen consists of a brief cardiorespiratory warm-up such as jogging, running in place, or jumping rope. Stretching should not be painful as you can easily damage soft tissues, ligaments, and tendons. To maximize flexibility, stretching exercises should be performed at least several times a day and four to five days a week.

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Figure 2. Penn State Football team stretching prior to practice

For flexibility testing, there aren’t extensive lists of testing procedures for football, or any other sport. Some general testing that could be used could be a sit and reach test. This would test the hamstring flexibility of the players. This could be useful since hamstring pulls are a common injury in football. Another simple way to test flexibility in football would be to have an athletic trainer passively stretch each player at various joints and gauge how good the player’s range of motion is. As stated earlier, an increased range of motion from good flexibility will lead to a decreased chance of injury. Endurance is the ability to maintain a high level of intensity in a specific activity for an extended period of time. Over the period of the game each player will need to perform his tasks repeatedly. This means a high level of endurance is required to compete at an elevated level throughout the game. Endurance, like all other aspects of fitness, is task specific. In other words, football does not require the same type of endurance that a marathon runner needs. Since we could not find any information on Penn State football’s endurance training, we looked at how most football teams generally train endurance. There are two types of endurance that football players train. These are speed endurance and strength endurance. Speed endurance is maintaining a high intensity anaerobic activity. This is done by developing coordination of slow and fast-twitch muscle fibers. To train speed endurance, football players perform a number of sprints at an intensity in excess of 85%. To test speed endurance, a coach could have players run several forty-yard sprints in a row. Then the coach could assess the player’s speed endurance by comparing the player’s best and worst times. The closer the times, the higher the level of speed endurance.

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Strength endurance is a muscle’s capacity to maintain the quality of the muscle’s contractile force over a period of time. Some ways to train strength endurance, specific to football, are running with a parachute, hitting sleds, or basically any activity where muscle contractions last for an extended period of time. An easy way to test strength endurance would be to use a single man sled, and see how far each player can take it. These training and testing methods not only improve strength endurance, but also maximal strength can be improved simultaneously. Maximal strength, or just strength as it is usually known, is the maximum amount of force that one can produce with a specific muscle. It is obvious that this is a very important feature of physical function to have in football. Every tackle, block, hit, and many other parts of the game call for the player to have as much force output as possible. Strength is arguably the most important aspect of fitness in football. Therefore, we focused on what Penn State’s football program does for strength training, and how it could be improved upon, then finally some simple strength testing that could be employed by them. The Penn State football team’s lifting program only uses isolated muscle weightlifting machines, known as Hammer Strength machines, to increase strength. The players’ common practice is to complete the maximum number of repetitions that they are able to accomplish for a given weight. Each week, either their repetitions or the amount of weight in which they are using is increased. Free weights are not utilized in their strength training regimen. This system of training poses many problems for the athletes for multiple reasons. Using only Hammer Strength machines does not allow the athletes to realize the full benefits of weightlifting and develop their strength to the fullest. Focusing more on power movements, or exercises that recruit large groups of muscles, would allow each athlete to not only improve a larger group of primary muscles, but also it would allow them to strengthen their stabilizing muscles as well. For example, performing an exercise such as the leg press to strengthen the quadriceps and hamstrings does not allow for the strengthening of the athlete’s core muscles such as the abdominals and paraspinals. Performing an exercise such as squats would not only strengthen the quadriceps and hamstrings but would also strengthen these core muscles along with other stabilizing muscles. Strengthening the stabilizer muscles is especially important for a football player. For instance, it is common to see a defender attempt to drag a ball carrier down by applying his weight to the ball carrier in a way that it would cause the ball carrier to lose his balance and fall to the ground. Increasing the strength of stabilizing muscles will increase his balance and ability to maintain an upright position when a load is added, causing a change in his center of mass and pressure. Not only can improved balance help performance but it can

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also help avoid many injuries of the lower body, including sprained ankles, torn knee ligaments, and hip injuries. Power movements, such as a power clean, would not only additionally improve stabilizing muscles, but it is also a task more specific to football than the Hammer Strength machines. Frequently on a football field, many “explosive” movements are performed. Common football moves such as a first step toward a defender or the quick release of the football during a pass, rely on the quickness of an athlete. Using power movements improves this explosiveness which is so important in football. Training with power movements improves the interaction of the fast-twitch muscle fibers and the nerve endings in which innervate these fibers that are found throughout a player’s body. In using an exercise such as a power clean these neuromuscular junctions are trained to perform at a much faster level through the use of certain strength training techniques and lifts. During this lift, quick contraction of the muscle fibers in the hamstrings, quadriceps, and calf muscles as well as the muscles found in the core are required to move the weight in the desired manner. Training these muscles to repeatedly fire at a quick and maximal rate will allow football players to reach maximum potential on the field through a newfound explosive ability. Using Hammer Strength machines alone would not allow an athlete to have the same benefits as can be acquired with power cleans. Strength can be easily assessed with any weight lifting exercise by having the athlete max out, or perform one repetition with the greatest possible weight. It is necessary that the players properly warm up and have spotters, professional instructors, and supervision, as one rep max tests can be somewhat dangerous due to the high exertion and probability of failure (coachr.org). As said in the opening paragraph, it is difficult to have a team-wide testing regimen due to the varying tasks that the many positions are required to perform in competition. Therefore, coaches should adapt testing procedures for each of the various positions, and perhaps even each individual athlete. For example, a wide receiver does not require the same strength, flexibility, and endurance as a lineman, and should therefore be tested differently. All of these tests, for flexibility, endurance, and strength, need to be assessed not only at the beginning of the season, but at various points throughout the season. That way the coaches can adapt the periodization programs that they use to train their athletes, to focus on areas that need improvement as seen from the assessments.

4. FITNESS ASSESSMENT IN RUGBY To be an elite athlete, one must posses certain specific skills. To make sure these skills are used to the highest ability possible, an athlete must perform fitness testing that include endurance, strength, and flexibility.

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According to Professor Mike Stone, head of Sports Physiology with the United States Olympic Committee, strength is the ability of the neuromuscular system to produce force. Within this definition, aspects such as resistance, speed and power are included. While strength can be either dynamic or static, it can be measured in a few different ways, including isometric ally, concentrically, eccentrically and plyometrically. Endurance, which can be associated with strength also, is defined as the ability to sustain a prolonged stressful effort or activity before reaching fatigue (Webster). Two of the most common forms of endurance related to sports are cardiovascular and muscular endurance. While cardiovascular endurance deals with a person’s ability to deliver oxygen to necessary tissues over a sustained period, muscular endurance involves a person being able to perform repeated contractions or perform contractions for a sustained period before reaching fatigue (McGlashan, 2003). Tests for endurance include different mile tests (e.g. twelve minute, three mile run), doing sit-ups or push-ups until fatigue, treadmill test, or Maximal Oxygen Uptake (VO2max). Lastly, flexibility involves the “ability to move joints and use muscles through their full range of motion” (McGlashan 2003). One of the important reasons for having good flexibility is to reduce the risk of injury. A few ways to measure flexibility include the sit and reach test, trunk rotation, and using a flexometer (Fitness Testing, 2007). With these three aspects of fitness testing, I researched the assessment of them in the sport of rugby. Even though rugby is thought to be football meets lacrosse, it is a high intensity sport. Professional rugby is an eighty minute game—two fortyminute halves with a ten minute break in between, so the average playing time is about thirty minutes a half. The other ten minutes are due to stoppages for injuries, conversions, penalty shots or ball out of play. Two teams play with fifteen players (eight forwards and seven backs) on the field each during the game. One interesting fact about the players of rugby is that each player’s physical make up is based on his position. The front row, players 1-3, is more suited for strength and power since these players are required to gain possession of the ball. They also have frequent contact with opponents and are limited to running with the ball. Players 4 and 5 are called loose forwards. They have large body masses and power. The loose forwards, players 6-8, also have bodies specified for strength and power to gain and retain ball possessions. They also have to be mobile and powerful in open field play, have excellent speed, acceleration and endurance (Duthie, et al., 2003). Players 9 and 10, the half backs, are the endurance players since they control ball possession and have good speed. Players 12 and 13 are the midfield, and they too possess strength, power, and speed due to the increased frequency of contact. Lastly, players 11, 14 and 15 are called outsides, and they need only to specialize in speed since they provide run support, chase down kicks and cover defenses (Duthie, et al., 2003). Because

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of the differences in the specificity of the positions, forwards have a greater body mass than backs. This is due to forwards being exposed more to contact compared to the backs, who are more geared to running with the ball. Since rugby is a highly intensive sport, fitness testing is a must to help evaluate players. With regards to strength, both muscular strength and power are tested in numerous ways. The vertical jump test is used to measure leg power. It can be measured by using measuring tape and a marking instrument (chalk or marker) or with a device called a Vertec or a jump mat. The most basic way to calculate the jump height is by finding the difference between the athlete’s standing reach height (reaching up a wall, but keeping the feet on the ground) and the jump height (jumping vertically while away from the wall) (Fitness Testing 2007). Another test is the maximal strength test. The purpose of this is to measure the isotonic strength of different muscle groups. To perform this test, an athlete simply lifts a substantial amount of weight (barbell, dumbbell or any other type of free weight) and completes one repetition without fatigue. Usually this test can be repeated during one session since it might take a while for the athlete to meet maximal strength. Another form of fitness testing that is crucial to professional rugby athletes is endurance testing. Since rugby is filled with bouts of sprinting that make it a high intensity sport, the measurement of VO2max is important to test (Kelton, 2004). This is usually measured with the aid of a treadmill where the athlete walks to the point of exhaustion, which would be his maximal oxygen uptake. Another method of testing endurance is the MultiStage Shuttle Run Test. This test can be performed as a team running continuously between cones that are twenty meters apart. The time it takes to make it from one cone to the next is recorded and can be used to figure out VO2max by using an equivalency chart (Fitness Testing, 2007). One of the mostly overlooked aspects of fitness testing is flexibility. I must point out that while flexibility is a good thing to have in any sport, “ligamentous laxity or joint looseness, and athletes at either extreme of the flexibility continuum are probably at increased risk of injury” (Stewart, et al., 2004). With that being said, one popular test is the sit and reach test. This measures the hamstrings and lower back by the athlete sitting on the floor with his/her feet on the stretch and reach box, and then reaching forward as far as he/she can for a total of four times, with the fourth being held for a count of two seconds. The measurements are scored based on a scoring sheet that includes a positive for beyond the toes or a negative before the toes. One more aspect of fitness testing that is very important for rugby players is speed testing. Just as endurance, strength, and flexibility help make an elite rugby player, speed is also a major contributor. Different sprint tests are performed by rugby players since the majority of the positions require speed. Tests are given at ten, twenty and forty meter

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distances, similar to tests performed by track athletes. The maximal running speed and acceleration are calculated and assessed. Consequently, by completing this test, an athlete could also perform an anaerobic test that measured fatigue (Kelton, 2004).

5. FITNESS ASSESSMENT IN CYCLIC SPORTS Endurance sport and movement events that push the body to the limit are often overlooked when it comes to the amount of training these men and women go through. The amount of specific training that is designed for individual aspects of their performance is misunderstood by some amateur coaches, which can lead to injuries, lack of performance, and getting to peak performance at the wrong time. When it comes to cyclic sports such as swimming and endurance running, there are major differences in the way these athletes train, but in the end its almost all the same, as all are striving for the same goal by almost the same means, e.g. periodization and leveled training. Some types of training include, but are not limited to, running and swimming.

5.1. How to Measure: a) Strength- weight training, plyo-metrics (training with one’s own body weight, i.e., pull-ups, push-ups, dips; b) Flexibility- measuring range of motion, sit-‘n’-reach test, counting strides or measuring gait, stretching for a certain amount of time and then measuring range; c) Endurance- timed mile, speed workouts (how long the athlete can hold the pace time), time the athlete for a certain distance or on a specific course (mile run indoors vs. mile run outside); 5.1.1. Strength These three types of training lead to maximal performance, and this paper will tell you how. Strength training by athletes is important in any sport, especially for cyclic sports like running. It is important to understand how to increase training with certain athletes to avoid injury. Measuring the athlete’s skill and progression can help to keep track of where the athlete needs to be in order to be able to perform to the best of his or her ability. There are many ways to increase an athlete’s ability and skill as a runner. The first step is to assess the athlete in order to understand where his or her abilities lie and what levels of force and challenges he or she can handle. This is very important for different training programs because not all athletes are at the same level. Coaches want to prevent any type of overtraining, but also want their athletes to be the best that they can be in that particular sport.

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Different seasons call for different types of training. Pre-season consists of much lifting and endurance to ensure that the athlete will be strong enough to handle the seasonal workouts. In this particular season it is very important to have a particular workout plan and training session to prevent early injury and burnout during the season. The in-season regimen consists of endurance runs and workouts to ensure that the athlete can keep the physical condition that he or she gained in pre-season stable. Post- season is needed so that the athlete does not increase chance of injury. This is a time where athletes take some time off from their daily workout and rest their bodies. This ensures that athletes do not get hurt from wear and tear injuries and that their mind set will be fresh for another year of practice ad training. Post season also consists of an easy workout so that the athlete can stay in shape but not wear him or herself out. Periodization is also applied to all types of training. This includes various workouts with changes in intensity and training volumes to achieve peak levels of fitness. This is done so that the athlete does not tire out and so that he or she reaches the optimal level at the correct time. There are many different strength-training techniques and starting in the weight room is one of them. First, help the athlete learn the machines, how to use them and how to increase weights if needed. Then devise a workout plan for each specific athlete so that he/she knows how much weight is needed and the specific number of repetitions and sets needed to achieve the optimal level of performance without injury. One can measure the increase of strength training through weights by monitoring the athlete’s performance and the addition of weights to each workout. This can be done by the athletic trainer’s observations or by a simple workout sheet that is used every time the athlete is in the weight room. Other types of training can include cross training and plyo-metrics. Cross training is need to prevent injury, but is also important because it targets the muscle group one would need doing the same repetitive movements. Some cross training exercises for running can include, but are not limited to, swimming, rock climbing, and kickboxing. All three of these exercises can target all parts of the body needed to strengthen running. According to Runner’s World Magazine, “Because of the low impact nature of most cross-training activities, injury-prone runners can beef up their ‘mileage’ using this formula without increasing their risk of injury” Plyo-metrics are also encouraged for all athletes during workouts and training. They consist of rapid eccentric movement followed by a short rest phase followed by an explosive concentric movement. This utilizes the stretch-reflex mechanism, allowing for much greater than normal force to be generated by pre-stretching a muscle…before it contracts” Some examples include drop jumping, standing jump, multiple jumps, single leg jumps, hops, and bounds. Neuromuscular firing patterns are developed to improve the muscle contractility of specific muscle groups (Mauro, 2005).

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Many athletes can be hooked to machines and tested for specific increased amounts of certain muscle fibers. This observation can reassure trainers that athletes are getting proper conditioning techniques and results. An increase of movement and strength training can decrease or reduce the pain of “runner’s knee” to as little as six to eight weeks. This can also relieve the recurrence of common injuries such as nagging hip and lower back pain. Overall strength training is highly important and encouraged in athletes especially among runners. Strength training is a key factor to prevent overtraining and injury. Weight training can be used for many things including injury prevention, rehabilitation, strength gain, building general or specific fitness, or to cross-train to improve abilities in other sports. Many people would state that the best way to get better at swimming would be to swim. But in order to get additional gains once a swimmer has maximized swim time would be to add dry land work such as strength training. Swimmers need a lot of cross-training, especially strength training, in conjunction with their usual swim training. Swimming all day long would not be good for the body of a swimmer. In fact, many swimmers often get injured when they begin to purely swim and do not incorporate a strength training workout into their program. In order to optimize strength and power in the water, swimmers must practice strength training outside of the water in a gym setting. For many swimmers, off season workouts are a lot less intense in strength training than pre-season and in-season strength training programs. Just prior to swim meets practices are often cut short in the water and strength training in the gym still occurs, but usually with lighter weights. A typical strength training routine for swimmers consists of a full body strength training workout three days a week for about half an hour. A full body strength workout is necessary because swimming requires the use of muscles throughout the entire body. There is no basic cookie cutter plan for strength training that applies to all swimmers. A swimmer’s strength training program often is based on individual needs, individual goals, a season plan, and available equipment. However, as some general weight training rules, it is essential that swimmers give muscles time to rebuild by not lifting two days in a row and, as some may say, to prevent injury by not “lifting to failure”. It is also essential to incorporate a warm up and cool down into any strength training program in order to avoid injury. In conclusion, for swimmers, or any individual participating in a strength workout, it is important to start light and gradually increase. The best way to prevent injury during a strength training program is through slow progress. Swimmers should include cross training such as dry land workouts of strength training. Strength training can be a major contributor to faster swimming by increasing general fitness, speed, strength, coordination, balance, and body awareness. These increased abilities create positive benefits in a swimmer’s swim training and performance.

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5.2. Flexibility Flexibility, which is an underrated aspect of sports, especially among males, makes a huge impact on the performance of athletes in cyclic sports. For some, running is an athlete’s main sport, such as cross country or track contestants; for others, running is a key component of an athlete’s training for another sport, such as football, basketball, or soccer. The main thing these two situations have in common is the ability to be flexible while running to protect your body. Dr. Nicholas Romanov, a running guru from Russia who specializes in injury diagnosis, prevention, and exercise rehabilitation, among other disciplines, has done a great deal of research on the sport of running. Dr. Romanov states that the ability to bend in one’s joints has three main components: mobility of joints; elasticity of ligaments and tendons; and muscle relaxation, providing their lengthening. All three parts require a separate approach and development, which varies with every individual. Romanov stresses that stretching and flexibility are not synonymous. He defines stretching as the forceful pull of muscles, tendons, and ligaments, which is not a body’s natural position. However, a muscle relaxing is a normal state, as is flexibility (Romanov, 2007). One factor to consider that directly affects flexibility is the running economy, or the submaximal energy cost of running at a given speed. Several recent research studies have suggested that trunk and lower limb flexibility are inversely related to running economy. After testing 100 males and females, the researchers determined that subjects who exhibited tightness in the trunk, which limited the turning of the leg, were the most economical at every speed test. The researchers hypothesize that they got these results because running occurs primarily in a forward direction, meaning that rotational motion is potentially energy-wasting and does not contribute to forward movement (Wilkinson & Williams 2007). As one ages, flexibility decreases. Joint range of motion decreases due to muscle stiffness. If practiced, flexibility can contribute to anti-aging. The way to improve flexibility or maintain it is to perform stretches. It is recommended to stretch three times a week for ten to thirty seconds and do three to five repetitions. If flexibility and stretching techniques are taught at a young age, it will benefit the individual in the future. To continue, flexibility is also important in athletes. It has been known to prevent injury and enhance performances. Flexibility should be practiced the same way athletes weight train, with specificity. While weight training, a springboard diver will not perform all the same exercises as a platform diver. Same is true with flexibility. For example, swimmers need flexible ankles to increase their range of kicking, while runners need stiff, strong calves and Achilles tendons to run on hard surfaces.

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More specifically with swimmers, the shoulder joint is typically the most flexible joint. This is needed to perform all four strokes in the sport. However, too much flexibility can cause injury. It is important that swimmers maintain shoulder strength along with flexibility. In addition to the shoulder, flexibility in the lower extremities is also beneficial. To improve underwater kicking or kicking during a stroke, flexible ankles, knees, hips and lower back are needed. Flexibility allows swimmers to be efficient in the water and therefore improve racing. As stated before, stretching increases flexibility. It is also important to note that stretches are beneficial when performed with warmed muscles. Stretching cold muscles could cause injury. Also if all limbs are used during an activity, the upper and lower body should be stretched equally. For instance, swimmers use both upper and lower extremities, so stretches for the triceps and latissimus dorsi are just as important as the quadriceps and hamstrings. Also it is important to know how a swimmer’s most flexible joint is measured. A goniometer is used to determine a shoulder joint’s range of motion. Different tools and techniques are used to measure other areas of the body, such as the standard sit-‘n’-reach and V-sit tests to test the hamstrings.

5.3. Endurance Endurance is an important component in performance for those individuals who participate in running. There are many different routines athletes can implement into their program to increase endurance. Several examples are: increasing the intensity of a workout over time, varying running speed during a workout, and training at the maximal level. There are also several ways to measure endurance, including heart rate and VO2 readings. The first example of building endurance is increasing the intensity of a workout. This is achieved by starting out slowly and gradually increasing the intensity by walking faster, running, or walking on an incline. During the workout, the individual should continually make the exercise more difficult, which will in turn help to increase endurance. A second example is to vary running speed during a workout. In this routine, the individual runs at normal training speed, but incorporates short bursts of speed throughout the workout, lasting anywhere from a few seconds to a few minutes. By varying the speed times and sections, the individual is training his/her body to endure running at higher levels (endurance). The third example is to train at a maximum level. This increases endurance since athletes are training their body to tolerate a higher level of performance (Cosgrove, 2007). Athletes can measure their endurance through a variety of methods such as checking heart rate and VO2max. As an athlete continues to build endurance, the resting heart rate (RHR) should continually decrease. By

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keeping a log of RHR from each training period and comparing the logs over time, an athlete can tell if his/her endurance has increased (Sinah, 2007). VO2max, or the maximal oxygen consumption during a workout, can also be measured to determine an increase in endurance. As endurance is increased, the VO2max of the individual increases as well (Wikipedia). When dealing with a cyclic sport such as swimming, the way that has been proven best for measuring endurance is using Lactate Testing. Lactate testing can act as a superb educational tool, giving swimmers accurate information about what is actually happening in their muscles when they train and enabling them to understand the effects of different sets and the importance of the control of relationships among the various training parameters. Lactate testing shows the changing relationship between effort and speed. More effort means more lactate. At low intensities, speed increases faster than the lactate; at higher intensities, the lactate changes faster than speed. It also shows oxygen use where it counts—in the muscles at the cellular level. There are three major components for proper lactate testing and figuring out the true endurance of an athlete. They are Aerobic Work, Measures of Endurance, Maximum Lactate Value. Many programs have used 4mM of lactate (4 milliliters of lactate at maximum effort) as their standardized measure of aerobic intensity. If one chooses a very low or very high intensity, results will not reflect the endurance capabilities accurately, so 4mM is a good choice and enables one to compare results with those of many other programs. Measuring endurance capabilities in swimmers is one of the easiest coaching tasks. Any timed-distance swim will provide information about the endurance capabilities of the swimmer. You will know how fast he/she, but even if the swimmer gives maximum effort, you will not know how much energy he/she has used to produce the speed. If the swimmer does not give maximum effort, you will know very little. Lactate testing during one of these sets will tell you the effort precisely, even if the swimmer swims sub-maximally. Lactic acid moving out of the muscles becomes lactate when it enters the bloodstream. As swimmers apply more effort to swim faster, we can measure more lactate. If they train to produce very high amounts of lactate and control their application of power, they will be able to swim even faster. The highest lactate result of a test is, therefore, a very important parameter— it corresponds to the maximum speed. Its abbreviation is LaMax. All three vital components are interrelated. For example, training that is designed to produce changes in aerobic conditioning will, necessarily, also change the LaMax and the relationship between aerobic conditioning and maximum lactate. The results of lactic testing can be used to produce a training regimen that can positively affect the swimmer by increasing endurance and establishing at what stage of the race a swimmer produces the most lactic acid, and it pinpoints where improvement is needed.

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These examples and real-world situations discussing the importance of training cannot be overlooked. The lack of knowledge of some coaches at the amateur level prevents youngsters from gaining the correct idea of not only how to train, but why they should train—not only to get better, but to avoid injuries that could be minor or catastrophic. Recently an Olympic runner from the United States collapsed and died while he was running. Not to say that the athlete did not train right, but it is an example to show that if that can happened to an athlete with the correct training and diet, then what could happen to immature bodies when they are incorrectly trained for strenuous physical activities? Outside the physicality of sports, there is a huge part that is mental as well. Being put on a training program that is correct, and being tested to see levels of performance and health, helps the mental aspect of an athlete’s ability. Mentally, when an athlete does the right thing, and is shown how to do the right thing when he/she is young, that athlete begins to have trust in the training which leads to him/her becoming a better athlete both physically and mentally. Some professional athletes feel they do not perform to their maximum potential because of the way their coaches run things, and it has nothing to do with their physical ability. Once an athlete believes in the program, it will have more benefits to lead that athlete to his or her greatest potential and most importantly will keep him or her on the field of play.

CONCLUSION Gymnastics uses the test designed by Mark D. Sleeper, to assess gymnasts in flexibility and neuromuscular endurance through the use of rope climbing challenges, hanging pikes, over-grip pull-ups, the pushup test, and the handstand hold test. Competitive figure skating requires a variety of training techniques that involve more then just training on ice. These athletes are required to weight train as well as participate in dance and aerobic activities to improve their performance. Injuries that occur in this sport include overuse and lower extremity injuries. Competitive dancing requires physical strength and coordination, as a result the prevalent injuries are related to overuse. The demand on the body in competitive dancing requires extensive stretching, which can lead to even more injuries. One of the underrepresented sports, cheerleading, showed clear signs of being similar to other sport related fitness testing while being tested using advanced methods that involved flexibility. This sport requires a lot of coordinated stunts that compromise the demands of flexibility, strength, agility, and balance. These sport-specific tests are important in reflecting and advancing the athlete’s performance. Each sport places specific, concentrated demands on the body. If these tests are administered regularly, the prevalence of injuries may decrease.

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Within the sport of rugby, fitness testing is very important. Unlike most sports, not all players are alike in rugby due to the fact that the different positions require different abilities. Flexibility is needed due to the high demands of running in the sport; therefore the hamstrings can’t be tight. By performing the sit and reach test, an athlete can be assessed on flexibility, and greater emphasis on that aspect can be placed when training. Strength and power are important to test because many of the positions require these for ball possession or to guard against the opposition, especially since there is no equipment other than the body. Endurance is very important to test because rugby is filled with repeated sprints, usually without any form of break in play. Testing for endurance can ultimately mean the difference between winning and losing, especially if one team or player hasn’t conditioned properly and has fatigued towards the end of a tight game. Last but not least, speed is just as important to test as the other three. Since most of the positions require speed while controlling ball possession or providing run support, speed is important. So the next time people say they are going to play rugby, stop and think about how skillful they are in these areas and you won’t look down on this sport again. If coaches were to focus on all of these aspects of physical fitness, not only in training, but also in testing their players for the specific tasks that are required during the game, they could adopt a more effective training periodization for their athletes. The end result would be that their athletes would function at a higher level with fewer injuries and better performance. Overall, as can be seen again from the previous text, one of the main reasons for injury is coaching errors, specifically with respect to the underestimation of fitness assessment throughout whole season. Hopefully, the aforementioned elaborations will gain popularity among young adults and make them realize that if they go into coaching, they hold the lives of those athletes in their hands and must make sure they don’t over train and overwork athletes, and thereby avoid injury.

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Thomas D.Q., Seegmiller J.G., Cook T.L., and Young B.A. (2004). Physiological Profile of the Fitness Status of Collegiate Cheerleaders. Journal of Strength and Conditioning Research, 18, 252-254. Webster’s Dictionary. Merriam-Webster’s Dictionary McGlashan, L. (2003). Do you measure up?” Fitness Testing for Rugby. Duthie, G, et al. (2003). Applied Physiology and Game Analysis of Rugby Union. Sports Medicine 33, 973-991. “Fitness Testing for Rugby” 13 Nov 2007. http://www.topendsports.com/sport/union/testing.htm. Kelton, J. “Fitness Testing Assignment: Rugby” 27 Sept 2004. 12 Nov 2007. http://physiotherapy.curtin.edu.au/resources/educationalresources/exphys/99/rugbye.cfm. Mauro, P. (2005) – www.trainingsmartonline.com http://www.trainingsmartonline.com/triathlon_plyometrics.php Romanov, N. (2007). Flexibility in Running. November 14, 2007, cf: from Pose Tech. http://www.posetech.com/training/archives/000375.html. Wilkinson, M. & Williams, A. (2007). Running Economy. November 14, 2006, from Peak Performance Sport Excellence. http://www.pponline.co.uk/encyc/1007.htm. Cosgrove, A. Why “Endurance” Training Lacks Staying Power. Retrieved November 8, 2007. http://www.alwyncosgrove.com/Endurance.html. Sinah, A. Heart Monitor Training. Retrieved November 8, 2007. Http://www.marathonguide.com/training/article/HeartMonitorTraining.cfm. “VO2 max”. Retrieved November 8, 2007. http://en.wikipedia.org/wiki/VO2_max. Sleeper, Mark D. "Gymnastics Functional Measurement Tool." 8 Jan. 2007. Department of Physical Therapy and Human Movement Sciences, Northwestern University. 5 Nov. 2007

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